B-OK: A Visual and Tactile Tool for HIV Treatment Adherence Support in a United States Urban Center.

Lack of adherence to antiretroviral therapy (ART) and poor retention in care are significant barriers to ending HIV epidemics. Treatment adherence support (TAS) effectiveness may be constrained by limited awareness and understanding of the benefits of ART, particularly the concepts of treatment as prevention and Undetectable=Untransmittable (U=U), for which substantial knowledge gaps persist. We used mixed methods to evaluate a straightforward visual and tactile tool, the B-OK Bottles ("B-OK"), that incorporates human-centered design and behavioral economics principles and is designed to change and strengthen mental models about HIV disease progression and transmission. We enrolled 118 consenting adults living with HIV who were clients of medical case managers at one of four case management agencies in Philadelphia. All participants completed a pre-intervention survey, a B-OK intervention, and a post-intervention survey. A subset (N=52) also completed qualitative interviews before (N=20) or after (N=32) B-OK. Participants had a median age of 55 years (IQR 47-60), about two-thirds were male sex (N=77, 65%), nearly three-quarters identified as non-Hispanic Black (N=85, 72%), and almost all reported receiving ART (N=116, 98%). Exposure to B-OK was associated with improved awareness and understanding of HIV terminology, changes in attitudes about HIV treatment, and increased intention to rely on HIV treatment for transmission prevention. Insights from qualitative interviews aligned with the quantitative findings as respondents expressed a better understanding of U=U and felt that B-OK clearly explained concepts of HIV treatment and prevention. These findings provide a strong rationale to further evaluate the potential for B-OK to improve TAS for PLWH.

Evaluation of four interventions using behavioural economics insights to increase demand for voluntary medical male circumcision in South Africa through the MoyaApp: A quasi-experimental study.

Background: While voluntary medical male circumcision (VMMC) reduces the risk of HIV transmission by 60%, circumcision coverage falls short of the UNAIDS 90% target. We investigated whether behaviourally informed message framing increased demand for VMMC. Setting: Adult users of the MoyaApp, a data free application in South Africa, who viewed a form designed to generate interest in VMMC during August-November 2022. Methods: A quasi-experimental study was conducted to evaluate four MoyaApp VMMC intervention forms against the Standard of Care (SOC) form. All forms enabled users to provide contact details for follow-up engagement by a call centre. The primary outcome was the proportion of forms submitted. Secondary outcomes included successful contact with the user, VMMC bookings/referrals and confirmed circumcision. Multivariable ordinary least-squares regression was used for the analysis. Results: MoyaApp VMMC form viewers totalled 118,337 of which 6% submitted a form. Foot-in-the-Door form viewers were more likely (+1.3 percentage points, p<0.01) to submit a form compared to the SOC group (6.3%). Active Choice (-1.1 percentage points, p<0.01) and Reserved for You (-0.05 percentage points, p<0.05) form viewers were less likely to submit a form compared to SOC. Users submitting on Foot-in-the-Door were less likely to be booked/referred compared to SOC (-5 percentage points, p<0.05). There were no differences between the intervention and SOC forms for successful contact and circumcisions. Conclusions: Message framing using behavioural insights was able to nudge men to engage with VMMC services. However, more work is needed to understand how to convert initial interest into bookings and circumcisions. Trial registration: South African Clinical Trials Registry DOH-27-062022-7811Pan-African Clinical Trials Registry PACTR202112699416418.

Applying behavioural economics principles to increase demand for free HIV testing services at private doctor-led clinics in Johannesburg, South Africa: A randomised controlled trial.

Background: Expanding free HIV testing service (HTS) access to include private clinics could increase testing rates. A donor funded programme, GP Care Cell, offered free HIV testing at selected private doctor-led clinics but uptake was low. We investigated whether HTS demand creation materials that used behavioural economics principles could increase demand for HIV testing at these clinics. Methods: We conducted a randomised controlled trial in Johannesburg, South Africa (January-April 2022) distributing brochures promoting HTS to adults in five private doctor-led clinic catchment areas. Individuals were randomised to receive three brochure types: (1) "Standard of care" (SOC) advertising a free HIV test and ART; (2) "Healthy lifestyle screening" promoted free low-cost health screenings in addition to HTS; and (3) "Recipient of care voucher" leveraged loss aversion and the endowment effect by highlighting the monetary value of free HTS. The primary outcome was presenting at the clinic following exposure to the brochures. Logistic regression compared outcomes between arms. Results: Of the 12,129 brochures distributed, 658 were excluded because of errors or duplicates and 11,471 were analysed. About 59% of brochure recipients were male and 50,3% were aged 25-34 years. In total, 448 (3.9%) brochure recipients presented at the private doctor-led clinics of which 50.7% were males. There were no significant differences in clinic presentation between the healthy lifestyle screening and SOC arm (Adjusted Odds Ratio [AOR] 1.02; 95% CI 0.79-1.32), and similarly between the recipient of care voucher and SOC arm (AOR 1.08; 95% CI 0.84-1.39). Individuals were more likely to attend clinics that were centrally located with visible branding for HTS (AOR=5.30; 95% CI: 4.14-6.79). Conclusion: Brochures that used behavioural insights did not increase demand for HTS at private doctor-led clinics. However, consistent distribution of the brochures may have potential to increase HIV testing uptake at highly visible private doctor-led clinics.

Incentives to promote accessing HIV care and viral suppression among HIV self-screening test users who obtain a reactive result.

Introduction: Achieving viral suppression in people with HIV is crucial in ending the AIDS epidemic. Among users of HIV self-screening tests, low rates of linkage to care and early retention in care are key obstacles to achieving viral suppression. This study sought to evaluate the efficacy of financial incentives in supporting HIV case management. Methods: Young adults within the inner city of Johannesburg, South Africa and surrounding areas who used HIV self-tests, were able to use WhatsApp to communicate with study personnel, reported a reactive or invalid result, and were confirmed to by HIV-positive were enrolled in the study. Participants were randomised to an intervention arm that received reminders and financial rewards for engaging in care, or to a control arm that received the standard of care. The primary outcome was HIV viral load at six months. Results: Among 2,388 HIV self-test kits that were distributed, 1757/2,388 (73,58%) recipients were able to use their phones to send photos to study personnel. 142/1,757 (8,08%) of these recipients reported reactive or invalid results. Upon confirmatory testing, 99/142 (69,71%) participants were identified as being HIV-positive and were enrolled in the study. 2 (1,41%) participants received an HIV negative result, and 41(28,87%) participants were either lost to follow-up or did not complete the confirmatory testing step. 20/99 (20,2%) from the intervention arm and 18/99 (18,18%) from the control arm completed the study (i.e., attended a 6 month follow up and participated in the exit interview). 29/99 (29,29%) were virally suppressed by at 6 months. Of those achieving viral suppression 15 (51,72%) were from the intervention arm. Conclusion: Financial incentives and reminders were not effective in promoting engagement with HIV care and viral suppression in this setting.

Planning and commitment prompts to encourage reporting of HIV self-test results: A cluster randomized pragmatic trial in Tshwane District, South Africa.

Reporting of HIV self-test results to encourage linkage to HIV care for those who receive a positive test result is a common challenge faced by HIV self-testing programs. The impact of self-testing programs is diminished if individuals who obtain a self-test do not use the test or seek confirmatory testing and initiate HIV treatment following a positive result. We conducted a cluster randomized trial of two interventions designed to increase reporting of HIV self-test results: a "plan and commit" intervention that leveraged insights from behavioral economics, and an enhanced usual care version of the standard HIV self-test community distribution protocol that promoted the importance of reporting results. The trial was conducted at community distribution sites for HIV self-tests in Tshwane Metropolitan Municipality, Gauteng Province, South Africa. The primary outcome was reporting of self-test results via a WhatsApp messaging system. We recruited 1,478 participants at 13 distribution sites over 24 days. In the plan and commit condition, 63/731 participants (8.7%) reported their test results via WhatsApp, compared to 59/747 participants (7.9%) in the enhanced usual care condition (n.s., p = 0.61). During the study period, 101/3,199 individuals (3.1%) who received a self-test under the standard protocol reported test results via WhatsApp, a significant difference across the three arms (p < .00001). Our results suggest that boosting the reporting of self-test results can be done solely through increasing the salience of the importance of reporting and a clear explanation of the procedure for reporting results. Trial Registration: ClinicalTrials.gov: NCT03898557.

Participatory Prototyping of a Tailored Undetectable Equals Untransmittable Message to Increase HIV Testing Among Men in Western Cape, South Africa.

Daily antiretroviral therapy (ART) suppresses viral replication, rendering HIV undetectable through viral load (VL) testing. People living with HIV (PLWH) who have an undetectable VL cannot transmit HIV to sexual partners or through giving birth, a message commonly referred to as U = U (undetectable equals untransmittable). To increase knowledge and understanding of U = U among men, who have poorer HIV testing and treatment outcomes than women, we engaged men from high HIV burden communities in Cape Town in two interactive human-centered design cocreation workshops to develop local U = U messaging for men. Two trained workshop facilitators, explained the U = U message to 39 adult men (in two separate workshops), and asked them how to effectively communicate U = U to other men in the local language (isiXhosa). Participant-designed messages sought to inform men about U = U to help assuage fears of testing HIV positive (by removing the stigma of living with HIV and being a vector of disease), and to explain that ART enables PLWH to live normal healthy lives, making HIV "untransmittable" to sex partners. Participants' messages emphasized that when virally suppressed, "I cannot spread HIV to the other person" and "(the pill) keeps on killing the virus so I can live a normal life for the rest of my life." Men cocreated simple local U = U messages to address fears of testing HIV positive and emphasizing ART's positive effects. Cocreated tailored messaging may reduce stigma associated with living with HIV and improve the uptake of HIV testing and treatment among South African men. This study was registered at clinicaltrials.gov under NCT04364165.

Undetectable = Untransmittable (U = U) Messaging Increases Uptake of HIV Testing Among Men: Results from a Pilot Cluster Randomized Trial.

HIV testing coverage in sub-Saharan Africa is lower among men than women. We investigated the impact of a peer-delivered U = U (undetectable equals untransmittable) message on men's HIV testing uptake through a cluster randomised trial with individual mobile clinic days as unit of randomisation. On standard of care (SOC) days, peer promoters informed men about the availability of HIV testing at the mobile clinic. On intervention days, peer promoters delivered U = U messages. We used logistic regression adjusting for mobile clinic location, clustering by study day, to determine the percentage of invited men who tested for HIV at the mobile clinic. Peer promoters delivered 1048 invitations over 12 days. In the SOC group, 68 (13%) of 544 men invited tested for HIV (3, 4.4% HIV-positive). In the U = U group, 112 (22%) of 504 men invited tested for HIV (7, 6.3% HIV-positive). Men in the U = U group had greater odds of testing for HIV (adjusted odds ratio = 1.89, 95% CI 1.21-2.95; p = 0.01). Tailored, peer-delivered messages that explain the benefits of HIV treatment in reducing HIV transmission can increase men's HIV testing uptake.

Shedding light on quality of care: a study protocol for a randomized trial evaluating the impact of the Solar Suitcase in rural health facilities on maternal and newborn care quality in Uganda.

BACKGROUND: Continued progress in reducing maternal and newborn morbidity and mortality in low-income countries requires a renewed focus on quality of delivery care. Reliable electricity and lighting is a cornerstone of a well-equipped health system, but most primary maternity care facilities in sub-Saharan Africa are either not connected to the electrical grid or suffer frequent blackouts. Lack of reliable electricity and light in maternity facilities may contribute to poor quality of both routine and emergency obstetric and newborn care, by hindering infection control, increasing delays in providing care, and reducing health worker morale. The "Solar Suitcase" is a solar electric system designed specifically for maternity care facilities in low-resource environments. The purpose of this trial is to evaluate the impact of the Solar Suitcase on reliability of light, quality of obstetric and newborn care, and health worker satisfaction. METHODS: We are conducting a study with 30 maternity care facilities in rural Uganda that lack access to a reliable, bright light source. The study is a stepped wedge cluster randomized controlled trial. Study facilities are identified according to predefined eligibility criteria, and randomized by blocking on baseline covariates. The intervention is a "Solar Suitcase", a complete solar electric system that provides essential lighting and power for charging phones and small medical devices. The primary outcomes are the reliability and quality of light during intrapartum care, the process quality of obstetric and newborn care, and health worker satisfaction. Outcomes will be assessed via direct clinical observation by trained enumerators (estimated n = 1980 birth observations), as well as interviews with health workers and facility managers. Lighting and blackouts will be captured through direct observation and via light sensors installed in facilities. DISCUSSION: A key feature of a high quality health system is appropriate infrastructure, including reliable, bright lighting and electricity. Rigorous evidence on the role of a reliable light source in maternal and newborn care is needed to accelerate the "electrification" of maternity facilities across sub-Saharan Africa. This study will be the first to rigorously assess the extent to which reliable light is an important driver of the quality of care experienced by women and newborns. TRIAL REGISTRATION: ClinicalTrials.gov : NCT03589625 (July 18, 2018); socialscienceregistry.org : AEARCTR-0003078 (dated June 16, 2018).