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Conditional Cash Transfers Improve Retention in PMTCT Services by Mitigating the Negative Effect of Not Having Money to Come to the Clinic

Yotebieng, Marcel MD, PhD, MPH; Moracco, Kathryn E. PhD, MPH; Thirumurthy, Harsha PhD, MPhil, MA; Edmonds, Andrew PhD, MSPH; Tabala, Martine Bs; Kawende, Bienvenu MD; Wenzi, Landry K. MD; Okitolonda, Emile W. MD, PhD; Behets, Frieda PhD, MPH

JAIDS Journal of Acquired Immune Deficiency Syndromes: February 1st, 2017 - Volume 74 - Issue 2 - p 150–157
doi: 10.1097/QAI.0000000000001219
Implementation Science

Objective: To elucidate the mechanisms by which a cash incentive intervention increases retention in prevention of mother-to-child transmission services.

Methods: We used data from a randomized controlled trial in Kinshasa, Democratic Republic of Congo. Perceptual factors associated with loss to follow-up (LTFU) through 6 weeks postpartum were first identified. Then, binomial models were used to assess interactions between LTFU and identified factors, and the cash incentive intervention.

Results: Participants were less likely to be LTFU if they perceived HIV as a “very serious” health problem for their baby vs. not [risk difference (RD), −0.13; 95% confidence interval (CI): −0.30 to 0.04], if they believed it would be “very likely” to pass HIV to their baby if they did not take any HIV drug vs. not (RD, −0.15; 95% CI: −0.32 to 0.02), and if they anticipated that not having money would make it difficult for them to come to the clinic vs. not (RD, 0.12; 95% CI: −0.07 to 0.30). The effect of each of the 3 factors on LTFU was antagonistic to that of receiving the cash incentive intervention. The excess risk due to interaction between the cash incentive intervention and the anticipated difficulty of “not having money” to come to the clinic was exactly equal to the effect of removing this perceived barrier (excess risk due to interaction, −0.12; 95% CI: −0.35 to 0.10).

Conclusions: Our analyses show that cash transfers improve retention in prevention of mother-to-child transmission services mainly by mitigating the negative effect of not having money to come to the clinic.

*Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH;

Departments of Epidemiology;

Health Behavior;

§Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC;

School of Public Health, The University of Kinshasa, Kinshasa, Democratic Republic of Congo; and

Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC.

Correspondence to: Marcel Yotebieng, MD, PhD, MPH, Division of Epidemiology, College of Public Health, 304 Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210-1351 (e-mail:

Supported by a grant from the President's Emergency Plan for AIDS Relief (PEPFAR) and the National Institute of Health and Child Development: NIHCD 1R01 HD075171. M.Y. is partially supported by NIAID U01AI096299 and NICHD 1R01 HD087993. The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit the article for publication.

The abstract for this article was presented at the 21st International AIDS Conference, July 18-22, 2016, Durban, South Africa.

The authors have no conflicts of interest to disclose.

M.Y., H.T., F.B., K.E.M., and A.E. designed the study. M.Y., E.W.O., B.K., and L.K.W. implemented the study and collected data. M.Y. analyzed the data. M.Y. wrote the first draft of the report with input from H.T., A.E., K.E.M., and F.B. All authors contributed to the final report.

Received April 11, 2016

Accepted October 12, 2016

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