Dermatology Hospital of Southern Medical University, Guangzhou, China.
Southern Medical University Institute for Global Health, Guangzhou, China.
JMIR Public Health Surveill. 2023 Mar 2;9:e43772. doi: 10.2196/43772.
Regular chlamydia and gonorrhea testing are essential for key populations, such as female sex workers (FSWs). However, testing cost, stigma, and lack of access prevent FSWs in low- and middle-income countries from receiving chlamydia and gonorrhea testing. A social innovation to address these problems is "pay it forward," where an individual receives a gift (free testing) and then asks whether they would like to give a gift to another person in the community.
This cluster randomized controlled trial examined the effectiveness and cost of the pay-it-forward strategy in increasing access to chlamydia and gonorrhea testing among FSWs in China.
This trial integrated a pay-it-forward approach into a community-based HIV outreach service. FSWs (aged 18 years or older) were invited by an outreach team from 4 Chinese cities (clusters) to receive free HIV testing. The 4 clusters were randomized into 2 study arms in a 1:1 ratio: a pay-it-forward arm (offered chlamydia and gonorrhea testing as a gift) and a standard-of-care arm (out-of-pocket cost for testing: US $11). The primary outcome was chlamydia and gonorrhea test uptake, as ascertained by administrative records. We conducted an economic evaluation using a microcosting approach from a health provider perspective, reporting our results in US dollars (at 2021 exchange rates).
Overall, 480 FSWs were recruited from 4 cities (120 per city). Most FSWs were aged ≥30 years (313/480, 65.2%), were married (283/480, 59%), had an annual income <US $9000 (301/480, 62.7%), and had never been tested for chlamydia (401/480, 83.5%) or gonorrhea (397/480, 82.7%). Chlamydia and gonorrhea test uptake in the pay-it-forward and standard-of-care arms were 82% (197/240) and 4% (10/240), respectively, with an adjusted proportion difference of 76.7% (lower bound 95% CI 70.8%). All those who tested positive were referred to and received treatment at local sexually transmitted infection clinics. This finding was consistent when adjusting for marital status, income, inconsistent condom use during commercial sex in the last 3 months, and HIV testing history. Among 197 women who received tests in the pay-it-forward arm, 99 (50.3%) donated money, with a median donation of US $1.54 (IQR 0.77-1.54). The economic cost per person tested was US $568.71 for standard of care and US $43.20 for pay it forward.
The pay-it-forward strategy has the potential to enhance chlamydia and gonorrhea testing for Chinese FSWs and may be useful for scaling up preventive services. Further implementation research is needed to inform the transition of pay-it-forward research into practice.
Chinese Clinical Trial Registry ChiCTR2000037653; https://www.chictr.org.cn/showprojen.aspx?proj=57233.
对于性工作者（FSW）等重点人群，定期进行衣原体和淋病检测至关重要。然而，检测费用、耻辱感和缺乏渠道使中低收入国家的 FSW 无法接受衣原体和淋病检测。一种解决这些问题的社会创新是“先付后得”，即个人获得一份礼物（免费检测），然后询问他们是否愿意将礼物送给社区中的另一个人。
本整群随机对照试验研究了“先付后得”策略在中国增加 FSW 接受衣原体和淋病检测的效果和成本。
本试验将“先付后得”方法纳入基于社区的艾滋病外展服务中。来自中国 4 个城市（集群）的外展团队邀请年龄在 18 岁及以上的 FSW 接受免费 HIV 检测。4 个集群以 1:1 的比例随机分为 2 个研究臂：“先付后得”臂（提供衣原体和淋病检测作为礼物）和标准护理臂（检测自费：11 美元）。主要结局是通过行政记录确定的衣原体和淋病检测参与情况。我们从卫生服务提供者的角度采用微观成本法进行了经济评估，并以美元（2021 年汇率）报告了我们的结果。
总体而言，从 4 个城市招募了 480 名 FSW（每个城市 120 名）。大多数 FSW 年龄≥30 岁（313/480，65.2%）、已婚（283/480，59%）、年收入<9000 美元（301/480，62.7%），从未接受过衣原体（401/480，83.5%）或淋病（397/480，82.7%）检测。“先付后得”和标准护理臂的衣原体和淋病检测参与率分别为 82%（197/240）和 4%（10/240），调整后的比例差异为 76.7%（下限 95%CI 70.8%）。所有检测呈阳性的人都被转介到当地性传播感染诊所接受治疗。这一发现与调整婚姻状况、收入、过去 3 个月商业性性行为中使用不一致的避孕套以及 HIV 检测史后一致。在接受“先付后得”臂检测的 197 名女性中，99 名（50.3%）捐了钱，中位数为 1.54 美元（IQR 0.77-1.54）。标准护理的人均检测费用为 568.71 美元，“先付后得”为 43.20 美元。
“先付后得”策略有可能提高中国 FSW 的衣原体和淋病检测率，并且可能有助于扩大预防性服务。需要进一步实施研究，为“先付后得”研究向实践的过渡提供信息。
中国临床试验注册中心 ChiCTR2000037653；https://www.chictr.org.cn/showprojen.aspx?proj=57233.
