Background: South Africa is home to the world's largest antiretroviral therapy program but sustaining engagement along the HIV care continuum has proven challenging in the country and throughout the wider region. Population mobility is common in South Africa, but there are important research gaps in describing this mobility and its impact on engagement in HIV care. Postpartum women and their infants in South Africa are known to be at high risk of dropping out of HIV care after delivery and are frequently mobile. Methods: In 2017, we developed a beta version of a smartphone application (app)-CareConekta-that detects a user's smartphone location to allow for prospective characterization of mobility. Now we will adapt and test CareConekta to conduct essential formative work on mobility and evaluate an intervention-the CareConekta app plus text notifications and phone calls and/or WhatsApp messages-to facilitate engagement in HIV care during times of mobility. During the 3-year project period, our first objective is to evaluate the feasibility, acceptability, and initial efficacy of using CareConekta as an intervention to improve engagement in HIV care. Our second objective is to characterize mobility among South African women during the peripartum period and its impact on engagement in HIV care. We will enroll 200 eligible pregnant women living with HIV and receiving care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. Discussion: This work will provide critical information about mobility during the peripartum period and the impact on engagement in HIV care. Simultaneously, we will pilot test an intervention to improve engagement with rigorously assessed outcomes. If successful, CareConekta offers tremendous potential as a research and service tool that can be adapted and evaluated in multiple geographic regions, study contexts, and patient populations. Trial registration: ClinicalTrials.gov: NCT03836625. Registered on 8 February 2019.
Background: Mobile health (mHealth) initiatives are increasingly common in low-resource settings, but the appropriateness of smartphone interventions is uncertain. To inform future mHealth interventions, we describe smartphone ownership, preferences and usage patterns among women living with HIV (WLHIV) in Gugulethu, South Africa. Methods: We screened pregnant WLHIV from December 2019 - February 2021 for the CareConekta trial. We describe sociodemographic characteristics and mobile phone ownership of all women screened (n=639), and smartphone use patterns among those enrolled in the trial (n=193). Results: 91% owned a mobile phone; 87% of those owned smartphones. Among those with smartphones, 92% used Android operating system version 5.0 or above, 98% of phones had GPS and 96% charged their phones <twice/day. Among 193 women enrolled, 99% owned the smartphone themselves; 14% shared their smartphone with someone but 96% of these possessed the phone most of the day. Median duration of smartphone ownership and current phone number was 12 [IQR:5-24] and 25 [IQR: 12-60] months, respectively. Participants reported a median of two [IQR: 1-2] phone numbers in the preceding two years. Receiving (100%) and making (99%) phone calls were the most common smartphone uses; least used were GPS (55%) and email (47%). WhatsApp (94%) was the favourite app reported. Conclusion: Smartphone ownership is very common in this low-resource, peri-urban setting. Phone sharing was uncommon, nearly all used the Android system and phones retained sufficient battery life. These results are encouraging to the development of mHealth interventions. Existing messaging platforms -- particularly WhatsApp -- are exceedingly popular and could be leveraged for interventions.
Background Mobile health interventions are common in public health settings in Africa, and our preliminary work showed that smartphones are increasing in South Africa. We developed a novel smartphone app—CareConekta—that used GPS location data to characterize personal mobility to improve engagement in HIV care among pregnant and postpartum women living with HIV in South Africa. The app also used the user’s location to map nearby clinics. Objective We aimed to describe the feasibility, acceptability, and initial efficacy of using the app in a real-world setting. Methods We conducted a prospective randomized controlled trial at a public sector clinic near Cape Town, South Africa. We enrolled 200 pregnant (third trimester) women living with HIV who owned a smartphone that met the required specifications. All participants installed the app, designed to collect 2 GPS heartbeats per day to geolocate the participant within a random 1-km fuzzy radius (for privacy). We randomized (1:1) participants to a control arm to receive the app with no additional support or an intervention arm to receive supportive phone calls, WhatsApp (Meta Platforms, Inc) messages, or both from the study team when traveling >50 km from the study area for >7 days. In addition to mobility data collected daily through the phone, participants completed questionnaires at enrollment and follow-up (approximately 6 months post partum). Results A total of 7 participants were withdrawn at enrollment or shortly after because of app installation failure (6/200, 3%) or changing to an unsuitable phone (1/200, 0.50%). During the study period, no participant’s smartphone recorded at least 1 heartbeat per day, which was our primary feasibility measure. Of the 171 participants who completed follow-up, only half (91/171, 53.2%) reported using the same phone as that used at enrollment, with the CareConekta app still installed on the phone and GPS usually enabled. The top reasons reported for the lack of heartbeat data were not having mobile data, uninstalling the app, and no longer having a smartphone. Acceptability measures were positive, but participants at follow-up demonstrated a lack of understanding of the app’s purpose and function. The clinic finder was a popular feature. Owing to the lack of consistent GPS heartbeats throughout the study, we were unable to assess the efficacy of the intervention. Conclusions Several key challenges impeded our study feasibility. Although the app was designed to reverse bill participants for any data use, the lack of mobile data was a substantial barrier to our study success. Participants reported purchasing WhatsApp data, which could not support the app. Problems with the web-based dashboard meant that we could not consistently monitor mobility. Our study provides important lessons about implementing an ambitious GPS-based study under real-world conditions in a limited-resource setting. Trial Registration ClinicalTrials.gov NCT03836625; https://clinicaltrials.gov/ct2/show/NCT03836625 International Registered Report Identifier (IRRID) RR2-10.1186/s13063-020-4190-x
PurposePregnant and postpartum women living with HIV in South Africa are at high risk of dropping out of care, particularly after delivery. Population mobility may contribute to disruptions in HIV care, and postpartum women are known to be especially mobile. To improve engagement in HIV care during the peripartum period, we developed CareConekta, a smartphone application (app) that uses GPS coordinates to characterise mobility and allow for real-time intervention. We conducted a randomised controlled pilot study to assess feasibility, acceptability and initial efficacy of the app intervention to improve engagement in HIV care. This cohort profile describes participant enrolment and follow-up, describes the data collected and provides participant characteristics.ParticipantsWe enrolled 200 pregnant women living with HIV attending routine antenatal care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. Eligible women must have owned smartphones that met the app’s technical requirements. Seven participants were withdrawn near enrolment, leaving 193 in the cohort.Findings to dateData were collected from detailed participant questionnaires at enrolment and follow-up (6 months after delivery), as well as GPS data from the app, and medical records. Follow-up is complete; initial analyses have explored smartphone ownership, preferences and patterns of use among women screened for eligibility and those enrolled in the study.Future plansAdditional planned analyses will characterise mobility in the population using the phone GPS data and participant self-reported data. We will assess the impact of mobility on engagement in care for the mother and infant. We also will describe the acceptability and feasibility of the study, including operational lessons learnt. By linking this cohort to the National Health Laboratory Service National HIV Cohort in South Africa, we will continue to assess engagement in care and mobility outcomes for years to come. Collaborations are welcome.Trial registration numberNCT03836625.
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