HIV/AIDS care and control

Will Mobile Technology "Do It"?Review on current technology

Richard Lester, MD, FRCPCBCCDC / University of British Columbia

University of Nairobi, WelTelJuly 25, 2012

CREDIT: http://www.armybase.us/2009/04/air-force-yields-in-f-22-fighter-dispute/

Can mobile (communication) technologies “Do it”?

mHealth-Hype?Problem: People living with HIV Response: People on ART People with mobile phones

mPhones =A Gift

HIV Cascade of care

Prevention TestingAccess/

Linkage to care

Access to treatments

(supply chain)

Adherence Retention

HIV Care & Prevention

• = preventionAccess (Uptake)

• = preventionAdherence

• = preventionRetention

Access + Adherence +Retention =Engagement

Two Randomized Controlled Trials (Kenya)

March 27, 2011 Nov 27, 2010

WelTel weekly SMS check-ins (two way):*24% improvement in achieving 95% adherence over 1y*19% improvement in achieving viral suppression at 1y

(NNT = 9 & 11)

SMS reminders/motivation (one way):*Weekly (short) messages 32% improvement in 90% adherence (MEMS) over 1y*9% decrease in treatment interruptions*No adherence improvement with daily, longer reminders*No viral load/clinical outcomes

243 references ID’d to Nov 2011:

Bella Hwang – mHealth Summit 2011

WelTel: PEPFAR (2.485M people)

Cost of SMS Intervention

Total Cost Savings Net Savings

Breakdown: Costs Saved of 2nd Line therapy

Breakdown: Costs Saved of Opportunistic Infections

Breakdown: Costs Saved for Clinic Time Needed

Year 1 2,920,259$ 6,147,108$ 3,226,850$ 1,107,088$ 1,338,673$ 3,701,347$ Year 2 14,601,293$ 49,263,454$ 34,662,161$ 5,535,441$ 6,693,365$ 37,034,648$ Year 3 29,202,586$ 172,638,554$ 143,435,968$ 11,070,882$ 13,386,730$ 148,180,942$

Figure . Costs of SMS Intervention vs. Costs Savings over 3 years for PEPFAR Global Cohort on ART (2.485M patients)

+230,000 suppressed

What doesn’t work?

Reminders or Support?

• Targeted adherence counselling • persistent effect on

adherence and viral suppression

• A medication reminder alarm device • no effect on

adherence or viral suppression

Chung et al. PLoS Med, March 2011Adherence to antiretroviral therapy: supervision or support? Lancet ID, Feb 2012http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70354-1/fulltext

Monitoring Adherence & Results

Challenges in Using Mobile Phones for Collection of Antiretroviral Therapy Adherence Data in a Resource-Limited Setting

SMS and IVR Adherence Real Time Monitoring in Uganda

Jessica E. Haberer1, 2, 3 , Julius Kiwanuka4, Denis Nansera4, Ira B. Wilson5 and David R. Bangsberg2, 3, 6

• (1) Department of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA(2) Harvard Initiative for Global Health, Mbarara University of Science and Technology, Kampala, Uganda, online: 8 June 2010

High acceptability for cell phone text messages to improve communication of laboratory results with HIV-infected patients in rural Uganda: a crosssectional survey study.

• BMC Med Inform Decis Mak. 2012 Jun 21;12(1):56. [Epub ahead of print]• Siedner MJ, Haberer JE, Bwana MB, Ware NC, Bangsberg DR.

Other cell phone studiesAIDS Patient Care STDS. 2011 Mar;25(3):153-61. Epub 2011 Feb 16.Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence

to antiretroviral therapy. N=19 adultsHardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik

PR

Trials. 2011 Jun 9;12:145.The challenges and opportunities of conducting a clinical trial in a low resource setting: the case of the

Cameroon mobile phone SMS (CAMPS) trial, an investigator initiated trial. N=198 adultsMbuagbaw L, Thabane L, Ongolo-Zogo P, Lang T.

AIDS Patient Care STDS. 2011 May;25(5):303-10. Epub 2011 Apr 2.Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial

test of concept trial. N=40 adultsKalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L.

Lancet. 2011 Aug 27;378(9793):795-803. Epub 2011 Aug 3.The effect of mobile phone text-message reminders on Kenyan health workers' adherence to

malaria treatment guidelines: a cluster randomised trial. N=2269 childrenZurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, Snow RW.

“mobile phone HIV” publications

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number (Pubmed)

number (Pubmed)

AIDS 2012: mHealth abstracts

• 27 abstracts “mobile/cell phones, text message”

AIDS 2012: RCT2

• TUPE673 - Poster Exhibition

SMS messaging improves treatment outcome among the HIV-positive Mayan population in rural Guatemala

» J.M. Ikeda1, R. Barrios2, J.B. Lopez Lopez3, N. Hearst4

– 226 HIV positive clients from the Integrated Care Clinic in Quetzaltenango

– The mean time to viral load suppression: 7 months intervention group and 10 months control group.

Summary of RCT Evidence on mHealth Interventions to improve ART outcomes

• Adherence monitoring by SMS? - ?– not yet known if effective for adherence promotion– Challenging to implement, cost, compliance, stigma?

• Targeted adherence counselling? - Y– improves adherence and viral suppression (1yr)

• Digital alarm reminders? - N– No improvement on adherence or VL (1yr)

• One way cell phone SMS reminders? – N/Y– no improvement in adherence (by MEMS), for daily reminders– effective with short weekly messages. (1yr)

• Two-way cell phone SMS çheck-ins’/access to HCW? -Y– Improves adherence and viral suppression (1yr)

• Level of Evidence: Grade A (weekly SMS)• Support (access to care) > Reminders?

My take home messages

• Keep it simple– Every extra step (complexity) loses someone

• Keep it low cost– Resource limited settings, vulnerable groups

• Conduct controlled studies– What really works, and what doesn’t?

• Seize the opportunity– mHealth is a gift

Can mobile (communication) technologies “Do it”?

Future Direction

Grand Challenges Canada• Formed a non-profit organization to

assist implementing the WelTel model

globally (WelTel International mHealth Society).

• PMTCT in Kenya– Supported by IDRC/GHRI

Current Research Projects:

• WelTel HAARTBC1– Oak Tree Clinic, Vancouver– Supported by BCCDC foundation

and Bristol-Myers-Squibb• WelTel LTBI

– BCCDC TB clinics, latent TB infection support (RCT)

– Supported by BCLA, CIHR• WelTel Retain

– Pre-ART retention in care with AMREF in Kenya

– Supported by NIMH

• EPIC– PrEP in San Francisco– Supported by NIMH

Thank you

Your health, in your handswww.weltel.org The future is now.