It helps me live, sends my children to school, and feeds me: a qualitative study of how food and cash incentives may improve adherence to treatment and care among adults living with HIV in Tanzania

ABSTRACT

Financial and in-kind incentives have been shown to improve outcomes along the HIV care cascade, however the potential mechanismsthrough which they work remain unclear. To identify the pathways through which incentives improve retention in care and adherence to antiretroviral therapy (ART), we conducted a qualitative study with participants in a trial evaluating conditional food and cash incentives for HIV-positive food insecure adults in Shinyanga, Tanzania. We found that the incentives acted through three pathways to potentially increase retention in care and adherence to ART: (1) addressing competing needs and offsetting opportunity costs associated with clinic attendance, (2) alleviating stress associated with attending clinic and meeting basic needs, and (3) by potentially increasing motivation. Participants did not report any harmful events associated with the incentives, but reported myriad beneficial effects on household welfare. Understanding how incentives are used and how they impact outcomes can improve the design of future interventions.

KEYWORDS:

• Tanzania
• HIV infection
• ART adherence
• retention
• incentives
• cash transfers
• food assistance
• qualitative

Acknowledgements

The authors are grateful to all of the participants in this study, who are currently participating in the main trial, and all of our study and clinic staff that made these studies possible. In addition, we thank Emily Ozer for critically reviewing our interview guide, Jan Cooper for helpful discussion on eliciting information about transfer use and motivation while data collection was ongoing, and Sergio Bautista for discussion and feedback on economic theory and a thoughtful review of the manuscript.

This study was approved by the Committee for Protection of Human Subjects at University of California Berkeley and by the National Institute for Medical Research in Tanzania. This manuscript is dedicated to the late Dr. Nancy Czaicki. The work described herein was part of Dr. Czaicki’s doctoral dissertation in Epidemiology at the University of California, Berkeley. She was an outstanding young scientist dedicated to improving the lives of people living with HIV. While she is deeply mourned around the world, we remember the brilliant happiness with which she lived her life and the sunshine she exemplified to the world.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Funding for this study was provided by the National Institute of Mental Health of the U.S. National Institutes of Health [grant number R03MH105327 to SIM], a supplemental grant to NC from the University of California Berkeley Population Center which was supported by NICHD (grant R24 HD07396401A1), and the University of CaliforniaBerkeley Center for Global Public Health Fellowship (NC).