Applications of Behavioral Economics to HIV Programs in Low and Middle Income Countries: A Scoping Review Using the EAST Framework

Despite significant gains and successes in many areas, progress in HIV prevention and treatment is uneven, highlighted in the 2022 UNAIDS report In Danger, and certain populations are being left behind. In particular, men and adolescent girls and young women (AGYW) are among the groups in danger of not reaching epidemic control targets. Among other calls for utilizing scientific innovations, PEPFARs Office of the Global AIDS Coordinator and Health Diplomacy recently highlighted the need to expand the use of innovative methods from behavioral science in HIV programs. One of these innovative, but underused, approaches is behavioral economics (BE), which leverages our predictable cognitive biases and mental shortcuts to both diagnose behavioral factors and positively influence behavior. The tools used by BE to change behavior are frequently called nudges, which tend to be low-cost and easy-to-implement interventions. This scoping review identified nudges applied to select client and provider behaviors along the HIV prevention, testing, and care and treatment continuum. It maps them to the commonly used EAST Framework, a simplified way to classify nudges for program design and highlights those that shifted behavior. The EAST Framework groups nudges into Easy, Attractive, Social, and Timely categories. This scoping review identified that Easy nudges were commonly applied as changes to the structure of HIV programs, influencing individual behavior through program changes. Nudges that directly targeted individuals most commonly fell into the Attractive and Social categories. Many of the individual-focused nudges in the Attractive and Social categories changed behavior, along with Easy nudges. Additionally, the mapping highlighted the dearth of nudges applied to provider behavior in the Low and Middle Income (LMIC) HIV space. Further integration of nudges into HIV programs and their evaluation using implementation science may help move the needle to end the HIV epidemic as a public health threat by 2030.