Is there a place for behavioural science in South Africa’s TLD transition programme?

One of the recent advances in HIV treatment is Dolutegravir (DTG) and its adoption as part of the first line for HIV treatment. DTG has better efficacy, fewer side effects, higher barrier to resistance and is more affordable than alternatives.  In 2019, the World Health Organisation (WHO) recommended dolutegravir-based regimens as the preferred first-line treatment for all people living with HIV. These recommendations were adopted by the South African government the same year with care recipients transitioning to the DTG containing first line regimen Tenofovir-Emtricitabine-Dolutegravir (TLD).


Although tremendous progress has been made in the roll-out of TLD in South Africa, there have been some challenges.  These challenges include the hesitancy of clinicians to initiate and switch care recipients onto TLD due to initial reports on drug safety. There has also been hesitancy of patients to switch, possibly because they feel well and stable on their current regimen or because they have heard about possible side effects. Considering the size of the South African treatment programme and the benefits of TLD over the Tenofovir/Emtricitabine/Efavirenz (TEE) regimen previously recommended, this transition is crucial for South Africa to achieve the UNAIDS goals for treatment and viral control. Applying behavioural science principles to the TLD transition programme has the potential to address some of the behavioural barriers from provider and care recipient perspectives that may be affecting adoption rates. 


In an ideal world, clinicians and care recipients would make optimal decisions based on available evidence. Behavioural science, however, tells us that people don’t always make optimal decisions, weighing out costs and benefits, but instead use mental shortcuts. These shortcuts may be helpful but may also lead to decision making biases that can result in health states not desired by the decision maker. In this Viewpoint, we explore several examples of how behavioural science can be used to facilitate the transition from TEE to TLD, considering the biases likely at play and the solutions (nudges) available to combat them.



Fig 1: TLD journey map: Illustrated by Laura Schmucker



Anchoring bias

This cognitive bias occurs when our decisions are influenced heavily by the first piece of information we are given about a topic. Initial studies highlighted the risk of neural tube defects (NTD) in children born to women using dolutegravir at conception. Although subsequent research showed that the risk of NTD was low, clinicians and some care recipients were anchored on the first evidence and guidance. Care recipients may also be anchored on the idea that changing regimens means they are failing on their current line of treatment. This may all be confusing and distressing for them.  


Ensuring that clinicians and care recipients understand the risks and also the benefits of TLD over TEE and that this information is salient is likely to lead to better decisions about patient treatment and less concerns. Another approach for addressing anchoring bias is to provide reasons why a particular anchor is inappropriate.  The anchor on NTD in particular only applies to persons with child bearing capacity and those wanting to conceive. Highlighting that for many individuals, this particular anchor has no relevance may be helpful.


This can all be done by using behaviourally informed communication material targeting care recipients, training and scientific webinars for clinicians. For clinicians, the guidance on clinical management of women of reproductive age on TLD must be clear, well documented and communicated.  




Present bias

This is the tendency to focus on the present moment that results in individuals placing greater value in small immediate rewards as opposed to larger future rewards.  


Clinicians have to contend with overburdened clinics and may worry that the process of changing regimens may slow down their work and create more hassle for them. For care recipients, present bias may occur when the benefits of changing from TEE to TLD may occur in the distant future and are not salient to the care recipient. In fact, if they are stable on treatment with no side effects they may see no added or tangible benefits of changing regimens.


Commitment devices may be useful to ensure clinicians prescribe TLD to all eligible care recipients despite the hassle and also that care recipients agree to go through the process.  These are tools that bridge the gap between intent (clear in a “cold” or “rational” state) and the desired behaviour (harder to perform in a “hot” state). An example may be signing clinicians up to give weekly statistics on their prescriptions or ordering less TEE for the clinic. Checklists can also be used as a cognitive tool that forces clinicians to systematically engage with certain topics, like whether or not a care recipient is on TLD.  Another way to address present bias is to rebalance the current versus future costs and benefits. A way to do this for clinicians would be that a pharmacist only accepts a script for TEE if there is a written justification for why there was no transition? This forces the clinician to mentally justify not changing while the written justification may be perceived as an additional cost in the present.




Status quo bias 

This is when individuals have a strong preference for things to stay the same as opposed to changing them.  For both clinicians and care recipients, this bias is likely at play resulting in failure to transition to TLD in spite of the overwhelming evidence that it is better for care recipients to be on TLD. 


A possible way to mitigate its impact is to re-enforce the TLD regimen as the default option. Practically, there are several ways this could be accomplished. One way is to pre-fill ART prescription pads with TLD, ensuring that this is the salient default.  In a study by King et al, they redesigned the prescription chart and saw a significant reduction in prescribing errors.  Meeker et al in their study found that a commitment poster in waiting rooms for better antibiotic use decreased inappropriate antibiotic prescribing. This would suggest that, in a similar way, a poster saying “All the clinicians in this clinic are committed to giving you the best HIV care – ask your provider today about the latest ARV drugs” could lead to an increase in TLD prescribing. 




Where to from here?

While a substantial evidence base exists on the benefits of behavioural science and nudges (not without question), context still matters. Although it seems clear that behavioural science may inform interventions to improve the uptake of TLD, more research is needed to understand what is likely to work best. Indlela has recently published the NUDGE handbook which provides clear guidance on how to practically apply behavioural science to bring about behaviour change.  We have also launched the Behavioural Hub (B-Hub), which will allow us to rapidly incorporate the perspectives of care recipients, community members and healthcare workers in the design and evaluation of nudges. The B-Hub can be used as a platform to test interventions quickly before roll out. These two resources can help with the design of interventions for the TLD transition. 


We would be remiss if we did not mention the importance of accounting for and addressing system level factors in this equation as detailed by Chater and Loewenstein in their paper. Health system challenges that include but are not limited to drug supply chain management and responsive laboratory services would also need to be addressed to ensure that once client and provider barriers to TLD transition are addressed, supply chain and drug stocks don’t present further challenges in the future. 


One of the core principles of nudging remains that of “libertarian paternalism” – pushing individuals gently towards a behaviour but allowing them an easy way out. The TLD transition is a complicated situation and any interventions in the current context need to consider the ethics of nudging.  Is this an appropriate situation for a nudge or should the transition be mandated (“shove”)? Should a care recipient be ‘encouraged’ or persuaded to change regimens if they are doing well on their current treatment and would rather not or do the benefits for the wider population outweigh the option of personal choice? Some controversial, yet interesting points to consider. We would love to hear your thoughts and hopefully learn more from these conversations.



By: Caroline Govathson Indlela’s Snr Nudge Associate |01.12.2022