Financial Incentives Do Not Improve Outcomes Among HIV-Positive Substance Users

Interventions to improve the health of HIV-positive people with substance use disorders did no better than usual treatment, according to a study published on July 12th in an HIV/AIDS themed issue of the Journal of the American Medical Association. The study showed no statistical differences among trial arms in rates of HIV viral suppression versus non-suppression or death. Read the findings in JAMA online.
 
Columbia University Mailman School of Public Health researcher Lisa R. Metsch, PhD and colleagues at Emory University, the University of Miami, San Francisco Department of Public Health, and more than 14 other collaborating institutions  designed a structured patient navigation intervention with and without  financial incentives to determine whether they would improve HIV-viral suppression rates among those who use drugs. To date, the effects of financial incentives on engagement in care and viral suppression had been mixed.
 
Persons with HIV infection and substance use disorders were recruited from 11 hospitals in major cities in the United States with high rates of HIV.  Participants were randomly assigned to either six months of patient navigation (care coordination with case management), six months of patient navigation plus financial incentives, or treatment as usual.  Patient navigation included up to 11 sessions of case management over 6 months. Financial incentives (up to $1,160) were provided for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual was the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use disorders treatment.  HIV viral load was measured at study entry and at 6 and 12 months.
 
There was no statistical difference in outcomes among the three groups at the 12 month follow-up, with approximately one-third of all participants being virally suppressed.
 
“Our data suggest that different strategies to integrate substance use disorders treatment into HIV care are needed to improve HIV outcomes with HIV-positive substance users,” said Dr. Lisa Metsch, who is the Stephen Smith Professor and Chair of the Department of Sociomedical Sciences at the Mailman School of Public Health.  “It should also be noted that participants in this trial face complex issues including considerable socioeconomic disadvantage,”  “Therefore, the study results raise the question of whether intensive, individual-level interventions are sufficiently broad enough to improve HIV outcomes among populations currently not benefitting from treatment.”
 
"We will not achieve an AIDS free generation if we don't address substance use and the other co-morbidities that come with substance use,” observed Dr. Metsch. “If we are to reach the UNAIDS plan of 90 90 90 in this country (90 percent know their HIV status, 90 percent on treatment, and 90 percent undetectable), we must get serious about hard-to-reach populations. This research is one example of where we need to find new strategies to end the spread of HIV by 2020.
 
The study was funded by the National Institute on Drug Abuse’s Clinical Trials Network, part of the National Institutes of Health. All authors have submitted forms for disclosure of potential conflicts of interest that are published in the paper.
 
Columbia University co-authors are Lauren Gooden, PhD and Paco Castellon, MPH in the Department of Sociomedical Sciences at the Mailman School of Public Health; and Susan Tross, PhD in Columbia’s Department of Psychiatry and the New York Psychiatric Institute.