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Patient Navigation Plus Financial Incentives Improve Outcomes for Persons Living with HIV Who Also Use Substances

Though treatment and care for persons living with HIV (PLWH) have improved dramatically over the last decade, many PLWH are not able to receive the optimal benefits. PLWH who also use substances are an especially vulnerable group, often having have lower rates of treatment initiation, retention, and antiretroviral therapy (ART) use. However, research has found that when this population receives support and interventions to improve adherence to treatment, it is possible to achieve similar outcomes to PLWH who do not have substance use-related problems.

One promising approach is the use of interpersonal strength-based support interventions like case management or patient navigation. Project HOPE, a study in the NIDA Clinical Trials Network, looked at the potential value of adding financial incentives (contingency management, CM) to a patient navigation behavioral intervention to see if that combination improved HIV outcomes among substance users with uncontrolled HIV. However, no difference between the two groups at the primary 12-month end-point (6 months after the study ended) were found. 

A secondary analysis of the data from Project HOPE, on the other hand, found that both patient navigation (PN) and patient navigation plus contingency management (PN+CM) improved viral load suppression (compared to usual care) at the 6-month mark. 

This article is reporting on another secondary analysis, aimed at expanding on those findings. For this one, researchers looked at documented performance of all target behaviors during the 6-month intervention, comparing outcomes for patient navigation vs. patient navigation plus CM.

The targeted behaviors were those deemed necessary to achieving a final goal of viral load suppression, and included:

  • attending PN sessions, 
  • attending HIV care visits, 
  • providing evidence of an active antiretroviral medication prescription, 
  • entering substance use disorder treatment, and 
  • providing drug negative urine samples at PN visits. 

Participants in the PN+CM group could earn incentive payments for meeting viral load criteria ($150 total), as well as PN visits ($220), paperwork completion ($80), and substance use-related targets ($310).

Results found that incentives were associated with shorter time to treatment initiation and higher rates of target behaviors during the 6-month intervention, with the exception of month-6 HIV care visits.

Viral suppression rates at the end of the 6-month intervention were not significantly different for the two groups, but were directly related to the number of behaviors completed for both care visits and validated medication. 

Conclusions: Financial contingency management incentives added to a patient navigation intervention were associated with better engagement, including earlier initiation and higher sustained rates of key health-related behaviors. Incentives were also associated with a shorter average time both to the initial HIV care visit and to first verified pick-up of HIV medication among those who ever initiated those behaviors.

These robust results suggest that incentives are a valuable tool for enhancing linkage to care, as well as speeding up or “kick starting” early steps in the care process.

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