Financial Incentives for Adherence to Hepatitis C Virus Clinical Care and Treatment: A Randomized Trial of Two Strategies

Abstract

Background.Although rates of sustained virologic response (SVR) after hepatitis C virus (HCV) treatment with direct-acting antivirals (DAAs) surpass 90% in trials and some more “real world” settings, some patients, such as those with substance use disorders, will be challenged to adhere to HCV care.Methods.To assess the feasibility of 2 strategies for financially incentivizing adherence to HCV care, patients with a substance use history prescribed 12 weeks of a sofosbuvir-containing regimen were randomized to either fixed or lottery-based monetary incentives for attending clinic appointments, pill count adherence >90%, and SVR achievement. Electronic medication monitoring provided an objective measure of DAA adherence.Results.Fifty-nine participants were randomized to the lottery (n = 31) or fixed-incentive (n = 28) arms. All 31 (100%) in the lottery arm and 24 of 28 (86%) in the fixed arm completed 12 weeks of therapy. By intent-to-treat, 93% in the lottery arm and 92% in the fixed arm achieved SVR (estimated difference: 0.5%; 95% confidence interval, −17.5 to 18.8). Overall, 92% of scheduled visits were attended without significant differences between arms. The mean adherence ratio (days with ≥1 bottle opening:monitored days) was 0.91 for lottery and 0.92 for fixed arms.Conclusions.In this pilot, fixed- and lottery-based financial incentives were successfully implemented and accepted by patients with a substance use history. High levels of HCV therapy and care adherence, as well as rates of SVR, were observed. Financial incentives may be useful to support treatment adherence in patients with substance use disorders and should be tested in a larger, randomized, controlled trial.

Real-world Efficacy of Direct-Acting Antiviral Therapy for HCV Infection Affecting People Who Inject Drugs Delivered in a Multidisciplinary Setting

“…Anecdotally, since the data lock that preceded this analysis, 9/13 LTFU individuals have been re-engaged in care, producing a residual LTFU rate of 2% (n/N = 4/229). This suggests that a multidisciplinary approach to managing social, psychiatric, medical, and addiction-related needs could be a highly relevant strategy to engage patients in care and re-engage those who were LTFU [ 25 ]. In fact, the use of multidisciplinary systems is key to addressing addiction-related needs, as treatment o f PWID in nonmultidisciplinary settings is not recommended given the diversity of their needs [ 26 ].…”

Obstacles to successful treatment of hepatitis C in uninsured patients from a minority population

“…These medications have sustained virologic response (SVR) rates as high as 97% in clinical trials, compared to approximately 50% with interferon-based regimens [ 12 ]. SVR is associated with decreased morbidity and mortality, and improved quality of life [ 13 ]. Despite these tangible benefits, insufficient research has been done on real-world treatment outcomes in uninsured HCV infected patients treated with DAAs, and even less in indigent patient populations [ 14 , 15 ].…”

Clients’ perceptions of barriers and facilitators to implementing hepatitis C virus care in homeless shelters

“…Participants reported that financial incentives may prove particularly useful in promoting uptake of HCV rapid testing and education in the shelter setting. Financial incentives may serve as a useful tool for engaging at risk people in HCV testing [32], such as homeless adults. As many participants had prior experience with HCV rapid testing, scaling up HCV prevention services so that they become a routine part of the intake process could be one way to ensure that those at highest risk of infection and transmission are tested and linked to care.…”