[This is an example of some of the exciting mHealth research presented at the mHealth Summit on December 3-5, 2012. This abstract and others are candidates for the iMedicalApps-mHealth Summit Research Award. Check here next week to see who was the winner of our award. ]
By: Mia L van der Kop, David Ojakaa, Lennie Bazira, Lehana Thabane, Lilian Mbau, Hellen Gakuruh, Koki Kinagwi, Edward Mills, Carlo Marra, Richard Lester, iMedicalApps-mHealth Summit Award Finalist
Mobile phone use has exploded in Africa, with the number of mobile subscribers increasing from 54 million to 649 million between 2003 and 2011.
Kenya is at the forefront of this growth, with one of the highest cell phone penetration rates in the region. One of our authors (RL), an infectious diseases physician, was living in Kenya completing an HIV immunology fellowship, when together with his colleagues, he noticed the rapid spread in mobile phone use and started to think about ways that cell phone technology could be used to improve HIV care. After brainstorming with patients and front line health care providers, the WelTel text-messaging service was born.
The WelTel intervention involves weekly check-ins. Each week, the message “Mambo?”, meaning “How are you?” in Swahili, is sent to patients. Patients are instructed to respond within 48 hours either that they are OK (sawa), or that they have a problem (shida). If patients respond that they are well, they are simply sent a message again the following week. If patients respond indicating a problem, or if they do not respond, then a clinician calls them to provide triage, advice, or general support.
To test the effectiveness of the intervention, Dr. Lester and colleagues conducted a multi-site randomized controlled trial among individuals initiating HIV treatment (WelTel Kenya1). At the end of one year, participants in the intervention arm had significantly improved medication adherence and suppression of viral load compared to those in the control arm. Importantly, patients receiving the service felt that ‘somebody cares’.
Shortly after the WelTel Kenya1 trial was published, the National Institutes of Health (NIH) put out a request for applications entitled “Promoting Engagement in Care and Timely Antiretroviral Initiation Following HIV Diagnosis”. NIH, the research community and program providers are concerned with engagement in pre-antiretroviral (pre-ART) care for several reasons.
First, it is an enormous problem. Rosen and Fox, two eminent researchers who have done comprehensive work on retention in HIV care in limited-resource settings, did a systematic review which found that less than one-third of patients testing positive for HIV remain continuously in care until they start HIV treatment. The problem with not being retained in care from the time of diagnosis is that patients then return to care when they are seriously ill, and initiate HIV treatment late, which results in a significantly increased risk of mortality and a greater use of healthcare resources. In response to NIH’s call, we partnered with the African Medical and Research Foundation (AMREF) and submitted a proposal to determine whether the WelTel intervention could help engage patients even before they start HIV treatment.
To determine whether regular contact with healthcare providers can help engage patients in this critical period of HIV care, we will conduct a randomized controlled trial at the Kibera Community Health Centre, which is a comprehensive care clinic serving over 4,000 HIV-infected individuals. The clinic is located in an area of Nairobi, Kenya known as Kibera, an informal urban settlement of about 2 square kilometres. Kibera is the second largest slum in Africa; the population the clinic serves lacks or has minimal access to basic services such as running water, sanitation, and electricity. Between 10 and 15% of Kibera’s population is infected with HIV, compared to a national prevalence of 6%.
For the WelTel Retain trial, we aim to recruit 686 participants, or 343 in each arm; recruitment is scheduled to start in January 2013. Patients will be eligible to participate if they are 18 years of age or older, HIV positive, have a cell phone or regular access to a cell phone, and have an HIV test at the clinic. Once enrolled, patients will be randomly allocated to the intervention or control arm. In addition to standard care, intervention arm participants will receive a weekly SMS ‘check-in’ to which they will be required to respond within 48 hours. An HIV clinician will follow-up and triage any problems that are identified.
Control arm participants will receive standard care. Patients will be followed for one year with a primary trial outcome of retention in care at 12-months. Ethical approval for the study has been received from the AMREF Ethics and Scientific Review Committee and the University of British Columbia. The trial has also been registered with clinicaltrials.gov (NCT01630304).
In addition to determining whether WelTel improves 12-month retention in care, we will also assess whether the intervention promotes retention in Stage 1 HIV care, which is the time from a positive HIV test to when a patient returns to the clinic to receive their CD4 results (at which point ART eligibility is determined). A cost-effectiveness evaluation of the intervention also forms an integral part of the study.
Overall, the WelTel Retain trial will contribute important information on the effectiveness of an established mHealth intervention to engage patients during the first year of HIV care, before initiating ART. Trial results and a cost-effectiveness evaluation will inform how WelTel might contribute to the long-term success of PEPFAR-funded programs, in which retention of patients is critical, and towards a sustainable global HIV/AIDS response.
Mia van der Kop is a doctoral student at the Karolinska Institutet, Department of Public Health Sciences, and an epidemiologist at the University of British Columbia Centre for Disease Control. Mia’s research focus is mHealth in global health, and more specifically, investigating whether the WelTel text-messaging service can improve retention in care among HIV patients.
Dr. David I. Ojakaa is currently the programme Manager for Research, Advocacy and Business Development at AMREF Kenya. He has a PhD in Demography from the University of Montreal in Canada. Dr. Ojakaa’s current research interests are collecting, analysing, and translating evidence in HIV/AIDS, TB, and Malaria programmes into policy action.
Dr. Lennie Bazira currently works with AMREF in Kenya as the Country Director responsible for overall country program leadership and management. She is a Health Economist with a Masters of Public Health Degree concentration in Health Economics from the University of Cape Town, and a Bachelor of Dental Surgery degree.
Dr. Lehana Thabane is a professor of biostatistics and associate chair of the Department of Clinical Epidemiology and Biostatistics at McMaster University (Hamilton, Ontario, Canada). Currently a clinical trial mentor for the Canadian Institutes of Health Research, Dr Thabane has provided statistical leadership in over 100 trials and co-authored over 200 publications in peer-reviewed journals.
Dr. Lilian Mbau is a physician at the AMREF clinic. She has extensive experience caring for HIV/AIDS patients and is the Lead Physician at the Kibera Community Health Centre.
Hellen Gakuruh is the Research Officer at AMREF’s Research, Advocacy and Business Development Unit. She has a Masters in biostatistics and has over six years experience in public health and demography research.