Feasibility and acceptability of financial incentives and peer-led life skills training for improving adherence to antiretroviral therapy among adolescents living with HIV in Rwanda: A pilot study

Abstract

Background The Human Immunodeficiency Virus (HIV) is the leading cause of death among adolescents in sub-Saharan Africa. Despite the long-term benefits of antiretroviral therapy (ART), adherence remains low among adolescents due to challenges related to cost, acquisition, and treatment regimen. Sub-optimal adherence to ART is associated with the development of viral resistance, treatment failure, and increased morbidity and mortality. Financial incentives and life skills training interventions have shown early promise in motivating protective behaviors, however, gaps still remain around effective and innovative ways to motivate adolescents to stay in HIV care. In partnership with youth, we developed an intervention to address their social and financial pressures in order to promote adherence. Methods A human-centered design approach was utilized to engage adolescents in the initial design of the intervention. Through random sampling, 72 adolescents ages 12–19 were then recruited from two clinics in Rwanda for the pilot study. Adolescents participated in three monthly peer-led life skills trainings at clinics and received financial incentives via mobile money upon clinic attendance and demonstration of suppressed viral load. Semi-structured interviews were then conducted with adolescents, healthcare workers, and caregivers to understand their experiences with the intervention. Results Participants responded favorably to the intervention because of the psychosocial, financial, and health benefits it provided. Caregivers felt that adolescents’ moods, attitudes, and overall well-being improved over time. Adolescents used funds to purchase school supplies and save for investments, thus mitigating their financial burdens. Additionally, we learned that logistical challenges such as SIM card registration and mobile phone access must be considered for scale-up of the intervention. Conclusions To our knowledge, this is the first intervention designed in partnership with youth in sub-Saharan Africa aimed at removing financial barriers to ART adherence. The findings suggest that involving youth in the design of programs, providing them with financial incentives, and training them to use and invest their money wisely has a positive effect on them and their families. Thus, to improve adherence to ART and retention in care among HIV-positive youth, it is critical to address their socioeconomic and psychosocial needs.

Receipt of a combined economic and peer support intervention and clinical outcomes among HIV-positive youth in rural Rwanda: A retrospective cohort

“…Our retrospective cohort analysis of a youth-focused combined peer-support and economic incentive program did not identify any association between Adolescent Support Group membership and improved clinical outcomes. Two previous small pilot studies have assessed similar interventions, with one observing no clinical improvements and the other not reporting on clinical outcomes [21,22]. However, both studies identified potential non-clinical benefits to program participation, including psychosocial improvements and financial benefits, through qualitative interviews.…”

“…Similarly, although economic challenges are often cited as a barrier to treatment adherence, very few youth-focused intervention have assessed the impact of providing economic support on treatment outcomes [16][17][18][19]. Furthermore, although interventions designed to promote treatment adherence and clinical outcomes among youth are commonly include multiple complementary components [20], only two previous studies have combined peer support and economic incentives to support youth with HIV, and both were small pilot studies designed to assess feasibility and safety rather than effectiveness [21,22].…”

Human-Centered Design for Public Health Innovation: Codesigning a Multicomponent Intervention to Support Youth Across the HIV Care Continuum in Mozambique

“…17 The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. Agency for International Development (USAID), and their implementing partners have used HCD to promote HIV prevention and reproductive health globally. Examples include pre-exposure prophylaxis (PrEP) rollout in Zambia; 18,19 integrating sexual and reproductive health and HIV testing and prevention 20 with promoting ART adherence for adolescent girls and young women in Rwanda; 21 improving TB preventative treatment uptake among people living with HIV in Kenya; 22 and promoting HIV service uptake among men who have sex with men in the Philippines. 23 Although HCD is increasingly being employed to develop public health services and programs, it remains a novel approach to intervention development and dissemination in global health research.…”