Cue-dose training with monetary reinforcement

Abstract

OBJECTIVE:To assess the feasibility and efficacy of two interventions for improving adherence to antiretroviral therapy regimens in HIV-infected subjects compared with a control intervention. DESIGN:Randomized, controlled, pilot study. SETTING: Department of Veterans Affairs HIV clinic and community-based HIV clinical trials site.PARTICIPANTS: Fifty-five HIV-infected subjects on stable antiretroviral therapy regimens. Subjects were predominantly male (89%) and African American (69%), and had histories of heroin or cocaine use (80%). INTERVENTIONS:Four weekly sessions of either nondirective inquiries about adherence (control group, C), cue-dose training, which consisted of the use of personalized cues for remembering particular dose times, and feedback about medication taking using Medication Event Monitoring System (MEMS) pill bottle caps, which record time of bottle opening (CD group), or cue-dose training combined with cash reinforcement for correctly timed bottle opening (CD ؉ CR). MEASUREMENTS:Opening of the pill bottle within 2 hours before or after a predetermined time was measured by MEMS. RESULTS:Adherence to the medication as documented by MEMS was significantly enhanced during the 4-week training period in the CD ؉ CR group, but not in the CD group, compared with the control group. Improvement was also seen in adherence to antiretroviral drugs that were not the object of training and reinforcement. Eight weeks after training and reinforcement were discontinued, adherence in the cashreinforced group returned to near-baseline levels. CONCLUSIONS:Cue-dose training with cash reinforcement led to transient improvement in adherence to antiretroviral therapy in a population including mostly African Americans and subjects with histories of drug abuse. However, we were not able to detect any sustained improvement beyond the active training period, and questions concerning the timing and duration of such an intervention require further study. Randomized, controlled clinical studies with objective measures of adherence can be conducted in HIV-infected subjects and should be employed for further evaluation of this and other adherence interventions.

Effect of Directly Observed Therapy for Highly Active Antiretroviral Therapy on Virologic, Immunologic, and Adherence Outcomes: A Meta-Analysis and Systematic Review

“…5–10 Unfortunately, nonadherence is common among HIV-positive patients because of the life-long nature of HAART, 11,12 adverse events, 13–15 and numerous psychosocial and economic stressors. 11,16–21 Interventions to improve HAART adherence vary widely and often include education and counseling, 22–25 patient reminders, 26,27 behavioral therapy, 27,28 and social support. 28–30 Other interventions promote combined strategies.…”

Environmental Influences on HIV Medication Adherence: The Role of Neighborhood Disorder

“…Contingency management approaches have shown short-term positive effects in increasing ARV adherence and lowering viral load among substance using HIV-positive patients (49-51), and have been recommended as a priority for research on HIV medical care linkage and retention (52). For economically disadvantaged HIV-positive individuals, short-term monetary incentives for adherence may prove to be one useful element in off-setting vulnerability to the environmental pressures of ARV street markets.…”

Financial incentives to improve progression through the HIV treatment cascade

“…These studies of incentivized ART adherence have all been small, and notably, the three studies that measured adherence outcomes after cessation of the incentive intervention [27–29] found that the benefits faded as early as 8 weeks later. This speaks to the difficulty of maintaining durable results for a complex behavior that requires long-term maintenance.…”