Results of a cluster-randomised trial of non-financial incentives to increase uptake of couples counselling and testing Dr Euphemia L Sibanda 21 ST International AIDS conference Durban, South Africa PACTR

Collaborative study Bautista, Sergio Copas, Andrew Cowan, Frances Gudukeya, Stephano Hatzold, Karin Mavedzenge, Sue McCoy, Sandi Mufuka, Juliet Padian, Nancy Sibanda, Euphemia Thirumurthy, Harsha Tumushime, Mary

Importance of CHTC CHTC is associated with – Better uptake of PMTCT 1,2 – Improved retention 1,3 – Reduction in sexual risk taking Cost effective, $16.6 per DALY averted 4 Highly effective ARV interventions for discordant couples underscore importance of CHTC WHO CHTC guidelines, Farquhar, J Acquir Immune Defic Syndr Becker, AIDS Behav, Conkling, J Int AIDS Soc, John, Int J STD AIDS 2008

Sub-optimal uptake of CHTC Uptake is less than 20% in most settings – 6-7% in Zimbabwe rural outreach Barriers include – Fear of consequences of HIV diagnosis – Fear of discussing CHTC – Present-biased preferences

Incentives may improve CHTC uptake Provide a reason to initiate discussion on CHTC Offer an ‘immediate’ perceived benefit What incentives may work? – Nature – Size

1 Formative Research Qualitative study to explore nature and size of incentives 2 Cluster randomised trial Randomisation, stratified by district and proximity to clinic (n=68) No incentiveIncentive Outcomes based on program data Proportion testing with a partner, per arm Prevalence of social harms 3 Telephone survey to determine % social harms among couples Study design

Focus group discussion methods 4 mixed gender FGDs held (n=34) Used vignettes to promote discussion about attitudes and views on CHTC Each ‘couple’ acted out a scene where one was convincing their partner to test together All FGDs were audio recorded, transcribed verbatim and translated and coded using framework analysis

Nature and size of incentives Household items – food, bath and laundry soap – Even small incentives will work The thing is, people like things that are given for free, even if a (sewing) needle were offered one would want it 49-year old married man Ah! money is a problem, we can actually cause divorces! Money causes too much talk, just giving them (non- monetary) gifts is better 45-year old married man, peasant farmer 25-year old single man, unemployed

Incentives offered Each person testing with a partner could choose one: Each valued at ~ US$ ml of cooking oil 200g petroleum jelly One bar laundry soap

The intervention Conducted in rural communities in four districts where PSI provide outreach HTC Community mobilisation prior to outreach – Control arm: Standard mobilisation – Intervention arm: Standard mobilisation + mention of incentives Outreach team went round communities offering HTC, with electronic data capture

Data analysis for trial Effects of incentives estimated using logistic regression – Adjustment for district & proximity to clinic - fixed effects – Adjustment for community/cluster - random effects Further adjustment planned for individual factors considered a priori to be important Factors combined so as to avoid collinearity and small cells

Telephone survey Conducted among couples who tested in 8 pragmatically selected clusters (4 in each arm) Three months after testing – Motivators for CHTC – Whether testing was forced – Whether harm ensued after CHTC

All communities N=68 Comparison n=34 Incentives n= outreach team-days n=10,932 (58 people tested/day) Available records n=10,580 (96.8%) Available records n=14,099 (94.7%) 212 outreach team-days n=14,885 (70 people tested/day) May 2015 – January 2016

Characteristics of people undergoing HTC Control (N=10,580) % Incentives (N=14,099) % Male4645 Age< Secondary/higher education7265 Married/cohabiting6280 Planning to have children2430 Partner/self current breastfeeding partners in the last year64 No condom at last sex7886 Current STI0.3 Previous HIV test6163 HIV+ result of current HIV test6.58.8

Effect of incentives on CHTC 1062 (10.0%) tested with partner in control arm 7852 (55.7%) tested with partner in incentives arm OR 12.7 (9.69 – 16.7) AOR 13.5 (10.5 – 17.4)

Effect of incentives among married/cohabiting testers 1025 (15.6%) tested with partner among those married/cohabiting in control arm 7540 (68.2%) tested with partner among those married/cohabiting in incentive arm OR 13.7 ( )

Association between CHTC and HIV Study armHIV+ Individual testers, n (%) HIV+ Couple testers, n (%) p-value (couple vs individual) Control593 (6.3)83 (7.9)0.07 Incentives449 (7.3%)757 (10.0)< (6.7%) control arm couples had discordant results 295 (7.9%) intervention arm couples had discordant results p=0.25

Telephone survey 427 couple-testers completed telephone interview – Response rate 61.3% 363 (85%) were in incentives arm Motivators to CHTC – no differences between arms – 396 (93%) reported desire to know each other’s status – 149 (41% in intervention arm) motivated by incentives – 30% planning a pregnancy – 21% retesting at end of window period – 22% confirmed/suspected unfaithfulness – “Other” – 3 participants (intervention arm) took the opportunity to disclose to partner

Social harms 6 & 5 participants “pressured”/were “pressured” by partner – 6 and 4 from incentive arm respectively Relationship unrest was reported by 8 (1.9%) – 6 in incentives arm – All 8 were due to HIV diagnosis of one or both None said it was due to incentives One reported physical violence 3 separations/divorce 9 (2.1%) regretted having tested with partner – 5 in the incentive arm

Discussion Incentives are effective in increasing CHTC – Potentially scalable given low cost Main motivator for testing is desire to know joint status Incentives to increase the uptake of CHTC are associated with identification of more HIV positives – Cannot rule out testing of known positives other than for disclosure purposes Ongoing cost effectiveness analysis Reported social harms related to CHTC in general – Need to find ways of supporting couples with HIV+ diagnosis

Acknowledgements Ministry of Health & Child Care District and community leadership Study participants