JMIR Publications

ABSTRACT

Background:

Regular chlamydia and gonorrhea testing are essential for key populations such as female sex workers (FSWs). However, testing cost, stigma, and lack of access prevent FSWs in low- and middle-income countries (LMICs) from receiving chlamydia and gonorrhea testing. A social innovation to address these problems is pay-it-forward, where an individual receives a gift (free testing) and then asks whether they would like to give a gift to another person in the community.

Objective:

This cluster randomized controlled trial examined the effectiveness and cost of the pay-it-forward strategy in increasing access to chlamydia/gonorrhea testing among FSWs in China.

Methods:

This trial integrated a pay-it-forward approach into a community-based HIV outreach service. FSWs aged 18 or above were invited by an outreach team from four Chinese cities (clusters) for free HIV testing. The four clusters were randomized into two study arms in a 1:1 ratio: a pay-it-forward arm (offered chlamydia/gonorrhea testing as a gift); and a standard of care arm (out-of-pocket cost for testing, $11). The primary outcome was chlamydia/gonorrhea test uptake ascertained by administrative records. We conducted an economic evaluation using a micro-costing approach from a health provider perspective, reporting our results in US dollars (2021).

Results:

Overall, 480 FSWs were recruited from four cities (120/city). Most FSWs were ≥30 years old (65·2%, 313/480), married (59·0%, 283/480), had an annual income < $9,000 (62·7%, 301/480), and had never been tested for chlamydia (83·5%, 401/480) or gonorrhea (82·7%, 397/480). Chlamydia and gonorrhea test uptake in the pay-it-forward and standard of care arms were 82% (197/240) and 4% (10/240), respectively, with an adjusted proportion difference of 76·7% (lower bound 95% CI: 70·8%). All those who tested positive were referred and received treatment at local STD clinics. This finding was consistent when adjusting for marital status, income, inconsistent condom use during commercial sex in the last three months, and HIV testing history. Among 197 women who received tests in the pay-it-forward arm, 99 (50·3%) donated money, with a median donation of $1·54 (IQR:0·77-1·54). The economic cost per person tested was $568·71 for the standard of care and $43·20 for pay-it-forward.

Conclusions:

Pay-it-forward strategy can enhance chlamydia and gonorrhea testing when integrated with other healthcare services and may be useful for scaling up preventive services. Further implementation research is needed to inform the transition of pay-it-forward research into practice. Clinical Trial: We registered the trial protocol (ChiCTR2000037653).