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）可预防艾滋病发病率、死亡率和传播。在使用抗逆转录病毒疗法时，非洲艾滋病毒抗体阳性者的预期寿命与艾滋病毒抗体阴性者的预期寿命相当。然而，与艾滋病毒有关的死亡率仍然很高，特别是在男子等难以接触到的人群中。在接受抗逆转录病毒疗法的260万南非人中，只有三分之一是男子，尽管男子占艾滋病毒抗体阳性者的45%。在整个艾滋病毒预防和护理过程中，艾滋病毒阳性男子的比例偏低，他们不太可能进行检测、与护理联系、开始抗逆转录病毒治疗，而且更有可能在后续治疗中失踪。很少有战略以男子为重点，即使有，也没有取得成功。我们能够实现60%的链接到艾滋病毒诊所，通过优化的艾滋病毒检测，点的护理CD 4检测和外行辅导员的支持，但需要创新的策略，以激励艾滋病毒阳性的男性发起和坚持ART。有条件的彩票激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，在性传播感染阴性的条件下，使用彩票奖励（50美元或100美元的现金奖励），在莱索托，“喜欢冒险”的人中，艾滋病毒发病率降低了60%;这是迄今为止预防艾滋病毒行为干预的最大效果之一。男人总是比女人更喜欢冒险，彩票对那些愿意冒险的人有吸引力。因为放弃艾滋病毒护理的男性是在赌他们的健康不会受到选择的影响，所以涉及赌博的策略可能会让他们重新参与护理;类似于预防艾滋病毒的彩票。对于艾滋病毒抗体阳性者，符合抗逆转录病毒疗法条件的男性有条件抽签奖励有可能克服与护理联系的结构和行为障碍，例如与女性相比的后勤障碍和风险认知差异。我们建议评估可行性，测试的有效性和计划实施的有条件的彩票激励链接策略，让男子在艾滋病毒护理和ART在夸祖鲁-纳塔尔，南非（彩票链接研究）。通过参与式实施过程，我们将让利益相关者（包括客户，供应商和卫生部领导人）评估有条件彩票激励措施的可行性。为了测试干预措施，120名艾滋病毒阳性男性将被随机分配到单独的优化链接包或优化链接包加有条件彩票激励。将在六个月时评估艾滋病毒阳性男子中病毒得到抑制并参与护理的比例。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（错过的诊所访视和错过的ART再填充）来识别有失访风险的男性。我们的假设是，有条件的彩票激励，以上和优化的联动包，将成功地达到男性和显着增加参与艾滋病毒护理和病毒抑制。

 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.