Goals for Adherence with Low-cost Incentives (GOALS)

Project Summary Treatment outcomes of HIV-positive youth in Uganda and elsewhere are threatened by low medication adherence. Despite the clear need for adherence support among youth, few interventions target this particularly vulnerable group during a time of heightened risk-taking behavior and unfinished development of cognitive control processes such as planning and goal-directed behavior. Incentives informed by behavioral economics (BE) have successfully changed a range of health behaviors by countering present bias (the tendency of overly discounting the future benefits of preventive health behaviors) including our own study that improved ART adherence. However, they have rarely been tested among youth living with HIV (YLWH) who are likely to particularly benefit from such extrinsic rewards given their observed problems with self-control. Traditional incentives that require individuals to reach a uniform, high eligible threshold by design leave out those unable to meet it, often most in need of support. In a pilot study, we tested a novel incentive design that allowed even those with low initial adherence to qualify for incentives, resulting in their improved adherence. BE theory suggests that the effort exerted to reach a goal depends on how far away it is from the participant; if the goal is within close reach, the participant shows great willingness to achieve it, but if the goal is set too high, s/he becomes demotivated and may give up. Based on this insight, we restructured our incentive design to allow participants to set their own eligibility threshold. We propose to build on our pilot results using a randomized controlled trial (RCT) to establish effectiveness. Our intervention, GOALS, proposes testing externally assigned sub-goals gradually increasing towards 90% (T1, n=140) and self-chosen, participatory interim goals (T2, n=140), against a traditional, fixed goal of 90% (T3, n=140). The control group (n=140) will receive the usual standard of care. The primary outcome is electronically measured ART adherence collected throughout the study and for 12 months after incentives are withdrawn to measure the persistence of behavior change; suppressed viral load will be the secondary outcome. The Specific Aims in year 1 (Improvement Phase) is to evaluate the relative effectiveness of the three incentivization approaches for improving adherence among YLWH. In year 2 (Maintenance Phase), we test the relative effectiveness of the three ways of incentivization for maintaining adherence. In year 3 (Persistence Phase) the goal is to investigate for 12 months the relative effectiveness of the three GOALS intervention arms at creating behavioral persistence once incentives are removed. Specific Aim 4 is to perform a cost-effectiveness analysis including a comparative analysis of those GOALS intervention arms that show a positive intervention impact for improving and/or maintaining adherence.