SMS messaging to improve retention and viral suppression in prevention of mother-to-child HIV transmission (PMTCT) programs in Kenya: A 3-arm randomized clinical trial

Kinuthia, John; Ronen, Keshet; Unger, Jennifer A.; Jiang, Wenwen; Matemo, Daniel; Perrier, Trevor; Osborn, Lusi; Chohan, Bhavna; Richardson, Barbra A.; John‐Stewart, Grace

doi:10.1371/journal.pmed.1003650

Cited by 32 publications

(54 citation statements)

References 37 publications

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“…The increasing availability and use of mobile technology provide an opportunity for improving health outcomes in low- and middle-income countries [ 9 ], and a variety of mobile health (mHealth) interventions have been developed to support the HIV care cascade [ 10 - 13 ]. Traditionally, mHealth platforms have concentrated on text-messaging or phone call interventions [ 10 , 11 ], and SMS which has been shown to improve HIV retention and VL suppression [ 14 ]. However, current trends are moving toward app-based interventions that allow the tailoring of content to match the needs and preferences of users and can provide multimedia content to enhance participation and further motivate behavior change.…”

Section: Introductionmentioning

confidence: 99%

Implementation of an mHealth App to Promote Engagement During HIV Care and Viral Load Suppression in Johannesburg, South Africa (iThemba Life): Pilot Technical Feasibility and Acceptability Study

Lalla-Edward¹,

Mashabane²,

Steward-Isherwood³

et al. 2022

JMIR Form Res

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Background South Africa has the largest HIV treatment program worldwide. Retention in care and medication adherence remain problematic necessitating innovative solutions for improving HIV care. The increasing availability and use of mobile technology can support positive clinical outcomes for persons living with HIV. iThemba Life is a mobile health app designed with input from South African health professionals and patients, promoting engagement with HIV care through access to medical results. Objective This study aimed to test the feasibility and acceptability of receiving HIV viral load (VL) results through the app and compare the time to HIV VL result return for study participants before and after app use. Methods Using convenience sampling, adults having routine VL phlebotomy were recruited from 2 Johannesburg health facilities. After signed consent, the app was downloaded on their Android smartphones, phlebotomy was performed, and the sample barcode was scanned through their phone to link the sample and app. Participants received a notification of the result availability and logged into the app to view results, their explanation and recommended action. Results Overall, 750 people were screened to enroll 500 participants. Of 750, 113 (15.1%) failed eligibility screening. 21.5% (137/637) had smartphone technical limitations preventing enrollment. Results were released to 92.2% (461/500) of participants’ phones. App technical issues and laboratory operational issues limited the number of released results. Approximately 78.1% (360/461) results were viewed in the app. Median time from notification of availability to result viewed being 15.5 hours (0.6; range 0-150 days). Turnaround time from phlebotomy to the result being received was 6 (range 1-167) days for users versus 56 days (range 10-430 days; P<.001) before app use. Overall, 4% (20/500) of participants received unsuppressed results (VL>1000 copies/mL). Turnaround time for unsuppressed results was 7 days for participants versus 37.5 days before app use (P<.001). The difference before and after app use in the suppressed and unsuppressed users for time from sample collection to result delivery was statistically significant. Of 20 participants, 12 (60%) returned for a confirmatory VL during the study period. The time from an unsuppressed VL to a confirmatory VL was 106 days for app users versus 203 days before app use (P<.001). Overall, 52.4% (262/500) of participants completed an exit survey; 23.2% (58/250) reported challenges in viewing their VL results. Moreover, 58% (35/60) reported that they overcame challenges with technical assistance from others, and 97.3% (255/262) wanted to continue using the app for VL results. Conclusions Using iThemba Life for VL results was well-received despite limited smartphone access for some participants. App users received results 10 times sooner than before the app and 5 times sooner if their VL >1000 copies/mL. This increased notification speed led to participants wanting to continue using iThemba Life.

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Section: Introductionmentioning

confidence: 99%

Implementation of an mHealth App to Promote Engagement During HIV Care and Viral Load Suppression in Johannesburg, South Africa (iThemba Life): Pilot Technical Feasibility and Acceptability Study

Lalla-Edward¹,

Mashabane²,

Steward-Isherwood³

et al. 2022

JMIR Form Res

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“…The mean age among trial participants ranged from 17 to 54 years. The primary target group for the text-message interventions were guardians of infant patients [ 19 , 20 , 24 , 25 , 36 , 37 , 39 , 40 , 46 , 47 ] where the mother was the receiver of the text message intervention, whilst the remaining trials solely targeted men [ 22 , 28 ] or women [ 32 , 33 , 35 , 44 , 46 , 48 – 50 ] or both men and women [ 23 , 26 , 27 , 29 – 31 , 34 , 38 , 41 , 43 , 45 ]. All trials were set in Sub-Saharan Africa with vast majority being set in Kenya (n = 17) followed by South Africa (n = 4) ( Fig 2 ).…”

Section: Resultsmentioning

confidence: 99%

“…The clinical areas in trials were HIV (n = 20), reproductive health (n = 4), antenatal health (n = 4), non-communicable diseases (n = 2), and malaria (n = 1). Ten trials reported that the text message content was developed based on health behavioral theories [ 19 , 24 , 28 , 30 , 32 , 34 , 35 , 37 – 39 ], eight reported that the content had been pre-tested or developed in consultation with experts, clinical staff and/or potential participants [ 21 , 23 , 25 , 26 , 31 , 39 , 44 , 46 ] and thirteen trials did not report either [ 20 , 22 , 27 , 29 , 33 , 36 , 41 , 43 , 45 , 47 – 50 ]. The content of the two-way text messages varied from supportive, educational, and motivational messages to reminders and quizzes with a two-way component of either replying to the message via text message or phone call or by requesting phone calls or additional information from the sender ( Table 1 ).…”

Section: Resultsmentioning

confidence: 99%

“…When looking across all trials, ten trials included appointment attendance as an outcome [ 19 , 20 , 24 – 26 , 28 , 31 , 39 , 41 , 44 ] and sixteen trials included medicine adherence as an outcome [ 21 , 22 , 25 , 27 , 29 – 31 , 36 , 37 , 39 , 41 , 43 – 45 , 48 , 49 ]. Medicine adherence was measured in multiple ways, including self-reported adherence, pill box openings and clinical outcomes affected by adherence such as change in mean systolic blood pressure, proportion of patients with HbA1c < 7%, or suppressed HIV viral load [ 21 , 25 , 28 , 29 , 32 , 34 , 35 , 38 , 40 , 42 , 44 ]. Other trials had reproductive health knowledge [ 31 , 39 ], adverse events [ 20 ], neonatal mortality [ 46 ], malnutrition [ 47 ], or unintended pregnancy as outcomes [ 33 ] ( Table 1 ).…”

Section: Resultsmentioning

confidence: 99%

“…One of these trials was an unpublished trial set in South Africa (results recorded in clinicaltrials.gov) found a marginally effect in the two-way text message group compared to the control group (OR: 1.9; 95% CI: 0.9 to 4.2) [ 41 ]. The other trial was 3-arm trial on prevention of mother-to-child transmission of HIV in Kenya [ 44 ]. The trial found that two-way text messages did not improve on-time clinic appointment attendance (aRR two-way compared to control : 1.01; 95% CI: 0.98 to 1.04) and medicine adherence (measured as viral load non-suppression at any time) compared to a one-way text message group or a control group (aRR two-way compared to control : 0.80; 95% CI:0.52 to 1.23) [ 44 ].…”

Section: Resultsmentioning

confidence: 99%

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Two-way text message interventions and healthcare outcomes in Africa: Systematic review of randomized trials with meta-analyses on appointment attendance and medicine adherence

et al. 2022

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Background The growing access to mobile phones in Africa has led to an increase in mobile health interventions, including an increasing number of two-way text message interventions. However, their effect on healthcare outcomes in an African context is uncertain. This systematic review aims to landscape randomized trials involving two-way text message interventions and estimate their effect on healthcare outcomes. Methods We searched Medline, Embase, Cochrane Central Register of Controlled Trials, The Global Health Library (up to 12 August 2021) and trial registries (up to 24 April 2020). Published and unpublished trials conducted in Africa comparing two-way text message interventions with standard care and/or one-way text message interventions were included. Trials that reported dichotomous effect estimates on healthcare appointment attendance and/or medicine adherence were assessed for risk of bias and included in meta-analyses. Results of other outcomes were reported descriptively. Results We included 31 trials (28,563 participants) all set in Sub-Saharan Africa with a wide range of clinical conditions. Overall, ten different trials were included in the primary meta-analyses, and two of these had data on both medicine adherence and appointment attendance. An additional two trials were included in sensitivity analyses. Of the 12 included trials, three were judged as overall low risk of bias and nine as overall high risk of bias trials. Two-way text messages did not improve appointment attendance, RR: 1.03; 95% CI: 0.95–1.12, I2 = 53% (5 trials, 4374 participants) but improved medicine adherence compared to standard care, RR: 1.14, 95% CI: 1.07–1.21, I2 = 8% (6 trials, 2783 participants). Conclusion Two-way text messages seemingly improve medicine adherence but has an uncertain effect on appointment attendance compared to standard care. Systematic review registration PROSPERO CRD42020175810.

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Effects of behavioural interventions on postpartum retention and adherence among women with HIV on lifelong ART: the results of a cluster randomized trial in Kenya (the MOTIVATE trial)

et al. 2022

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Introduction: Retention in HIV care and adherence to antiretroviral therapy (ART) during pregnancy and postpartum for women living with HIV (WLWH) are necessary to optimize health outcomes for women and infants. The objective of this study was to evaluate the impact of two evidenced-based behavioural interventions on postpartum adherence and retention in WLWH in Kenya. Methods: The Mother-Infant Visit Adherence and Treatment Engagement (MOTIVATE) study was a cluster-randomized trial enrolling pregnant WLWH from December 2015 to August 2017. Twenty-four health facilities in southwestern Kenya were randomized to: (1) standard care (control), (2) text-messaging, (3) community-based mentor mothers (cMM) or (4) textmessaging and cMM. Primary outcomes included retention in care and ART adherence at 12 months postpartum. Analyses utilized generalized estimating equations and competing risks regression. Per-protocol analyses examined differences in postpartum retention for women with high versus low levels of exposure to the interventions. Results: We enrolled 1331 pregnant WLWH (mean age 28 years). At 12 months postpartum, 1140 (85.6%) women were retained in care, 96 women (7.2%) were lost-to-follow-up (LTFU) and 95 (7.1%) were discontinued from the study. In intention-to-treat analyses, the relative risk of being retained at 12-months postpartum was not significantly higher in the intervention arms versus the control arm. In time-to-event analysis, the cMM and text arm had significantly lower rates of LTFU (hazard ratio 0.44, p = 0.019). In per-protocol analysis, the relative risk of 12-month postpartum retention was 24-29% higher for women receiving at least 80% of the expected intervention compared to the control arm; text message only risk ratio (RR) 1.24 (95% confidence interval [CI] 1.16-1.32, p<0.001), cMM only RR 1.29 (95% CI 1.21-1.37, p<0.001) and cMM plus text RR 1. 29 (1.21-1.37, p<0.001). Women LTFU were younger (p<0.001), less likely to be married (p<0.001) and more likely to be newly diagnosed with HIV during pregnancy (p<0.001). Self-reported ART adherence did not vary by study arm. Conclusions: Behavioural interventions using peer support and text messages did not appear to improve 12-month postpartum retention and adherence in intention-to-treat analyses. Higher levels of exposure to the interventions may be necessary to achieve the desired effects.

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SMS messaging to improve retention and viral suppression in prevention of mother-to-child HIV transmission (PMTCT) programs in Kenya: A 3-arm randomized clinical trial

Cited by 32 publications

References 37 publications

Implementation of an mHealth App to Promote Engagement During HIV Care and Viral Load Suppression in Johannesburg, South Africa (iThemba Life): Pilot Technical Feasibility and Acceptability Study

Implementation of an mHealth App to Promote Engagement During HIV Care and Viral Load Suppression in Johannesburg, South Africa (iThemba Life): Pilot Technical Feasibility and Acceptability Study

Two-way text message interventions and healthcare outcomes in Africa: Systematic review of randomized trials with meta-analyses on appointment attendance and medicine adherence

Effects of behavioural interventions on postpartum retention and adherence among women with HIV on lifelong ART: the results of a cluster randomized trial in Kenya (the MOTIVATE trial)

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