Do Financial Incentives Improve An HIV Patient's Outcomes?

Gift Cards Used to Incentivize Viral Control, Continuity of Care

Photo Credit: Joe Raedle/Getty Images

It was in 2011 that Dr. Mark Hull of the British Columbia Centre for Excellence in HIV/AIDS formally proposed the idea of providing financial incentives as a means of retaining HIV patients in care since, in his own words, "any behavior that is reinforced by a reward usually increases in frequency."

The practice, called contingency management (CM) and conditional cash transfers (CCT), has been implemented in a number of other public health sectors, including a program in San Francisco for injecting drug users (IDUs), which aimed to increase completion rates of a three-dose hepatitis B vaccination series.

In analyzing the results, researchers at the University of California, San Francisco concluded that the monthly cash incentives increased the rate of completion from 25% to 70%.

Soon after, based on this and other pieces of research, the U.K.'s National Institute for Health and Care Excellence (NICE) began recommending the use of vouchers for agencies working with illicit drug users—either to improve abstinence rates in those on methadone treatment or to incentivize testing for HIV, hepatitis B, hepatitis C and tuberculosis.

Contingency Management in Patients with HIV

Only recently did investigators begin to look into the effectiveness of CM/CCT in people with HIV.  One such study, presented at the 2015 Conference on Retroviruses and Opportunistic Infections (CROI), aimed to assess whether financial incentives, in the form of redeemable gift cards, might

  • encourage people in high-risk communities to get tested for HIV;

The study, called HPTN 065 TLC-Plus ("Testing and Linkage to Care Plus Treatment") was conducted at 37 HIV testing sites and 39 care centers in Washington, D.C.

and the Bronx, New York, both of which have high incidence rates in poorer black and Hispanic neighborhoods. The study was designed so that half the sites would provide financial incentives, while the other half wouldn't.

For sites offering financial incentives, the following were provided:

  • A 25% gift card for anyone who came in for an HIV test
  • ​A $100 gift card if the person returned for their HIV test results
  • A $70 gift card if a person on therapy maintained an undetectable viral load, up to three cards per year

In total, nearly 42,000 gift cards were distributed to over 9,000 patients over a two-year period.  

In analyzing the results, the investigators reported a few modest gains in the some of the sites, but from an overall standpoint, there was no significant difference in any of the categories, whether from sites offering financial incentives or those that did not.

However, there were some bright spots. According to the researcher, patients with hospital-based care had 5% better rates of viral suppression if provided incentives, while overall rates of  suppression appeared to increase by 5% during the last three months of the study—suggesting, perhaps, that adherence improves the longer a patient remains in care.

Meanwhile, continuity of care was seen to improve in smaller clinics with fewer than 186 patients (19%), as well as in non-hospital sites like community centers and private practices (11%).

Whether these results will be sufficient enough to recommend implementation is largely up to interpretation.

Contingency Management in Resource-Limited Setting

Despite the less-than-compelling results, there is some evidence that financial incentives may work in resource-limited settings where average incomes can be as low as $250 per year.

In one Tanzanian study published in 2011, researchers reported that young people given a $25 in cash every four months to remain free of sexually transmitted infections (STIs) did 25% better than those who received nothing.  By contrast, no changes in infection rates were seen in young people given $10 every four months as compared to those who received no incentive.

In a similar study in rural Malawi (where average annual salaries hovering around $100), there was also no difference in HIV infection rates between individuals receiving no financial incentive and those who received either $4 or $16 dollars each year to remain HIV-free.

In light of such research, a number of bioethicists and legal analysts have begun to express concern as to whether the practice of conditional cash transfers is reasonable in high-prevalence settings, or if freedom of choice is being compromised by effectively coercing a person into compliance (particularly if incentives are later removed).

In addressing the issue, Professor Michael Sandel of Harvard University summed up the ethical concerns by stating: "We need to recognise that there are some things than money can't buy, and other things that money can buy but shouldn't."


Hull, M. "Conditional cash transfers and contingency management strategies in substance users." Sixth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. 2011; Rome, Italy; presentation TUSY030.

Seal, K.; Kral, A.; Lorvick, J.; et al. "A randomized controlled trial of monetary incentives vs. outreach to enhance adherence to the hepatitis B vaccine series among injection drug users." Drug and Alcohol Dependence. August 20, 2003; 71(2):127-131.

Public Health England. "Contingency management in drug treatment." London, England; accessed 26 February, 2015.

HIV Prevention Trials Network (HTPN). "HPTN 065 (TLC-Plus): A Study to Evaluate the Feasibility of a Community-Focused Approach for HIV Prevention in the United States." Accessed February 26, 2015.

Watts, C. "Structural economic interventions to address women's vulnerability to HIV infection in sub-Saharan Africa." Sixth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. 2011; Rome, Italy; presentation TUSY0303.

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