Financial Incentives May Improve Treatment Adherence, Viral Suppression Among HIV Patients

Financial incentives can increase viral suppression, as well as regular clinic attendance, among patients with HIV.

In a study published in JAMA Internal Medicine, investigators sought to determine whether the use of financial incentives improved linkage to care and viral suppression in HIV-positive patients.

The study was a community-based clinical trial conducted in 37 HIV test sites and 39 HIV care sites in the Bronx, New York, and Washington, DC, which were randomized to financial incentives or standard of care.

Participants at financial incentive test sites who tested positive for HIV received coupons redeemable for $125 cash-equivalent gift cards upon linkage to care. Patients who underwent antiretroviral therapy (ART) at financial incentive care sites received quarterly $70 gift cards if virally suppressed.

For linkage to care, the primary outcome was the proportion of HIV-positive patients at the test site who linked to care within 3 months. The primary outcome for viral suppression was the proportion of established patients at HIV care sites with suppressed viral loads at <400 copies/mL, assessed at each quarter.

The continuity in care outcome was defined as the proportion of patients with CD4+ cell count or HIV viral load test results in the surveillance system during at least 4 of 5 prior calendar quarters.

Overall, 1061 coupons were handed out for linkage to care at 18 financial incentive test sites, and 39,359 gift cards were dispensed to 9641 HIV-positive patients eligible for gift cards at 17 financial incentive care sites.

Although financial incentives did not increase linkage to care, the results of the study showed that they did significantly increase viral suppression. The proportion of patients with viral suppression was 3.8% higher at financial incentive sites compared with the standard of care sites.

The proportion of viral suppression among patients who were not consistently virally suppressed previously was 4.9% higher at financial incentive sites. Furthermore, continuity in care was 8.7% higher at financial incentive sites.

Limitations to the study were that the affect of financial incentives may have been diluted because all patients in care at HIV care sites—–including those not receiving treatment––were included in the viral suppression outcome assessment because treatment status is not available in the surveillance system; for some nonresident patients receiving care at sites in Washington, DC, their CD4+ and viral load data were reported to their jurisdiction of residence rather than Washington, DC, potentially hindering the complete capture of data; and there was limited power to assess changes in linkage to care because linkage was high at baseline, and the number of patients with HIV who were identified per site was substantially lower than expected.

“Effective interventions are needed to garner the benefits of antiretroviral therapy for the individual and for the society,” said lead investigator Wafaa El-Sadr, MD, MPH. “The results of this study are encouraging and should motivate efforts to pursue the further assessment of using financial incentives in HIV treatment programs and to determine their potential impact when scaled up.”

The authors noted that the findings demonstrated the feasibility of using financial incentives in a large community-wide effort and the successful linkage of large-scale research with the established surveillance system. However, more research needs to be done to determine the cost-effectiveness of their findings.

“While our findings offer an innovative intervention for achieving the treatment and prevention potential of antiretroviral therapy, a strategy that offers great promise for control of HIV in the United States and globally, more research is needed to determine how such an intervention can be implemented in programs and at scale,” the authors concluded.