Pay-it-forward: new model to increase STI Testing and build a healthy and cohesive community

release date:2019-06-10 18:13

Pay-it-forward: new model to increase STI Testing and build a healthy and cohesive community

 Gonorrhea and chlamydia are two common sexually transmitted infections (STI) that increase HIV risk among many key populations, including gay and bisexual men. However, most men are not tested, in part because of fees and low community engagement. A new study from researchers at the  University of North Carolina Project China evaluates an innovative testing strategy, pay-it-forward, to increase gonorrhea and chlamydia testing among gay men in China. The pay-it-forward model uses an initial funding pool to provide free gonorrhea and chlamydia tests to men as a gift and then lets them decide whether they want to pay it forward to support other people’s testing. While this general concept has been used in many businesses, this study breaks ground in applying it to health.

 Pay-it-forward for health started in 2017 as a small pilot led by the UNC Project-China team (see here: Building on this pilot, UNC postdoctoral fellow Fan Yang, medical student Philip Zhang, and UNC Project China Assistant Director Weiming Tang designed a randomized controlled trial (RCT). The purpose of the RCT was to assess the effectiveness of pay-it-forward in increasing test uptake in contrast to two comparison groups – a standard of care group, where tests were offered at fixed regular prices; and a pay-what-you-want group, where tests were offered free and men who tested could pay any desired amount for the tests they received. This design was intended to understand whether pay-it-forward is superior to a standard-of-care approach by increasing test uptake by at least 20% among this population. Also, it aimed to tease out whether the same effect can be achieved by merely making prices flexible, as implemented in the pay-what-you-want comparison group.

 The team built this study within three HIV testing sites in Beijing and Guangzhou, in collaboration with Blued, the largest gay online dating mobile application in China, and Zhitong LGBT Center which serves gay men and other LGBTQ individuals in the metropolitan Guangzhou areas. Many community volunteers enthusiastically took part in the design, piloting, and implementation of the randomized trial study.

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 The RCT showed that pay-it-forward increased the gonorrhea and chlamydia screening test uptake by 38% compared to the standard of care. Within the pay-it-forward arm, 95% of men chose to donate some amount towards other’s testing. A related qualitative analysis examined reasons why gay men were more willing to test through pay-it-forward. The qualitative analysis concluded some participants were motivated by the contagious kindness pay-it-forward has generated, while others were driven by the free services which were otherwise unaffordable. A 30-year old pay-it-forward participant commented “This is a type of passing forward of trust…normally when you buy something, it’s a market exchange, one hand pays and one hand takes. But this has sentiment” after receiving his pay-it-forward test.

 Dr. Stefan Baral, an Associate Professor at Johns Hopkins not involved in the study, noted, “Intersecting biological, network, and structural factors work together to increase STI incidence among gay men in resource-constrained environments. The study by Yang et al. provides critical data to inform STI testing interventions in this group, underlining the need for subsequent research and action.” Currently, the team have several studies planned to leverage the Pay-it-forward to improve other preventive health service uptake, including vaccination in rural community health centers in China.

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