Can a 'Pay-It-Forward' Model for STI Testing Work in the US?: Public Health Watch

Ever since the release of a film about a teacher who tasks his students with devising a plan to change the world for the better, the phrase “Pay It Forward” (the title of the movie, released in 2000) has come to mean taking care of others in hopes that society will later return the favor.

Recently, however, public health specialists have put a different spin on the concept, using it to encourage at-risk populations to take care of themselves by putting them in a position to better their communities at the same time. But can the model work in the United States, where money is everything in health care?

“The success of pay-it-forward…is likely related to the financial incentive—free things often decrease barriers to uptake,” Joseph D. Tucker, MD, PhD, associate professor at the University of North Carolina School of Medicine, director at UNC Project-China, and the leader of a project employing the concept, told Contagion®. “But the success of pay-it-forward to inspire trust is likely related to the strong community engagement baked into the program. I think this would work best in places where there is a group that has a sense of collective identity and lacks uptake of some fee-based health service.”

Dr. Tucker’s project, which was designed to increase uptake of gonorrhea and chlamydia testing among men who have sex with men in China, was chronicled in a paper published on January 1^st in The Lancet Infectious Diseases and received funding from the National Institutes of Health, Southern Medical University Dermatology Hospital, and the Doris Duke Charitable Foundation. It compared testing uptake in a pay-it-forward model in which men were offered free testing and given the option to donate money to fund testing for future participants, with a standard-of-care model, in which men paid a standard price for testing (about ¥150, or $21.50). The pay-it-forward program was in place for 3 months, after which both sites switched to standard of care offering dual testing for 3 months.

In all, 203 men were enrolled in the pay-it-forward group, while 205 were charged the standard price for testing, and the differences in testing uptake were striking, with 109 (54%) of those in the pay-it-forward group getting tested, compared to just 12 (6%) of those in the standard-of-care group. Of the 109 men who received testing in the pay-it-forward group, 97 donated toward testing for future participants. Notably, the testing offered in the study was the first gonorrhea test for 97 (80%) of the participants and the first chlamydia test for 104 (86%). Ultimately, 5 (4%) of the participants were diagnosed with gonorrhea and 15 (12%) were diagnosed with chlamydia as a result.

Historically, China, like most low- and middle-income countries, has a poor track record when it comes to testing for sexually transmitted infections (STIs) among high-risk populations such as men who have sex with men, according to Dr. Tucker. Here in the United States, where testing rates are higher, he said, “there are still gaps in routine screening”—despite efforts by the US Centers for Disease Control and Prevention.

Could a pay-it-forward approach help fill these gaps? Philip A. Chan, MD, medical director of the STD Clinic at Miriam Hospital-Providence, which is the only publicly funded STD clinic in Rhode Island, isn’t so sure, and neither is Julia Raifman, ScD, assistant professor of health law, policy, and management at Boston University School of Public Health, who has published articles on related topics in the past.

“The cost of care is still a significant barrier for STI testing in the United States,” Dr. Chan, who is also an associate professor of medicine and associate professor of behavioral and social sciences at Brown University, said. “Many people in the [United States] remain uninsured and don’t have access to health care including STI testing. Even for people who are insured, rising out-of-pocket costs related to co-pays and deductibles may present barriers to STI testing. These barriers may be more pronounced among undeserved populations.”

“I think we should structure our health system to support public health and health equity, rather than in a manner that puts the onus on patients whose health is largely shaped by the broader social context,” Dr. Raifman added.

And as rates of STIs, including chlamydia, gonorrhea, and syphilis, continue to increase in the United States, driven in part by increases among men who have sex with men, she continued, it’s vital that an approach that removes cost of care as a barrier, and financial burdens from at-risk populations, comes to the fore.

A commentary published January 9^th in the Journal of the American Medical Association describes a model used by a clinic in Denver in which patients are offered free “express testing.” In this approach, patients effectively collect samples for testing themselves, without undergoing a physical exam, thereby mitigating the need for—and co-pay and fees related to—a physical exam.

“Treating sexually transmitted infections is important for preventing onward transmission for the whole community, not just those who have sexually transmitted infections,” Dr. Raifman said. “Across countries, approaches such as ensuring everyone has health insurance coverage for basic services such as STI treatment and that public health initiatives such as STI treatment are covered at no or low cost will benefit all of society.”

In other words, the patients themselves aren’t necessarily the only ones who should “pay it forward.”