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Agreements with cash incentives boost patient adherence to HIV therapy and rates of viral suppression
Michael Carter, 2017-05-30 10:30:00
Patients who enter into a contract
with their HIV healthcare provider to receive cash incentives in return for
high levels of antiretroviral therapy adherence (ART) are more likely to achieve
sustained viral suppression compared to patients in a control arm,
investigators from the United States report in the online edition of AIDS.
The study recruited patient with
ongoing viral replication despite at least six months of ART. Individuals who
entered into a commitment contract were approximately four times more likely to
have viral suppression compared to patients in a control arm at an
unanticipated follow-up approximately three months after the end of the
“This study demonstrated the
feasibility of using commitment contracts in HIV care,” comment the
investigators. “A notable feature of our study is that after the incentives for
ART adherence and provider visits were removed, participants who had been offered
a commitment contract for ART adherence were more likely to achieve virological
suppression relative to individuals who had been assigned a conditional cash
transfer for provider visits and relative to individuals who had been assigned
to standard of care.”
Adherence is key to the success of
ART. However, many patients find it difficult to achieve the high levels of
adherence needed for sustained viral suppression. Factors associated with
sub-optimal adherence include socio-economic status, mental health and
Research exploring the effect of
monetary incentives on ART adherence has had mixed results. Investigators in
Alabama wanted to see if offering cash incentives in combination with contracts
to adhere to HIV therapy increased rates of viral suppression.
They designed a single-centre
randomised controlled trial. Patients with a detectable viral load (above 200
copies/ml) despite at least six months of ART were eligible for inclusion.
Forty patients were recruited to
the study. They were randomised into two arms.
Patients in the first arm (21
individuals) received a $30 cash incentive to attend their scheduled HIV clinic
appointment (provider visit incentive [PVI] arm). Patients in the second arm
(19 patients) received a similar $30 cash incentive but in addition to attending
their follow-up appointments also entered into an agreement to adhere to their
ART (incentive choice [IC] arm). A third study arm consisted of 70
non-randomised patients with ongoing viral replication despite ART and who
received standard of care.
Patients attended five follow-up
visits. Patients who entered into a commitment contract only received the $30
cash reward if they took at least 90% of their treatment doses since the last
study visit (adherence was assessed using dose-recording pill caps).
Viral load was measured at the
fifth study visit and then at an unscheduled study visit approximately three
months after the last of the incentivised study visits.
At the fifth study visit, 42% of
patients who entered into commitment contracts had viral suppression, compared
to 38% of patients who received incentives for attending appointments and 34%
of individuals in the unrandomised control arm. The chances of viral
suppression did not differ significantly between the three groups.
At the sixth, unscheduled, visit,
68% of patients in the adherence agreement arm were virally suppressed,
compared to 43% of patients in the appointment incentive arm and 41% of
patients in the control arm. The chances of viral suppression did not differ
between the adherence agreement and appointment incentive groups. However,
patients who entered into an adherence commitment were approximately four times
more likely to have viral suppression compared to individuals in the control
arm (aOR = 3.93; 95% CI, 1.19-13.04, p = 0.025).
“Commitment contracts can improve
ART adherence and virological suppression,” conclude the authors. They suggest that the commitment contract may have been more effective not only because of the direct incentive, but also because the element of choice gave participants greater feelings of personal engagement and empowerment in management of their condition.