3.11. Component A: financial reward for viral suppression, and compensation in general
medication adherence behavior, HIV viral suppression, depressed
ADVERSE EFFECTS, VIRUS, LIVER DAMAGE, MEDICATION SIDE EFFECTS
As noted above, participants received compensation for study activities such as assessments and providing laboratory reports, and all participants could receive a financial reward if they achieved HIV viral suppression at the first FU assessment: fixed compensation ($300) or a lottery prize (maximum prize $500). Those who did not achieve viral suppression received $50. Overall, compensation for study activities was viewed as highly acceptable among participants, was the primary reason they joined the study, and for many, led them to feel respected and valued in the study (“They [S-CAP2] don't give you pressure, they give you encouragement. [Compensation] did play a role as part of the encouragement I felt. Because I feel like they understood the fact that you don't live life for free and your time is valuable”). Compensation in general was described as promoting study engagement and participants commonly reported that it, along with a positive experience with staff and study activities, encouraged them to remain active for the duration of the study. We found both fixed compensation and lottery prizes enhanced these positive experiences related to study participation and were not seen as coercive or pressuring.Participants' views on the attitudinal and behavioral effects of financial rewards could be organized into three main themes: in some cases, the financial reward was seen as sufficient to motivate changes in HIV medication adherence behavior (that is, serving as “nudge” and a source of hope and encouragement), and in other cases, it was appreciated but not necessarily a primary motivating factor or reason to achieve viral suppression. Third, some participants reported the financial reward increased their motivation to achieve viral suppression, but this motivation was not sufficient to overcome serious structural and individual-level barriers to HIV medication adherence. Qualitative results did not yield evidence of any major differences in participants views on financial rewards based on whether they received fixed compensation or a lottery prize, although the lottery prize came across as more exciting and memorable than fixed compensation. Regarding the first theme where the financial reward served as a nudge, Bryant, a 40-year-old cisgender, heterosexual Black man who was diagnosed with HIV < 10 years ago, was assigned to an experimental condition that included the lottery prize and noted:It encourages me to reach the goal of becoming undetected and also just a reminder. Like listen, you know, I should stay on taking my meds every time I should be taking them.Mark was a 60-year-old cisgender, heterosexual Black man who as diagnosed with HIV 30 years ago, who was also assigned to an experimental condition that included the lottery prize. He did achieve viral suppression, and won the largest possible prize. While the funds were appreciated, and the experience of spinning the prize wheel was exciting, he noted that the prize was not the actual reason for his change in behavior.She spins the wheel, you can hear it. […] So, listen to it. So, she's spinning it and I'm hearing it. I kept saying, “Oh man, I want to win this money. I want to win this money.” She says, “Mr. [name redacted], you won.” I was like, “Thank you.” But I'm not doing it for the money. […] I try not to look at it like that. I try to look at this as a beneficial thing. It's a helpful thing for me. Like you all kept me on track with this, and I'm just continue on being on track, you know, when the study is over. You know, I'm continue on, you know, staying on track with it. I'm not doing this for that. You know, I'm doing it to benefit me health-wise, not financial-wise. Health-wise, you know, because money doesn't mean anything for me. You know what I mean? I grew up poor. We didn't have anything. So when, you know, when I get a little few dollars every now and then, I put it toward my apartment or I treat myself or something or I help somebody out that's less fortunate.Mark continued:It wasn't about the money, it was about the hope that you all gave me, the encouragement, man, to stay on time and take the medications on time. You know what I mean? Because, you know, for a long time, I used to get real depressed, being detected [having detectable viral load].Jason, a 35-year-old cisgender, gay Black man, described a 20-year history living with HIV during which he had achieved viral suppression only once, in part because of concerns about HIV medication side effects and because he sold his medication to meet financial needs. Yet, during his time in the study, he seriously considered taking HIV medication, and began to explore his fears about the adverse health consequences of not doing so. The chance to win a lottery prize increased his motivation for viral suppression, but ultimately, financial constraints prevented him from doing so. Yet, he also believed that if he achieved undetectable HIV viral load, he would continue taking HIV medication.I have a serious issue with the medication as a whole, regarding long term. Short term is great. Long terms is not so great to continue to that medicine in your body once you have leveled off and get the virus out of the body due to the fact of the kidney and the liver damage. […] I can tell you right now, I actually have a desire to take my meds. I'm currently trying to get over this mental health hump and financial crunch. […] The fact of I need to take my meds or I'm going to die. Or it's either choosing to take the meds and stay financially twisted, because that $350– that's my biggest check, is the medicine I sell. […] That final end to the bonus of possibly getting $500 for the undetectable almost made me take my bottle. I'll pop the pill, because I knew, I know if I pop the pill in about 40 days my body bounces like right back [to undetectable viral load]. […] I almost did it. But then—I did it but then I didn't. […] It's all finances for me.Thus, Jason highlights the complexities of HIV management in the context of chronic poverty.In summary, the COVID-19 pandemic intensified existing financial strains for many participants. Study compensation was a release valve for financial pressures for most and even offered positive experiences during periods of sustained stress. The financial reward component was acceptable to participants, no adverse effects were detected, and the component influenced attitudes and behaviors in a number of ways.