Integrating Financial Incentives for Viral Load Suppression into HIV Care Coordination Programs: Considerations for Development and Implementation

Abstract

Context: Interventions that support durable viral load suppression (VLS) among people living with HIV (PLWH) who face barriers to treatment adherence are needed to maintain optimal individual health, prevent new HIV infections, and advance health equity. Efficacy trials indicate that financial incentives (FIs) are a promising strategy for promoting VLS, although less is known about their implementation in “real-world” settings. This article describes considerations for the development and implementation of FI interventions identified in existing literature, and how they informed the scale-up of a multilevel treatment adherence support program designed to increase VLS among PLWH in New York City. Program: The UndetectablesSM VLS Program comprises a social marketing campaign and a “tool kit” of evidence-based HIV treatment adherence strategies, including quarterly FIs ($100) that patients receive for achieving or maintaining an undetectable viral load (<200 copies/mL; also referred to as VLS). The intervention was developed and pilot tested by Housing Works Community Healthcare and the University of Pennsylvania from 2014 to 2016. Initial findings from the pilot evaluation showed a statistically significant positive effect on VLS. Implementation: The New York City Department of Health and Mental Hygiene contracted with 7 agencies across New York City to scale up The Undetectables Program over a 3-year period (2016-2019) by integrating the program into existing services for PLWH. Evaluation Plans: Quality indicators (eg, percentage of clients who received an FI each quarter; percentage of clients who were virally suppressed at 90 days postenrollment) will be used to measure program performance and impact over time. Discussion: Recommendations for implementing FIs for PLWH include packaging FIs with client-centered, evidence-based adherence strategies, incorporating FIs into existing service delivery systems, and obtaining organization-wide buy-in to facilitate their implementation. Implementation science research is needed to identify strategies to effectively implement and sustain evidence-based FI interventions.

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

“…The Baobab tree, also known as the ‘tree of life’ locally, was a positive image known by residents where the trees are numerous in the community. Similarly, a social marketing campaign intervention in the USA involved utilised graphic novels using a group of inspirational superheroes called ‘The Undetectables’ as a priming stimulus to engage and motivate people living with HIV (PLWHIV) to manage their ART adherence [ 144 ]. Other examples included personalised reminder messages, cues, or feedback to inform the individual of their adherence or remind them of the medication times via text messages or phone calls (Table 2 ).…”

“…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 ...…”

Lifetime cost of HIV management in Australia: an economic model

“…The impact of changing the starting age of the cohort from 48 years to 38 and 56 years (IQR for patient age from the AHOD study). 25 4. Reducing the price of patented ART by 20-90%.…”

Are Financial Incentives Appropriate Means of Encouraging Medication Adherence Among People Living With HIV?

“…Based on the initial success of the intervention, this message of a client-centered incentives approach hit its mark when the city's department of health funded a scale-up of the program to include other agencies seeking to improve HIV treatment effectiveness among vulnerable PWH. 20 It is important to note here that though redistributive justice through the mechanism of financial incentives was a new mode of patient advocacy, the organization's activities were already rooted in principles of client self-reliance and economic justice. Formed as a membership organization of clients, staff, and volunteers, the organization has a strong commitment to advocacy with and on behalf of low-income PWH.…”