Date Published: February 9, 2017
Publisher: Public Library of Science
Author(s): Elizabeth Greene, Allison Pack, Jill Stanton, Victoria Shelus, Elizabeth E. Tolley, Jamilah Taylor, Wafaa M. El Sadr, Bernard M. Branson, Jason Leider, Natella Rakhmanina, Theresa Gamble, Rashida A. Ferrand.
HPTN 065 (TLC-Plus) evaluated the feasibility and effectiveness of providing quarterly $70 gift card financial incentives to HIV-infected patients on antiretroviral therapy (ART) to encourage ART adherence and viral suppression, and represents the largest study to-date of a financial incentive intervention for HIV viral suppression. A post-trial qualitative substudy was undertaken to examine acceptability of the financial incentives among those receiving and implementing the intervention.
Between July and October 2013, semi-structured interviews were conducted with 72 patients and 12 investigators from 14 sites; three focus groups were conducted with 12 staff from 10 sites. Qualitative data collection elicited experiences with and attitudes about the intervention, including philosophical viewpoints and implementation experiences. Transcripts were analyzed in NVivo 10. Memos and matrices were developed to explore themes from different participant group perspectives.
Patients, investigators, and staff found the intervention highly acceptable, primarily due to the emotional benefits gained through giving or receiving the incentive. Feeling rewarded or cared for was a main value perceived by patients; this was closely tied to the financial benefit for some. Other factors influencing acceptability for all included perceived effectiveness and health-related benefits, philosophical concerns about the use of incentives for health behavior change, and implementation issues. The termination of the incentive at the end of the study was disappointing to participants and unexpected by some, but generally accepted.
Positive experiences with the financial incentive intervention and strategies used to facilitate implementation led to high acceptability of the intervention, despite some reluctance in principle to the use of incentives. The findings of this analysis provide encouraging evidence in support of the acceptability of a large-scale financial incentive intervention for HIV viral suppression in a clinical setting, and offer valuable lessons for future applications of similar interventions.
Antiretroviral therapy (ART) is critical to reducing HIV-related morbidity and mortality [1–5], as well as the risk of transmission to HIV-uninfected individuals . Sustained adherence to ART can achieve the levels of viral suppression necessary to prevent HIV transmission, afford clinical benefit and avert development of resistant viral strains . However, adherence remains a key challenge to realizing the full public health potential of ART in the US and worldwide [8–10].
Seventy-six patients from 14 sites completed the interview; 72 were included in this analysis (two did not meet eligibility criteria, one never received a financial incentive, and one appeared to be intoxicated during the interview). Additionally, 12 investigators from 14 sites completed the interview, and three focus group discussions were conducted with 12 staff members from 10 sites (Table 2). Patients ranged in age from 14 to 72 years (median age 48); 61% were male; 60% Black, 15% white, and 21% Hispanic (Table 3). The majority of patients (76%) reported an annual income of less than $20,000. (Individual-level data were not collected as part of the HPTN 065 study, and the demographic data that can be ascertained from U.S. Surveillance data for the population of patients in care at sites participating in HPTN 065 are not yet available for comparison). Patients were recruited from 4 of the 5 pre-defined subcategories; if subcategory definitions were not met, the participant was classified as “other” (Table 1). The majority of patients (75%) had received at least five gift cards over the course of the intervention.
Few studies have qualitatively explored the acceptability of financial incentives when used for health-related behavior change (particularly related to HIV), and among those that have, the populations studied have mostly been the general public, potential recipients, and/or potential implementers of a hypothetical financial incentive . This study is unique in that it explored acceptability of financial incentives among actual recipients (patients) and implementers (investigators and staff) of a large-scale multi-site study about the feasibility and effectiveness of financial incentives for viral suppression among HIV-infected patients on ART. In addition, the strategic timing of the qualitative data collection and analysis—before study results on the effectiveness of the intervention were available—enabled the sharing of impressions, beliefs and attitudes based primarily on experiences with the financial incentive intervention, without the influence of the study outcome and any subsequent related discourse. The findings of this substudy reveal important insights into how a financial incentive intervention for health behavior change may be best implemented in a clinical setting. Regardless of how effective any biomedical or behavioral interventions are in the context of a clinical trial, or how great the need for them may be, their success relies in great part on user acceptance, uptake, and adherence. Qualitative studies like this one, in complement to clinical trials, are important tools for understanding the real-world contexts in which tested interventions are implemented and the factors necessary to ensure that they are acceptable to those they are intended to help.
HPTN 065 represents the largest study to-date of the use of financial incentives among HIV-infected patients receiving ART to maintain viral suppression. The success and long-term sustainability of financial incentive interventions are dependent on their acceptability by both recipients of the incentive as well as by those implementing the intervention. Positive experiences with the financial incentive intervention in the HPTN 065 study and strategies used to overcome implementation challenges facilitated high acceptability of the intervention, despite some resistance in principle to the use of financial incentives to influence health behaviors. The findings of this analysis provide encouraging evidence for the acceptability of a large-scale financial incentive intervention for viral suppression in a clinical setting, and offer valuable lessons for the future use of financial incentives.