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BackgroundA more nuanced understanding of behavioural responses to incentives over time, particularly after they are removed, could guide more effective interventions. In this study, we build on the primary trial evaluation to explore the dynamic effectiveness of small, short-term monthly financial incentives on HIV care-seeking behaviours during and after incentive removal.MethodsWe conducted a 32-site cluster-randomised controlled trial (NCT04201353) among adult antiretroviral therapy (ART) initiates (<30 days) in four regions of Lake Zone, Tanzania. HIV care and treatment clinics were randomly assigned 1:1 to the intervention (up to 6 monthly cash transfers of 22 500 TZS each (~US$10), conditional on appointment attendance) or standard of care. Using time-to-event analysis, we assess the effect of incentives on three HIV-care seeking behaviours: missed appointment by >4 days, <90% ART adherence and interruption in treatment of >28 days.ResultsAmong 1990 participants, we found large significant reductions in rate of missed appointments (hazard ratio (HR), 95% CI: 0.51, 0.39 to 0.68), <90% ART adherence (HR, 95% CI: 0.58, 0.41 to 0.83) and interruption in treatment (>28 days without ART) (HR, 95% CI: 0.54, 0.35 to 0.83) during the 6 months of incentives, but no effects after their removal. HRs by month reveal similar findings, with dramatic and consistent reductions in risk concentrated in months 2–6 that disappear in month 7, immediately after incentives are discontinued.ConclusionsThese results highlight the value of short-term incentives for initiating new care-seeking behaviours and emphasise a need for innovative design choices, such as escalating rewards or incorporation of time- or context-based cues, that may help motivate sustained behaviour change after their removal.Trial registration numberNCT04201353.

Background Financial incentives are increasingly used to achieve UNAIDS' 95–95-95 goals for ending HIV by 2030. While evidence supports their effectiveness, scaling these interventions remains challenging. This study examines the implementation successes and challenges of a financial incentive intervention in Tanzania, delivered via an mHealth application that provides automated mobile money disbursements, biometric identification, and SMS reminders. Methods Conducted alongside a Hybrid Type 1 Effectiveness-Implementation trial, the study evaluated financial incentives given to adults starting ART at 32 clinics. We used the Structured Assessment of Feasibility, Compatibility Beliefs in Technology (CBIT) scales, and the Program Sustainability Assessment Tool. Perspectives from 657 participants living with HIV and 90 clinic staff were collected using Proctor’s implementation science framework. Results Clinic staff rated the mHealth system highly on CBIT subscales for perceived usefulness, ease of use, and compatibility, each scoring over 6 out of 7. Integration and applicability of the financial incentive within the mHealth system were well received, with 93.0% of staff agreeing it improved job performance. Among participants, 86.4% found SMS reminders helpful for attending appointments, and 76.7% felt the cash delivery met their expectations. Challenges included unreliable fingerprint identification and undelivered SMS reminders. Conclusions Despite issues with fingerprint identification and SMS delivery, the financial incentive intervention via mHealth was found to be acceptable, feasible, and potentially sustainable in resource-limited settings, with support from host governments. Future research should enhance the intervention's effectiveness and optimize biometric identification methods. Trial registration ClinicalTrials.gov NCT04201353. Registered 17 December 2019, https://clinicaltrials.gov/study/NCT04201353

Financial incentives have demonstrated effectiveness in improving outcomes for people living with HIV; however, little is known about their impact on intimate partner violence (IPV) in this vulnerable population. A cluster-randomized trial investigating financial incentives and viral suppression was conducted in the Lake Zone of Tanzania (clinicaltrials.gov: NCT0420135). Between May 2021-March 2022, 32 clinics were randomized 1:1 to receive the standard of care (SOC) or to offer 22,500 TZS (~$10 USD) to individuals initiating antiretroviral therapy monthly for up to 6 months, conditional on clinic attendance. An intention-to-treat analysis was conducted to examine the effect of financial incentives on IPV among partnered women at 6 months ( n  = 494), with prevalence differences (PD) and 95% confidence intervals (CI) estimated using generalized estimating equations. Subgroup analyses were conducted among women partnered at 6 months only and women partnered at both baseline and 6 months. Past 6-month IPV was reported by 241 (48.8%) partnered women. Emotional IPV was the most common form of violence (47.8%), followed by physical (7.5%) and sexual IPV (5.1%). There were no significant differences in past 6-month IPV between arms in the primary (49.6% SOC vs. 48.1% incentive, PD: -0.02, 95% CI: -0.18, 0.15) or subgroup analyses. These findings suggest that small, short-term financial incentives used to improve HIV treatment outcomes do not significantly alter IPV risks, however with the width of the CIs it is not possible to rule out small and moderate-sized effects. Further research among larger samples is needed as financial incentive programs are brought to scale for people living with HIV.