A systematic review led by Dorian Ho (UNC BSPH-2025), and Joseph Tucker, co-director of UNC Project-China and a member of the UNC Institute for Global Health and Infectious Diseases, found that givers leveraged altruism, agency, and relationality with recipients to improve distribution and use of health services in their social networks. Distributing or donating services to others could foster a prosocial identity that increased givers’ concern and responsibility for others’ health needs. Published in JAMA Network Open, the findings suggested that donation-based interventions could improve service uptake among marginalized populations using psychosocial assets already within those networks.
“When people share health services within their networks, they’re not just distributing tests or supplies—they’re building prosocial identities that strengthen community health,” said Ho, working with UNC Project-China, and now an MD Candidate at Icahn School of Medicine at Mount Sinai in New Jersey. “These interventions help communities support each other’s health in ways traditional systems often can’t.”Donation-based pro-social interventions involve someone receiving a free health service and then distributing or donating to support health services for others. Examples within the HIV and sexually transmitted infection (STI) literature include secondary distribution of HIV self-tests, secondary syringe exchange, and pay-it-forward for STI testing. These interventions answer research and policy recommendations to incorporate prosocial behaviors into HIV/STI services.
Secondary distribution involves participants giving health services (HIVST kits, syringes) to persons in their social or sexual networks. Pay it forward involves a participant being given a free health service and offered the opportunity to donate money to support another participant’s health service.”
Methods and Results
The review followed rigorous guidelines, including PRISMA and the Cochrane Handbook, to ensure a thorough and transparent approach. The research team searched five major databases—PubMed, CINAHL, Embase, PsycInfo, and Scopus—covering all studies up to January 23, 2024. They also hand-checked references of included studies and additional relevant papers. The search strategy, developed with a research librarian, focused on donation-based interventions, including terms like secondary distribution, social network distribution, pay-it-forward, and concepts related to reciprocity.
In total, 27 studies involving 1,543 participants were included, providing qualitative evidence on three types of donation-based interventions. These included secondary distribution of HIV self-test (HIVST) kits (15 studies), secondary syringe exchange among people who inject drugs (PWID) (10 studies) and pay-it-forward programs for STI testing among men who have sex with men (MSM) (2 studies). The studies came from low-income (5 studies), middle-income (13 studies), and high-income countries (12 studies).
Distribution Dynamics
The review revealed that donation-based interventions are shaped by a complex interplay of motivations, social facilitators, and practical or relational barriers. Together, these factors influence whether and how givers share health services within their networks.
Motivations
To begin, motivations for distribution were central to understanding why individuals chose to share health resources. Many givers were driven by altruism and a strong sense of moral responsibility. Their decisions were often grounded in a desire to protect peers, partners, and community members from HIV transmission, reflecting both personal concern and perceived social obligations. Beyond altruism, distribution also fostered a sense of agency and empowerment. By providing others with HIV self-tests, clean syringes, or other services, givers felt they were actively promoting healthier behaviors and challenging stigmatizing stereotypes about their communities. In some settings, transactional motivations also played a role, as distribution could provide financial or material benefits.
Facilitators
These motivations were strengthened—or constrained—by the social environments in which distribution took place. Community norms of sharing, particularly within marginalized groups, made donation-based interventions feel natural and acceptable. Social proximity and reciprocal relationships helped givers introduce services, reinforce trust, and create ongoing cycles of care. Practical facilitators, such as simple instructions and clear procedural knowledge, further enabled givers to confidently distribute health services and support recipients in using them correctly.
Barriers
However, the act of distributing health services was not without challenges. Some donors, particularly those engaged in secondary syringe exchange, encountered a heavy burden of responsibility. In certain contexts, distributing syringes placed individuals at risk of legal consequences or unwanted social roles. While HIV self-testing and pay-it-forward activities were generally less burdensome, they were not entirely free of risk. A small number of participants reported social harms—including relationship strain or, in rare cases, physical or sexual abuse—resulting from the disclosure dynamics or tensions created by distributing HIV self-test kits.
Results
The review makes clear that donation‑based interventions tap into altruism, agency, and social relationships to strengthen HIV and STI service use. By nurturing prosocial motivation within communities, these approaches offer an effective way to improve access to essential health services—especially for marginalized groups who benefit most from network‑based support.
“Community generosity is a powerful driver of HIV and STI service uptake,” Ho said.
Read the publication: Motivations, Facilitators, and Barriers of Donation-Based Interventions in HIV and Sexually Transmitted Infection Research