The Unattractive Free

Does “FREE” make HIV testing services more or less desirable?



The COVID-19 outbreak has disrupted the provision of HIV testing services due to the re-allocation of human resources towards COVID-19 responses and the overall reduced facility visits due to COVID-19 fears. While the reallocation of resources was unavoidable, challenges in HIV testing uptake existed prior to the COVID-19 outbreak. HIV testing is the gateway to HIV prevention and treatment services and innovative approaches are required to increase and maintain the demand for these valuable services, particularly in countries like South Africa where HIV infection rates continue to remain high. 



FREE HIV Testing

HIV testing services are provided for free in public health facilities in an effort to reduce the financial barrier to accessing these services. Despite these efforts, there remains a gap between actual testing uptake and that required to meet the 95 95 95 goals. In 2019, about 92% of people living with HIV were aware of their status.  


Most HIV demand creation material promotes FREE HIV testing services. Yet, it remains unclear whether the promotion of free health services achieves the intended outcomes. Is the concept of “free” becoming unattractive to the intended users? While this question has not been answered on free HIV testing promotion, a number of studies on the use of mosquito nets to prevent malaria have shown that nets provided for a minimal fee increased demand and usage compared to free nets (1,2). These studies highlight the sense of ownership and urgency to use the net when there is monetary value attached to it. 


The applicability of these studies to accessing free HIV studies has not been established. However, behavioural science can help us understand the contextual and cognitive challenges that hamper  interest in accessing healthcare services that are rendered for free. It can also offer insights into alternatives that might help improve the uptake of these services.   



Behavioural heuristics and cognitive biases 

Behavioural heuristics, or “mental shortcuts” that facilitate problem-solving and probability judgements, are central in explaining human behaviour in relation to the uptake of services (3).  Generally, people rely on these shortcuts when making decisions and can display cognitive biases when doing so. For example, a person who is newly diagnosed with HIV may anchor on one story they heard about someone feeling sick from ARVs, when this may not be representative of all people in care, and this may discourage them from initiating ART.  In this post we discuss cognitive biases such as loss aversion and the endowment effect and how we can leverage these to increase the uptake of HIV testing services.



What are the alternatives to ‘FREE’?

Although cost can be an important barrier to HIV testing uptake, a person being offered ‘free’ testing may assume a lower quality service with unattractive attributes like long waiting periods and inexperienced staff. Offering free testing may therefore not be enough to drive uptake and may in fact discourage some from testing. We test an alternative theory in our Behavioural Insight Test (BIT project) with the Foundation for Professional Development (FPD).


The aim of this BIT is to determine whether HTS demand creation material leveraging behavioural science principles increases demand for HIV testing at clinics operated by general practitioners. This is not representative of those testing at public facilities. 


The BIT project has three arms: 1) brochures that advertise the availability of comprehensive and free health screening and 2) vouchers that emphasise the value of HIV testing services that can be obtained for free 3) standard of care promotional materials for HTS. Read more on the intervention arms for the FPD BIT project here.


In one of the study arms, we offer a ZAR100 HIV testing voucher to participants with an instruction to redeem the voucher from a participating GP practice before a specified date. The voucher leverages the principles of loss aversion and the endowment effect. Loss aversion refers to the idea that individuals tend to want to avoid losses more strongly than they enjoy equivalent gains. The endowment effect is a byproduct of loss aversion and describes how people tend to value things that they own more than something that does not yet belong to them (4). 





Receiving a voucher highlighting the monetary value of the “free” HIV test may be more effective than offering free testing only, since it gives a sense of ownership of the value of the test (endowment) and therefore potentially an aversion to losing this value by not testing (loss aversion) and “losing” the amount of the voucher.  


We suggest that demand creation material for HIV testing needs to closely consider and adopt behavioural principles to account for the ways people think and make health decisions. With the growing demand to keep the momentum within HIV testing programmes, behavioural science offers insights for rethinking how HTS is promoted. Behavioural changes have the potential to increase the uptake of HTS even in contexts where resources remain constrained.  Our approach is one potential solution that can be tested and implemented to move the needle on HTS uptake. Another possible recommendation is providing testing at locations more frequently associated with paid healthcare such as GPs or private pharmacies. 

 By: Simamkele Bokolo Indlela Nudge Associate |06.12.2021

This disclaimer informs readers that the views, thoughts, and opinions expressed in the text belong solely to the author, and not necessarily to the author’s employer, organization, committee or other group or individual.


  1. Moscibrodzki P, Dobelle M, Stone J, Kalumuna , Chiu YM and Hennig N. 2018.Free versus purchased mosquito net ownership and use in Budondo sub-county, Uganda. Malaria Journal, 17, 363
  2. Comfort A.B and Krezanoski P.J. 2017. The effect of price on demand for and use of bednets: evidence from a randomized experiment in Madagascar. Health Policy and Planning, 32: 178–193
  3. The Decision Lab, Why do we take mental shortcuts? Accessed online at
  4. Kahneman D, Knetsch J.L and Thaler R.H. 1991. Anomalies: The Endowment Effect, Loss Aversion, and Status Quo Bias. The Journal of Economic Perspectives, 5(1): 193-206

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