A Conditional Economic Incentive Fails to Improve Linkage to Care and Antiretroviral Therapy Initiation Among HIV-Positive Adults in Cape Town, South Africa

Abstract

Interventions to improve antiretroviral therapy (ART) access are urgently needed to maximize the multiple benefits from ART. This pilot study examined the effect of a conditional economic incentive on linkage to care and uptake of treatment following ART referral by a mobile health clinic. Between April 2015 and May 2016, 86 individuals (≥18 years old) referred for ART in a resource-limited setting were randomized (1:1) to a control group or to an incentive: R300 cash (∼$23, or 3.5 days minimum wage in the domestic worker sector), conditional upon starting ART within 3 months. Outcome data were obtained from clinic records. The incentive effects on linkage to care (first clinic visit within 3 months) and ART initiation (treatment uptake within 3 months) were assessed using logistic regression. Overall, 67% linked to care and 42% initiated ART within 3 months after referral. No significant differences were found between the incentive and non-incentive group in terms of linkage to care [adjusted odds ratio (aOR): 0.70, 95% confidence interval (CI): 0.26-1.91] and initiation of ART (aOR: 0.67, 95% CI: 0.26-1.78). Ordinary least-squares regression analysis showed that incentivized individuals linked to care in fewer days (-7.9, 95% CI: -18.09 to 2.26) and started treatment in fewer days (-7.3, 95% CI: -27.01 to 12.38), but neither result was statistically significant. Our findings demonstrate poor treatment uptake by both the intervention and control participants and further highlight the challenge in achieving universal early treatment access. Further research is required to understand how economic incentives, which have been shown to have many benefits, can be applied to improve linkage to HIV care and treatment.

The effect of demand-side financial incentives for increasing linkage into HIV treatment and voluntary medical male circumcision: A systematic review and meta-analysis of randomised controlled trials in low- and middle-income countries

“…Of the 5 linkage to ART trials, 2 involved newly diagnosed HIV positive adults at the clinic; one was among pregnant women attending postpartum services, one was among individuals testing HIV positive during mobile HIV testing [ 30 ], and the final one was among PWID ( Table 2 ). Three trials found that FIs significantly improved linkage to ART as reported by the original authors ( Table 4 ).…”

A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries

“…Several studies of potentially promising interventions have not shown gains for ART initiation. No benefit was seen in a South African study involving a conditional economic incentive (39% intervention versus 45% control; adjusted odds ratio (AOR) = 0.67; 95% CI = 0.26-1.78) [30] or in a Kenyan study involving weekly text message (WelTel Retain; 82% versus control 78%) [31], or a sexual trauma coping intervention for women with a history of sexual abuse in South Africa (91% intervention versus 88% SoC) [32].…”

Financial incentives for achieving and maintaining viral suppression among HIV-positive adults in Uganda: a randomised controlled trial

“…[3][4][5] However, evidence is mixed when it comes to repeated behaviors such as retention in clinical care and medication adherence. 6 Several studies conducted in SSA recently have shown that financial incentives are effective in promoting retention and ART adherence, although these studies have not assessed viral suppression outcomes. 7,8 In the US, on the other hand, one study showed that financial incentives lead to a modest increase in viral suppression rates while another showed no effects.…”