van de Weerd J 1995 Evaluatie doorstroomprogramma Huishoud en Consumentenwete...
Using financial incentives to increase testing uptake versie 2
1. Using financial incentives to
increase testing uptake and
reduce risk behavior in men
Jennie van de Weerd
18 January 2011
2. Overview of presentation
The problem
The intervention
Objectives
Literature review
Costing model
Discussion
3. The problem
For every 2 HIV+ people put on treatment, another 5
are getting infected. This calls for innovative ways to
prevent HIV transmission and stop the epidemic
STIs accounted for more than 26% of all deaths and
over 5 million DALYs in 2000 in RSA. Over 98% of
this burden was due to HIV/AIDS.
African males between 25-49 have been identified
as a RSA specific MARP with HIV+ at 27.3%,
declining comprehensive knowledge and low HIV
testing levels.
4. The problem
Testing HIV+ has a significant effect on
reducing risk behavior. Effect of testing HIV-
is less pronounced.
The Cost Effectiveness of HIV-testing has
been proven in several studies.
New HIV testing models (PIT, UT, mobile)
still necessitate first step by tester. This is
difficult in areas and populations where
stigma is high.
5. The intervention – IY / DTHF / MSR
Desmund Tutu HIV foundation reaches out to hard to reach
populations in informal settlements around Cape Town with the
Tutu-tester.Testing is free and integrated in health check to
reduce stigma
Incentive of ZAR 75/- is offered by Indlu Yegazi to daily labourers
(on special days when Tutu tester is near Men-on-the-Side-of-
the-Road site).
MSR have low testing levels and high HIV+. Incentive is paid
irrespective of testing result.
When testing HIV-, test can be repeated after 6 months.
Incentive is intended to motivate MSR to stay negative during
this period.
HIV+ are referred to treatment program of DTHF
6. Objectives
Aim:
Explore whether providing incentive based HIV-
testing for men could be an effective way of HIV-
prevention
Objectives:
1. Literature review on the use of incentive-based
systems to increase uptake of preventive services
and change behaviour with a focus on HIV-testing
2. Assess the potential cost-effectivenees of
incentive provision for HIV-testing and behaviour
change in South Africa
7. Use of incentive-based systems to
increase uptake of preventive
services and change behaviour with a
focus on HIV-testing
Literature review
8. Specific objectives literature review
Which theories exist to explain the motivation and
determinants for men to take up HIV-testing and
change behaviour?
What are determinants for HIV-testing uptake in
South Africa?
Which examples exist of increases in uptake of
services, strengthened adherence to treatment or
changed behaviour due t o the use of material
incentives?
What are the ethics of providing a financial incentive
(to a specific group)?
9. Theories: Motivation!
Behavioural economics: opportunity cost,
time-preference, rationality (maximizer)
Communication theory: therapeutic alliance
Cognitive dissoncance theory
HIV Prevention
Information
HIV Prevention
Motivation
HIV Prevention
Behavioral Skills
HIV Preventive
Behavior
IMB-model with stigma as environmental factor.
10. Determinants for testing uptake in men
Costs and access to HIV-testing
Physical access and willingness and ability to absorb monetary and time-
related costs to go for a test
Stigma
Family based stigma less a problem for men, though fear to loose position in
the community.
Risk perception
Low risk perception and HIV is only one of the threats faced, most of which
are considered more pressing and immediate.
Motivation to test
High opportunity costs, high stigma and low risk perception result in low
motivation to test. Correct knowledge is low (positively related with being
tested)
11. Lessons learned from other interventions
Contingency management:
The systematic reinforcement of desired behaviour and
the withholding of reinforcement or punishmeent of
undesired behavour. Conditional Cash Transfer
programs are considered to fall under this definition.
•51 articles included referring to 49 studies;
•9 reviews referring to 235 studies
•Only 2 studies were done in Africa
•15 referred to HIV preventive behaviour
•CM mainly used in sustance abuse (drug, alcohol, smoking)
related high risk populations.
•WB finished proof of concept study in Malawi and Tanzania
12. Lessons learned(cont.)
Simple or complex target behaviour?
Target population
Choice of incentive
Incentive size
Incentive provision: frequency and timing
Incentive duration
13. Ethical considerations
At population level: Paying an incentive from
public health or economic efficiency point of
view to create positive externalities (for HIV
testing: better treatment results, reduction in
rate of HIV transmission)
At individual level: autonomy and informed
uptake. Height of incentive and way testing is
provided will determing whether this can be
guaranteed
14. Assess the potential cost-effectiveness
of incentive provision for HIV-testing
and behaviour change in South Africa
Costing model
15. Specific objectives costing model
What is the additional cost of providing an incentive
per HIA over a 5-year period to a cohort of men?
What is the potential cost saving per HIA over a five-
year period to a cohort of men?
What is the necessary reduction in the chance of
getting infected with HIV and the necessary time-
span to justify the current provision of an incentive?
How are the outcomes of the calculation model
influenced by different values of the key variables
(sensitivity analysis)?
16. Costing model
Motivated to test = n
HIV+
HIV-
On ART treatment
Not on ART treatment
Lost to follow up
Men on the side of the Road
(MSR)
Men on the side of the Road
(MSR)
1-nl
p
1-p
nl
t
1-t
IncentiveI
Model parameters
[1]
Current situation
(control)[2]
Incentive effect
Chance to become
infected (p)
0.20 0.15, 0.10, 0.05,
0.00
Incentive value (I) 0 10.22 US$
Number of testers
(n)
3696 4416[3]
Number of tests (nt) 2 2
Loss to follow up
(nl)[4]
0.15 0.00, 0.05, 0.10
[1] All parameters in the model can be changed.
[2] Based on the M&E 2009 data for MSR
[3] In 2009, utilisation rate was 77% of full capacity per day (40 testers) without incentive and 92% with incentive
[4] No data could be retrieved from DTHF/IY. Rutledge et al, 2002 found average attrition over 12 sexually transmitted HIV prevention interventions based
17. Number of men tested and HIA
-500
0
500
1.000
1.500
2.000
2.500
1 2 3 4 5
Testers p(i)=0,15
Testers p(i)=0,00
HIA with p(i)=0.15
HIA with p(i)=0.00
Extra HIV+ with
p(i)=0.15
Uptake of testing will be higher and loss to follow up lower, therefore more
HIV+. Thus HIA can even be negative (yellow line).
18. Cost of incentive provision
0
500
1.000
1.500
2.000
2.500
3.000
3.500
4.000
4.500
5.000
1 2 3 4 5
Year
US$
HIA nl(i) = 0.10
p(i)=0.10
HIA nl(i) = 0.10 Disc.
p(i)=0.10
HIA nl(i) = 0.00
p(i)=0.10
HIA nl(i) = 0.00 Disc.
p(i)=0.10
Cost of incentive per HIA increases after 2 years, more so for a
lower loss to follow up and bigger reductions of the chance to get
infected (since more testers mean more incentive costs).
19. Potential cost saving
Potential cost saving per
HIA slowly increases over
time
Cost saving is negative for
p=0.15 over 2 years
regardless of level of loss to
follow up.
Average cost saving evens
out with different nl and p
but number of HIA differs
(thus indirect infections and
costs)
Potential cost savings per HIA with different loss
to follow up over 2 years
-10000
-5000
0
5000
nl(i)=0.10 nl(i)=0.05 nl(i)=0.00
Chance to get infected intervention group
CostperHIAinUS$
p=0.15
p=0.10
p=0.05
p=0.00
Potential cost savings per HIA with different loss
to follow up over 5 years
0
2000
4000
6000
8000
nl(i)=0.10 nl(i)=0.05 nl(i)=0.00
Chance to get infected intervention group
CostperHIAinUS$ p=0.15
p=0.10
p=0.05
p=0.00
21. Conclusions and recommendations
Incentives will reduce the opportunity costs for testing and
appeals to most important role of men (breadwinner)
After testing enrolment, engaging men will be important since it is
the incentive which make men enroll, not the intention to change.
DTHF/IY ensures informed uptake through counselling. Payment
of incentive depends on the test not on the result (autonomy).
Incentive provision seems to be most cost-effective after 2 years.
Chance to get infected has to be reduced to less than 15%.
There is room to increase value and/or frequency of incentive
without affecting the CE of incentive provision.
Incentive provision alone will not change behaviour. There is
need for intense folllow up and behavioural interventions (IMB
mobel) to sustain complex behaviour change.
Editor's Notes
This is only one slide, but actually has a lot of information.
The IMB model states that for effective HIV prevention interventions, you need to work on information, motivation and skills to be effective. If one of the three elements is less developed, this will result in lower or no behaviour change. This model was generalized (validated) for South Africa. Stigma was added as an important environmental factor influencing all elements. Studies have shown that in the short-term this approach to prevention is most effective for men.
As explained, stigma influences all elements of the IMB model in South Africa, but motivation to go for testing is severely hindered. Stigma attached to testing increases the opportunity cost of going for testing. A second problem is that people prefer to have a reward now (f.ex. Sex without a condom), than the may-be risk of acquiring HIV in the future (time-preference). Assuming (neo-classical theory) that a man will maximize his utility, he will not go for testing in this situation – a perfectly rational choice. An incentive can reduce the opportunity costs of going for testing (overcome the barrier of stigma), strengthen the time preference (reward is provided immediately) so that it will be rational for the person to go for testing.
How long would you need to continue paying? COgnitive dissonance theory suggests that even though initial engagamenet with the program depends on the payment of the incentive, communication with the service providers, enhancement of skills and provision of information can influence motivation so that people as social creatures want to comply with behaviour which is advocated as being good. Communication theory terms this therapeutic alliance and implies that this is sufficient to sustain behaviour.
A study in Eastern Cape found taht every 1 km a man lives away from a tesing facility, reduces the likelihood of going to test. Combined with the lower health centre utilisation of men, PIT might not be the answer to increase testing by men. Mobile testing brings testing facility closer to men but although testing is for free, time spend for testing cannot be spend earning money.
Men indicate to prefer to live in doubt than knowing that they are HIV+ (or that the community knows this). Embedding testing in comprehensive health check could address the issue of stigma and acceptability and reduce in higher uptake.
Higher succes rates in simple behaviour (one-off visits) than in complex sustained behaviour change since motivation is external (example of a weight gain study where the incentivized group actually did worse in the long run). Expected that HIV testing will increase but sustained behaviour change will be more difficult. Also, stimulating demand alone is not sufficient, supply of services should be sufficient and of satisfactory quality.
The more targetted the intervention (focus on a specific group) the more costly is becomed. Targetting can also induce stigma. Lastly, the incentive will also be paid to people who already behave as expected. So in a way you always pay too much.
Is incentive provision necessary ? It is the provider who is paying, but probably another budget who will profit of the cost saving (IY is paying but treatment program of DTHF benefits). Should there be a conditionality (experience shows that when incentives are paid with sufficient income effect people will send their children to school, though adopting highly stigmatized HIV testing is less likely without conditionality. Positive enforcement is nicer for client and provider. In-kind – less liked by clients, cash carries a security risk, vouchers seems to be a safe option. Flat payment, escalating incentive or lottery system (escalating most motivating). Incentive provision alone does not change behaviour – most succesful were those interventions that combined this with attention to the other IMB elements.
Determing the exact threshold of incentive height to induce change is difficult and will vary from person to person. Likely that if incentive has only a price effect (on a service which is already not appealing to the client), this will not induce change.
Frequency varies from daily to longer term. Reinforcement should be applied as closely as possible to the target behaviour. Frequency and timing are strongly linked to the magnitude of the incentive and the expected behaviour.
Incentive is an extrinsic moivator – sustaining behaviour will depend on whether a person has internalized the motivation to behave and the norms in his social networks. Working on Skills and information is therefore important. OPtimal duration of incentive provision will depend on the interplay between all 7 elements.
When incentive is too heigh, men will test no matter what the consequences (and not get information and skills!). When incentive is too low, MSR will not bother to test. This is hardly informed decision making either seen the low level of correct knowledge and high levels of stigma.
