Economic Incentives for HIV testing in children and adolescents: Efforts to reach the first 95! Getting to the first 95 for children and adolescents: Innovative approaches for pediatric case finding IAS Satellite Session – JSI/AIDSFree Project and Partners July 23, 2018 Grace McHugh Biomedical and Research Training Institute Harare, Zimbabwe

I have no conflict of interest to declare.

Background Children rely on caregivers to access HIV testing and care Delayed diagnosis of HIV leads to increase risk of mortality Efforts to increase access to entry point of HIV care are urgently required

Evidence for Incentives Malawi- Cash incentives to men doubled the rate of returning to clinic to obtain HIV results Thornton et al, Am Econ Rev. 2008 South Africa- Financial incentives increased HIV testing rates in unemployed men: strong association between HIV-testing yield and use of incentivized testing  Nglazi et al, J Acquir Immune Defic Syndr. 2012 Zimbabwe- Non-monetary incentives increased HTC for couples Sibanda et al, Lancet Global Health. 2017 No trial to date looking at incentivising testing of older children and adolescents

Approach to Incentivisation Household randomized controlled trial, nested with a HIV prevalence survey Targeting 8-17 year olds No incentive vs. $2 vs. Lottery ( $0, $2 or $10) Outcome: % of households with at least 1 child taking a HIV test within 4 weeks of enrolment 3 arm randomised controlled trial to compare the effect on HIV test uptake at primary care clinics by children aged 8-17 years Children in eligible households i.e. with at least 1 child in the eligible age group, if their HIV status was unknown, were enrolled as part of a door to door HIV prevalence survey. Participants were anonymously tested for HIV through OMT testing as part of a HIV prevalence survey being performed in the neighbourhood Participants were referred to their local primary care clinic for RDT testing, where study HIV counsellors were available to perform the test

2050 households 472 households 654 households 562 households 649 No Incentive 740 $2 Incentive 661 Lottery 477 with at least one child with unknown HIV status 660 with at least one child with unknown HIV status 566 with at least one child with unknown HIV status Households were excluded if children were not available after 3 visits to the house Of those who had at least 1 child of unknown HIV status, reasons for further exclusion were if all children were found to be HIV+ or child refused participation in the study 472 households 654 households 562 households

No Incentive $2 Lottery 93/472 (20%) HIV test 316/654 (48%) HIV test 223/562 (40%) HIV test Factors associated with increased uptake of HIV testing in control group were lower household income, smaller household size and older age of participants

Odds Ratio P-value Adjusted OR No Incentive 1 $2 3.81 (2.90-5.01) <0.001 3.67 (2.77-4.85) Lottery 2.68 (2.02-3.56) 2.66 (2.00-3.55) Adjusted for community and number of children in household as fixed effects and for research assistant as a random effect.

No Incentive $2 Lottery Household size 5(4-6)   No Incentive $2 Lottery Household size 5(4-6) Eligible children in household 1(1-2) 2(1-2) Age of household head 41 (35–49) 42 (36–51) Education None or Primary Secondary Higher 14 (3%) 397 (84%) 60 (13%) 34 (5%) 521 (80%) 99 (15%)  28 (5%) 468 (83%) 66 (12%) Regular household income per month No regular income or <US$200 $200–500 >$500  274 (58%) 128 (27%) 69 (15%)  355 (54%) 161 (25%) 138 (21%)  338 (60%) 140 (25%) 84(15%)

HIV prevalence according to arm No Incentive (n=113) $2 (n=551) Lottery (n=335) HIV prevalence 0 (0%) 4 (1%) 6 (2%)

Pros and Cons Pro Con Increased uptake of testing Rewarded for behaviour which should be standard procedure Engages families with health services Coercive “Demystifies testing” Linkage to care Helps to reach a targeted group Sustainability, cost, future exposure to HIV

Conclusion Financial incentives show promise! Lottery with a 1 in 8 chance of winning a cash prize may be a more cost-effective approach Potential for scalability for identifying children at risk of perinatally acquired HIV infection A potential approach for differentiated HIV testing Lottery may be more cost effective in low resource settings, for identification of children living with perinatally acquired HIV infection if would be a once off test until risk of acquisition increases upon sexual debut. If finances allowed it would be more generalizable

Thank You Participants and their families Research team and staff Subathira Dakshina Ethel Dauya Tsitsi Bandason Victoria Simms Katharina Kranzer Helen Weiss Rashida Ferrand www.brti.co.zw

References Kranzer K, Simms V, Bandason T, et al. Economic incentives for HIV testing by adolescents in Zimbabwe: a randomised controlled trial. The Lancet HIV. 2018 Simms V, Dauya E, Dakshina S, et al. Community burden of undiagnosed HIV infection among adolescents in Zimbabwe following primary healthcare-based provider-initiated HIV testing and counselling: A cross-sectional survey. PLoS Medicine.