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Cell phone intervention improves ART adherence and HIV suppression: RCT

By Richard Lester | 06 Oct, 2010 Last edited by Robert Szypko on 02 Aug 2011

Thank you all for the interesting discussions, including those on adherence monitoring. I would like to start a fresh discussion on mHealth based adherence interventions. We've recently completed a large multi-center randomized controlled trial (RCT)using structured text messaging (SMS) between health care workers and patients initiating antiretroviral therapy (ART) in Kenya. To our knowledge it is the first mHealth adherence intervention effectiveness trial in a resource-limited setting. (Are there more?)
We enrolled 538 patients (from two urban clinics and one rural clinic) into the study and followed them each for about 1 year. We'll be reporting the results as a late-breaker at the IDSA meeting in Vancouver on October 23rd and at the mHealth Summit in Washington, DC in November.

Check out:
www.idsociety.org/IDSA2010.htm and www.mhealthsummit.org

The protocol was very simple and thus popular among patients, who could access the program even through shared phones.
One of the issues we should discuss is patient-centered 'support' versus health-worker based 'monitoring and evaluation'. Support is likely to be valued most by patients, while monitoring is likely to be valued most by health service providers. While not mutually exclusive, these approaches may have important implications in mHealth service uptake and scalability.

I look forward to meeting those of you who will be attending these meetings. A few of our Kenyan team will be at the mHealth Summit.

Attached resource:
  • Mobilizing cell phones to improve antiretroviral adherence and follow-up in Kenya: a randomized controlled trial in progress (external URL)

    Link leads to: http://www.who.int/medicines/publications/monitor/emm3_issue_2/en/index.html

    Summary: Thank you all for the interesting discussions, including those on adherence monitoring. I would like to start a fresh discussion on mHealth based adherence interventions. We've recently completed a large multi-center randomized controlled trial (RCT)using structured text messaging (SMS) between health care workers and patients initiating antiretroviral therapy (ART) in Kenya. To our knowledge it is the first mHealth adherence intervention effectiveness trial in a resource-limited setting. (Are there more?)
    We enrolled 538 patients (from two urban clinics and one rural clinic) into the study and followed them each for about 1 year. We'll be reporting the results as a late-breaker at the IDSA meeting in Vancouver on October 23rd and at the mHealth Summit in Washington, DC in November.

    Check out:
    www.idsociety.org/IDSA2010.htm and www.mhealthsummit.org

    The protocol was very simple and thus popular among patients, who could access the program even through shared phones.
    One of the issues we should discuss is patient-centered 'support' versus health-worker based 'monitoring and evaluation'. Support is likely to be valued most by patients, while monitoring is likely to be valued most by health service providers. While not mutually exclusive, these approaches may have important implications in mHealth service uptake and scalability.

    I look forward to meeting those of you who will be attending these meetings. A few of our Kenyan team will be at the mHealth Summit.

    Source: WHO Essential Medicines Monitor

    Keywords: Adherence & Retention, africa, AIDS, Clinical Guidelines, Community Health Workers, Conferences & Meetings, HIV, Kenya, Monitoring & Evaluation, Monitoring & Measurement, Publications & Research, reminders, Research, SMS, text messaging

Replies

 

Shelly Batra, MD Replied at 7:14 AM, 6 Oct 2010

Dear All,

Operation ASHA has successfully utilised biometrics to ensure adherance  in TB patients , in slum communities of New Delhi, India. We have installed biometric devices at 13 DOTS centres, and right now, more than 730 patients have been registered in this program.  Not only that, our Counselors carry a similar device when they go for default tracking. This prevents 'gaming' of the system. Each new patient is enrolled in the system by storing his/her fingerprints in a 10" computer. When the patient comes for the medication, our Counselor identifies the patient by taking the fingerprint again, and then and only then is TB treatment adninistered. The biometrics have been designed and perfected by Microsoft Research and IIH (Innovators in health). I shall be doing a poster presentation on this at the mHealth summit in Washington DC, Nov 8-10. 

Shelly Batra, MD
President, Operation ASHA
Fighting Tuberculosis Worldwide
www.opasha.org

Jessica Haberer, MD, MS Replied at 9:44 AM, 6 Oct 2010

Hi Richard and Shelly,

You both are doing great work!

Richard, I have a few questions/comments about your study:

1. Did you use a PIN to identify study participants, especially those with shared phones? I published a small pilot study of SMS and IVR for self-reported adherence by caregivers of HIV+ children in Uganda, and we had lots of problems with the PIN (Haberer et al, Challenges Using Mobile Phones for Collection of Antiretroviral Therapy Adherence Data in a Resource-Limited Settin,g AIDS and Behavior, 2010). We've modified protocols and training and are having much better luck with our ongoing, expanded study. I'll be presenting those resutls at the mHealth Summit. Maybe we can compare notes there?

2. What % cell phone ownership did you find in your study setting? In the area of Uganda where I work, it's only about 50%, which may explain some of the problems we came across.

3. I also found that most participants really like this type of interaction. Many in my studies also feel that "someone is caring for them".

4. Have you considered a short code to allow for patients to send SMS to the clinic? I've used this set up in both Kenya and Uganda with good success, but of course, if increases system costs.

Regards,
Jessica

Shelly Batra, MD Replied at 2:19 AM, 7 Oct 2010

Thank you, Jessica, looking forward to meeting you at the mhealth summmit.

Richard Lester Replied at 12:45 PM, 7 Oct 2010

Thanks Jessica and Shelly. I can't discuss the trial results too much due to embargos, but look forward to discussions in Washington.

Thomas Odeny Replied at 2:38 AM, 8 Oct 2010

Great studies! Richard, we are also conducting a large mHealth adherence intervention trial in Kisumu, Kenya. It is geared more towards HIV prevention rather than treatment. Maybe we can discuss more and share experiences after you release your results at the mHealth summit.

Harsha Thirumurthy Replied at 11:35 PM, 8 Oct 2010

Richard,

Thanks for initiating this discussion on mHealth based adherence interventions. The study in Nairobi seems very promising. My colleagues and I recently completed an RCT of SMS reminders among patients initiating ART at a clinic in Nyanza Province, Kenya. We enrolled 720 patients and followed them for periods ranging from 6-18 months; adherence was measured using medication event monitoring system (MEMS) caps. The communication with patients was in the form of "one-way" SMS reminders to patients (i.e. patients could not respond to the messages). There were four intervention groups that received reminders of different frequency and length. The frequency of the SMS reminder was either daily or weekly. The length was either a very short reminder to take medications or a longer one that provided some encouragement so that patients would feel that somebody cares for them). We too had to deal with some of the logistical issues you faced - such as ensuring battery charge, maintaining a minimum amount of credit.

Compared to the mHealth intervention your team implemented, this one is less interactive with patients (in that it does not provide for active communication from patient to clinic), but the advantage is that it may be lower cost to automate and implement. There are a number of issues that would be interesting to discuss further and receive comments on. A few that come out of this study are:

1. What is the optimal frequency with which to contact patients through SMS? 2. What types of messages are most effective?

It would be interesting to know about other mHealth applications to ART adherence (and health behavior more generally) that are currently being evaluated.

We reported some results in an abstract at the IAS meetings in Vienna (abstract no CDB0207) and currently the paper reporting 12-month results of the interventions are undergoing peer-review. Perhaps we can discuss further at the mHealth summit.

K. Rivet Amico, PhD Replied at 5:02 AM, 9 Oct 2010

Harsha,

Really interesting! I was wondering...(relative to your #2 below) for the encouragement messaging, did participants write their own messages for encouragement they could receive (so, more like getting a message from yourself that has some kind of meaning to you) or was it more one of several possible messages someone could get from the clinic/project (someone sending you encouragement)? Also- for the encouragement message, how were they selected so that they would be meaningful and private?

Rivet



K Rivet Amico, PhD
Research Scientist
Center for Health, Intervention and Prevention
University of Connecticut
810 360 8716
800 518 0243 (fax)

Paul Gardner-Stephen Replied at 6:26 AM, 9 Oct 2010

Hello all,

This is really encouraging to hear how mobile telephone technology is being harnessed to improve patient outcomes.

I am the founder and director of the Serval Project (servalproject.org) which is a not-for-profit that has as its aim making telecommunications freely available to all people, regardless of economic, geopolitical or other impediment.

We are achieving this by making a free mesh mobile telephony system that we are passionately pursuing. At this stage, we can setup free mobile telephone networks over distances of up to a few kilometres, provided a few prerequisites can be met.

We are keen to start trialling our technology to aid those in need, and supporting medical activities is a key area that we are keen to explore.

We would be very interested in working with any project that can see value in free mobile and/or fixed telecommunications over the relatively short distances that we can achieve today, and also the longer distances we will achieve as we pursue our technology road map.

We see the current round of the Gates Foundation Grand Challenges program has a category for low-cost mobile phone applications, and are interested in submitting to this program in conjunction with a medical project to begin exploring how we can use out technology to help save and improve lives.

If any of you are interested in this concept, please do not hesitate to contact me.

Dr. Paul Gardner-Stephen.

Richard Lester Replied at 9:20 PM, 9 Oct 2010

Harsha,
The Kisumu study appears to ask and answer some important questions. Overall, it sounds like we are finally seeing some important evidence emerge in this field. I look very much forward to hearing more about your findings, as well as those of the others.
Best,
Rich

This Community is Archived.

This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.