Using financial incentives to increase HIV testing uptake and reduce risk behaviour in men

Project report
Using financial incentives to increase
testing uptake and reduce risk
behaviour in men
Masters in Public Health – Health System Management
Candidate number: T6423
Jennie van de Weerd
Submitted: 30 September 2010
Word count: 6963

LSHTM: MPH –HSM: T6423
i
Abstract
Introduction
Treatment will not stop the HIV epidemic in South Africa, but needs to be combined
with cost-effective approaches to prevention for those hardest to reach. This
research explores whether paying incentives could increase uptake of HIV-testing
and behaviour change for daily labourers living in informal settlements in Cape
Town.
Method
A literature review brought together 128 articles about behaviour change theories
and economics, HIV-testing uptake, examples incentive paying schemes and ethics
involved in paying incentives to patients. A calculation model looked at CE for
incentive provision per HIA and potential cost saving per HIA.
Results
The IBM-model and behavioural economics provide concepts to explain why paying
an incentive is effective. Motivation seems the most important factor to explain
testing enrolment. Stigma and risk perception need addressing by provision of
information and skills. Although incentive provision for simple tasks has shown
results, limited evidence exists to support incentive payment for complex behaviour
change. Careful balancing of the 7 elements of contingency management and the
combination of incentive provision with behavioural interventions is called for while
autonomy of the client should be considered. The extra cost of incentive provision
can be justified by the potential cost savings in treatment.

Using financial incentive to increase testing uptake and reduce risk behaviour in men
ii
Discussion
The case for incentive provision for uptake of HIV-testing is clear, but not for
behaviour change. The contingent link between sexual behaviour and HIV at
individual level is weak. Incentive provision should therefore be combined with
behavioural interventions and alternative reinforcements. The potential cost-
effectiveness of incentive provision warrants further research.

iii
Foreword
Today, I can only be happy to zip this document and upload it to the London School
Website over the remains of my crashed laptop, using a laptop gracefully provided
by the ICT department of my employer. My husband and children will be equally
happy, since it will mean that I can participate again in our family life. And, it is high
time to rediscover my friends and colleagues. All in all, writing this report was a
heavy but interesting journey which made me grow.
Charles Maisel of Indlu Yegazi and Nienke van Schaik en Linda Gail-Bekker of
Desmond Tutu HIV Foundation (Tutu tester) triggered me to start this journey. I want
to thank them for their support and wish them success in their on-going work. I would
like to thank Piya Hanvoravongchai, my supervisor, and the PH project support team
of LSHTM for pointing me in the right direction when I almost lost the way.
Last but not least, I would like to thank the authors that sent their articles when
requested and Nadine Pakker who made it possible to gather most of my data.

iv
Table of contents
Abstract ...................................................................................... i
Foreword....................................................................................iii
List of tables and figures ..............................................................vi
Tables in Annex...........................................................................vi
List of Abbreviations ...................................................................vii
List of Abbreviations ...................................................................vii
1. Introduction ....................................................... 1
1.1. Background .......................................................................1
1.2. Incentivized testing: DTHF Tutu tester and Indlu Yegazi ..........3
1.3. Report lay out ....................................................................5
2. Methodology ....................................................... 6
2.1. Aim and objectives .............................................................6
2.2. Literature review ................................................................6
2.3. Potential Cost effectiveness................................................ 10
2.4. Ethical considerations........................................................ 13
3. Results................................................................. 14
3.1. Behaviour change Theories ................................................ 14
3.1.1. The IMB-model ........................................................... 14
3.1.2. Behavioural economics ................................................ 15
3.1.3. Motivation as entry point ............................................. 16
3.2. HIV-testing uptake determinants ........................................ 18
3.2.1. Costs and access to HIV-testing .................................... 18
3.2.2. Stigma....................................................................... 18
3.2.3. Risk perception ........................................................... 19
3.2.4. Motivation to test........................................................ 19
3.3. Lessons from incentivized schemes..................................... 20
3.3.1. Overview included studies and reviews .......................... 20
3.3.2. Target behaviour......................................................... 20
3.3.3. Target population........................................................ 22
3.3.4. Incentive ................................................................... 23
3.3.5. Incentive size ............................................................. 24
3.3.6. Incentive-provision: frequency and timing...................... 25
3.3.7. Incentive duration....................................................... 26
3.4. Ethical considerations........................................................ 27
4. Costing model results ....................................... 28
4.1. Number of men tested and HIV-infections averted ................ 28
4.2. Cost of incentive provision ................................................. 29
4.3. Potential cost saving ......................................................... 30
4.4. One-way sensitivity analysis .............................................. 30

v
5. Discussion ........................................................ 32
5.1. Limitations....................................................................... 32
5.2. Theories .......................................................................... 33
5.3. Screening uptake.............................................................. 34
5.4. Incentivized schemes: Lessons learned ............................... 34
5.5. Ethics.............................................................................. 36
5.6. Cost effectiveness............................................................. 37
5.7. Conclusions...................................................................... 38
Literature....................................................................I
Annex 1: The TUTU TESTER......................................................... IX
Annex 2: Client risk assessment form ............................................ X
Annex 3: Calculation of odds ratio ...............................................XII
Annex 4: List of excluded articles ................................................ XV
Annex 5: Explanation of parameters used.................................... XIX
Annex 6: CRE form .................................................................. XXV
Annex 7: Confidentiality agreement ........................................ XXXVI
Annex 8: Health behaviour theories ....................................... XXXVII
Annex 9: Overview of studies............................................... XXXVIII
Annex 10: Ethical issues around payment of incentive..................XLIX
Annex 11: Calculation results number of testers and HIA................. LI
Annex 12: Calculation results additional cost of incentive ................LV
Annex 13: Calculation results potential cost savings ..................... LIX
Annex 14: Calculation results one-way sensitivity analysis........... LXIII
Annex 15: Calculation results HIV-testing cost per DALY ............ LXVII

vi
List of tables and figures
Table 1: M&E data DTHF for Tutu tester 2009..............................................4
Table 2: Combination of search terms........................................................8
Table 3: Type of documents included ........................................................9
Table 4: Parameter values used in model ................................................. 12
Figure 1: No of AIDS deaths under 4 scenario's South Africa, ...........................2
Figure 2: Markov model MSR................................................................ 11
Figure 3: Fisher's IMB model (Fisher, 2005) .............................................. 15
Figure 4: Number of testers, HIA and HIV+ ............................................... 28
Figure 5: Cost incentive provision / HIA.................................................... 29
Figure 6: One-way sensitivity averaged over 2 years.................................... 31
Tables in Annex
A-Table 1: Odds ratio using 2009 M&E data DTHF ..................................... XII
A-Table 2: Odds of men compared to women .......................................... XIII
A-Table 3: Odds MSR compared to other men ......................................... XIII
A-Table 4: Odds MSR compared to women............................................. XIII
A-Table 5: Odds MSR compared to all others ...........................................XIV
A-Table 6: First time testers compared to others ........................................XIV

vii
List of Abbreviations
AIDS - Acquired Immuno Deficiency Syndrome
ART - Anti Retroviral Therapy
ARV - Anti Retro Viral
BMI - Body Mass Index
BMJ - British Medical Journal
CCT - Conditional Cash Transfer
CE - Cost Effectiveness
CE - Cost Effectiveness
CI - Confidence Interval
CINAHL - Cumulative Index to nursing and allied health literature
CM - Contingency Management
CPI - Consumer Price Index
CRE - Combined Risk Assessment and Ethics form
DALY - Disability Adjusted Life Years
DTHF - Desmond Tutu HIV Foundation
GDP - Gross Domestic Product
HARP - Highly Active Retroviral Prevention
HIA - HIV-infection Averted
HIV - Human Immunodeficiency Virus
IDU - Intravenous Drug Users
IMB - Information, motivation, behaviour model
IY - Indlu Yegazi
KIU - Keep It Up
LDL-C - Low-density lipoprotein-cholesterol
LSHTM - London School of Hygiene and Tropical Medicine
M&E - Monitoring and Evaluation
MARP - Most At Risk Population
MCH - Mother and Child Health
MSR - Men on the Side of the Road
na - Not applicable
NDOH - National Department of Health (South Africa)
NICE - National Institute of Clinical Excellence (UK)
OR - Odds Ratio
PIT - Provider Initiated Testing
PMTCT - Prevention of Mother to Child Transmission
PPD - Purified Protein Derivate
RCT - Randomized Controlled Trial
RSA - Republic of South Africa
SASA - South African Statistical Agency
STD / STI - Sexual Transmitted Disease / Infection
TB - Tuberculosis
UNAIDS - Joint United Nations Program on HIV/AIDS
UNICEF - United Nations Childrens’ Fund
US - United States
VBRT - Voucher Based Reinforcement Therapy
VCT - Voluntary Counselling and Testing
WHO - World Health Organization
ZAR - South African Rand

1
1. Introduction
1.1. Background
A South African survey found that 73.3% of women and 66.1% of men had tested for
HIV in Western Cape (Shisana et al., 2009)1
compared to the universal access target
of 75% by 20102
. Tests during the survey showed an HIV-prevalence of 12.8% in
first-time testers and 16.3% for others (Peltzer et al., 2009). STIs accounted for more
than 26% of all deaths and over 5 million DALYs in 2000 in South Africa and over
98% of this burden was due to HIV/AIDS (Johnson et al., 2007). African males (25-
49) have been identified as a country-specific most at risk group (MARP) with
prevalence levels of 23.7%. Comprehensive knowledge of HIV/AIDS declined from
40.6% to 28%3
in this group (Shisana et al., 2009) while access to and utilization of
HIV-services is significantly lower (NDOH, 2008).
The need to seriously expand testing coverage is well acknowledged in the
“Universal Access-campaign” (UNAIDS and WHO, 2004). But reaching the next
client will be increasingly expensive as more effort is needed to convince him (Glick,
2005; Marseille et al., 2007). Over the last years, with treatment becoming more and
more available, different delivery models of HIV-testing are introduced to increase
uptake (Western Cape Province, 2009).
1
South Africa overall data of 2008 indicate that only 43% of men and 56.7% of women ever received
an HIV test and test results (UNAIDS et al., 2009). Cape Town is in Western Cape Province.
2
Accessed from www.unaidsrstesa.org on 18 June 2010.
3
Comparing 2008 with 2005 data.

2
Cost-effective prevention efforts are needed, because for every two persons put on
treatment another five get infected (Global HIV prevention working group, 2010).
Figure 1 shows four scenarios for South Africa indicating that only a combination of
treatment and prevention can reduce HIV deaths in the country (Johnson et al.,
2007).
Figure 1: No of AIDS deaths under 4 scenario's South Africa,
Source Johnson et al., 2007
The importance of HIV-testing as a gateway to treatment and as a secondary
prevention method by inducing behaviour change in those testing HIV positive is
acknowledged (Valdiserri et al., 2003; Glick, 2005; Global HIV Prevention working
group, 2010) and has been shown to be a cost-effective intervention (Galárraga et
al., 2009; Denison et al., 2009).
Evidence of testing as an effective prevention intervention for those testing negative
is inconclusive (Elwy et al, 2002; Hageman et al., 2009). Could this be caused by the
fact that even the newly proposed service-delivery methods are still focussed on
increasing access to testing from a supply side perspective? In “Three letter Plague”
(Steinberg, 2008) the struggle of a young South African black man to decide whether

3
or not to take an HIV-test is narrated. In the end, although being aware of the threat
HIV poses, knowing where to go for a test and the fact that treatment is available,
the main character decides not to take an HIV-test. He is not alone.
1.2. Incentivized testing: DTHF Tutu tester and Indlu Yegazi
In the Cape Town metropolitan area, the Desmond Tutu HIV Foundation reaches out
to hard to reach populations with their Tutu Tester mobile tester (see Annex 1). The
Tutu tester frequents informal settlements. Clients are given a comprehensive health
check, including tests for hypertension, diabetes and obesity. As part of HIV
counselling, clients are helped to complete a risk assessment form and make a plan
to reduce their risk of attracting AIDS (Annex 2). Condom demonstrations are given
and condoms are provided free of charge. DTHF works together with Indlu Yegazi
(IY), a NGO offering HIV-testing to daily labourers4
. They are paid an incentive of
around ZAR 75/- to motivate them to test5
. When testing negative, these men on the
side of the road (MSR) can come back after 6 months to test again6
. It is assumed
that this can provide the men the necessary motivation to stay negative and come
back to test.
Table 1 shows data from Desmond Tutu HIV Foundation Tutu mobile tester (DTHF)
for 2009. While 29% of women tested reported that this is their first test, this is 47%
for men7
.
4
These men stand at the side of the road each day waiting for a prospective employer and are
therefore called Men on the side of the road (MSR).
5
Level of incentive varies depending on the average wage per day paid.
6
Limited demographic information is available on the MSR targeted by IY and limited data is
collected. Most of the men are African and have lower educational levels (unskilled jobs). Men testing
positive are referred to the care and treatment services of DTHF. Indlu Yegazi is contemplating
offering a different incentive for men adhering to care services.
7
While 27% is comparable to the mean of Western Cape, 47% for men is much higher.

4
Table 1: M&E data DTHF for Tutu tester 2009
Female Male No-incentive With incentiveTutu tester
2009 data8
n % n % n % n %
Total 3191 41 4648 59 3001 65 1647 35
First test 925 29 2169 47 1281 43 888 54
HIV positive 207 6 405 9 155 5 250 15
1st
test, HIV+ 75 36 260 12 85 7 175 20
Zooming in on the results of the MSR over 2009, one might conclude that specific
attention for this group is necessary since 54% have not tested before (20% above
the provincial level) and 20% of this group’s first testers is positive. MSR have
significant higher odds of testing for the first time (1.57), testing HIV+ (3.29) and
testing HIV+ for the first time (especially when compared to other men: 3.45). Some
real differences seem to exist between the populations in terms of uptake of HIV-
testing and HIV prevalence. Annex 3 gives an overview of odds ratio calculated for
this group of testers.
Seen these results, it is not surprising that the Western Cape province indicates that
uptake of testing by men has their focus (Western Cape Province, 2009). Since
transmission from male to female is much easier and due to power inequalities it is
men’s behaviour placing women at risk, men are key to controlling the spread of HIV
and STI (Elwy et al., 2002).
8
Derived from monitoring and evaluation data from the DTHF – Tutu tester. This is a mobile testing
unit deployed in Cape Town, South Africa (Nyanga and Masiphumele district). Data reflect 201 days
testing without incentive and 45 times with incentive.

5
1.3. Report lay out
With a big burden of disease caused by unhealthy behaviour9
, incentives directed
towards patients may have a great impact on public health and cost of care (Volpp et
al, 2009; Volpp et al, 2009a). The question is whether providing incentives would
indeed increase testing uptake and behaviour change.
The incentivized testing intervention can be termed a contingency management
approach defined as “the systematic reinforcement of desired behaviour and the
withholding of reinforcement or punishment of undesired behaviour” (Higgins and
Petry, 1999). Conditional Cash Transfers (CCT) are considered to fall in this
definition. Different incentive type interventions exist, though application of these
principles in Africa or on HIV risk-reduction is so far limited (Volmink and Garner,
1997; Haug and Sorensen, 2006). Interventions using material incentives provided to
patients mainly focus on interventions to reduce substance abuse in Europe and
America while Conditional Cash Transfer (CCT) programs have been successful in
Latin America. One proof of concept CCT pilot study is currently underway in
Tanzania assessing effectiveness of the use of incentives for young adults to test
negative for STIs (DeWalque et al., 2010).
This report presents available evidence from interventions aimed at changing
behaviour or increasing service uptake using incentives. Chapter 2 provides the
methodology of the research. In chapter 3, the results from the literature research
are presented followed by the cost modelling in chapter 4. The concluding chapter
discusses the results.
9
Preventable disease estimated at 40% for the US by Volpp et al (2009a). To compare STIs in South
Africa consists of 26% of DALY of which 98% is due to AIDS.

6
2. Methodology
2.1. Aim and objectives
The aim of the research is to explore whether providing incentive based HIV-testing
for men could be an effective10
way of HIV prevention.
Specific objectives of the research are:
1) Conduct a literature review on the use of incentive-based systems to
increase uptake of preventive services and change behaviour with a
focus on HIV-testing.
2) Based on available cost data, assess the potential cost-effectiveness of
incentive provision for HIV-testing and behaviour change in South
Africa.
2.2. Literature review
To address objective 1 “the use of incentive-based systems to increase uptake of
preventive services and change behaviour”, six databases were searched
(Cochrane, Pubmed, Embase, BMJ, Google scholar and CINAHL) to address the
following search questions.
1) Which theories exist to explain the motivation and determinants for men
to take up HIV-testing and change behaviours?
2) What are determinants for HIV-testing uptake in South Africa?
10
Effective is defined as increasing uptake of testing and reducing risky behaviour measured by a
lower incidence of HIV.

7
3) Which examples exist of increases in uptake of services, strengthened
adherence to treatment or changed behaviour due to the use of
material11
incentives?
4) What are the ethics of providing a financial incentive (to a specific
group)?
A number of key terms were identified based on these research questions. Different
spelling options for words were used12
.
Table 2 presents searches using a combination of key terms. Boolean operators
“AND” and “OR” were used to respond to the research questions13
. A total of 2720
articles were found. Articles that focussed on provider-incentives, incentives to
recruit patients in trials or non-material incentives were excluded after reviewing the
summary.
11
Cash or no-cash
12
See example in table 2: behaviour change / behavior change but also men / male
13
Only articles published from 1995 were included. Language was no restriction.

8
Table 2: Combination of search terms
Combination of search terms Cochrane14
Pubmed
15
Embase BMJ GoogleScholar CINAHL Total
Total (T) and Relevant (R) articles T R T R T R T R T R T R T R
[“HIV testing” or “HIV test”] AND incentive 5 1 15 4 6 0 50 7 200
16
1 4 2 280 13
17
Incentive AND [patient OR client] AND [financial OR
material OR economic]
83 20 137 7 29 6 32 5 200
18
7 125 9 606 38
19
Intervention AND promotion AND incentive 29 8 11 4 20 2 162 10 200
20
13 15 3 437 35
21
[HIV or AIDS or STI or STD] AND [intervention or
promotion or prevention or testing] AND [incentive or
cash or reward or payment or gift or remuneration or
compensation or bonus or prize or lottery]
51 8 164 12 194 12 83 3 181
22
4 86 10 759 25
23
[HIV or STD or STI or AIDS ] AND [“Conditional Cash
Transfer” or “Contingency Management”]
13 3 22 10 22 8 1 1 26 5 11 5 95 20
24
Sexual AND “Behaviour change” AND [incentive or
cash or reward or payment or gift or remuneration or
compensation or bonus or prize or lottery]
6 1 32 1 0 0 - 0
-
200 16 7 0 245 18
“risk reduction” AND [male OR men] AND incentive
AND HIV
10 0 84 3 3 1 - 0 200 1 1 1 298 4
25
Total 197 41 465 41 274 29 328 26 1207 47 249 30 2720 118
26
14
Search in fields: title, abstract and key words
15
Search in fields: title and abstract
16
The first 200 of 5670 articles were reviewed by title and abstract
17
2 articles were overlapping across databases
18
The first 200 of a total of 6460 documents were reviewed by title and abstract
19
20
The first 200 of a total 19,400 documents were reviewed by title and abstract
21
5 articles overlapping across databases
22
Search in field: intitle
23
24
25
26
35 articles overlapping across searches

9
Of these 118 articles, 7 could not be retrieved, 7 were already included in a review
which was part of the research and 31 were excluded after full text review. Reasons
are listed in Annex 4. This resulted in a final number of 73 documents.
A further search of article references and websites was conducted to find additional
information on theories underlying the provision of incentives, information on
determinants for HIV-testing uptake in South Africa and the ethics of incentive
provision. This resulted in a final number of 128 articles and books as presented in
table 3.
Table 3: Type of documents included
StudyQuestion
RCT
28
Cohort Cross-
sectional
Review Other
27
Total
1 2 1 1 5 10 19
2 1 14 2 4 21
3 3029
10 2 9 24 75
4 2 4 7 13
Total 32 12 19 20 45 128
27
Other includes books, background articles, reports, editorial notes and letters in journals.
28
Randomized controlled trial
29
2 pilot studies were not randomized, but worked with control group

10
2.3. Potential Cost effectiveness
To respond to objective 2 “assess the potential cost-effectiveness of incentive
provision for HIV-testing and behaviour change in the context of South Africa” a
model was developed to compare the DTHF normal mobile testing intervention
without incentive (control group) with the DTHF/IY incentivized intervention modelled
on the MSR population (intervention group). Calculations were made based on the
full capacity of one mobile testing unit in one year using accounting costs from a
provider perspective thus excluding cost to the tester or society due to the limited
costing data available (UNAIDS, 2000). The two outcomes of interest are the
additional cost of providing an incentive per additional HIV-infection averted (HIA)
and the potential cost saving per HIA30
.
A Markov model was developed to answer the following questions, compared with
the current mobile testing intervention of DTHF:
1. What is the additional cost of providing an incentive per HIA over a five-year
period to a cohort of men?
2. What is the potential cost saving per HIA over a five-year period to a cohort of
men?
3. What is the necessary reduction in the chance of getting infected with HIV
and the necessary time-span to justify the current provision of an incentive31
?
4. How are the outcomes of the calculation model influenced by different values
of the key variables (sensitivity analysis)?
30
Potential cost saving per HIV-infection prevented is the cost of providing an incentive minus the
cost that otherwise would have been paid to treatment.
31
ZAR75 per test, 2 tests a year, n=4416 men

11
The model (see figure 2) describes the chance of a man to become infected in a
given time period (year) based on his initial state. Whether or not the man has tested
before – his ‘history’ – is not considered (Sanderson and Gruen, 2006). Thus it
assumes that chance of getting infected and loss to follow up will stay the same over
time. Except for the incentive and parameter values, the flow of the model will be the
same for the control group.
Figure 2: Markov model MSR
Four positive effects of providing an incentive are assumed by DTHF/IY. First, more
men will be interested to take up testing. This is reflected in the utilization rates (77%
vs. 92%) of the DTHF vs. DTHF/IY intervention32
. Secondly, more men will test
regularly at the recommended intervals. Thus, the percentage of men lost to follow
up (nl) will be lower in the incentivized group and the number of tests (and thus
incentive) performed will be higher in the incentivized group (nt). Third, because of
32
The 2009 M&E data show that on DTHF/IY days, a number close to the full capacity of 40 testers a
day is tested.
Motivated to test
= n
HIV+
HIV-
On ART treatment
Not on ART treatment
Lost to follow up
Men on the side of
the Road (MSR)
Men on the side of
the Road (MSR)
1-nl
p
1-p
nl
t
1-t
nl: % of men lost to follow up
p: chance of becoming infected
?: chance that when HIV+
treatment is initiated immediately
Incentive
I

12
the incentive, men will be motivated to change behaviour thus reducing the chance
(p) to become infected compared to the control group. Furthermore, men will be
diagnosed with HIV earlier on, so the percentage of men needing to go on ART
immediately will be lower (t). Due to the limitations in available data, the model
however assumes that all diagnosed HIV+ will be put on treatment.
The Markov model formed the basis for the development a costing model prepared
in Microsoft Excel 200333
. Cost data were retrieved for the provision of HIV/AIDS
testing, ART treatment and other services in South Africa (Cape Town) in the last 5
years. Parameter values are presented in table 4.
Table 4: Parameter values used in model
Model parameters
34
Current situation (control)
35
Incentive effect
Chance to become infected (p) 0.20 0.15, 0.10, 0.05, 0.00
Incentive value (I) 0 10.22 US$
Number of testers (n) 3696 441636
Number of tests (nt) 2 2
Loss to follow up (nl)
37
0.15 0.00, 0.05, 0.10
Two outcomes of interest were calculated: the incentive cost per HIV+ case directly
prevented and the potential cost saving per HIV-infection directly prevented38
.
Budget data from IY were utilized to calculate the cost of providing an incentive.
33
Attached as separate file to this report.
34
All parameters in the model can be changed.
35
Based on the M&E 2009 data for MSR
36
In 2009, utilisation rate was 77% of full capacity per day (40 testers) without incentive and 92% with
incentive
37
No data could be retrieved from DTHF/IY. Rutledge et al, 2002 found average attrition over 12
sexually transmitted HIV prevention interventions based upon social learning to be 15%. The normal
intervention of DTHF could be considered an intervention like this. The incentive is an added extra.
38
Potential cost saving per HIV-infection prevented is the cost of providing an incentive minus the
total cost that would have been paid to treatment if the infection was not averted.

13
A one-way sensitivity analysis was performed testing the influence of varying the
value of variables n, nl, nt, I and p in the intervention (i) group on the overall outcome
of the intervention. Annex 5 presents underlying assumptions, data sources and
limitations of the parameters used. All costs are standardized to 2009 using the
consumer price indexes of South African Statistical Agency39
. A discounting rate of
3% is used (Mathers et al, 2006). Discounting enables to take into account the fact
that people would like to have benefits now and pay later so cost in the future are
decreased with this percentage (Belli et al., 1998).
2.4. Ethical considerations
Ethics clearance was obtained from LSHTM (reference 009/06). Annex 6 presents
the Approved CRE form. After obtaining the ethical clearance, the scope of the study
was limited. Only M&E data from DTHF Tutu tester were used. Annex 7 presents the
confidentiality agreement signed with the DTHF.
39
http://www,statssa,gov,za/timeseriesdata/excel_format,asp accessed on 7July 2010

14
3. Results
3.1. Behaviour change Theories
3.1.1. The IMB-model
Fisher states that prevention interventions fail because they are not rooted in
theory40
, provide information only – which is not sufficient to change behaviour - and
focus on general patterns of behaviour rather than information, skills and
motivational support specially targeting the group addressed (Fishbein and Guinan,
1996; Rutledge, 2002; Fisher, 2005; Albarracín et al., 2005; Medlin et al., 2008).
According to the Information – Motivation – Behaviour model (IMB), any intervention
aimed at behaviour change should 1) give information which is relevant to the
intended behaviour change and the specific population, 2) also work on social
support systems and motivation of the individual and lastly 3) train skills of the
individual so that he is able to behave in the intended manner41
. The model is simple
and has been validated in various settings (DiClementi et al, 2009; Mimiaga et al.,
2009). A US-RCT found the model to be most effective for men (Kalichman et al.,
2005). Figure 3 presents the model.
40
Annex 8 provides background on three main categories of health behaviour theories.
41
Five skills are identified as necessary for HIV prevention: Self-acceptance of sexuality, acquisition
of behaviourally relevant information, negotiation of preventive behaviour with partner, performance of
public prevention acts and consistent performance of prevention behaviour (Mimiaga et al., 2009).

15
Figure 3: Fisher's IMB model (source Fisher, 2005)42
The model was generalized to the South African context although with special
attention on AIDS related stigma as an important environmental factor which
adversely influences all three elements of the model (Kalichman and Simbayi, 2003;
Kalichman et al., 2006). Effective prevention should also include interventions to
increase service availability, promotion of testing at population level and biomedical
strategies (Coates et al., 2008). Evidence suggests that for the short term, a full IMB
counselling model is most effective for men (Kalichman et al., 2005).
3.1.2. Behavioural economics
Behavioural economics helps to explain why paying an incentive will increase the
motivation for individuals to change behaviour. People prefer to have a reward now
than the ‘may-be’ risk of acquiring HIV in the future (time-preference) (Loewenstein
et al., 2007; Volpp et al., 2009a). By putting a price on staying HIV-, the opportunity
cost of risky sex increases. Neoclassical theory assumes individuals to be rational,
making the choices that maximize utility subject to constraints in time and budget
(Eichler, 2006; Jochelson, 2007; Finkelstein et al., 2008). Preferences – which may
42
Kalichman et al. (2006) uses the terms AIDS knowledge (HIV prevention information), behavioural
intentions (motivation) and self-efficacy (behavioural skills).
HIV Prevention
Information
HIV Prevention
Motivation
HIV Prevention
Behavioral Skills
HIV Preventive
Behavior

16
vary from day to day (Kiene et al., 2008) - also influence the perceived opportunity
costs of engaging in risky sex. When the next opportunity to receive an incentive is
too far off or the incentive is too small, time-preference can actually explain
engagement in risk-sex if the individual wants to maximize his utility (Medlin and
DeWalque, 2008).
3.1.3. Motivation as entry point
The IMB model suggests that for different populations, the trigger for behaviour
change will be different. Paying an incentive assumes that motivation is the entry
point to behaviour change. The incentive can overcome stigma and thus have men
enrol for a test and participate in a risk assessment. The question however, is also
how to change behaviour43
. Paying an incentive increases external motivation. How
long an incentive needs to be paid to internalize motivation? Also, should the
incentive be stable over time, increase or decrease to maintain the level of
motivation.
A reduction in opportunity cost attracts people that are less interested to change
behaviour (Glick, 2005; Cahill and Perera, 2008). Economic theory would suggest
that when an incentive is no longer paid, there is no reason to sustain the behaviour.
The intrinsic motivation for individuals to change behaviour is their aim to maximize
utility which they do when they get the incentive. When the incentive is stopped
behaviour which is maximizing utility – which could be risky sexual behaviour rather
than using condoms – is again adopted (Kane et al., 2004a).
43
The transtheoretical model identifies 5 stages of change: 1) precontemplative (no intention to
change), 2) contemplative stage (considering change), 3) ready for action stage (exploratory attempts
to adopt behaviour), 4) action stage and finally 5) maintenance stage (behaviour has become routine)
(Fishbein and Guinan, 1996).

17
Behavioural learning theory suggests that after several rounds of rewards, the
behaviour is automated so even though payment is stopped, behaviour will be
sustained (Kellog et al., n.d.). Cognitive dissonance theory suggests that even
though initial engagement with the program depends on the payment of the
incentive, communication with the service providers, enhancement of skills and
provision of information can influence motivation so that individuals as social
creatures want to comply with behaviour which is advocated as being good (Corrigan
et al., 2005). Communication theory implies that therapeutic alliance will be built by
regular interaction and this regular reinforcement will in time be sufficient to sustain
the desired behaviour (Kiene et al., 2008).

18
3.2. HIV-testing uptake determinants
3.2.1. Costs and access to HIV-testing
In Western Cape44
, men test significantly less than women (Western Cape Province,
2009). An Eastern Cape study found that every one kilometre a man lives away from
a testing facility, reduces the likelihood that a man will test (Hutchinson and
Mahlalela, 2006). PIT45
might therefore not be the only answer to increase testing
uptake by men. Mobile testing, a strategy suggested to reach Most At Risk
Populations (MARP) brings testing facilities closer to people. Black African Males
between 25 and 49 years are identified as a country specific MARP for South Africa
(Shisana et al., 2009).
Physical access to a testing facility is important, but also the willingness and ability to
absorb the monetary and time-related costs to go for a test. (Weinreb and Stecklov,
2009; Nyanzi-Wakholi et al., 2009; Peltzer et al., 2009; Jepson et al., 2000). A meta-
analysis of HIV risk-reduction interventions in the US found that tangible incentives
had a positive effect on the participation and retention of men in screening programs
(Durantini and Albarracín, 2009).
3.2.2. Stigma
Stigma is another important influence on the decision to go for testing. Men indicated
that they preferred to live in doubt and would only go for VCT when they were sick.
Men do not fear family based stigma so much, but are more scared to loose their
position in the community (Day et al., 2003; Holzemer and Uys, 2004; Nyanzi-
44
Cape Town is located in the Western Cape province of South Africa.
45
Provider initiated testing has been introduced in all public health facilities in the Western Cape.

19
Wakholi et al., 2009). The possibility of testing HIV+ and the stigma attached to this,
thus reduces the acceptability and uptake. Embedding HIV-testing in a more
comprehensive health check could address the issue of stigma and acceptability,
and result in higher uptake (O’Donnell, 2009).
3.2.3. Risk perception
For many people, the motivation to use VCT is low because they do not see
themselves as at risk for HIV/AIDS, even in high-prevalence areas or following high-
risk behaviour (Hutchinson and Mahlalela, 2006; Kalichman et al., 2008; Hageman et
al., 2009; Johnston et al., 2010). But even if they consider themselves at risk, HIV is
only one of the threats they face most of which are considered more pressing and
immediate than HIV/AIDS (Kalichman et al., 2006). In Western Cape, self reported
condom use is very low pointing to high-risk sexual intercourse (Johnson and
Budlender, 2002; Shisana et al., 2009). The DTHF/IY M&E data indicate that MSR
are 2.88 times more likely to test HIV+ while they are much less likely to have tested
before (see Annex 3). Social networks strongly influence the individual’s perceptions
of risk surrounding HIV/AIDS and their preventive behaviours (Hutchinson et al.,
2007).
3.2.4. Motivation to test
With high opportunity costs to go for testing, high levels of stigma and low risk
perception possibly due to incorrect knowledge, motivation to test will be low. Correct
knowledge of HIV transmission – positively associated with being tested for HIV - is
only 43.8% in Black African Male overall and 34.1% in Western Cape (Shisana et al.,
2009). The fact that DTHF provides mobiles HIV-testing embedded in a more
comprehensive health check apparently does not overcome the barriers to test for

20
MSR. The next paragraph explores evidence to assess if, as stated by the men
(Indlu Yegazi, 2009) a financial incentive could increase uptake and change
behaviour.
3.3. Lessons from incentivized schemes
3.3.1. Overview included studies and reviews
Fifty-one articles were included referring to 49 studies: 30 RCTs, 10 cohorts, 2 cross
sectional designs and 9 reviews. Of these 37 were conducted in the US and only 2 in
Africa46
(Malawi and Tanzania). Fifteen studies referred to HIV-related incentive
interventions. Others were related to compliance (5), uptake of preventive health
services (4), smoking cessation (4), substance abuse (4), tuberculosis (6) and weight
loss (4). The 9 reviews referred to 7 studies covering a total of 235. None of the
reviews specifically targeted HIV-related behaviour change. Annex 9 provides
information on the studies. Lessons from the included articles are presented along
the 7 core issues to be considered when looking at or designing a contingency
management program are 1) Targeted behaviour, 2) Choice of target population, 3)
Choice of incentive, 4) Incentive magnitude, 5) Frequency of incentive distribution,
6) Timing of incentive and 7) Duration of the incentive provision (Razavi et al., 2009;
Kellog et al., n.d.).
3.3.2. Target behaviour
Target behaviour is complex or simple (Kane et al., 2004 and 2004a). Simple
behaviours are one-off activities, treatment adherence, return visits to collect results,
attendance at educational activities, completion of a procedure, enrolment. Twenty-
two of the included studies refer to such simple behaviours and show that incentive
46
Malawi and Tanzania.

21
provision results in higher success rates, higher enrolment and attraction of MARP
(Chaisson et al., 1996; Fitzgerald et al., 1999; White et al, 1998; Kelen, 1996; Bloch
et al., 2006; Corrigan et al., 2005; Corrigan and Bogner, 2007; Haukoos et al., 2005).
The more complex and sustained the targeted behavioural outcomes47
, the weaker
the evidence of effectiveness of incentives. After the incentives stop, relapses occur
and differences with the control group diminish or disappear completely (Kane et al.,
2004; Cahill and Perera, 2008; Haug et al, 2006; Brandon et al., 2007; Forde and
Zeuner, 2009; Oliver, 2009; Volpp, 2009; Marteau et al., 2009). Results from CCTs
suggest that the programs increase the use of preventive services and improve
intermediate outcome measures, but long-term effectiveness has not been assessed
(Anderson, 2010; Lagarde et al, 2007; Lagarde et al, 2009; Razavi et al., 2009).
Ten of the 15 HIV-related studies referred to simple behaviour. In the five referring to
complex behaviour, one used self-report of behaviour change to measure behaviour
change (Petry et al., 2010) while it is important that target behaviour can be
measured objectively to avoid bias. Two studies saw risk behaviour change not
related to risky sex but substance abuse48
(Ghitza at al., 2008; Hanson et al., 2008).
The Tanzania-study used STI infection as proxy for HIV-infection since chances to
get infected with HIV are small and distant even when engaging in risky sex (Medlin
and DeWalque, 2008)49
. The Malawi study used pregnancy rates and early marriage
as proxy for risky sexual behaviour (Baird et al, 2009)50
.
47
Smoking cessation, weight loss, substance abuse.
48
Harm reduction measures like bleaching of needles, syringes exchange etc.
49
Risk of HIV transmission in men during penile-vaginal intercourse is 0.01-0.1%. Risk of
transmission will be higher if an STI is present (Baggaley et al., 2008).
50
The main target behaviour of the incentive provision was to increase school attendance and reduce
drop-out for girls. Effect on sexual behaviour and early marriage were a by-product of the increase in
school attendance (both in number of girls and length of attendance).

22
While stimulating demand is important, the capacity of the supply side system to
offer quality services in sufficient quantity also needs to be addressed (Morris et al.,
2004; Lagarde et al., 2007; Medlin and DeWalque, 2008; Adato and Bassett, 2009;
Bassett, 2008; Baird et al., 2009; Lagarde et al., 2009; Schafer, 2010; Banerjee et
al., 2010; Lim et al., 2010)
3.3.3. Target population
Paying an incentive increases the cost of normal treatment, therefore it is suggested
to target for specific populations and behaviour with high public health impact
(Higgins et al., 2002; DeWalque et al., 2010; Lim et al., 2010)51
. The studies show
that paying an incentive is effective in reaching MARP which were targeted in 24 of
the included studies. But the more targeted the intervention and the more
conditioned, the more expensive it becomes administratively. Furthermore, targeting
can induce stigma (Forde and Zeuner, 2009). And the incentive will be paid to
people that already behave as intended (Lagarde et al, 2007; Volpp et al, 2009a). In
12 studies attrition was still high, attributed to the height of the incentive, the physical
distance to the service and/or the quality of service provision (White et al., 1998;
Carey et al., 2005; Gift et al., 2005; Ghitza et al., 2008; Petry et al., 2010). Two
studies found that success rates were higher in men than women (Tulsky et al.,
2000; Chaisson et al., 1996).
51
Populations to be addressed are treatment recalcitrant, hard-to-reach or most at risk populations
(MARP).

23
3.3.4. Incentive
The first question is whether incentive provision is necessary. Since incentive
provision is expensive compared to other interventions, cost-effectiveness might
easier be achieved with another intervention (Chaisson et al., 1996; Villano et al.,
2002; Morris et al., 2004; Petry et al., 2004; Adato and Bassett, 2009; Heil et al.,
2008; Ghitza et al., 2008; Banerjee et al., 2010). This is especially true when looking
from a provider-perspective as potential cost-savings might benefit another budget.
Incentives can be conditional or unconditional. While unconditional cash transfers
have shown to improve health seeking behaviour, it is not likely that people with low
risk perception and high stigma will change HIV-related risk behaviour when no
condition applies to the cash transfer (Stitzer, 2006). Incentives can be positive or
negative. Positive approaches seem to be more effective possibly because it
reinforces individuals’ sense of personal achievement (Jochelson, 2007; Heil et al.,
2008). Positive reinforcement is also more enjoyable for clients and providers (Kellog
et al., n.d.). Incentives can be in-kind, vouchers or cash. In-kind incentives are less
appreciated by clients than the more flexible vouchers or cash and require more time
and effort from the service provider52
. With cash, clients could purchase unintended
items53
and the necessity to keep stocks of cash at the service-delivery point carries
a security risk (DTHF/IY, personal comment; Alfers and Butterfoss, 2000; Kane et
al., 2004 and 2004a; Hanson et al., 2008; Cahill and Perera, 2009).
Flat payments for task completion or regular flat payments were provided in 22
studies. Escalating incentives with a reset value were used in 12. These incentives
grow, the longer you do (not) exhibit the behaviour, the higher your payment
52
Staff need to go buy the items in sufficient quantities. Articles have to be stored somewhere etc.
53
Alcohol, drugs etc.

24
becomes. Once you relapse, payments are reset to the original value (Pilling et al.,
2007; Mayor, 2007; Volpp et al., 2009; Heil et al., 2008; Cahill and Perera, 2008).
Nine researches used a lottery system. Participants can win draws for big prices.
Lottery systems were introduced to enable continuous or escalating reinforcement at
a lesser cost. The incentive provided is the right to take a draw in the lottery with a
chance to win a price varying from 0 to 1. Lottery and escalating incentives are more
effective in longer-term reinforcement (Petry et al., 2004; Cahill and Perera, 2009).
The HIV-interventions saw a mix of flat payments, lottery and escalating incentives.
Interventions that combined incentives with strengthened provider interaction,
support groups, information provision, skills building or other supportive interventions
were more successful to sustain behaviour after incentive provision ceased
(Chaisson et al., 1996; Corrigan and Bogner, 2007; Jochelson, 2007; Finkelstein et
al., 2008; Higgins et al., 2002, Kane et al., 2004a).
3.3.5. Incentive size
The success of the incentives depends on the size of the incentive. Determining the
exact threshold to inducing change is difficult (Lagarde et al, 2007; Volpp et al,
2009a). If the incentive is too high, the target group might not be motivated to
change behaviour but to earn the money (Higgins et al., 2002; Forde and Zeuner,
2009; Volpp et al.,2009; Kane et al, 2004; Volpp et al, 2008; Seaverson et al, 2009).
If the latter, after stopping the incentive, people will fall back in their old behaviour
(Kane et al, 2004; Volpp et al., 2008; Higgins et al, 2002). Lottery-type incentives
included in this study could grow very large. Flat and/or recurrent payments were
more modest ranging from 2 to 30 US$ per event. The HIV study in Tanzania linked

25
the payment of either US$30 or US$60 per year which is 7.5-15% of GDP and 12-
24% of the average annual income of participants54
. As a result, the STI infection
reduced (from 12 to 9%) and only for the higher incentive (Anonymous, 2010).
3.3.6. Incentive-provision: frequency and timing
Incentives should be distributed frequent enough to keep it ever-present in the minds
of the target group but not too frequent in order to contain costs (Medlin and
DeWalque, 2008). The studies included pay incentives for each successful
measurement. Frequency of payment can be daily in case of substance abuse
treatment, weekly, monthly, one-off payment, monthly or every four months. In case
of lotteries, big price draws are sometimes organised for the attainment of a ‘super-
goal’ on top of escalating incentives or regular lotteries. Reinforcement should be
applied as soon as possible following the target behaviour to establish a strong
contingent link (Haug and Sorensen, 2006; Stitzer et al., 2006; Medlin and
DeWalque, 2008). It is therefore necessary to define a target behaviour which is
close to the consequence and objectively quickly and cheaply measurable.
Frequency and timing are strongly linked to the magnitude of the incentive and the
expected behaviour. If the frequency is high and the target behaviour is wanted by
the target group, a lower incentive will suffice (Rigsby et al., 2000; Schroeder et al.,
2006; Volpp et al, 2008; Seaverson et al., 2009). If the target behaviour is wanted for
the public and frequency of reinforcement is lower55
, the incentive should be higher
(Bloch et al., 2006; Volpp et al., 2006; Volpp et al., 2009; Anonymous, 2010).
54
GDP in Tanzania was US$400 and the average annual income earned by participants in this study
was US$250. DTHF/IY pays half a day’s wage (ZAR 75 or US$10.22) to go for HIV-testing.
55
A reduction in sexual behaviour might not be a felt need by the targeted group (as is the case in
MSR). Therefore, more effort is necessary to convince them to change behaviour. If cost of

26
3.3.7. Incentive duration
The studies show that incentives - as extrinsic motivators - are useful to initiate
behaviour change, though sustaining this behaviour after the incentive has stopped
will depend on whether the person is or has become intrinsically motivated and the
norms in his social network (Corrigan et al., 2005; Jochelson, 2007; Sorensen et al.,
2007; Volpp et al., 2008; Hanson et al., 2008; Rigsby et al., 2000; Petry et al., 2010).
Therefore it is necessary to focus on increasing the individual’s perception of skill,
competence and desire to change behaviour (Gaither et al., 2009). Self belief and
confidence to change are critical to sustain behaviour (Forde and Zeuner, 2009).
Of 20 included studies aiming at complex behaviour change, seven provided
incentives for 3 or less months of which six reported no or limited long-term
behaviour change56
. Incentive-provision for three months seems insufficient to
change complex behaviour. What the optimal time of reinforcement will depend on
the combination of all 7 principles of CM (Kellog et al., n.d.).
measurement is high, there is a need to have limited reinforcement moments or to otherwise pay
without measurement in some instances. Another option is to have intermediate steps (proxy
indicators) which are less distant and/or cheaper to measure.
56
No follow up was reported in the last study.

27
3.4. Ethical considerations
All studies retrieved justified paying an incentive from a public health or an economic
efficiency point of view. The economic rational to pay an incentive to go for HIV-
testing can be found in the fact that it creates positive externalities57
that warrant its
subsidy to maximize uptake by the population (Jepson et al, 2000; Childress et al.,
2002; Lagarde et al., 2009). At individual level, the picture is more complicated.
Annex 10 provides an overview of arguments found in the literature.
Looking at the four dimensions of humanity in health58
, the key issue to consider
here is how to ensure autonomy and informed uptake. If the incentive is too high,
MSR will not bother informing themselves about possible consequences. In that
case, to maximize utility, they should test. However, if the incentive is too low or non-
existent, MSR will not test. This can also not be termed as informed or autonomous
decision making seen the low level of correct knowledge and the high levels of
stigma. Thus the height of the incentive and the way the testing is provided will
determine whether autonomy and informed decision making is ensured.
57
Individual can access treatment earlier which leads to better treatment results. Testing positive has
shown to lead to behaviour change and possible reduction in rates of HIV-transmission.
58
Smith et al. (2005) distinguishes autonomy, dignity, beneficence and non-maleficence as the four
elements of humanity in health.

28
4. Costing model results
The costing model was used to make calculations varying the chance to become
infected and loss to follow up as an effect of the incentive over time59
.
4.1. Number of men tested and HIV-infections averted
Since the uptake of testing increases due to the incentive and the loss to follow up is
estimated to be lower in this group, the average number of men that tests per year
will be higher compared to the control group. Because of this, even with lower
prevalence, more HIV-infections can be discovered. HIA can therefore even be
negative as shown in figure 4. Complete calculations for different (discounted) values
of p(i) and nl are included in Annex 11.
-500
0
500
1.000
1.500
2.000
2.500
1 2 3 4 5
Testers p(i)=0,15
Testers p(i)=0,00
HIA with p(i)=0.15
HIA with p(i)=0.00
Extra HIV+ with
p(i)=0.15
Figure 4: Number of testers, HIA and HIV+
59
Control group parameters p(c)=0.20, nl(c)=0.15, n(c)= 3696. Intervention group n(i)=4416. For
explanation of parameters and limitations, see Annex 5.

29
4.2. Cost of incentive provision
Figure 5 shows that costs of incentive per HIA rapidly increases after year 2, more
so for lower loss to follow up and bigger reductions in the chance to get infected
since more testers means more incentive costs.
0
500
1.000
1.500
2.000
2.500
3.000
3.500
4.000
4.500
5.000
1 2 3 4 5
Year
US$
HIA nl(i) = 0.10
p(i)=0.10
HIA nl(i) = 0.10 Disc.
p(i)=0.10
HIA nl(i) = 0.00
p(i)=0.10
HIA nl(i) = 0.00 Disc.
p(i)=0.10
Figure 5: Cost incentive provision / HIA
The average cost of incentive provision per HIA for p(i)=0.15 for different levels of
follow up in the first two years is US$8065. After this cost increases considerably,
since the number of HIA plummet. Average costs of incentive provision vary from
US$346 to US$95660
averaged over 2 years and US$351 to US$ 200961
over 5
years. For all calculations, see annex 12.
60
Nl(i)=0.10 and p(i)=0.00 (lowest) to nl(i)=0.00 and p(i)=0.10 (highest)
61
Nl(i)=0.10 and p(i)=0.00 (lowest) to nl(i)=0.00 and p(i)=0.10 (highest)

30
4.3. Potential cost saving
Potential cost saving was calculated using treatment cost derived from Cape Town
plus the cost of incentive provision. Over time, potential cost saving per HIA slowly
increases. If an incentive is paid for two years, the average potential savings are
negative for p(i)=0.15 regardless which level of loss to follow up is chosen. This is
not the case when calculating average savings over 5 years. Highest average cost
savings per HIA of US$3472 over 2 years are found for p(i)=0.00 and nl(i)=0.00 for
1242 HIA. Over 5 years, the highest cost savings per HIA is US$6515 for p(i)=0.10
and nl(i)=0.00 but with 166 HIA. Annex 13 provides more detail.
4.4. One-way sensitivity analysis
Different levels of loss to follow up and chance to get infected for the intervention
group were presented above. Three other situations are modelled. The first assumes
that for both control and intervention, the number of men tested starts at 4800. The
second foresees an increase of the current incentive to a full-day salary (US$16.32)
to attract all the MSR and encourage follow-up visits even when labour is available
for the day. Lastly, a 6 month interval might be insufficient to reinforce behaviour
change so what happens when 4 tests need to be performed to achieve a chance in
behaviour. Loss to follow up in the intervention group was set at nl(i)=0.10.
Starting with the same number of men in each group leads to a reduction of average
cost of incentive provision per HIA since the total number of testers is higher and
because both groups have the same size now relatively more HIV+ men will be

31
discovered in the control group62
. Testing 4 times a year is only possible when
n=240063
. This results in a significantly higher number of HIA averted compared to
the original situation and thus to a lower cost of incentive provision per HIA. The
reason is however not the more intensive testing, but the fact that less men are
tested in the incentive situation thus less potential HIV+ cases are detected. The cost
of incentive provision per HIA is mostly influenced by variations in the cost of the
incentive itself. Cost presented in figure 6 are averaged over 2 years, cost over 5
years show a similar pattern.
0
200
400
600
800
1000
1200
1400
1600
p(i)=0.10 p(i)=0.05 p(i)=0.00
Different chances of infection
Averagecostofincentiveper
HIAUS$
Base situation
n=4800
Incentive US$16.32
4 tests
Figure 6: One-way sensitivity averaged over 2 years
This analysis shows that the model is responsive for changes in important
parameters and reacts as expected. The potential cost saving per HIA averaged
over 2 years strongly reduces from an average of about US$5.000 across different
values of p(i) to around US$3.000 for all scenarios. Calculation tables can be found
in Annex 14.
62
Model so far assumed differential intake based on the data from DTHF which saw an increased
utilization of the DTHF tester when an incentive is provided.
63
Full capacity of one mobile tester is 9600 tests per year.

32
5. Discussion
5.1. Limitations
This research set out to explore whether providing incentive based HIV-testing for
men could be an effective64
way of HIV prevention. Although a variety of databases
were consulted and considerable time was spent searching literature, it is possible
that relevant publications (especially grey literature) were missed. Publication bias
might have resulted in a too positive impression if failed experiments were not
officially published. Several of the studies published had small numbers of
participants which might have affected the power of the research and thus its
conclusions. Assessing publications for inclusion in the research was done by only
one person which might have caused bias as well. The literature search found a very
limited number of studies referring to incentive provision and focussing on men, on
Africa and on HIV-related risk behaviour, let alone a combination of these three
elements.
The calculations made with the developed model were based on limited data. There
are real opportunities to expand the model by including the costs of mobile test
provision65
, mortality figures for both groups, differential initiation on ART66
, changing
infection risk over time67
, using real life data of a cohort of DTHF men68
and including
64
Effective is defined as increasing uptake of testing and reducing risky behavior measured by a
lower incidence of HIV.
65
When more people test, the unit cost per test decreases due to better capacity utilisation.
66
Now assumed that all testing HIV+ started ART. CD4 count information would be necessary to
include different initiation timing. Cleary et al. (2006) found mortality in the first year on ART. Ideally, in
the intervention group HIV would be detected earlier, resulting in later initiation on ART and lower
mortality once on ART compared to the control group.
67
Markov model is memoryless. It assumes that the chances to become infected will remain stable
over time.
68
Were not available in time to be included.

33
indirect HIA because of behaviour change of MSR69
. Including these details is
expected to result in a stronger case for incentive provision since cost ART provision
will be lower and higher utilisation leads to lower unit cost (Marseille et al., 2007) and
the number of HIA will be higher due to the effects outside the targeted population.
The adopted provider perspective does not include cost and benefits for the MSR or
the society as a whole. DTHF integrates both testing and treatment in its activities,
therefore cost saving could be included here in the provider model. An incentive is
not likely to be a cost-effective intervention for a stand-alone testing unit or a unit
with a separate budget since cost-savings will be made under another budget (Kahn
et al., 2006). Taking a broader perspective could accommodate this, but was not
possible in the available time and budget for this thesis.
5.2. Theories
According to behavioural economics, MSR will want to maximize utility and will not
change behaviour when the opportunity costs to do so are higher than maintaining
their behaviour. The incentive lowers the opportunity costs of HIV-testing. Men will
be able to overcome the barriers caused by stigma since the incentive appeals to the
most important role MSR identify for themselves – the breadwinner role (Indlu
Yegazi, 2009).
Regular return visits will allow the building of therapeutic alliance with the provider
thus internalizing this external motivation and reinforcing the ‘good’ behaviour. The
69
Kahn et al. (2006) mentions that each infected individual is responsible for one other new infection.
Thus one HIA directly prevented should actually count double. Seen the expected high risk behaviour
of MSR, the indirect-HIA might actually be higher than 1.

34
risk-assessment format which is filled can help build the necessary skills. Thus
combining the incentive and regular DTHF HIV-testing provision will work on all
elements of the IMB model and make sustained behaviour change possible.
5.3. Screening uptake
The DTHF approach already brings testing close to the men, embedding it in a
comprehensive health check which will reduce stigma and opportunity costs of
utilisation. One-day testing plus the availability of an on-site CD4-count machine and
possibility to refer to a treatment program also contribute to high uptake. However,
the 2009 DTHF M&E data show that MSR are not effectively reached even with this
program. Paying an incentive can has attracted MARP in several other settings.
However, it is important to realize that it is the incentive that makes the MSR test for
HIV and not the intention to change behaviour70
. After enrolment, engaging the men
will be of key importance.
5.4. Incentivized schemes: Lessons learned
Targeting must be kept simple to avoid extra cost. In the DTHF/IY example, all MSR
are eligible to enrol at specific sites. This simple approach avoids problems at the
site, since it will be difficult to pay one person but not the next and is administratively
easy. But how do you treat a MSR coming for a follow up visit at a non-IY site? It is
probably more cost-effective to attach the incentive to the MSR and have vouchers
available in the Tutu tester at each testing site.
70
Pre-contemplative stage in the trans-theoretical theory of change (Fishbein and Guinan, 1996).

35
Uptake of HIV-testing is simple behaviour with a clear target which can be
immediately reinforced with a payment. Payment is made once, irrespective of the
testing result. Testing positive has shown to induce a positive behaviour change.
Since because of the incentive, more MSR will test, incentive provision will have a
public health impact. The expected behaviour change for those testing positive might
be less than otherwise observed since men will enrol in the pre-contemplative stage.
Using financial incentives to reduce risk behaviour in MSR is more complicated. First
of all, testing for HIV is not a good proxy for safe sexual behaviour since even with
unsafe sex the chance of contracting HIV is distant. The contingent link is weak. A
MSR might have engaged in unsafe sex, test negative and get an incentive plus the
message to change behaviour. By why would he? To ensure immediate
reinforcement, other proxies need to be chosen. The Tanzania study uses STI which
might be a better proxy, but providing immediate tests on site will be very expensive
(Anonymous, 2010). Payment of an incentive combined with other support activities
working on information, motivation and skills of people have shown promising results
(Villano et al., 2002; Gift et al., 2005; Jochelson, 2007). DTHF/IY could therefore
consider combining monthly visits for health education talks or peer support group
meetings with an incentive (possibly escalating) with a half yearly check up which in
the case of DTHF also includes testing for syphilis. Incentives for monthly visits could
be smaller especially if they are organised at times when the MSR do not work.
The incentive needs to be meaningful for the participant. The Tanzania study saw
behaviour change only in the arm which received 24% of the average annual income
of the participants (Anonymous, 2010). The Malawi example saw a change in

36
behaviour with payments of 2 to 8% of monthly income. However, payments were
not to the main income-earner of the family and behaviour was to be avoided not
changed (Baird et al., 2009). DTHF/IY provides an incentive which is less than the
daily wage of MSR. Paying a full day’s wage will make going for testing a real choice
for MSR, not only those that did not get work. Although it is not likely that a lottery
approach will appeal to the target group, after an initial period of intensive contact
and establishing therapeutic alliance one can start playing around with the incentive
– increasing or decreasing it. This might allow reduction of payments over time.
It is assumed that after some time, behaviour is automated and/or motivation is
internalized. For complex behaviour change, 3 months of reinforcement is insufficient
and incentive provision alone will not suffice to change behaviour. Seen the possible
cost effectiveness of providing the incentives, one might ask why not pay the
incentive over a much longer time.
5.5. Ethics
DTHF/IY ensures informed uptake of testing through the pre- and post-test
counselling. After counselling MSR can decide not to the test. However, payment of
the incentive depends on doing the test (though not on the test result)71
. Men that
come to test, have no work for the day. Seen their economic situation, they need
money to keep themselves going. This will affect their freedom to choose to reject
the test. This however can be justified by the public health benefit of behaviour
change. For the individual, early detection of HIV virus through regular tests will
enhance treatment outcomes.
71
MSR testing positive are referred to the treatment program of DTHF.

37
5.6. Cost effectiveness
The calculation model suggests that incentive provision seems to be most cost-
effective after two years. After this, potential cost savings per HIA decrease while the
cost of incentive provision per HIA increase for all levels of p(i) and nl(i). With current
utilization levels, a reduction of p(i) to 0.15 will not be cost effective averaging
US$8065 for incentive provision and a negative potential cost saving.
The commission on macroeconomics and health recommends that when the cost of
an intervention per DALY is below the GDP per capita, it is very cost-effective
(Cleary et al., 2006). Combining VCT CE estimates and cost for mobile testing from
literature72
with the cost of incentive provision from the model, the total cost of VCT
per DALY using a high cost estimate for VCT ranges from US$233-USS$311 per
DALY for different values of p(i). A low cost estimate for VCT brings the total cost of
VCT per DALY at US$54 to US$132. Both are well below the GDP rate of South
Africa73
. Annex 15 provides the full calculations.
Seen the above, there is room to increase the value of the incentive and the
frequency of provision to attain low attrition and high reduction of chances to become
infected without affecting the cost-effectiveness of incentive provision.
72
A generalized CE estimate for VCT in sub-Saharan Africa reported US$1956/- per HIA (Galárraga
et al., 2009). Kahn et al. (2006) reported cost for testing per HIA from a South African Primary Health
Care unit at US$ 162. A Kenyan study found that mobile testing results in a US$17.54 extra cost per
test done (Grabbe et al., 2010).
73
The World Bank puts GDP per capita for South Africa at US$10,291 in 2009, accessed on 16 June
2010 from http://data.worldbank.org/country/south-africa.

38
5.7. Conclusions
This research shows that while supply side activities are important, specific attention
to stimulate the demand for services by MARP is important. Incentive provision is
one way to reach them. But, even though CE is expected to be high, incentive
provision needs to be combined with intense follow up and behavioural interventions
to internalize motivation and sustain behaviour change. The approach however is
promising and needs further testing in order to design a less resource intensive but
effective approach which can be scaled up.

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Article Number: 272.

Using financial incentives to increase HIV testing uptake and reduce risk behaviour in men

Using financial incentives to increase HIV testing uptake and reduce risk behaviour in men

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