Cell phones for HIV Care and Health Promotion: What Works

Richard Lester, MD, FRCPCBCCDC and

University of British ColumbiaWelTel.org

Saskatoon HIV AIDS Research Endeavour(SHARE)

May 15, 2012

Disclosures – support received

Non-corporate• PEPFAR• CDC/CDC Foundation• WHO• BCCDC Foundation• IDRC/GHRI• AMMI/CIHR/BMS• Gates Foundation• ICID (UManitoba)• NIH (NIMH)

Corporate• Bristol-Myers-Squibb

mHealth: What is it?

Wikipedia: a term used for the practice of medical and public health, supported by mobile devices.

NIH: the delivery of healthcare services via mobile communication devices

Emerged as a sub-segment of eHealth:– Using information and communication

technology (ICT) for health services and information, such as computers, mobile phones, communications satellite, patient monitors, etc, for health services and information.

Is it all HYPE?

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

mHealth applications• Emergency response systems (e.g., road traffic accidents, emergency obstetric care)• Human resources coordination, management, and supervision• Mobile synchronous (voice) and asynchronous (SMS) telemedicine diagnostic and

decision support to remote clinicians• Clinician-focused, evidence-based formulary, database and decision support

information available at the point-of-care• Pharmaceutical Supply Chain Integrity & Patient Safety Systems (e.g. Sproxil and

mPedigree) • Clinical care and remote patient monitoring• Health extension services• Health services monitoring and reporting• Health-related mLearning for the general public• Training and continuing professional development for health care workers• Health promotion and community mobilization• Support of long-term conditions, for example in diabetes self-management

Wikipedia, accessed Jan 30, 2012

HIV-Not Hype?Problem: People living with HIV Response: People on ART People with mobile phones

An Opportunity?

• Kenya Population= 39,002,772

• 7.1% 2007 adult HIV prevalence

•1 physician/2 nurses per 10,000 population

•~16 million mobile phone subscribers

Kenya: Dual Epidemics

Lester et al. AIDS Vol 20, 17 Nov, 2006

2005

Outbreak!(Safaricom virus)

Can cellphones improve HIV care?

WelTel Kenya1: RCT

Screening(581+)

Randomized(538)

Pumwani(251)

SMS(120)

Follow-up

control(131)

Follow-up

Coptic(209)

SMS(117)

Follow-up

control(92)

Follow-up

Kajiado(78)

SMS(36)

Follow-up

control(42)

Follow-up

InclusionAdults (> 18 years) starting ARTAdequate phone access (owned/shared)Informed consent

Randomization

Baseline survey

6 month

12 month

Powered to show 10% improvement in adherence

Exclusion (44)Inadequate phone accessRefused/Unable

SMS n=273Control n=265

WelTel Kenya1: 2-way weekly (SMS) interactive check-ins.

n=11,983 SMS logs

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

1 2 3 4 5 6 7 8 9 10 11 12

No response

Sawa (fine)

Shida (problem)

Prop

ortio

n o

f w

eekl

y SM

S re

spon

ses

Months since recruitment

(6.1% ‘SHIDA’)(2.0% ‘SHIDA’)

WelTel Kenya1

Reason for SHIDA responses

Problem responses* Unique problem responses*

Total 377 (100) 140 (100)

Health issues 272 (72) 121 (86)

Non-health issues 40 (11) 33 (24)

Missing/unreachable 67 (18) 50 (36)

Reason participant did not respond

Non-responsesn=3730n (%)ƚ

Unique participantnon-responses

n=260n (%)ƚ

Cell phone problems 822 (22) 205 (79)

Participant factors 463 (12) 172 (66)

Outcome (ITT)SMS group

no. (%)

Control group

no. (%)

RR (95%CI) P value

Self-reported adherence (> 95%) 168 (62) 132 (50) 0.81

(0.69 - 0.94) 0.006

Viral suppression (<400 copies/ml) 156 (57) 128 (48) 0.85

(0.72 - 0.99) 0.040

Ancillary analysis

Complete case

Adherence (n=358)

Viral suppression (n=400) 

168 (91)

156(75)

132 (91)

128 (66)

1.00(0.94 – 1.07)

0.88(0.77 - 1.00)

0.94

0.047

WelTel Kenya1: Outcomes

WelTel Kenya1: Subgroup analysis (VL)

0.125 0.25 0.5 1 2

SMS group better Control group better

OverallGender

femalemale

Cell phone shares

ownsClinic

PumwaniKajiadoCoptic

WHO stage1234

Residencerural

urban

101/177 (57)55/96 (57)

22/34 (65)134/239 (56)

75/120 (63)20/36 (56)61/117 (52)

31/52 (60)42/67 (63)56/101 (55)5/9 (56)

30/51 (59)126/222 (57)

0.66 (0.43 -1.00)0.80 (0.45 -1.42)

0.36 (0.14 -0.94)0.78 (0.54 -1.12)

0.54 (0.33 -0.89)0.54 (0.22 -1.34)1.05 (0.61 -1.81)

0.94 (0.44 -1.98)0.58 (0.28 -1.17)0.58 (0.33 -1.00)1.28 (0.23 -7.19)

0.51 (0.23 -1.12)0.75 (0.52 -1.10)

Summary

• SMS patients 24% more likely to be adherent to ART (NNT=9)

• SMS patients 19% more likely to have suppressed VL (NNT=11)

• 98% said would like program to continue• 97% said would recommend it to a friend

Lester & Karanja Lancet Infectious Diseases Vol 8 December 2008

Western Kenya RCT: One-way SMS ‘reminders’Pop-Eleches et al. AIDS, 2011

Adherence by MEMS caps: daily vs. weekly & long vs. short reminders (VL not available.)

Two Randomized Controlled Trials (Kenya)

March 27, 2011 Nov 27, 2010

Summary

• Short, weekly reminders improved adherence– Weekly reminders 53% achieved 90% adherence– Control 40% achieved 90% adherence (p=.03)

• Daily reminders no effect

LEVEL 1b Evidence that Weekly SMS can improve ART adherence.

Centre for Evidence-Based Medicine, Oxford

243 references ID’d to Nov 2011:

What doesn’t work?

Nairobi Kenya RCT: ART counselling vs. remindersChung et al. PLoS Med, March 2011

• A medication reminder alarm device had no effect on adherence or viral suppression

Emerging ART adherence innovations:

ABSTRACT: Adherence to antiretroviral therapy (ART) represents one of the strongest predictors of progression to AIDS, yet it is difficult for most patients to sustain high levels of adherence. This study compares the efficacy of a personalized cell phone reminder system (ARemind) in enhancing adherence to ART versus a beeper. Twenty-three HIV-infected subjects on ART with self-reported adherence less than 85% were randomized to a cellular phone (CP) or beeper (BP). CP subjects received personalized text messages daily; in contrast, BP subjects received a reminder beep at the time of dosing. Interviews were scheduled at weeks 3 and 6.Adherence to ART was measured by self-report (SR, 7-day recall), pill count (PC, past 30 days at baseline, then past 3 weeks), Medication Event Monitoring System (MEMS; cumulatively at 3 and 6 weeks), and via a composite adherence score constructed by combining MEMS, pill count, and self report. A mixed effects model adjusting for baseline adherence was used to compare adherence rates between the intervention groups at 3 and 6 weeks. Nineteen subjects completed all visits, 10 men and 9 females. The mean age was 42.7 ± 6.5 years, 37% of subjects were Caucasian and 89% acquired HIV heterosexually. The average adherence to ART was 79% by SR and 65% by PC at baseline in both arms; over 6 weeks adherence increased and remained significantly higher in the ARemind group using multiple measures of adherence. A larger and longer prospective study is needed to confirm these findings and to better understand optimal reminder messages and user fatigue.

Boston Medical Centre

Other Innovations: TBD

Real-Time Electronic Adherence Monitoring is Feasible, Comparable to Unannounced Pill Counts, and Acceptable.

AIDS Behav. 2011 Mar 30.Haberer JE, Robbins GK, Ybarra M, Monk A, Ragland K, Weiser SD, Johnson MO, Bangsberg DR.SourceHarvard Institute for Global Health, 104 Mt Auburn St, 3rd floor, Cambridge, MA, 02138, USA,

jhaberer@partners.org.Abstract

Second generation electronic medication adherence monitors provide real-time data on pill bottle opening behavior. Feasibility, validity, and acceptability, however, have not been established. Med-eMonitor is a multi-compartment adherence device with reminder and education capacity that transmits data through a telephone connection. Monthly adherence levels were measured for 52 participants over approximately 3 months using the Med-eMonitor (unadjusted and adjusted for participant confirmed dosing) and unannounced pill counts. HIV RNA was assessed before and after the 3-month period. Acceptability of Med-eMonitor was determined. Over 92% of Med-eMonitor data was transmitted daily. Unannounced pill counts significantly correlated with adjusted Med-eMonitor adherence (r = 0.29, P = 0.04). HIV RNA significantly correlated with unannounced pill counts (r = -0.34, P = 0.02), and trended toward a significant correlation with unadjusted Med-eMonitor adherence (r = -0.26; P = 0.07). Most, but not all, participants liked using the Med-eMonitor. Med-eMonitor allows for real-time adherence monitoring and potentially intervention, which may be critical for prolonging treatment success.

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.

How do cell phone communications improve ART adherence?

• Adherence to antiretroviral therapy: supervision or support?– Lancet Infectious Diseases, February 2012– http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70354-1/fulltext

• Adherence and Retention – social capital?Binagwaho A, Ratnayake N (2009). PLoS Med 6(1): e18.

mHealth for HIV/AIDS control:Where is it going?

What is the potential impact?Improved adherence and viral

suppression (retention?)1. Improves health2. Improves society3. Improves economy4. Reduces costs (drug

resistance)5. Controls pandemic

(treatment as prevention)

Challenges:

• Can it be improved?• Is it cost-effective?• Can it be scaled up?

M-poweredThe convergence of mobile telephony and health care is under way

Wireless health care

...Mr Gates, however, warned the participants not to celebrate too soon. Just because an m-health pilot scheme appears to work in some remote locale, he insisted, don’t “fool yourself” into thinking it really works unless it can be replicated at scale. Rafael Anta of the Inter-American Development Bank was even more cautious: “We know little about impact and nothing about business models.”Happily, evidence of m-health’s usefulness is at last starting to trickle in. A study this week in the Lancet, a medical journal, shows that something as simple as sending text messages to remind Kenyan patients to take their HIV drugs properly improved adherence to the therapy by 12%. ...“Middle-income countries are where most innovation in health care is going to come from.”

Nov 11th 2010 | WASHINGTON, DC | from the print edition

mHealth Summit 2012 (Bella Hwang)

Scale-up1. Kenya – approx. 500, 000 ART patients

2. PEPFAR (global) – approx. 2.5 million ART patients  Costs

Activity Based Costing – SMS Intervention:•$11.75 USD/year per patient – Kenya•$10.21 USD/year per patient - PEPFAR

Cost Savings  

Models used:•Freedberg et al. J Acquir Immune Defic Syndr 2006; 43(Suppl 1):S113-118.•Bishai D et al. AIDS 2007; 21(10):1333-1340.•Grant AD et al. Am J Trop Med Hyg 2001 65: 810-21.

mHealth Summit 2012 (Bella Hwang)

PEPFAR (n=2.5 million)

UNAIDS: 2010 Global Report

New Projects

Your health, in your hands

www.weltel.org

Harnessing mobile phone usage for HIV and horizontal health systems improvement:

Prevention of mother-to-child transmission (PMTCT)

Pumwani Maternity Hospital, NairobiPRINCIPAL RESEARCHER: • Joshua Kimani, University of Nairobi, KenyaPRINCIPAL DECISION-MAKER• Peter Cherutich, Ministry of Health, Kenya

Africa Health Systems Initiative Support to African Research Partnerships (AHSI-RES)

This study, funded by the NIH, will be conducted with AMREF and will involve over 700 participants at the Kibera Community Health Centre in Nairobi, Kenya.

WelTel RetainPromoting engagement in

pre-ART HIV care through SMS

This study will determine if the WelTel intervention improves patient retention in the first stage of HIV care and at 12-months.

We will also evaluate the cost-effectiveness of the intervention.

What about here?

• 65,000 people living with HIV

• ~72% of ALL Canadians (24 million people) have a cell phone!

WelTel: LTBI

Latent Tuberculosis Infection• Only 50 – 60% complete

therapy for LTBI (BCCDC)• Pilot – 16 patients

– median age of participants was 47 (range 21-82)– (56%) were female. (n=14)– 79% of participants would like the program to continue

and 86% would recommend it to a friend.– Report side effects quickly (93%) – helped them feel hopeful about their care (100%).

• BC Lung Association: Randomized control trial (RCT)

WelTel BC1 (HIV)Oak Tree Clinic

– HIV support for women and families

• Informative study• Clinic client survey• Pilot: 5x5 SMS

•<24yYouth

•>50yMature

•>3h awayRemote

•ImmigrantsESL:•Poor adherenceNon-

suppressed

Support: Bristol-Myers Squibb (BMS) through BCCDC Foundation

5x5 SMS pilot

Barriers to adherence• Forgetting• Drug use• Co-morbid depression• Side effects• Lack of social support

http://womenonthefence.com/wp-content/uploads/2011/06/depression.jpg

http://z.about.com/d/hepatitis/1/0/k/0/-/-/InjectingDrugs.jpg http://frank.itlab.us/forgetting/think.gif

http://forladiesbyladies.com/wp-content/uploads/2010/02/3_vomiting.jpg

Pre-Study Questionnaire

• Clinic attendants were asked to fill out a brief questionnaire re:– Cell phone possession

and use.– Thoughts about mHealth

interventions.– Age– Language – Gender

langleytoday.ca

Demographics

Languages used

At home # (%)

To text # (%)

English 152 (82.6%)

170 (94.4%)

French 6 (3.3%) 3 (1.7%)

Punjabi 7 (3.8%) 1 (0.6%)

African 10(5.4%) 2 (1.1%)

1st Nations 1 (0.5%) 0 (0%)

European 5 (2.7%) 2 (1.1%)

Asian 3 (1.6%) 2 (1.1%)

Demographics

Number(%)

(n=180)

Age:median(range)

39 (11-63)

Gender Female Male Transgender

136 (78.2%)

35 (26.1%)3 (1.7%)

A majority of patients used English at home, but an even greater number used English when texting.

Cell phone stats…Cell Phone Statistics

Number (%)

Own a cell phone No Yes-basic Yes-smart phone

33 (19.0%)80 (46.0%)61 (35.0%)

Share a cell phone Yes-household Yes-other

13 (7.5%)6 (3.4%)

Have texting plan No Yes-pay/text or limited Yes-unlimited

21 (14.5%)33 (22.8%)91 (62.7%)

Have internet on phone No Yes

95 (60.9%)61 (39.1%)

Frequency of texting Never Rarely (once/month) Occasionally (once/week) Frequently (few/week) Very frequently (daily)

37 (22.3%)11 (6.6%)

19 (11.4%)41 (24.7%)58 (34.9%)

• 180 patients polled

• 81% owned a cell phone

• 88% used text messaging

• 43% of above access the internet from their phone

• 71% text message at least weekly

• 83% believed the intervention could assist in clinical care/follow up

Risks and benefits…

Perceived Benefits/Risks

Number (%)

“Could this intervention benefit you?” No Yes Don’t know

22 (12.6%)

109 (62.6%)

43 (24.7%)

“What are the benefits?” Easy access to care Reminders Ability to contact Multiple Reasons Would rather text

14 (20.6%)

18 (26.5%)

29 (42.6%)4 (5.9%)3 (4.4%)

“What are the risks / concerns?” None Confidentiality Other

84 (62.7%)

36 (26.9%)

14 (10.4%)

• 2/3 felt the intervention could benefit them

• Major concern: confidentiality

The Intervention

Platform sends SMS“How are you?”

Positive response (ex: “I’m good”)

Negative response(ex: “I have a question”)

No response in 48 hrs

SMS: “Great, text you again next week”

Phone call from RNSMS: “I haven’t heard from

you, everything okay?

Positive response

Negative or no response

Gaps in care: Avoidance“I think I was depressed, or in a rut or something. I didn’t feel like going anywhere or doing anything … The doctor started getting a hold of me and they asked me to start coming back in again. And then [outreach worker] makes it easy.”

– Non-suppressed“I don’t know, maybe I just got tired of medicine … I didn’t want to tell anybody, I just I didn’t want to share to anybody. Myself I don’t even know why. I know it was not a good thing to do.” – ESL

“I’ve avoided the clinic at times, but usually because there was something wrong and I didn’t want to deal with it … I’d come in and see [doctor], I just would avoid the gynecologist because I didn’t want to go and find out if I had cancer or not.” - Distance

Interest in TextingIt wouldn’t bug me, it would make me think that somebody cares, actually.” – Non suppressed

I feel like with text messaging you can just ask whatever you want and it’s not going to be something that’s going to be like embarrassing or, like, I just feel more comfortable texting” -Youth

“Just a good reminder as well. You know, little things, and you know, keeping me on track, keeping me in touch, right, that’s always a good thing.” - Mature

Texting would be great… I like to stay in contact with Oaktree. It’s important to me because I haven’t been well. So to be able to have continuous contact with them, and I haven’t… because of lack of phone and stable living environment.” – Non suppressed

I could tell you right now that I have several clients that I think that

would really benefit who right now we have no way of communicating

with, right, and who are less likely to come to the clinic. – Healthcare

worker

“I’m really technology literate, and it would just make my life a lot easier to be able to text my

doctor” - Youth

Concerns about Texting“If you’re sending a text, I should know who’s texting and their questions. It shouldn’t always be on HIV.” - ESL

If there’s a serious problem I want to talk to somebody, I don’t want to text them, especially if I’m sick”- Mature

“Privacy is a must” - ESL

I think one thing is to get hold of them, and the other thing is actually to provide care. And sometimes even if you

actually get hold of them, that doesn’t necessarily mean that you actually provide care. – Healthcare worker

“A text message usually prompts other work: so, consulting other team members, or pulling lab results, or doing other things, so that volume could increase” – Healthcare worker

The only problem I would have probably in the future would be with the arthritis… right now my wrists and my thumbs are

pretty sore” – Mature

Nursing PracticeHi! This is Karen, we changed the ultrasound appt to thurs at 10am. There r a couple of instructions. Is

there a number I can call u on?

Thurs at 10am at [location]. U have to eat a fat free supper on Wed and then

fast from midnight on.

When is the appt?

Dr. M wants to ask how your breathing is these days.  Have u

been able to take the septra?

How are you?

I’m ok I missed my ultrasound yesterday can u

rebook please?

Nursing PracticeHi! This is Karen, I’m sorry to hear that [name]. Let us know if there is anything we can do to support you.”

It b gd to find a frief counselor.. My x mother in law passed away in April too along w/ 2 friends up north .. April has been very heart breaking

Patient put in contact with Oak Tree counselor who referred patient to grief counselors closer to her, as well as opportunities for aboriginal healing ceremonies.

How are you?

A really gd friend of ours was murdered last thurs..

she was only 23

Examples of Texting…• WTBC1-14 (Mature)• Subject: “So im on my way getting my six

month at home group I feel awesome awesome the best yet :-*”

• Patient letting us know how she is doing. This patient was given a phone and taught to text because of WelTel BC1.

• WTBC1-04 (Youth)• WelTel: “How are you?”• Subject: “Good”• A typical response from youth in WelTel BC1 so

far.

NIH: EPIC Enhance PrEP in Communities 

San FranciscoDepartment of Public HealthAlbert Liu, Jonathan Fuchs et al.• Interactive SMS + Next step

counselling to improve adherencePotential deployment sites:• US (San Francisco, Boston)• Peru (Lima and Iquitos)• Brazil (Rio and Sao Paolo)• others

Adherence = prevention

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?

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

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

The future is now

“All I’m saying is now is the time to develop the technology to deflect an asteroid.”

Thanks!

Ref: Audio & Visuals

• Lancet podcast – http://download.thelancet.com/flatcontentassets/audio/lancet/2010/9755_27novembe

r.mp3

• Scientific American podcast (1min)– http://www.scientificamerican.com/podcast/episode.cfm?id=text-message-outreach-im

proves-hiv-10-11-10

• CBC News The National (3min)– http://www.cbc.ca/video/#/Shows/1221254309/ID=1380546967

• The Economist:– http://www.economist.com/node/17465455