Incentives to improve couples' HIV testing uptake and cost-effectiveness
Authors: Kristin Wall, Susan Allen
Journal: The Lancet Global Health (2017)

Couples' HIV testing and counselling (CHTC) is a well-tested, feasible, and acceptable intervention and reduces HIV transmission through serostatus-based counselling that increases condom use among discordant couples (many of whom did not know that discordance was possible) and reduces concurrent partnerships among all couples.1Kilembe W Wall KM Mokgoro M et al.Knowledge of HIV serodiscordance, transmission, and prevention among couples in Durban, South Africa.PLoS One. 2015; 10: e0124548Crossref Scopus (23) Google Scholar, 2Doherty IA Myers B Zule WA et al.Seek, test and disclose: knowledge of HIV testing and serostatus among high-risk couples in a South African township.Sex Transm Infect. 2016; 92: 5-11Crossref PubMed Scopus (16) Google Scholar, 3Kenyon CR Kirungi W Kaharuza F Buyze J Bunnell R Who knows their partner's HIV status? Results from a nationally representative survey in Uganda.J Acquir Immune Defic Syndr. 2015; 69: 92-97Crossref PubMed Scopus (15) Google Scholar, 4Allen S Tice J Van de Perre P et al.Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa.BMJ. 1992; 304: 1605-1609Crossref PubMed Scopus (383) Google Scholar, 5Allen S Meinzen-Derr J Kautzman M et al.Sexual behavior of HIV discordant couples after HIV counseling and testing.AIDS. 2003; 17: 733-740Crossref PubMed Scopus (396) Google Scholar, 6Wall KM Kilembe W Vwalika B et al.Sustained effect of couples' HIV counselling and testing on risk reduction among Zambian HIV serodiscordant couples.Sex Transm Infect. 2017; 93: 259-266Crossref PubMed Scopus (36) Google Scholar Almost two-thirds of incident HIV infections in sub-Saharan Africa occur among stable couples,7Chemaitelly H Awad SF Shelton JD Abu-Raddad LJ Sources of HIV incidence among stable couples in sub-Saharan Africa.J Int AIDS Soc. 2014; 17: 18765Crossref PubMed Scopus (52) Google Scholar and an estimated greater than 50% of new adult HIV infections could be averted by CHTC.8Dunkle KL Stephenson R Karita E et al.New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data.Lancet. 2008; 371: 2183-2191Summary Full Text Full Text PDF PubMed Scopus (395) Google Scholar However, very few couples in Africa have been tested to date, and CHTC is often not available. To broadly implement CHTC in real-world settings, development of sustainable and locale-specific strategies to increase uptake is crucial. In The Lancet Global Health, Euphemia Sibanda and colleagues9Sibanda EL Tumushime M Mufuka J et al.Effect of non-monetary incentives on uptake of couples' counselling and testing among clients attending mobile HIV services in rural Zimbabwe: a cluster-randomised trial.Lancet Glob Health. 2017; 5: e907-e915Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar present data from the first trial supporting use of non-monetary incentives to increase uptake of CHTC and case identification. The large effect size associated with the inexpensive incentives supports consideration of incorporating context-specific incentives into CHTC programmes. Over 20% of couples in the intervention group reported that they would not have undergone CHTC without incentives. Importantly, incentives did not increase social harms and were found to be feasible, acceptable, and non-coercive. We similarly found in Zambia that small non-monetary items that promote good health (including soap, chlorine, deworming medication, screening and treatment for urinary schistosomiasis, and blood pressure and diabetes screening) increased follow-up testing among HIV-discordant (adjusted odds ratio [aOR]=2·93 [95% CI 1·41–6·09], p=0·0039) and concordant-negative (aOR=2·06 [1·53–2·76], p<0·0001) CHTC couples.10Czaicki NL Davitte J Siangonya B et al.Predictors of first follow-up HIV testing for couples' voluntary HIV counseling and testing in Ndola, Zambia.J Acquir Immune Defic Syndr. 2014; 66: e1-e7Crossref PubMed Scopus (10) Google Scholar However, CHTC uptake and follow-up remains low in most settings, and further studies of low-cost sustainable incentives and other factors influencing CHTC uptake and follow-up (to promptly identify seroconversions and linkage to care) are needed. Most couples undergoing CHTC in the study by Sibanda and colleagues9Sibanda EL Tumushime M Mufuka J et al.Effect of non-monetary incentives on uptake of couples' counselling and testing among clients attending mobile HIV services in rural Zimbabwe: a cluster-randomised trial.Lancet Glob Health. 2017; 5: e907-e915Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar were motivated by desire to learn their joint serostatus. Among the few individuals who reported already knowing that they were HIV positive, those couples underwent CHTC to facilitate disclosure. In a different study in Malawi,11Rosenberg NE Mtande TK Saidi F et al.Recruiting male partners for couple HIV testing and counselling in Malawi's option B+ programme: an unblinded randomised controlled trial.Lancet HIV. 2015; 2: e483-e491Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar assisted contact tracing successfully recruited male partners of HIV-positive women to CHTC to facilitate HIV status disclosure and engagement in care. Partner notification to engage serodiscordant and concordant-positive couples in CHTC to facilitate disclosure or develop joint risk reduction plans based on joint status is a novel strategy that warrants further investigation. More HIV cases were diagnosed in the intervention group, supporting CHTC as a high yield intervention for identifying serodiscordant and concordant-positive couples, and indicating that nominal incentives might be a cost-effective, non-coercive, and sustainable strategy to identify HIV-positive individuals. Future studies of incentive cost-effectiveness will be important to inform CHTC implementation. We declare no competing interests. Effect of non-monetary incentives on uptake of couples' counselling and testing among clients attending mobile HIV services in rural Zimbabwe: a cluster-randomised trialSmall non-monetary incentives, which are potentially scalable, were associated with significantly increased CHTC and HIV case diagnosis. Incentives did not increase social harms beyond the few typically encountered with CHTC without incentives. The intervention could help achieve UNAIDS 90-90-90 targets. Full-Text PDF Open Access