HIV Unplugged: Advances in Mobile Health

The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission.

AIDS CLINICAL ROUNDS

Ankita Kadakia, MD Assistant Clinical Professor Owen Clinic

Objectives

Discuss mobile health (mHealth) technology specifically for resource limited settings

How mHealth technology can be used to bridge the health care delivery gap specifically for HIV/AIDS care

Using mHealth technology targeted towards the Ugandan healthcare system

http://www.who.int/mediacentre/factsheets/fs310/en/index1.html

http://www.unaids.org/en/resources/campaigns/globalreport2013/factsheet/

Doctors, Nurses, Midwives / 10 Million Population

Crisp N, Chen L. N Engl J Med 2014;370:950-957

Global Health Workforce and Burden of Disease by WHO Region

Crisp N, Chen L. N Engl J Med 2014;370:950-957

BURDEN OF DISEASE

HEALTH CARE WORKERS

The healthcare delivery gap

DIAGNOSIS TREATMENT

Harvard Department of Global Health and Social Medicine

“Despite unprecedented financial resources and medical advances care is prevented from consistently reaching the patients who need it.”

“The Know-Do gap , the often neglected work of getting effective therapies (the know) to the people who need them (the do)” -Paul Farmer, MD

What is the adherence rate to ARVS in sub-saharan Africa?

A) 10%

B) 33%

C) 55%

D) 77%

E) 95%

Mills Edward J. et al JAMA August 6,2009 Vol 290, No 679-690

What is the adherence rate to ARVS in sub-saharan Africa?

A) 10%

B) 33%

C) 55%

D) 77%

E) 95%

Mills Edward J. et al JAMA August 6,2009 Vol 290, No 679-690

Factors Affecting Adherence in Resource Limited Areas

Transportations issues Payment for services and

medications Illness and co-morbid

conditions Inability to obtain

consistent supplies of medication

Food insecurity Alcohol use Religious beliefs and

stigma Higher CD4 counts and

complacency Increased adherence with

cell phone users

Magutu D et al, Factors affecting first month adherence to antiretroviral therapy for HIV positive adults in South Africal; Afr J AIDS Res. 2010 Millis EJ et al, J Acquir Immune Defic Syndrome. 2013 May 1;63(1)e:23-7

Factors Affecting Adherence in Resource Limited Areas

Transportations issues Payment for services and

medications Illness and co-morbid

conditions Inability to obtain

consistent supplies of medication

Food insecurity Alcohol use Religious beliefs and

stigma Higher CD4 counts and

complacency Increased adherence with

cell phone users

Magutu D et al, Factors affecting first month adherence to antiretroviral therapy for HIV positive adults in South Africal; Afr J AIDS Res. 2010 Millis EJ et al, J Acquir Immune Defic Syndrome. 2013 May 1;63(1)e:23-7

2014 Winner of the World Press Photo Award: African migrants in Dijbouti

A Global Connection

http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014

Connectivity The most rapidly

growing global cellular market!

http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014

Can mHealth Bridge the Delivery Gap?

DIAGNOSIS TREATMENT

Convenient, Mobile, Cheap, Efficient and Fits in Your Pocket … Mobile Doctor

mHealth Point of Care Diagnostics

Why do POC diagnostics improve healthcare delivery in resource limited settings? Improve scalability: shifting health delivery to the local

level (healthcare community worker) Reduce cost Improve early detection: increasing the yield of disease

diagnosis Improve access to previously underserved populations Improve treatment rates

Bridging the Human Delivery Gap with mHealth in Health Care Delivery Systems of Resource Limited

Study Investigators and Collaborators Ankita Kadakia MD Sanjeev Bhavnani MD (The Scripps Research Institute) Rakhi Sharma MA (Disaster Relief, The World Bank) James Saturday BSc (Kabale Regional Medical Center) Elizabeth Ekirapa-Kiracho PhD (Makerere University School of Public Health) Peterson Kyebambe MD (Nagaru Hospital, Kampala Uganda)

Kabale Uganda 1 hospital system >600,000 people 200 beds 300 patient visits/day 13 doctors

Average time to CD4/VL

Flow Cytometry for CD4 count

CD4 count performed twice per year

Samples are grouped and processed at central facility distant from the collection site (9hours by bus once weekly)

Viral load results take 60-90 days

Galiwango RM et al. (2014) Field Evaluation of PIMA Point-of-Care CD4 Testing in Rakai, Uganda. PLoS ONE 9(3): e88928. doi:10.1371/journal.pone.0088928

Implementation of POC in Resource Limited Areas

1. Identify the major disease burdens in the community Choose a POC based on community based needs Specific factors leading to the delivery-care gap

2. Is the POC diagnostic suitable for use in rural areas? Diagnostic robustness, ease of use, accuracy and cost Is the POC an improvement over the current method of

diagnosis?

3. Organizational infrastructure Adequate medical, financial, human and technological

resources?

http://globalhealth.mit.edu/wp-content/uploads/2011/07/Assessing-POC-diagnostics.pdf

Study Objectives

1 • How to create a rural mHealth clinic

• Determine the cellphone penetration and assess the digital literacy rates among users in a rural setting

3 • Create a community based mHealth research

Study Objectives

1 • Creating a rural mHealth clinic

2 • Determine the cellphone penetration and assess

the digital literacy rates among users

3 • Create a community based mHealth research

mHealth Hospital Clinic

Creating a rural mHealth Clinic Creating a rural mHealth Clinic

Creating a rural mHealth Clinic

Point-of-Care ECG

Point-of-Care Pediatric Cardiac Ultrasound

Study Objectives

3 • Create a community based mHealth research model

Digital Literacy

Sophistication of cellphone use Do you own a

cellphone? Is it a smartphone? Do you use the

camera? Do you text message? Do you use mobile

payments? Do you use the

internet?

Cellphone Penetration

What % of people in Kabale own a cellphone?

Non-Smartphone Smartphone

Digital Literacy

85% 85%

85% 90%

Cellphoneownership

Smartphone SMS text Camerausage

Mobilepayments

Internetusage

Healthcare Worker (n=14) Patient (n=24)

Digital Literacy

85% 85%

85% 90%

Cellphoneownership

Smarphone SMS text Camerausage

Mobilepayments

Internetusage

Digital Literacy

85% 85%

85% 90%

Cellphoneownership

Smarphone SMS text Camerausage

Mobilepayments

Internetusage

Study Objectives

3 • Create a community based mHealth research model

Community Based Research

Horowitz CR et al. Community Based Participatory Research From the Margin to the Mainstream. Are Researchers Prepared? Circulation 2009;119:2633-2642

Community Based Participatory Research

Horowitz CR et al. Community Based Participatory Research From the Margin to the Mainstream. Are Researchers Prepared? Circulation 2009;119:2633-2642

Community Advisory Board

Community

Social Organizations

School System

Physician

Caregivers Patients

Adminstration

Healthcare System

Community Based mHealth Research

Community Based Healthcare Needs

General Examinations

Vaccinations

Healthy Lifestyle Education

Postpartum Education

Patient Assessment

102030405060708090 Healthcare Practitioner Patient

Study Objectives

3 • Create a community based mHealth research model • mHealth device usability and barriers to use

mHealth Usability

WHO Health Technology Assessment

World Health Organization: Health Technology Assessment of Medical Devices

1. Clinical effectiveness 2. Appropriateness 3. Implementation

Can the technology work? Can the technology work in this setting? How and should the technology be implemented in

this setting? By physicians? By all healthcare workers? By patients?

mHealth Usability

World Health Organization: Health Technology Assessment of Medical Devices

Local mHealth Usability

0%10%20%30%40%50%60%70%80%90%

Can thesedeviceswork?

Easy to use? Usefulfeatures?

Increaseefficiency of

caredelivery?

Use by allhealthcareworkers?

90% 100%

100% 100%

Rapid Connectivity!

Point-of-Care Implementation Identify key gaps in rural healthcare

delivery

Select POC diagnostics appropriate for resource limited settings

Ensure effective training, treatment and support

Improved Health Outcomes?

mHealth HIV

Text messaging for medication adherence

Lab-on-a-Chip and Microfluidics

Mobile-Elisa (mElisa)

Future Directions

mHealth HIV

Future Directions

How can the Cellphone help with medication adherence?

mHealth HIV

Future Directions

Lab-on-a-Chip

Lab on a Chip

•Clinical trial in Muhima Hospital, Kigali, Rwanda •Commercially available sera/ plasma samples of HIV /Syphilis tested in the mChip at Columbia University, HIV sensitivity 100%, specificity 95%, Syphilis 100%, 81% •Commercial ELISA HIV 100/98-100% and Syphilis ab 82-100/97-100% •70 specimens collected from known HIV positive men and women •1 out of 70 specimens tested was falsely negative, 98-100% sensitivity/88-100 specificity •67 samples for duplex HIV/Syphilis mChip yielded 100%/94% sensitivity and 100%/76% specificity

m-ELISA CD4 count

mHealth HIV

Future Directions

•Tested 17 HIV/AIDS patients and 18 transplant patients on immunosuppression •Compared with Flow cytometry as gold standard •97% accuracy rate compared with flow cytometry

HIV Viral Load Pipeline

www.aslm.org

Simple Amplification Based Assay(SAMBA)

Lee, Helen et al, J Infect Dis. (2010) 201 (supplement 1): s65-s71

•HIV-1 viral nucleic acid based assay for dipstick, 2 hours for result •Sample prep for extraction of viral RNA, isothermal amplification of viral nucleic acid, rapid visual detection of amplification products by dipstick •Tests subtype B and Non-B strains •63 positive /6 negative samples from Royal College of London, 100% reproducible resultscompared with the same samples tested with Roche Taqman HIV-1 assay

mHealth HIV

Future Directions

HIV Patient

Cardiac

Hepatitis Skin

mHealth HIV

HIV Patient

Sensing

Dissemination

Monitoring Education

Prevention

The Future Now

Necessity is the mother of Innovation

Thank you

HIV Unplugged: Advances in Mobile Health

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