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Evidence Update #1: Incentives to improve sexually transmissible infection (STI) and blood-borne virus (BBV) testing and treatment| December 14, 2021 |
Why is this issue important?
Sustained approaches to increase STI and BBV testing and treatment in priority populations are required to reduce STI and BBV prevalence. Incentives have been identified as a way to motivate and reinforce testing and treatment behaviours.
What we did
We undertook a rapid review of the literature to identify studies exploring incentives to improve STI and BBV testing and treatment. Two databases (Proquest and PubMed) were searched for Australian and international literature published between 2011-2020. We included studies that were most relevant to the Australian context. As this was a rapid review, other relevant studies may have been missed.
What we found
Incentives increased STI and BBV testing and treatment uptake in a range of contexts. Most of the incentives were small (e.g. AUD$10 for a test or to attend an appointment). There was limited literature on non-monetary incentives (e.g., transport assistance).
- Incentives can be an acceptable and effective strategy to increase STI and BBV testing and treatment uptake and adherence.
- Community and stakeholder consultation and an evidence-informed approach are essential to ensure incentives are ethical and tailored to the target group's needs.
- Some studies found that after the incentives concluded, appointment attendance decreased, indicating a drop in motivation to attend.
- Providing incentives beyond funding periods is a challenge to sustainability.
- Cost-benefit studies suggest incentives are cost-effective in preventing the health issue or for early diagnosis, as health outcomes are more costly when diagnosis is late.
- More research is needed to explore the impact of non-monetary incentives (e.g. food vouchers or travel assistance), incentives in specific population groups and incentives to increase hepatitis B (HBV) testing and treatment uptake.
Below is a summary of findings in the context of human immunodeficiency virus (HIV), HBV, hepatitis C (HCV) and STIs, including chlamydia.
We identified three reviews exploring incentives in the context of HIV. With regards to HIV, incentives comprised cash (ranging from A$5 - $100), gift cards or microcredit, non-monetary rewards such as food vouchers, food-aid, free-of-charge testing vouchers and vocational testing. These were received if participants accessed HIV testing services and linkage to care. Target populations varied per study, such as adult drug users, adults who were HIV positive, adolescents and pregnant women. Cash, food aid or microcredit were consistently and independently linked with higher HIV testing uptake among adults (1). Non-monetary rewards such as food vouchers or free-of-charge testing vouchers demonstrated higher uptake rates in an incentivised group (varied populations) for all studies under review (2). Additionally, incentives offered at a non-clinical setting demonstrated higher uptake rates compared to incentives offered at a clinical setting (3).
We identified four intervention studies focused on HIV. These studies explored HIV prevention, testing, linkage-to-care, and treatment uptake in priority populations, including black men who have sex with men and adults attending HIV care sites. Incentives received were gift cards (reloadable 1:1 for dollars or fixed AUD$70 – $125) or a combination of cash, debit card deposit and gift cards. Broadly, incentives were received for completion of activities related to engagement in HIV care, such as appointment attendance, peer-support group attendance, engaging in substance abuse treatment, adherence to antiretroviral therapy treatment) and achieving viral suppression. Overall, findings across the studies support incentives for better engagement in the intervention, earlier initiation and higher sustained rates of key health-related behaviours related to achieving viral load suppression (8, 9, 11). Increases were observed in awareness of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis, use of PrEP, and screening for HIV and STIs (5). Notably, results of one study indicated that after the withdrawal of incentives, findings at the 9-months post-intervention withdrawal showed evidence of durable effects of incentives on continuity in care, with trend for continued higher viral suppression. Incentives did not have a significant effect on linking HIV-positive individuals to care in one study (11). The evidence suggests incentives may work as a tool to engage the target population with the intervention and to achieve viral suppression, but additional studies are needed to explore financial incentives in relation to linkage-to-care. Success was attributed to interventions tailored to the target population, interventions that utilised peer support and engagement in care that was strengths-based and focused on improving broader social determinants of health (such as social inclusion and access to services) (5, 8, 9).
HBV and HCV
We found two studies that examined the cost-benefit of interventions related to HCV and HBV. To increase HCV testing uptake, participants received gift cards (AUD$10-20) for being tested or for referring friends/family members to be tested. In another study, people who inject drugs who completed an HBV vaccination received cash (A$18–30) to treat opioid dependence. Both studies applied cost-benefit analysis, with findings suggesting uptake of the screening and vaccination is a cost-effective use of healthcare resources. Current incentive amounts used in programs could be increased without increasing the cost per person completing testing/initiating treatment (4). Both studies highlight the benefit of earlier diagnosis and treatment, which mitigates the risk of costly adverse health outcomes in the long-term, considering the greater cost of acquiring HBV and HCV at a later stage and the subsequent impacts, versus the cost of implementing a financial incentive to enable earlier diagnosis (4, 13).
No further studies were found that addressed HBV. We found two studies focused on improving HCV treatment uptake amongst adults with a substance use history. An AUD$20 gift card was received by attendees at an HCV treatment centre, which improved appointment attendance. However, after the incentives concluded, attendance decreased, indicating a decrease in motivation (7). This is consistent with findings from the systematic review of HIV testing uptake (1) and may undermine intrinsic motivation. In addition, sustainability of the incentive beyond funding periods is identified as a challenge (7). A similar study compared the provision of a lottery-based incentive (average total received per client was AUD$355) compared to fixed incentives (average total received per client was AUD$327) for adhering to HCV treatment and attending clinic appointments. Both groups (86% of the fixed incentive and 100% of the lottery-based incentive) completed the full treatment, indicating both incentive types were successful and accepted by patients with a substance use history (12). Notably, the amount was chosen to offset clinic transportation costs and lost wages and appear large enough to motivate health-seeking behaviour.
Additionally, increases in intervention attendance were evident in an evaluation of a peer-based intervention for Aboriginal people. Participants received instalments of AUD$10-$20 for attending education sessions, testing for STIs and BBVs, attending follow-up appointments, for bringing a friend to an appointment and if the friend knew the information provided in the education session. Participants were more likely to report risks for BBVs in their lifetime, including injecting drug use, and were more likely to test for STI/BBVs (15). Ethical issues were raised from qualitative feedback from staff and participants of essentially paying at-risk groups (such as those with a history of substance abuse) to adopt certain behaviours. It is therefore recommended that an understanding of the perspectives of the community, as well as the evidence-base regarding incentive payments, should be key elements of staff training and program planning, and to mitigate inequities arising from the incentive-based nature of the program or disruption of services (10).
Incentives in the context of STI testing uptake were explored in one review alongside HIV testing uptake. Incentives for STI testing were cash (AUD$1-$35) or entry into a cash lottery (AUD$66), or non-monetary rewards such as food vouchers or free-of-charge testing vouchers amongst varied target populations. Consistent with the HIV testing uptake findings, results from all studies demonstrated higher rates of uptake in an incentivised group. However, the study highlights more research is needed on specific populations to understand the conditions needed to ensure incentivisation is effective in improving STI testing uptake (3).
We found three intervention studies specific to chlamydia testing, targeted at young people and young adults (11-30 years old). A fourth study targeted attendees at a sexual health clinic aged 16 years and older. Across the studies, participants received cash or vouchers (AUD$10-20) for completing testing. Studies comparing incentivised and non-incentivised groups found uptake higher in the incentivised group (6, 16), with one study also utilising testing for gonorrhoea (6). When comparing incentive types, vouchers (AUD$10-20), but not prize draws (ranging in value from a AUD$90 voucher to a AUD$3700 holiday for four) were found to increase chlamydia screening coverage (17). Qualitative insight indicated young people felt incentives affected their decision to have the chlamydia test, and a small proportion stated that it made no difference (14). Overall, these findings support the use of incentives in encouraging public health action (17). However, this needs to be carefully managed to avoid abuse such as impersonation or providing invalid samples (6). Furthermore, testing rates were less than ideal in some studies, suggesting a range of strategies reflecting a holistic approach will be required to increase chlamydia testing/re-testing in young people alongside an incentive strategy.
There was limited literature on non-monetary incentives (e.g., transport assistance). Two reviews explored retention in HIV care and adherence to antiretroviral therapy, using economic strengthening initiatives. Food rations are associated with improvements in care-seeking and medication pick-up, and transportation showed positive trends for care and treatment. However, evidence quality is moderate and based heavily on integrated interventions (2). Findings from studies utilising food vouchers or free-of-charge testing vouchers (populations varied) demonstrated higher rates of uptake in an incentivised group (3).
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