Background

Financial incentives promote use of HIV services and might support adherence to the sustained antiretroviral therapy (ART) necessary for viral suppression, but few studies have assessed a biomarker of adherence or evaluated optimal implementation. We sought to determine whether varying sized financial incentives for clinic attendance effected viral suppression in patients starting ART in Tanzania.

Methods

In a three-arm, parallel-group, randomised controlled trial at four health facilities in Shinyanga region, Tanzania, adults aged 18 years or older with HIV who had started ART within the past 30 days were randomly assigned (1:1:1) using a tablet-based application (stratified by site) to receive usual care (control group) or to receive a cash incentive for monthly clinic attendance in one of two amounts: 10 000 Tanzanian Shillings (TZS; about US$4·50) or 22 500 TZS (about $10·00). There were no formal exclusion criteria. Participants were masked to the existence of two incentive sizes. Incentives were provided for up to 6 months via mobile health technology (mHealth) that linked biometric attendance monitoring to automated mobile payments. We evaluated the primary outcome of retention in care with viral suppression (<1000 copies per mL) at 6 months using logistic regression. This trial is registered with ClinicalTrials.gov, NCT03351556.

Findings

Between April 24 and Dec 14, 2018, 530 participants were randomly assigned to an incentive strategy (184 in the control group, 172 in the smaller incentive group, and 174 in the larger incentive group). All participants were included in the primary intention-to-treat analysis. At 6 months, approximately 134 (73%) participants in the control group remained in care and had viral suppression, compared with 143 (83%) in the smaller incentive group (risk difference [RD] 9·8, 95% CI 1·2 to 18·5) and 150 (86%) in the larger incentive group (RD 13·0, 4·5 to 21·5); we identified a positive trend between incentive size and viral suppression (p trend=0·0032), although the incentive groups did not significantly differ (RD 3·2, −4·6 to 11·0). Adverse events included seven (4%) deaths in the control group and 11 (3%) deaths in the intervention groups, none related to study participation.

Interpretation

Small financial incentives delivered using mHealth can improve retention in care and viral suppression in adults starting HIV treatment. Although further research should investigate the durability of effects from short-term incentives, these findings strengthen the evidence for implementing financial incentives within standard HIV care.

Funding

National Institute of Mental Health at the US National Institutes of Health.

中文翻译：

---

促进坦桑尼亚接受抗逆转录病毒治疗的 HIV 成人患者继续接受护理和病毒抑制的经济激励措施：一项三臂随机对照试验。

背景

财政激励促进了 HIV 服务的使用，并可能支持坚持病毒抑制所必需的持续抗逆转录病毒疗法 (ART)，但很少有研究评估依从性的生物标志物或评估最佳实施。我们试图确定在坦桑尼亚开始接受抗逆转录病毒治疗的患者中，针对就诊的不同规模的经济激励措施是否会影响病毒抑制。

方法

在坦桑尼亚 Shinyanga 地区四家医疗机构的三组平行组随机对照试验中，在过去 30 天内开始接受抗逆转录病毒治疗的 18 岁或以上的 HIV 成人被随机分配 (1:1:1)使用基于平板电脑的应用程序（按站点分层）接受常规护理（对照组）或获得以下两种金额之一的每月诊所就诊的现金奖励：10 000 坦桑尼亚先令 (TZS；约 4·50 美元) 或 22 500 TZS（约 10·00 美元）。没有正式的排除标准。参与者被掩盖了两种激励规模的存在。通过将生物识别出勤监控与自动移动支付联系起来的移动健康技术 (mHealth) 提供了长达 6 个月的奖励。我们评估了病毒抑制保留治疗的主要结果（< 1000 份/毫升）在 6 个月时使用逻辑回归。该试验已在 ClinicalTrials.gov 注册，NCT03351556。

发现

2018 年 4 月 24 日至 12 月 14 日期间，530 名参与者被随机分配到一个激励策略（对照组 184 名，较小激励组 172 名，较大激励组 174 名）。所有参与者均被纳入主要意向治疗分析。在 6 个月时，对照组中大约 134 (73%) 名参与者继续接受治疗并获得病毒抑制，而较小激励组中有 143 (83%) 名参与者（风险差异 [RD] 9·8，95% CI 1· 2 到 18·5) 和 150 (86%) 在较大的激励组（RD 13·0、4·5 到 21·5）；我们确定了激励大小和病毒抑制之间的积极趋势（p 趋势 = 0·0032），尽管激励组没有显着差异（RD 3·2，-4·6 到 11·0）。不良事件包括对照组中的 7 例（4%）死亡和干预组中的 11 例（3%）死亡，

解释

使用移动医疗提供的小额经济激励可以提高开始接受 HIV 治疗的成年人的护理和病毒抑制的保留率。尽管进一步的研究应该调查短期激励措施效果的持久性，但这些发现加强了在标准 HIV 护理中实施经济激励措施的证据。

资金

美国国立卫生研究院国家心理健康研究所。