IDWeek: Look at behavior economics to improve ART adherence

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Making HIV medications free or low cost is very important for removing barriers to HIV care access, but it’s not enough to ensure adherence, Kevin Volpp said at IDWeek. HIV/AIDS programs must take behavioral economics into account when designing programs to promote adherence and ensure people living with HIV remain in the cascade of care.

“Simply providing information won’t ensure adherence,” Volpp said. “Individual behavior is key to optimizing outcomes once effective treatments exist,” he added. Studies show that people are “predictably rational” with their behaviors, he said. These behaviors include being more affected by losses than potential gains, regret aversion, being inconsistent with preferences and behaviors over time, and having problems with self-control. These are, Volpp said, common behaviors that must be acknowledged when designing public health programs.

Studies like HPTN 052 closed the debate on whether or not biomedical interventions like treatment as prevention work just as well at reducing HIV transmission as interventions based on behavioral changes, Jean Nachega of Johns Hopkins said. But test and treat models assume high adherence, and HIV programs won’t achieve high adherence if they’re not able to keep people in the cascade of care, he said.

Jean Nachega, Rochelle Walensky, and Kevin Volpp

Jean Nachega, Rochelle Walensky, and Kevin Volpp

“We need a reality check,” Nachega said. HIV programs must address the problem of patients coming in for care only when they’re very sick by finding ways to engage people infected with HIV who don’t feel sick. Programs must also find ways to address poor linkage and poor retention, he said.

Males, young people, people who are unemployed or of lower socioeconomic status, have a low CD4 count, are ineligible for ART, or only have access to rural clinics are less likely to link to HIV programs, Nachega said.

There are very few evidence-based interventions to improve adherence to the HIV cascade, Nachega said, and more research evaluating novel interventions are needed urgently. Some methods that have shown promise are offering food incentives, assisting with transportation, and promoting community adherence clubs so patients have fewer clinic visits while receiving psycho-social support from within the community.

Next generation incentives are much needed, Volpp said, and will likely leverage wireless medication devices to monitor adherence. Using mobile phones to remind patients to take their medications not only helps with adherence but also connects people to community health workers who can answer questions and provide help outside the clinic setting, Nachega said.

Moving away from the clinic setting in providing HIV care may improve adherence and keeping people in the cascade of care, the presenters said, as qualitative data shows that patients dislike clinic visits that require taking time off from work to spend an entire day seeking care. Providing antiretroviral care in the home may be the answer, as a randomized trial in Blantyre, Malawi, is investigating right now, Nachega said.

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