Financial incentives improve HIV viral suppression, retention in care
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Financial incentives improved viral suppression and retention in care in adults beginning HIV treatment in Tanzania, according to results from a randomized controlled trial published in The Lancet HIV.
“These findings contribute to a gap in understanding the effects of financial incentives on a biomarker of HIV treatment adherence,” Carolyn A. Fahey, MPH, of the University of California, Berkeley School of Public Health’s division of epidemiology, and colleagues wrote. “To our knowledge, this is the first randomized trial in a low-income and middle-income country (LMIC) to evaluate the effect of financial incentives for treatment-seeking behavior on HIV viral suppression in a general population.”
Fahey and colleagues enrolled 530 adults from four health facilities in the Shinyanga region of Tanzania who had initiated ART within the past 30 days. They randomly assigned 184 participants to a control group, 172 to a smaller incentive group that was given the equivalent of $4.50 for monthly clinic attendance, and 174 to a larger incentive group that was given the equivalent of $10 for monthly clinic attendance.
Monetary incentives were delivered to participants via mobile health technology (mHealth). Outcome of retention care with viral suppression was the study’s primary outcome.
At 6 months, 73% of participants in the control group, 83% (risk difference [RD] = 9.8; 95% CI, 1.2-18.5) of participants in the smaller incentive group and 86% (RD = 13; 95% CI, 4.5-21.5) of participants in the larger incentive group were virally suppressed and remained in care. The researchers identified a positive trend among incentive size and viral suppression (P = .0032), but the trend did not significantly differ between either incentive groups (RD = 3.2; 95% CI, –4.6 to 11).
“This study provides an important contribution to understanding the potential of financial incentives to achieve viral suppression in LMICs,” the researchers concluded. “Although further research should investigate the durability of effects from short-term incentives, such as those provided in this study, these findings strengthen the evidence for implementing small financial incentives within standard HIV care as part of a comprehensive strategy for epidemic control.”
Perspective
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Gitanjali Pai, MD, AAHIVS
The study by Fahey and colleagues is the first such study to use the simplest but perhaps the most important parameter in compliance — regular clinical attendance after starting ART treatment — and linking it with incentives. It has made good use of technology for data collection. Maximum drop-offs in HIV care cascades are seen in the first 6 months of treatment, and this is the crucial time to get patient buy-in for compliance and HIV viral load suppression. It is heartening to see the impact of small financial incentives on ART adherence.
The study has done well to further disaggregate the data based on wealth index. A decreasing RD between the control group and the higher wealth group points to measures other than financial incentives for the higher income group. The absence of a statistically significant difference between the two incentive groups points to a diminishing return from increasing the incentive amount.
The paper has cited incentive-based studies in other countries on various cohort groups (such as those using drugs) with varying incentive amounts, incentive forms, time of disbursement, trigger for distribution and so on. It has also alluded to research elsewhere, where financial incentives were provided to stratified cohorts, such as pregnant women. The results indicate the possible dependence of outcome on many factors other than monetary benefits, such as geography and social background.
The authors have rightly added a cautionary note against oversimplified conclusions in view of the impact of multiple conditions on outcome. As stated by the authors, the study shows potential for a scalable financial incentive program to increase compliance. The study format and outcome based on parameters and attributes gives sufficient pointers to the design of an optimal incentive scheme. There is ample scope for more such studies with clever use of biosensors that should also study the outcome of withdrawal of incentives. Considering the financial burden of HIV and its direct and indirect morbidity and mortality, providing a financial incentive may prove more cost-effective and may also hasten the path toward our goal of HIV elimination by 2030. This study has generated hope that a combination of monetary incentives and innovative interventions can achieve this.
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