Using Peer-Referral Chains with Incentives to Promote HIV Testing and Identify Undiagnosed HIV Infections Among Crack Users in San Salvador

Abstract

In El Salvador, crack users are at high risk for HIV but they are not targeted by efforts to promote early HIV diagnosis. We evaluated the promise of peer-referral chains with incentives to increase HIV testing and identify undiagnosed HIV infections among networks of crack users in San Salvador. For 14 months, we offered HIV testing in communities with a high prevalence of crack use. For the following 14 months, we promoted chains in which crack users from these communities referred their peers to HIV testing and received a small monetary incentive. We recorded the monthly numbers of HIV testers, and their crack use, sexual risk behaviors and test results. After launching the referral chains, the monthly numbers of HIV testers increased significantly (Z = 6.90, p < .001) and decayed more slowly (Z = 5.93, p < .001), and the total number of crack-using testers increased nearly fourfold. Testers in the peer-referral period reported fewer HIV risk behaviors, but a similar percentage (~5 %) tested HIV positive in both periods. More women than men received an HIV-positive diagnosis throughout the study (χ 2 (1, N = 799) = 4.23, p = .040). Peer-referral chains with incentives can potentially increase HIV testing among networks of crack users while retaining a focus on high-risk individuals.

Intervention Reach and Sexual Risk Reduction of a Multi-level, Community-Based HIV Prevention Intervention for Crack Users in San Salvador, El Salvador

“…Our results indicate that Encuentro showed some promise in reaching a community population of crack users and in changing the risk behaviors of those who had directly received any components. These results add to a growing literature on the effectiveness of multi-level interventions [30][31][32][33][34][35], including our own previous analysis of the effects of the introduction of the social network component, which significantly increased the monthly numbers of HIV tests among crack users [36].…”

“…In an earlier paper analyzing only the effects of introducing the Social Network HIV testing intervention, we found that the total number of monthly testers increased significantly and decayed more slowly, and the total number of crack-using testers increased almost 4-fold. HIV prevalence among crack users and non-users was approximately 5% [36]. Given the emphasis on treatment as prevention in the current era of HIV prevention, increasing testing rates among crack users is of utmost importance.…”

Incentivized Peer Referrals for Tuberculosis Screening: Evidence from India

“…Following the recent WHO guidelines, public health scholars and practitioners have begun to explore peer referrals as a case-finding tool. Some studies focus on HIV case finding among high-risk communities (see, e.g., Glasman et al (2016); Gwadz et al (2017); Shangani et al (2017)), and one study considers identification of malaria cases (Faye, 2012). In the context of TB, Joshi et al (2017) implement a peer-led screening project in Nepal, where 30 volunteers received intensive training to perform TB screening, collect sputum samples, accompany the newly diagnosed patients to obtain treatment, and support them during treatment.…”

Cumulative Effects of Adding a Small Group Intervention to Social Network Testing on HIV Testing Rates Among Crack Users in San Salvador, El Salvador

“…Encuentro included community HIV testing, social network HIV testing, small group sexual risk reduction interventions, and community events, which were rolled out sequentially, in order to determine the individual and cumulative effects of different intervention components using an interrupted time series design. We have published results showing the effectiveness of the social network HIV testing component using dual incentives and peer referral, in increasing the number of monthly HIV tests, particularly among crack users [ 19 ]. An additional publication showed that exposure to multiple Encuentro components significantly reduced times participants had condomless sex [ 20 ].…”

“…An additional publication showed that exposure to multiple Encuentro components significantly reduced times participants had condomless sex [ 20 ]. The present study reports the cumulative effects of the social network HIV testing and small group interventions on the community’s rates of HIV testing, beyond the increase that we saw with the introduction of the social network HIV testing intervention alone [ 19 ]. We expected to observe increases in community HIV testing rates after the completion of each group cycle, as participants may seek out HIV tests themselves and encourage others to do so after considering their own risk behaviors and encouraging their peers to do so.…”