Preferences for HIV prevention conditional cash transfers among Black/African American and Latinx cisgender MSM in Los Angeles

Abstract

Objectives:

In Los Angeles, cisgender men who have sex with men (MSM) – particularly Black/African American and Latinx individuals – are a high-priority population for new HIV prevention interventions. Incentive programs that pay people for engaging in healthy behaviors, also known as “conditional cash transfers” (CCTs), are a promising strategy, but there is little evidence about their use in Black/African American and Latinx cisgender MSM.

Design and methods:

We surveyed 133 cisgender MSM who identified as Black/African American or Latinx and included a discrete choice experiment to elicit their preferences for CCTs to incentivize preexposure prophylaxis (PrEP) use and, separately, HIV testing.

Results:

Our findings suggest that respondents preferred more frequent payments of higher monetary value (e.g., a 35.2 percentage point increased probability of choosing a PrEP use CCT with $1200 versus $300 payment, and a 49.7 percentage point increased probability of choosing an HIV testing CCT with $1200 versus $300 payment). Additionally, respondents showed a preference for receiving CCT payments in cash over gift card payments (a 9.4 percentage point increased preference in the PrEP use CCT, and an 11 percentage point increased preference in the HIV testing CCT), particularly among those who were unemployed. Younger respondents had a stronger preference for more frequent payments. Higher monetary amounts were more strongly preferred by those with greater educational attainment and those who were employed.

Conclusions:

This preimplementation research highlights important, and heterogeneous, preferences in the design details of a HIV prevention CCT for Black/African American and Latinx cisgender MSM in Los Angeles.

Introduction

New approaches will be needed to reach the Ending the HIV Epidemic (EHE) vision [1], including in the priority jurisdiction of Los Angeles County where there is a relatively high HIV burden especially among Black/African American and Latinx men [2]; and where use of oral preexposure prophylaxis (PrEP) is low among Black and Latino MSM [3,4], and a disproportionate share of people who identify as Black/African American or as Latinx are unaware of their HIV status [2].

Financial incentives in exchange for health behaviors (also known as conditional cash transfers, CCTs) have been shown to positively impact health behaviors [5–11], but there is relatively little evidence of their impact on HIV prevention [12–14]. This study aimed to inform the design of a CCT program for high-priority groups in Los Angeles County – i.e., MSM who identify as Black/African American or Latinx. We use a discrete choice experiment (DCE) to examine preferences for CCT interventions for PrEP use and HIV testing [15,16], and apply behavioral economic principles which we posit may help identify CCT designs that can achieve maximal impact by better contending with humans’ cognitive biases [10,17].

Methods

We conducted a cross-sectional survey that included a DCE; by asking respondents to choose between two options that differ on specific attributes, and by randomly varying attribute combinations shown to a respondent, DCE results isolate the causal effect of each attribute on respondents’ choices [15].

The survey asked sociodemographic questions and behavioral questions related to HIV prevention and risk. This was followed by two DCEs, one about a CCT for PrEP use and one about a CCT for HIV testing. The PrEP use DCE had four attributes: amount of money to be received for participation ($300, $600, or $1200 total per year; there is a treatment incentive program in Los Angeles County that pays $600 each year [18], so our CCT tested multiples of this amount), frequency of CCT payment (monthly, trimonthly, or annually), format of CCT payment (cash or gift card), and type of PrEP (oral daily pills, or bimonthly injectable). The HIV testing DCE had the same attributes for CCT amount, frequency, and format. Respondents were randomized to see eight DCE choice-sets for a PrEP CCT and eight choice-sets for an HIV testing CCT (see examples in Appendix Figure 1, Supplemental Digital Content).

Research staff distributed material about the study at two federally qualified health centers in Los Angeles and via E-Mail listservs of HIV researchers and community organizations in the Los Angeles area; and the study advertised on social media platforms and dating apps/sites. Potential participants were directed to fill out an online interest form, which research staff used to contact them to assess eligibility: being 18 years of age or older; self-identified as a cisgender male; self-identified as MSM; and living in Los Angeles County. Eligibility was assessed in English or Spanish, and eligible participants were invited to participate in an interviewer-administered survey in English or Spanish, either by Zoom or in-person. All participants provided verbal informed consent (in English or Spanish) prior to participation.

We used linear probability models to estimate the influence of each attribute on the probability of choosing a given CCT design; linear models produce unbiased estimates with more intuitively interpretable results for DCEs [15]. For sensitivity analyses, we also used conditional logit models. Estimation details can be found in Supplemental Text 1.

To inform potential intervention targeting, we used interaction terms to assess whether attribute preferences varied significantly by age, educational attainment, employment status, recent PrEP experience, recent HIV testing behavior (for the testing DCE), and racial identity (for which we chose Black/African American as the comparison analytic group given the high level of medical mistrust in this population due to many years of systemic discrimination, marginalization, and oppression [19], and a large literature showing the association between mistrust and HIV prevention in this group [20–25]). Due to limited statistical power, these are exploratory analyses.

We used standard willingness to pay (WTP) techniques to estimate how much people would give up for different payment frequencies, payment types, and PrEP modalities [26,27]. We modeled the cash value as a continuous variable, and divided each attribute level coefficient by the coefficient on the continuous cash variable.

The Institutional Review Board at the University of California Los Angeles reviewed and approved this study (protocol #22-000822).

Results

From July 2023 to January 2024, we conducted 304 screenings and 173 people (56.7%) were eligible. We enrolled 133 participants. Most respondents were under the age of 40; 49.6% identified as being Hispanic/Latinx, 36.8% identified as being Black/African American, and 13.5% identified as being mixed race; over 60% had a college/university- or graduate-level education; 54.9% of respondents reported full-time employment (Appendix Table 1, Supplemental Digital Content). Approximately half the sample reported using PrEP in the prior year, just over half of whom were daily PrEP users (Appendix Table 2, Supplemental Digital Content).

Attributes of a conditional cash transfer for preexposure prophylaxis use

Respondents were 13.3 percentage points more likely to choose options with a monthly payment frequency than an annual payment frequency (Fig. 1), preferred payment in cash rather than as a gift card (by 9.3 percentage points), and preferred receiving more money rather than less. The amount of money was the most influential attribute. We saw no significant preference for incentivizing oral or injectable PrEP. Participants would give up $345 each year to receive monthly payments rather than an annual payment; and would give up $244 each year to get their payments in cash rather than via gift card.

Fig. 1.

Preferences for attributes of a conditional cash transfer for PrEP use.

Respondents under age 30 had a 9.0 percentage point greater preference for monthly versus annual payments than respondents aged 30 or older (P < 0.1) (Appendix Table 3, Supplemental Digital Content, Appendix Figure 2, Supplemental Digital Content). Respondents who had completed college or beyond had a significantly greater (12.7 additional percentage points) preference for larger monetary payments than respondents who had not completed college (Appendix Table 4, Supplemental Digital Content, Appendix Figure 3); as did respondents who were working compared to those who were not working (12.5 additional percentage points) (Appendix Table 5, Supplemental Digital Content, Appendix Figure 4). Respondents who were not working significantly preferred cash payments rather than gift cards by an additional 11.2 percentage points, compared to employed respondents (Appendix Table 5, Supplemental Digital Content, Appendix Figure 4, Supplemental Digital Content).

The main results – preference for frequent, cash, larger-amount payments – were largely similar when looking within PrEP-naïve and PrEP-experienced groups (Appendix Table 6, Supplemental Digital Content, Appendix Figure 5, Supplemental Digital Content), and among respondents who identified as Black/African American and those who did not identify as Black/African American (Appendix Table 7, Supplemental Digital Content, Appendix Figure 6, Supplemental Digital Content).

Attributes of a conditional cash transfer for HIV testing

Respondents indicated a preference for more frequent, cash, and higher-amount payments in a CCT for HIV testing (Fig. 2); and when converted to willingness-to-pay estimates, respondents were willing to give up $155 in order to get monthly payments rather than annual payments, and $205 to get paid in cash rather than as a gift card. There were no significantly different preferences when looking at subgroups of respondents by age, educational attainment, employment status, or racial/ethnic identity (Appendix Tables 8–11, Supplemental Digital Content, Appendix Figures 7–10, Supplemental Digital Content). Respondents who were already getting tested for HIV more frequently had a significantly stronger preference (12.2 additional percentage points) for frequent payments than those who were testing less frequently (Appendix Table 12, Supplemental Digital Content, Appendix Figure 11, Supplemental Digital Content).

Fig. 2.

Preferences for attributes of a conditional cash transfer for HIV testing.

All main results were nearly identical when we used a conditional logit model rather than a linear probability model (Appendix Figure A12, Supplemental Digital Content).

Discussion

Preimplementation studies like this one provide important insights for researchers and interventionists who can subsequently design evaluation studies for HIV prevention CCTs which, if shown to be effective and implementable, can be incorporated into policy and practice at-scale. In this study of Black/African American and Latinx cisgender men who have sex with men in Los Angeles, respondents expressed a preference for HIV prevention CCT interventions administered in cash and with frequent payouts. Although respondents overall preferred more money, they were willing to forego some of this money to receive cash and frequent payments. This willingness to trade-off money for other design features has been found in other DCEs about CCTs [28–30]. This suggests that “more money” may not be the sole motivating feature of a successful CCT for certain groups which is particularly salient in resource-constrained contexts where there may be programmatic or policy limitations to how much individuals can be paid.

Younger people (under age 30) had a stronger preference for more frequent payments, which may reflect time-inconsistent preferences (immediacy/present bias) and temporal discounting that may be different for younger people and have been identified in the broader literature [29,31,32] (although some studies have found the opposite to be true, with greater time discounting among older people [33]).

Cash was preferable to gift card payments in this sample. Previous CCT DCEs for HIV prevention and treatment have not reached consensus on preferred format for payment including cash [29], food vouchers [34], gift cards for “fun” or luxury items (i.e., cinema, cosmetics) [17], and lack of a clear preference [30] – which underscores the importance of local formative research to understand preferences of the specific population where a CCT intervention would be implemented. In our study, the preference toward cash payment was more pronounced for unemployed respondents. Preimplementation research should therefore also seek to disentangle preferences across important subgroups, to better anticipate for whom a CCT design may be tailored for optimal success.

In the DCE to reward HIV testing, frequent-testers exhibited a stronger preference for rewards of greater monetary value – in other words, more money may be needed to motivate people who are already testing often. This echoes findings from other DCEs about HIV testing CCTs which suggest that underlying behaviors, including HIV testing frequency, may affect people's preferences [35,36]. However, it is crucial to prioritize infrequent (or never) testers when designing interventions; a CCT to focus on infrequent-testers that provides payments every three months (a stated preferred in this group) would align well with current HIV testing recommendations for PrEP use, so could help establish routines for testing and PrEP.

Several limitations should be considered when interpreting these findings. First, this was a relatively small study so results should be generalized with caution. In addition, some eligible potential participants did not engage in the survey and we are not able to assess potential nonresponse bias. The small sample size also limits statistical power, especially for our subgroup analyses. A potential limitation of all DCE studies is that people's stated preferences may not align with their actual preferences, or behavior, when an intervention is offered. This preimplementation research should therefore be followed by a pilot test and a fully-powered randomized controlled trial. Further, a political and social commitment to the use of public funds to support health promotion in the form of cash incentives would need to accompany any promising effectiveness result to be able to have programmatic sustainability.

Acknowledgements

Authors’ contributions: Conceptualization: Corrina Moucheraud, Wendy Garland, Terry Smith, Risa M. Hoffman, Raphael Landovitz; Formal Analysis: Corrina Moucheraud, Dillon Trujillo, Zachary Wagner; Funding acquisition: Corrina Moucheraud, Raphael Landovitz; Investigation: Corrina Moucheraud, Dillon Trujillo; Methodology: Corrina Moucheraud, Zachary Wagner, Raphael Landovitz; Writing – original draft: Corrina Moucheraud, Dillon Trujillo, Zachary Wagner; Writing – review & editing: All authors.

Funding: Research reported in this publication was supported by the National Institute Of Mental Health under Award Number P30MH058107. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Acknowledgments: We are grateful to Charlotte (Jade) Christey for her valuable role in supporting data collection activities, and we thank Enrique Rivero for his assistance during data collection. We appreciate all the logistical support provided by the UCLA Center for Health Policy Research; the UCLA Center for HIV Identification, Prevention, and Treatment Services; and APLA Health & Wellness. We acknowledge the Los Angeles County Department of Public Health, Division of HIV and STD Programs, who was a key partner in this study. Lastly, we thank all the survey respondents for their time and for sharing their valuable insights with us.

Conflicts of interest

R.L. reports participation in the scientific and/or data safety advisory boards for Merck, RedQueen Therapeutics, and ViiV (significant commercial interest). For the remaining authors none were declared.