"It gets people through the door": a qualitative case study of the use of incentives in the care of people at risk or living with HIV in British Columbia, Canada

BMC Medical Ethics

Vicky Bungay¹  Stuart J. Murray²  Marilou Gagnon³  Ross Upshur⁴  Adrian Guta⁵ 

[1] Canada Research Chair in Gender, Equity and Community Engagement, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, V6T2B5, Vancouver, BC, Canada;Canada Research Chair in Rhetoric and Ethics, Department of English Language and Literature, Carleton University, 1125 Colonel By Drive, K1S 5B6, Ottawa, ON, Canada;Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, V8N 5M8, Victoria, BC, Canada;Dalla Lana Chair in Clinical Public Health, Dalla Lana School of Public Health, 678-155 College Street, M5T 3M7, Toronto, ON, Canada;School of Social Work, University of Windsor, 167 Ferry Street, N9A 0C5, Windsor, ON, Canada;

关键词: AIDS;    Canada;    Behavioural economics;    Case study;    Ethics;    HIV;    Incentives;    Qualitative;   

DOI  :  10.1186/s12910-020-00548-5

来源: Springer

【 摘 要 】

BackgroundThere has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care—each one representing an interconnecting step in the "HIV Cascade."MethodsThe main objective of this qualitative case study was to document the experiences of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes.ResultsOur findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve (and sustain) viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional—thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional.ConclusionsWe identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care—an area of life previously not subject to monetary exchanges.

【 授权许可】

CC BY