Improving HIV/AIDS Care: Promoting HIV/AIDS Treatment Adherence Through Physician Peer Effects and Behavioral Incentives for Patients
This dissertation identifies new healthcare policy mechanisms for promoting greater adherence among both physicians and patients to the HIV medication guidelines. The first chapter uses insurance claims data for the sample, compiled by Dr. Arleen Leibowitz, of HIV-infected patients who were insured by Medicare and Medicaid in California between 2007 and 2010 to analyze physicians’ adherence to the clinical care guidelines for prescribing HIV medications. The second and third chapters were written in collaboration with Dr. Sebastian Linnemayr, and describe the impact of the Rewarding Adherence Program (RAP) on promoting greater medication adherence among HIV-infected patients in Kampala, Uganda. The second chapter was originally published in AIDS and Behavior in May of 2015, and the third chapter was published in AIDS in March of 2017.
The first chapter examines the role of physician networks in promoting quality (more adherent) HIV care. Physicians’ non-adherence to clinical care guidelines has been observed for many health conditions, and has particularly damaging repercussions for both HIV-infected patients’ health and for policies to reduce the domestic HIV epidemic. I identify physician peers through shared patients and develop repeated observations of medication regimen and disease monitoring quality across physicians and patients. Using the structure of physician networks to create instrumental variables, I find heterogeneous effects across peer types. Generalist peers have no effect on medication decisions, but a one percent improvement in HIV specialist peers’ medication regimen quality increases generalists’ medication regimen quality by 0.15 percent. Simulations how that improving generalists’ network connections to specialists could provide adherent edication regimens to an additional 2,779 patients in California in 2010, reducing the annual number of new infections by 5 percent. These findings illustrate the potential for network connections to diffuse complex treatment protocols and suggest specific mechanisms for reducing the HIV epidemic, which is disproportionately burdening underrepresented demographic communities in the U.S.
The second chapter describes the influence of behavioral decision biases on patients’ medication adherence. Behavioral economic theory has been used to study a number of health behaviors such as smoking and drug use, but there is little knowledge of how these insights relate to HIV prevention and care. In this chapter, we present novel evidence on the prevalence of the common behavioral decision-making errors of present-bias, overoptimism, and information salience among 155 Ugandan HIV patients, and quantify their association with lower medication adherence. These findings indicate that behavioral economic tools may be used to screen for future adherence problems and to better design and target interventions addressing these behavioral biases and the associated suboptimal adherence.
The third chapter measures the impact of behavioral economic incentives on combating decision biases and improving patients’ HIV medication adherence in sub-Saharan Africa. 155 HIVpositive men and women in Kampala, Uganda aged 19-78 were randomized to 1 of 2 intervention groups or a control group receiving the usual standard of care. Participants in the first intervention group were eligible for prize drawings conditional on attending scheduled clinic appointments; eligibility in the second group was based on antiretroviral medication adherence measured by medical event monitoring system caps. Results from the first nine months of this intervention show statistically significant improvements in the percent of participants who maintain mean adherence rates of 90% or higher in both intervention groups relative to the control. Such behavioral incentives represent a highly cost-effective and scalable mechanism for improving adherence in this region.