Protocol of a randomized controlled trial to test the effects of client-centered Representative Payee Services on antiretroviral therapy adherence among marginalized people living with HIV.

BACKGROUND: Client-Centered Representative Payee (CCRP) is an intervention modifying implementation of a current policy of the US Social Security Administration, which appoints organizations to serve as financial payees on behalf of vulnerable individuals receiving Social Security benefits. By ensuring beneficiaries' bills are paid while supporting their self-determination, this structural intervention may mitigate the effects of economic disadvantage to improve housing and financial stability, enabling self-efficacy for health outcomes and improved antiretroviral therapy adherence. This randomized controlled trial will test the impact of CCRP on marginalized people living with HIV (PLWH). We hypothesize that helping participants to pay their rent and other bills on time will improve housing stability and decrease financial stress. METHODS: PLWH (n = 160) receiving services at community-based organizations will be randomly assigned to the CCRP intervention or the standard of care for 12 months. Fifty additional participants will be enrolled into a non-randomized ("choice") study allowing participant selection of the CCRP intervention or control. The primary outcome is HIV medication adherence, assessed via the CASE adherence index, viral load, and CD4 counts. Self-assessment data for ART adherence, housing instability, self-efficacy for health behaviors, financial stress, and retention in care will be collected at baseline, 3, 6, and 12 months. Viral load, CD4, and appointment adherence data will be collected at baseline, 6, 12, 18, and 24 months from medical records. Outcomes will be compared by treatment group in the randomized trial, in the non-randomized cohort, and in the combined cohort. Qualitative data will be collected from study participants, eligible non-participants, and providers to explore underlying mechanisms of adherence, subjective responses to the intervention, and implementation barriers and facilitators. DISCUSSION: The aim of this study is to determine if CCRP improves health outcomes for vulnerable PLWH. Study outcomes may provide information about supports needed to help economically fragile PLWH improve health outcomes and ultimately improve HIV health disparities. In addition, findings may help to refine service delivery including the provision of representative payee to this often-marginalized population. This protocol was prospectively registered on May 22, 2018 with ClinicalTrials.gov (NCT03561103) .

The impact of representative payee services on medication adherence among unstably housed people living with HIV/AIDS.

Rates of viral suppression among people living with HIV/AIDS remain low, especially within marginalized populations such as people who are unstably housed. Representative payee is a service in which the US Social Security Administration appoints an individual or an organization to provide financial management for vulnerable individuals who are unable to manage their finances including housing payments. Little or no published research examines the association between financial management services such as representative payee and HIV clinical adherence. We conducted a pilot study with 18 unstably housed participants living with HIV/AIDS to examine the impact of representative payee services on viral suppression. Of the 11 participants who were not virally suppressed at baseline, 9 (81.8%) of them had achieved viral suppression at six-month follow-up (p = .004). Our findings suggest that providing unstably housed people living with HIV/AIDS with representative payee services may help them to improve their housing stability and clinical adherence. Additional research is needed to fully explore correlations between representative payee services and viral suppression.