Brief Report: Financial Incentives and Real-Time Adherence Monitoring to Promote Daily Adherence to HIV Treatment and Viral Suppression Among People Living With HIV: A Pilot Study

Abstract

Background: Interventions to promote medication adherence and viral suppression are needed among HIV-positive individuals. We aimed to determine the feasibility, acceptability, and preliminary impact of daily financial incentives linked to real-time adherence monitoring among treatment-experienced individuals.Methods: At an HIV clinic in Philadelphia, we conducted a pilot randomized trial among treatment-experienced HIV-positive adults with unsuppressed viral loads (.400 copies/mL). Participants randomized to the intervention group were eligible for daily lottery-based financial rewards dependent on antiretroviral therapy (ART) adherence, measured by a wireless-enabled electronic pill bottle. Participants also received a financial incentive for achieving viral suppression at 3 months. The control group received the standard of care. We measured acceptance and feasibility through follow-up survey at 3 months, viral suppression at 3 months, and adherence.Results: Among 29 participants, 28 (93%) completed 3-month follow-up, and 24 (83%) completed a 3-month laboratory visit. Electronic pill bottles were highly acceptable to participants, with most strongly agreeing that they worked well, were reliable, and easy to use. Among those who received the intervention, 77% were very satisfied with their experience. Among those who completed the 3month laboratory visit, viral suppression was achieved by 40% in the intervention group and 29% in the control group. ART adherence $80% was achieved by 36% and 25% in the intervention and control groups, respectively.Conclusions: Daily financial incentives coupled with real-time adherence monitoring are a promising strategy to support ART adherence among HIV-positive individuals who are not virally suppressed. This novel approach warrants testing in a larger trial.

Implementation of Electronic Adherence Monitors and Associated Interventions for Routine HIV Antiretroviral Therapy in Uganda: Promising Findings

“…Our study focused on assessment of implementing real-time adherence monitoring and associated interventions, rather than the effects on ART adherence itself which have been published in the literature (7)(8)(9)(10)(11)(12). Nonetheless, we did identify potentially clinically meaningful episodes (i.e., >7 days) of non-adherence among four of the 51 study participants (8%) over just 3 months of follow-up per participant.…”

“…For example, real-time monitors can automatically trigger text message reminders if a dose is not taken within a defined time period and/or connections can be made to known social support systems (7). Alternatively, incentives can be delivered for demonstrated adherence (8,9). Electronic adherence monitors have been shown to be acceptable and improve ART adherence in multiple, although not all, contexts (7)(8)(9)(10)(11)(12); however, their use has largely been limited to research studies because of expense and concerns about impact on clinical operations.…”

“…Alternatively, incentives can be delivered for demonstrated adherence (8,9). Electronic adherence monitors have been shown to be acceptable and improve ART adherence in multiple, although not all, contexts (7)(8)(9)(10)(11)(12); however, their use has largely been limited to research studies because of expense and concerns about impact on clinical operations. Because the cost of these devices has been reduced dramatically in recent years, they now have potential for use in routine clinical care, and study of their acceptability and impact on routine clinical experiences is warranted.…”

Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review

“…Other examples include text-based ART medication reminders and mindfulness exercises to reduce HIV viral load (Table 2). Culturally relevant and gender-specific messaging to engage in HIV prevention [30,101] Loss framed lottery intervention to encourage dual contraception methods to prevent HIV infection [86] HIV to take PrEP medication [142] HIV management Use of priming stimuli that is empowering or culturally meaningful to improve adherence to ART and retention in care [143,144] Use of financial rewards as priming to improve adherence to ART and to suppress viral load count [49,145] Providing safe sex materials as priming to practice safe sex to prevent HIV transmission [146] Personalised cues and reminder messages for remembering dose times to support ART adherence [72,74,147,148] Affect HIV prevention Creating positive emotion for HIV testing or accessing HIV services [111,139,149,150] Peer-led group sessions to learn skills for self-efficacy and positive sexual health behaviours [31] Increasing risk perception towards HIV to encourage HIV prevention behaviours [99,151] HIV management Creating positive emotion for HIV care retention and ART adherence through social, financial, or non-financial support [99,111,143,146] Group sessions targeting positive affect to increase skills for self-efficacy to encourage ART adherence and viral load suppression [146,[152][153][154] Motivational messages to encourage ART adherence [147,150,155] Commitment HIV prevention Use of binding contracts with financial deposits to encourage HIV testing or clinic visits [139,[156]…”

“…In one study, patients would receive congratulations for attending the clinic three consecutive on-time visits for HIV care, and they were given a sticker to proudly place on an interactive poster publicly displayed in the clinic to celebrate and acknowledge their achievement [143]. Another study involved a multi-component positive affect intervention for MSM who used drugs, eight core skills, and meditation exercises were delivered to them to increase positive affect among HIV management Use of non-explicit commitment devices in the form of financial incentives for ART adherence and viral load suppression goal in the future [108,144,147,154,[169][170][171][172][173][174][175][176][177][178][179][180][181] Use of non-explicit commitment devices in the form of financial incentives to meet HIV testing, linkage to HIV care and clinic attendance goal in the future [172,182,183] Use of non-explicit commitment devices in the form of non-financial incentives for ART adherence and viral load suppression goal in the future [74,147,155] Use of non-explicit commitment devices in the form of non-financial incentives to meet HIV testing, linkage to HIV care and clinic attendance goal in the future [117,143,146,[184][185][186] Ego HIV prevention HIV education sessions alongside financial education programmes to target ego and self-efficacy [18,31,99,[187][188][189] HIV education sessions and peer support to target ego and increase HIV risk perception ...…”