A Conditional Economic Incentive Fails to Improve Linkage to Care and Antiretroviral Therapy Initiation Among HIV-Positive Adults in Cape Town, South Africa

Interventions to improve antiretroviral therapy (ART) access are urgently needed to maximize the multiple benefits from ART. This pilot study examined the effect of a conditional economic incentive on linkage to care and uptake of treatment following ART referral by a mobile health clinic. Between April 2015 and May 2016, 86 individuals (≥18 years old) referred for ART in a resource-limited setting were randomized (1:1) to a control group or to an incentive: R300 cash (∼$23, or 3.5 days minimum wage in the domestic worker sector), conditional upon starting ART within 3 months. Outcome data were obtained from clinic records. The incentive effects on linkage to care (first clinic visit within 3 months) and ART initiation (treatment uptake within 3 months) were assessed using logistic regression. Overall, 67% linked to care and 42% initiated ART within 3 months after referral. No significant differences were found between the incentive and non-incentive group in terms of linkage to care [adjusted odds ratio (aOR): 0.70, 95% confidence interval (CI): 0.26-1.91] and initiation of ART (aOR: 0.67, 95% CI: 0.26-1.78). Ordinary least-squares regression analysis showed that incentivized individuals linked to care in fewer days (-7.9, 95% CI: -18.09 to 2.26) and started treatment in fewer days (-7.3, 95% CI: -27.01 to 12.38), but neither result was statistically significant. Our findings demonstrate poor treatment uptake by both the intervention and control participants and further highlight the challenge in achieving universal early treatment access. Further research is required to understand how economic incentives, which have been shown to have many benefits, can be applied to improve linkage to HIV care and treatment.