It is increasingly recognized that cash and in-kind incentives can motivate behavior change and improve outcomes along the HIV care continuum. Under the right circumstances, incentives can increase the demand for HIV testing, change short-term sexual behavior, enhance linkage to care after HIV diagnosis, and promote short-term antiretroviral therapy (ART) adherence. However, there is a paucity of long-term follow-up data about incentive-based programs for people living with HIV infection (PLHIV). This research gap limits our understanding of whether these approaches are worthwhile investments, especially in the generalized HIV epidemics in Sub-Saharan Africa. The proposed research will advance global knowledge about the long-term effectiveness of incentives for ART adherence and retention in care, and their potential effectiveness for re-engagement in care. We will build on preliminary data from a study we conducted in Shinyanga, Tanzania which found that short-term cash and food assistance improved ART adherence and retention in care among food insecure PLHIV after 6 and 12 months of follow-up. We will now leverage our established research program to determine the long-term effectiveness of these incentive strategies. In our 2-year study, we will first determine 24-month adherence and retention outcomes using medical and pharmacy records for the 781 PLHIV who were alive at the end of our previous study, which concluded after 12 months of follow-up (Aim 1). Then, leveraging an existing program of home based care, we will determine the prevalence of undocumented transfers and deaths among the subset of patients found to be lost to follow-up or transferred in clinic records. We will use these data from home visits to adjust estimates of the interventions' effectiveness on retention in HIV care and mortality (Aim 2). Among the PLHIV found to be disengaged from care, we will conduct a pilot study of a one-time cash incentive to encourage PLHIV to re-engage with care, with the goal of mitigating the barriers posed by transportation and opportunity costs (Aim 3). At the conclusion of the project, we will know the long-term effectiveness of cash and food incentives for adherence and retention, and whether they can also be used for re-linking PLHIV to care, data highly relevant to `Treat All' programs in Fast Track countries. This timely information will be widely applicable to the spectrum of incentive-based programs currently being designed, implemented, or under consideration to improve the health of PLHIV. Furthermore, this research will help policy makers understand whether incentive-based programs should be incorporated into ongoing `treatment as prevention' (TasP) programs. 1
Although there is increasing evidence that financial and in-kind incentives can improve the health of people living with HIV infection, there are significant gaps in our understanding of how long these benefits are sustained. In this study, we will evaluate the long-term effectiveness of an incentive-based intervention for Tanzanian adults living with HIV infection that improved short-term retention in care and adherence to antiretroviral treatment. Our findings will result in generalizable knowledge about the long-term effectiveness of cash and food incentives for treatment adherence, retention in HIV care, and re-engagement in care.
