HIV-infected substance users are less likely to be virally suppressed due to lower rates of adherence to treatment and engagement in care. We tested the impact of patient navigation (PN) and contingency management (CM) on increasing viral suppression (<200 copies/µL) in HIV-infected substance users who were poorly engaged in care
Project Hope (CTN0049) is a completed 3-arm RCT to test 6 months of PN and PN+CM versus treatment as usual (TAU) on increasing 12-month viral suppression rates. The PN arm included up to 11 sessions in which navigators motivated participants to attend HIV care and substance use treatment and provided instrumental support including making and attending appointments with participants. PN+CM added contingency management; participants could earn up to $1,160 for target behaviors including attending HIV care visits, picking up medications, attending substance use treatment, providing drug-free urines, and achieving viral suppression. Differences in viral suppression at 12 months, the primary outcome, were tested by treatment arm using intention-to-treat analysis with generalized estimating equations for binary outcomes. Results are final.
801 HIV-infected out of care substance users were recruited from 11 hospitals in the US between July 2012 and January 2014. The sample was predominately male (68%), black (78%) and middle aged (m=44, SD=10). Participants reported use of stimulants (81%), marijuana (55%), high levels of alcohol (49%) and opioids (26%). Median CD4 count was 109. Viral suppression at baseline was similar across arms (PN=11%, PN+CM=10%, TAU=11%, p=.930).The percentage of patients attending at least 6 PN sessions was 74% in PN and 90% in the PN+CM arms. Average payment to an incentivized PN+CM participant was $668. Viral suppression at 12 months, available for 752 (94%), was not different across the 3 arms (PN=36%, PN+CM=38%, TAU=34%, p=.311). In secondary analyses, viral suppression (PN=39%, PN+CM=46%, TAU=35%, p(PN+CM vs TAU)=.038) and attendance at an HIV care visit (PN=79%, PN+CM=87%, TAU=69%, p(PN vs TAU)=.003); p(PN+CM vs PN)=.014) at 6 months were significantly different between arms.
PN and PN+CM had improved indicators of HIV care in the short run, but these improvements are transitory and did not persist. At the primary 12 month assessment, neither PN nor PN+CM had any impact on viral suppression in this sample of difficult to treat, substance using, unsuppressed HIV positive individuals recruited in the hospital.