Page 1 Use of modest financial incentives to improve engagement of drug users in HIV testing and post- test follow-up: results of a randomized controlled trial Mark Hull 1, Charles Otieno 1, Marianne Harris 1, Joel Singer 2, Erin Ding 1, Julia Zhu 1, Thomas Kerr 1, Evan Wood 1, Kate Shannon 1, Rolando Barrios 1, Robert Hogg 1, Nancy Petry 3, Julio Montaner 1 1. BC Centre for Excellence in HIV/AIDS, Vancouver, BC 2. CIHR Canadian HIV Trials Network, Vancouver, BC 3. University of Connecticut Health Center, Farmington, CT, USA

Page 2 Background A significant proportion of HIV+ individuals (~25% in BC 1 ) are not linked to medical care – Either have not been tested for HIV, or if HIV+ have not been assessed for ART eligibility Interventions to improve HIV testing rates among at-risk populations are required to strengthen the HIV care cascade 1. Montaner et al., CROI 2013, #1029

Page 3 Background Conditional cash transfers (Incentives) have been used successfully to improve goal-related activities amongst IDU populations – Improved rates of completion of TB screening processes Chaisson, R et al. JAIDS 1996;11:455, Perlman, D et al J. Urban Health 2003;80:428. – Completion of hepatitis B vaccine series Randomized trial of monetary incentive vs. outreach nurses, 69% vs. 23% completion. Seal, K et al. Drug and Alcohol Depend 2003; 71:127. Use of incentives for completion of HIV screening has been shown to increase return rates amongst participants in an ED-based program Haukoos, J. Acad Emerg Med 2005;7:617.

Page 4 Objective To evaluate the efficacy of offering a modest financial incentive linked to HIV testing and post-test counseling in a substance-using population – To evaluate the efficacy of incentives in assessing ART-eligibility amongst HIV+ individuals not currently engaged in care

Page 5 Methods Entry criteria: Inclusion – Age >19 years – At risk for HIV, or HIV+ by self-report with no recent evaluation of HIV status (CD4 cell count or HIV VL) – Reside in Vancouver – Report drug use at least once in the past 3 months alcohol, heroin, cocaine, cocaine/heroin combinations, methamphetamines, injectable morphine and codeine, but excluding isolated marijuana use Exclusion – Known HIV with use of antiretrovirals in the past 12 months

Page 6 Sample Population N=301 Sample Population N=301 Control Arm Incentives Arm Standard of care counseling and HIV testing plus financial incentive Randomized 1:1 Standard of care counseling and HIV testing without financial incentive Study Design Visit 1 (Laboratory Testing) Visit 2 (Results) Timeline of follow-up Incentives $10 – Laboratory testing $15 – Returning for results and post-test counseling within 4 weeks Participants recruited between February and August 2012

Page 7 The protocol and informed consent form were approved by the UBC/Providence Health Care Research Ethics Board The study is supported by the National Institute on Drug Abuse and the CIHR Canadian HIV Trials Network – registered on ClinicalTrials.gov (NCT )

Page 8 Statistical analysis Chi-square test or Fisher’s exact test were used for analysis of categorical variables Wilcoxon rank-sum test was used for continuous variables A multivariate logistic regression model considering possible confounders was used to estimate the probability of completing testing and returning for test results, with the variable of interest being receipt of incentives

Page 9 Baseline Demographics VariableControl Group (N=150) Incentive Group (N=151) p value Median age (IQR), years43 (36-50)45 (36-51)0.604 Male gender, N (%)103 (68.7%)98 (64.9%)0.488 Ethnic group, N (%) Caucasian Aboriginal Black Asian Hispanic/Latino Other 82 (54.7%) 58 (38.7%) 4 (2.7%) 1 (0.7%) 0 (0%) 2 (3.3%) 85 (56.3%) 62 (41.1%) 3 (2.0%) 0 (0%) 1 (0.7%) 0 (0%) Housing, N (%) Homeless Unstable (SRO) 23 (15.3%) 60 (40.0%) 32 (21.2%) 90 (59.6%) IQR, Interquartile range SRO, Single-room occupancy hotel

Page 10 Baseline characteristics cont’d VariableControl Group (N=150) Incentive Group (N=151) p value Type of drug, N (%) Heroin only Cocaine only Methamphetamine only Multiple drugs Not specified 21 (14%) 15 (10%) 8 (5%) 39 (26%) 67 (44%) 28 (18.5%) 15 (10%) 70 (46%) 10 (7%) <0.001 Frequency of use, N (%) Not specified Occasionally Regularly Daily 67 (44%) 15 (10%) 23 (15%) 45 (30%) 10 (7%) 30 (20%) 43 (28%) 68 (45%)

Page 11 HIV Testing and post-test counseling P<0.001

Page 12 Factors associated with HIV Screening completion VariableOdds Ratio (95% CI)p value Randomized study arm Control arm Incentives arm (15.63, 64.80) <0.001 Adjusted for age, gender, ethnicity, housing and frequency of drug use CI, Confidence interval

Page 13 HIV eligibility screening among known HIV+ cases VariableControl Group (N=17)Incentive Group (N=13)p value Completed lab testing N (%) 9 (52.9%)13 (100%)0.004 Returned for post-test counseling N (%) 5 (29.4%)12 (92.3%)0.001 CD4 count (cells/ mm 3 ) Median (IQR) 440 ( )315( )0.881 HIV RNA (copies/mL) Median (IQR) 19,175 (1,353-34,972)19,657 (239-48,458)0.170

Page 14 Hepatitis C Screening 122 individuals were found to be HCV Antibody positive – 98 in incentives arm (64% tested), 24 in control arm (50% tested) p Of 122 individuals, only 71 (58%) had self- reported known HCV+ status at study entry

Page 15 Limitations Single centre study Relatively circumscribed drug-using population in the DTES neighbourhood of Vancouver – No new HIV cases identified Drug use patterns missing for subjects, notably in the control arm

Page 16 Future Directions Phase 2 of this study is underway to examine the effect of incentives on increasing engagement and retention in ART programs – Evaluation of incentive-linked testing in a non- randomized fashion – Incentives linked to clinic visits and achieving undetectable plasma viral load

Page 17 Conclusion The use of modest financial incentives increased rates of HIV testing and post-test follow-up among drug users Significantly more individuals with known HIV but no engagement in care completed laboratory studies to evaluate ART eligibility Incentive-linked testing may be a strategy for engaging hard-to-reach populations such as drug users in HIV testing interventions as a component of “Treatment as Prevention” programs – Cost-effectiveness of this incentives strategy must still be determined

Page 18 Acknowledgement We would like to thank all participants and study personnel This study was funded by National Institutes of Health – National Institute on Drug Abuse