Principal Findings
infections, gonorrhea, chlamydia
INFECTIONS, GONORRHEA
Upstream reciprocity theory suggests that people who are cared for by someone are more likely to help others. Our study confirmed this theory by promoting chlamydia and gonorrhea testing among FSWs in China through a pay-it-forward approach. Our study extends the existing literature by testing the effectiveness of the pay-it-forward approach in increasing STI testing uptake among FSWs, conducting the study in an outreach setting outside of a formal clinic, and integrating the approach with HIV services. As a social innovation approach, we found that the pay-it-forward intervention dramatically increased STI testing uptake among Chinese FSWs and that the participants covered a substantial portion of the costs associated with testing.Women in the pay-it-forward arm had higher chlamydia and gonorrhea testing uptake than women in the standard-of-care arm. This finding is consistent with previous studies among Chinese MSM, which suggest that the pay-it-forward approach can motivate more people to use STI testing services [Lack of community engagement and low social trust are 2 critical barriers to STI testing uptake among FSWs [Our findings indicate that the pay-it-forward strategy increased STI testing uptake and reduced barriers to sustaining STI testing. STI testing among FSWs reduces STI transmission and adverse sexual and reproductive health consequences. The pay-it-forward approach provides an alternative to using limited public funding to maintain or expand testing. Our findings need to be extended beyond this initial research study, as they have several public health implications. First, a pay-it-forward strategy could reduce costs for STI testing for funding bodies and dramatically remove the financial barrier to STI testing among participants. Second, unlike the free-testing approach, the pay-it-forward method could generate strong community ownership and trust. Third, as an approach to increase testing uptake and the regularity of testing, the pay-it-forward intervention has a robust public health benefit. Improving testing coverage and the regularity of testing could reduce the high chlamydia and gonorrhea prevalence among Chinese FSWs (17.3% for chlamydia in our study) by identifying and treating asymptomatic infections earlier, thus reducing morbidity and onward transmission to the clients of FSWs and their other sexual partners [