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HIV clinic in East Orange offers incentives to poor patients to take medication
  By Rohan Mascarenhas/The Star-Ledger
April 06, 2010
After three years of working at an HIV/AIDS clinic in Newark, Stephen Smith noticed a puzzling phenomenon among his poorer patients: More than 90 percent of them weren't taking the medications they needed to survive.

"We had a system that allowed us to check the level of HIV in the blood of patients and it just weren't going down," said Smith, the former medical director at the Peter Ho Memorial Clinic at Saint Michael's Medical Center in Newark. "A colleague turned to me and asked, 'Why are we doing this?'"
Among the obstacles to treating HIV/AIDS - lack of health insurance or the social stigma, for example - persuading patients to take their meds seems an unlikely problem. But surveys of medical providers throughout New Jersey repeatedly find a variety of factors, from homelessness to lack of education, as reasons why patients to not take their meds.
Now, Smith believes he has come up with strategy rarely tried in the fight against HIV/AIDS. Starting this week at a new clinic in East Orange, he will offer patients a $25 grocery coupon if tests show they have taken their medications for three consecutive months. Female patients will also receive help to pay for pap smears and mammograms.
Smith hopes the program, funded with more than a half-million dollars in federal grants under the Ryan White Act as well as through private donations, will expand to a Newark clinic that's scheduled to open this summer.
Smith's efforts are being closely followed by the state's AIDS specialists, who have watched with concern as infection rates disproportionately affect poor and minority populations. In 2007, the Newark metropolitan area had the 11th highest number of AIDS cases - nearly 20,500 - among 103 urban areas in the country with more than 500,000 residents. That same year, Essex County had nearly four times the number of people living with HIV/AIDS as the rest of the state.
"We have to build strategies that address poverty and economic issues," said Paula Toynton, director of the New Jersey AIDS partnership. " ... This approach is interesting - paying people to take care of themselves? But we already know corporations offer gyms and incentives to employees to stay in good health."
The cash incentive comes in response to the changing snapshot of those infected with HIV/AIDS. A February article in the New England Journal of Medicine found that although rates have fallen among the general population, they continue to remain high among the poor and minorities in inner-cities.
The article also specifically cited the HIV rate of 3 percent among African-American males in Newark, an infection rate similar to that in Rwanda and Burundi, two developing countries in Africa. The national rate, according to the report, was less than 1 percent.
dolores-harrison-hiv.jpg Matt Rainey/The Star-LedgerDolores Harrison, who is a patient of his, visits the clinic's first day with her "pill box, " which has all the anti-retroviral cocktails she needs to take daily.
Newark had 6,043 residents living with HIV and AIDS in 2007, the highest number among the 10 biggest cities in the state. East Orange came in fourth, with 1,318 cases.
Smith said the new epidemiological profile demands new strategies. He estimated that well over 90 percent of suburban patients follow their medical regimen properly.
"The needs for inner-city patients are very different from those in the suburbs," he said. "The socioeconomic equation is that it becomes prohibitive to think about the future. For them, it's next day, this week, next week. But if you get it right, treating HIV is easy now."
Dolores Harrison, diagnosed with HIV in 2000, said the pill cocktails could be confusing and required daily attention.
"Most people take a cocktail that consists of maybe two or three pills," the East Orange resident said. "I take all my HIV meds every day, around the same time in the morning. You need the medication to be in your system at all times."
Although cash coupons have worked in other areas, like weigh control and smoking cessation programs, little research has been done in HIV prevention, said Sally Hodder, the director of HIV programs at the New Jersey Medical School. In addition, she said, the stigma attached to HIV/AIDS remains strong in certain communities and may not be adequately countered by $25.
"I think humans all respond to positive reward but in this setting, we need to look at it and see what works," she said.
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