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CROI 2015: Financial Incentives Did Not Improve Linkage to Care or HIV Viral Suppression

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A U.S. study that offered patients gift cards to present for HIV care after testing, and also to stay in care and maintain an undetectable viral load, did not succeed in its main aims and with most patients. Rates of linkage to care, retention in care, and viral suppression were not significantly higher in centers where patients received gift cards than in ones where they did not, according to research presented at the recent 2015 Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle. However, the study did produce some improvement in the proportion of people who remained in care. And it improved viral suppression rates in smaller and under-performing centers.

[Produced in collaboration with Aidsmap]

Presenter Wafaa El-Sadr, director of HIV at Columbia University School of Public Health in New York, said that financial incentives have a potential role in treatment as prevention in specific locations and populations.

The HPTN 065 Study

The HPTN 065 study presented qualitative findings at the HIV Research for Prevention Conference last October in Cape Town, South Africa. After some initial misgivings, both patients and staff found the gift card scheme acceptable, and in the case of the patients, useful; many were poor and spent the gift cards on necessities.

The study operated at 34 HIV testing sites and 37 care sites (many co-located) in the Bronx, New York, and Washington DC. There were 32 sites based in hospitals and 39 in community facilities. It ran from January 2011 through March 2013, with a period of maximum activity during the last 3 months of 2012.

The sites were randomized either to offer the standard of care or to offer:

  • A $25 gift card if patients presented for care within 3 months of HIV testing and got an initial CD4 count and viral load test done, with an additional $100 if they completed a care plan with their doctor.
  • A $70 gift card for each time they had a viral load test done and they were virally suppressed (maximum of once every 3 months).

The number of people who tested HIV-positive and were eligible for the testing and linkage to care component was 1109 (average per site: 33); 1061 actually received gift cards, of which 80% were redeemed. There were roughly twice as many people referred to care in Washington DC as in the Bronx.

About two-thirds of study participants in the Bronx and three-quarters in DC were men, 30% in the Bronx and 60% in DC were gay, and roughly 50% in the Bronx and 70% in DC were black, with most other patients being Hispanic/Latino; 1 in 6 and 1 in 4, respectively, was under 25.

The number of patients eligible for the viral load component was 19,185, with slightly more in the Bronx than DC; 9641 of these (average per site: 438) were on antiretroviral therapy and eligible for the $70 gift cards. These patients made a total of 49,650 visits and 39,359 gift cards were dispensed (79% of visits), with relatively more dispensed in the Bronx; 84% were redeemed. The make-up of the patient group was similar to the linkage-to-care group, except that fewer in the Bronx were male and gay.

Results

The headline news of the study was that the cards made no statistically significant difference to the proportion of people presenting for care within 3 months, nor to the proportion who were virally suppressed.  

There was, however, a significant increase of 8.1% in the proportion of patients in regular care, when this was defined as the proportion who attended at least 4 out of the last 5 quarterly visits. There was also a significant, though modest, rise of 5.4% in the proportion virally suppressed in the 3 months October to December 2012 -- the period that saw the largest number of gift cards handed out.

In the linkage-to-care component, it was notable that the 4 sites that had the poorest rate of linking patients to care, with baseline linkage rates of 20% to 50%, greatly improved their performance, with 3 to getting 100% of patients linked and 1 to 90%. However, these were all small centers that did not contribute much to the overall average figure.

The same phenomenon was observed with the viral suppression gift cards. The most poorly performing clinics -- defined as those with fewer than two-thirds of their patients with undetectable viral loads at baseline -- saw the biggest improvement, with a 10.4% rise in the proportion of patients virally suppressed, and a 13.2% rise during the "peak period."

The most poorly performing clinics were also in general the smallest ones (defined as serving fewer than the mean level of 186 patients) and the financial incentive produced a significant rise of 11.4% patients being virally suppressed during the peak period.

El-Sadr commented that the reason these small centers were less successful was not generally due to physician experience, but more often because they had fewer resources such as staff to follow-up patients who dropped out of care.

Where Cash Incentives Do Work

In a separate presentation at the conference, David Wilson of the World Bank reviewed 3 studies in Africa in which offering young people cash incentives to stay free of sexually transmitted infections (STIs) or HIV, or to reduce their sexual risk behavior, had worked.

In a study in Tanzania, young people offered $60 a year to stay STI-free had 25% fewer STIs. In Lesotho, adolescent girls offered $50 or $100 tickets for the national lottery -- i.e., just the chance for a prize, not actual cash -- had 33% lower HIV incidence, rising to 39% for girls offered the $100 tickets. It made no difference in boys, however.

In Malawi, young women were paid $15 per month to stay in school. As well as 35% fewer dropping out of school, girls offered the $15 had 60% lower HIV prevalence and 76% lower herpes simplex-2 (genital herpes) prevalence, were 33% less likely to have sex, and were 30% less likely to get pregnant. They not only had less sex, but when they did, they chose partners less likely to have HIV and closer to their age range. Further research showed that girls with older boyfriends received an average of $6.50 a month -- quite a lot in a country where per-capita GDP is $287.50. Essentially, the $15-a-month scheme was able to out-price the going rate.

Other schemes not mentioned by Wilson looking at orphans in Kenya and South Africa have also been successful.

In contrast, CROI attendees also heard this year that the considerable investment U.S. PEPFAR funding had made in abstinence-only programs made no measurable difference with regard to sexual risk behavior.

3/13/15

References

WM El-Sadr, BM Branson, G Beauchamp, et al. Effect of Financial Incentives on Linkage to Care and Viral Suppression: HPTN 065. 2015 2015 Conference on Retroviruses and Opportunistic Infections. Seattle, February 23-24, 2015. Abstract 29.

D Wilson. Social Protection, Financial Incentives, and Prevention of HIV2015 Conference on Retroviruses and Opportunistic Infections. Seattle, February 23-24, 2015. Symposium presentation 75.