Understanding the role of incentives for achieving and sustaining viral suppression: A qualitative sub-study of a financial incentives trial in Uganda.

BACKGROUND: Viral suppression among people living with HIV (PLHIV) is essential for protecting health and preventing HIV transmission, yet globally, rates of viral suppression are sub-optimal. Interventions to improve HIV prevention and care cascade outcomes remain vital. Financial incentives hold promise for improving these outcomes, yet to date, clinical trial results have been mixed. METHODS: This qualitative sub-study, embedded in a trial (NCT02890459) in Uganda to test whether incentives are effective for achieving viral suppression in PLHIV, sought to enhance our understanding of the factors that influence this outcome. Forty-nine (n = 49) PLHIV, purposely sampled to balance across gender, study arm, and viral suppression status, were interviewed to explore barriers and motivations for care engagement, adherence, and viral suppression, and attributions for decision-making, including perceived influence of incentives on behaviors. RESULTS: While many participants with undetectable viral load (VL) who received incentives said the incentives motivated their ART adherence, others expressed intrinsic motivation for adherence. All felt that incentives reduced burdens of transport costs, lost income due to time spent away from work, and food insecurity. Incentives may have activated attention and memory for some, as excitement about anticipating incentives helped them adhere to medication schedules. In comparison, participants who were randomized to receive incentives but had detectable VL faced a wider range, complexity and severity of challenges to care engagement. Notably, their narratives included more accounts of poor treatment in clinics, food insecurity, and severe forms of stigma. With or without incentives, adherence was reinforced through experiencing restored health due to ART, social support (especially from partners), and good quality counseling and clinical care. CONCLUSIONS: In considering why incentives sometimes fail to achieve behavior change, it may be helpful to attend to the full set of factors- psychological, interpersonal, social and structural- that militate against the behavior change required to achieve behavioral outcomes. To be effective, incentives may need to be combined with other interventions to address the spectrum of barriers to care engagement.

Knowledge and practice of testicular self-examination among secondary students at Ntare School in Mbarara District, South western Uganda.

INTRODUCTION: Testicular self-examination (TSE) is a screening technique that involves inspection of the appearance and palpation of the testes to detect any changes from the normal. Globally, the incidence of cancer has increased among which is testicular cancer (TC). Data on this topic among male secondary school adolescents in Uganda is limited therefore this study sought to assess the knowledge and practice of testicular self-examination among secondary students at Ntare School, Mbarara District in south western Uganda. The objective of the study is to assess the knowledge and practice of testicular self-examination among secondary students at Ntare School in Mbarara district, south western Uganda. METHODS: We conducted a descriptive cross-sectional quantitative study among 165 students. Recruitment was made using simple random sampling technique. Respondents were selected among advanced level (A' level) male students studying at Ntare School in Mbarara district, south western Uganda. Structured self-administered questionnaires were used for data collection. RESULTS: Of the male students, 41.8% reported to have knowledge about TSE and only 23.6% practiced TSE. Most students rated their knowledge of TSE to be below 5 (from 1-10). Of the 39 students who admitted performing TSE, only 16 did so as recommended (monthly). CONCLUSION: The knowledge and practice of TSE were low among adolescent secondary school boys in Ntare School in Mbarara District, south western Uganda. This suggests that these students are unaware of the value of this personal health promotion tool which is fundamental in early diagnosis of testicular cancer.

Leveraging incentives to increase HIV testing uptake among men: qualitative insights from rural Uganda.

BACKGROUND: Few studies have explored how economic incentives influence behavioral outcomes. This study aimed to identify pathways of action of an incentives-based intervention to increase men's participation in HIV testing. METHODS: The qualitative study was embedded in a randomized-controlled trial that compared effectiveness of gain-framed, loss-framed and lottery-based incentives to increase HIV testing among men. Following testing at a community health campaign, 60 in-depth interviews were conducted with men systematically sampled on the basis of age, incentive group, and campaign attendance. Data were coded deductively and inductively for thematic content analysis. RESULTS: Incentives addressed men's structural, interpersonal and individual-level barriers to testing: offered at convenient locations, incentives offset costs of testing, in lost wages, which are exacerbated when livelihoods required mobility. Interpersonal barriers included anticipated stigma/fear of disclosure, social obligations, and negative peer influences. Providing incentives in public settings provided "social proof" that prizes could be won, and facilitated social support and positive norms by promoting testing with trusted others. Incentives had little influence when men appraised prize values to be low, disbelieved they would win a prize, or were already intrinsically motivated to test. Yet, incentives provided a behavioral 'cue to action' for many men who perceived themselves to be susceptible to HIV and perceived HIV disease to be severe, acting as secondary motivator for testing that "sweetened the deal". CONCLUSION: Incentives can be an important 'lever' to promote men's healthy behaviors in resource-poor settings. HIV testing in convenient, public settings, when paired with incentives, provides multiple pathways to stimulate men's testing uptake. TRIAL REGISTRATION: Registered with ClinicalTrials.gov on 08/10/2016, ID: NCT02890459. The first participant was enrolled on 11th April 2016.