1. 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

2. I have no conflict of interest to declare.

3. 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

4. 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

5. Approach to Incentivisation
Household randomized controlled trial, nested with a HIV prevalence survey
Targeting 8-17 year olds
No incentive vs. $ 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

6. 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

7. 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

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

9. 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%)

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

11. 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

12. 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

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

14. 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 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.