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Paying for antiretroviral adherence: is it unethical when the patient is an adolescent?
  1. Justin Healy1,
  2. Rebecca Hope1,
  3. Jacqueline Bhabha2,
  4. Nir Eyal2
  1. 1YLabs, Cambridge, Massachusetts, USA
  2. 2Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Justin Healy, YBank, 3 Concord Av, Cambridge, MA 02138, USA; justinhealy{at}


With the expansion of antiretroviral treatment programmes, many children and adolescents with HIV in sub-Saharan Africa could expect to live healthy lives. Yet adolescents have the highest levels of poor antiretroviral adherence and of loss to follow-up compared with other age groups. This can lead to increased morbidity and mortality, to the development of drug-resistant strains, and to high societal costs. While financial incentives have been extensively used to promote medication adherence among adults, their use among adolescents remains rare. And while there is a large body of ethical literature exploring financial incentives among adults, little philosophical thought has gone into their use among adolescents. This paper explores three oft-mentioned ethical worries about financial incentives for health behaviours and it asks whether these concerns are more serious in the context of incentives for improving adolescent adherence. The three worries are that such incentives would unduly coerce adolescents' decision-making, would compromise distributive justice and would crowd out intrinsic motivations and non-monetary values. Our tentative conclusion is that more empirical investigation of these concerns is necessary, and that at this point they are not compelling enough to rule out trials in which adolescents are incentivised for antiretroviral adherence.

  • Coercion
  • HIV Infection and AIDS
  • Public Health Ethics
  • Behavioural Research

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  • Twitter Follow Rebecca Hope at @YLabsGlobal and YLabs at @YLabsGlobal

  • Contributors All four authors contributed in all four of the ICMJE criteria for authorship. JH originally formulated the paper's main question and was helped by RH, JB and NE in the development and refinement of the resulting arguments. Each author actively participated in the drafting of the original paper and the adjustments following reviewer comments. All authors have approved this final draft and are happy to be held accountable for its contents.

  • Competing interests RH is one of the co-investigators of a pilot study investigating the feasibility and acceptability of financial literacy training, peer support and financial incentives for adolescents living with HIV in Rwanda.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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