How do repeated financial incentives affect HIV care-seeking behaviours over time? Evidence from a cluster-randomised controlled trial
Ten dollars a month doubles HIV appointment keeping, but the gain disappears the day you stop paying.
01Research in Context
What this study did
Winters et al. (2026) paid adults with HIV about ten dollars each month if they came to clinic.
They ran a cluster-randomized trial: some clinics paid, others did not.
The team watched for six months, then stopped the money and kept watching.
What they found
While the cash flowed, missed visits, poor pill taking, and treatment breaks were cut in half.
The day payments stopped, all gains vanished.
Behavior returned to the same level as clinics that never paid.
How this fits with other research
Davison et al. (1984) saw the same quick lift and crash with a simple co-pay discount in a family clinic.
Kohlenberg et al. (1976) and Wearden et al. (1983) also showed that once money ends, energy use and weight control slip back.
Garner et al. (2025) ran a near-twin trial: ten-dollar incentives in HIV clinics, but paid staff instead of patients.
Taken together, the pattern is clear: small cash buys fast change, but the effect lives only while the cash flows.
Why it matters
If you use money to shape health behavior, plan for the fade. Pair the incentive with skills training or natural rewards so clients can keep the behavior when payments end.
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02At a glance
03Original abstract
A more nuanced understanding of behavioural responses to incentives over time, particularly after they are removed, could guide more effective interventions. In this study, we build on the primary trial evaluation to explore the dynamic effectiveness of small, short-term monthly financial incentives on HIV care-seeking behaviours during and after incentive removal. We conducted a 32-site cluster-randomised controlled trial (NCT04201353) among adult antiretroviral therapy (ART) initiates (<30 days) in four regions of Lake Zone, Tanzania. HIV care and treatment clinics were randomly assigned 1:1 to the intervention (up to 6 monthly cash transfers of 22 500 TZS each (~US$10), conditional on appointment attendance) or standard of care. Using time-to-event analysis, we assess the effect of incentives on three HIV-care seeking behaviours: missed appointment by >4 days, <90% ART adherence and interruption in treatment of >28 days. Among 1990 participants, we found large significant reductions in rate of missed appointments (hazard ratio (HR), 95% CI: 0.51, 0.39 to 0.68), <90% ART adherence (HR, 95% CI: 0.58, 0.41 to 0.83) and interruption in treatment (>28 days without ART) (HR, 95% CI: 0.54, 0.35 to 0.83) during the 6 months of incentives, but no effects after their removal. HRs by month reveal similar findings, with dramatic and consistent reductions in risk concentrated in months 2–6 that disappear in month 7, immediately after incentives are discontinued. These results highlight the value of short-term incentives for initiating new care-seeking behaviours and emphasise a need for innovative design choices, such as escalating rewards or incorporation of time- or context-based cues, that may help motivate sustained behaviour change after their removal. NCT04201353.
BMJ Global Health, 2026 · doi:10.1136/bmjgh-2025-022505