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Adherence to Isoniazid Prophylaxis in the Homeless
A Randomized Controlled Trial
Jacqueline Peterson Tulsky, MD;
Louise Pilote, MD, MPH, PhD;
Judith A. Hahn, MA;
Andrew J. Zolopa, MD;
Michele Burke, BS, RN;
Margaret Chesney, PhD;
Andrew R. Moss, PhD
Arch Intern Med. 2000;160:697-702.
Objectives To test 2 interventions to improve adherence to isoniazid preventive therapy for tuberculosis in homeless adults. We compared (1) biweekly directly observed preventive therapy using a $5 monetary incentive and (2) biweekly directly observed preventive therapy using a peer health adviser, with (3) usual care at the tuberculosis clinic.
Methods Randomized controlled trial in tuberculosis-infected homeless adults. Outcomes were completion of 6 months of isoniazid treatment and number of months of isoniazid dispensed.
Results A total of 118 subjects were randomized to the 3 arms of the study. Completion in the monetary incentive arm was significantly better than in the peer health adviser arm (P=.01) and the usual care arm (P=.04), by log-rank test. Overall, 19 subjects (44%) in the monetary incentive arm completed preventive therapy compared with 7 (19%) in the peer health adviser arm (P=.02) and 10 (26%) in the usual care arm (P=.11). The median number of months of isoniazid dispensed was 5 in the monetary incentive arm vs 2 months in the peer health adviser arm (P=.005) and 2 months in the usual care arm (P=.04). In multivariate analysis, independent predictors of completion were being in the monetary incentive arm (odds ratio, 2.57; 95% CI, 1.11-5.94) and residence in a hotel or other stable housing at entry into the study vs residence on the street or in a shelter at entry (odds ratio, 2.33; 95% CI, 1.00-5.47).
Conclusions A $5 biweekly cash incentive improved adherence to tuberculosis preventive therapy compared with a peer intervention or usual care. Living in a hotel or apartment at the start of treatment also predicted the completion of therapy.
From the Departments of Medicine, Positive Health Program (Dr Tulsky), Epidemiology and Biostatistics (Ms Hahn and Dr Moss), and Medicine (Dr Moss), San Francisco General Hospital, University of California, San Francisco; Department of Medicine, Division of Clinical Epidemiology, Montreal General Hospital, McGill University, Montreal, Quebec (Dr Pilote); Department of Medicine, Division of Infectious Diseases, Stanford University, Stanford, Calif (Dr Zolopa); and Center for AIDS Prevention Studies, Department of Medicine (Dr Chesney), University of California, San Francisco. Ms Burke was a student at the University of California, San Francisco, at the time of the writing of this article.
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