Pay-it-forward dual gonorrhea/chlamydia test uptake among men who have sex with men in China: a pragmatic, quasi-experimental study

Background: Chinese men who have sex with men (MSM) rarely receive gonorrhea/chlamydia testing. The purpose of this pilot study was to evaluate a pay-it-forward strategy to increase gonorrhea/chlamydia testing among MSM. Pay-it-forward has one person receive a gift, then asks the same person if they would like to give a gift to another person. Methods: We used a quasi-experimental pragmatic study to compare a pay-it-forward model to standard of care at two HIV testing sites for MSM. A pay-it-forward program was implemented for three months, during which men were offered free gonorrhea/chlamydia testing and given the option of donating money toward testing for future participants. Both sites then switched to standard of care for three months, offering dual testing at the standard price. We compared test uptake and financial costs in the two groups. Findings: 408 men were included in this study. 203 men were offered pay-it-forward, and 205 were offered standard of care. Overall, 109 (109/203, 53·7%) men received gonorrhea/chlamydia testing in the pay-it-forward group and 12 (12/205, 5·9%) men received gonorrhea/chlamydia testing in the standard of care group (adjusted odds ratio 19·73, 95%CI 10·02-38·85). This was a first gonorrhea or chlamydia test for 86% (104/121) of men. 89% (97/109) of men in the pay-it-forward group donated some amount. The incremental unit cost per test in the pay-it-forward group was 67 USD, compared to 503 USD in the standard of care group. Interpretation: Pay-it-forward may be a sustainable model for expanding integrated HIV testing services among MSM in China