• 1.

    UNAIDS , 2014. Fast-track Ending the AIDS Epidemic by 2030. Available at: https://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf. Accessed October 3, 2021.

  • 2.

    U.S. Department of Heatlh and Human Services , 2021. Ending the HIV Epidemic: About Ending the HIV Epidemic: Plan for America: Overview. Available at: https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview. Accessed October 3, 2021.

    • Crossref
    • Export Citation
  • 3.

     Ministerio de Salud Pública del Ecuador, n.d. Estrategia Nacional de Salud Pública para VIH/SIDA-ITS. Available at: https://www.salud.gob.ec/programa-nacional-de-prevencion-y-control-de-vihsida-its/. Accessed October 3, 2021.

    • Crossref
    • Export Citation
  • 4.

    Ministerio de Salud Pública del Ecuador , 2012 . Guía de Prevención y Control de la Transmisión Materno Infantil del VIH y Sífilis Congénita, y de Atención Integral de Niños/as con VIH/Sida. Available at: https://tinyurl.com/75uzzsfp. Accessed October 3, 2021.

    • PubMed
    • Export Citation
  • 5.

    Sanchez-Gomez A et al.2014. HIV and syphilis infection in pregnant women in Ecuador: prevalence and characteristics of antenatal care. Sex Transm Infect 90: 7075.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Deblonde J, De Koker P, Hamers FF, Fontaine J, Luchters S, Temmerman M , 2010. Barriers to HIV testing in Europe: a systematic review. Eur J Public Health 20: 422432.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Atnafu Gebeyehu N, Yeshambel Wassie A, Abebe Gelaw K , 2019. Acceptance of HIV testing and associated factors among pregnant women attending antenatal care in Gunino Health Center, southern Ethiopia 2019: an institutional based cross-sectional study. HIV AIDS (Auckl) 11: 333341.

    • Search Google Scholar
    • Export Citation
  • 8.

    Pignatelli S et al.2006. Factors predicting uptake of voluntary counselling and testing in a real-life setting in a mother-and-child center in Ouagadougou, Burkina Faso. Trop Med Int Health 11: 350357.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Hlongwa M, Mashamba-Thompson T, Makhunga S, Hlongwana K , 2020. Barriers to HIV testing uptake among men in sub-Saharan Africa: a scoping review. Afr J AIDS Res 19: 1323.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Centers for Disease Control and Prevention , 2020. HIV Testing. Available at: https://www.cdc.gov/hiv/testing/index.html. Accessed October 3, 2021.

    • Crossref
    • Export Citation
  • 11.

    Goldberg J, Macis M, Chintagunta P , 2018. Incentivized Peer Referrals for Tuberculosis Screening: Evidence from India. Cambridge, MA: The National Bureau of Economic Research.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Iajya V, Lacetera N, Macis M, Slonim R , 2013. The effects of information, social and financial incentives on voluntary undirected blood donations: evidence from a field experiment in Argentina. Soc Sci Med 98: 214223.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Grieco D, Lacetera N, Macis M, Di Martino D , 2018. Motivating cord blood donation with information and behavioral nudges. Sci Rep 8: 252.

  • 14.

    Macis M, Grunauer M, Gutierrez E, Izurieta R, Phan P, Reina Ortiz M, Rosas C, Teran E , 2021. Using incentives and nudging to improve non-targeted HIV testing in Ecuador: a randomized trial. AIDS Behav 25: 25422550.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Ministerio de Salud Pública del Ecuador , 2017. Informe GAM Ecuador—Monitoreo Global del Sida 2017 | Ecuador 2017 UNAIDS UNGASS Progress Report. Available at: https://tinyurl.com/yw95j2jr. Accessed October 3, 2021.

  • 16.

    Hernandez I et al.2017. Risk factors associated with HIV among men who have sex with men (MSM) in Ecuador. Am J Men Health 11: 13311341.

  • 17.

    Hernandez I et al.2019. Risk factors for HIV and STI among female sex workers in a high HIV prevalent region of Ecuador. Cogent Med 6: 1565292.

    • Search Google Scholar
    • Export Citation
  • 18.

    World Bank , 2021. PPP Conversion Factor, GDP (LCU per international $)—Ecuador. Available at: https://data.worldbank.org/indicator/PA.NUS.PPP?locations=EC. Accessed September 20, 2021.

  • 19.

    The Joint United Nations Programme on HIV/AIDS , 2019. Country Factsheets. Ecuador |2019. Available at: https://www.unaids.org/en/regionscountries/countries/ecuador. Accessed May 10, 2021.

    • Crossref
    • Export Citation
  • 20.

    Calle Roldán J, Acuña C, Ríos P , 2017. Meìtodo de buìsqueda activa comunitaria para la captacioìn de gestantes y pueìrperas en Ecuador. Rev Panam Salud Publica 41: 16.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21.

    Ministerio de Salud Pública del Ecuador , 2018. Boletín Anual VIH/sida y Expuestos Perinatales 2018. Available at: https://tinyurl.com/w76h6bck. Accessed October 3, 2021.

    • Crossref
    • Export Citation
  • 22.

    Ministerio de Salud Pública del Ecuador , 2019. Boletín Anual VIH/sida y Expuestos Perinatales2019. Available at: https://tinyurl.com/4r25xs4t. Accessed October 3, 2021.

    • Crossref
    • Export Citation
  • 23.

    López-Cevallos D, Chi C, Ortega F , 2014. Consideraciones para la transformación del sistema de salud del Ecuador desde una perspectiva de equidad. Rev Salud Publica (Bogota) 16: 346359.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Quizhpe E, Sebastian MS, Teran E, Pulkki-Brannstrom AM , 2020. Socio-economic inequalities in women’s access to health care: has Ecuadorian health reform been successful? Int J Equity Health 19: 178.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25.

    Lopez-Cevallos D, Chi C , 2012. Inequity in health care utilization in Ecuador: an analysis of current issues and potential solutions. Int J Equity Health 11: A6A6.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Granda ML, Jimenez WG , 2019. The evolution of socio-economic health inequalities in Ecuador during a public health system reform (2006–2014). Int J Equity Health 18: 31.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    OPS , 2013. La salud de los Pueblos Indiìgenas y Afrodescendientes en Ameìrica Latina. Boletín Estadístico. Available at: https://tinyurl.com/4mt6w2we. Accessed October 3, 2021.

    • Crossref
    • PubMed
    • Export Citation
  • 28.

    Linnemayr S, Stecher C, Saya U, MacCarthy S, Wagner Z, Jennings L, Mukasa B , 2020. Behavioral Economics Incentives to Support HIV Treatment Adherence (BEST): protocol for a randomized controlled trial in Uganda. Trials 21: 9.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Liu JX, Shen J, Wilson N, Janumpalli S, Stadler P, Padian N , 2019. Conditional cash transfers to prevent mother-to-child transmission in low facility-delivery settings: evidence from a randomised controlled trial in Nigeria. BMC Pregnancy Childbirth 19: 32.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Galarraga O, Sosa-Rubi SG , 2019. Conditional economic incentives to improve HIV prevention and treatment in low-income and middle-income countries. Lancet HIV 6: e705e714.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Njuguna IN et al.2021. Financial incentives to increase pediatric HIV testing: a randomized trial. AIDS 35: 125130.

  • 32.

    Ndyabakira A et al.2019. Leveraging incentives to increase HIV testing uptake among men: qualitative insights from rural Uganda. BMC Public Health 19: 1763.

  • 33.

    Choko AT et al.2019. 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 16: e1002719.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Thomas R et al.2020. Improving risk perception and uptake of voluntary medical male circumcision with peer-education sessions and incentives, in Manicaland, east Zimbabwe: study protocol for a pilot randomised trial. Trials 21: 108.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Chamie G, Ndyabakira A, Marson KG, Emperador DM, Kamya MR, Havlir DV, Kwarisiima D, Thirumurthy H , 2020. A pilot randomized trial of incentive strategies to promote HIV retesting in rural Uganda. PLoS One 15: e0233600.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36.

    Wagner Z, Montoy JCC, Drabo EF, Dow WH , 2020. Incentives versus defaults: cost-effectiveness of behavioral approaches for HIV screening. AIDS Behav 24: 379386.

  • 37.

    Atkins D et al.2020. Use of the Consolidated Framework for Implementation Research (CFIR) to characterize healthcare workers’ perspectives on financial incentives to increase pediatric HIV testing. J Acquir Immune Defic Syndr.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Brittain K, Mellins CA, Remien RH, Phillips T, Zerbe A, Abrams EJ, Myer L , 2019. HIV-status disclosure and depression in the context of unintended pregnancy among South African women. Glob Public Health 14: 10871097.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Watt MH, Knippler ET, Knettel BA, Sikkema KJ, Ciya N, Myer L, Joska JA , 2018. HIV disclosure among pregnant women initiating ART in Cape Town, South Africa: qualitative perspectives during the pregnancy and postpartum periods. AIDS Behav 22: 39453956.

    • Search Google Scholar
    • Export Citation
  • 40.

    Bulterys MA et al.2021. Correlates of HIV status nondisclosure by pregnant women living with HIV to their male partners in Uganda: a cross-sectional study. J Acquir Immune Defic Syndr 86: 389395.

    • Search Google Scholar
    • Export Citation
  • 41.

    Duff P et al.2018. Realizing women living with HIV’s reproductive rights in the era of ART: the negative impact of non-consensual HIV disclosure on pregnancy decisions amongst women living with HIV in a Canadian setting. AIDS Behav 22: 29062915.

    • Search Google Scholar
    • Export Citation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 

 

Financial Incentives, Not Behavioral Nudges, Led to Optimized HIV Testing among Pregnant Women in a High-Burden Urban Population in Ecuador

View More View Less
  • 1 College of Public Health, University of South Florida, Tampa, Florida;
  • | 2 Escuela de Medicina, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador;
  • | 3 Laboratorio Clínico Microlab Diagnostic, Esmeraldas, Ecuador;
  • | 4 Johns Hopkins Carey Business School, Baltimore, Maryland;
  • | 5 National Bureau of Economic Research, Cambridge, Maryland;
  • | 6 Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland
Restricted access

ABSTRACT.

Behavioral economic principles are increasingly being used in the fight against HIV, including improving voluntary testing in sub-Saharan Africa and South America. However, behavioral nudges have not been widely tested as a strategy to optimize HIV testing in pregnant women. Here, we assessed whether behavioral nudges or financial incentives were effective in optimizing HIV testing among pregnant women in a high-HIV burden setting. A randomized clinical trial was conducted between May 21 and Oct 5, 2018, to allocate pregnant women in Ecuador into three study arms: information only, soft commitment (i.e., a behavioral nudge), and financial incentives. All participants received an informational flyer, including the address of a testing location. Participants in the soft-commitment arm signed and kept a form on which they committed to get tested for HIV. Those in the financial incentive arm received a $10 incentive when tested for HIV. A stepwise logistic regression analysis estimated the effect of the study arms on HIV testing rate. Participants in the financial-incentive arm had higher odds of getting an HIV test (adjusted odds ratio 17.06, P < 0.001) as compared with information-only participants. Soft-commitment had the opposite effect (adjusted odds ratio 0.14, P = 0.014). Financial incentives might be useful in improving HIV testing among pregnant women, especially among those who might be at higher risk but who have not completed an HIV test.

    • Supplemental Materials (PDF 166 KB)

Author Notes

Address correspondence to Miguel Reina Ortiz, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL 33647. E-mail: miguelreina@usf.edu

Financial support: This research was supported by the Creative and Novel Ideas in HIV Research (CNIHR) Program through a supplement to the University of Alabama at Birmingham (UAB) Center For AIDS Research funding (P30 AI027767). This funding was made possible by collaborative efforts of the Office of AIDS Research, the National Institute of Allergy and Infectious Diseases, and the International AIDS Society.

Authors’ addresses: Miguel Reina Ortiz and Ricardo Izurieta, College of Public Health, University of South Florida, Tampa, FL, E-mails: miguelreina@usf.edu and ricardoi@usf.edu. Michelle Grunauer and Carlos Rosas, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador, E-mails: mgrunauer@usfq.edu.ec and rcrvaxel@hotmail.com. Erika Gutierrez, Laboratorio Clínico Microlab Diagnostic, Esmeraldas, Ecuador, E-mail: microlab_diagnostic@hotmail.com. Mario Macis and Phillip Phan, Johns Hopkins Carey Business School, Baltimore, MD, E-mails: mmacis@jhu.edu and pphan@jhu.edu. Enrique Teran, Escuela de Medicina, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador, E-mail: eteran@usfq.edu.ec.

Save