Identity-Based Behavioral Economic Incentives Increased PrEP Adherence for Transgender and Nonbinary Adults in a Trans-Led PrEP Navigation Program

Tailored supports are needed to maximize PrEP engagement among transgender and nonbinary (TGNB) adults, a population disproportionately impacted by HIV with low PrEP use, due to structural and economic barriers, particularly among TGNB individuals of color. This study piloted the integration of identity-based behavioral economic incentives, which use the science of decision-making to encourage beneficial behaviors, within an ongoing community-led, multi-component PrEP navigation program called PrEP Well . Prizes were selected through TGNB community input, were TGNB-affirming and specific to community needs, and included items sourced from TGNB-owned businesses; participants earned prize-wheel spins for PrEP-related steps. Among 108 TGNB adults at a trans-led Los Angeles community center (2022–2023; 36 enrolled before and 72 after incentives began), we conducted a non-randomized pilot trial assessing the acceptability, feasibility, and preliminary effects of incorporating these incentives into PrEP Well . Pilot results showed that, compared to standard PrEP Well , the addition of identity-based behavioral economic incentives was seen as feasible and acceptable, and produced a moderate effect on PrEP adherence at 90 days post-enrollment (78.6% vs. 56.3%, X 2 (1, 108) = 4.38, p < .05, φ = 0.20). Dose-response models indicated that each additional spin earned through the incentive program further increased the odds of PrEP adherence at 90 days by about 4.7-fold (95% confidence interval [2.34, 9.32], B = 1.54, p < .001). This improvement was achieved at a modest additional cost of approximately $51 per participant. Integrating behavioral economic incentives into community-based, identity-affirming service delivery models may be a promising, cost-effective approach for enhancing PrEP engagement and improving HIV prevention outcomes among TGNB adults.