Long-Term Effects of Incentives for HIV Viral Suppression: A Randomized Clinical Trial.

Achieving viral suppression in people living with HIV improves their quality of life and can help end the HIV/AIDS epidemic. However, few interventions have successfully promoted HIV viral suppression. The purpose of this study was to evaluate the long-term effectiveness of financial incentives for viral suppression in people living with HIV. People living with a detectable HIV viral load (≥ 200 copies/mL) were randomly assigned to Usual Care (n = 50) or Incentive (n = 52) groups. Incentive participants earned up to $10 per day for providing blood samples with an undetectable or reduced viral load. During the 2-year intervention period, the percentage of blood samples with a suppressed viral load was significantly higher among Incentive participants (70%) than Usual Care participants (43%) (OR = 7.1, 95% CI 2.7 to 18.8, p < .001). This effect did not maintain after incentives were discontinued. These findings suggest that frequent delivery of large-magnitude financial incentives for viral suppression can produce large and long-lasting improvements in viral load in people living with HIV. ClinicalTrials.gov Identifier: NCT02363387.

Abstinence-contingent wage supplements for adults experiencing homelessness and alcohol use disorder: A randomized clinical trial.

This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. A randomized clinical trial was conducted from 2019 to 2022. After a 1-month Induction period, 119 participants were randomly assigned to a Usual Care Control group (n = 57) or an Abstinence-Contingent Wage Supplement group (n = 62). Usual Care participants were offered counseling and referrals to employment and treatment programs. Abstinence-Contingent Wage Supplement participants could earn stipends for working with an employment specialist and wage supplements for working in a community job but had to maintain abstinence from alcohol as determined by transdermal alcohol concentration monitoring devices to maximize pay. Abstinence-Contingent Wage Supplement participants reported significantly higher rates of alcohol abstinence than Usual Care participants during the 6-month intervention (82.8% vs. 60.2% of months, OR = 3.4, 95% CI 1.8 to 6.3, p < .001). Abstinence-Contingent Wage Supplement participants were also significantly more likely to obtain employment (51.3% vs. 31.6% of months, OR = 2.6, 95% CI 1.5 to 4.4, p < .001) and live out of poverty (38.2% vs. 16.7% of months, OR = 3.7, 95% CI 2.0 to 7.1, p < .001) than Usual Care participants. These findings suggest that Abstinence-Contingent Wage Supplements can promote alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. ClinicalTrials.gov Identifier: NCT03519009.

Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV.

Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.

Technology-assisted opioid education for out-of-treatment adults with opioid use disorder.

OBJECTIVE: To evaluate the feasibility and potential efficacy of a technology-assisted education program in teaching adults at a high risk of opioid overdose about opioids; opioid overdose; and opioid use disorder medications. METHOD: A within-subject, repeated-measures design was used to evaluate effects of the novel technology-assisted education program. Participants (N = 40) were out-of-treatment adults with opioid use disorder, recruited in Baltimore, Maryland from May 2019 to January 2020. The education program was self-paced and contained three courses. Each course presented information and required answers to multiple-choice questions. The education program was evaluated using a 50-item test, delivered before and after participants completed each course. Tests were divided into three subtests that contained questions from each course. We measured accuracy on each subtest before and after completion of each course and used a mixed-effects model to analyze changes in accuracy across tests. RESULTS: The technology-assisted education program required a median time of 91 min of activity to complete. Most participants completed the program in a single day. Accuracy on each subtest increased only after completion of the course that corresponded to that subtest, and learning comparisons were significant at the p < .001 level for all subtests. Accuracy on each subtest was unchanged before completion of the relevant course, and increases in accuracy were retained across subsequent tests. Learning occurred similarly independent of participant education, employment, and poverty. CONCLUSIONS: Technology-assisted education programs can provide at-risk adults with access to effective education on opioids, opioid overdose, and opioid use disorder medications. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychosocial Interventions to Promote Undetectable HIV Viral Loads: A Systematic Review of Randomized Clinical Trials.

Suppressing HIV viral loads to undetectable levels is essential for ending the HIV/AIDS epidemic. We evaluated randomized controlled trials aimed to increase antiretroviral medication adherence and promote undetectable viral loads among people living with HIV through November 22, 2019. We extracted data from 51 eligible interventions and analyzed the results using random effects models to compare intervention effects between groups within each intervention and across interventions. We also evaluated the relation between publication date and treatment effects. Only five interventions increased undetectable viral loads significantly. As a whole, the analyzed interventions were superior to Standard of Care in promoting undetectable viral loads. Interventions published more recently were not more effective in promoting undetectable viral loads. No treatment category consistently produced significant increases in undetectable viral loads. To end the HIV/AIDS epidemic, we should use interventions that can suppress HIV viral loads to undetectable levels.

Effects of incentives on viral suppression in people living with HIV who use cocaine or opiates.

BACKGROUND: Antiretroviral therapy (ART) adherence is essential to maintenance of undetectable viral loads among people living with HIV, which improves health and reduces HIV transmission. Despite these benefits, some people living with HIV do not maintain the level of adherence required to sustain an undetectable viral load. This problem is particularly common among people who use drugs. OBJECTIVE: To determine effects of incentivizing viral suppression in people living with HIV who used cocaine or opiates. METHODS: In this secondary analysis of data collected during a randomized controlled trial, participants (N=102) with detectable HIV viral loads (>200 copies/mL) were randomly assigned to a Usual Care or Incentive group. Usual Care participants did not earn incentives for viral suppression. Incentive participants earned incentives ($10/day maximum) for providing blood samples with reduced or undetectable (<200 copies/mL) viral loads. All participants completed assessments every three months. Results collected during the first year were compared based on group assignment and drug use. RESULTS: Among participants who used cocaine or opiates, Incentive participants (n = 27) provided more (OR:4.0, CI:1.6-10.3, p = .004) blood samples with an undetectable viral load (69 %) than Usual Care participants (n = 25; 41 %). Among participants who did not use cocaine or opiates, Incentive participants (n = 25) provided more (OR:4.1, CI:1.5-10.7, p = .005) blood samples with an undetectable viral load (78 %) than Usual Care participants (n = 25; 36 %). Effects of incentives did not differ by drug use (OR:1.0, CI:0.3-4.0, p = .992). CONCLUSIONS: Incentivizing viral suppression can promote undetectable viral loads in people living with HIV who use cocaine or opiates.

Effects of incentivizing viral suppression in previously incarcerated adults living with HIV.

Background: The amount of HIV in a person's blood can be suppressed to an undetectable level through antiretroviral therapy medications (ART). Adhering to an ART regimen can improve a person's health and reduce HIV transmission. Despite these benefits, many people with HIV do not maintain the level of adherence required to achieve an undetectable viral load. This problem is particularly common among people who have been incarcerated.Objective: To determine effects of incentivizing viral suppression in previously incarcerated adults with HIV.Methods: Adults with HIV (N = 102) and detectable viral load (>200 copies/mL) were randomly assigned to a Usual Care or Incentive group. Usual Care participants did not earn incentives for viral suppression. Incentive participants earned incentives ($10/day maximum) for providing blood samples with a reduced or undetectable (<200 copies/mL) viral load. Assessments were conducted every 3 months. Results collected during the first year were aggregated and compared based on group assignment and incarceration history.Results: Previously incarcerated participants in the Incentive group provided more (OR: 2.9; CI: 1.3-6.8; p <.05) blood samples with an undetectable viral load (69%) than those in the Usual Care group (41%). Never-incarcerated participants in the Incentive group provided more (OR: 6.8; CI: 2.2-21.0; p <.01) blood samples with an undetectable viral load (78%) than those in the Usual Care group (36%). Effects of incentives did not differ by incarceration history.Conclusions: Incentivizing viral suppression can increase viral suppression (undetectable viral load) in people who have been incarcerated.

Incentives for Viral Suppression in People Living with HIV: A Randomized Clinical Trial.

The HIV/AIDS epidemic can be eliminated if 73% of people living with HIV take antiretroviral medications and achieve undetectable viral loads. This study assessed the effects of financial incentives in suppressing viral load. People living with HIV with detectable viral loads (N = 102) were randomly assigned to Usual Care or Incentive groups. Incentive participants earned up to $10 per day for 2 years for providing blood samples that showed either reduced or undetectable viral loads. This report presents data on the 1st year after random assignment. Incentive participants provided more (adjusted OR = 15.6, CI 4.2-58.8, p < 0.001) blood samples at 3-month assessments with undetectable viral load (72.1%) than usual care control participants (39.0%). We collected most blood samples. The study showed that incentives can substantially increase undetectable viral loads in people living with HIV. Financial incentives for suppressed viral loads could contribute to the eradication of the HIV/AIDS epidemic.

Serial alternative response training as intervention for target response resurgence.

Failure to reinforce appropriate behavior could result in resurgence of previously extinguished problem behavior and degradation of previously effective treatments such as differential reinforcement of alternative behavior (DRA). We analyzed arbitrary responses (i.e., switch flipping) exhibited by 3 adults with developmental disabilities to compare the effect of a traditional DRA intervention against the effect of a serial DRA intervention on the magnitude of target response resurgence using a 2-component multiple schedule. The target response served as an analogue to problem behavior, and alternative responses served as analogues to socially appropriate alternative responses. In all cases, the percentage of total responding allocated toward target response resurgence was less in the serial DRA component than in the traditional DRA component. Furthermore, we observed both reversion and recency for 2 of 3 subjects. Our data provide preliminary evidence suggesting that serial DRA may produce more durable and desirable outcomes than traditional DRA.

Choice in a variable environment: effects of d-amphetamine on sensitivity to reinforcement.

Four pigeons responded under a 7-component mixed schedule in which each component arranged a different left:right reinforcer ratio (27:1, 9:1, 3:1, 1:1, 1:3, 1:9, 1:27). Components were unsignaled, and the order within each session was randomly determined. After extensive exposure to these contingencies, effects of a range of doses of d-amphetamine (0.3-5.6mg/kg) on estimates of sensitivity to reinforcement at several levels of analysis were assessed. Under non-drug conditions, the structure of choice was similar to that previously reported under this procedure. That is, responding adjusted within components to the reinforcer ratio in effect (i.e., sensitivity estimates were higher in the 2nd than in the 1st half of components), and individual reinforcers produced "preference pulses" (i.e., each food presentation produced an immediate, local, shift in preference toward the response that just produced food). Although there was a general tendency for d-amphetamine to reduce overall sensitivity to reinforcement, the size of this effect and its reliability varied across pigeons. Further analysis, however, revealed that intermediate d-amphetamine doses consistently reduced sensitivity immediately following reinforcer presentations; that is, these doses consistently attenuated preference pulses.

Development and maintenance of choice in a dynamic environment.

Four pigeons were exposed to a concurrent procedure similar to that used by Davison, Baum, and colleagues (e.g., Davison & Baum, 2000, 2006) in which seven components were arranged in a mixed schedule, and each programmed a different left∶right reinforcer ratio (1∶27, 1∶9, 1∶3, 1∶1, 3∶1, 9∶1, 27∶1). Components within each session were presented randomly, lasted for 10 reinforcers each, and were separated by 10-s blackouts. These conditions were in effect for 100 sessions. When data were aggregated over Sessions 16-50, the present results were similar to those reported by Davison, Baum, and colleagues: (a) preference adjusted rapidly (i.e., sensitivity to reinforcement increased) within components; (b) preference for a given alternative increased with successive reinforcers delivered via that alternative (continuations), but was substantially attenuated following a reinforcer on the other alternative (a discontinuation); and (c) food deliveries produced preference pulses (immediate, local, increases in preference for the just-reinforced alternative). The same analyses were conducted across 10-session blocks for Sessions 1-100. In general, the basic structure of choice revealed by analyses of data from Sessions 16-50 was preserved at a smaller level of aggregation (10 sessions), and it developed rapidly (within the first 10 sessions). Some characteristics of choice, however, changed systematically across sessions. For example, effects of successive reinforcers within a component tended to increase across sessions, as did the magnitude and length of the preference pulses. Thus, models of choice under these conditions may need to take into account variations in behavior allocation that are not captured completely when data are aggregated over large numbers of sessions.

Rapid acquisition of preference in concurrent schedules: effects of d-amphetamine on sensitivity to reinforcement amount.

In the present study, effects of d-amphetamine on sensitivity to reinforcement amount under concurrent schedules were examined using a rapid-acquisition procedure. Four pigeons key pecked under single concurrent variable-interval 30-s schedules of grain presentation. Two different reinforcer-amount ratios (7:1 and 1:7) changed across sessions according to a 31-step pseudo-random binary sequence (PRBS). After at least four times through the PRBS, response ratios generally tracked the session-to-session changes in amount ratios; estimates of sensitivity ranged from 0.26 to 0.31 across the four pigeons. Effects of a range of doses of d-amphetamine (0.3-5.6mg/kg) then were determined. For 3 of 4 pigeons, at least one dose, which did not dramatically alter overall response output or bias, decreased sensitivity to reinforcement amount. These results suggest that reducing sensitivity of responding to reinforcement amount may be one behavioral mechanism of stimulants, which may have implications for interpreting drug effects on self-control.