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Use of modest financial incentives to improve
engagement of drug users in HIV testing and posttest follow-up: results of a randomized controlled
trial
Mark Hull1, Charles Otieno1, Marianne Harris1, Joel Singer2, Erin
Ding1, Julia Zhu1, Thomas Kerr1, Evan Wood1, Kate Shannon1,
Rolando Barrios1, Robert Hogg1, Nancy Petry3, Julio Montaner1
1. BC Centre for Excellence in HIV/AIDS, Vancouver, BC
2. CIHR Canadian HIV Trials Network, Vancouver, BC
3. University of Connecticut Health Center, Farmington, CT, USA
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Background
• A significant proportion of HIV+ individuals
(~25% in BC1) are not linked to medical care
– Either have not been tested for HIV, or if HIV+
have not been assessed for ART eligibility
• Interventions to improve HIV testing rates
among at-risk populations are required to
strengthen the HIV care cascade
1. Montaner et al., CROI 2013, #1029
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Background
• Conditional cash transfers (Incentives) have been
used successfully to improve goal-related activities
amongst IDU populations
– Improved rates of completion of TB screening processes
.
Chaisson, R et al. JAIDS 1996;11:455 , Perlman, D et al J. Urban Health 2003;80:428
– Completion of hepatitis B vaccine series
• Randomized trial of monetary incentive vs. outreach nurses, 69%
vs. 23% completion. Seal, K et al. Drug and Alcohol Depend 2003; 71:127.
• Use of incentives for completion of HIV screening has
been shown to increase return rates amongst
participants in an ED-based program Haukoos, J. Acad Emerg
Med 2005;7:617.
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Objective
• To evaluate the efficacy of offering a modest
financial incentive linked to HIV testing and
post-test counseling in a substance-using
population
– To evaluate the efficacy of incentives in assessing
ART-eligibility amongst HIV+ individuals not
currently engaged in care
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Methods
Entry criteria:
• Inclusion
– Age >19 years
– At risk for HIV, or HIV+ by self-report with no recent
evaluation of HIV status (CD4 cell count or HIV VL)
– Reside in Vancouver
– Report drug use at least once in the past 3 months
• alcohol, heroin, cocaine, cocaine/heroin combinations,
methamphetamines, injectable morphine and codeine, but
excluding isolated marijuana use
• Exclusion
– Known HIV with use of antiretrovirals in the past 12
months
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Study Design
Control
Arm
Standard of care
counseling and HIV
testing without
financial incentive
Sample
Population
N=301
Incentives
Arm
Randomized 1:1
Timeline of follow-up
Visit 1
(Laboratory
Testing)
Standard of care
counseling and HIV
testing plus financial
incentive
within 4 weeks
Incentives
$10 – Laboratory testing
$15 – Returning for results
and post-test counseling
Visit 2
(Results)
Participants recruited between February and August 2012
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• The protocol and informed consent form were
approved by the UBC/Providence Health Care
Research Ethics Board
•The study is supported by the National Institute
on Drug Abuse and the CIHR Canadian HIV Trials
Network
–registered on ClinicalTrials.gov (NCT01526421)
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Statistical analysis
• Chi-square test or Fisher’s exact test were used for
analysis of categorical variables
• Wilcoxon rank-sum test was used for continuous
variables
• A multivariate logistic regression model considering
possible confounders was used to estimate the
probability of completing testing and returning for
test results, with the variable of interest being
receipt of incentives
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Baseline Demographics
Variable
Median age (IQR), years
Male gender, N (%)
Ethnic group, N (%)
Caucasian
Aboriginal
Black
Asian
Hispanic/Latino
Other
Housing , N (%)
Homeless
Unstable (SRO)
Control Group
(N=150)
Incentive Group p value
(N=151)
43 (36-50)
45 (36-51)
0.604
103 (68.7%)
98 (64.9%)
0.488
0.628
82 (54.7%)
58 (38.7%)
4 (2.7%)
1 (0.7%)
0 (0%)
2 (3.3%)
85 (56.3%)
62 (41.1%)
3 (2.0%)
0 (0%)
1 (0.7%)
0 (0%)
0.983
23 (15.3%)
60 (40.0%)
32 (21.2%)
90 (59.6%)
IQR, Interquartile range
SRO, Single-room occupancy hotel
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Baseline characteristics cont’d
Variable
Type of drug, N (%)
Heroin only
Cocaine only
Methamphetamine
only
Multiple drugs
Not specified
Frequency of use, N (%)
Not specified
Occasionally
Regularly
Daily
Control Group
(N=150)
Incentive Group p value
(N=151)
21 (14%)
15 (10%)
8 (5%)
28 (18.5%)
28 (18.5%)
15 (10%)
39 (26%)
67 (44%)
70 (46%)
10 (7%)
67 (44%)
15 (10%)
23 (15%)
45 (30%)
10 (7%)
30 (20%)
43 (28%)
68 (45%)
<0.001
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HIV Testing and post-test
counseling
P<0.001
P<0.001
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Factors associated with HIV
Screening completion
Variable
Randomized study arm
Control arm
Incentives arm
Odds Ratio (95% CI) p value
<0.001
1.00
31.83 (15.63, 64.80)
Adjusted for age, gender, ethnicity, housing and frequency
of drug use
CI, Confidence interval
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HIV eligibility screening among
known HIV+ cases
Variable
Control Group (N=17)
Incentive Group (N=13) p value
Completed lab testing
N (%)
9 (52.9%)
13 (100%)
0.004
Returned for post-test
counseling
N (%)
5 (29.4%)
12 (92.3%)
0.001
CD4 count (cells/mm3)
Median (IQR)
440 (290-680)
315(120-535)
0.881
19,175 (1,353-34,972)
19,657 (239-48,458)
0.170
HIV RNA (copies/mL)
Median (IQR)
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Hepatitis C Screening
• 122 individuals were found to be HCV
Antibody positive
– 98 in incentives arm (64% tested), 24 in control
arm (50% tested) p. 0.06
• Of 122 individuals, only 71 (58%) had selfreported known HCV+ status at study entry
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Limitations
• Single centre study
• Relatively circumscribed drug-using
population in the DTES neighbourhood of
Vancouver
– No new HIV cases identified
• Drug use patterns missing for subjects,
notably in the control arm
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Future Directions
• Phase 2 of this study is underway to examine
the effect of incentives on increasing
engagement and retention in ART programs
– Evaluation of incentive-linked testing in a nonrandomized fashion
– Incentives linked to clinic visits and achieving
undetectable plasma viral load
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Conclusion
• The use of modest financial incentives increased rates of
HIV testing and post-test follow-up among drug users
• Significantly more individuals with known HIV but no
engagement in care completed laboratory studies to
evaluate ART eligibility
• Incentive-linked testing may be a strategy for engaging
hard-to-reach populations such as drug users in HIV
testing interventions as a component of “Treatment as
Prevention” programs
– Cost-effectiveness of this incentives strategy must still be
determined
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Acknowledgement
We would like to thank all participants and study
personnel
This study was funded by National Institutes of
Health – National Institute on Drug Abuse
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