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Weiming Tang, PhD, Joseph Tucker, MD, PhD, and David van Duin, MD, PhD

Pay-it-forward programs, whereby someone receives a gift or free service and then gives a gift to another person in return, have expanded during the COVID-19 pandemic and provide an opportunity for healthcare providers to reduce costs, increase uptake of interventions such as testing and vaccines, and promote sustainability.

Weiming Tang, PhD, and Joseph Tucker, MD, PhD, explain how kindness can be contagious in healthcare in a recent article published in Nature Medicine. Now, a five-year $3 million R01 grant will fund a study that considers how pay-it-forward approaches can increase gonorrhea testing among gay and bisexual men in south China.

Tang is first author of the study and co-director of UNC Project-China, who recently returned to the Department of Medicine to serve as associate professor in infectious diseases. Tucker is also an associate professor of infectious diseases, joined by David van Duin, MD, PhD, professor of infectious diseases. Other members of the study team include Kurt Gray, PhD, Rohit Ramaswamy, PhD, MPH, and Fei Zou, PhD.

Study Outline

Most men who have sex with men (MSM) do not receive gonorrhea testing, contributing to delayed treatment and potentially amplifying antimicrobial resistance. Poor test uptake is often related to costs associated with STD testing and minimal community engagement. The study will test a pay-it-forward intervention to enhance gonorrhea testing among MSM. Pay-it-forward involves an individual receiving a gift (in this case, a gonorrhea test) and then be provided the opportunity to give a gift (in this case, money to support gonorrhea testing) to another person.

Specific Aims

The study extends strong research collaborations between Southern Medical University in Guangzhou, SESH (Social Entrepreneurship to Spur Health), and the UNC IGHID. It will use a three-arm cluster randomized controlled trial to compare gonorrhea testing uptake in a standard pay-it-forward strategy arm, a community-engaged pay-it-forward strategy arm, and a control arm reflecting current practice. It will determine mechanisms through which different pay-it-forward strategies activate upstream reciprocity to influence gonorrhea testing and donations. It will also examine the impact of enhanced gonorrhea testing on the development of gonorrhea resistance. Based on prior work, the study team hypothesizes that a community-engaged pay-it-forward strategy will increase gonorrhea test uptake rates compared to the standard strategy, and that pay-it-forward in general is superior to the current practice of paid testing.

The study will also provide a new financing mechanism to support gonorrhea testing, test implementation strategies to enhance the effectiveness of this mechanism, and provide more detailed information about the relationship between increasing testing and the development of antimicrobial resistance. It will also have significant public health implications for the delivery of sexual minority health services in low and middle-income countries, aligned with the mission of NIAID.

Read more about the pay-it-forward principle and how researchers believe it can encourage healthy behaviors and mobilize community resources, in Nature Medicine.