Home‐Based Intervention to Test and Start (HITS): a community‐randomized controlled trial to increase HIV testing uptake among men in rural South Africa

Abstract

Introduction The uptake of HIV testing and linkage to care remains low among men, contributing to high HIV incidence in women in South Africa. We conducted the “Home‐Based Intervention to Test and Start” (HITS) in a 2x2 factorial cluster randomized controlled trial in one of the World’s largest ongoing HIV cohorts in rural South Africa aimed at enhancing both intrinsic and extrinsic motivations for HIV testing. Methods Between February and December 2018, in the uMkhanyakude district of KwaZulu‐Natal, we randomly assigned 45 communities (clusters) (n = 13,838 residents) to one of the four arms: (i) financial incentives for home‐based HIV testing and linkage to care (R50 [$3] food voucher each); (ii) male‐targeted HIV‐specific decision support application, called EPIC‐HIV; (iii) both financial incentives and male‐targeted HIV‐specific decision support application and (iv) standard of care (SoC). EPIC‐HIV was developed to encourage and serve as an intrinsic motivator for HIV testing and linkage to care, and individually offered to men via a tablet device. Financial incentives were offered to both men and women. Here we report the effect of the interventions on uptake of home‐based HIV testing among men. Intention‐to‐treat (ITT) analysis was performed using modified Poisson regression with adjustment for clustering of standard errors at the cluster levels. Results Among all 13,838 men ≥ 15 years living in the 45 communities, the overall population coverage during a single round of home‐based HIV testing was 20.7%. The uptake of HIV testing was 27.5% (683/2481) in the financial incentives arm, 17.1% (433/2534) in the EPIC‐HIV arm, 26.8% (568/2120) in the arm receiving both interventions and 17.8% in the SoC arm. The probability of HIV testing increased substantially by 55% in the financial incentives arm (risk ratio (RR)=1.55, 95% CI: 1.31 to 1.82, p < 0.001) and 51% in the arm receiving both interventions (RR = 1.51, 95% CI: 1.21 to 1.87 p < 0.001), compared to men in the SoC arm. The probability of HIV testing did not significantly differ in the EPIC‐HIV arm (RR = 0.96, 95% CI: 0.76 to 1.20, p = 0.70). Conclusions The provision of a small financial incentive acted as a powerful extrinsic motivator substantially increasing the uptake of home‐based HIV testing among men in rural South Africa. In contrast, the counselling and testing application which was designed to encourage and serve as an intrinsic motivator to test for HIV did not increase the uptake of home‐based testing.

CD4+ T-Cell Count at Antiretroviral Therapy Initiation in the “Treat-All” Era in Rural South Africa: An Interrupted Time Series Analysis

“…Efforts to improve early ART initiation through enhanced HIV testing and linkage to care are critical, as are targeted interventions to boost male engagement with services. Interventions such as community-based multidisease screening [36], patientcentered and personalized services [36], financial incentives [48], and community-based ART initiation and monitoring for men [49] have shown success. While the scalability and sustainability of such interventions are unknown, the need for a holistic approach-such as integrating HIV services with noncommunicable disease services, addressing the wider determinants of health [50], reducing stigma, strengthening the health system including human and other resources, and improving health service quality-alongside more individualized interventions remains.…”

Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review

“…Other examples include text-based ART medication reminders and mindfulness exercises to reduce HIV viral load (Table 2). Culturally relevant and gender-specific messaging to engage in HIV prevention [30,101] Loss framed lottery intervention to encourage dual contraception methods to prevent HIV infection [86] HIV to take PrEP medication [142] HIV management Use of priming stimuli that is empowering or culturally meaningful to improve adherence to ART and retention in care [143,144] Use of financial rewards as priming to improve adherence to ART and to suppress viral load count [49,145] Providing safe sex materials as priming to practice safe sex to prevent HIV transmission [146] Personalised cues and reminder messages for remembering dose times to support ART adherence [72,74,147,148] Affect HIV prevention Creating positive emotion for HIV testing or accessing HIV services [111,139,149,150] Peer-led group sessions to learn skills for self-efficacy and positive sexual health behaviours [31] Increasing risk perception towards HIV to encourage HIV prevention behaviours [99,151] HIV management Creating positive emotion for HIV care retention and ART adherence through social, financial, or non-financial support [99,111,143,146] Group sessions targeting positive affect to increase skills for self-efficacy to encourage ART adherence and viral load suppression [146,[152][153][154] Motivational messages to encourage ART adherence [147,150,155] Commitment HIV prevention Use of binding contracts with financial deposits to encourage HIV testing or clinic visits [139,[156]…”

“…In one study, patients would receive congratulations for attending the clinic three consecutive on-time visits for HIV care, and they were given a sticker to proudly place on an interactive poster publicly displayed in the clinic to celebrate and acknowledge their achievement [143]. Another study involved a multi-component positive affect intervention for MSM who used drugs, eight core skills, and meditation exercises were delivered to them to increase positive affect among HIV management Use of non-explicit commitment devices in the form of financial incentives for ART adherence and viral load suppression goal in the future [108,144,147,154,[169][170][171][172][173][174][175][176][177][178][179][180][181] Use of non-explicit commitment devices in the form of financial incentives to meet HIV testing, linkage to HIV care and clinic attendance goal in the future [172,182,183] Use of non-explicit commitment devices in the form of non-financial incentives for ART adherence and viral load suppression goal in the future [74,147,155] Use of non-explicit commitment devices in the form of non-financial incentives to meet HIV testing, linkage to HIV care and clinic attendance goal in the future [117,143,146,[184][185][186] Ego HIV prevention HIV education sessions alongside financial education programmes to target ego and self-efficacy [18,31,99,[187][188][189] HIV education sessions and peer support to target ego and increase HIV risk perception ...…”

Interventions to Increase HIV Testing Uptake in Global Settings

“…Similar successes were described in another intervention with HIV self-testing targeted to men and young adults in Malawi: 90% of eligible participants accepted HIV testing [ 49 ]. A study in rural South Africa found that home-based testing, coupled with financial incentives, improved uptake of HIV testing among men [ 50 ].…”