Background: Enhancing the HIV continuum is critical. HPTN 065 evaluated the effect of financial incentives (FI) on linkage to care (L2C) and viral suppression (VS) in Bronx, NY (BNY) and Washington, DC (DC).
Methods: A total of 34 (16BNY/18DC) HIV test sites and 37 (20 BNY/ 17 DC) care sites were randomized to FI or standard of care. At FI test sites, HIV+ persons received coupons ($125) redeemable if care visit occurred within 3 months (M). At FI care sites, patients (Pts) on ART could earn $70 gift card per quarter with VS. Lab data reported to HIV Surveillance were used for primary site-level outcomes: for L2C, CD4 or VL within 3M of HIV+ test; for VS, VL<400 copies/ml in engaged Pts (>2 visits in last 15 M); for continuity in care, CD4 or VL in 4 of prior 5 quarters. FI sites reported numbers of eligible Pts, coupons, and gift cards dispensed. GEE were used to compare FI and SOC outcomes (Figure).
Results: 1,346 HIV+ PTS (443 BNY/903 DC) were included in evaluation of L2C at 15 hospitals and 19 community sites: In BNY/DC, respectively, 66%/76% were men, 35%/49% MSM, 50%/70% Black, 46%/10% Hispanic; 20% <25 years in both cities. On average 15,780 Pts were in care (8,927 BNY/6,853 DC) at 17 hospitals and 20 community sites: 57%/74% were men, 19%/48% MSM, 47%/72% Black and 48%/6% Hispanic in BNY/DC. For L2C, 1,061 coupons (238 BNY/823 DC) were dispensed and 194 (82%)/644(78%) redeemed in BNY/DC. For VS, 9,641 Pts (5,275 BNY/4,366 DC) were potentially eligible for gift cards, 84% of 49,650 visits qualified for cards (81% BNY/87% DC) and 39,359 gift cards were dispensed (23,265 BNY/16,094 DC).
For L2C, FI did not significantly increase overall L2C above SOC (OR: 1.05, 95%CI: 0.69, 1.58, p0.83) and no effect was noted in subsets of sites. For VS, while FI did not significantly increase VS overall (3.9%, CI: –3.5%, 11.2%, p0.3), substantial increases were noted at hospital clinics (4.9%, CI: 0.9%, 8.9%, p0.02), smaller sites (<185 patients in care) (9.6%, CI:1.2%,17.9%, p0.03), sites with lower VS at baseline (<65%) (10.4%, CI: 2.0%,18.7%, p0.01) and at peak of intervention (5.5%, CI:0.6%,10.5%, p0.03). No difference was noted by city for L2C or VS. FI increased continuity of care by 8% overall (CI: 2.1%, 13.9%, p0.008), and at community clinics, smaller sites, and sites with higher baseline VS.
Conclusions: FI did not increase L2C. However, use of FI for VS showed promising effectiveness for sites with fewer patients, lower VS and hospital-based clinics and offers potential for treatment as prevention.