BACKGROUND: The potential benefits of anti-retroviral therapy for HIV is not fully realized because of difficulties in adherence with demanding treatment regimens, especially among injection drug users. METHODS: HIV-positive methadone patients who were less than 80% adherent with their primary anti-retroviral therapy were randomized to a trial of incentives for on-time adherence. Adherence was rewarded with an escalating scale of vouchers redeemable for goods. Both intervention and control group visited a medication coach twice a month. The cost of the intervention was determined by micro-costing. Other costs were obtained from administrative data and patient report of out-of-system care. RESULTS: During the 12-week intervention period, the incremental direct cost of the intervention, including treatment vouchers, was $942. The voucher group incurred $2572 in anti-retroviral drug cost, significantly more than the $1973 incurred by the comparison group (p<.01). Adherence, as measured by on-time openings of an electronically monitored vial, was 78% in the intervention group and 56% in the control group. CONCLUSIONS: The incremental direct cost of voucher incentives was $292 per month. If the observed increase in adherence from voucher incentives can be sustained in the long-term, the literature suggests that disease progression will be slowed. Further research is needed to evaluate if the improvement can be sustained or achieved at lower cost. Mitigation of treatment resistance and reduction in HIV transmission are additional benefits that favor adoption.
AIMS: To conduct an economic evaluation of the first 6 months' trial of treatment vouchers and case management for opioid-dependent hospital patients. DESIGN: Randomized clinical trial and evaluation of administrative data. SETTING: Emergency department, wound clinic, in-patient units and methadone clinic in a large urban public hospital. PARTICIPANTS: The study randomized 126 opioid-dependent drug users seeking medical care. INTERVENTIONS: Participants were randomized among four groups. These received vouchers for 6 months of methadone treatment, 6 months of case management, both these interventions, or usual care. FINDINGS: During the first 6 months of this study, 90% of those randomized to vouchers alone enrolled in methadone maintenance, significantly more than the 44% enrollment in those randomized to case management without vouchers (P < 0.001). The direct costs of substance abuse treatment, including case management, was 4040 dollars for those who received vouchers, 4177 dollars for those assigned to case management and 5277 dollars for those who received the combination of both interventions. After 3 months, the vouchers alone group used less heroin than the case management alone group. The difference was not significant at 6 months. There were no significant differences in other health care costs in the 6 months following randomization. CONCLUSION: Vouchers were slightly more effective but no more costly than case management during the initial 6 months of the study. Vouchers were as effective and less costly than the combination of case management and vouchers. The finding that vouchers dominate is tempered by the possibility that case management may lower medical care costs.
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