Can a conditional financial incentive (CFI) reduce socio-demographic inequalities in home-based HIV testing uptake? A secondary analysis of the HITS clinical trial intervention in rural South Africa

Maxime Inghels; Hae-Young Kim; Thulile Mathenjwa; Maryam Shahmanesh; Janet Seeley; Sally Wyke; Nuala McGrath; Benn Sartorius; H Manisha Yapa; Adrian Dobra; Till Bärnighausen; Frank Tanser

doi:10.1016/j.socscimed.2022.115305

Can a conditional financial incentive (CFI) reduce socio-demographic inequalities in home-based HIV testing uptake? A secondary analysis of the HITS clinical trial intervention in rural South Africa

Soc Sci Med. 2022 Oct:311:115305. doi: 10.1016/j.socscimed.2022.115305. Epub 2022 Sep 1.

Authors

Affiliations

¹ Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK; Centre Population et Développement (UMR 196 Paris Descartes - IRD), SageSud (ERL INSERM 1244), Institut de Recherche pour le Développement, Paris, France. Electronic address: MInghels@lincoln.ac.uk.
² Africa Health Research Institute, KwaZulu-Natal, South Africa; Department of Population Health, New York University School of Medicine, New York, NY, USA; KwaZulu-Natal Innovation and Sequencing Platform, KwaZulu-Natal, South Africa. Electronic address: haeyoung.kim09@gmail.com.
³ Africa Health Research Institute, KwaZulu-Natal, South Africa. Electronic address: Thulile.Mathenjwa@ahri.org.
⁴ Africa Health Research Institute, KwaZulu-Natal, South Africa; Institute for Global Health, University College London, London, United Kingdom. Electronic address: m.shahmanesh@ucl.ac.uk.
⁵ Africa Health Research Institute, KwaZulu-Natal, South Africa; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa. Electronic address: Janet.Seeley@LSHTM.ac.uk.
⁶ Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom. Electronic address: Sally.Wyke@glasgow.ac.uk.
⁷ Africa Health Research Institute, KwaZulu-Natal, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Department of Social Statistics and Demography, Faculty of Social Sciences, University of Southampton, Southampton, United Kingdom. Electronic address: n.mcgrath@soton.ac.uk.
⁸ Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA. Electronic address: benn.sartorius@ndm.ox.ac.uk.
⁹ Africa Health Research Institute, KwaZulu-Natal, South Africa; The Kirby Institute, University of New South Wales, Sydney, NSW, Australia. Electronic address: Manisha.Yapa@ahri.org.
¹⁰ University of Washington, Seattle, WA, USA. Electronic address: adobra@uw.edu.
¹¹ Africa Health Research Institute, KwaZulu-Natal, South Africa; Heidelberg Institute of Global Health (HIGH), Heidelberg University, 69120 Heidelberg, Germany. Electronic address: till.baernighausen@uni-heidelberg.de.
¹² Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa. Electronic address: FTanser@lincoln.ac.uk.

PMID: 36084520
DOI: 10.1016/j.socscimed.2022.115305

Abstract

In sub-Saharan Africa, home-based HIV testing interventions are designed to reach sub-populations with low access to HIV testing such as men, younger or less educated people. Combining these interventions with conditional financial incentives (CFI) has been shown to be effective to increase testing uptake. CFI are effective for one-off health behaviour change but whether they operate differentially on different socio-demographic groups is less clear. Using data from the HITS trial in South Africa, we investigated whether a CFI was able to reduce existing home-based HIV testing uptake inequalities observed by socio-demographic groups. Residents aged ≥15 years in the study area were assigned to an intervention arm (16 clusters) or a control arm (29 clusters). In the intervention arm, individuals received a food voucher (∼3.5 US dollars) if they accepted to take a home-based HIV test. Testing uptake differences were considered for socio-demographic (sex, age, education, employment status, marital status, household asset index) and geographical (urban/rural living area, distance from clinic) characteristics. Among the 37,028 residents, 24,793 (9290 men, 15,503 women) were included in the analysis. CFI increased significantly testing uptake among men (39.2% vs 25.2%, p < 0.001) and women (45.9% vs 32.0%, p < 0.001) with similar absolute increase between men and women. Uptake was higher amongst the youngest or least educated individuals, and amongst single (vs in union) or unemployed men. Absolute uptake increase was also significantly higher amongst these groups resulting in increasing socio-demographic differentials for home-based HIV testing uptake. However, because these groups are known to have less access to other public HIV testing services, CFI could reduce inequalities for HIV testing access in our specific context. Although CFI significantly increased home-based HIV testing uptake, it did not do so differentially by socio-demographic group. Future interventions using CFI should make sure that the intervention alone does not increase existing health inequities.

Keywords: Financial incentives; HIV; Home-based HIV testing; Inequalities; South Africa.

Grants and funding

MR/P024378/1/MRC_/Medical Research Council/United Kingdom