Financial incentives can influence control of HIV in some clinical settings

HPTN 065 (TLC-Plus) tested the effect of financial incentives in two ways: 1) to encourage HIV-positive people to seek medical care (linkage-to-care) and 2) to encourage HIV patients to take their ART medication regularly, thereby keeping their HIV under control (viral suppression). HPTN 065 was conducted at 37 HIV testing and 39 care sites across the Bronx, New York and Washington, D.C. Half of these testing and care sites were randomized (assigned by chance) to offer financial incentives, while the other half operated normally, offering what is referred to as the standard-of-care. These two communities were selected because of their high HIV rates and existing efforts to ramp up HIV testing and linkage-to-care.

For the viral suppression part of the study, gift cards in the amount of $70 were offered to patients who were on HIV treatment and had undetectable virus in their blood at clinic visits. Patients could be eligible for a gift card every three months if they maintained viral suppression (defined as having an undetectable viral load). Over the course of the study, nearly 40,000 gift cards were dispensed to more than 9,000 patients at care clinics that offered financial incentives.

Study findings show that financial incentives had no overall significant effect on achieving a sustained increase in viral suppression. However, in specific types of clinical settings such as at hospital-based clinics, and those with lower viral suppression, financial incentives enhanced viral suppression. Viral suppression was five percent higher at hospital-based clinics and 10 percent higher at clinics where fewer patients previously had an undetectable viral load, when compared to similar clinics that did not offer financial incentives.

After financial incentives had been in effect for 18 months, the number of patients who achieved viral suppression, overall, was five percent higher at sites using financial incentives compared to those not offering the incentives. Additionally, viral suppression was 11 percent higher at sites with a smaller number of patients and 13 percent higher at sites with fewer patients having an undetectable viral load at the beginning of the study.

Researchers also examined the effect of financial incentives on how often patients came for clinic visits. The study showed that eight percent more patients returned for quarterly lab tests at sites offering financial incentives, when compared with sites that did not offer incentives.

For the linkage-to-care part of the study, more than 1,000 coupons were given at testing sites that offered financial incentives. Coupons could be redeemed for two gift cards, a $25 gift card when patients had their blood drawn for HIV-related tests, and a $100 gift card when they returned to receive test results and develop an individualized health care plan.

When comparing testing sites that dispensed coupons with those that did not, study results show there was no significant improvement in the percentage of people who were successfully linked to medical care after HIV diagnosis, possibly due to the fact that there were fewer than anticipated HIV-positive individuals identified at the HIV test sites.

It should be noted that over the course of the study, both linkage-to-care and viral suppression increased at almost all sites -- regardless of whether they offered financial incentives.

"Financial incentives did not work overall for achieving viral suppression. The results offer promise for using such incentives in a targeted manner, for example in those sites where fewer people have their HIV under control," said Dr. Wafaa El-Sadr, HPTN Principal Investigator and study chair. "Garnering the benefits of HIV treatment for the individual and the community are important priorities and both require achieving high levels of control of HIV."

These findings are part of the three-year HPTN 065 (TLC-Plus) study, which explored the feasibility of implementing a community-focused strategy to expand HIV testing, diagnose patients, and link them to medical care to begin and stay on treatment. The study was designed to inform future HIV prevention efforts in the US that aim at utilizing this promising approach.

According to the U.S. Centers for Disease Control and Prevention, only a quarter of the 1.1 million Americans living with HIV are virally suppressed. By enabling people unaware of their HIV infection to get tested, get engaged in care, and take antiretroviral therapy, HIV-positive people have a better chance of living longer, healthier lives and greatly reducing their chance of passing the virus on to their sex partners.