Incentivizing Adherence with HIV Treatment: Use of Conditional Cash Transfers in Large US Study

The evidence supporting the effectiveness of conditional cash transfers is promising in low-income settings, yet little evidence exists in its application to health in the United States (US). Most studies have not examined the durability of effect. To fill this gap, a clinic randomized experiment, including 15,780 HIV-positive patients at 34 clinics in New York, NY and Washington, DC, offered quarterly financial incentives ($70 gift cards) for viral suppression, an important outcome for individual benefit from HIV treatment as well as a societal benefit as viral suppression is associated with decreased sexual transmission of HIV to others. Over two years, 39,363 gift cards offered at clinics randomized to cash transfers significantly increased the proportion of patients with viral suppression compared to clinics continuing standard care. Based on a mathematical model of HIV disease progression and HIV transmission to others, we estimate these financial incentives lowered total costs, gained patient health, and reduce new HIV infections by 8%. We identify economies of scale related to clinic and population heterogeneity. By improving adherence to HIV drugs, we suggest conditional cash transfers are likely dominant or cost-effective compared to standard healthcare in the US. Finally, we apply new evidence to show the durability of effect on health outcomes after discontinuation of financial incentives.