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Using Incentives and Nudging to Improve Non-Targeted HIV Testing in Ecuador: A Randomized Trial

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Abstract

Under-detection of HIV/AIDS still burdens many low- and middle-income countries (LMICs). Our randomized trial investigated the effects of financial incentives and a behavioral nudge to induce HIV testing and learning HIV status in Ecuador. In the control group, 12.2% of participants agreed to testing, and 5.3% learned results. A financial incentive paid at testing increased the fraction of participants tested by 50.1 percentage points (95% CI 38.8 to 61.4) and the fraction who learned their status by 8.9 percentage points (95% CI 5.3 to 12.5); the nudge had no effect. The HIV-positive rate was 1.2% in the control group, and incentives prompted a 4.7 percentage point (95% CI 0.5 to 8.9) higher proportion of HIV-positive detection. Incentives also induced earlier testing, suggesting reduced procrastination. This suggests that information with appropriately timed small financial incentives can improve HIV testing and detection of new cases in the general population in LMIC settings.

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Data Availability

Data for replication purposes is available from the corresponding author upon reasonable request.

Code Availability

The code used to produce the analyses is available from the corresponding author upon reasonable request.

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Acknowledgements

We are grateful to the Creative and Novel Ideas in HIV Research (CNIHR) leadership and to 2017 and 2018 CNIHR workshop participants for valuable comments and support. We gratefully acknowledge the support of the Municipality of Esmeraldas, especially Mayor Lenin Lara, and Council Member Rubin Perea. We thank Adriana Elba Campos for excellent research assistance, and Sheronda Gordon for outstanding administrative support. We are especially grateful to Dr. Diogenes Cuero Caicedo and his team at the Fundacion Raices. Dr. Cuero Caicedo passed away prematurely in January 2019. He will be missed by many in his community of Esmeraldas. This article is dedicated to his memory.

Funding

This research was supported by the Creative and Novel Ideas in HIV Research (CNIHR) Program through a supplement to the University of Alabama at Birmingham (UAB) Center For AIDS Research funding (P30 AI027767). This funding was made possible by collaborative efforts of the Office of AIDS Research, the National Institute of Allergy and Infectious Diseases, and the International AIDS Society.

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Authors and Affiliations

  1. Johns Hopkins Carey Business School, 100 International Dr, Baltimore, MD, USA

    Mario Macis & Phillip Phan

  2. Hopkins Business of Health Initiative, Baltimore, MD, USA

    Mario Macis

  3. Colegio de Ciencias de La Salud, Universidad San Francisco de Quito, Quito, Ecuador

    Michelle Grunauer, Erika Gutierrez, Carlos Rosas & Enrique Teran

  4. College of Public Health, University of South Florida, Tampa, FL, USA

    Ricardo Izurieta & Miguel Reina Ortiz

  5. Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA

    Phillip Phan

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  1. Mario Macis
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Contributions

MM, MG, RI, MRO, PP, and ET conceived and designed the study. CR and EG conducted the fieldwork and collected the data. ET and MM supervised the study. ET was responsible for the lab analysis. MM performed the statistical analysis. MM and PP and wrote the first draft. All authors contributed to the interpretation of the results, revised the manuscript for important intellectual content, and approved the final version.

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Correspondence to Mario Macis.

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Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical Approval

The study was approved by the Johns Hopkins Homewood Institutional Review Board and by the Institutional Review Board of the Universidad San Francisco de Quito in Ecuador.

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Verbal informed consent was obtained prior to the interview and intervention.

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Macis, M., Grunauer, M., Gutierrez, E. et al. Using Incentives and Nudging to Improve Non-Targeted HIV Testing in Ecuador: A Randomized Trial. AIDS Behav 25, 2542–2550 (2021). https://doi.org/10.1007/s10461-021-03215-x

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  • DOI: https://doi.org/10.1007/s10461-021-03215-x

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