Understanding the Mechanism of Action of Cash and In-Kind Transfers to Improve the Health of People Living with HIV Infection in Tanzania

 描述（由申请人提供）：越来越多的人认识到，激励措施可以激励行为改变，并改善艾滋病毒护理连续体的结果沿着。在适当的情况下，财政激励措施可以增加对艾滋病毒检测的需求，改变短期性行为，加强艾滋病毒诊断后与护理的联系，并促进抗逆转录病毒治疗（ART）的坚持。然而，我们对激励措施改善健康的途径以及它们是否会产生意想不到的后果和好处的理解存在重大差距。这些知识差距阻碍了对为什么激励措施在某些项目中有效而在另一些项目中无效的明确解释，并限制了我们对未来项目中应包括哪些组成部分的理解。了解激励措施改变行为的机制以及它们最适合谁是至关重要的，以便指导在各种环境中扩大基于激励的方案，包括针对艾滋病毒感染者（PLHIV）的方案。我们有机会通过利用我们正在进行的对坦桑尼亚Shinyanga粮食不安全的艾滋病毒感染者进行短期粮食和现金转移的研究来解决这一知识差距。这项研究包括粮食不安全的艾滋病毒感染者，他们被随机分配接受6个月的粮食或现金转移，以诊所就诊为条件，旨在减少ART依从性和保留护理的障碍。这里提出的混合方法的研究探讨了未解决的问题，在家长的研究，并将使用两种互补的方法，以探索通过激励措施的运作途径。在目标1中，我们将进行一项定性研究，包括32个深入的采访，探讨个人，家庭和结构性因素对决策过程的影响，如何利用食物或现金援助，以及这如何影响坚持。在目标2中，我们将使用来自576名艾滋病毒感染者的定量调查数据来研究粮食不安全的艾滋病毒感染者如何利用粮食或现金援助，是否有意想不到的积极或消极结果，以及转移对12个月的依从性的影响是否取决于接受者的特征，如依从性的动机和对未来的期望。在研究结束时，我们将更好地了解激励措施可以改善ART依从性和护理保留的机制。我们还将知道在这种情况下使用的激励措施是否对艾滋病毒感染者或其家庭产生了额外的意外好处或不利影响。这一及时的信息可能广泛适用于目前正在设计、实施或考虑的现金和实物援助方案，以改善艾滋病毒感染者的健康。

 DESCRIPTION (provided by applicant): It is increasingly recognized that incentives can motivate behavior change and improve outcomes along the HIV care continuum. Under the right circumstances, financial incentives can increase the demand for HIV testing, change short-term sexual behavior, enhance linkage to care after HIV diagnosis, and promote antiretroviral therapy (ART) adherence. However, there are significant gaps in our understanding of the pathways through which incentives improve health, as well as whether they have unintended consequences and benefits. These knowledge gaps preclude definitive explanation of why incentives work in some programs but not others, and limit our understanding of which components to include in future programs. Understanding the mechanisms through which incentives change behavior and for whom they work best is essential in order to guide the scale-up of incentive-based programs in a variety of settings, including those targeting people living with HIV infection (PLHIV). We have the opportunity to address this knowledge gap by leveraging our ongoing study of short-term food and cash transfers for food insecure PLHIV in Shinyanga, Tanzania. This study includes food insecure PLHIV who are randomized to receive 6 months of food or cash transfers, conditional on clinic visit attendance, which is intended to reduce barriers to ART adherence and retention in care. The mixed-methods study proposed here explores unaddressed questions in the parent study and will use two complementary approaches in order to explore the pathways through which incentives operate. In Aim 1, we will conduct a qualitative study consisting of 32 in-depth interviews with PLHIV to explore the influence of personal, familial, and structural factors on the decision-making process of how food or cash assistance is utilized and how this influences adherence. In Aim 2, we will use quantitative survey data from 576 PLHIV to examine how food insecure PLHIV utilize food or cash assistance, whether there are unanticipated positive or negative outcomes, and whether the transfers' effect on adherence at 12 months is heterogeneous depending on the recipient's characteristics, such as motivation for being adherent and expectations about the future. At the conclusion of the research, we will have a better understanding of the mechanisms through which incentives may improve adherence to ART and retention in care. We will also know whether the incentives used in this setting had additional unintended benefits or adverse effects among PLHIV or their households. This timely information may be widely applicable to the spectrum of cash and in-kind assistance programs currently being designed, implemented, or under consideration to improve the health of PLHIV.