Financial incentives can improve secondary distribution of HIV self-tests
Authors: Yuxin Ni, Ying Lu, Yi Zhou, Gifty Marley, Weiming Tang
Journal: The Lancet Global Health (2021)

In The Lancet Global Health, Augustine T Choko and colleagues1Choko AT Fielding K Johnson CC et al.Partner-delivered HIV self-test kits with and without financial incentives in antenatal care and index patients with HIV in Malawi: a three-arm, cluster-randomised controlled trial.Lancet Glob Health. 2021; 9: e977-e988Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar described the effectiveness of secondary distribution of HIV self-test kits (HIVST) in increasing test uptake. In the study, the authors mentioned that one possible reason for fewer kits being distributed among women in the HIVST plus financial incentive group than among those in the HIVST alone group was the concern about how their male partners or male sexual contacts would use the incentives. Hence, the authors suggested that using non-cash incentives might be an effective alternative to overcome this concern. However, because of the study design and data analysis issues, we consider the suggested explanation to be potentially inaccurate. First, whether the researchers considered and examined all potential effects of financial incentives on HIVST uptake is questionable. It was also unclear if HIVST users could only receive cash incentives when they brought back used kits and got retested in facilities. This financial incentive strategy that aimed to promote HIVST might have instead introduced additional barriers to HIVST uptake and reduced the effect of HIVST. This effect was evidenced in the study findings, in which, for the antenatal care cohort, fewer partners reported to the clinic in the HIVST plus incentive group (65·2%) than the HIVST alone group (73·0%; p<0·0001).1Choko AT Fielding K Johnson CC et al.Partner-delivered HIV self-test kits with and without financial incentives in antenatal care and index patients with HIV in Malawi: a three-arm, cluster-randomised controlled trial.Lancet Glob Health. 2021; 9: e977-e988Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar Additionally, an essential benefit of self-testing is that it enables individuals to test for HIV privately and at their convenience, thus circumventing several barriers to HIV testing.2WHOWHO recommends HIV self-testing: evidence update and considerations for success.https://www.who.int/publications-detail-redirect/WHO-CDS-HIV-19.36Date: 2019Date accessed: July 1, 2021Google Scholar Therefore, the study could have adopted a digital verification approach instead of requiring partners to report at the clinic for verification to receive the allocated incentive. For example, in a secondary-distribution programme in China, partners of indexed people were allowed to take photographs of their results and upload them to an online system, and they received incentives after results verification by trained staff from a community-based organisation. This approach has shown notable effectiveness in expanding HIVST among Chinese men who have sex with men and would have been more convenient to the partners, especially in this era of COVID-19.3Lu Y Ni Y Li X He X et al.Monetary incentives and peer referral in promoting digital network-based secondary distribution of HIV self-testing among men who have sex with men in China: study protocol for a three-arm randomized controlled trial.BMC Public Health. 2020; 20: 911Crossref PubMed Scopus (9) Google Scholar, 4Zhou Y Lu Y Ni Y et al.Monetary incentives and peer referral in promoting digital network-based secondary distribution of HIV self-testing among men who have sex with men in china: a three-arm randomized controlled trial.SSRN. 2021; (published online March 3.) (preprint).https://papers.ssrn.com/abstract=3795303Google Scholar, 5Wu D Zhou Y Yang N et al.Social media-based secondary distribution of human immunodeficiency virus/syphilis self-testing among Chinese men who have sex with men.Clin Infect Dis. 2020; 26ciaa825Crossref Scopus (15) Google Scholar Moreover, although the women having concerns about the potential misuse of financial incentives probably hindered HIVST distribution, a subanalysis to further identify other possible effects of the incentive approach (if any) would have been helpful (eg, stratifying by sex in the index cohort). These results would have given additional support to the speculation on whether the concerns of the women substantially hindered the secondary distribution of HIVST, or whether the implementation of the incentive strategy introduced new barriers to secondary distribution of HIVST. In the worst case, female index participants might have motivated more sexual contacts to consider HIVST, which would further contradict the assumptions made in this Article.1Choko AT Fielding K Johnson CC et al.Partner-delivered HIV self-test kits with and without financial incentives in antenatal care and index patients with HIV in Malawi: a three-arm, cluster-randomised controlled trial.Lancet Glob Health. 2021; 9: e977-e988Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar In summary, the incentive strategy would have prevented the effectiveness of HIVST, and a further data analysis that assesses the intervention effect in men versus women in the index cohort is needed. In addition, integrating digital health reporting systems and allowing participants to report the test results electronically could address the challenges in this study. We declare no competing interests. Financial incentives can improve secondary distribution of HIV self-tests – Authors' replyWe appreciate the careful consideration of our Article1 in The Lancet Global Health from Yuxin Ni and colleagues, but we must respectfully disagree with most of their concerns about our study. Full-Text PDF Open AccessThe secondary distribution of HIV self-testing kitsThe study by Augustine Choko and colleagues1 has shown that the secondary distribution of HIV self-testing (HIVST) kits, by pregnant women attending antenatal care to their male partners and by index patients attending general health care to their sexual contacts, can increase the number of men testing for HIV. Choko and colleagues reported that the mean proportion of partner testing in the antenatal care cohort was 35·0% (SD 10·0) in the standard care group versus 73·0% (13·1) in the HIVST only group and 65·2% (11·6) in the HIVST plus financial incentive group. Full-Text PDF Open Access