Do lottery incentive strategies increase engagement in HIV care and uptake of antiretroviral therapy among South African men?

 描述(由申请人提供)：抗逆转录病毒疗法(ART)可预防艾滋病毒的发病率、死亡率和传播。当使用抗逆转录病毒疗法时，非洲艾滋病毒阳性者的预期寿命与艾滋病毒阴性者相当。然而，与艾滋病毒相关的死亡率仍然很高，特别是在男性等难以接触到的人群中。在接受抗逆转录病毒治疗的260万南非人中，只有三分之一是男性，尽管男性占艾滋病毒阳性者的45%。在整个艾滋病毒预防和护理连续体系中，艾滋病毒阳性男子的比例偏低，他们不太可能进行检测、与护理挂钩、发起抗逆转录病毒治疗，而且更有可能迷失在后续行动中。很少有战略把重点放在男性身上，即使他们这样做了，他们也没有成功。我们能够通过优化的艾滋病毒检测、看护点CD4检测和业馀顾问支持方案实现60%与艾滋病毒诊所的联系，但需要创新的战略来激励艾滋病毒阳性男性发起并坚持抗逆转录病毒治疗。有条件的彩票奖励策略是一种创新的、高收益的艾滋病毒预防策略。最近的一个有效干预的例子是，以性传播感染阴性为条件的抽奖奖励(50美元或100美元的现金奖励)，将莱索托喜欢冒险的个人的艾滋病毒发病率降低了60%；这表明了迄今为止预防艾滋病毒的行为干预的最大效果之一。男性一贯比女性更喜欢冒险，而彩票吸引了那些愿意冒险的人。因为放弃艾滋病毒护理的男性是在赌博，认为他们的健康不会受到这一选择的影响，所以涉及赌博的策略可能会让他们重新参与护理；这类似于预防艾滋病毒的彩票。对于艾滋病毒阳性、符合抗逆转录病毒治疗条件的男性，有条件的彩票激励措施有可能克服与护理挂钩的结构性和行为障碍，例如后勤障碍和与女性相比在风险认知上的差异。我们建议评估南非夸祖鲁-纳塔尔地区有条件彩票激励联系战略的可行性、有效性和计划实施情况，以使男性参与艾滋病毒护理和抗逆转录病毒治疗(彩票与联系研究)。通过参与性的实施过程，我们将让利益相关者(包括客户、提供者和卫生部领导人)评估有条件的彩票激励措施的可行性。为了测试干预措施，120名HIV阳性男性将被随机分为单独优化的链接方案或优化的链接方案加有条件的彩票激励。将在六个月后评估艾滋病毒阳性男子被病毒抑制并接受护理的比例。为了计划实施和操作实践，我们将评估干预的增量成本，并探索使用常规收集的数据(关于错过诊所就诊和错过ART补充物)来识别有失去后续行动的风险的男性。我们的假设是，在优化的链接方案之外，有条件的彩票激励措施将成功地惠及男性，并显著增加对艾滋病毒护理和病毒抑制的参与。

 DESCRIPTION (provided by applicant): Antiretroviral therapy (ART) prevents HIV morbidity, mortality and transmission. When ART is used, the life expectancy of HIV-positive persons in Africa is comparable to that of HIV-negative persons. However, HIV- associated mortality continues to be high, particularly among hard to reach populations such as men. Of the 2.6 million South Africans on ART only a third are men, despite men making up 45% of HIV-positive persons. HIV-positive men are underrepresented throughout the HIV prevention and care continuum, being less likely to test, link to care, initiate ART, and more likely to be lost to folow-up. Few strategies have focused on men, and when they have they have not been successful. We were able to achieve 60% linkage to HIV clinics through an optimized package of HIV testing, point-of-care CD4 testing and lay-counselor support but innovative strategies are needed to motivate HIV-positive men to initiate and adhere to ART. Conditional lottery incentive strategies are an innovative, high-yield strategy for HIV prevention. A recent example of an effective intervention used a lottery incentive (a cash prize of $50 or $100) conditioned on being STI negative, which decreased HIV incidence by 60% among 'risk-loving' individuals in Lesotho; demonstrating one of the largest effects to date of a behavioral intervention for HIV prevention. Men are consistently and significantly more risk-loving that women, and lotteries appeal to those willing to take risks. Because men who drop HIV care are gambling that their health will not be affected by the choice, strategies that involve a gamble may re-engage them in care; analogous to lotteries for HIV prevention. For HIV-positive, ART eligible men conditional lottery incentives have the potential to overcome both structural and behavioral barriers to linking to care, such as logistic barriers and differences in risk perception compared to women. We propose to assess feasibility, test the effectiveness and plan implementation of conditional lottery incentive linkag strategies to engage men in HIV care and ART in KwaZulu-Natal, South Africa (the Lottery to Link Study). Through a participatory implementation process we will engage stakeholders (including clients, providers and Department of Health leaders) to assess the feasibility of conditional lottery incentives. To test the intervention, 120 HIV-positive men will be randomized to an optimized linkage package alone or an optimized linkage package plus a conditional lottery incentive. The proportion of HIV-positive men virally suppressed and engaged in care will be assessed at six months. To plan implementation and operational practices, we will assess the incremental cost of the intervention and explore the use of routinely collected data (on missed clinic visits and missed ART refills) to identify men at risk for loss to follow-up. Our hypothesis is that conditional lottery incentives, above and beyond an optimized linkage package, will successfully reach men and markedly increase engagement in HIV care and viral suppression.