Paying HIV Patients Increases Viral Suppression, Improves Treatment Adherence

Physicians have identified an effective new method for improving treatment adherence in HIV patients — paying them for good compliance.

According to a new study from treatment centers in the Bronx, NY and Washington, DC, giving HIV patients gift cards resulted in a 4% increase in viral suppression.

“While seemingly modest, an increase of 4% in viral suppression with FI [financial incentives] may potentially have considerable clinical and preventive implications on a population level, particularly in settings and among patients with less than robust viral suppression,” the study read.

Given the context that 13% of people who are HIV positive do not know their HIV status and approximately only 33% of HIV-positive patients in the U.S. have achieved viral suppression, financial incentives can play a role in closing this gap between HIV infection and successful treatment, according to Wafaa Ed-Sadr MD, MPH, MPA, University Professor of Epidemiology and Medicine at Columbia University and director of the Global Health Initiative at the Mailman School of Public Health.

In previous studies of financial incentives achieving desirable outcomes for health behaviors, 10 of 11 meta-analyses have shown positive results, the El-Sadr group wrote. In addition, other studies have reported that financial incentives have reduced the risk for contracting HIV.

This current study is believed to be the largest of its kind to investigate the impact of financial incentives on HIV care outcomes. The financial arm of the study ran from April 2011 through January 2013.

The research is based on an analysis of data in 20 HIV care sites in The Bronx and 19 in Washington, D.C. where 9,641 people with HIV were established patients and eligible for gift cards. Those receiving ART (anti-retroviral therapy) received $70 gift cards for each quarter they were virally suppressed (<400 copies per mL.) At 17 financial incentive sites, 39,356 gift cards were distributed. At the end of the study there was a 4% higher increase in viral suppression as compared with standard of care sites.

This statistically significant effect was achieved at sites in Washington, D.C. where overall the suppression rate of increase was 6.6 percent higher and by 4.9 percent higher among patients whose viral suppression had not been consistent at baseline. The study attributes the higher results in Washington, D.C. to the New York policy of starting ART in HIV patients regardless of the CD4 count. This made it harder to detect the effect size at The Bronx sites, the authors said. Also Washington, D.C. sites might have shown a higher rate of increase because at baseline they had a lower proportion of patients making regular clinic visits and achieving viral suppression.

Hospital sites also showed a higher rate of suppression increase (4.9 percent), which the study related to the number of patients seen there who were less “financially secure” and therefore for whom a financial reward was “more meaningful,” the study said.

The study also looked at whether financial incentives would increase the connection with care for HIV patients. At 18 test sites in The Bronx and Washington, D.C. randomized to linkage to care, 1061 patients received gift cards. They earned a $25 coupon for getting blood drawn for HIV related tests and a $100 coupon for meeting with a clinician to develop a care plan. Within three months, the coupons were redeemable for the gift cards.

The increase in the proportion of care at the linkage sites was 8.7% higher, but the study did not find this increase statistically significant when compared with standard of care control sites. This increase included new patients and past patients who had not been consistent in their care.

The study concluded that “while our findings offer an innovative intervention for achieving the treatment and prevention potential of anti-retroviral 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.”

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