1. Conditional Cash Transfers and Contingency Management Strategies in Substance Users Mark Hull MD, MHSc, FRCPC Clinical Assistant Professor, University of British Columbia Research Scientist, BC Centre for Excellence in HIV/AIDS

2. Objectives Substance use (DU) and barriers to HAART Incentives in the setting of DU Contingency Management in DU –Applications to treatment and prevention of HIV Adherence Limitations

3. Introduction Mathers, B et al. Lancet 2008; 372:1733. HIV Prevalence among DU

4. Barriers to Care StructuralIndividual-levelProvider-level Criminalization of behaviour Addiction- related instability Physician perceptions MarginalizationComorbid conditions IncarcerationHomelessness/ food insecurity Adapted from Wood, E. et al AIDS 2008;22:1247

5. Barriers to care Diminished response Similar mortality outcomes Wood, E et al. CMAJ 2003;169: 656.Wood, E et al. JAMA 2008;300: 550.

6. Interventions to improve HAART adherence Directly observed therapy (DOT) –A recent meta-analysis did not identify a clear benefit over self-administration (pooled relative risk 1.04; 95% CI 0.91 – 1.20) Ford, N et al. Lancet 2009;374:2064. Links to methadone maintenance programs Palepu, A et al. Drug Alcohol Depend 2006;84:188. Intensive case management strategies Kushel, M et al. Clin Infect Dis 2006;43: 234.

7. Incentive-based Programs in DU Client or patient-targeted conditional cash transfers (CCT) have become a means to achieve performance-based results. –Smoking cessation programs Volpp, K et al NEJM 2009;360:699. –Weight-loss programs Volpp, K et al. JAMA 2008;300:2631. In DU CCT has taken the form of: –1. Limited incentives for completion of specific health- related tasks. –2. Contingency management interventions designed to shape long-term behaviours for reduction in substance use.

8. Incentive-based Programs in DU Limited incentives have been used to increase uptake of preventative health activities: –Small ($5-25) monetary incentives –Food vouchers Improved rates of completion of TB screening processes –Return for PPD screening Chaisson, R et al. JAIDS 1996;11:455 ; FitzGerald JM et al. Int J Tuberc Lung Dis 1999;3:153. –Completion of screening chest X-ray 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.

9. Contingency Management Key features to CM programs: –Identification of clinically relevant behaviour –Objective measurement of the behaviour –Selection of a reinforcer desirable to the target population –Linking target behaviour to the application of the reinforcer

10. Contingency Management Strategies for reinforcement should take into account a number of principles: –Escalation of the reinforcer The longer the desired behaviour occurs, the more the reinforcer is increased to maintain the behaviour –Reset features If the behaviour does not occur, the reinforcer is reset to lower levels –Immediacy of the reinforcer Reinforcement should occur as soon as possible after the desired behaviour is observed.

11. Contingency Management Strategies Voucher-based Higgins, ST et al. Life Sci 1994;55:159. Higgins, ST et al. Addiction 2007;192:271. Silverman, K et al. Drug and Alcohol Depend 1996;41:197. Fishbowl prize draw Petry, N et al. J Consult Clin Psychol 2000;68:250-7 ; Petry, N et al. J Consult Clin Psychol 2005;73:1005. CM can be used to target substance abstinence – opiates and stimulants, attendance, and goal-directed activities. Meta-analyses of CM show clear benefit for improved abstinence and attendance Lussier, JP et al. Addiction 2006;102:192. ; Prendergast, M et al. Addiction 2006;101:1546.

12. Incentives for HIV treatment and prevention. Improved HIV screening –Improved uptake of followup for HIV testing in the ER Kelen, GD et al. Ann Emerg Med 1996;27:687. Haukoos, JS et al. Acad Emerg Med 2005;12:617. Attendance at HIV risk reduction group session Deren, S et al. Public Health Reports 1994;109:549. Change in HIV risk behaviours (CM) –Methamphetamine use and URAI Shoptaw, S et al. Drug and Alchol Depend 2005; 78:125. –Cocaine use and risk behaviours Schroeder, JR et al. Addictive Behaviours 2006;31:868. –CM arms superior to CBT, but majority of effects due to the impact on decreased substance use.

13. Incentives for HIV prevention and treatment - Adherence Sorensen 2007Rosen 2007Javanbakht 2006 Voucher based CM (n=66) Prizebowl CM (n= 56) Incentive (n=90) MEMS adherence Viral load suppression 12 weeks16 weeks48 weeks 78% vs. 58% adherent Not sustained 61% → 76% adherent Not sustained 55% vs. 28% had 1 log reduction Sorensen. Drug and Alcohol Depend. 2007Rosen. AIDS Pt Care and STD’s 2007Javanbakht, M et al. JIAPAC 2006

14. Limitations Limited evidence for durability of HIV-related CM interventions –Longer period of CM likely needed. ?cost-effectiveness Care provider aversion – Increased drug use with monetary incentive Not seen in studies Riley, E. J Urban Health 2005;82:142. –Issues of fairness –Coercion in marginalized populations Not seen when assessed Festinger D, et al. Drug Alcohol Depend. 2008;96:128.

15. The Future Use of CM has been advocated as a component of the UK NICE policy guideline for substance use treatments. –Adapted by some sites in Australia. Evaluation of incentives for HIV Treatment and Prevention underway: –HPTN 065 TLC Plus RCT of financial incentive for linkage to care and viral load suppression. –BC CFE Seek and Treat RCT of CM for linkage to care and viral load suppression in DU.

16. Acknowledgements Dr Nancy Petry PhD – University of Connecticut Health Center Shoshana Kahana PhD – National Institute on Drug Abuse National Institute on Drug Abuse