Evaluating the impact of conditional micro-incentives on linkage to HIV care in rural South Africa: results from the Home-Based Intervention to Test and Start (HITS) trial.

Abstract

Timely linkage from HIV diagnosis to care is critical for effective treatment and epidemic control. We evaluated the effectiveness of conditional micro-incentives on linkage to HIV care in the Home-Based Intervention to Test and Start (HITS) trial, a real-world implementation trial in rural South Africa. Of 45 communities in uMkhanyakude, KwaZulu-Natal, 16 were randomized to micro-incentive arms offering food vouchers (R50 [US$3]) conditional on completing home-based HIV counseling and testing (HBHCT) and linkage to care within 6 weeks, and 29 to non-incentive arms. All individuals were eligible for HBHCT, enrolled between February and December 2018, and followed for 1 year. The primary outcome was linkage to care at 1 year among men; secondary outcomes included linkage within the 6-week voucher eligibility period among men and women, and at 1 year among women. Intention-to-treat analyses were performed using Poisson regression adjusted for study arms. Among 13 894 men and 19 884 women eligible for the study (aged ≥15 years), home-based testing uptake was 21% (n = 2867) and 29% (n = 5795), yielding 122 (4.3%) and 375 (6.5%) new diagnoses, respectively. Overall, micro-incentives nearly doubled HIV-positive diagnoses. Among men, micro-incentives did not increase linkage to care within the 6-week voucher eligibility period (risk ratio [RR] = 0.78, 95% CI: 0.51-1.21) or at 1 year (RR = 1.08, 95% CI: 0.86-1.35). Among women, micro-incentives increased linkage to care within 6 weeks by 51% (RR = 1.51; 95% CI: 1.03-2.21), with no residual impact at 1 year (RR = 1.07, 95% CI: 0.91-1.26). In a hyperendemic rural African setting, once-off micro-incentives can substantially increase early linkage to HIV care among women during the incentive eligibility period but are inadequate to significantly improve care engagement among men. Trial Registration  ClinicalTrials.gov NCT03757104.