A study conducted by researchers from the University of California Berkeley School of Public Health shows that providing cash incentives for HIV-positive adults undergoing antiretroviral therapy in Tanzania helped increase the retention of those in care, increasing viral suppression among those in HIV treatment.
The study’s authors say that the findings are evidence that financial incentives for those in HIV care and antiretroviral therapy work.
“Short-term economic support, in the form of a short-term cash transfer, can significantly improve the likelihood that people are able to comply with their HIV treatment in the vulnerable window when they are starting HIV treatment,” Sandra McCoy, study co-author and professor of epidemiology and biostatistics at Berkeley Public Health, said.
The study, carried out between April and June 2019, included 530 participants. A control group was not given cash. One group was given cash incentives of 10,000 Tanzanian Shillings (about $4.50) and another group was given 22,500 Tanzanian Shillings (about $10) each time they attended monthly clinic visits for antiretroviral therapy.
Researchers found that for the control group that was not given a cash incentive, 73% remained in care and continued to have viral suppression. For the group given the smaller cash incentive, that percentage increased to 83%. For the group given the larger cash incentive, 86% remained in care.
Researcher Carolyn Fahey, a PhD student at Berkeley Public Health, says that socio-economic factors can be a strong impediment to continuing antiretroviral therapy. “The cost of bus fare, insufficient food, stigma, and discrimination are all reasons for missing appointments, so that suggests that effective delivery of HIV care should keep in mind the social determinants of health as obstacles to treatment adherence,” Fahey said.
“A small amount of money can go a long way in terms of helping people overcome barriers to access the care they need.”
Researchers emphasised that remaining in HIV treatment was important in reducing the spread of HIV to others.
“In essence, it’s critically important that people living with HIV are compliant with their HIV treatment so that they can improve their own health, so that the treatment can prevent transmission of HIV to others, and so we can achieve global goals for HIV epidemic control,” McCoy said. “The study suggests that programs to economically support people living with HIV have the potential to accelerate individual, community, and global goals towards reducing HIV incidence.”
Abstract
Background: Financial incentives promote use of HIV services and might support adherence to the sustained antiretroviral therapy (ART) necessary for viral suppression, but few studies have assessed a biomarker of adherence or evaluated optimal implementation. We sought to determine whether varying sized financial incentives for clinic attendance effected viral suppression in patients starting ART in Tanzania.
Methods: In a three-arm, parallel-group, randomised controlled trial at four health facilities in Shinyanga region, Tanzania, adults aged 18 years or older with HIV who had started ART within the past 30 days were randomly assigned (1:1:1) using a tablet-based application (stratified by site) to receive usual care (control group) or to receive a cash incentive for monthly clinic attendance in one of two amounts: 10 000 Tanzanian Shillings (TZS; about US$4·50) or 22 500 TZS (about $10·00). There were no formal exclusion criteria. Participants were masked to the existence of two incentive sizes. Incentives were provided for up to 6 months via mobile health technology (mHealth) that linked biometric attendance monitoring to automated mobile payments. We evaluated the primary outcome of retention in care with viral suppression (<1000 copies per mL) at 6 months using logistic regression. This trial is registered with ClinicalTrials.gov, NCT03351556.
Findings: Between April 24 and Dec 14, 2018, 530 participants were randomly assigned to an incentive strategy (184 in the control group, 172 in the smaller incentive group, and 174 in the larger incentive group). All participants were included in the primary intention-to-treat analysis. At 6 months, approximately 134 (73%) participants in the control group remained in care and had viral suppression, compared with 143 (83%) in the smaller incentive group (risk difference [RD] 9·8, 95% CI 1·2 to 18·5) and 150 (86%) in the larger incentive group (RD 13·0, 4·5 to 21·5); we identified a positive trend between incentive size and viral suppression (p trend=0·0032), although the incentive groups did not significantly differ (RD 3·2, −4·6 to 11·0). Adverse events included seven (4%) deaths in the control group and 11 (3%) deaths in the intervention groups, none related to study participation.
Interpretation: Small financial incentives delivered using mHealth can improve retention in care and viral suppression in adults starting HIV treatment. Although further research should investigate the durability of effects from short-term incentives, these findings strengthen the evidence for implementing financial incentives within standard HIV care.
Funding: National Institute of Mental Health at the US National Institutes of Health.
Authors
Carolyn A Fahey, Prosper F Njau, Emmanuel Katabaro, Rashid S Mfaume, Nzovu Ulenga, Natalino Mwenda, Patrick T Bradshaw, William H Dow, Nancy S Padian, Nicholas P Jewell, Sandra I McCoy
[link url="https://publichealth.berkeley.edu/news-media/research-highlights/small-financial-incentives-can-improve-hiv-patient-retention-and-care/"]Berkeley Public Health material[/link]
[link url="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(20)30230-7/fulltext"]The Lancet HIV abstract[/link]