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

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  • 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 Diagnostics, 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

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.

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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 Diagnostics, 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.

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