Financial Incentives for Linkage to Care and Viral Suppression Among HIV-Positive Patients: A Randomized Clinical Trial (HPTN 065)

Abstract

Importance: Achieving linkage to care and viral suppression in human immunodeficiency virus (HIV)-positive patients improves their well-being and prevents new infections. Current gaps in the HIV care continuum substantially limit such benefits.

Objective: To evaluate the effectiveness of financial incentives on linkage to care and viral suppression in HIV-positive patients.

Design, setting, and participants: A large community-based clinical trial that randomized 37 HIV test and 39 HIV care sites in the Bronx, New York, and Washington, DC, to financial incentives or standard of care.

Interventions: Participants at financial incentive test sites who had positive test results for HIV received coupons redeemable for $125 cash-equivalent gift cards upon linkage to care. HIV-positive patients receiving antiretroviral therapy at financial incentive care sites received $70 gift cards quarterly, if virally suppressed.

Main outcomes and measures: Linkage to care: proportion of HIV-positive persons at the test site who linked to care within 3 months, as indicated by CD4+ and/or viral load test results done at a care site. Viral suppression: proportion of established patients at HIV care sites with suppressed viral load (<400 copies/mL), assessed at each calendar quarter. Outcomes assessed through laboratory test results reported to the National HIV Surveillance System.

Results: A total of 1061 coupons were dispensed for linkage to care at 18 financial incentive test sites and 39 359 gift cards were dispensed to 9641 HIV-positive patients eligible for gift cards at 17 financial incentive care sites. Financial incentives did not increase linkage to care (adjusted odds ratio, 1.10; 95% CI, 0.73-1.67; P = .65). However, financial incentives significantly increased viral suppression. The overall proportion of patients with viral suppression was 3.8% higher (95% CI, 0.7%-6.8%; P = .01) at financial incentive sites compared with standard of care sites. Among patients not previously consistently virally suppressed, the proportion virally suppressed was 4.9% higher (95% CI, 1.4%-8.5%; P = .007) at financial incentive sites. In addition, continuity in care was 8.7% higher (95% CI, 4.2%-13.2%; P < .001) at financial incentive sites.

Conclusions and relevance: Financial incentives, as used in this study (HPTN 065), significantly increased viral suppression and regular clinic attendance among HIV-positive patients in care. No effect was noted on linkage to care. Financial incentives offer promise for improving adherence to treatment and viral suppression among HIV-positive patients.

Trial registration: clinicaltrials.gov Identifier: NCT01152918.

Conflict of interest statement

Conflict of Interest Disclosures: Dr El-Sadr reports grants from National Institute of Allergy and Infectious Diseases during the conduct of the study. Dr Donnell reports grants from Bill and Melinda Gates Foundation during the conduct of the study. Ms Beauchamp reports grants from NIAID and NIH during the conduct of the study. Dr Zingman reports grants from NIH during the conduct of the study. Dr Elion reports being a member of advisory panels for Gilead, ViV, and Merck, and a member of the speakers bureaus for Gilead, ViV, Merck, and Jansen. Dr Gamble reports grants from NIAID and NIH during the conduct of the study. Dr Branson reports personal fees from FHI 360, Gilead Sciences, and Siemens Healthcare Diagnostics during the conduct of the study. No other disclosures are reported.

Figures

Figure 1.. CONSORT Flow Diagram of Site Inclusion

DOH indicates Department of Health; FI, financial incentives; HIV, human immunodeficiency virus; SOC, standard of care; VL, viral load.

Figure 2.. Change in Proportion of Patients With Viral Suppression by Arm and Site

HIV care sites randomized to the 2 study arms are ordered by baseline viral suppression. Dark blue lines indicate baseline proportion of patients virally suppressed at baseline. Bars for each site indicate mean change in proportion of patients virally suppressed and the width of the bar is relative to the number of patients in care at the site. Bars in blue indicate increase and bars in orange indicate decrease in proportion of patients virally suppressed.