Elsevier

The Lancet

Volume 376, Issue 9755, 27 November–3 December 2010, Pages 1838-1845
The Lancet

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Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial

https://doi.org/10.1016/S0140-6736(10)61997-6Get rights and content

Summary

Background

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.

Methods

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.

Findings

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).

Interpretation

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.

Funding

US President's Emergency Plan for AIDS Relief.

Introduction

Health programmes that use mobile communication technologies are emerging with the aim of strengthening health systems.1, 2, 3 The United Nations Joint Programme on HIV/AIDS (UNAIDS) and WHO have added wireless communication technologies to their strategic plans.4, 5 However, at present no published clinical trial has reported the use of mobile health technologies to improve patient-centred outcomes in developing countries.

Present efforts to control the HIV/AIDS pandemic include treatment with antiretroviral therapy (ART), targeted prevention strategies, and treatment as prevention measures (ie, prevention of HIV spread by treating HIV positive people and thereby reducing the risk of onward transmission).6, 7 However, widespread progress at controlling the pandemic is restricted by poor infrastructure and increasing health-system costs.

The number of mobile (cell) phone users is rapidly expanding (4·5 billion mobile phone subscribers are expected worldwide by 2012),8 mainly because of free market forces (ie, capitalism) and the demand for rapid wireless communications for personal use and to aid multi-sector economic development (eg, trade, tourism, and infrastructure); thus, mobile technology has the potential to be used in health systems worldwide. A wide range of medical services could be improved by providing patient-focused support and management through the health-care system.

Maximum adherence to ART in patients with HIV improves health outcomes and prevents drug resistance.9 Adherence is also important for programme cost containment.10 If mobile phone use does improve health outcomes in resource-limited settings, this mobile health technology could thus be included in health-system strategies and help improve health development goals.11

In this trial, we aimed to assess whether mobile phone communication between health-care workers and patients initiating ART in Kenya2, 12 improved drug adherence and suppression of plasma HIV-1 RNA load.

Section snippets

Patients

Patients initiating ART were recruited from three different HIV clinics that are involved in intense ART provision scale-up. The University of Nairobi Pumwani Clinic serves a very low-income population in Nairobi13 and the Coptic Hope Center for Infectious Diseases operates out of a faith-based hospital located in a higher-income area of Nairobi.14 The Kajiado Clinic is a government health centre in a large rural district. We chose these three locations because they should represent the

Results

Between May, 2007, and October, 2008, we enrolled 581 participants (figure 1). Consecutive enrolment was attempted; however, one site enrolled alternate patients into separate studies. After screening, 39 patients were excluded because they had inadequate phone access and four declined participation. Accordingly, 538 patients were randomly assigned: 273 to the SMS intervention and 265 to standard care. Ten participants (seven in the SMS group and three in the control group) withdrew from the

Discussion

This study shows that mobile health innovations can improve HIV treatment outcomes. Patients who received the SMS support were more likely to report adherence to ART and were more likely to have their viral load suppressed below detection levels than patients who received the standard care alone.

The primary analysis classed all-cause attrition as treatment failures. Thus, the higher follow-up rates and lower mortality reported in the intervention group contributed to the positive intervention

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