Enhancing Patient Navigation with Contingent Incentives to Improve Healthcare Behaviors and Viral Load Suppression of Persons with HIV and Substance Use

Abstract

This secondary analysis compares health behavior outcomes for two groups of HIV+ substance users randomized in a 3-arm trial [1] to receive Patient Navigation with (PN+CM) or without (PN) contingent financial incentives (CM). Mean age of participants was 45 years; the majority was male (67%), African American (78%), unemployed (35%), or disabled (50%). Behaviors incentivized for PN+CM were (1) attendance at HIV care visits and (2) verification of an active HIV medication prescription. Incentives were associated with shorter time to treatment initiation and higher rates of behaviors during the 6-month intervention with exception of month 6 HIV care visits. Median HIV care visits were 3 (IQR 2-4) for PN+CM versus 1.5 (IQR 0-3) for PN (Wilcoxon p < 0.001); median validated medication checks were 4 (IQR 2-6) for PN+CM versus 1 (IQR 0-3) for PN (Wilcoxon p < 0.001). Viral suppression rates at end of treatment were not significantly different for the two groups but were directly related to the number of behaviors completed for both care visits (χ2(1) = 7.69, p = 0.006) and validated medication (χ2(1) = 8.49, p = 0.004). Results support use of incentives to increase performance of key healthcare behaviors. Adjustments to the incentive program may be needed to achieve greater rates of sustained health behavior change that result in improved viral load outcomes.

Trial registration: ClinicalTrials.gov NCT01612169.

Keywords: HIV healthcare; contingency management; medication adherence; patient navigation; substance users; viral suppression.

Conflict of interest statement

Drs. Stitzer, Metsch, Feaster, Gooden, del Rio, and Sorensen have received grants from the National Institute on Drug Abuse, National Institutes of Health (NIH). The authors declare that they have no other competing interests or conflicts of interest.

Figures

FIG. 1.

shows the percentage of participants in PN (N = 266) and PN+CM (N = 271) who achieved 0–4 HIV care visits (top panel) and had 0–7 validated medication checks (bottom panel) during the 6-month intervention. Medications were validated by the participant showing a pill bottle or providing other verification that s/he was in possession of an active prescription. Incentives with escalating value were available independently for both targets with a total of $180 available for HIV care visits and $170 for validated medication checks. PN, patient navigation; CM, contingent financial incentives.

FIG. 2.

shows the percent of participants in each intervention month who attended at least one HIV care visit (top panel) and the percent that had at least one validated medication check (bottom panel during each month of the 6-month intervention). Data are shown for PN (N = 266) and PN+CM (N = 271) participants.

FIG. 3.

shows mean number of HIV care visits attended (top panel) and validated medication checks (bottom panel) for PN and PN+CM participants categorized into low (0–5), medium (6–8), and high (9–11) total number of PN sessions attended out of a possible 11 sessions. Bracketed bars with asterisks indicate significant differences between PN and PN+CM means. Sample sizes for PN session attendance categories are low (N = 68), medium (N = 94), and high (N = 104); sample sizes for PN+CM are low (N = 27), medium (N = 42), and high (N = 202).

FIG. 4.

shows the percent of all participants collapsed across PN and PN+CM (N = 508 due to missing viral load data) with suppressed viral load (≤200 copies/mL) at the 6-month assessment as a function of HIV care visits attended (top panel) and number of validated medication checks (bottom panel). Sample sizes for HIV care visits are 0 (N = 90), 1–2 (N = 180), and 3–4 (N = 238). Sample sizes for validated medication check categories are 0–1 (N = 188), 2–3 (N = 103), 4–5 (N = 95), and 6–7 (N = 122). Data for PN and PN+CM groups separately are shown in Tables 2 and 3.