AIDS and Behavior

, Volume 17, Issue 7, pp 2283–2292 | Cite as

Conditional Economic Incentives to Improve HIV Treatment Adherence: Literature Review and Theoretical Considerations

  • Omar GalárragaEmail author
  • Becky L. Genberg
  • Rosemarie A. Martin
  • M. Barton Laws
  • Ira B. Wilson
Substantive Review


We present selected theoretical issues regarding conditional economic incentives (CEI) for HIV treatment adherence. High HIV treatment adherence is essential not only to improve individual health for persons living with HIV, but also to reduce transmission. The incentives literature spans several decades and various disciplines, thus we selectively point out useful concepts from economics, psychology and HIV clinical practice to elucidate the complex interaction between socio-economic issues, psychological perspectives and optimal treatment adherence. Appropriately-implemented CEI can help patients improve their adherence to HIV treatment in the short-term, while the incentives are in place. However, more research is needed to uncover mechanisms that can increase habit formation or maintenance effects in the longer-term. We suggest some potentially fruitful avenues for future research in this area, including the use of concepts from self-determination theory. This general framework may have implications for related research among disadvantaged communities with high rates of HIV/AIDS infection.


Antiretroviral HIV treatment Adherence to medication Economic incentives Contingency management Conditional cash transfers 


Se presentan aspectos teóricos sobre incentivos económicos condicionados para la adherencia al tratamiento del VIH. Una alta adherencia al tratamiento antirretroviral es esencial para mantener la salud de las personas que viven con el VIH y también para reducir la transmisión del virus. La literatura de incentivos abarca varias décadas y disciplinas diferentes, por lo que selectivamente se señalan conceptos útiles de la economía, la psicología y el tratamiento clínico del VIH para dilucidar la compleja interacción entre el entorno socioeconómico, la perspectiva psicológica y la adherencia óptima al tratamiento. Programas de incentivos adecuadamente implementados pueden ayudar a los pacientes a mejorar su adherencia al tratamiento del VIH en el corto plazo, mientras los incentivos se mantienen. Sin embargo, se requieren más estudios para descubrir los mecanismos que promueven la formación de hábitos a largo plazo. Se sugieren áreas para investigaciones futuras como la incorporación de conceptos de la teoría de la autodeterminación. Este marco conceptual general puede ser aplicado a la investigación con las poblaciones más desfavorecidas y las tasas más altas de VIH/SIDA.

Palabras Clave

Tratamiento Antirretroviral contra el VIH/SIDA Adherencia a medicamentos Incentivos económicos condicionados Manejo de contingencias Transferencias monetarias condicionadas 



We thank Don Operario and Caroline Kuo for helpful discussions; and Gary Rose for comments on an earlier draft. This work was supported in part by the National Institutes of Health/Fogarty International Center (K01-TW008016-04) that provided support for Dr. Galárraga; and also by a training grant from the Agency for Healthcare Research and Quality (1T32HS019657-01) that provided support for Dr. Genberg.


  1. 1.
    Hogg RS, Heath KV, Yip B, et al. Improved survival among HIV-infected individuals following initiation of antiretroviral therapy. JAMA. 1998;279(6):450–4.PubMedCrossRefGoogle Scholar
  2. 2.
    Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. AIDS clinical trials group 320 study team. N Engl J Med. 1997;337(11):725–33.PubMedCrossRefGoogle Scholar
  3. 3.
    Hirsch M, Steigbigel R, Staszewski S, et al. A randomized, controlled trial of indinavir, zidovudine, and lamivudine in adults with advanced human immunodeficiency virus type 1 infection and prior antiretroviral therapy. J Infect Dis. 1999;180(3):659–65.PubMedCrossRefGoogle Scholar
  4. 4.
    Bangsberg DR, Perry S, Charlebois ED, et al. Non-adherence to highly active antiretroviral therapy predicts progression to AIDS. AIDS. 2001;15(9):1181–3.PubMedCrossRefGoogle Scholar
  5. 5.
    Simoni JM, Amico KR, Pearson CR, Malow R. Strategies for promoting adherence to antiretroviral therapy: a review of the literature. Curr Infect Dis Rep. 2008;10(6):515–21.PubMedCrossRefGoogle Scholar
  6. 6.
    Haug NA, Sorensen JL, Gruber VA, Lollo N, Roth G. HAART adherence strategies for methadone clients who are HIV-positive: a treatment manual for implementing contingency management and medication coaching. Behav Modif. 2006;30(6):752–81.PubMedCrossRefGoogle Scholar
  7. 7.
    Haug NA, Sorensen JL. Contingency management interventions for HIV-related behaviors. Curr HIV/AIDS Rep. 2006;3(4):154–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Rosen MI, Dieckhaus K, McMahon TJ, et al. Improved adherence with contingency management. AIDS Patient Care STDs. 2007;21(1):30–40.PubMedCrossRefGoogle Scholar
  9. 9.
    Sorensen JL, Haug NA, Delucchi KL, et al. Voucher reinforcement improves medication adherence in HIV-positive methadone patients: a randomized trial. Drug Alcohol Depend. 2007;88(1):54–63.PubMedCrossRefGoogle Scholar
  10. 10.
    Petry NM, Rash CJ, Byrne S, Ashraf S, White WB. Financial reinforcers for improving medication adherence: findings from a meta-analysis. Am J Med. 2012;125(9):888–96.PubMedCrossRefGoogle Scholar
  11. 11.
    Defulio A, Silverman K. The use of incentives to reinforce medication adherence. Prev Med. 2012;. doi: 10.1016/j.ypmed.2012.04.017.Google Scholar
  12. 12.
    Griffith JD, Rowan-Szal GA, Roark RR, Simpson DD. Contingency management in outpatient methadone treatment: a meta-analysis. Drug Alcohol Depend. 2000;58(2-Jan):55–66.PubMedCrossRefGoogle Scholar
  13. 13.
    Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction. 2006;101(2):192–203.PubMedCrossRefGoogle Scholar
  14. 14.
    Prendergast M, Podus D, Finney J, Greenwell L, Roll J. Contingency management for treatment of substance use disorders: a meta-analysis. J Subst Abuse Treat. 2006;101(11):1546–60.Google Scholar
  15. 15.
    Dutra L, Stathopoulou G, Basden SL, Leyro TM, Powers MB, Otto MW. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry. 2008;165(2):179–87.PubMedCrossRefGoogle Scholar
  16. 16.
    Higgins ST, Silverman K, Heil SH, editors. Contingency management in substance abuse treatment. New York: Guilford Press; 2008.Google Scholar
  17. 17.
    Dallery J, Meredith SE, Budney AJ. Contingency management in substance abuse treatment. In: Walters ST, Rotgers F, editors. Treating substance abuse: theory and technique. 3rd ed. New York: Guilford Press; 2012.Google Scholar
  18. 18.
    Giuffrida A, Torgerson DJ. Should we pay the patient? Review of financial incentives to enhance patient compliance. BMJ. 1997;315(7110):703–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Fiszbein A, Schady N, Ferreira FHG. Conditional cash transfers: reducing present and future poverty [Chapter 2: Economic Rationale]. Washington D.C.: World Bank; 2009.CrossRefGoogle Scholar
  20. 20.
    Loewenstein G, Brennan T, Volpp KG. Asymmetric paternalism to improve health behaviors. JAMA. 2007;298(20):2415–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Rabin M. Psychology and economics. J Econ Lit. 1998;36(1):11–46.Google Scholar
  22. 22.
    DellaVigna S. Psychology and economics: evidence from the field. J Econ Lit. 2009;47(2):315–72.CrossRefGoogle Scholar
  23. 23.
    Frederick S, Loewenstein G, O’Donoghue T. Time discounting and time preference: a critical review. J Econ Lit. 2002;40(2):351–401.CrossRefGoogle Scholar
  24. 24.
    Laibson D. Golden eggs and hyperbolic discounting. Q J Econ. 1997;112(2):443–77.CrossRefGoogle Scholar
  25. 25.
    Zimbardo PG, Boyd JN. Putting time in perspective: a valid, reliable individual-differences metric. J Pers Soc Psychol. 1999;77(6):1271–88.CrossRefGoogle Scholar
  26. 26.
    Boyd JN, Zimbardo PG. Time perspective, health, and risk taking. In: Strathman A, Joireman J, editors. Understanding behavior in the context of time: theory, research, and application. Mahwah: Lawrence Erlbaum Associates; 2005.Google Scholar
  27. 27.
    Murphy JG, MacKillop J, Vuchinich RE, Tucker JA. The behavioral economics of substance abuse. In: Walters ST, Rotgers F, editors. Treating substance abuse: theory and technique. 3rd ed. New York: Guilford; 2012.Google Scholar
  28. 28.
    Marshall A. Principles of economics. London and New York: Macmillan; 1890.Google Scholar
  29. 29.
    Strecher VJ, Rosenstock IM. The health belief model. In: Glanz K, Lewis FM, editors. Health behavior and health education: theory, research and practice. San Francisco: Jossey-Bass; 1997.Google Scholar
  30. 30.
    Deci EL, Ryan RM. A motivational approach to self: integration in personality. Nebr Symp Motiv. 1990;38:237–88.PubMedGoogle Scholar
  31. 31.
    Deci EL, Koestner R, Ryan RM. A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychol Bull. 1999;125(6):627–68. discussion 692-700.PubMedCrossRefGoogle Scholar
  32. 32.
    Ryan RM, Deci EL. Intrinsic and extrinsic motivations: classic definitions and new directions. Contemp Educ Psychol. 2000;25(1):54–67.PubMedCrossRefGoogle Scholar
  33. 33.
    Deci EL, Ryan RM. The “what” and “why” of goal pursuits: human needs and the self-determination of behavior. Psychol Inq. 2000;11(4):227–68.CrossRefGoogle Scholar
  34. 34.
    Deci EL, Ryan RM. Self-determination theory: a macrotheory of human motivation, development, and health. Can Psychol. 2008;49(3):182–5.CrossRefGoogle Scholar
  35. 35.
    Rigby CS, Deci EL, Patrick BC, Ryan RM. Beyond the intrinsic extrinsic dichotomy—self-determination in motivation and learning. Motiv Emotion. 1992;16(3):165–85.CrossRefGoogle Scholar
  36. 36.
    Cameron J. Negative effects of reward on intrinsic motivation—A limited phenomenon: comment on Deci, Koestner, and Ryan (2001). Rev Educ Res. 2001;71(1):29–42.CrossRefGoogle Scholar
  37. 37.
    Cameron J, Banko KM, Pierce WD. Pervasive negative effects of rewards on intrinsic motivation: the myth continues. Behav Analyst. 2001;24(1):1–44.Google Scholar
  38. 38.
    Pierce WD, Cameron J, Banko KM, So S. Positive effects of rewards and performance standards on intrinsic motivation. Psychol Rec. 2003;53:561–79.Google Scholar
  39. 39.
    Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009;64(6):527–37.PubMedCrossRefGoogle Scholar
  40. 40.
    Williams GC, Rodin GC, Ryan RM, Grolnick WS, Deci EL. Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol. 1998;17(3):269–76.PubMedCrossRefGoogle Scholar
  41. 41.
    Ryan RM, Deci EL. Self-regulation and the problem of human autonomy: does psychology need choice, self-determination, and will? J Pers. 2006;74(6):1557–85.PubMedCrossRefGoogle Scholar
  42. 42.
    DiIorio C, McCarty F, Resnicow K, et al. Using motivational interviewing to promote adherence to antiretroviral medications: a randomized controlled study. AIDS Care. 2008;20(3):273–83.PubMedCrossRefGoogle Scholar
  43. 43.
    Bandura A. Social learning theory. Englewood Cliffs: Prentice Hall; 1977.Google Scholar
  44. 44.
    Azjen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs: Prentice-Hall; 1980.Google Scholar
  45. 45.
    Prochaska JO, Norcross JC, DiClemente CC. Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: W. Morrow; 1994.Google Scholar
  46. 46.
    Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood: Dow Jones-Irwin; 1984.Google Scholar
  47. 47.
    Roozen HG, Boulogne JJ, van Tulder MW, van den Brink W, De Jong CA, Kerkhof AJ. A systematic review of the effectiveness of the community reinforcement approach in alcohol, cocaine and opioid addiction. Drug Alcohol Depend. 2004;74(1):1–13.PubMedCrossRefGoogle Scholar
  48. 48.
    Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80-94.Google Scholar
  49. 49.
    Farmer P. Social scientists and the new tuberculosis. Soc Sci Med. 1997;44:347–58.PubMedCrossRefGoogle Scholar
  50. 50.
    Simoni JM, Huh D, Frick PA, et al. Peer support and pager messaging to promote antiretroviral modifying therapy in Seattle: a randomized controlled trial. J Acquir Immune Defic Syndr. 2009;52(4):465–73.PubMedCrossRefGoogle Scholar
  51. 51.
    Simoni JM, Frick PA, Huang B. A longitudinal evaluation of a social support model of medication adherence among HIV-positive men and women on antiretroviral therapy. Health Psychol. 2006;25(1):74–81.PubMedCrossRefGoogle Scholar
  52. 52.
    Koenig LJ, Pals SL, Bush T, Pratt Palmore M, Stratford D, Ellerbrock TV. Randomized controlled trial of an intervention to prevent adherence failure among HIV-infected patients initiating antiretroviral therapy. Health Psychol. 2008;27(2):159–69.PubMedCrossRefGoogle Scholar
  53. 53.
    Deering KN, Shannon K, Sinclair H, Parsad D, Gilbert E, Tyndall MW. Piloting a peer-driven intervention model to increase access and adherence to antiretroviral therapy and HIV care among street-entrenched HIV-positive women in Vancouver. AIDS Patient Care STDs. 2009;23(8):603–9.PubMedCrossRefGoogle Scholar
  54. 54.
    DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23(2):207–18.PubMedCrossRefGoogle Scholar
  55. 55.
    Ware NC, Idoko J, Kaaya S, et al. Explaining adherence success in sub-Saharan Africa: an ethnographic study. PLoS Med. 2009;6(1):e11.PubMedCrossRefGoogle Scholar
  56. 56.
    Bandura A. Human agency in social cognitive theory. Am Psychol. 1989;44(9):1175–84.PubMedCrossRefGoogle Scholar
  57. 57.
    Fisher JD, Amico KR, Fisher WA, Harman JJ. The information-motivation-behavioral skills model of antiretroviral adherence and its applications. Curr HIV/AIDS Rep. 2008;5(4):193–203.PubMedCrossRefGoogle Scholar
  58. 58.
    Fisher JD, Fisher WA, Amico KR, Harman JJ. An information-motivation-behavioral skills model of adherence to antiretroviral therapy. Health Psychol. 2006;25(4):462–73.PubMedCrossRefGoogle Scholar
  59. 59.
    Bury M. Chronic illness as biographical disruption. Sociol Health Illn. 1982;4:167–82.PubMedCrossRefGoogle Scholar
  60. 60.
    Charmaz K. Loss of self: a fundamental form of suffering in the chronically ill. Sociol Health Illn. 1983;5:168–95.PubMedCrossRefGoogle Scholar
  61. 61.
    Aujoulat I, Marcolongo R, Bonadiman L, Deccache A. Reconsidering patient empowerment in chronic illness: a critique of models of self-efficacy and bodily control. Soc Sci Med. 2008;66:1228–39.PubMedCrossRefGoogle Scholar
  62. 62.
    Baumgartner LM. The incorporation of the HIV/AIDS identity into the self over time. Qual Health Res. 2007;17:919–31.PubMedCrossRefGoogle Scholar
  63. 63.
    Serpe RT. Stability and change in self: a structural symbolic interactionist explanation. Soc Psychol Q. 1987;50:44–55.CrossRefGoogle Scholar
  64. 64.
    Auld MC. Disentangling the effects of morbidity and life expectancy on labor market outcomes. Health Econ. 2002;11(6):471–83.PubMedCrossRefGoogle Scholar
  65. 65.
    Rigsby MO, Rosen MI, Beauvais JE, et al. Cue-dose training with monetary reinforcement: pilot study of an antiretroviral adherence intervention. J Gen Int Med. 2000;15(12):841–7.CrossRefGoogle Scholar
  66. 66.
    Javanbakht M, Prosser P, Grimes T, Weinstein M, Farthing C. Efficacy of an individualized adherence support program with contingent reinforcement among nonadherent HIV-positive patients: results from a randomized trial. J Int Phys AIDS Care. 2006;5(4):143–50.Google Scholar
  67. 67.
    Charness G, Gneezy U. Incentives to exercise. Econometrica. 2009;77(3):909–31.CrossRefGoogle Scholar
  68. 68.
    Roll JM, Higgins ST, Badger GJ. An experimental comparison of three different schedules of reinforcement of drug abstinence using cigarette smoking as an exemplar. J Appl Behav Anal. 1996;29(4):495–504. quiz 504-5.PubMedCrossRefGoogle Scholar
  69. 69.
    Deren S, Stephens R, Davis WR, Feucht TE, Tortu S. The impact of providing incentives for attendance at AIDS prevention sessions. Public Health Rep. 1994;109(4):548–54.PubMedGoogle Scholar
  70. 70.
    Kamb ML, Rhodes F, Hoxworth T, et al. What about money? Effect of small monetary incentives on enrollment, retention, and motivation to change behaviour in an HIV/STD prevention counselling intervention. The Project RESPECT Study Group. Sex Transm Infect. 1998;74(4):253–5.PubMedCrossRefGoogle Scholar
  71. 71.
    Simoni JM, Amico KR, Smith L, Nelson K. Antiretroviral adherence interventions: translating research findings to the real world clinic. Curr HIV/AIDS Rep. 2010;7(1):44–51.PubMedCrossRefGoogle Scholar
  72. 72.
    McNairy ML, El-Sadr WM. The HIV care continuum: no partial credit given. AIDS. 2012;26(14):1735–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Benabou R, Tirole J. Intrinsic and extrinsic motivation. Rev Econ Stud. 2003;70(3):489–520.CrossRefGoogle Scholar
  74. 74.
    Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Omar Galárraga
    • 1
    Email author
  • Becky L. Genberg
    • 1
  • Rosemarie A. Martin
    • 2
  • M. Barton Laws
    • 1
  • Ira B. Wilson
    • 1
    • 3
  1. 1.Department of Health Services, Policy & PracticeBrown UniversityProvidenceUSA
  2. 2.Department of Behavioral and Social SciencesBrown UniversityProvidenceUSA
  3. 3.The Warren Alpert Medical SchoolBrown UniversityProvidenceUSA

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