Protocol of a randomized controlled trial to test the effects of client-centered Representative Payee Services on antiretroviral therapy adherence among marginalized people living with HIV

Background Client-Centered Representative Payee (CCRP) is an intervention modifying implementation of a current policy of the US Social Security Administration, which appoints organizations to serve as financial payees on behalf of vulnerable individuals receiving Social Security benefits. By ensuring beneficiaries’ bills are paid while supporting their self-determination, this structural intervention may mitigate the effects of economic disadvantage to improve housing and financial stability, enabling self-efficacy for health outcomes and improved antiretroviral therapy adherence. This randomized controlled trial will test the impact of CCRP on marginalized people living with HIV (PLWH). We hypothesize that helping participants to pay their rent and other bills on time will improve housing stability and decrease financial stress. Methods PLWH (n = 160) receiving services at community-based organizations will be randomly assigned to the CCRP intervention or the standard of care for 12 months. Fifty additional participants will be enrolled into a non-randomized (“choice”) study allowing participant selection of the CCRP intervention or control. The primary outcome is HIV medication adherence, assessed via the CASE adherence index, viral load, and CD4 counts. Self-assessment data for ART adherence, housing instability, self-efficacy for health behaviors, financial stress, and retention in care will be collected at baseline, 3, 6, and 12 months. Viral load, CD4, and appointment adherence data will be collected at baseline, 6, 12, 18, and 24 months from medical records. Outcomes will be compared by treatment group in the randomized trial, in the non-randomized cohort, and in the combined cohort. Qualitative data will be collected from study participants, eligible non-participants, and providers to explore underlying mechanisms of adherence, subjective responses to the intervention, and implementation barriers and facilitators. Discussion The aim of this study is to determine if CCRP improves health outcomes for vulnerable PLWH. Study outcomes may provide information about supports needed to help economically fragile PLWH improve health outcomes and ultimately improve HIV health disparities. In addition, findings may help to refine service delivery including the provision of representative payee to this often-marginalized population. This protocol was prospectively registered on May 22, 2018 with ClinicalTrials.gov (NCT03561103).

Despite initial “kicking and screaming” unstably housed persons report high satisfaction with representative payee program

Purpose – The purpose of this paper is to explore unstably housed persons satisfaction with representative payee services. Design/methodology/approach – Surveys were distributed through two different methods, which consisted of mailings and dispersal by program staff members. Findings – Participants overwhelmingly reported that they were satisfied with representative payee services with 77 percent of the stand-alone housing participants and 86 percent of the scattered site participants reported being “satisfied” or “very satisfied” with representative payee services. Similarly, 92 percent of stand-alone participants and 82 percent of scattered site participants reported being satisfied with their abilities to care for their needs. The lowest reported satisfaction with the program was with the timeliness of getting spending checks, with 85 percent of participants being satisfied in the stand-alone location and only 63 percent of participants reporting satisfaction in the scattered site setting. Research limitations/implications – This research is limited by the fact that it is an evaluation of one program and does not have a comparison group. Additionally, clients self-selected to participate in the research and results are not generalizable. Future research should ascertain whether aspects of harm reduction and peer staff have an impact on client outcomes as well as representative payee satisfaction. The study was conducted in a metropolitan area in the Northeast USA, which includes the city of Pittsburgh, Pennsylvania and surrounding areas. Given that this region includes both city and suburban areas, it is likely the results are translatable to multiple geographic areas. Practical implications – Results of this research indicate that use of harm reduction and peer staff could be factors in client satisfaction with representative payee services thereby increasing the possibility that clients will sign up for this service and receive the benefits of the program. Social implications – Having a representative payee program imposed on clients whether voluntarily or involuntarily can be an extremely anxiety provoking experience. Increasing satisfaction with this service will lend to improved quality of life for clients as well as improved relationships with providers which may lead to more engagement in care. Originality/value – This paper provides a new perspective on representative payee programs since it shows positive satisfaction, as well as use of harm reduction and peer staff, which varies from previous studies.