Preparing a financial incentive program to improve retention in HIV care and viral suppression for scale: using an implementation science framework to evaluate an mHealth system in Tanzania

Laura Packel, Carolyn Fahey, Atuganile Kalinjila, Agatha Mnyippembe, Prosper Njau, Sandra I McCoy, Laura Packel, Carolyn Fahey, Atuganile Kalinjila, Agatha Mnyippembe, Prosper Njau, Sandra I McCoy

Abstract

Background: Viral suppression is key to ending the HIV epidemic, yet only 58% of people living with HIV (PLHIV) in sub-Saharan Africa are suppressed. Cash transfers are an effective strategy to improve retention in care, but little is known about optimization of implementation; for example, designing effective programs that integrate into existing clinic workflows. We studied implementation of an mHealth system to deliver cash transfers to support retention.

Methods: We conducted a mixed-methods study assessing implementation of an mHealth cash transfer study. This was part of a larger, hybrid implementation-effectiveness randomized controlled trial evaluating cash transfers conditional on visit attendance for viral suppression among Tanzanian PLHIV initiating ART. An mHealth system using fingerprint identification and mobile payments was used to automatically disburse mobile money to eligible PLHIV. We used Proctor's framework, assessing implementation of the mHealth system from the perspectives of PLHIV and clinicians. We analyzed mHealth system data and conducted surveys (n = 530) and in-depth interviews (n = 25) with PLHIV, clinic and pharmacy staff (n = 10), and structured clinic observations (n = 2293 visits).

Results: One thousand six hundred fifty-one cash transfers were delivered to 346 PLHIV in the cash arms, 78% through mobile money. Among those in the cash arms, 81% registered their mobile money account with the mHealth system by study end, signaling high adoption. While acceptability for fingerprinting and mobile payments was high among PLHIV, interviews revealed mixed views: some had privacy concerns while others felt the system was secure and accurate, and provided some legitimacy to the clinical visits. Pharmacists praised system efficiency, but concerns about duplicative recordkeeping and added work arose. Clinic staff voiced excitement for the system's potential to bring the cash program to all patients and simplify workflows; yet concerns about multiple systems, staffing, and intermittent connectivity tempered enthusiasm, highlighting structural issues beyond program scope. Structured observations revealed a steep learning curve; repeat fingerprint scans and manual entry declined as the system improved.

Conclusions: Biometric identification and mobile payments were acceptable to most patients and staff. Fingerprinting encountered some feasibility limitations in the first months of testing; however, mobile payments were highly successful. Biometric identification and mobile payments may provide a scalable mechanism to improve patient tracking and efficiently implement financial incentives in low-resource settings.

Trial registration: Name of the registry: clinicaltrials.gov Trial registration number: NCT03351556 Date of registration: 11/24/2017 Checklists: StaRI (included with submission). Note CONSORT for cluster-randomized trials was used for the main trial but is not directly applicable to this manuscript.

Keywords: ART; Conditional Cash Transfers; HIV/ADS; Implementation Science; Retention in Care; Viral Suppression.

Conflict of interest statement

The authors declare that they have no competing interests

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Fingerprint scan success rate, by study month

References

    1. Avert. Global information and education on HIV and AIDS. [cited 2019 Dec 1]. Available from:
    1. HIV/AIDS JUNP on, others . Fast-track: ending the AIDS epidemic by 2030. Geneva: UNAIDS; 2014.
    1. McCoy SI. Improving the efficiency of HIV testing with peer recruitment, financial incentives, and the involvement of persons living with HIV infection. J Acq Immune Defic Syndr. 2013;63(2):e56–e63. doi: 10.1097/QAI.0b013e31828a7629.
    1. Björkman-Nyqvist M. Evaluating the impact of short term financial incentives on HIV and STI incidence among youth in Lesotho: a randomized trial. In: 7th IAS Conference on HIV Pathogenesis, Treatment, and Prevention. Kuala Lumpur; 2013.
    1. Baird SJ. Impact of a cash transfer program for schooling on prevalence of. In: HIV and HSV-2 in. Malawi: a;
    1. de Walque D. Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. BMJ Open. 2012;2(1):000747. doi: 10.1136/bmjopen-2011-000747.
    1. Galarraga O. Conditional economic incentives to improve HIV treatment adherence: literature review and theoretical considerations. AIDS Behav. 2013;17(7):2283–2292. doi: 10.1007/s10461-013-0415-2.
    1. Solomon S. Chennai, India in 19th Conference on Retroviruses and Opportunistic Infections. 2012. The impact of voucher incentives on linkage to care and ART initiation among drug users.
    1. Haukoos JS. The effect of financial incentives on adherence with outpatient human immunodeficiency virus testing referrals from the emergency department. Acad Emerg Med. 2005;12(7):617–621. doi: 10.1197/j.aem.2005.02.016.
    1. Thornton R. The demand for and impact of learning HIV status: evidence from a field experiment. Am Econ Rev. 2008;98(5):1829–1863. doi: 10.1257/aer.98.5.1829.
    1. Cluver L. Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study. Lancet Glob Health. 2013;1(6):362–370. doi: 10.1016/S2214-109X(13)70115-3.
    1. Handa S. The government of Kenya’s cash transfer program reduces the risk of sexual debut among young people age 15-25. PLoS One. 2014;9:85473. doi: 10.1371/journal.pone.0085473.
    1. Singer AW, Weiser SD, McCoy SI. Does food insecurity undermine adherence to antiretroviral therapy? A systematic review. AIDS and Behavior. 2015;19(8):1510–26.
    1. Young S. A review of the role of food insecurity in adherence to care and treatment among adult and pediatric populations living with HIV and AIDS. AIDS Behav. 2013;18(S5):505–515. doi: 10.1007/s10461-013-0547-4.
    1. McCoy SI. Rationale and design of a randomized study of short-term food and cash assistance to improve adherence to antiretroviral therapy among food insecure HIV-infected adults in Tanzania. BMC Infect Dis. 2015;15(1):490. doi: 10.1186/s12879-015-1186-3.
    1. Buzdugan R, Bautista-Arredondo S, McCoy SI. The promise of behavioral economics for HIV/AIDS treatment and care. In: 21th International AIDS Conference. Durban; 2016.
    1. Chaiyachati KH. Interventions to improve adherence to antiretroviral therapy: a rapid systematic review. AIDS. 2014;2:187–204. doi: 10.1097/QAD.0000000000000252.
    1. El-Sadr WM. HPTN 065 in Conference on Retroviruses and Opportunistic Infections. 2015. Effect of financial incentives on linkage to care and viral suppression.
    1. Galarraga O, Sosa-Rubi SG. Conditional economic incentives to improve HIV prevention and treatment in low-income and middle-income countries. Lancet HIV. 2019;6(10):e705–e714. doi: 10.1016/S2352-3018(19)30233-4.
    1. Krishnamoorthy Y, Rehman T, Sakthivel M. Effectiveness of financial incentives in achieving UNAID fast-track 90-90-90 and 95-95-95 target of HIV care continuum: a systematic review and meta-analysis of randomized controlled trials. AIDS Behav. 2021;25(3):814–825. doi: 10.1007/s10461-020-03038-2.
    1. Kohler H-P, Thornton RL. Conditional cash transfers and HIV/AIDS prevention: unconditionally promising? World Bank Econ Rev. 2011;26(2):165–190. doi: 10.1093/wber/lhr041.
    1. Fahey CA, Mwenda N, Bhattarai PR, Mneney J, Katabaro E, Njau PF, et al. Feasibility and acceptability of a biometric mHealth system for monitoring retention in HIV services and delivering financial incentives to adults initiating antiretroviral therapy in Tanzania. 2019.
    1. Fahey CA, Njau PF, Katabaro E, Mfaume RS, Ulenga N, Mwenda N, et al. Financial incentives to promote retention in care and viral suppression in adults with HIV initiating antiretroviral therapy in Tanzania: a three-arm randomised controlled trial. Lancet HIV. 2020; [cited 2020 Oct 7]; Available from: .
    1. Bastard M, Pinoges L, Balkan S, Szumilin E, Ferreyra C, Pujades-Rodriguez M. Timeliness of clinic attendance is a good predictor of virological response and resistance to antiretroviral drugs in HIV-infected patients. PLOS ONE. 2012;7(11):e49091. doi: 10.1371/journal.pone.0049091.
    1. Ministry of Health and Social Welfare . Tanzania National eHealth Strategy 2012 – 2018. Tanzania: Ministry of Health, Community Development, Gender, Elderly and Children, National AIDS Control Programme; 2013.
    1. Bank W. Tanzania mainland poverty assessment. Geneva: World Bank; 2019. 10.1596/33031.
    1. Tanzania Commission for, Zanzibar AIDS Commission AC. Tanzania HIV Impact Survey (THIS) 2016-2017: final report. Dar es Salaam; 2018.
    1. Packel L, Njau P, Fahey C, Ramadhani A, Dow WH, Jewell NP, McCoy S. Optimizing the efficiency and implementation of cash transfers to improve adherence to antiretroviral therapy: study protocol for a cluster randomized controlled trial. Trials. 2020;21(1):963. doi: 10.1186/s13063-020-04899-7.
    1. Schnall R, Cho H, Liu J. Health Information Technology Usability Evaluation Scale (Health-ITUES) for usability assessment of mobile health technology: validation study. JMIR Mhealth Uhealth. 2018;6(1):e4. doi: 10.2196/mhealth.8851.
    1. Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Mental Health Mental Health Serv Res. 2009;36(1):24–34. doi: 10.1007/s10488-008-0197-4.
    1. StataCorp . Stata Statistical Software: Release 15. College Station: StataCorp LLC; 2017.
    1. Tolley EE, Ulin PR, Mack N, Robinson ET, Succop SM. Qualitative methods in public health: a field guide for applied research. San Francisco: Wiley; 2016:531.
    1. Dedoose Version 8.0.35, web application for managing, analyzing, and presenting qualitative and mixed method research data. Los Angeles: SocioCultural Research Consultants, LLC; 2018. Available from:
    1. Ansar S, Singer D, Klapper L, Demirguc-Kunt A. The Global Findex Database 2017: Measuring Financial Inclusion and the Fintech Revolution. Geneva: World Bank Group; 2018.
    1. Ford E. The potential of digital cash transfers to strengthen the link between humanitarian assistance and social protection. Bath: Bath Papers in International Development and Wellbeing; 2017.
    1. Chehade N, McConaghy P, Meier CM. Humanitarian cash transfers and financial inclusion. 2020.
    1. Aker JC, Boumnijel R, McClelland A, Tierney N. Payment mechanisms and antipoverty programs: evidence from a mobile money cash transfer experiment in Niger. Econ Dev Cult Change. 2016;65(1):1–37. doi: 10.1086/687578.
    1. Ahmad AH, Green C, Jiang F. Mobile Money, Financial inclusion and development: a review with reference to African experience. J Econ Surveys. 2020;34(4):753–792. doi: 10.1111/joes.12372.
    1. UN Capital Development Fund. Better than cash alliance. Better Than Cash Alliance. [cited 2021 Mar 12]. Available from:

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