HIV/AIDS care and control
Will Mobile Technology "Do It"?
Review on current technology
Richard Lester, MD, FRCPC
BCCDC / University of British Columbia
University of Nairobi, WelTel
July 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
HIV Cascade of care
Access/
Prevention
Testing
Linkage to
care
Access to
treatments
(supply
chain)
Adherence
Retention
HIV Care & Prevention
Access
(Uptake)
Adherence
Retention
• = prevention
• = prevention
Access +
Adherence +
Retention =
• = prevention
Engagement
Two Randomized Controlled Trials (Kenya)
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)
Nov 27, 2010
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
March 27, 2011
243 references ID’d to Nov 2011:
Bella Hwang – mHealth Summit 2011
WelTel: PEPFAR (2.485M people)
Year 1
Year 2
Year 3
Breakdown:
Costs Saved of
Cost of SMS Total Cost
2nd Line
Intervention Savings
Net Savings
therapy
$ 2,920,259 $ 6,147,108 $ 3,226,850 $
1,107,088
$ 14,601,293 $ 49,263,454 $ 34,662,161 $
5,535,441
$ 29,202,586 $ 172,638,554 $ 143,435,968 $ 11,070,882
+230,000 suppressed
Breakdown:
Costs Saved of
Opportunistic
Infections
$ 1,338,673
$ 6,693,365
$ 13,386,730
Breakdown:
Costs Saved for
Clinic Time
Needed
$ 3,701,347
$ 37,034,648
$ 148,180,942
Figure . Costs of SMS Intervention vs. Costs Savings over 3 years for PEPFAR Global Cohort on ART (2.485M patients)
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 2011
Adherence to antiretroviral therapy: supervision or
support? Lancet ID, Feb 2012
http://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 ResourceLimited 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 studies
AIDS 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 adults
Hardy 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 adults
Mbuagbaw 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 adults
Kalichman 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 children
Zurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, Snow RW.
“mobile phone HIV” publications
number (Pubmed)
30
25
20
15
number (Pubmed)
10
5
0
2009
2010
2011
2012
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
• WelTel HAARTBC1
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:
– 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
www.weltel.org
The future is now.