Financial incentives can improve secondary distribution of HIV self-tests – Authors' reply
Authors: Augustine T Choko, Moses K Kumwenda
Journal: The Lancet Global Health (2021)

We appreciate the careful consideration of our Article1Choko 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 The Lancet Global Health from Yuxin Ni and colleagues, but we must respectfully disagree with most of their concerns about our study. We agree with the observation that the lower reported testing in the financial incentive group is of interest and can be puzzling. However, we wish to differ from the claim that the offer of an incentive negatively affected HIV self-testing, because such an effect is unknown and thus is merely speculative. The argument that providing financial incentives impeded implementation or delivery of the kits from women to male partners is interesting. First, our pilot trial that preceded the current trial showed no difference in male-partner testing even when incentives of varying amounts and nature (eg, lottery or fixed amount) were offered.2Choko AT Corbett EL Stallard N et al.HIV self-testing alone or with additional interventions, including financial incentives, and linkage to care or prevention among male partners of antenatal care clinic attendees in Malawi: an adaptive multi-arm, multi-stage cluster randomised trial.PLoS Med. 2019; 16e1002719Crossref PubMed Scopus (64) Google Scholar More importantly, it is worth noting that the incentive was intended to increase clinical attendance, not self-testing.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 Indeed, women expressed concern in our qualitative study regarding potential misuse and abuse of the incentive by the male partners,3Choko AT Kumwenda MK Johnson CC et al.Acceptability of woman-delivered HIV self-testing to the male partner, and additional interventions: a qualitative study of antenatal care participants in Malawi.J Int AIDS Soc. 2017; 2021610Crossref PubMed Scopus (56) Google Scholar although the findings did not indicate whether such misuse would lead to lower male-partner testing. Therefore, we feel that an entirely new study, perhaps a qualitative one that focuses on the questions around the role of financial incentives in HIV self-testing that could be embedded in a trial implementing a similar strategy, might unpick the subtle explanations beyond what we have posited and what Ni and colleagues are suggesting. In fact, this issue, in our view, will not be addressed by the analysis that Ni and colleagues suggest because it is observed in both the antenatal care and the index cohorts. The suggestion of using digital tools is very interesting but simply not feasible in extremely resource-poor settings, such as the one where the study was done, in rural and periurban southern and eastern Malawi. More than 50% of the general population does not have a working smart phone. Therefore, although the addition of digital tools is possible in other settings, it remains a challenge in sub-Saharan Africa and other parts of low-income and middle-income countries. We declare no competing interests. Financial incentives can improve secondary distribution of HIV self-testsIn The Lancet Global Health, Augustine T Choko and colleagues1 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. 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