JAMA 2016;316(2):156-170. [doi: 10.1001/jama.2016.8914]
Lisa R. Metsch, PhD (Columbia University, FNA Node), Daniel J. Feaster, PhD (University of Miami, Miller School of Medicine, FNA Node), Lauren Gooden, PhD, MPH (University of Miami, Miller School of Medicine, FNA Node), Tim Matheson, PhD (San Francisco Dept. of Public Health, WS Node), Maxine Stitzer, PhD (Johns Hopkins, MA Node), Moupali Das, MD (San Francisco Dept. of Public Health, WS Node), Mamta K. Jain, MD, MPH (University of Texas Southwestern Medicine Center, TX Node), Allan E. Rodriguez, MD (University of Miami, FNA Node), Wendy S. Armstrong, MD (Emory University School of Medicine, FNA Node), Gregory M. Lucas, MD, PhD (Johns Hopkins, MA Node), Ank E. Nijhawan, MD (University of Texas Southwestern Medicine Center, TX Node), Mari-Lynn Drainoni, PhD (Boston University School of Public Health, NEC Node), Patricia Herrera, MD (John H. Stroger, Jr. Hospital
of Cook County, OV Node), Pamela Vergara-Rodriguez, MD (John H. Stroger, Jr. Hospital
of Cook County, OV Node), Jeffrey M. Jacobson, MD (Drexel University College of Medicine), Michael J. Mugavero, MD (University of Alabama, SC Node), Meg Sullivan, MD (Boston University School of Public Health, NEC Node), Eric S. Daar, MD (UCLA, PR Node), Deborah K. McMahon, MD (University of Pittsburgh), David C. Ferris, MD (Mount Sinai St Luke's), Robert Lindblad, MD (CTN Clinical Coordinating Center, Emmes), Paul VanVeldhuisen, PhD (CTN Data & Statistics Center, Emmes), Neal Oden, PhD (CTN Data & Statistics Center, Emmes), Pedro C. Castellon, MPH (Columbia University, FNA Node), Susan Tross, PhD (New York State Psychiatric Institute, GNY Node), Louise F. Haynes, MSW (Medical University of South Carolina, SC Node), Antoine Douaihy, MD (University of Pittsburgh), James L. Sorensen, PhD (University of California, San Francisco, WS Node), David S. Metzger, PhD (University of Pennsylvania, OV Node), Raul N. Mandler, MD (NIDA Center for the CTN), Grant N. Colfax, MD (University of California, San Francisco, WS Node), Carlos del Rio, MD (Emory University, FNA Node).
This is the Primary Outcomes Article for CTN-0049. Substance use is a major driver of the HIV epidemic and is associated with poor HIV care outcomes. Patient navigation (care coordination with case management) and the use of financial incentives for achieving predetermined outcomes are interventions increasingly promoted to engage patients in substance use disorders treatment and HIV care, but there is little evidence for their efficacy in improving HIV-1 viral suppression rates. This study aimed to assess the effect of a structured patient navigation intervention with or without financial incentives to improve HIV-1 viral suppression rates among patients with elevated HIV-1 viral loads and substance use recruited as hospital inpatients.
From July 2012 - January 2014, 801 patients with HIV infection and substance use from 11 hospitals across the United States were randomly assigned to receive patient navigation alone (n=266), patient navigation plus financial incentives (n=271), or treatment as usual (n=264). HIV-1 plasma viral load was measured at baseline and at 6 and 12 months. Patient navigation included up to 11 sessions of care coordination with case management and motivational interviewing techniques over 6 months. Financial incentives (up to $1160) were provided for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual was the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use disorders treatment. The primary outcome was HIV viral suppression (less than or equal to 200 copies/mL) relative to viral nonsuppression or death at the 12-month follow-up.
Of 801 patients randomized, 261 (32.6%) were women (mean [SD] age, 44.6 years [10 years]). There were no differences in rates of HIV viral suppression versus nonsuppression or death among the 3 groups at 12 months. Eighty-five of 249 patients (34.1%) in the usual-treatment group experienced treatment success compared with 89 of 249 patients (35.7%) in the navigation-only gruop, for a treatment difference of 1.6%, and compared with 98 of 254 patients (38.6%) in the navigation-plus-incentives group, for a treatment difference of 4.5%. The treatment difference between the navigation-only and navigation-plus-incentives group was -2.8%.
Conclusions: Among hospitalized patients with HIV infection and substance use, patient navigation with or without financial incentives did not have a beneficial effect on HIV viral suppression relative to nonsuppression or death at 12 months vs. treatment as usual. These findings do not support these interventions in this setting and indicate that other approaches are needed to improve HIV outcomes in this vulnerable population. (Article (Peer-Reviewed), PDF, English, 2016)
Keywords: Case management | Contingency management (CM) | CTN primary outcomes | Motivational incentives | Motivational interviewing (MI) | HIV/AIDS | Retention - Treatment | JAMA (journal)
Document No: 1213, PMID: 27404184, PMCID: PMC5339876.
Submitted by CTN Dissemination Librarians, 7/18/2016.