Financial incentives to increase pediatric HIV testing in Kenya: A pilot randomized clinical trial

Background Initiating antiretroviral therapy (ART) prior to the onset of symptomatic disease improves survival in HIV-infected children. However, HIV diagnosis in children is often delayed due to caregiver reluctance to test and financial barriers. A pilot study was conducted to assess acceptability of financial incentives to motivate pediatric testing, and to determine incentive amount and format for a larger efficacy trial. Materials and Methods HIV-infected female caregivers at Kisumu County Hospital, Kenya, who had children of unknown HIV status aged 0-12 years, were randomized to receive KSH 500 (~$5), KSH 1000 (~$10) or, KSH 1500 (~$15) payment conditional on child testing within 2 months. At the child HIV testing visit, data on socio-demographics, incentive preference, and impact of testing on health seeking behavior was collected. Results Of 1,991 female caregivers screened, 71 (4%) had children of unknown status age 0-12 years, 1,250 (63%) had tested all their children, 506 (25%) had children of unknown status but aged >12, 163 (8%) had no children, and 1 caregiver declined to give information. Of 71 eligible, 60 (85%) were randomized with equal allocation between arms. Forty-four (73%) tested children in the 2-month window; 15 (75%), 14 (70%) and 15 (75%) in the KSH 500, KSH 1000, and KSH 1500 arms, respectively (p>0.99). Uptake was significantly higher than in a recent cohort with similar procedures but no incentives (72% vs. 14%, p<0.001). Incentives were delivered as cash (55%) or as mobile phone money transfer (45%). A third (36%) preferred incentives to be provided as cash, and 32% had no specific preference. Preferred non-cash incentives included agricultural items (50%), household goods (43%), health services (29%), or food vouchers (21%). Conclusion Financial incentives were acceptable and increased pediatric HIV testing in this urban clinic. The similarity between testing rates in the 3 arms warrants evaluation of lower incentive values; a larger efficacy trial comparing testing rates across $0, $1.25, $2.50, $5, and $10 arms began in January 2017.