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How Small Nudges Could Drive Big Changes in the Global HIV Epidemic

HIV Nudge

Major scientific breakthroughs in recent years have finally made it possible to imagine a world without HIV and AIDS. HIV treatment can improve the health of people living with HIV and shut down transmission. Doctors now know how to prevent, test for, and treat the disease, but getting people who need prevention and treatment services most to take action presents what health care providers refer to as “last mile” challenges.  

In South Africa, the country hit hardest hit by the HIV epidemic, behavioral factors are a major reason why HIV services are not widely used and are ultimately the leading barriers to ending the HIV epidemic.

With nearly 7.2 million people in the country living with HIV — almost 1 in 5 adults — the epidemic is threatening South Africa’s population health, economic well-being, and gender equality. Nearly 740 new cases are diagnosed every day. But, answers are within reach.

“Over the past decade, effective prevention and treatment services have become freely available to people in South Africa who are at risk for and living with HIV. But ensuring that the highest-risk population of 15-34-year-olds uses those services remains a challenge,” said Harsha Thirumurthy, PhD, an associate professor of Medical Ethics & Health Policy at the Perelman School of Medicine and the associate director of the Penn Center for Health Incentives and Behavioral Economics (CHIBE).

Using lessons learned from behavioral economics — a field of research that provides insights on how people make decisions and uses those insights to try to help people make choices that are consistent with their own long-term interests — Thirumurthy and collaborator Alison Buttenheim, PhD MBA, an associate professor of Nursing at the University of Pennsylvania and an associate director at CHIBE, are leading two projects focused on improving health outcomes in South Africa in partnership with several local organizations.

With a new $5 million grant from the Bill and Melinda Gates Foundation, Buttenheim and Thirumurthy have launched Indlela: Behavioral Insights for Better Health — a first-of-its-kind unit focused specifically on developing “nudges” and other low-cost behavioral interventions to help improve the delivery of health care in South Africa.

Nudges — small adjustments in a person’s environment that can prompt large changes in their behavior — have proven to be effective in improving health outcomes at very low cost. For example, Thirumurthy and colleagues showed that inexpensive text messages sent to patients receiving HIV treatment led to improved medication adherence. In other studies, researchers from Penn Medicine’s Nudge Unit have shown that small changes to electronic medical records, such as actively prompting or reminding a physician to offer a patient a flu shot, can dramatically improve flu vaccination rates.

The Bill and Melinda Gates Foundation grant will support the development of the Indlela unit and enable it to engage with government, research, and HIV services providers in South Africa. In its first three years, Indlela (which means “the way” or “the path” in Zulu) will focus on building local capacity to design and test interventions that use behavioral economics within HIV prevention and treatment programs. For example, HIV service providers may improve the framing of messages about the effectiveness of HIV treatment to encourage use of treatment by people living with HIV. Alternatively, some programs may offer incentives in the form of public recognition of clinics that do the best in retaining patients in HIV care. The project is jointly led by Thirumurthy and Buttenheim at Penn and by local partner HE2RO (Health Economics and Epidemiology Research Office) at the University of the Witwatersrand (Wits University) in South Africa.

The goal of Indlela over the next three years is to further the application of behavioral economics within public sector HIV service delivery in South Africa. This can serve as a model for other countries in sub-Saharan Africa that face HIV epidemics. Over time, the Indlela unit will also expand beyond HIV and address non-communicable diseases and other pressing public health issues in South Africa.

While the Indlela unit’s activity ramps up this year with behavioral economics workshops and intervention design and testing, Thirumurthy and Buttenheim have also set their sights set on even bigger opportunities to implement behavioral economics solutions in the country.

Last month, the MacArthur Foundation announced the Top 100 finalists in its 100&Change competition, which offers a single $100 million grant to help solve one of the world’s most critical social challenges. Among the finalists is a proposed collaboration between CHIBE, the Ezintsha unit at Wits University, and Discovery Vitality (part of Africa’s largest private insurance company). The collaboration proposes to implement behavioral economics interventions at scale in South Africa increase the use of HIV services— which are currently not being used by nearly half of the people living with or at risk for HIV infection in the country, Buttenheim said.

“Proven, low-cost behavioral interventions to close that gap exist and are having a tremendous impact on health around the world, but they aren’t being implemented at scale in this area, where it’s arguably needed most,” Buttenheim added.

In their MacArthur Foundation 100&Change proposal, the team suggests a three-pronged solution that leverages nudges, social networks, and community partners in order to end HIV in South Africa. Their solution is one that can easily be replicated in other countries in sub-Saharan Africa that also face an HIV epidemic.

The team has previously shown that their solution is highly effective in South Africa and other countries in Africa. For example, in studies conducted between 2015-2017, the team pioneered a social network-based approach to distributing easy-to-use HIV self-tests. Women accessing health facilities were offered multiple HIV self-tests to facilitate partner and couples testing. The approach resulted in over 90 percent partner testing and 60 percent couples testing. Taking the idea — now an approach recommended by the World Health Organization — to scale, could result in much higher coverage of HIV testing among hard-to-reach individuals.

Finally, the team hopes that through the development of partnerships with retail pharmacies and mobile testing and treatment units, clinical services can be delivered directly to high-risk and underserved communities where transportation and access to clinics are major barriers to HIV prevention and treatment.

The MacArthur Foundation will announce the top 10 proposals in May 2020 and the winning 100&Change proposal in the fall. If selected, Thirumurthy says the team will further drive down HIV incidence in the next five years, and end HIV in South Africa by 2030.

“We’ve seen these solutions work in myriad small ways to effect big change. It’s time now to put our full weight behind deploying behavioral economics strategies as a primary driver of creating healthier communities,” Buttenheim said. “We have every indication that these solutions will work, and if they produce the kind of results we expect, we’ll have a powerful platform for addressing HIV and other global health issues not just in South Africa, but around the world.”

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