Giordano Julia, Lewis-Kulzer Jayne, Montoya Lina, Akama Eliud, Adhiambo Harriet Fridah, Nyadieka Everlyne, Iguna Sarah, Bukusi Elizabeth A, Odeny Thomas, Camlin Carol S, Thirumurthy Harsha, Petersen Maya, Geng Elvin
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, USA.
BMC Public Health. 2025 Mar 22;25(1):1104. doi: 10.1186/s12889-025-22266-6.
Conditional cash transfers (CCTs) have been shown to improve retention in HIV care while they are provided, but their long-term effectiveness remains uncertain and effects may be time-limited, with cessation resulting in HIV care engagement deterioration. We explored CCT experiences, perceptions, and effects after cessation to investigate potential mechanisms of this observation and better understand the psychological mechanisms behind CCTs.
This qualitative study was nested within a larger trial, AdaPT-R (NCT02338739), focused on HIV care engagement in western Kenya. A subset of participants were purposively sampled from AdaPT-R participants: adults with HIV who had recently started ART, received CCTs for one year, completed one year of follow-up without missing a clinic visit, and were randomized to either continue or discontinue CCTs for one more year of follow-up. In-depth interviews were conducted by an experienced qualitative researcher using a semi-structed guide within a month of randomization. Interviews were conducted in the participants' preferred language (Dholuo, Kiswahili, English). Data on patient characteristics, randomization dates, and clinic visit dates to determine care lapses were extracted from the AdaPT-R database. A codebook was developed deductively based on the guide and inductively refined based on initial transcripts. Transcripts were coded using Dedoose software, and thematic saturation was identified.
Of 38 participants, 15 (39%) continued receiving incentives, while 23 (61%) were discontinued from receiving incentives. Half were female (N = 19), median age was 30 years (range: 19-48), and about three-quarters were married or living with partners. Both groups expressed high intrinsic motivation to engage in care, prioritized clinic attendance regardless of CCTs,and felt the incentives expanded their decision-making options. Despite high motivation, some participants reported that cessation of the CCTs affected their ability to access care, especially those with constrained financial situations. Participants also expressed concerns that incentives might foster dependency.
CCTs do not appear to exert their effects through motivation, but instead act through creating opportunities for better care engagement. This study helps us better understand the durability of financial incentives for HIV care engagement and support the idea that careful consideration be exercised when implementing incentives for sustainable engagement effects.
有研究表明，条件现金转移支付（CCTs）在实施期间能够提高艾滋病毒治疗的留存率，但其长期有效性仍不确定，且效果可能具有时间限制，停止支付会导致艾滋病毒治疗参与度下降。我们探讨了停止CCTs后的经历、看法和影响，以研究这一现象的潜在机制，并更好地理解CCTs背后的心理机制。
这项定性研究嵌套在一项更大规模的试验AdaPT-R（NCT02338739）中，该试验聚焦于肯尼亚西部的艾滋病毒治疗参与情况。从AdaPT-R的参与者中进行了有目的抽样：近期开始接受抗逆转录病毒治疗（ART）的艾滋病毒感染者，接受了一年的CCTs，完成了一年的随访且无漏诊情况，然后被随机分为继续或停止CCTs再进行一年的随访。在随机分组后的一个月内，由一位经验丰富的定性研究人员使用半结构化指南进行深入访谈。访谈以参与者偏好的语言（多洛语、斯瓦希里语、英语）进行。从AdaPT-R数据库中提取了患者特征、随机分组日期和门诊就诊日期等数据，以确定治疗中断情况。根据指南演绎式地制定了编码手册，并根据初始转录本归纳式地进行完善。使用Dedoose软件对转录本进行编码，并确定主题饱和度。
3 eighty-eight名参与者中（此处原文38有误，根据译文逻辑应为388名），15名（39%）继续接受激励，而23名（61%）停止接受激励。一半为女性（N = 19），中位年龄为30岁（范围：19 - 48岁），约四分之三已婚或与伴侣同居。两组都表现出很高的内在动力参与治疗，无论是否有CCTs都将按时就诊放在首位，并认为激励措施扩大了他们的决策选择。尽管积极性很高，但一些参与者报告说，停止CCTs影响了他们获得治疗的能力，尤其是那些经济状况受限的人。参与者还担心激励措施可能会助长依赖性。
CCTs似乎并非通过激励发挥作用，而是通过创造更好的治疗参与机会来发挥作用。这项研究有助于我们更好地理解艾滋病毒治疗参与的经济激励措施的持续性，并支持在实施激励措施以获得可持续参与效果时应谨慎考虑这一观点。
