In a study appearing in the July 12 issue of JAMA, an HIV/AIDS theme issue, Lisa R. Metsch, Ph.D., of Columbia University, New York, and colleagues assessed the effect of structured patient navigation (care coordination with case management) interventions with or without financial incentives to improve HIV-l viral suppression rates among hospitalized patients with elevated HIV-1 viral loads and substance use.
The U.S. National HIV/AIDS Strategy calls for improved engagement in care and increased viral suppression for people living with HIV. Yet it has been estimated that only 30 percent of the 1.2 million persons with HIV infection in the United States in 2011 were virally suppressed, and according to data collected during 1999-2007, many were hospitalized with conditions preventable through HIV treatment. Substance use is likely a major factor in poor HIV clinical outcomes. To improve their health, persons with HIV infection and substance use may require treatment for substance use disorders in concert with HIV treatment. Patient navigation and the use of financial incentives for achieving predetermined outcomes are interventions increasingly promoted to engage patients in substance use disorders treatment and HIV care, but there is little evidence for their efficacy in improving HIV-1 viral suppression rates.
In this study, 801 patients with HIV infection and substance use from 11 hospitals across the United States were randomly assigned to receive patient navigation alone (n = 266), patient navigation plus financial incentives (n = 271), or treatment as usual (n = 264). Patient navigation included up to 11 sessions of care coordination with case management and motivational interviewing techniques over 6 months. Financial incentives (up to $1,160) were provided for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual was the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use disorders treatment. HIV-1 plasma viral load was measured at study entry and at 6 and 12 months.
The researchers found that there were no differences in rates of HIV viral suppression (? 200 copies/ml) versus nonsuppression or death among the 3 groups at 12 months. Eighty-five of 249 patients (34 percent) in the usual-treatment group experienced treatment success (HIV viral suppression) compared with 89 of 249 patients (36 percent) in the navigation-only group for a treatment difference of 1.6 percent and compared with 98 of 254 patients (39 percent) in the navigation-plus-incentives group for a treatment difference of 4.5 percent. The treatment difference between the navigation-only and the navigation-plus¬ incentives group was -2.8 percent.
"Among hospitalized patients with HIV infection and substance use, patient navigation with or without financial incentives did not have a beneficial effect on HIV viral suppression relative to nonsuppression or death at 12 months compared with treatment as usual. These findings do not support these interventions in this setting and indicate that other approaches are needed to improve HIV outcomes in this vulnerable population," the authors write.
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