Innovative incentive strategies for sustainable HIV testing and linkage to care

 描述(由申请人提供)：到目前为止，在艾滋病毒检测方面投入了大量资源，但全球超过一半的成年人仍然不知道自己的艾滋病毒状况。尤其是男性远低于国际艾滋病毒检测目标，那些艾滋病毒感染风险最高的人往往最不可能参加以社区为基础的流动艾滋病毒检测工作。感染艾滋病毒的男性与护理相关的比率也低于女性。男性检测和与护理“差距”的联系都对包括治疗即预防(TasP)在内的艾滋病毒综合预防战略的实施构成了挑战。因此，确定干预措施以增加对男性--特别是从事高危行为的男性--的艾滋病毒检测是撒哈拉以南非洲的一项艾滋病毒预防优先事项。尽管经济激励--以采取某项行动为条件的经济奖励--被发现在改变低收入国家的健康行为方面是有效的，但现有的激励方法未能纳入行为经济学的重要见解，为“更聪明的”基于激励的干预留下了空间，这种干预可以更有效、更便宜地增加对艾滋病毒检测的接受和与护理的联系。这种干预措施的长期可持续性和成本效益也尚未明确确定。这项研究将实施和评估新的以激励为基础的干预措施，以增加高危男子中的艾滋病毒检测，并将艾滋病毒感染者与治疗联系起来。目标1将建立在行为经济学理论和研究的基础上，并测试这样的前提：(1)以抽奖形式提供的激励，与艾滋病毒检测的少量固定激励相比，可能更有效；(2)个人表现出“损失厌恶(不愿失去他们已经拥有的东西)，因此对从艾滋病毒检测中获得一些东西的可能性(即标准的固定激励)的动机不如从不检测中失去一些东西的可能性”。以抽奖为基础的激励措施可能对有风险偏好的个人最具吸引力，从而确保以有针对性和廉价的方式推广艾滋病毒检测。在一项三臂随机对照试验中，基于彩票和损失厌恶的激励措施将与固定激励措施进行比较。目标2将利用个人决策模式中存在的损失厌恶，来检查艾滋病毒检测呈阳性的男性是否更有可能将护理联系在一起，如果向他们提供的激励具有唾液特征，那么早期联系就会立即受益。目标3将通过分析不再提供激励措施时一次性激励措施对后续艾滋病毒检测的影响，来评估增加检测的新型经济激励措施的可持续性和成本效益。这项研究将促进对激励如何以及为什么影响决策的科学理解，同时还将确定低成本、可持续的方法，以增加高危个人对艾滋病毒检测的需求，改善与护理的联系，并最终促进综合艾滋病毒预防战略的实施。

 DESCRIPTION (provided by applicant): Significant resources have been invested in HIV testing to date, yet over half of adults globally remain unaware of their HIV status. Men in particular fall well below international HIV testing targets and those at highest risk of HIV infection are often the least likely to participate in community-based mobile HIV testing efforts. HIV- infected men also link to care at lower rates than women. Both the male testing and linkage to care "gaps" pose a challenge for the implementation of combination HIV prevention strategies, including treatment as prevention (TasP). Identifying interventions to increase HIV testing among men - particularly those engaged in high-risk behaviors - is thus an HIV prevention priority in sub-Saharan Africa. Although economic incentives - the offer of economic rewards that are conditional on undertaking a certain action - have been found to be effective in modifying health behaviors in low-income countries, existing approaches to incentives have failed to incorporate prominent insights from behavioral economics, leaving room for "smarter" incentive-based interventions that can be more effective and less expensive in increasing uptake of HIV testing and linkage to care. The long-term sustainability and cost-effectiveness of such interventions have also yet to be clearly established. This study will implement and evaluate novel incentive-based interventions to increase HIV testing among high-risk men and link HIV-infected adults to treatment. Aim 1 will build on insights from behavioral economics theories and studies, and test the premises that (1) incentives in the form of lotteries, with smal probabilities of winning high-value prizes as a result of HIV testing, may be more powerful than small, fixed incentives for HIV testing; and (2) individuals display "loss aversion (a reluctance t lose something they already own) and therefore are less motivated by the possibility of gaining something from HIV testing (i.e. a standard fixed incentive) than the possibility of losing something from not testing. The lottery-based incentives are likely to be most appealing to individuals with risk-seeking preferences, thereby ensuring that HIV testing is promoted in a targeted and inexpensive manner. Lottery and loss aversion-based incentives will be compared to fixed incentives, in a three-arm, randomized controlled trial. Aim 2 will draw upon the existence of loss aversion in individuals' decision-making patterns to examine whether men who test HIV-positive are more likely to link to care if the incentive offered to them features a saliet, immediate benefit to early linkage. Aim 3 will assess the sustainability and cost-effectiveness of novel economic incentives to increase testing by analyzing the effect of one-time incentives on subsequent HIV testing when incentives are no longer offered. The study will advance the scientific understanding of how and why incentives influence decision-making while also identifying low-cost, sustainable ways to increase demand for HIV testing among high-risk individuals, improve linkage to care, and ultimately facilitate the implementation of combination HIV prevention strategies.