Conditional Cash Transfers and
Contingency Management
Strategies in Substance Users
Mark Hull MD, MHSc, FRCPC
Clinical Assistant Professor, University of
British Columbia
Research Scientist, BC Centre for Excellence
in HIV/AIDS
Objectives
• Substance use (DU) and barriers to
HAART
• Incentives in the setting of DU
• Contingency Management in DU
– Applications to treatment and prevention of
HIV
• Adherence
• Limitations
Introduction
HIV Prevalence among DU
Mathers, B et al. Lancet 2008; 372:1733.
Barriers to Care
Structural
Individual-level
Criminalization
of behaviour
Addictionrelated
instability
Marginalization Comorbid
conditions
Incarceration
Homelessness/
food insecurity
Adapted from Wood, E. et al AIDS 2008;22:1247
Provider-level
Physician
perceptions
Barriers to care
Diminished response
Wood, E et al. CMAJ 2003;169: 656.
Similar mortality outcomes
Wood, E et al. JAMA 2008;300: 550.
Interventions to improve
HAART adherence
• Directly observed therapy (DOT)
– A recent meta-analysis did not identify a clear
benefit over self-administration (pooled
relative risk 1.04; 95% CI 0.91 – 1.20) Ford, N et al.
Lancet 2009;374:2064.
• Links to methadone maintenance
programs Palepu, A et al. Drug Alcohol Depend 2006;84:188.
• Intensive case management strategies
Kushel, M et al. Clin Infect Dis 2006;43: 234.
Incentive-based Programs
in DU
• Client or patient-targeted conditional cash
transfers (CCT) have become a means to
achieve performance-based results.
– Smoking cessation programs Volpp, K et al NEJM 2009;360:699.
– Weight-loss programs Volpp, K et al. JAMA 2008;300:2631.
• In DU CCT has taken the form of:
– 1. Limited incentives for completion of specific healthrelated tasks.
– 2. Contingency management interventions designed
to shape long-term behaviours for reduction in
substance use.
Incentive-based Programs
in DU
• Limited incentives have been used to increase uptake of
preventative health activities:
– Small ($5-25) monetary incentives
– Food vouchers
• Improved rates of completion of TB screening processes
– Return for PPD screening Chaisson, R et al. JAIDS 1996;11:455 ; FitzGerald JM et al. Int J
Tuberc Lung Dis 1999;3:153.
– Completion of screening chest X-ray Perlman, D et al J. Urban Health 2003;80:428.
• Completion of hepatitis B vaccine series
– Randomized trial of monetary incentive vs. outreach nurses,
69% vs. 23% completion. Seal, K et al. Drug and Alcohol Depend 2003; 71:127.
Contingency Management
• Key features to CM programs:
– Identification of clinically relevant behaviour
– Objective measurement of the behaviour
– Selection of a reinforcer desirable to the
target population
– Linking target behaviour to the application of
the reinforcer
Contingency Management
• Strategies for reinforcement should take into
account a number of principles:
– Escalation of the reinforcer
• The longer the desired behaviour occurs, the more the
reinforcer is increased to maintain the behaviour
– Reset features
• If the behaviour does not occur, the reinforcer is reset to
lower levels
– Immediacy of the reinforcer
• Reinforcement should occur as soon as possible after the
desired behaviour is observed.
Contingency Management
Strategies
• Voucher-based Higgins, ST et al . Life Sci 1994;55:159. Higgins, ST
et al. Addiction 2007;192:271. Silverman, K et al. Drug and Alcohol Depend
1996;41:197.
• Fishbowl prize draw Petry, N et al. J Consult Clin Psychol
2000;68:250-7 ; Petry, N et al. J Consult Clin Psychol 2005;73:1005.
• CM can be used to target substance
abstinence – opiates and stimulants,
attendance, and goal-directed activities.
• Meta-analyses of CM show clear benefit
for improved abstinence and attendance
Lussier, JP et al. Addiction 2006;102:192. ; Prendergast, M et al. Addiction
2006;101:1546.
Incentives for HIV treatment
and prevention.
• Improved HIV screening
– Improved uptake of followup for HIV testing in the ER
Kelen, GD et al. Ann Emerg Med 1996;27:687. Haukoos, JS et al. Acad Emerg Med
2005;12:617.
• Attendance at HIV risk reduction group session
Deren, S et al. Public Health Reports 1994;109:549.
• Change in HIV risk behaviours (CM)
– Methamphetamine use and URAI Shoptaw, S et al. Drug and
Alchol Depend 2005; 78:125.
– Cocaine use and risk behaviours Schroeder, JR et al. Addictive
Behaviours 2006;31:868.
– CM arms superior to CBT, but majority of effects due
to the impact on decreased substance use.
Incentives for HIV prevention and
treatment - Adherence
Sorensen 2007 Rosen 2007
Javanbakht
2006
Voucher based
CM (n=66)
MEMS
adherence
12 weeks
78% vs. 58%
adherent
Not sustained
Incentive
(n=90)
Viral load
suppression
48 weeks
55% vs. 28%
had 1 log
reduction
Prizebowl CM
(n= 56)
MEMS
adherence
16 weeks
61% → 76%
adherent
Not sustained
•Sorensen. Drug and Alcohol Depend. 2007
•Rosen. AIDS Pt Care and STD’s 2007
•Javanbakht, M et al. JIAPAC 2006
Limitations
• Limited evidence for durability of HIV-related CM
interventions
– Longer period of CM likely needed.
• ?cost-effectiveness
• Care provider aversion
– Increased drug use with monetary incentive
• Not seen in studies Riley, E. J Urban Health 2005;82:142.
– Issues of fairness
– Coercion in marginalized populations
• Not seen when assessed Festinger D, et al. Drug Alcohol Depend.
2008;96:128.
The Future
• Use of CM has been advocated as a component
of the UK NICE policy guideline for substance
use treatments.
– Adapted by some sites in Australia.
• Evaluation of incentives for HIV Treatment and
Prevention underway:
– HPTN 065 TLC Plus
• RCT of financial incentive for linkage to care and viral load
suppression.
– BC CFE Seek and Treat
• RCT of CM for linkage to care and viral load suppression in
DU.
Acknowledgements
• Dr Nancy Petry PhD – University of
Connecticut Health Center
• Shoshana Kahana PhD – National
Institute on Drug Abuse
• National Institute on Drug Abuse