Effect of incentives for medication adherence on health care use and costs in methadone patients with HIV
Introduction
The advent of highly active anti-retroviral therapy (HAART) markedly reduced the morbidity and mortality from HIV/AIDS (Palella et al., 1998, Palella et al., 2003, Walensky et al., 2006). Although anti-retroviral treatment reduced HIV-related hospitalizations, it is expensive and has increased total health care cost (Keiser et al., 2001, Pinkerton and Holtgrave, 1999). Anti-retrovirals account for 73% of HIV health care costs (Schackman et al., 2006). Nevertheless, this treatment causes sufficient improvement in survival and quality of life to be cost-effective, with incremental cost-effectiveness ratios between $13,000 and $23,000 per quality-adjusted life year (QALY) (Freedberg et al., 2001).
The potential benefit of anti-retroviral therapy is not being fully realized. An important limitation is the relatively poor adherence to the demanding treatment regimen. Adherence rates are 60–90%, depending on the adherence measure and the population studied (Bangsberg et al., 2000, Bangsberg et al., 2001, Gifford et al., 2000). Poor adherence with anti-retroviral treatment has been associated with higher HIV viral loads (Gifford et al., 2000, Paterson et al., 2000), progression to AIDS (Bangsberg et al., 2001), and death (Hogg et al., 2002). Among patients with low CD4 counts, failure to fill enough HAART prescriptions to cover at least 75% of the first year of follow-up resulted in five times the relative risk of death (Wood et al., 2003b).
A number of different strategies have been developed to improve treatment adherence. Short-term trials have shown that a variety of methods can be used to improve medication adherence, but longer-term studies have been less successful in showing sustained improvements or actual improvements in health (Haynes et al., 2005). Interventions have included information, counseling, reminders, reinforcement, and direct supervision (Lucas et al., 2007, Tuldra and Wu, 2002, Uldall et al., 2004). Directly observed therapy programs are effective (Kagay et al., 2004, Lanzafame et al., 2000, Mitty and Flanigan, 2004) but they are probably too expensive to be cost-effective (Bozzette and Gifford, 2003).
HIV-positive injection drug users have realized smaller benefits from HAART than other individuals with the disease. A study at one site found that the advent of HAART was associated with a 34% increase in the disease free survival of injection drug users, compared to a 135% increase in non-injection drug users (Poundstone et al., 2001). Although treatment rates have been increasing, injection drug users are less likely to obtain any anti-retroviral therapy or HAART (Celentano et al., 2001).
Once HAART has been prescribed, injection drug users are also more likely to have difficulty with adherence (Lucas et al., 2001). Reduction in substance abuse and enrollment in methadone maintenance are associated with improved adherence (Lucas et al., 2002).
Contingency management has been successfully employed in methadone treatment (Calsyn et al., 1994, Hall et al., 1977, Sindelar et al., 2007). Voucher incentives have helped methadone patients reduce their use of opiates (Silverman et al., 1996b) and cocaine (Silverman et al., 1996a). Contingency management has improved methadone patients’ adherence with medications, including treatment for tuberculosis (Elk et al., 1993). A pilot study showed that behavioral training and cash reinforcements can improve short-term adherence among HIV-positive patients with substance use disorders (Rigsby et al., 2000).
We conducted a clinical trial to test a contingency management program to improve the HAART adherence of HIV-positive clients of a methadone maintenance program. In a previous paper, we reported effectiveness findings (Sorensen et al., 2007). We now describe the cost of the intervention, its effect on health care utilization and cost, and its potential cost-effectiveness.
Section snippets
Methods
This randomized controlled trial evaluated incentives for medication compliance among HIV-positive patients enrolled in two methadone maintenance clinics in San Francisco, California. Incentives were provided in the form of vouchers redeemable for goods. It was considered unethical to randomize individuals with documented adherence problems to standard care, so the control group was provided with medication coaching. The trial evaluated the incremental effect of voucher incentives in patients
Results
A total of 86 individuals were eligible and agreed to participate in the study. Of these, 66 completed the 4-week baseline assessment with less than 80% adherence to their key anti-retroviral medication. Randomization assigned 34 participants to voucher incentives and 32 to the comparison group. At intake, participants had a mean CD4 count of 300 and a median viral load of less than 75 copies/mL. Half had viral levels below the limit of quantifiable detection. Two participants died during the
Discussion
This study showed that voucher incentives can improve the adherence to anti-retroviral therapy of HIV-positive patients enrolled in methadone maintenance.
Conflicts of interest
The authors have no conflicts of interest.
Acknowledgements
The authors express gratitude to the staff and patients of the Opiate Treatment Outpatient Program (Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital) and the Market Street Clinic of the Bay Area Addiction Research and Treatment Programs. We are grateful for the participation Anne Park, Anna Veluz, Jennifer Reeve, Kevin Ahern, Nicole Lollo, Mary Ann Hauf, Robin Sera, Gregory Roth, and TeChieh Chen in carrying out the study.
Role of the funding source: This
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