Achieving HIV viral suppression and reducing stimulant use in San Francisco pilot programme

Ayesha Appa from University of California and colleagues report results from a single-arm 12-week pilot contingency management (CM) designed to increase rates of HIV viral suppression and reduce stimulant use in 31 people with stimulant use disorder (StUD) attending the Ward 86 HIV clinic in San Francisco. This paper is published as a major article in the January 2026 issue of CID. [1]

CM is a behavioural intervention that is established as a first-line treatment for StUD based on results from at least five randomised controlled studies, but it is still rarely used. It includes an escalating incentive scheme, usually financial, with weekly urine testing for stimulants – and in this case also for ARVs (tenofovir).

The incentive was the chance to win an increasing number of prize draws with each draw having a 50% chance of immediate monetary reward (range $1 to $100, mean value $6). Stimulant and ARV point-of-care tests gave immediate feedback and results were assessed separately so that participants could prioritise their health goals.

At baseline, only 17/31 (55%) participants had viral suppression <200 copies/mL which increased to 23/26 (88% of those retained) at week 12 (p<0.01). Enrolment criteria included having had at least one detectable viral load result in the previous 18 months and actively wanting to increase adherence or reduce stimulant use.

Study demographics included: race/ethnicity 45% Black, 42% white and 26% Latinx. Self-reported gender included 15 cisgender men, 7 cisgender women, 6 transgender women, 2 genderqueer people and 1 preferred not to disclose.

Although participants only attended a mean of 5/12 visits (42%) and 5/31 discontinued the CM programme, this was also reflective of the scale of StUD: 77% used methamphetamine, 35% cocaine, 19% concurrent fentanyl and 41% had had a previous opioid overdose. A majority of participants were homeless (19/31, 60%).

Among the 26/31 who attended study visits, 61/110 (56%) stimulant tests were negative and 98% (89/91) of tenofovir tests were positive.

Participants gained a mean of $85 overall, but further details are unclear as the paper reports SD of about $150).

Qualitative interviews highlighted the importance of running the programme within a trusted HIV care setting and the individual commitment of non-judgemental programme staff.

The results showed the feasibility of increasing rates of viral suppression in people with complex lives. Future plans include increasing the connection with the clinic by including two visits every week.

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The results from this pilot study support further studies and use in clinical settings.

Although cost-effectiveness results were not presented, the financial aspect of the programme involved minimal costs, especially when compared to the cost of ART and providing care, and given the costs averted from achieving viral suppression.