Does It Work to Pay People to Come to Clinic? A Top HIV Clinical Development of 2017
It is an ugly but obvious truth that people will do all sorts of stuff for money -- sometimes even things that are in their best interests. This fact is the basis of the field of contingency management, in which financial incentives are used to promote desirable health behaviors, such as abstinence from substance abuse, medication adherence, and clinic retention.
The descending steps of the HIV care cascade are prime targets for the promotion of good health behavior and were the focus of a U.S. HIV Prevention Trials Network (HPTN) trial in which HIV testing and care sites were randomized to maintain the standard of care or to provide financial incentives for linkage to and retention in HIV care and viral suppression. The trial was conducted only in the Bronx, New York City, and Washington, D.C., at 37 HIV testing sites and 39 HIV care sites. At the testing sites, patients diagnosed with HIV infection received coupons redeemable for $25 following a blood draw at their clinic visit and $100 after meeting with the clinician there. At care sites, patients with a suppressed viral load at quarterly routine visits received a $70 gift card. A total of 1,061 coupons were dispensed to 9,641 eligible patients.
Overall, financial incentives were not found to significantly increase linkage to care, which was generally high at well over 80% at both standard of care and intervention sites. However, viral suppression was associated with receipt of financial incentives. At baseline, approximately two-thirds of patients had suppressed viremia and, over the course of the study, the change in the proportion with viral suppression was greater for those at financial incentive sites compared with control sites. The difference in the change was modest at 4%, but among those without viral suppression at baseline, the effect of the financial incentive was stronger. Financial incentives had a more profound impact on viral suppression in Washington, D.C., than in the Bronx, where there was earlier adoption of antiretroviral treatment at high CD4 cell counts and, therefore, possibly more people at the control sites were suppressed.
Care continuity (as measured by CD4 cell count or viral load obtained in four of the past five quarters) was also greater among those receiving financial incentives, increasing by 16% at the intervention sites compared with a 2% decrease at the control sites.
The Bottom Line
Incentives make the world go around, and there has been a growing interest in harnessing the power of rewarding good health behavior with cold hard cash. Paying people to do the right thing might be fresh fodder for ridicule on Fox News, but financial incentives are not that uncommon. For example, most workplace insurance policies offer lower rates for those with lower body mass indexes or employees who don't smoke -- and money saved is money to burn. While controversy exists about the notion of paying people to do what they should from a purely objective standpoint, if successful, such incentives make sense and can be cost saving.
The HPTN trial was ambitious in that it enrolled sites caring for a variety of patients, some of whom could use an incentive and others who didn't need one, and this might have diluted the effect of the intervention. But, despite that, a strong signal remains that the incentives helped. The study stands in contrast to another trial published last year that looked at incentivizing care engagement behaviors that could lead to viral suppression among hospitalized HIV-positive people with a history of substance abuse. In that study, the incentives were provided in concert with a patient navigation intervention and were compared with the navigation alone and with a control of usual care. There were no differences in the outcomes of interest among the three study arms, possibly due to a paucity of substance abuse counseling available to these participants. The lesson is that not all financial incentives are created equally, and there are a number of factors to consider when designing these studies, including the use of gift cards versus vouchers versus cash, the immediacy of the reward to the action, and the selection of the behavior to promote that will be most likely to lead to the desired outcome.
While financial incentives are promising and should be further studied (the AIDS Clinical Trials Group is about to launch a study of incentivizing the oral lead-in to long-acting antiretrovirals in patients with suboptimal adherence), they are not a panacea for the structural barriers that keep people from appearing in the columns of the HIV care cascade. We should not only incentivize actions that help people to overcome the obstacles that impede their getting into and staying in care but, at the same time, work to better understand and reduce these barriers -- because, although money helps, it is not all about the Benjamins.
David Alain Wohl, M.D., is a professor of medicine in the Division of Infectious Diseases at the University of North Carolina (UNC). He is site leader of the UNC AIDS Clinical Trials Unit at Chapel Hill, director of the North Carolina AIDS Education and Training Center (AETC), and co-directs HIV services for the North Carolina state prison system. In 2014, he became co-director of the UNC-Duke Clinical RM Ebola Response Consortium.