abstract: 'Background

  Viral suppression among people living with HIV (PLHIV) is essential for

  protecting health and preventing HIV transmission, yet globally, rates

  of viral suppression are sub-optimal. Interventions to improve HIV

  prevention and care cascade outcomes remain vital. Financial incentives

  hold promise for improving these outcomes, yet to date, clinical trial

  results have been mixed.

  Methods

  This qualitative sub-study, embedded in a trial (NCT02890459) in Uganda

  to test whether incentives are effective for achieving viral suppression

  in PLHIV, sought to enhance our understanding of the factors that

  influence this outcome. Forty-nine (n = 49) PLHIV, purposely sampled to

  balance across gender, study arm, and viral suppression status, were

  interviewed to explore barriers and motivations for care engagement,

  adherence, and viral suppression, and attributions for decision-making,

  including perceived influence of incentives on behaviors.

  Results

  While many participants with undetectable viral load (VL) who received

  incentives said the incentives motivated their ART adherence, others

  expressed intrinsic motivation for adherence. All felt that incentives

  reduced burdens of transport costs, lost income due to time spent away

  from work, and food insecurity. Incentives may have activated attention

  and memory for some, as excitement about anticipating incentives helped

  them adhere to medication schedules. In comparison, participants who

  were randomized to receive incentives but had detectable VL faced a

  wider range, complexity and severity of challenges to care engagement.

  Notably, their narratives included more accounts of poor treatment in

  clinics, food insecurity, and severe forms of stigma. With or without

  incentives, adherence was reinforced through experiencing restored

  health due to ART, social support (especially from partners), and good

  quality counseling and clinical care.

  Conclusions

  In considering why incentives sometimes fail to achieve behavior change,

  it may be helpful to attend to the full set of factors- psychological,

  interpersonal, social and structural- that militate against the behavior

  change required to achieve behavioral outcomes. To be effective,

  incentives may need to be combined with other interventions to address

  the spectrum of barriers to care engagement.'
affiliation: 'Camlin, CS (Corresponding Author), Univ Calif San Francisco, Dept Obstet
  Gynecol \& Reprod Sci, San Francisco, CA 94115 USA.

  Camlin, Carol S.; Getahun, Monica, Univ Calif San Francisco, Dept Obstet Gynecol
  \& Reprod Sci, San Francisco, CA 94115 USA.

  Marson, Kara; Emperador, Devy; Chamie, Gabriel, Univ Calif San Francisco, Dept Med,
  San Francisco, CA 94143 USA.

  Ndyabakira, Alex; Byamukama, Ambrose; Kwarisiima, Dalsone, Infect Dis Res Collaborat,
  Kampala, Uganda.

  Thirumurthy, Harsha, Univ Penn, Perelman Sch Med, Philadelphia, PA USA.'
article-number: e0270180
author: Camlin, Carol S. and Marson, Kara and Ndyabakira, Alex and Getahun, Monica
  and Emperador, Devy and Byamukama, Ambrose and Kwarisiima, Dalsone and Thirumurthy,
  Harsha and Chamie, Gabriel
author-email: carol.camlin@ucsf.edu
author_list:
- family: Camlin
  given: Carol S.
- family: Marson
  given: Kara
- family: Ndyabakira
  given: Alex
- family: Getahun
  given: Monica
- family: Emperador
  given: Devy
- family: Byamukama
  given: Ambrose
- family: Kwarisiima
  given: Dalsone
- family: Thirumurthy
  given: Harsha
- family: Chamie
  given: Gabriel
da: '2023-09-28'
doi: 10.1371/journal.pone.0270180
files: []
issn: 1932-6203
journal: PLOS ONE
keywords-plus: 'CONDITIONAL CASH TRANSFERS; ANTIRETROVIRAL THERAPY; CARE; ADULTS;

  RETENTION; ADHERENCE; LINKAGE'
language: English
month: JUN 30
number: '6'
number-of-cited-references: '23'
orcid-numbers: Camlin, Carol/0000-0001-5615-1164
papis_id: 47227869c615888cef8d3e0f5393d551
ref: Camlin2022understandingrole
times-cited: '0'
title: 'Understanding the role of incentives for achieving and sustaining viral suppression:
  A qualitative sub-study of a financial incentives trial in Uganda'
type: Article
unique-id: WOS:000892027900066
usage-count-last-180-days: '0'
usage-count-since-2013: '1'
volume: '17'
web-of-science-categories: Multidisciplinary Sciences
year: '2022'