Enhancing patient navigation to improve intervention session attendance and viral load suppression of persons with HIV and substance use: a secondary post hoc analysis of the Project HOPE study

Abstract

BackgroundInterventions are needed to improve viral suppression rates among persons with HIV and substance use. A 3-arm randomized multi-site study (Metsch et al. in JAMA 316:156–70, 2016) was conducted to evaluate the effect on HIV outcomes of usual care referral to HIV and substance use services (N = 253) versus patient navigation delivered alone (PN: N = 266) or together with contingency management (PN + CM; N = 271) that provided financial incentives targeting potential behavioral mediators of viral load suppression.AimsThis secondary analysis evaluates the effects of financial incentives on attendance at PN sessions and the relationship between session attendance and viral load suppression at end of the intervention.MethodsFrequency of sessions attended was analyzed over time and by distribution of individual session attendance frequency (PN vs PN + CM). Percent virally suppressed (≤200 copies/mL) at 6 months was compared for low, medium and high rate attenders. In PN + CM a total of $220 could be earned for attendance at 11 PN sessions over the 6-month intervention with payments ranging from $10 to $30 under an escalating schedule.ResultsThe majority (74%) of PN-only participants attended 6 or more sessions but only 28% attended 10 or more and 16% attended all eleven sessions. In contrast, 90% of PN + CM attended 6 or more visits, 69% attended 10 or more and 57% attended all eleven sessions (attendance distribution χ2[11] = 105.81; p < .0001). Overall (PN and PN + CM participants combined) percent with viral load suppression at 6-months was 15, 38 and 54% among those who attended 0–5, 6–9 and 10–11 visits, respectively (χ2(2) = 39.07, p < .001).ConclusionIn this secondary post hoc analysis, contact with patient navigators was increased by attendance incentives. Higher rates of attendance at patient navigation sessions was associated with viral suppression at the 6-month follow-up assessment. Study results support use of attendance incentives to improve rates of contact between service providers and patients, particularly patients who are difficult to engage in care. Trial Registration clinicaltrials.govIdentifier: NCT01612169.

How patient navigators view the use of financial incentives to influence study involvement, substance use, and HIV treatment

“…They indicate that, from the navigator’s point of view, the incentives were helpful for increasing positive behaviors, including attendance at navigation sessions and HIV care visits, particularly for participants who were financially disadvantaged or lacking in other motivators, but were less helpful for addressing the unhealthy behavior of drug use. The viewpoints expressed by navigators are generally consistent with objective findings from secondary data reported in the main study outcomes paper (Metsch et al, 2016) and post-hoc analyses (M. Stitzer, Matheson, et al, 2017; M.…”

“…Consistent with the objective data on patient navigation session attendance (M. Stitzer, Matheson, et al, 2017) patient navigators reported that the financial incentives helped motivate people to attend navigation sessions early on.…”

“…Project HOPE found that there were no differences between groups in viral load at 12 months follow-up (6 months after completion of the interventions); however, at 6 months participants in the patient navigation group with incentives were more likely to be virally suppressed and to have engaged in HIV care than participants in the treatment as usual condition (Metsch et al, 2016). Additional secondary analyses that compared behavioral outcomes for patients receiving navigation with and without financial incentives have shown that those with incentives attended substantially more navigation sessions (M. Stitzer, Matheson, et al, 2017), and had more HIV care sessions and more validated medication prescription checks than those without incentives (M.…”

Substance use and the HIV care continuum: important advances

“…Contingency management, the strategy of rewarding people for desired behaviors, was a key component of Project HOPE, a NIDA Clinical Trials Network study that used peer navigators to link hospitalized patients with untreated HIV and substance use disorders to HIV treatment. Providing monetary incentives to attend peer navigator sessions increased visit attendance and HIV viral suppression at 6 months [ 12 ]. Similar strategies might be tested in outpatient HIV clinics where the prevalence of substance use disorders remains high.…”

Prescribing Opioids as an Incentive to Retain Patients in Medical Care: A Qualitative Investigation into Clinician Awareness and Perceptions

“…Multiple studies have focused on systems-level changes to improve HIV retention in care including providing onsite comprehensive services and reducing structural barriers via patient navigation (Gardner et al, 2005; Higa, Marks, Crepaz, Liau, & Lyles, 2012; Willis et al, 2013). Financial-based contingency management approaches have also demonstrated efficacy in promoting treatment engagement and viral suppression in patients with comorbid HIV and substance use disorder (SUD; (Stitzer et al, 2017). A recent systematic review reported that only three studies have tested contingency management interventions among PLWH with a comorbid substance use disorder (Herrmann et al, 2017).…”