saves money; improves health
Our new study shows that Visa gift cards given to HIV patients virally suppressed can achieve health (and healthcare cost) gains that may outweigh the program costs.
Paying people to take their HIV drugs was estimated to improve health, reduce HIV transmissions, and save money from a societal perspective in our new #ValueinHealth paper @ISPORJournals with @HIVptn @CDC_HIVAIDS @fredhutch @UW_Pharmacy @ICAP_ColumbiaUhttps://t.co/sS0sZ0x97n pic.twitter.com/hqCjxnJUjh— Infectious Economics (@InfectiousEcon) January 31, 2019
There is little prior evidence of effective interventions to improve viral suppression, despite this being a critical step in the HIV care continuum as described in the National HIV/AIDS Strategy for the United States.
The HPTN 065 Trial
In the HIV Prevention Trials Network (HPTN) 065 community-based clinical trial, 39 HIV care sites in the Bronx, New York, and Washington, DC, were site-randomized to financial incentives or standard of care (El-Sadr 2017). The trial found financial incentives of $70 significantly increased viral suppression and regular clinic attendance among HIV-positive patients. The overall proportion of patients with viral suppression was 3.8% higher (95% CI, 0.7%-6.8%; P = .01) at financial incentive sites compared with standard of care sites, using a random effects model.
The intervention effect for viral suppression was estimated using linear regression for the site-aggregated proportion of virally suppressed patients in each of the 5 quarters with arm as the primary covariate, adjusting for sites’ baseline proportion virally suppressed, weighted by the average number of patients at each site during the assessment period, and using a GEE approach with exchangeable correlation structure to ac- count for 5 quarterly measures for each site.
Our cost-effectiveness analysis
We conducted an economic evaluation of the two-year HPTN 065 financial incentive intervention in order to project the lifetime costs and health outcomes for patients and their sexual partners. Below is a conceptual model of the ways costs and benefits accrue with the intervention offering patients $70 each quarterly clinic visit with HIV viral suppression (<400 copies/ml).
Building on existing HIV prevention frameworks and HIV care continuum models, we developed a Markov model of disease progression and transmission to sexual partners. We used data from the HPTN 065 Study (n = 16,208), Positives for Prevention Survey, CDC HIV/AIDS Surveillance, and published literature to inform the model parameter values.
What we learned
We found financial incentives to be cost-effective for a patient because improved viral suppression can extend life (adding productivity) and improve CD4+ counts (lowering healthcare costs and spending more time in healthier states.
From a societal perspective using a lifetime horizon, financial incentives for viral suppression gained 0.06 QALYs per patient and avoided $4,210 per patient compared to the standard of care. Restricted to a healthcare sector perspective, excluding non-healthcare costs and productivity, financial incentives for viral suppression were cost-effective with an ICER of $49,877 per QALY gained compared to the standard of care .
These findings may not be transferrable to other epidemic settings where key inputs such as staff salary, the cost of HIV drugs, and willingness to pay for health gains may differ substantially.
- El-Sadr WM, Donnell D, Beauchamp G, Hall HI, Torian L V., Zingman B, et al. Financial Incentives for Linkage to Care and Viral Suppression Among HIV-Positive Patients. JAMA Internal Medicine 2017;177:1083–92. doi:10.1001/jamainternmed.2017.2158.
- Adamson B, El-Sadr W, Dimitrov D, Gamble T, Beauchamp G, Carlson J, Garrison L, Donnell D. The Cost-Effectiveness of Financial Incentives for Viral Suppression: HPTN 065 Study. Value in Health, 22 (2019) 194e202. https://doi.org/10.1016/j.jval.2018.09.001.
ART, antiretroviral therapy
QALYs, quality-adjusted life years
ICER, incremental cost-effectiveness ratio