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

Background: Interventions 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.

Aims: This 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.

Methods: Frequency 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.

Results: The 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).

Conclusion: In 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.

Keywords: Contingent incentives; HIV health care; HIV substance users; Patient navigation; Session attendance; Vial suppression.

Fig. 1

The contrasting distribution of PN visit attendance for participants in the PN (N = 266) and PN + CM (N = 271) treatment groups. Bars indicate the percentage of participants in the designated treatment group who achieved each total number of PN visits from 0 to 11 during a 6-month intervention. Incentives were available on an escalating scale starting at $10 and increasing to $30 per visit; PN + CM could earn a total of $220 for attending all visits

Fig. 2

shows mean number of PN visits attended per month during the 6-month intervention for PN (N = 266) and PN + CM (N = 271) participants

Fig. 3

The percent of all participants collapsed across PN and PN + CM (N = 508 due to missing viral load data) with suppressed viral load (≤200 copies/mL) at the 6-month assessment as a function of PN visits attended. Number of visits attended has been divided into 3 functional categories: low (0–5 visits; N = 78), moderate (6–9 visit; N = 169) and high (10–11 visits; N = 261)