How understanding human bias can improve HIV prevention
Without fully acknowledging the biases to human behaviour in the design and rollout of HIV prevention interventions, HIV infections will continue to soar, or at best, the control of the epidemic will face unacceptable and unsustainable costs.
HIV/AIDS has been ever-present since it was first described in 1981. In the following decades millions of lives have been lost, billions of dollars spent, and immeasurable potential has been missed in the face of HIV. Despite the great strides we have made in HIV prevention and care, 37.7 million people are living with HIV today, and 1.5 million people became newly infected with HIV in 2020, with adolescent girls and young women (AGYW) bearing the brunt of the epidemic in sub-Saharan Africa. Could understanding the biases to human behaviour and how they affect the uptake and use of HIV prevention methods could offer new insights to help end HIV/AIDS? This is where behavioural economics comes in.
Although a cure for HIV/AIDS is yet to be found, much progress has been made since the 1980s. HIV/AIDS has in many ways been unmasked, with decades of research giving people access to multitudes of information and resources about HIV prevention and how to support those living with the virus. In the last two decades, antiretroviral therapy (ART) has transformed HIV into a chronic and manageable condition; ongoing improvements in the efficacy of and accessibility to ART continue to allow more people to benefit from this life-saving intervention. A host of other HIV prevention methods have also played a critical role in tackling the HIV epidemic, including male and female condoms, post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), voluntary male circumcision, and prevention of mother-to-child transmission, not forgetting the increased availability and acceptability of family planning services and HIV testing and counselling services. Today, long-acting multi-purpose prevention technologies that can prevent both HIV and unintended pregnancy are also in development. But how can we facilitate the uptake of and adherence to these tools?
HIV prevention interventions, and health interventions in general, assume that people are rational beings who will do what is in the best interest of their health. In other words, we assume that people understand the purpose of HIV prevention methods and that they will use them no matter what. But either by nature or circumstance, people are often irrational.
Research has shown that people will engage in condomless sex or have multiple sex partners, even when this increases their risk of acquiring or transmitting HIV and other sexually transmitted infections, or becoming pregnant. Similarly, some individuals do not adhere to ART, even in the absence of side effects, despite knowing that it will keep them healthy. People do not act this way because they don’t want the best for their health but because they have inherent behavioural biases – and these biases affect our decision making. For instance, sex workers may offer condomless sex at a premium, despite a greater risk of acquiring HIV, because they are acted on by present bias. Present bias is the tendency to settle for a seemingly smaller present reward, such as an increased payment for sex, rather than prioritising a more beneficial long-term reward, such as reduced risk or acquiring HIV and subsequent poorer health outcomes. Additionally, someone may not take their medication because they are acted on by the intention-action gap, where an individual wants to do something but does not actually go through with it. In this instance, the individual in question may want to take their medication but is not able to due to reasons such as treatment-related stigma or difficulties in scheduling their medication.
While these biases interact with structural factors, such as socioeconomic status or social capital, an individual is likely unaware that they even exist or affect them in the way they do. Studying behavioural biases in this context can offer novel insights into HIV prevention interventions by exploring the underlying biases inherent to human nature and their implications for novel interventions.
Without fully acknowledging the biases to human behaviour in the design and rollout of HIV prevention interventions, HIV infections will continue to soar, or at best, the control of the epidemic will face unacceptable and unsustainable costs. Behavioural economics is grounded in the understanding of these biases and should be included as a key component of any HIV prevention research, from inception to rollout. Through diversifying our research lens, we can better inform the formulation, design, delivery, and promotion of HIV prevention technologies that are acceptable, appropriate, and affordable.
The UPTAKE project is a unique and novel opportunity to tap into behavioural change attributes in a bid to reduce and eliminate HIV infections. It is an opportunity to consider the perceptions, needs, and behaviours of Ugandan and Kenyan AGYW and female sex workers in planning the design and delivery of HIV prevention technologies. The results from this study will have tangible, real-world impacts, informing researchers, implementers, and policymakers on how to roll out long-acting HIV prevention technologies that meet the needs of key populations in Kenya and Uganda, and even beyond.