HIV Infections Clinical Trial
Official title:
The Lotto to Link Study: A Prospective, Interventional, Randomized Study of Conditional Incentives to Engage HIV-positive Men in HIV Care in KwaZulu-Natal, South Africa
In this study the investigators will adapt and strengthen, test effectiveness, and explore implementation of conditional lottery incentive linkage strategies to engage men in HIV care and ART in KwaZulu-Natal, South Africa.
Of the 2.6 million South Africans on antiretroviral therapy (ART)1 only a third are men,
despite men making up 45% of HIV-positive persons.2 HIV-positive men are underrepresented
throughout the HIV prevention and care continuum, being less likely to test, link to care,
initiate ART, and more likely to be lost to follow-up. Few strategies have focused on men,
and when they have they have not been successful. Even with community-based HIV testing,
referral, text message reminders, and lay-counselor support (an optimized testing and linkage
to care package), doctors are only able to achieve 60% linkage to HIV care and ART among men.
HIV-positive men who are not in care are at risk for HIV-associated morbidity and mortality,
and their HIV-negative partners are at risk of HIV acquisition. Innovative strategies are
needed to motivate HIV-positive men to engage in care, and specifically to initiate and
adhere to ART.
Introducing a gamble, the chance of winning a lottery, into linkage to HIV care interventions
could make engagement in care more attractive to men. Men are often risk-takers and linking
to care successfully is a gamble: start ART vs. risk no ART. A lottery incentive strategy has
been successfully used to increase uptake of HIV prevention; in one recent example, lottery
incentives, conditioned on being STI (sexually transmitted infection) negative, decreased HIV
incidence by 60% among 'risk-loving' individuals in Lesotho, demonstrating one of the largest
effects to date of a behavioral intervention for HIV prevention. Given this prevention
success, the investigators hypothesize that lottery incentives have the potential to overcome
both structural and behavioral factors for linking HIV positive men to care, addressing
logistical challenges and risk preferences specific to men. For scale-up and implementation,
the investigators need to sculpt the content of lottery incentive strategies as well as the
approach to identify men not in care for whom lottery incentives are likely to work.
In this study the investigators will adapt and strengthen, test effectiveness, and explore
implementation of conditional lottery incentive linkage strategies to engage men in HIV care
and ART in KwaZulu-Natal, South Africa (the Lotto to Link Study). With the investigators
experienced, multi-disciplinary team, the investigators have drawn on their previous
successful community-based counseling and testing and linkage to prevention and care work to
strengthen linkage strategies for HIV-positive ART eligible men who are not in care.
The investigators will do 1) qualitative interviews to inform the study design, 2) conduct an
individual randomized study of conditional lottery incentives compared to an optimized
linkage package for HIV-positive men, and 3) finally, estimate the costs associated with
conditional incentives and retention in care.
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