Cash incentives versus defaults for HIV testing: A randomized clinical trial

PLoS One. 2018 Jul 6;13(7):e0199833. doi: 10.1371/journal.pone.0199833. eCollection 2018.


Background: Tools from behavioral economics have been shown to improve health-related behaviors, but the relative efficacy and additive effects of different types of interventions are not well established. We tested the influence of small cash incentives, defaults, and both in combination on increasing patient HIV test acceptance.

Methods and findings: We conducted a randomized clinical trial among patients aged 13-64 receiving care in an urban emergency department. Patients were cross-randomized to $0, $1, $5, and $10 incentives, and to opt-in, active-choice, and opt-out test defaults. The primary outcome was the proportion of patients who accepted an HIV test. 4,831 of 8,715 patients accepted an HIV test (55.4%). Those offered no monetary incentive accepted 51.6% of test offers. The $1 treatment did not increase test acceptance (increase 1%; 95% confidence interval [CI] -2.0 to 3.9); the $5 and $10 treatments increased test acceptance rates by 10.5 and 15 percentage points, respectively (95% CI 7.5 to 13.4 and 11.8 to 18.1). Compared to opt-in testing, active-choice testing increased test acceptance by 11.5% (95% CI 9.0 to 14.0), and opt-out testing increased acceptance by 23.9 percentage points (95% CI 21.4 to 26.4).

Conclusions: Small incentives and defaults can both increase patient HIV test acceptance, though when used in combination their effects were less than additive. These tools from behavioral economics should be considered by clinicians and policymakers. How patient groups respond to monetary incentives and/or defaults deserves further investigation for this and other health behaviors.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Choice Behavior*
  • Female
  • HIV / physiology
  • HIV Infections / diagnosis*
  • HIV Infections / psychology
  • HIV Infections / virology
  • Humans
  • Male
  • Mass Screening / economics*
  • Mass Screening / psychology
  • Mass Screening / statistics & numerical data*
  • Middle Aged
  • Motivation
  • Patient Acceptance of Health Care / psychology*
  • Young Adult

Grant support

The project described was supported by Award Number RC4AG039078 from the National Institute On Aging to WHD. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute On Aging or the National Institutes of Health.