Financial incentives improve HIV self-testing outcomes in Malawian men
Financial incentives for men in sub-Saharan Africa can significantly improve linkages to HIV prevention and treatment services after self-testing.
Using HIV self-testing to link Malawian men to HIV prevention and treatment services was most successful when paired with a financial incentive, according to a study among male partners of women attending antenatal care (ANC) services in the city of Blantyre – Malawi’s second largest city.
Near-universal HIV testing of women in ANC is one of the great success stories of the HIV response, and particularly in endemic East and Southern Africa. It also provides an excellent opportunity to develop unique interventions to get men testing for HIV. Regionally, just over half (52%) of men are aware of their status, and AIDS-related deaths are 27% higher among men than women. Reversing the HIV epidemic here will require engaging men in HIV prevention and treatment services.
This two-stage cluster randomised control trial enrolled 2,349 pregnant women attending an ANC clinic for the first time for their current pregnancy, with a primary male partner not known to be on HIV treatment. The women were then grouped into six arms – the standard of care (SOC) in Malawi arm and one of five intervention arms.
In the SOC arm, women were sent home with a letter inviting men to come in for an HIV test at a male-friendly clinic and told of the availability of fast-track referrals to HIV treatment or voluntary medical male circumcision (VMMC) services.
In the intervention arms, all women were given two HIV self-tests to take home to their partner: one arm offered this only; two arms offered an additional fixed cash financial incentive of $3 or $10; a fourth arm offered a 10% chance of winning $30 in a lottery; and a fifth arm included a phone call to the male partner on the day the woman enrolled in the trial, which was repeated five days later if the partner did not come to the clinic. Outcomes were measured at 28 days.
Across all intervention arms, there was a high uptake of male partner testing, with women self-reporting in interviews partner testing ranging from 87% to 95.4%, this compared to just 17% in the SOC arm. This affirms previous research that HIV self-testing is highly agreeable to men in the region.
But linking men to care remains critical, and the study reveals that 28.8% of the men had an HIV test and attended a clinic in the 28 days. Broken down, in the SOC arm, just 13% of men attended the clinic within the 28 days; 17.5% in the self-test only arm; 40.9% of the men in the $3, and 51.7% in the $10 incentive arms; 18.6% of men attended the clinic in the lottery arm, and 22.3% of men in the reminder call group attended a clinic.
The study was conducted in two stages to assess effectiveness or reports of any adverse outcomes, including intimate partner violence – of which none were reported. The lottery arm was, however, dropped due to a lack of significant effectiveness at stage one, the self-test only arm was only continued because of the importance of this intervention for HIV testing policy in Malawi.
Of the 676 men who did attend the male-friendly clinic, 6.8% were confirmed to be HIV-positive, all were referred to antiretroviral treatment (ART) and 91.3% of the men started treatment on the same day.
“This… adds to the body of mixed evidence concerning incentives and linkage,” state the authors in their discussion, “as well as establishing the principle that linkage interventions can increase health benefits from secondary distribution HIVST strategies”.
The findings, published this week in PLOS Medicine, show that secondary distribution of HIV self-testing kits accompanied by interventions to promote timely linkage into the HIV care and prevention cascade is a promising new approach for routine ANC, that is both effective and cost-effective.