Adherence to isoniazid prophylaxis in the homeless: a randomized controlled trial.
OBJECTIVE
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.
Tulsky
J P
JP
Department of Medicine, San Francisco General Hospital, University of California, 94110-0874, USA.
Pilote
L
L
Hahn
J A
JA
Zolopa
A J
AJ
Burke
M
M
Chesney
M
M
Moss
A R
AR
D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000008:administration & dosage*; D005260:Female; D006293:Health Promotion; D006703:Ill-Housed Persons / Q000706:statistics & numerical data*; D006798:Housing; D006801:Humans; D007182:Income; D007538:Isoniazid / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D009042:Motivation; D015999:Multivariate Analysis; D016017:Odds Ratio; D010349:Patient Compliance / Q000706:statistics & numerical data*; D018579:Patient Selection; D011237:Predictive Value of Tests; D012307:Risk Factors; D012494:Sampling Studies; D012495:San Francisco; D016896:Treatment Outcome; D014397:Tuberculosis, Pulmonary / Q000517:prevention & control*
D000995:Antitubercular Agents; D007538:Isoniazid