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

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Project Summary Recently the number of people initiating antiretroviral (ART) treatment (“treatment initiators”) has increased but too many fail to achieve viral suppression. Healthy routines are key to achieving long-term behavioral change and healthy outcomes, but few people manage to form them on their own. Existing interventions typically suggest that people anchor the targeted behavior to an existing routine, but fail to support participants during the time it takes to turn the behavior into a routine, with the result that typically fewer than half end up carrying the targeted behavior out automatically. Behavioral economics (BE) points to two important biases preventing many people from translating their good intentions into successful routines; it also suggests two readily implementable approaches to counter these same biases: the bias of lack of salience of chronic treatment adherence (i.e. over time, the more pressing needs of daily life dominate good intentions) can be countered by low-cost reminder messages sent via mobile phone during the time it takes to turn pill-taking into a routine behavior. Present bias (i.e. giving in to short-term temptations, which can lead to skipping pill doses) explains why many people have trouble sticking to their good intentions. Using small, intermittent incentives until the behavior becomes a routine is a novel approach that has the potential to be a game changer for establishing the (currently elusive) goal of long-term high ART adherence. The proposed R34 study will be implemented in a Ugandan HIV clinic in a 12-month randomized controlled trial (RCT) among treatment initiators to establish feasibility, acceptability, and preliminary efficacy of the intervention. Following formative work in Phase 1, all study participants will be told about the importance of routine pill-taking and receive a leaflet with strategies for anchoring pill-taking to an existing routine. Participants in the first intervention group (n=50) will then receive daily text messages for 3 months to reinforce that information (Message group). Participants in the second intervention group (n=50) will receive the same messages, but will also have a chance of winning small rewards conditional on high and timely medication adherence (Incentive group). Participants in the Control group will receive the usual standard of care. Persistence of adherence (primary outcome) and timely pill- taking (secondary outcome) will be measured using MEMS caps for 9 months after the 3-months intervention, and retention in care as well as viral loads (secondary outcomes) will be assessed at month 12. Specific Aim 1 will be to evaluate the feasibility and acceptability of INMIND and develop the intervention using the ADAPT- ITT framework. Based on these insights, Specific Aims 2a and 2b will test the preliminary effectiveness of the intervention, including the relative effectiveness of two different implementation approaches (i.e. text messages alone vs. together with small BE-based incentives). Specific Aim 3 will collect data allowing adaptation of intervention parameters for a subsequent R01 application to test the intervention at scale.