An article by Skarbinski & Mermin, discussed in my recent blog, Skarbinski & Mermin (STI/blogs), throws into sharp light the problem of the 45.2% of the HIV/AIDS infected population who are diagnosed but lost to follow-up. According to their estimate this group are responsible for 61.3% of transmissions. Various local attempts have been made to address this problem through more “wrap-around” approaches to health care (Bocour & Less (STI/blog)), or through computer assisted self-interviewing (Dombrowski & Golden (STI). Another approach is the use of financial incentives. Relatively small-scale and local experiments in various forms of conditional cash transfer have been described by a number of studies recently featured in STIs. These have aimed, for example, to reduce STIs and pregnancy among Latino youth in San Francisco (Minnis & Padian (STI)), to encourage HIV-infected men to bring their wives for testing in Pakistan (Khan & Khan (STI), to incentivize villagers to remain HIV-free in Lesotho (Bjoerkman-Nyqvist & Svensson (STI)), or to promote syphilis testing amongst indigenous groups in Edmonton, Canada (Gratrix & Talbot (STI)).
Yet what role could financial incentives play in the broader context of mainstream HIV management in the US? Could they help to address the problem of retention in HIV care across the range of HIV care settings?
A recent US study, HPTN 065 (TLC-Plus) reported at the 2015 Conference on Retroviruses and Opportunistic Infections (CROI) addresses this very question. It involved two-year RCT in a total of 37 testing sites in Bronx and Washington DC., randomized to an intervention and a control arm. The intervention offered incentives for both linkage-to-care, and viral suppression. For linkage-to-care, the incentive consisted in the issue to HIV diagnosed of a $25 coupon redeemable when the participant returned to have blood taken for laboratory tests, and a $100 coupon redeemable when he/she returned for test results and to discuss a long-term care plan. For viral suppression, it took the form of the issue of a $70 gift card to patients taking medication at the end of every three months if they had an undetectable viral load. Over the duration of the trial, 1,061 coupons were given for linkage-to-care, and 40,000 gift cards were dispensed to 9,153 patients for viral suppression.
Disappointingly, no overall increase was observed in intervention compared to control settings, either in linkage-to-care or in the proportion of patients achieving viral suppression. However, the intervention brought significant improvements in viral suppression and continuity of care (completion of four out of five possible visits for tests in last 15 months) within certain specific care settings. In particular, these were: care settings where <65% of the patients were achieving viral suppression at the start of the study (improvements of 10% overall, 13% as measured in the last three months of the study); small-scale care settings (improvements of 13% as measured in the last three months, and of 19% overall in continuity of care). The investigators conclude that there may be a role for financial incentives in specific health care settings.