A Systematic Review on Promoting Adherence to Antiretroviral Therapy in HIV-infected Patients Using Mobile Phone Technology
Abstract
Objective Adherence to antiretroviral therapy (ART) is paramount to successful long-term suppression of human immunodeficiency virus (HIV). For poorly adherent patients with HIV, barriers to remaining adherent may be overcome by the implementation of targeted interventions delivered via mobile devices. This systematic review is focused specifically on mobile phone technologies to deliver adherence interventions in HIV/acquired immunodeficiency syndrome (AIDS) populations.
Methods This review (PROSPERO #CRD42017065131) systematically extracted data from published literature from five databases on mobile phone interventions to improve adherence to ART for HIV. The reported studies had been conducted between 2007 and 2017. Risk of bias was assessed using the Cochrane method ranking each criterion as low, high, or unclear risk of bias.
Results Of the 835 articles returned, we identified 26 randomized controlled trials (RCTs), retrospective and prospective cohort trials, or mixed method studies with a comparison group that fit criteria for inclusion. No standard measure of adherence was consistent throughout the examined studies, and assessments by self-report, pill counting, and medication event monitoring system (MEMS) were utilized. The studies reported mixed results, with 17 reporting significant improvements to adherence, 3 reporting improvements without supplying p-values, and 6 reporting no significant change or a reduction in adherence.
Conclusion The mixed nature of the results exemplifies the need for more comprehensive approaches and larger scale trials to confirm results observed in limited cohort sizes. To better retain satisfactory adherence within the HIV population, and especially in low-resource settings, we recommend that future interventions incorporate multiple strategies: mobile-based reminders, social support structures, and personalized content.
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- HIV+ persons with co-occurring bipolar disorder (HIV+/BD+) have elevated rates of medication nonadherence. We conducted a 30-day randomized controlled trial of a two-way, text messaging system, iTAB (n = 25), compared to an active comparison (CTRL) (n = 25) to improve antiretroviral (ARV) and psychotropic (PSY) adherence and dose timing. Both groups received medication adherence psychoeducation and daily texts assessing mood. The iTAB group additionally received personalized medication reminder texts. Participants responded to over 90 % of the mood and adherence text messages. Mean adherence, as assessed via electronic monitoring caps, was high and comparable between groups for both ARV (iTAB 86.2 % vs. CTRL 84.8 %; p = 0.95, Cliff's d = 0.01) and PSY (iTAB 78.9 % vs. CTRL 77.3 %; p = 0.43, Cliff's d = -0.13) medications. However, iTAB participants took ARVs significantly closer to their intended dosing time than CTRL participants (iTAB: 27.8 vs. CTRL: 77.0 min from target time; p = 0.02, Cliff's d = 0.37). There was no group difference on PSY dose timing. Text messaging interventions may represent a low-burden approach to improving timeliness of medication-taking behaviors among difficult-to-treat populations. The benefits of improved dose timing for long-term medication adherence require additional investigation.
- Objectives: To assess the effectiveness of Short Message Service (SMS) reminder messages on antiretroviral and cotrimoxazole prophylaxis adherence among HIV-positive youths as well as the relative effectiveness of SMS with and without a response option. Methods: Eligible HIV-positive patients aged 15 to 22 years at 2 HIV clinics in Kampala, Uganda, participated in a year-long parallel individual-randomized controlled trial and were assigned in a 1-to-1-to-1 ratio to a weekly SMS message group, weekly SMS message with response option group, or a usual-care control group. Results: We enrolled 332 participants. Electronically measured mean adherence was 67% in the control group, 64% in the 1-way SMS group (95% confidence interval [CI] = 0.77, 1.14), and 61% in the 2-way SMS group (95% CI = 0.75, 1.12) in an intent-to-treat analysis. Results for secondary outcomes and complete-case analysis were similarly statistically insignificant across groups. Conclusions: Despite previous evidence that interventions using SMS reminders can promote antiretroviral therapy adherence, this study shows that they are not always effective in achieving behavior change. More research is needed to find out for whom, and under what conditions, they can be beneficial. Trial registration: ClinicalTrials.gov identifier: NCT00830622. (Am J Public Health. Published online ahead of print October 19, 2017: e1-e7. doi:10.2105/AJPH.2017.304089).
- The objective of this integrative review was to describe current US trends for health technology-enabled adherence interventions among behaviorally HIV-infected youth (ages 13–29 years), and present the feasibility and efficacy of identified interventions. A comprehensive search was executed across five electronic databases (January 2005–March 2016). Of the 1911 identified studies, nine met the inclusion criteria of quantitative or mixed methods design, technology-enabled adherence and or retention intervention for US HIV-infected youth. The majority were small pilots. Intervention dose varied between studies applying similar technology platforms with more than half not informed by a theoretical framework. Retention in care was not a reported outcome, and operationalization of adherence was heterogeneous across studies. Despite these limitations, synthesized findings from this review demonstrate feasibility of computer-based interventions, and initial efficacy of SMS texting for adherence support among HIV-infected youth. Moving forward, there is a pressing need for the expansion of this evidence base.
- Background: Combination antiretroviral therapy (cART) as treatment for human immunodeficiency virus (HIV) infection is effective and available, but poor medication adherence limits benefits, particularly in vulnerable populations. In a Kenyan randomized controlled trial, a weekly text-messaging intervention (WelTel) improved cART adherence and HIV viral load (VL). Despite growing evidence for short message service (SMS) text-message interventions in HIV care, there is a paucity of data utilizing these interventions in marginalized or female cohorts. Objective: This study was undertaken to assess whether the standardized WelTel SMS text-message intervention applied to a vulnerable, predominantly female, population improved cART adherence and VL. Methods: We conducted a repeated measures study of the WelTel intervention in high-risk HIV-positive persons by measuring change in VL, CD4 count, and self-reported adherence 12 months before and 12 months after the WelTel intervention was introduced. Inclusion criteria included VL ≥200 copies/mL, indication for treatment, and meeting vulnerability criteria. Participants were given a mobile phone with unlimited texting (where required), and weekly check-in text messages were sent for one year from the WelTel computer platform. Clinical data were collected for control and intervention years. Participants were followed by a multidisciplinary team in a clinical setting. Outcomes were assessed using Wilcoxon signed ranks tests for change in CD4 and VL from control year to study end and mixed-effects logistic regressions for change in cART adherence and appointment attendance. A secondary analysis was conducted to assess the effect of response rate on the outcome by modeling final log10 VL by number of responses while controlling for mean log10 VL in the control year. Results: Eighty-five participants enrolled in the study, but 5 withdrew (final N=80). Participants were predominantly female (90%, 72/80) with a variety of vulnerabilities. Mean VL decreased from 1098 copies/mL in the control year to 439 copies/mL at study end (P=.004). Adherence to cART significantly improved (OR 1.14, IQR 1.10-1.18; P<.001), whereas appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). A response was received for 46.57% (1753/3764) of messages sent and 9.62% (362/3764) of text messages sent were replied to with a problem. An outcome analysis examining relationship between reply rate and VL did not meet statistical significance (P=.07), but may be worthy of investigating further in a larger study. Conclusions: WelTel may be an effective tool for improving cART adherence and reducing VLs among high-risk, vulnerable HIV-positive persons. Trial Registration: Clinicaltrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/6qK57zCwv)
- Background: Adherence to treatment remains the cornerstone of long term viral suppression and successful treatment outcomes among patients receiving Antiretroviral Therapy (ART). Objective(s): Evaluate the effectiveness of mobile phone reminders and peer counseling in improving adherence and treatment outcomes among HIV positive patients on ART in Malaysia. Methods: A single-blind, parallel group RCT conducted in Hospital Sungai Buloh, Malaysia in which 242 adult Malaysian patients were randomized to intervention or control groups. Intervention consisted of a reminder module delivered through SMS and telephone call reminders by trained research assistants for 24 consecutive weeks (starting from date of ART initiation), in addition to adherence counseling at every clinic visit. The length of intended follow up for each patient was 6 months. Data on adherence behavior of patients was collected using specialized, pre-validated Adult AIDS Clinical Trial Group (AACTG) adherence questionnaires. Data on weight, clinical symptoms, CD4 count and viral load tests were also collected. Data was analyzed using SPSS version 22 and R software. Repeated measures ANOVA, Friedman's ANOVA and Multivariate regression models were used to evaluate efficacy of the intervention. Results: The response rate after 6 months follow up was 93%. There were no significant differences at baseline in gender, employment status, income distribution and residential location of respondents between the intervention and control group. After 6 months follow up, the mean adherence was significantly higher in the intervention group (95.7; 95% CI: 94.39-96.97) as compared to the control group (87.5; 95% CI: 86.14-88.81). The proportion of respondents who had Good (>95%) adherence was significantly higher in the intervention group (92.2%) compared to the control group (54.6%). A significantly lower frequency in missed appointments (14.0% vs 35.5%) (p = 0.001), lower viral load (p = 0.001), higher rise in CD4 count (p = 0.017), lower incidence of tuberculosis (p = 0.001) and OIs (p = 0.001) at 6 months follow up, was observed among patients in the intervention group. Conclusion: Mobile phone reminders (SMS and telephone call reminders) and peer counseling are effective in improving adherence and treatment outcomes among HIV positive patients on ART in Malaysia. These findings may be of potential benefit for collaborative adherence planning between patients and health care providers at ART commencement.
- Background In randomized controlled trials, short message service (SMS) programs have improved adherence to HIV antiretroviral therapy (ART). In response, the World Health Organization recommended use of SMS programs to support ART. However, there is limited data on real-world implementations of SMS programs. Methods We conducted a retrospective cohort study of an SMS program to improve ART adherence in a government-run HIV clinic in rural South Africa. We analyzed data from all adult patients who 1) enrolled at the clinic before the observation period (July 2013 through June 2014), 2) had ≥1 ART prescriptions in the observation period, and 3) had data on phone number availability (N = 2255). Our main outcome measure was prescription coverage, defined as the presence of a valid ART prescription for each day observed. We fit generalized linear mixed models adjusted for pre-program prescription coverage, demographics, and ART duration, dosing, and regimen. Results Exposure to the SMS program was independently associated with greater prescription coverage (AOR = 1.23, 95% CI 1.13–1.34, P < 0.001) compared with non-exposure, although the absolute increase in prescription coverage was small (4.7 days of ART prescription coverage per average patient per year). Among a subset of patients (n = 725) whose pre-program prescription coverage was <100%, the corresponding mean expected absolute increase in prescription coverage was 8.2 days per year. Conclusions Our primary finding was that an SMS reminder program implemented in routine clinical care was associated with a small increase in prescription coverage of uncertain clinical significance.
- Aim: The aim of this study was to examine the acceptability and efficacy of interactive short message service (SMS) in improving medication adherence in antiretroviral treatment (ART)-naïve individuals living with HIV/AIDS in Hengyang, Hunan, China. Background: SMS via mobile phone has emerged as a potential tool for improving ART adherence. However, most studies used SMS only as a medication reminder, with few studies exploring the effect of comprehensive, interactive SMS. Patients and methods: In a randomized controlled trial, 100 HIV-positive patients on ART for <3 months were randomized into control or intervention arm. Participants in the control group received routine standard instruction for ART medication in the HIV clinics, while the intervention group received 6 months of an SMS intervention in addition to the standard care. A total of 124 text messages within 6 modules were edited, preinstalled, and sent to participants according to personalized schedules. Knowledge (of HIV and HIV medications), self-reported antiretroviral adherence (Visual Analog Scale [VAS] and Community Programs for Clinical Research on AIDS [CPCRA] Antiretroviral Medication Self-Report), and CD4 count were assessed at baseline and immediate post-intervention. Intervention participants were interviewed after completion of the study about their satisfaction with and acceptability of the SMS intervention. Results: Baseline assessments were comparable between arms. Repeated-measures analysis showed that both HIV-related and ART medication knowledge of the intervention group showed better improvement over time than those of the control group after the intervention (P<0.0001). For the adherence measures, compared with the control group, participants in the intervention group had significantly higher VAS mean score (Z=2.735, P=0.006) and lower suboptimal adherence rate (Z=2.208, P=0.027) at the end of the study. The intervention had no effect on CD4 cell count. Almost all (96%) intervention participants reported satisfaction or high satisfaction with the SMS intervention, with 74% desiring to continue to receive the SMS intervention. The preferred frequency of messages was 1-2 messages per week. Conclusion: An interactive SMS intervention with comprehensive content shows promising efficacy in promoting medication adherence in ART-naïve individuals. Future work might further refine its ability to optimally tailor the intervention for individual preferences.
- Background . Antiretroviral medications are key for prevention of mother-to-child transmission (PMTCT) of HIV, and transmission mitigation is affected by service delivery, adherence, and retention. Methods . We conducted a cluster-randomized controlled study in 26 facilities in Nyanza, Kenya, to determine the efficacy of SMS text messages on PMTCT outcomes. The relative risk and confidence intervals were estimated at the facility level using STATA. Results . 550 women were enrolled, from June 2012 to July 2013. The median age was 25.6 years, and 85.3% received ARVs. Maternal ARV use was similar between the intervention and control arms: 254/261 (97.3%) versus 241/242 (99.6%) at 34–36 weeks of gestation and 234/247 (94.7%) versus 229/229 (100%) at delivery. Among infants, 199/246 (80.9%) and 209/232 (90.1%) received ARVs (RR: 0.91; 95% CI: 0.77–1.14); 88% versus 88.6% were tested for HIV at 6 weeks, with 1/243 (0.4%) and 3/217 (1.4%) positive results in the intervention and control arms, respectively. Communication increased in both the intervention and control arms, with the mean number of 7.5 (SD: 5.70) compared with 6 (SD: 9.96), p<0.0001 . Conclusions . We identified high ARV uptake and infant HIV testing, with very low HIV transmission. Increased communication may influence health-seeking behaviors irrespective of technology. The long-term effectiveness of facilitated communication on PMTCT outcomes needs to be tested. The study has been registered on ClinicalTrials.gov under the identifier NCT01645865 .
- Background: African Americans (AA) experience high levels of health disparities for several diseases, yet remain underrepresented in clinical trials and other types of research. The high ownership of smartphones among AA puts them in a unique position to be recruited into e-Health/m-Health interventions. Objective: This article is a systematic review of the participation of AA in e-Health/m-Health interventions, the diseases/health conditions targeted, and the recruitment and retention strategies used. Materials and methods: A systematic review was done with PubMed, PsycINFO, Web of Science, EBSCOhost, and CINAHL databases, as well as hand searches of 14 journals. The search was restricted to studies conducted in the United States and that were published between January 2000 and June 2016. Twenty-three distinct search terms were used. Results: After removal of duplicates, 565 studies were screened and assessed for eligibility, and 56 met the inclusion criteria. Eight studies had exclusively AA participants. Eighty percent of the studies had female participants. Participants were recruited primarily from clinics/healthcare facilities. Forty-five percent of the studies provided monetary incentives. Only five studies addressed retention of participants. The diseases/health conditions that were studied included overweight/obesity, diabetes, physical activity, cardiovascular conditions, nutrition, prenatal health, and HIV. Conclusion: There was a low representation of AA in the studies in this review. Opportunities exist to engage AA in e-Health/m-Health research, but researchers must go beyond the traditional one-size-fits-all approach to determine what mixture of incentives and recruitment/retention strategies would work best for a particular health condition, population group, or community.
- Background Sexually transmitted infections (STIs) pose a serious public health problem globally. The rapid spread of mobile technology creates an opportunity to use innovative methods to reduce the burden of STIs. This systematic review identified recent randomised controlled trials that employed mobile technology to improve sexual health outcomes. Methods The following databases were searched for randomised controlled trials of mobile technology based sexual health interventions with any outcome measures and all patient populations: MEDLINE, EMBASE, PsycINFO, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, NHS Health Technology Assessment Database, and Web of Science (science and social science citation index) (Jan 1999–July 2014). Interventions designed to increase adherence to HIV medication were not included. Two authors independently extracted data on the following elements: interventions, allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. Trials were assessed for methodological quality using the Cochrane risk of bias tool. We calculated effect estimates using intention to treat analysis. ResultsA total of ten randomised trials were identified with nine separate study groups. No trials had a low risk of bias. The trials targeted: 1) promotion of uptake of sexual health services, 2) reduction of risky sexual behaviours and 3) reduction of recall bias in reporting sexual activity. Interventions employed up to five behaviour change techniques. Meta-analysis was not possible due to heterogeneity in trial assessment and reporting. Two trials reported statistically significant improvements in the uptake of sexual health services using SMS reminders compared to controls. One trial increased knowledge. One trial reported promising results in increasing condom use but no trial reported statistically significant increases in condom use. Finally, one trial showed that collection of sexual health information using mobile technology was acceptable. Conclusions The findings suggest interventions delivered by SMS interventions can increase uptake of sexual health services and STI testing. High quality trials of interventions using standardised objective measures and employing a wider range of behavioural change techniques are needed to assess if interventions delivered by mobile phone can alter safer sex behaviours carried out between couples and reduce STIs.
- There are conflicting findings about whether mobile phone text message reminders impact on antiretroviral adherence. We hypothesized that text reminders sent when dosing was late would improve adherence and HIV viral suppression. ART-naïve participants, from a South African outpatient ART clinic, were randomised to standard of care (SoC, three pre-treatment education sessions), or intervention (SoC and automated text reminders if dosing >30 minutes late). Dosing time was recorded by real-time electronic adherence monitoring devices (EAMD), given to participants at ART start. CD4 cell count and HIV RNA were determined at baseline, 16 and 48 weeks. Primary outcome was cumulative adherence execution by EAMD. HIV-1 viral suppression (<40 copies/ml) at week 48 and count of treatment interruptions (TIs) >72 hours were secondary outcomes. Analysis was by intention to treat (missing=failure). Registration was with the Pan-African Clinical Trials Registry: PACTR201311000641402. 230 participants were randomly assigned to control (n=115) or intervention (n=115) arms. Median adherence was 82.1% (IQR 56.6-94.6%) in the intervention arm, compared to 80.4% (IQR 52.8-93.8%) for SoC (adjusted odds ratio (aOR) for adherence 1.08, 95%CI:0.77-1.52). Suppressed HIV RNA (<40 copies/ml) occured in 80 (69.6%) of control and 75 (65.2%) of intervention; aOR for virological failure in intervention arm 0.77, 95%CI:0.42-1.40). In the intervention arm the count of TIs of >72hours was reduced (adjusted incident rate ratio 0.84, 95%CI:0.75-0.94). Text message reminders linked to late doses detected by real-time adherence monitoring reduced the number of prolonged treatment interruptions, but did not significantly improve adherence or viral suppression.
- Background: HIV and AIDS are major public health problems in the world and Africa. In Cameroon, the HIV prevalence is 5.1%. Cellphones have been found to be useful in the provision of modern health care services using short message services (SMS). This study assessed the effectiveness of SMS in improving the adherence of people living with HIV and AIDS to their treatment and care in Cameroon. Methods: This intervention study used a randomized controlled trial design. Ninety participants seeking treatment at the Nkwen Baptist Health Center were recruited between August and September 2011 using a purposive sampling method. They were randomly allocated into the intervention and control groups, each containing 45 participants. In the intervention group, each participant received four SMSs per week at equal intervals for four weeks. The patients were investigated for adherence to ARVs by evaluating the number of times treatment and medication refill appointments were missed. Data were collected using an interviewer-administered questionnaire before and after intervention and analysed on STATA. Results: The baseline survey indicated that there were 55(61.1%) females and 35(38.9%) males aged 23 - 62 years; the mean age was 38.77 ± 1.08. Most participants were teachers [12 (13.3%)], farmers [11 (12.2%)], and businessmen [24 (26.7%)]. Adherence to ARVs was 64.4% in the intervention group and 44.2% in the control group (p = 0.05). 2(4.4%) patients in the control group failed to respect their drug refill appointments while all the 45(100%) participants in the intervention group respected their drug refill appointments. 54.17% of married people and 42.9% of the participants with primary and secondary levels of education missed their treatment. Key reasons for missing treatment were late home coming (54%), forgetfulness (22.5%), and travelling out of station without medication (17.5%). Other factors responsible for non-adherence included involvement in outdoor business (60.87%), ARV stock out (37.8%), and not belonging to a support group (10.23%). Twenty eight (62.22%) subjects in the intervention group were able to take their treatment regularly and on time. Conclusion: SMS improved adherence to ARVs. Key constraints which affect adhere to ARV medication can be addressed using SMS.
- High levels of adherence are required to achieve the full benefit of ART. We assess the effectiveness of electronic adherence monitoring devices among patients failing second-line ART, as measured by viral load suppression. Cohort study of Wisepill™ real-time adherence monitoring in addition to intensified adherence counselling over 3 months in adults with a viral load ≥400 copies/ml on second-line ART in Johannesburg, South Africa between August 2013 and January 2014. Patients were sent SMS reminders upon missing a scheduled dose. We compared outcomes to earlier historical cohorts receiving either intensified adherence counselling or adherence counselling alone. Overall, 63 % of the participants (31/49) took >80 % of their prescribed medication; this dropped from 76 to 53 and 49 % at 1, 2 and 3 months post-enrolment respectively. Compared to those with good adherence (>80 %), participants with poor adherence (≤80 %) had a higher risk for a subsequently elevated viral load ≥400 copies/ml (relative risk (RR) 1.47 95 % CI 0.97-2.23). Participants found the intervention "acceptable and useful" but by 6 months after eligibility they were only slightly more likely to be alive, in care and virally suppressed compared to those who received intensified adherence counselling (44.9 vs. 38.5 %; RR 1.19; 95 % CI 0.85-1.67) or adherence counselling alone (44.9 vs. 40.9 %; RR 1.12; 95 % CI 0.81-1.56). In patients with an elevated viral load on second-line ART electronic adherence monitoring was associated with a modest, but not significant, improvement in viral suppression.
- Background: HIV infection is clinically managed with antiretroviral therapy (ART), but only with sustained adherence. Cost-efficient interventions to improve and sustain ART adherence remain a pressing priority for populations challenged by non-adherence. Purpose: To test the independent and interactive effects of (a) brief phone-delivered self-regulation counseling and (b) daily phone-delivered text message medication reminders on HIV adherence and HIV viral suppression. Method: A randomized 2 (5-sessions of phone-delivered adherence support counseling vs. contact-matched control) x 2 (daily ART text reminders vs. no reminders) trial with primary endpoints of monthly phone-based unannounced pill count-determined ART adherence and HIV viral suppression monitored over 12-months. Results: Self-regulation adherence counseling demonstrated significant improvements in achieving 90% ART adherence relative to the control group over the first 6-months of follow-up. Effects remained significant in sensitivity analyses conducted at 85% and 95% adherence. Counseling also demonstrated modest but significant effects on HIV suppression. There were no main effects or interactions for daily text message reminders, with some evidence for adverse effects on adherence self-efficacy. Conclusions: Brief adherence support counseling delivered by phone demonstrates clinically meaningful improvements in ART adherence and HIV suppression, although these benefits were not evidenced in all patients or in the long-term. Advancing adherence interventions along with an effective means for sustaining gains in adherence remain priorities if ART is to achieve its potential clinical and public health benefits.
- Objective: Explore effects of four types of SMS plus real-time adherence monitoring on antiretroviral therapy adherence: 1) daily reminders, 2) weekly reminders, 3) reminders triggered after a late or missed dose (delivered to patients) and 4) notifications triggered by sustained adherence lapses (delivered to patient-nominated social supporters). Design: Pilot randomized controlled trial. Methods: Sixty-three individuals initiating ART received a real-time adherence monitor and randomized (1:1:1):Scheduled SMS reminders (daily for one month, weekly for two months), then SMS reminders triggered by a late or missed dose (no monitoring signal within two hours of expected dosing); SMS notifications to social supporters for sustained adherence lapses (no monitoring signal for >48 hours) added after three monthsTriggered SMS reminders starting at enrollment; SMS notifications to social supporters added after three monthsControl: No SMSHIV RNA was determined at nine months. Percent adherence and adherence lapses were compared by linear generalized estimating equations and Poisson regression, respectively. Results: Median age was 31 years, 65% were female, and median enrollment CD4 count was 322 cells/ml; 97% took once daily tenofovir/emtricitabine/efavirenz. Compared to Control, adherence was 11.1% higher (p = 0.04) and >48-hour lapses were less frequent (IRR 0.6, p = 0.02) in the Scheduled SMS arm. Adherence and >48-hour lapses were similar in the Triggered SMS arm and Control. No differences in HIV RNA were seen. Conclusions: Scheduled SMS reminders improved ART in the context of real-time monitoring. Larger studies are needed to determine the impact of triggered reminders and role of social supporters in improving adherence.
- Objective: This pilot study tested the preliminary efficacy of a theory-based bidirectional text messaging intervention (TEXT) on antiretroviral (ART) adherence, missed care visits, and substance use among people with HIV. Method: Participants with recent substance use and ART nonadherence from 2 nonurban HIV clinics were randomized to TEXT or to usual care (UC). The TEXT intervention included daily queries of ART adherence, mood, and substance use. The system sent contingent intervention messages created by participants for reports of adherence/nonadherence, good mood/poor mood, and no substance use/use. Assessments were at preintervention, postintervention, and 3-month postintervention follow-up. Objective primary outcomes were adherence, measured by past 3-month pharmacy refill rate, and proportion of missed visits (PMV), measured by medical records. The rate of substance-using days from the timeline follow-back was a secondary outcome. Results: Sixty-three patients participated, with 33 randomized to TEXT and 30 to UC. At preintervention, adherence was 64.0%, PMV was 26.9%, and proportion of days using substances was 53.0%. At postintervention, adherence in the TEXT condition improved from 66% to 85%, compared with 62% to 71% in UC participants (p = .04). PMV improved from 23% to 9% for TEXT participants and 31% to 28% in UC participants (p = .12). There were no significant differences between conditions in substance-using days at postintervention. At 3-month follow-up, differences were not significant. Conclusions: Personalized bidirectional text messaging improved adherence and shows promise to improve visit attendance, but did not reduce substance using days. This intervention merits further testing and may be cost-efficient given its automation. (PsycINFO Database Record
- Technology, including mobile technologies and social media, offers powerful tools to reach, engage, and retain youth and young adults in HIV prevention and care interventions both in the USA and globally. In this report, we focus on HIV, technology, and youth, presenting a synthesis of recently published (Jan 2014-May 2015) observational and experimental studies relevant for understanding and intervening on HIV risk, prevention, and care. We present findings from a selection of the 66 relevant citations identified, highlighting studies that demonstrate a novel approach to technology interventions among youth in regard to content, delivery, target population, or public health impact. We discuss current trends globally and in the USA in how youth are using technology, as well as emergent research issues in this field-including the need for new theories for developing technology-based HIV interventions and new metrics of engagement, exposure, and evaluation.
- HIV-positive adolescents and young adults often experience suboptimal medication adherence, yet few interventions to improve adherence in this group have shown evidence of efficacy. We conducted a randomized trial of a two-way, personalized daily text messaging intervention to improve adherence to antiretroviral therapy (ART) among N = 105 poorly adherent HIV-positive adolescents and young adults, ages 16-29. Adherence to ART was assessed via self-reported visual analogue scale (VAS; 0-100 %) at 3 and 6-months for mean adherence level and proportion ≥90 % adherent. The average effect estimate over the 6-month intervention period was significant for ≥90 % adherence (OR = 2.12, 95 % CI 1.01-4.45, p < .05) and maintained at 12-months (6 months post-intervention). Satisfaction scores for the intervention were very high. These results suggest both feasibility and initial efficacy of this approach. Given study limitations, additional testing of this intervention as part of a larger clinical trial with objective and/or clinical outcome measures of adherence is warranted.
- Poor treatment adherence is a main barrier for effective antiretroviral therapy (ART) globally. HIV-related knowledge may affect understanding and utilization of HIV medical information, hence limited health literacy is a known barrier to treatment adherence. A cross-sectional study included 494 HIV-infected individuals from the Bissau HIV Cohort in Guinea-Bissau. They completed a questionnaire designed for assessment of adherence and HIV-related knowledge. A majority were female, 41% were illiterate, 25% did not take the medicine during the last 4 days, and 23% skipped their medicine during weekends. The most frequent reasons for not taking medicine were simply forgetting, side effects, lack of food, and being too ill to attend the clinic. Nonadherent patients had a lower level of HIV-related knowledge. Main barriers for nonadherence were side effects, food insecurity, and simply forgetting. Lack of HIV-related knowledge about ART and HIV may be a barrier to nonadherence. © The Author(s) 2015.
- A pilot randomized clinical trial of youth ages 15–24 nonadherent to antiretroviral therapy (ART) utilizing daily cell phone support was found to have significant improvement in self-reported adherence and HIV RNA. Understanding acceptability and feasibility is critical for future implementation in clinic settings. Exit interviews were obtained from participants and adherence facilitators (AF). Acceptability was assessed from content analysis of exit interviews. Feasibility was assessed via intervention retention and study retention rates. Thirty-seven eligible youth were enrolled with 19 assigned to the intervention. Seven (37%) discontinued the intervention either due to missing over 20% of calls for two consecutive months (N = 5) or missing 10 consecutive calls (N = 2). Sixteen participants completed exit interviews, 15 reported the call length was just right, 13 reported they would have liked to continue calls after the 24-week intervention, and all participants reported they would recommend the intervention to friends. Scheduling and making calls required less than one hour per week per participant. Providing cell phone support to youth nonadherent to ART was acceptable and feasible. While the cost is low compared to the price of ART, healthcare systems will need to explore how to cover the cost of providing cell phones (incentive).
- Real-time adherence monitoring is now possible through medication storage devices equipped with cellular technology. We assessed the effect of triggered cell phone reminders and counseling utilizing objective adherence data on antiretroviral (ART) adherence among Chinese HIV-infected patients. We provided ART patients in Nanning, China, with a medication device ("Wisepill") to monitor their ART adherence electronically. After 3 months, we randomized subjects within optimal (≥95%) and suboptimal (<95%) adherence strata to intervention vs. control arms. In months 4-9, intervention subjects received individualized reminders triggered by late dose-taking (no device-opening by 30 minutes past dose time), and counseling using device-generated data. Controls received no reminders or data-informed counseling. We compared post-intervention proportions achieving optimal adherence, mean adherence, and clinical outcomes. Of 120 subjects enrolled, 116 (96.7%) completed the trial. Pre-intervention, optimal adherence was similar in intervention vs. control arms (63.5% vs. 58.9%, respectively; p=0.60). In the last intervention month, 87.3% vs. 51.8% achieved optimal adherence (risk ratio (RR) 1.7, 95% Confidence Interval (CI) 1.3-2.2); mean adherence was 96.2% vs. 89.1% (p=0.003). Among pre-intervention suboptimal adherers, 78.3% vs. 33.3% (RR 2.4, CI 1.2-4.5) achieved optimal adherence; mean adherence was 93.3% vs. 84.7% (p=0.039). Proportions were 92.5% and 62.9% among optimal adherers, respectively (RR 1.5, CI 1.1-1.9); mean adherence was 97.8% vs. 91.7% (p=0.028). Post-intervention clinical outcomes were not significant. Real-time reminders significantly improved ART adherence in this population. This approach appears promising for managing HIV and other chronic diseases and warrants further investigation and adaptation in other settings.
- The aim of this systematic review of reviews is to identify mobile text-messaging interventions designed for health improvement and behavior change and to derive recommendations for practice. We have compiled and reviewed existing systematic research reviews and meta-analyses to organize and summarize the text-messaging intervention evidence base, identify best-practice recommendations based on findings from multiple reviews, and explore implications for future research. Our review found that the majority of published text-messaging interventions were effective when addressing diabetes self-management, weight loss, physical activity, smoking cessation, and medication adherence for antiretroviral therapy. However, we found limited evidence across the population of studies and reviews to inform recommended intervention characteristics. Although strong evidence supports the value of integrating text-messaging interventions into public health practice, additional research is needed to establish longer-term intervention effects, identify recommended intervention characteristics, and explore issues of cost-effectiveness.
- Less than one-third of HIV-infected pregnant women eligible for combination antiretroviral therapy (ART) globally initiate treatment prior to delivery, with lack of access to timely CD4 results being a principal barrier. We evaluated the effectiveness of an SMS-based intervention to improve access to timely antenatal ART.We conducted a stepped-wedge cluster randomized trial of a low-cost programmatic intervention in 20 antenatal clinics in Gaborone, Botswana. From July 2011-April 2012, 2 clinics were randomly selected every 4 weeks to receive an ongoing clinic-based educational intervention to improve CD4 collection and to receive CD4 results via an automated SMS platform with active patient tracing. CD4 testing before 26 weeks gestation and ART initiation before 30 weeks gestation were assessed.Three-hundred-sixty-six ART-naïve women were included, 189 registering for antenatal care under Intervention and 177 under Usual Care periods. Of CD4-eligible women, 100 (59.2%) women under Intervention and 79 (50.6%) women under Usual Care completed CD4 phlebotomy before 26 weeks gestation, adjusted odds ratio (aOR, adjusted for time that a clinic initiated Intervention) 0.87 (95% confidence interval [CI]0.47-1.63, P = 0.67). The SMS-based platform reduced time to clinic receipt of CD4 test result from median of 16 to 6 days (P
- Background: Optimal adherence is critical to achieve the benefits of antiretroviral treatment (ART). The aim of the study is to evaluate the use of mobile devices as a strategy to improve adherence to ART, measured by Viral Load (VL) in HIV+ patients less than 25 years of age. Methods: A prospective study was conducted in a cohort of HIV+ patients less than 25 years of age. HIV+ patients, on ART, VL >1000 copies/mL, using mobile devices and suboptimal adherence (SOA) were included. The intervention was based on a mobile generic contact twice a month using text message and Facebook during 32 weeks. Extended communications were generated by the patient. VL was performed before and after the intervention. Results: 25 patients were included. Three were excluded and 22 patients were enrolled. Mean age was 17.2 ± 6.1 years (range: 6-25); 15(68%) were female; mean baseline VL was 25,100copies/mL (range: 500,000-1,020copies/mL), mean log was 4.3(Range: 3-5.7log). Each participant received a total of 16 contacts, 84% (296) were answered by the patient. 54%(189) of the contacts generated extended communications. After the strategy implementation 20/22 VL results were available. 13/20 (65%) were undetectable, 14/20 (70%) had VL < 1000 copies/mL. 6/20 (30%) VLs had no changes. Conclusions: The use of mobile devices and social networks is a valid tool to improve ART adherence in pediatric and young adults HIV+ patients, evaluated through VL. The strategy is feasible. The reminder messages trigger additional communications between patients and health provider and better engagement with HIV care. Longer follow up time is needed.
- AimsAdherence to medication is a major problem that affects 50-60% of chronically ill patients. As mobile phone use spreads rapidly, a new model of remote health delivery via mobile phone - mHealth - is increasingly used. The objective of this study is to provide a comprehensive overview of how mHealth can be used to improve adherence to medication. MethodsA systematic literature review was conducted using four databases (CINAHL, PubMed, Scopus and PsycARTICLES). Eligible articles available on March 2014 had to be written in English or Spanish and have a comparative design. Articles were reviewed by two authors independently. A Cochrane Collaboration tool was used to assess the studies based on their internal validity. ResultsOf the 1504 articles found, 20 fulfilled the inclusion criteria [13 randomised clinical trials (RCT), one quasi-RCT, one non-randomised parallel group study and five studies with a pre-post design]. Nearly all the trials were conducted in high-income countries (80.0%). Articles were categorised depending on the target population into three different groups: (i) HIV-infected patients, n=5; (ii) patients with other chronic diseases (asthma, coronary heart disease, diabetes mellitus, hypertension, infectious diseases, transplant recipients and psoriasis), n=11; and (iii) healthy individuals, n=4. Adherence improved in four of the studies on HIV-infected patients, in eight of the studies on patients with other chronic diseases, and in 1 study performed in healthy individuals. All studies reported sending SMS as medication reminders, healthy lifestyle reminders, or both. Only one trial (HIV-infected patients) had a low risk of bias. Conclusions Our results showed mixed evidence regarding the benefits of interventions because of the variety of the study designs and the results found. Nevertheless, the interventions do seem to have been beneficial, as 65% of the studies had positive outcomes. Therefore, more high-quality studies should be conducted.
- Abstract Poor adherence to combination antiretroviral therapy (ART) is a major global challenge. In this study we examined the efficacy of a smartphone application incorporating personalized health-related visual imagery that provided real-time information about the level of medication and the patient's level of immunoprotection, in order to improve adherence to ART. We randomized 28 people on ART to either a standard or augmented version of the smartphone application. The augmented version contained components that illustrated participants' current estimated plasma concentrations of antiretroviral drugs and the immune protection provided by ART. Adherence to ART was assessed at baseline and at 3 months using self-reported adherence, pharmacy dispensing records, and HIV viral load. Information was also collected on illness and medication beliefs and use of the application. Participants who received the augmented application showed a significantly higher level of self-reported adherence to ART at three months (p=0.03) and decreased viral load (p=0.023) as compared to individuals using the standard version. Greater usage of the extra components of the augmented application was associated with greater perceived understanding of HIV infection and increased perceived necessity for ART. Smartphone applications that incorporate personalized health-related visual imagery may have potential to improve adherence to ART.
- Importance Medication nonadherence, which has been estimated to affect 28% to 31% of US patients with hypertension, hyperlipidemia, and diabetes, may be improved by electronic medication packaging (EMP) devices (adherence-monitoring devices incorporated into the packaging of a prescription medication).Objectives To investigate whether EMP devices are associated with improved adherence and to identify and describe common features of EMP devices.Evidence Review Systematic review of peer-reviewed studies testing the effectiveness of EMP systems in the MEDLINE, EMBASE, PsycINFO, CINAHL, International Pharmaceutical Abstracts, and Sociological Abstracts databases from searches conducted to June 13, 2014, with extraction of associations between the interventions and adherence, as well as other key findings. Each study was assessed for bias using the Cochrane Handbook for Systematic Reviews of Interventions; features of EMP devices and interventions were qualitatively assessed.Findings Thirty-seven studies (32 randomized and 5 nonrandomized) including 4326 patients met inclusion criteria (10 patient interface–only “simple” interventions and 29 “complex” interventions integrated into the health care system [2 qualified for both categories]). Overall, the effect estimates for differences in mean adherence ranged from a decrease of 2.9% to an increase of 34.0%, and the those for differences in the proportion of patients defined as adherent ranged from a decrease of 8.0% to an increase of 49.5%. We identified 5 common EMP characteristics: recorded dosing events and stored records of adherence, audiovisual reminders to cue dosing, digital displays, real-time monitoring, and feedback on adherence performance.Conclusions and Relevance Many varieties of EMP devices exist. However, data supporting their use are limited, with variability in the quality of studies testing EMP devices. Devices integrated into the care delivery system and designed to record dosing events are most frequently associated with improved adherence, compared with other devices. Higher-quality evidence is needed to determine the effect, if any, of these low-cost interventions on medication nonadherence and to identify their most useful components.
- Introduction: Access to antiretroviral treatment (ART) has substantially improved over the past decade. In this new era of HIV as a chronic disease, the continued success of ART will depend critically on sustained high ART adherence. The objective of this review was to systematically review interventions that can improve adherence to ART, including individual-level interventions and changes to the structure of ART delivery, to inform the evidence base for the 2013 WHO consolidated antiretroviral guidelines. Design: A rapid systematic review. Methods: We conducted a rapid systematic review of the global evidence on interventions to improve adherence to ART, utilizing pre-existing systematic reviews to identify relevant research evidence complemented by screening of databases for articles published over the past 2 years on evidence from randomized controlled trials (RCTs). We searched five databases for both systematic reviews and primary RCT studies (Cochrane Library, EMBASE, MEDLINE, Web of Science, and WHO Global Health Library); we additionally searched ClinicalTrials.gov for RCT studies. We examined intervention effectiveness by different study characteristics, in particular, the specific populations who received the intervention. Results: A total of 124 studies met our selection criteria. Eighty-six studies were RCTs. More than 20 studies have tested the effectiveness of each of the following interventions, either singly or in combination with other interventions: cognitive-behavioural interventions, education, treatment supporters, directly observed therapy, and active adherence reminder devices (such as mobile phone text messages). Although there is strong evidence that all five of these interventions can significantly increase ART adherence in some settings, each intervention has also been found not to produce significant effects in several studies. Almost half (55) of the 124 studies investigated the effectiveness of combination interventions. Combination interventions tended to have effects that were similar to those of single interventions. The evidence base on interventions in key populations was weak, with the exception of interventions for people who inject drugs. Conclusion: Tested and effective adherence-enhancing interventions should be increasingly moved into implementation in routine programme and care settings, accompanied by rigorous evaluation of implementation impact and performance. Major evidence gaps on adherence-enhancing interventions remain, in particular, on the cost-effectiveness of interventions in different settings, long-term effectiveness, and effectiveness of interventions in specific populations, such as pregnant and breastfeeding women.
- Access to mobile phone technology has rapidly expanded in developing countries. In Africa, mHealth is a relatively new concept and questions arise regarding reliability of the technology used for health outcomes. This review documents strengths, weaknesses, opportunities, and threats (SWOT) of mHealth projects in Africa. A systematic review of peer-reviewed literature on mHealth projects in Africa, between 2003 and 2013, was carried out using PubMed and OvidSP. Data was synthesized using a SWOT analysis methodology. Results were grouped to assess specific aspects of project implementation in terms of sustainability and mid/long-term results, integration to the health system, management process, scale-up and replication, and legal issues, regulations and standards. Forty-four studies on mHealth projects in Africa were included and classified as: "patient follow-up and medication adherence" (n = 19), "staff training, support and motivation" (n = 2), "staff evaluation, monitoring and guidelines compliance" (n = 4), "drug supply-chain and stock management" (n = 2), "patient education and awareness" (n = 1), "disease surveillance and intervention monitoring" (n = 4), "data collection/transfer and reporting" (n = 10) and "overview of mHealth projects" (n = 2). In general, mHealth projects demonstrate positive health-related outcomes and their success is based on the accessibility, acceptance and low-cost of the technology, effective adaptation to local contexts, strong stakeholder collaboration, and government involvement. Threats such as dependency on funding, unclear healthcare system responsibilities, unreliable infrastructure and lack of evidence on cost-effectiveness challenge their implementation. mHealth projects can potentially be scaled-up to help tackle problems faced by healthcare systems like poor management of drug stocks, weak surveillance and reporting systems or lack of resources. mHealth in Africa is an innovative approach to delivering health services. In this fast-growing technological field, research opportunities include assessing implications of scaling-up mHealth projects, evaluating cost-effectiveness and impacts on the overall health system.
- This systematic review assesses the published literature to describe the landscape of mobile health technology (mHealth) for HIV/AIDS and the evidence supporting the use of these tools to address the HIV prevention, care, and treatment cascade. The speed of innovation, broad range of initiatives and tools, and heterogeneity in reporting have made it difficult to uncover and synthesize knowledge on how mHealth tools might be effective in addressing the HIV pandemic. To do address this gap, a team of reviewers collected literature on the use of mobile technology for HIV/AIDS among health, engineering, and social science literature databases and analyzed a final set of 62 articles. Articles were systematically coded, assessed for scientific rigor, and sorted for HIV programmatic relevance. The review revealed evidence that mHealth tools support HIV programmatic priorities, including: linkage to care, retention in care, and adherence to antiretroviral treatment. In terms of technical features, mHealth tools facilitate alerts and reminders, data collection, direct voice communication, educational messaging, information on demand, and more. Studies were mostly descriptive with a growing number of quasi-experimental and experimental designs. There was a lack of evidence around the use of mHealth tools to address the needs of key populations, including pregnant mothers, sex workers, users of injection drugs, and men who have sex with men. The science and practice of mHealth for HIV are evolving rapidly, but still in their early stages. Small-scale efforts, pilot projects, and preliminary descriptive studies are advancing and there is a promising trend toward implementing mHealth innovation that is feasible and acceptable within low-resource settings, positive program outcomes, operational improvements, and rigorous study design
- Context: Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is one of the world's most challenging pandemics. For treatment with Highly Active Anti-Retroviral Therapy (HAART) to be effective, high rate of adherence is essential. Aim: To demonstrate the effect of adherence counseling and text message reminders in improving patients' adherence to HAART. Settings and Design: A randomized control trial among non-adherents was carried out in a tertiary hospital in Nigeria between March and July, 2011. Materials and Methods: A total of 104 patients: 45 males (43.3%) and 59 females (56.7%) participated in the study. They were randomized into intervention and control groups. The intervention group received monthly adherence counseling and twice weekly short message reminders for four months, while the control group received only standard care. Self-reported adherence and CD4+ cell counts were measured pre- and post-intervention. Statistical Analysis Used: Data was analysed using Statistical Package for Social Sciences (SPSS) version 18. Risk rates, Chi-square, Mann-Whitney U test and Cohen's effect size were calculated. Level of significance was set at P = 0.05. Results: At post-intervention, 76.9% of the intervention group and 55.8% of the control group achieved adherence (χ2 = 5.211, P = 0.022, RR = 0.75 (0.55-0.96), Cohen's w = 0.224). Also, median CD4+ cell count of the intervention group increased from 193 cells/ml to 575.0 cells/ml against 131.0 cells/ml to 361.5 cells/ml in the control group (P = 0.007). Conclusion: Adherence counseling and text message reminders improved adherence among HIV patients. Its adoption for HIV patient management is advocated.
- Mobile phone technology is a novel way of delivering health care and improving health outcomes. This trial investigates the use of motivational mobile phone text messages (SMS) to improve adherence to antiretroviral therapy (ART) over six months. CAMPS was a single-site randomized two-arm parallel design trial in Yaoundé, Cameroon. We enrolled and randomized HIV-positive adults on ART, aged 21 years and above to receive a weekly standardized motivational text message versus usual care alone. The primary outcome was adherence measured using a visual analogue scale (VAS), number of doses missed (in the week preceding the interview) and pharmacy refill data. Outcomes were measured at 3 and 6 months. Service providers and outcome assessors were blinded to allocation. Analysis was by intention-to-treat. Between November and December 2010, 200 participants were randomized, with 101 in the intervention group and 99 in the control group. At 6 months, overall retention was 81.5%. We found no significant effect on adherence by VAS>95% (risk ratio [RR] 1.06, 95% confidence interval [CI] 0.89, 1.29; p = 0.542; reported missed doses (RR 1.01, 95% CI 0.87, 1.16; p>0.999) or number of pharmacy refills (mean difference [MD] 0.1, 95% CI: 0.23, 0.43; p = 0.617. One participant in the intervention arm reported a possible disclosure of status. Standardized motivational mobile phone text messages did not significantly improve adherence to ART in this study. Other types of messaging or longer term studies are recommended. REGISTRATION: 1. Pan-African Clinical Trials Registry; PACTR201011000261458 2. Clinicaltrials.gov; NCT01247181.
- OBJECTIVES:: Large unselected studies on representative samples of HIV-infected patients with a whole battery of neuropsychological tests and cerebral MRI scan are required to assess (i) the frequency of neurocognitive impairment (NCI), (ii) the determinants of mild neurocognitive disorders (MND), or HIV-associated dementia (HAD) and (iii) the relationship between NCI and MRI scan findings. METHODS:: Investigation of 400 consecutively enrolled HIV-1 infected adults from the ANRS CO3 Aquitaine Cohort, using standardized neurocognitive tests chosen to achieve consistency with Frascati's criteria. Half of the patients had a cerebral MRI scan allowing gray and white matter volumes measurement. Factors associated with NCI were studied by logistic regression models. RESULTS:: Median age of participants was 47 years, 79% were male and 89% received combination antiretroviral treatment (cART), of whom 93% had plasma HIV RNA <500 copies/mL. Median CD4 count was 515/mm. Prevalence of NCI was 59% including 21% of asymptomatic NCI, 31% of MND, and 7% of HAD. A low level of education, prior neurologic AIDS-defining disorders event, anxiety, depressive symptoms and prior history of brain damage were independent associated with MND or HAD, but neither HIV- nor cART-related variables. The presence of NCI was significantly associated with lower grey matter fraction. INTERPRETATION:: In this large unselected cohort, a high prevalence of symptomatic neurocognitive disorders was mainly related to its traditional determinants and associated with grey matter atrophy at early stages of the disease.
- Adherence is central to the success of antiretroviral therapy. Supporting adherence has gained importance in HIV care in many national treatment programs. The ubiquity of mobile phones, even in resource-constrained settings, has provided an opportunity to utilize an inexpensive, contextually feasible technology for adherence support in HIV in these settings. We aimed to assess the influence of mobile phone reminders on adherence to antiretroviral therapy in South India. Participant experiences with the intervention were also studied. This is the first report of such an intervention for antiretroviral adherence from India, a country with over 800 million mobile connections.
- Mobile phones provide a low cost method of addressing certain health system needs in developing countries. We examined SMS-supported interventions for prevention, surveillance, management and treatment compliance of communicable and non-communicable diseases in developing countries. We searched both peer-reviewed and grey literature reporting the use of SMS messages for disease prevention, surveillance, self-management and compliance in developing countries. A total of 98 applications fulfilled the inclusion criteria (33 prevention, 19 surveillance, 29 disease management and 17 patient compliance applications). In 31 projects, the SMS applications were evaluated. The majority of applications focused on HIV/AIDS and were located in India, South Africa and Kenya. Most used bulk (push) messaging. In general, they were well accepted by the population. The review provides further evidence that mobile phones are an appropriate and promising tool for disease control interventions in developing countries.
- Objective: This study sought to determine if dynamically tailored medication messages delivered to people living with HIV (PLWH) via text messaging would be well received and enhance adherence and clinical outcomes. Methods: A preexperimental proof-of-concept study with 52 men who have sex with men (MSM) recruited from a health clinic focused on promoting the well-being of gay, lesbian, bisexual, and transgender people. Inclusion criteria were being an English speaking HIV-positive MSM, aged 25 or older. Participants also had to agree to allow access to their medical records, have a cell phone, and be able to receive text messages over the 3-month intervention period. Participants completed baseline surveys that assessed various demographic, social, and health questions; received text messages over 3 months; answered weekly adherence questions via two-way messaging; and completed a follow-up survey at the end of the intervention period. Clinical outcomes were abstracted from participants' medical records at baseline and follow-up. Self-reported medication adherence and clinical outcomes, including CD4 counts and viral load. Results: Participants were receptive to the text messaging intervention, and reported reading and liking the messages. Self-reported medication adherence significantly improved among participants who began the study as nonadherent and received tailored medication reminders. Overall viral load significantly decreased and CD4 count significantly increased from baseline to follow-up. Conclusions: The results demonstrate that using two-way text messaging to dynamically tailor adherence messages may enhance adherence and improve important clinical outcomes for PLWH.
- More than 34 million people are presently living with HIV infection. Antiretroviral therapy (ART) can help these people to live longer, healthier lives, but adherence to ART can be difficult. Mobile phone text-messaging has the potential to help promote adherence in these patients. To determine whether mobile phone text-messaging is efficacious in enhancing adherence to ART in patients with HIV infection. Using the Cochrane Collaboration's validated search strategies for identifying randomised controlled trials and reports of HIV interventions, along with appropriate keywords and MeSH terms, we searched a range of electronic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), MEDLINE (via PubMed), PsycINFO, Web of Science, and the World Health Organization (WHO) Global Index Medicus. The date range was from 01 January 1980 to 01 November 2011. There were no limits to language or publication status. Randomised controlled trials (RCTs) in which patients or their caregivers (in the case of infants and children) of any age, in any setting, and receiving ART were provided with mobile phone text messages as a means of promoting adherence to ART. Two authors independently examined the abstracts of all identified trials. We initially identified 243 references. Seventeen full-text articles were closely reviewed. Both authors abstracted data independently, using a pre-designed, standardised data collection form. When appropriate, data were combined in meta-analysis. Two RCTs from Kenya were included in the review. One trial compared short weekly text messages against standard care. The other trial compared short daily, long daily, short weekly and long weekly messages against standard care. Both trials were with adult patients.In the trial comparing only short weekly messages to standard care, text messaging was associated with a lower risk of non-adherence at 12 months (RR 0.77, 95% CI 0.63 to 0.93) and with the non-occurrence of virologic failure at 12 months (RR 0.83, 95% CI 0.69 to 0.99).In the trial that compared different intervals and lengths for text-messaging to standard care, long weekly text-messaging was not significantly associated with a lower risk of non-adherence compared to standard care (RR 0.79, 95% CI 0.60 to 1.04). Patients receiving weekly text-messages of any length were at lower risk of non-adherence at 48 weeks than were patients receiving daily messages of any length (RR 0.79, 95% CI 0.64 to 0.99). There were no significant differences between weekly text-messaging of any length (RR 1.01, 95% CI 0.75 to 1.37) and between short or long messaging at either interval (RR 0.99, 95% CI 0.78 to 1.27). Compared to standard care, any daily text-messaging, whether short or long, did not reduce the risk for non-adherence (RR 0.99, 95% CI 0.82 to 1.20).In meta-analysis of both trials, any weekly text-messaging (i.e. whether short or long messages) was associated with a lower risk of non-adherence at 48-52 weeks (RR 0.78, 95% CI 0.68 to 0.89). The effect of short weekly text-messaging was also significant (RR 0.77, 95% CI 0.67 to 0.89). There is high-quality evidence from the two RCTs that mobile phone text-messaging at weekly intervals is efficacious in enhancing adherence to ART, compared to standard care. There is high quality evidence from one trial that weekly mobile phone text-messaging is efficacious in improving HIV viral load suppression. Policy-makers should consider funding programs proposing to provide weekly mobile phone text-messaging as a means for promoting adherence to antiretroviral therapy. Clinics and hospitals should consider implementing such programs. There is a need for large RCTs of this intervention in adolescent populations, as well as in high-income countries.
- A growing proportion of patients on antiretroviral therapy in resource-limited settings have switched to second-line regimens. We carried out a systematic review in order to summarize reported rates and reasons for virological failure among people on second-line therapy in resource-limited settings. Two reviewers independently searched four databases and three conference websites. Full text articles were screened and data extracted using a standardized data extraction form. We retrieved 5812 citations, of which 19 studies reporting second-line failure rates in 2035 patients across low-income and middle-income countries were eligible for inclusion. The cumulative pooled proportion of adult patients failing virologically was 21.8, 23.1, 26.7 and 38.0% at 6, 12, 24 and 36 months, respectively. Most studies did not report adequate information to allow discrimination between drug resistance and poor adherence as reasons for virological failure, but for those that did poor adherence appeared to be the main driver of virological failure. Mortality on second-line was low across all time points. Rates of virological failure on second-line therapy are high in resource-limited settings and associated with duration of exposure to previous drug regimens and poor adherence. The main concern appears to be poor adherence, rather than drug resistance, from the limited number of studies accessing both factors. Access to treatment options beyond second-line remains limited and, therefore, a cause for a concern for those patients in whom drug resistance is the identified cause of virological failure.
- To assess whether a warning system based on mobile SMS messages increases the adherence of HIV-infected Brazilian women to antiretroviral drug-based treatment regimens and their impressions and satisfaction with respect to incoming messages. A randomized controlled trial was conducted from May 2009 to April 2010 with HIV-infected Brazilian women. All participants (n=21) had a monthly multidisciplinary attendance; each participant was followed over a 4-month period, when adherence measures were obtained. Participants in the intervention group (n=8) received SMS messages 30 min before their last scheduled time for a dose of medicine during the day. The messages were sent every Saturday and Sunday and on alternate days during the working week. Participants in the control group (n=13) did not receive messages. Self-reported adherence, pill counting, microelectronic monitors (MEMS) and an interview about the impressions and satisfaction with respect to incoming messages. The HIV Alert System (HIVAS) was developed over 7 months during 2008 and 2009. After the study period, self-reported adherence indicated that 11 participants (84.62%) remained compliant in the control group (adherence exceeding 95%), whereas all 8 participants in the intervention group (100.00%) remained compliant. In contrast, the counting pills method indicated that the number of compliant participants was 5 (38.46%) for the control group and 4 (50.00%) for the intervention group. Microelectronic monitoring indicated that 6 participants in the control group (46.15%) were adherent during the entire 4-month period compared to 6 participants in the intervention group (75.00%). According to the feedback of the 8 participants who completed the research in the intervention group, along with the feedback of 3 patients who received SMS for less than 4 months, that is, did not complete the study, 9 (81.81%) believed that the SMS messages aided them in treatment adherence, and 10 (90.90%) responded that they would like to continue receiving SMS messages. SMS messaging can help Brazilian women living with HIV/AIDS to adhere to antiretroviral therapy for a period of at least 4 months. In general, the results are encouraging because the SMS messages stimulated more participants in the intervention group to be adherent to their treatment, and the patients were satisfied with the messages received, which were seen as reminders, incentives and signs of affection by the health clinic for a marginalized population.
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- The success of potent antiretroviral treatment for HIV infection is primarily determined by adherence. We systematically review the evidence of effectiveness of interventions to increase adherence to antiretroviral treatment in sub-Saharan Africa. We identified 27 relevant reports from 26 studies of behavioural, cognitive, biological, structural, and combination interventions done between 2003 and 2010. Despite study diversity and limitations, evidence suggests that treatment supporters, directly observed therapy, mobile-phone text messages, diary cards, and food rations can effectively increase adherence in sub-Saharan Africa. However, some interventions are unlikely to have large or lasting effects, and others are effective only in specific settings. These findings emphasise the need for more research, particularly for randomised controlled trials, to examine the effect of context and specific features of intervention content on effectiveness. Future work should assess intervention targeting and selection of interventions based on behavioural theories relevant to sub-Saharan Africa.
- Antiretroviral drugs have been shown to reduce risk of mother-to-child transmission of human immunodeficiency virus (HIV) and are also widely used for post-exposure prophylaxis for parenteral and sexual exposures. Observational data, ecological studies and models suggest that sexual transmission may be lower in couples in which one partner is infected with HIV and the other is not and the infected partner is on antiretroviral therapy (ART). To determine if ART use in an HIV-infected member of an HIV-discordant couple is associated with lower risk of HIV transmission to the uninfected partner compared to untreated discordant couples. We used standard Cochrane methods to search electronic databases and conference proceedings with relevant search terms without limits to language. Randomised controlled trials, cohort studies and case-control studies of HIV-discordant couples in which the HIV-infected member of the couple was being treated or not treated with ART DATA COLLECTION AND ANALYSIS: Abstracts of all trials identified by electronic or bibliographic scanning were examined independently by two authors. We initially identified 1814 references and examined 24 in detail for study eligibility. Data were abstracted independently using a standardised abstraction form. One randomised controlled trial and seven observational studies were included in the review. These eight studies identified 464 episodes of HIV transmission, 72 among treated couples and 392 among untreated couples. The rate ratio for the single randomised controlled trial was 0.04 [95% CI 0.00, 0.27]. All index partners in this study had CD4 cell counts at baseline of 350-550 cells/µL. Similarly, the summary rate ratio for the seven observational studies was 0.34 [95% CI 0.13, 0.92], with substantial heterogeneity (I(2)=73%). After excluding two studies with inadequate person-time data, we estimated a summary rate ratio of 0.16 [95% CI 0.07, 0.35] with no noted heterogeneity (I(2)=0%). We also performed subgroup analyses among the observational studies to see if the effect of ART on prevention of HIV differed by the index partner's CD4 cell count. Among couples in which the infected partner had ≥350 CD4 cells/µL, we estimated a rate ratio of 0.02 [95% CI 0.00, 2.87]. In this subgroup, there were 61 transmissions in untreated couples and none in treated couples. ART is a potent intervention for prevention of HIV in discordant couples in which the index partner has ≤550 CD4 cells/µL. A new multicentre randomised controlled trial confirms the suspected benefit seen in earlier observational studies. Questions remain about durability of protection, the balance of benefits and adverse events associated with earlier therapy, long-term adherence and transmission of ART-resistant strains to partners. Resource limitations and implementation challenges must also be addressed.Counselling, support, and follow up, as well as mutual disclosure, may have a role in supporting adherence, so programmes should be designed with these components. In addition to ART provision, the operational aspects of delivering such programmes must be considered.
- Adherence to antiretroviral therapy (ART) represents one of the strongest predictors of progression to AIDS, yet it is difficult for most patients to sustain high levels of adherence. This study compares the efficacy of a personalized cell phone reminder system (ARemind) in enhancing adherence to ART versus a beeper. Twenty-three HIV-infected subjects on ART with self-reported adherence less than 85% were randomized to a cellular phone (CP) or beeper (BP). CP subjects received personalized text messages daily; in contrast, BP subjects received a reminder beep at the time of dosing. Interviews were scheduled at weeks 3 and 6. Adherence to ART was measured by self-report (SR, 7-day recall), pill count (PC, past 30 days at baseline, then past 3 weeks), Medication Event Monitoring System (MEMS; cumulatively at 3 and 6 weeks), and via a composite adherence score constructed by combining MEMS, pill count, and self report. A mixed effects model adjusting for baseline adherence was used to compare adherence rates between the intervention groups at 3 and 6 weeks. Nineteen subjects completed all visits, 10 men and 9 females. The mean age was 42.7 ± 6.5 years, 37% of subjects were Caucasian and 89% acquired HIV heterosexually. The average adherence to ART was 79% by SR and 65% by PC at baseline in both arms; over 6 weeks adherence increased and remained significantly higher in the ARemind group using multiple measures of adherence. A larger and longer prospective study is needed to confirm these findings and to better understand optimal reminder messages and user fatigue.
- There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P = 0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.
- Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients were randomised (1:1) by simple randomisation with a random number generating program to a mobile phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h. Randomisation, laboratory assays, and analyses were done by investigators masked to treatment allocation; however, study participants and clinic staff were not masked to treatment. Primary outcomes were self-reported ART adherence (>95% of prescribed doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma HIV-1 viral RNA load suppression (<400 copies per mL) at 12 months. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00830622. Between May, 2007, and October, 2008, we randomly assigned 538 participants to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk [RR] for non-adherence 0·81, 95% CI 0·69-0·94; p=0·006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0·84, 95% CI 0·71-0·99; p=0·04). The number needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI 5·0-29·5) and the NNT to achieve viral load suppression was 11 (5·8-227·3). Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcome in resource-limited settings. US President's Emergency Plan for AIDS Relief.
- To correlate self-reported antiretroviral adherence with virologic suppression. Prospective observational study of adherence to therapy nested in a randomized comparative trial of frequent versus infrequent monitoring of plasma HIV RNA. Five university-affiliated HIV clinics. A group of 173 HIV-infected patients with a mean baseline CD4 count of 142 x 10(6) cells/l (range 3-515) of whom 164 and 119 completed adherence questionnaires at 2 and 6 months, respectively. Individualized, unrestricted antiretroviral therapy. Patients were classified into four groups by adherence to therapy in the previous 4 weeks (< 80%, 80-95%, 95-99%, 100%). Plasma HIV RNA levels and CD4 lymphocyte counts were measured bimonthly. Recreational drug or alcohol use was associated with decreased adherence, whereas frequency of HIV RNA monitoring, demographic variables, (age, gender, education, and risk group) and stage of disease had no effect. Greater HIV suppression at 6 months was seen across four categories of increasing adherence (P = 0.009 for linear trend). Patients reporting < 80% adherence at 6 months had a 0.2 log10 copies/ml increase in HIV RNA and a loss of 19 x 10(6) CD4 cells/l compared with a 1.1 log10 copies/ml decrease in HIV RNA and an increase of 72 x 10(6) CD4 cells/l in those reporting 100% adherence (P = 0.02). Self-reported poor adherence (< 80%) and drug or alcohol use predicted non-response of HIV RNA at 6 months of antiretroviral therapy.
