# Pay-it-forward gonorrhea testing among men who have sex with men: The PIONEER pragmatic randomized controlled trial

> **NIH NIH R01** · UNIV OF NORTH CAROLINA CHAPEL HILL · 2021 · $638,835

## Abstract

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. We have developed 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. Pay-it-forward is an example of upstream reciprocity theory suggesting that people
who are helped by someone feel a “warm glow” that makes them more likely to help others. Pay-it-forward has
been used to encourage people to donate something to another person. But in this study, we will test the
effectiveness of two levels of implementation strategies based on upstream reciprocity to motivate gift
recipients to get tested for gonorrhea. Specifically, we will compare a standard pay-it-forward implementation
strategy with minimal encouragement to get tested and a community-engaged pay-it-forward strategy
alongside a control arm in which men pay for their own STD test. Our pilot randomized controlled trial in two
cities found that pay-it-forward substantially increased gonorrhea testing compared to the control arm (56% in
the pay-it-forward arm, 18% in control arm). Our pilot data also suggests that greater MSM community
engagement (e.g., MSM participatory activities to create testing messages) increases donations to the
program, reinforcing the hypothesis that a community-engaged implementation strategy can activate upstream
reciprocity. Intensified testing could also decrease antibiotic resistance. Building on our UNC Project-China
research infrastructure in China, we propose the Pay-It-forward gONorrhEa tEsting RCT (PIONEER). The
study has the following specific aims: (1) to 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; (2) to determine mechanisms through which
different pay-it-forward strategies activate upstream reciprocity to influence gonorrhea testing and donations;
(3) to examine the impact of enhanced gonorrhea testing on the development of gonorrhea resistance. Based
on our prior work, we hypothesize 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. Our proposal is innovative because it provides a new financing mechanism to
support gonorrhea testing, tests implementation strategies to enhance the effectiveness of this mechanism,
and will provide more detailed information about the relationship between increasing testing and the
development of antimicr...

## Key facts

- **NIH application ID:** 10185281
- **Project number:** 1R01AI158826-01
- **Recipient organization:** UNIV OF NORTH CAROLINA CHAPEL HILL
- **Principal Investigator:** Joseph David Tucker
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $638,835
- **Award type:** 1
- **Project period:** 2021-03-19 → 2026-02-28

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10185281

## Citation

> US National Institutes of Health, RePORTER application 10185281, Pay-it-forward gonorrhea testing among men who have sex with men: The PIONEER pragmatic randomized controlled trial (1R01AI158826-01). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10185281. Licensed CC0.

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