iLink: Incentives for Linkage to HIV Treatment and Care

Dates: August 2014 – August 2019

Funding: National Research Foundation


A considerable number of individuals diagnosed HIV-positive are lost to follow-up before initiation of antiretroviral therapy (ART). This is especially true in South Africa, the country with the largest population living with HIV worldwide. Novel interventions are urgently needed to improve linkage to HIV treatment and care post-diagnosis, as increased ART coverage will reduce AIDS-related morbidity and mortality, and HIV incidence. Conditional economic incentives (CEIs) have great potential to improve linkage to care and treatment after HIV diagnosis.

Based on theoretical principles from behavioural economics and psychology, a financial reward is given based on the completion on an objective outcome. While previously employed to improve ART adherence, uptake and completion of HIV testing, and reduction of HIV and HSV-2 prevalence, this approach has yet to be tested for improving ART initiation. CEIs have the potential to both increase the rewards and decrease the costs of several discrete behavioural decisions en route to ART, and ‘nudge’ people to ART initiation. By providing incentives given on achieving different outcomes, the proposed research will add to our understanding of how CEIs may best be employed to achieve the main outcome of interest: ART initiation.

We employ a mixed methods approach. A qualitative assessment of the factors that deter individuals from engaging in a particular behaviour, despite being offered an economic incentive for this behaviour, will improve our understanding of salient factors influencing loss to follow-up treatment and care. Quantitative components will gather data on the necessary size of a CEI to motivate CD4 count testing and ART initiation, and include a randomised pilot trial to assess the acceptability and feasibility of using CEIs to increase ART initiation. Results may have broader implications for theory-driven, behavioural approaches to HIV prevention and treatment.