Pay-it-forward to increase testing for hepatitis B and C: a community-led randomized controlled trial in China

Abstract Hepatitis B virus (HBV) and hepatitis C virus (HCV) testing rates remain low in China, especially among men who have sex with men (MSM). Pay-it-forward involves having a person receive a free test with community-generated messages and then asks if those who received a free test would like to donate money or test to support subsequent other people to also receive free testing. This study aimed to evaluate the capacity of a pay-it-forward strategy with active community participation to promote HBV and HCV testing among MSM in China. We undertook a two-arm superiority cluster-randomized trial led by MSM community-based organizations in two cities in the Jiangsu Province, China. As part of the intervention, MSM peers were actively involved in planning and leading the trial. Enrolled MSM were randomized to the pay-it-forward (intervention) and standard-of-care (control) arms in groups of ten. Men randomized to the pay-it-forward arm received free HBV and HCV testing and were offered a chance to pay-it-forward by donating money to support the testing of another anonymous person. In the standard-of-care arm, each participant paid for their HCV and HBsAg antibody rapid test at US $7.7/test. Only the staff who performed data analyses were blinded. The primary outcome was the proportion of men tested for HBV and HCV. We pre-specified sub-analyses based on substance use, risky sexual behaviors, and people older than 30 years. The trial was registered in the China Clinical Trial Registry (ChiCTR 2100046140). Between March and October 2021, 322 MSM were randomized to the pay-it-forward (n=160) and standard-of-care (n=162) arms. HBV and HCV rapid testing was notably higher in the pay-it-forward arm (59.4%) than in the standard-of-care arm (25.3%) (proportion difference (PD) 34.4%, 95% CI lower bound 26.9%). Sub-analyses demonstrated that the pay-it-forward intervention was effective among people who use substances, people with risky sexual behaviors, and older individuals. Among men in the pay-it-forward arm, 101/160 (63%) donated some amount to future participants, and the total donation amount covered over half (68%) of the test cost in the pay-it-forward arm. Economic evaluation found that the pay-it-forward model was cheaper than the standard of care, considering economic or financial costs per person tested. The pay-it-forward approach improved HBV and HCV testing among an at-risk populations in a resource-constrained environment. Pay-it-forward model appeared to be managed successfully in a real-world setting, especially as a part of community-led efforts to reach higher-risk populations.