Conditional cash transfers and uptake of and retention in prevention of mother-to-child HIV transmission care: a randomised controlled trial

Abstract

Background Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. Objective To determine whether small, increasing cash payments conditional on attending scheduled clinic visits and receiving proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care through six weeks postpartum. Methods Newly diagnosed HIV-infected women, ≤32 weeks pregnant, were recruited at antenatal care clinics in Kinshasa, Democratic Republic of Congo, and assigned in a 1:1 ratio to an intervention or control group using computer-based randomization. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services ($5, plus $1 increment at each subsequent visit), while the control group received usual care. Outcomes assessed included: 1) retention in care at six weeks postpartum, and 2) to uptake PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services through six weeks postpartum. Analyses were intent-to-treat. Results Between April 2013 and August 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomized. At six weeks post-partum, the proportion of participants retained in care was higher in the intervention group than the control group (174/216, 80·6% vs. 157/217, 72·4%; risk ratio (RR), 1·11; 95% confidence interval (CI), 1·00–1·24). The proportion of participants who attended all clinic visits and accepted proposed services was higher in the intervention group than the control group (146/216, 67·6% vs. 116/217, 53·5%; RR, 1·26; 95% CI, 1·08–1·48). Results were similar after adjusting for marital status, age, and education. Conclusions Among newly diagnosed HIV-infected women, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation.

A systematic review of interventions to improve postpartum retention of women in PMTCT and ART care

“…On this note, we would also like to point readers to the randomized trial by Yotebieng et al . [29], which was published after this systematic review had been completed. Eight of the studies in Table 10 are cluster-randomized trials and one is a stepped wedge randomized trial.…”

“…Concerning the use of monetary incentives to increase postpartum ART retention, we would like to point out that a large randomized trial, published after we had completed this systematic review, evaluated the effect of conditional cash transfers on retention in PMTCT at six weeks postpartum in Kinshasa [29]. The trial found a 12.5% higher probability of retention at six weeks postpartum for women in the intervention compared to the control arm (81% vs. 72%; RR ratio: 1.11; 95% CI: 1.00–1.24), which was marginally significant ( p =0.055).…”

HIV transmission and retention in care among HIV‐exposed children enrolled in Malawi's prevention of mother‐to‐child transmission programme

“…A similar tracing intervention at a large district hospital in Lilongwe was less successful: only half of the children could be traced and only one-third of those who were located could be returned to care [25]. Conditional cash transfers or transport reimbursements are other possible interventions to improve retention in care [33]. HIV testing within PMTCT programmes could be improved by addressing logistical challenges such as shortages of dried blood spot sample test kits [34].…”

Conditional Cash Transfers to Increase Retention in PMTCT Care, Antiretroviral Adherence, and Postpartum Virological Suppression: A Randomized Controlled Trial

“…Analysis of the primary endpoints of the trial (retention in and uptake of PMTCT services) has been reported. 17 Only participants who were retained in care through the 6-week postpartum visit were including in this analysis.…”

“…We recently completed a randomized controlled trial evaluating the impact of conditional cash transfers on retention in and uptake of PMTCT services in Kinshasa, Democratic Republic of Congo (DRC). Previous results 17 showed that providing HIV-infected women with small and increasing cash transfers, conditional on attending scheduled clinic visits and accepting available PMTCT services, substantially increases the proportion of women who remain in care and receive available PMTCT services through 6 weeks postpartum. However, as recently demonstrated in a large trial of pre-exposure prophylaxis, adherence to scheduled visits and participation in study procedures when there are incentives conditioned on these specific behaviors do not always translate to adherence to prophylactic treatment.…”