There is increased interest in use of financial incentives to achieve desired health, including HIV-related, behaviors. The HPTN 065 study demonstrated that financial incentives (FI) were associated with 3.8% [(0.7%-6.8%), p=0.014) higher viral suppression (VS) and with 8.7% [(4.2%,13.2%), p=0.0001] higher continuity in care (CC) among patients at sites randomized to FI versus (vs) standard of care (SOC) in the Bronx, NY (BNY) and Washington, DC (DC). Whether the effects of FI are durable beyond withdrawal of FI is unclear. We assessed VS and CC at FI versus SOC sites post-intervention to determine durability of FI.
A total of 37 (20 BNY/ 17 DC) care sites with 51,782 patients in care (28,439 BNY/23,343 DC), were site-randomized to FI or SOC. At FI sites, patients on ART could earn $70 gift card per quarter with VS. Lab data reported to HIV Surveillance were used for site-level outcomes: for VS, VL less than 400 copies/ml in engaged patients (≥2 visits in last 15 months); for CC, CD4 or VL in 4 of prior 5 quarters. Post-intervention effects were assessed for the three quarters after discontinuation of FI (Apr-Dec 2013). GEE was used to compare FI and SOC site-level outcomes during the FI intervention and post-intervention (Table).
Post-intervention, a trend remained for an increase in VS by 2.7% (-0.3%, 5.6%, p=0.076) was noted at FI vs SOC sites. This difference in VS between FI and SOC sites was reduced from the 3.8% increase in VS to 2.7%, but was persistent nonetheless. Notably, in the subgroups of sites where FI achieved a significant increase in VS during the intervention, we noted a reduced but durable effect post-intervention at FI vs SOC sites: at DC sites 4.4% higher (p=0.057), at hospital-based sites 4.8% higher (p=0.003) and at sites with high baseline VS 3.2% higher (p=0.066). The significant increase in CC during FI intervention was sustained post-intervention with 7.5% (p=0.007) higher CC at FI vs SOC sites. A durable significant effect of FI post-intervention on CC persisted at sites randomized to FI vs SOC in BNY (p=0.010), at hospital-based sites (p=0.019) and at sites with higher baseline VS (p=0.014).
Post discontinuation of FI, data from this large study showed evidence of durable effects of FI, both on VS and CC, at sites that were previously randomized to FI vs SOC. These findings suggest that behaviors motivated by FI may last beyond the provision of the FI, increasing the potential cost-effectiveness of FI strategies.