Financial incentives for pediatric HIV testing (FIT): caregiver insights on incentive mechanisms, target populations, and acceptability for programmatic scale up

Abstract

Introduction Children living with HIV experience gaps in HIV testing globally; scaling up evidence-based testing strategies is critical for preventing HIV-related mortality. Financial incentives (FI) were recently demonstrated to significantly and substantially increase uptake of pediatric HIV testing. However, questions remain about whether and how FI should be integrated into programmatic delivery, including concerns about unintended consequences and FI mechanism. Methods This qualitative follow-up study to the FIT trial (NCTNCT03049917) was conducted in Kenya. Fifty-four caregivers (adults living with HIV with one or more children of unknown HIV status) were purposively selected to fill three strata: caregivers enrolled in the trial who tested their child(ren), caregivers enrolled who did not test their child(ren), and caregivers unexposed to the trial. In-depth interviews were conducted with caregivers using semi-structured interview guides. Transcripts were analyzed using conventional content analysis to identify considerations for programmatic integration of FI. Results Caregivers reported two mechanisms by which FI functioned: directly offsetting direct or indirect costs or nudging caregivers to take action sooner than they would have otherwise. Caregivers had diverse opinions about whether FI should be used to motivate caregivers to test their children, but generally found FI acceptable for broader programmatic implementation. Opinions differed on who should be the target population for programmatic scale up. While some caregivers believed FI was compensation for the person in charge of child health, others thought it should operate as income for those who were in need. Some caregivers believed FI should be targeted towards caregivers who had not tested their children despite being in HIV care for a long time. Despite overall high perceived acceptability and feasibility, some concerns were raised about unintended consequences of FI, including caregivers bringing ineligible children (or children who did not belong to them) to collect an incentive and fears of caregivers becoming dependent on FI, having a potentially detrimental impact on linkage to care and retention for children. Conclusions FI were considered highly acceptable and feasible for programmatic scale-up by caregivers. FI operated both by directly offsetting costs and by nudging parents to take action.