INcentives and ReMINDers to Improve Long-term Medication Adherence (INMIND)

Project Summary/Abstract Globally, 75% of people living with HIV (PLWH) are receiving antiretroviral therapy (ART), but only 67% of them are virally suppressed, with ART medication nonadherence as a key barrier. Routines are associated with high long-term medication adherence, but have been difficult to establish through interventions. One promising routinization approach is to pair, or ‘anchor,’ a new behavior to an already existing routine, as behaviors consistently performed in response to the same contextual cue (e.g., an existing routine) are carried out with little or no cognitive effort. However, such anchoring interventions do not support participants during the lengthy routinization process and typically work only for participants with high motivation. In a novel R34 pilot study, we successfully established ART pill-taking routines by incorporating behavioral economics insights into the traditional anchoring approach. We used components from current anchoring interventions (e.g., asking all participants to create an anchoring plan by picking an existing routine to pair with their ART pill-taking) and augmented them in two ways based on our proven behavioral economics-based intervention components: (1) in a Messages group, participants received daily reminder messages for three months to increase salience and help participants stick to their anchoring plan; and (2) an Incentives group received the same messages but also small monthly prizes for taking ART pills around the time of their chosen existing routine to combat participants’ present bias. We found that participants who stuck with their anchoring plans maintained high ART adherence, even after the messages and prizes were withdrawn, and that messages alone were sufficient for some participants while others needed both messags and prizes to successfully routinize ART adherence. Thus, in this R01 proposal we will test these intervention components in a Sequential, Multiple Assignment, Randomized Trial (SMART) design to identify the optimal sequencing (from low-resource messages to higher-resource prizes) to cost-effectively promote long-term ART adherence among all treatment initiators. The Specific Aims are to: SA1 (Primary): Test the first-stage main effect of Messages vs. Control on the maintenance of ART adherence (primary outcome) and viral suppression (secondary outcome). SA2 (Secondary): Examine (a) the second-stage main effect of receiving monthly vs. weekly prizes on the primary and secondary outcomes among first-stage non-responders, and (b) the total intervention effect of Messages among responders vs. the first- and second- stage components among non-responders. SA3: Perform a cost-effectiveness analysis, including a comparison of INMIND components among responders and non-responders, and conduct information dissemination activities in Uganda after completion of the trial. The results of this study can be generalized to other chronic diseases requiring long-term medication adherence, and our cost-effectiveness analysis and information dissemination activities will inform our subsequent Stage V implementation research.