The most recent strategic call to action of the WHO sets the elimination of pediatric HIV as agoal . While the past decade of research and field implementation has focused on building infrastructure and ensuring that parents have access to HIV care and treatment, additional attention must be paid to the behavior change required to eliminate vertical transmission. The goal of this debate is to introduce a set of principles from the field of behavioral economics that could be engineered into interventions to improve utilization of services and retention of mothers through high quality prevention of mother-to-child transmission (PMTCT) programs.
The prevention of mother-to-child transmission of HIV consists of four prongs: prevention of HIV among women of reproductive age, prevention of unintended pregnancies among women living with HIV, prevention of vertical transmission, and treatment . PMTCT efforts over the past decade have focused on developing the proper clinical protocols to prevent vertical transmission, delivering those interventions through health care facilities, and evaluating the PMTCT health services infrastructure [3–9]. This supply-side approach to PMTCT in the developed world has certainly been successful, with vertical transmission rates reduced from 35% to less than 2% between the early 1990’s to present day . In low-income countries, on the other hand, estimates of vertical transmission range from 15% to 40% .
The PMTCT cascade comprises 18 months of care from the initial antenatal visit and HIV testing through ARV treatment, intrapartum care, infant testing, infant feeding education and infant/mother treatment . Results from mathematical models of the PMTCT cascade conclude that in order to reduce the number of infants infected by HIV and ensure mothers receive life-saving interventions, each step in the PMTCT cascade must be delivered (and utilized) with greater than 90% reliability [12, 13]. However, recent estimates of retention of HIV-positive pregnant mothers through the full PMTCT cascade (including antenatal, intrapartum, and postpartum care) are inadequate for elimination of transmission. Based on data from the Elizabeth Glaser Pediatric AIDS Foundation, of a 100 pregnant women that attend antenatal clinic, 92 will be counseled, 77 will be tested for HIV and 69 will receive test results . These numbers fall far short of the 90% retention rate necessary at each step to reduce transmission rates.
In order to address the shortcomings of current PMTCT programs, the WHO outlined seven strategic directions that are aimed at addressing the supply-side of the PMTCT equation, particularly focused on addressing areas such as technical guidance, integration and coordination within health care systems, and measurement of program impact on vertical transmission . Undoubtedly, many structural barriers to accessing care still exist, such as transportation to clinics, lack of treatment supplies, long wait times and costly appointments [15, 16]. The implicit assumption, however, in focusing on infrastructure building through this strategic direction is, “If you build it, they will come.” However, we know from a variety of health fields, from immunizations to blood pressure screenings, access to services does not necessarily mean people will use those services [17, 18]. PMTCT services are no different. Even in well-resourced settings such as urban Vietnam, researchers found that, women were still not receiving counseling, were not opting in to ARV prophylaxis and were choosing not to follow feeding guidelines .
Recent research has identified many social and behavioral correlates of failure to access existing PMTCT services or to adhere to treatment protocols, including HIV-related stigma, exclusive breast-feeding stigma, lack of partner support and negative attitudes toward health workers [19–21]. Non-participation in PMTCT is clearly not solely related to “bad” choices by mothers– the struggle for more supply of quality PMTCT resources in developing countries must continue. At the same time, however, attention must now include the demand side of the PMTCT equation: How do we motivate HIV-positive pregnant women to utilize available PMTCT services, and to initiate and adhere to treatment protocols when the resources are available to them ? Researchers and policy-makers must consider the behavioral and social correlates of failure to access existing PMTCT services.
Behavioral economics, a field that builds heavily on findings from psychology, economics and finance, recognizes the inherent complexity of human decision-making and the significant influence of community, culture, and context at the moment of decision-making in everyday health decisions . Interventions based on behavioral economic principles have been shown to be successful in smoking cessation, weight loss, medication adherence and maintenance of sobriety [23–27]. By understanding the many drivers behind health-related decisions, behavioral economics is one tool that can help us better address the demand-side of the PMTCT equation (i.e., increase the number of mothers who receive HIV testing, who adhere to medication recommendations and who return for visits).
Below we introduce five behavioral economics principles and suggest specific ways in which intervention workers in under-resourced settings or policymakers may apply these concepts to PMTCT interventions to address the utilization and retention challenges that currently impede progress towards the goal of eliminating mother-to-child transmission of HIV.