R U OK? Texting Improves ART Compliance, HIV Suppression Rates

Neil Osterweil

November 10, 2010

November 10, 2010 — Reaching out to someone with text messages of support can improve drug adherence and virologic suppression rates in HIV-infected patients starting on antiretroviral therapy (ART), results of an Africa-based study suggest.

Patients who were randomly assigned to receive cell phone text messages asking about their health and reminding them of the availability of support services were significantly more likely to have taken all or most of their prescribed doses of ART medications within the past month and to have HIV viral RNA loads below 400 copies/mL than patients who did not receive text messages, reported Richard T. Lester, MD, from the University of Nairobi, in Kenya, and colleagues in Kenya, Canada, and the United States.

"Although the uptake of wireless telecommunication devices is becoming ubiquitous, introduction of mobile health initiatives is variable. We believe that the patient-centered communication effect, in particular the timely support of a patient by a health professional, is universal and can be improved by mobile telecommunication," the investigators write in an article published online November 9 in the Lancet.

In an accompanying commentary, Benjamin H. Chi, MD, and Jeffrey S. A. Stringer, MD, from the Centre for Infectious Disease Research in Zambia in Lusaka and the University of Alabama School of Medicine in Birmingham, Alabama, emphasize that "technology-based approaches represent only one of many effective means that should be considered by policy makers and health providers to improve adherence to antiretrovirals. A comprehensive multipronged approach tailored to the specific needs of individual local settings must be used if maximum gains in patients' health are to be realized."

The investigators evaluated whether short message service (SMS, or text) messages between healthcare workers and patients could help improve compliance and viral control rates. They focused on 2 HIV clinics in Nairobi and 1 in a rural area of Kenya.

They used a computerized random number–generating program to select cell phone numbers of patients in the program. Patients were randomly assigned to receive the intervention (273 patients) or to a control group receiving standard care (265 patients). All of the patients were adults aged 18 years and older who were starting ART for the first time and who had either daily or near-daily access to a cell phone. Illiterate patients were assisted by literate partners.

Each Monday morning, patients in the intervention group received a text from health workers with the Kiswahili phrase "Mambo?" meaning "How are you?" or a similar message. Patients were instructed to respond within 48 hours with a text saying that they were either doing well ("Sawa") or had a problem ("Shida").

Patients who reported a problem or did not respond within 48 hours received a call from a clinician. All communications were recorded in a study log.

The primary study outcomes were self-reported ART adherence, defined as taking more than 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, defined as fewer than 400 copies per mL at 12 months. The primary analysis was by intention to treat.

In all, 156 (57%) of 273 patients in the SMS group experienced viral suppression compared with 128 (48%) of 265 control patients. The relative risk for virologic failure in the intervention group was 0.85 (95% confidence interval [CI], 0.72 - 0.99; P = .04).

Patients in the intervention group were also significantly more likely to report adherence, at 62% vs 50% of control patients (relative risk for nonadherence, 0.81; 95% CI, 0.69 - 0.94; P = .006). The number needed to treat to achieve greater than 95% adherence was 9, and to achieve viral load suppression it was 11.

The intervention cost about $20 (US) per 100 patients per month and "is also probably less expensive than in-person community adherence interventions on the basis of travel costs alone. Thus, the intervention could be both cost effective and cost saving," the investigators write.

The trial was supported by the US Presidents Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention cooperative agreement . One author is an employee of the US Centers for Disease Control and Prevention; other authors are supported by grant funding from National Institutes of Health: Canadian Institutes of Health Research; Association of Medical Microbiology and Infectious Diseases-Bristol Myer Squibb, Canada; and the University of Manitoba–hosted International Center for Infectious Diseases National Training Center for Infectious Diseases. One author serves as a 2-tier Canada Research Chair in global health, and another serves as a 1-tier Canada Research Chair in resistance and susceptibility to infections. The remaining authors and the commentary authors have disclosed no relevant financial relationships.

Lancet. Published online November 9, 2010.