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www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Improved retention in HIV care following SMS reminders in Mozambique

Authors: D. Joseph Davey*, W. Ponce*, O. Augusto**, E. Jetha**, D. Traca*, S. Mazivile***, C. Palha de Sousa**

*ARK, Mozambique**University of Eduardo Mondlane, Mozambique

*** Provincial Director of Health, Maputo Province


Background

• Only 74% of people who started ART in 2011 were still on treatment after 12-months (MoH) .

• Despite various interventions to improve patient adherence the number of patients defaulting from treatment is still increasing

• ARK launched a study, SMSaúde or ‘SMS for health’, to test the hypothesis that sending regular SMS reminders would improve retention in HIV care among an adult population in Mozambique.


ART Cohort:Assessed for eligibility Nov 2011- Mar 2012

417 Allocated to SMS intervention

366 (31%) Exclusion criteria: 140 (38%) illiterate 99 (27%) didn’t own cell phone 106 (29%) illiterate + no phone 21 (6%) other reasons

413 Allocated to control (standard of care)

Randomized (n=830)

Follow-up :(mean 16 months)

Nov, 2011 - May, 2013

5 (<1%) declined to participate

Screened (n=1,201)


SMSaúde Study Sites

HC. Machava 2 (Urban)

349 ART patients

HC. Matola (Urban)

349 ART Patients

HC. Namaacha (Rural)

132 ART patients


How do the SMS reminders work?

5

Electronic patient record database is connected to the SMSaúde Platform to send automatic regular reminders to patients

Modem in health facility used to send SMSs over Vodacom network

Patients received regular SMSs reminding them of appointments (1 week and 2 days before and 2 days after missed appointments)

HIV+ pregnant women also received educational messages about the importance of antenatal & post-natal care, institutional birth and infant testing for HIV


Results: Demographic information

* P<0.05

Control SMS Total p-value Gender

Female 243 (58.8%) 253 (60.7%) 496 (59.8%) 0.59

Male 170 (41.2%) 164 (39.3%) 334 (40.1%)

Education Primary 307 (74%) 302 (72%) 609 (73.4%)

0.479Secondary 94 (23%) 102 (24%) 196 (23.6%)

Marital status Cohabiting 212 (51%) 217 (52%) 429 (51.7%)

0.508Single 140 (34%) 147 (35%) 187 (34.6%)Married 29 (7%) 19 (5%) 48 (5.8%)Widow 32 (8%) 32 (8%) 64 (7.7%)


Incidence of loss to follow up* at 12-months per 100 person years

* Loss to follow up: Patients who didn’t come in for drug pick up or clinical visit for >60 days (MoH Definition)

Control Intervention RR p-value

All patients 7.2 (5.2-9.9) 5.2 (3.6-7.6) 0.71 (0.439-1.178) 0.180

Urban patients 7.7 (5.5-10.9) 4.2 (2.7-6.7) 0.56 (0.319-0.969) 0.035

Recently initiated on

ART (<3 months)

13.1 (7.6-22.5) 4.9 (2.0-11.7) 0.37 (0.138-1.00) 0.045

Urban recently initiated (<3

months) 14.9 (8.7-25.7) 4.5 (1.7-12) 0.30 (0.105-0.866) 0.021


Accumulated risk among urban patients


Accumulated risk among urban, recent ART initiated (< 3 months)


Stratified multivariate Cox regression analysis (urban)

URBAN< 3 months on ART > 3 months on ART

Factor (at enrolment) RR RR CI p RR RR CI p

Receive SMS 0.24 0.072 - 0.767 ** 1.24 0.569 - 2.685

Male 1.14 0.411 - 3.169 2.07 0.937 - 4.555 *

> 30 years old 0.57 0.165 - 1.966 0.60 0.234 - 1.545

At least secondary education

1.41 0.432 - 4.590 0.38 0.127 - 1.125 *

Single 1.59 0.308 - 8.228 2.35 1.054 - 5.249 **

BMI < 20 1.04 0.291 - 3.734 3.88 1.743 - 8.623 ***

Absolute CD4 count <200 4.84 1.358-17.236 ** 1.65 0.664 - 4.077

Live far (>5 km) 0.35 0.089 - 1.388 0.94 0.350 - 2.534

*p<0.1; **p<0.05; ***p<0.01


Stratified multivariate Cox regression analysis (rural)

RURAL

Factor (at enrolment) RR RR CI p

Receive SMS 1.08 0.228 - 5.114

Male 3.36 0.677 - 16.727

> 30 years old 0.86 0.145 - 5.083

At least secondary education 2.46 0.612 - 9.892

Single 0.82 0.082 - 8.275

BMI < 20 1.78 0.383 - 8.314

Absolute CD4 count <200 2.23 0.517 - 9.624

Live far (>5 km) 4.66 1.004 - 21.612 **

*p<0.1; **p<0.05; ***p<0.01


Summary of findings• SMS reminders did not have an overall

impact on retention in care, however, subgroup analysis shows that there is impact in:– Retention in ART care among urban

patients– Retention in ART care among early ART

patients (<3 months on treatment)


Discussion• SMS reminders can have a significant impact on

improving retention in care, especially among urban and early-initiated ART patients.

• Women were less likely to own their own cell phone and were less literate, which prevented them from participating in the study.

• Designing m-Health strategies in rural contexts remains a challenge due to weak infrastructure, illiteracy, and cell-phone ownership.


Next steps• Further analysis need on:

– the lack of impact in rural health facilities – cost effectiveness of intervention

• Continue ART follow up: for 24 months with support from USAID

• Test SMSaude on a larger scale: in 16 facilities in Gaza Province (rural area), targeting >70,000 patients with support from DFID


Obrigada & Kanimambo!Acknowledgements:

• Study funded by ARK, implemented in partnership with the Ministry of Health, University of Eduardo Mondlane with

support from Vodacom • Thank you to: Dr Samu Dube and Sabina Morley, ARK,

Ministry of Health, Mozambique• Doctors, Nurses, Counselors and Data Entry staff & Patients

who participated in the study.


The total number of African mobile telephone subscribers -2009

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