St Mary’s Hospital in London is testing the use of cash incentives, in combination with motivational interviewing, in an effort to improve the adherence of a small group of HIV-positive young people. The rationale and first results of the programme were presented in two posters at the British HIV Association conference in Birmingham this week.
As highlighted at the International AIDS Society conference in Rome last year, there is increasing interest in the potential of programmes which give financial incentives to people in order to encourage HIV testing, linkage to care and avoidance of infection. The approach has also been used in the UK to encourage young women to screen for chlamydia.
St Mary’s has a relatively large cohort of individuals who acquired HIV through vertical transmission, and has been at the forefront of developing services for young people as they transition from paediatric to adult HIV services.
Difficulties with adherence in childhood are often carried through into adulthood. Despite intensive support, St Mary’s staff have found that around one in five of the young people at their clinic have significant problems in this respect, with potentially very serious consequences. The scheme is only offered to young people with these characteristics.
The idea of financial incentives was raised during consultation with young people attending the service. The scheme combines the payment of financial incentives dependent on virological results with the use of motivational interviewing techniques by a nurse and a psychologist. Motivational interviewing aims to help people clarify their own strengths and aspirations, evoke their motivations for change, and promote autonomy of decision making.
The financial incentives are seen to be there primarily to encourage engagement with the healthcare team and clinic attendance. Payment of incentives is contingent on both participating in motivational interviewing and achieving key treatment outcomes.
Participants may be paid £25 or £50 ($40 or $80) at various time points during the one-year programme, dependent on having a reduction in viral load or maintaining an undetectable viral load. The maximum that an individual can receive is £200.
The clinicians hope that good habits established with the support of the scheme may be perpetuated after the payments cease.
Twelve young people were invited to take part, of whom eleven accepted. The youngest was 16 and the oldest 23. At baseline, median CD4 count was just 30 cells/mm3, with no participant having a CD4 count above 160 cells/mm3. Median viral load was 12,870 copies/ml.
At the end of their involvement in the scheme, five of the eleven participants achieved the intended outcome of maintaining an undetectable viral load for six months. Moreover, another four did achieve an undetectable viral load at least once, which would be of some medical benefit.
Median CD4 count after the programme was 140 cells/mm3. With £1300 paid out in financial incentives, the clinicians calculate each gain of 50 CD4 cells to have cost £76.
It’s important to remember that these individuals have a long history of finding adherence extremely challenging and have already been offered adherence support in many different ways.
The authors conclude: “The financial rewards appeared to encourage attendance and engagement. This in turn allowed intervention to identify emotional and logistical solutions to adherence difficulties for a significant number of this vulnerable group.”
They anticipate modifications and refinements of the scheme, with the aim of improving its impact.