exchangeable for food or household goods boosts rates of linkage and retention
in HIV care among people living with HIV who inject drugs, according to research published in
the online edition of Clinical Infectious
Diseases. However, voucher incentives were not associated with increased
rates of virological suppression, a finding the investigators think should be
explored in future research. The study was conducted in Chennai, India.
Globally, people who inject drugs are one of the groups most affected by HIV. Typically, people who inject
drugs have poorer outcomes than other people living with HIV. In many settings,
rates of linkage and retention in HIV care are especially low among people who inject drugs.
quarter of people who inject drugs in Chennai, India, are living with HIV. This group
has a high mortality rate.
team of investigators wanted to see if rates of linkage and retention in HIV
care would be increased by providing people who inject drugs with voucher incentives to
attend antiretroviral treatment (ART) clinics.
designed a small pilot study involving 120 people living with HIV who use drugs. Recruitment
took place between 2009 and 2010 and the study lasted twelve months.
All the study participants
were eligible to initiate antiretroviral therapy according to the national
guidelines in India.
randomised into an incentive or a control arm. The incentive consisted of
vouchers worth between INR200 and INR400 (US$4-8) for presenting at a government
ART clinic, attending monthly follow-up appointments, starting ART and
achieving an undetectable viral load. The vouchers could be exchanged for food
or household goods. People in the control arm of the study were not offered incentives for
achieving treatment goals. However, they had an opportunity to win vouchers in
a “prize bowl”.
The median age was
39 years and 91% of participants were male. Median baseline CD4 count was
between 248 and 268 cells/mm3, and median baseline viral load was between
55,000 copies/ml and 125,000 copies/ml. Fifty-three people had hepatitis C virus co-infection.
A total of 19 study participants died during follow-up, a mortality rate of 17.9 per 100 person-years.
Seven deaths were related to tuberculosis and three were classified as non-AIDS
Results of the
study favoured the provision of vouchers.
People in the
incentive arm were significantly more likely to link with HIV care than people in the control arm (n = 49 vs 33, p = 0.002).
Analysis of the participants attending an ART centre showed that 45% of those in the incentive arm compared
to 27% of those in the control arm started HIV treatment (p = 004).
for incentive vouchers started antiretrovirals significantly sooner than people in the
control group (p = 0.015).
After taking into
account potential confounders, the investigators found that voucher incentives
were associated with an almost threefold increase in the chances of starting
HIV treatment (HR = 2.93; 95% CI, 1.39-6.20).
People in the incentive group
also had more monthly follow-up visits compared to people in the control group
(median 8 vs 4, p = 0.005).
incentives were not associated with improved outcomes. Approximately a third of people in both study arms had an undetectable viral load at the end of the
study and CD4 count increases at the twelve-month follow-up point were also
voucher incentives were associated with higher rates of linkage to care, ART
initiation and retention to care among drug users,” comment the authors. “These
findings illustrate the potential for voucher incentives to improve multiple
steps in the HIV care continuum.”
further research is needed “to characterize the steps in the care continuum
where incentives will be most beneficial and to develop integrated
multi-faceted interventions to engage and retain marginalized populations of
HIV-infected persons in care.”