A research team that studied the benefits of patient navigation services with or without financial incentives for hospitalized individuals with HIV and substance use disorders are warning against too gloomy an interpretation of the results. While the two active treatments did not significantly decrease viral suppression rates at 12 months compared with usual care, results at 6 months (as the study’s interventions were concluding) were more encouraging.

Therefore, the researchers are emphasizing that the takeaway from this study of a seriously ill population should not be one of “incentives don’t work,” but rather that “we can do more,” in the words of study lead author Lisa R. Metsch, Ph.D.

“At the end of the intervention protocol, there is a significant difference,” Metsch, who chairs the Department of Sociomedical Sciences at Columbia University’s Mailman School of Public Health, told ADAW. “Those who received the intervention with incentives were more likely to be virally suppressed.”

In total, the study findings that were published in the July 12 JAMA illustrate a great deal about the importance of comprehensive services for a population with such great and diverse needs that it often is not even included in research study samples. As pointed out to ADAW by Maxine Stitzer, Ph.D., the Johns Hopkins University Department of Psychiatry professor who designed the study’s contingency management protocol, sustained and effective care for this population would prove to be costly — not so much in the cost of patient incentives, but in securing the care navigators needed to help engage patients in both HIV and substance use care.

Study parameters

The study selected patients from 11 hospitals with high numbers of HIV patients and a high prevalence of substance use problems in the HIV population, from 11 major metropolitan areas scattered across the country. The 801 patients were randomized to one of three treatment conditions: 6 months of patient navigation services to help connect them with HIV and substance use treatment services; the same 6 months of navigation along with patient financial incentives to achieve a number of health behaviors, and usual care, which mainly involved standard referral to services in the community.

Metsch described the overall study population as “individuals out of HIV care, not engaged in the system, in the hospital, very sick, with untreated substance use.”

The patient navigators, who received 24 hours of initial training for the task, used a strengths-based case management approach and employed motivational interviewing techniques. They helped patients address any logistical challenges to receiving ongoing care, and they maintained a hands-on strategy by accompanying patients to their first substance use disorder and HIV treatment appointments.

The cash incentives in the study, Stitzer explained, departed from what has been used in most research that ties them to one particular desired behavior. The incentives in this study were designed to provide ongoing positive reinforcement, and were used in an attempt to achieve seven different outcomes, from attending treatment appointments to providing negative drug test specimens to having an active prescription for antiretroviral therapy. Those receiving incentives were eligible to earn a maximum of $1,160 over the 6-month intervention period.

”This is the right population for this kind of an [intensive] intervention,” said Stitzer.

The researchers assessed both HIV and substance use outcomes, with the primary outcome of HIV viral suppression at 12 months. At 6 months, as the interventions ended, 46.2 percent of the group receiving navigation with incentives was virally suppressed, compared with 35.2 percent of the group receiving usual care. But at 12 months, the viral suppression rates were much closer: 38.6 percent in the navigation with incentives group and 34.1 percent in the usual-care group (the 12-month rate for the navigation-only group was 35.7 percent).

Both Metsch and Stitzer acknowledged that substance use outcomes were generally disappointing, with no significant differences among the groups in drug-screen results, self-reported drug use or severity at 6 or 12 months. Moreover, engagement rates in professional substance use services were low across the board, with the highest being just 30.6 percent in the navigation with incentives group.

Yet they added that the 6-month results in viral suppression rates offer some cause for optimism. Stitzer added with regard to research on interventions in general, “The world keeps hoping that we’ll have permanent effects of interventions. But that doesn’t tend to happen. The interventions tend to be effective when they are in place.”

Improving engagement

Metsch said that with linkages to substance use treatment being less successful than hoped for in this study, she concludes that if the research were to be designed over again, “We’d try to start the substance use services directly in the hospital setting.”

She cited other factors that also should be accounted for in interpreting the results related to substance use. “We were limited by treatment availability in a particular area,” Metsch said. Many patients were primary stimulant users, complicating the task of identifying ideal treatment options, she said.

Also, outcomes in Southern study sites were worse than elsewhere, the researchers reported. Atlanta, Miami and Birmingham, Ala., were among the study sites.

Stitzer says the 6-month outcomes on viral suppression should have care providers taking heart and seeking to make their services as attractive as possible to the types of high-need patients treated in this study.

Bottom Line…

Use of patient navigation services with financial incentives did not result in 12-month improvement in HIV viral suppression rates among HIV patients with substance use disorders, but encouraging results at 6 months might offer reason for optimism.