Jesse Coleman University of British Columbia, BC Centre for Disease Control

1. Your health, in your hands Effects of a Mobile Phone Short Message Service (SMS) on Antiretroviral Treatment Adherence in Kenya (WelTel Kenya1): A Randomized Trial Jesse Coleman University of British Columbia, BC Centre for Disease Control ICIUM, Antalya, Turkey Nov 14, 2011 Original research by Dr. Richard Lester et al.

2. The Unfortunate Gap Kenya Clinic Survey, July 2005 • Despite often making <$2/day… • Most patients attending HIV clinics had cell phone access • Used for almost everything… • But not used for health management Lester et al. AIDS Vol 20, 17 Nov, 2006

3. The PHE: WelTel Kenya1 Clinical Trial (NCT00830622) ... Compared to the current standard of care (SOC) Hypothesis: • The cell phone intervention (SMS), through regular communication with patients, will improve: • ART adherence • (30 day self-report at 6 and 12m) • HIV plasma viral suppression • (<400 copies/ml) at 12m • Also, health, social, and economic outcomes

4. “Sawa” = Fine “Shida” = Problem *Protocol: SMS (text messaging) SMS ‘check-in’ SMS: “Mambo? = How RU?” Monday If necessary Health Advice <48h SMS response *Derived from focused group discussions with HCW and patients

5. Study Participants and Randomization Exclusion (44) Inadequate phone access Refused/Unable Inclusion Adults (> 18 years) starting ART Adequate phone access (owned/shared) Informed consent Baseline survey Randomization 6 month 12 month SMS n=273 Control n=265 Powered to show 10% improvement in adherence

6. Patient Characteristics =Equity =Access Cell phone access 84% owned cell phone 16% shared a phone 0.3% had a land line Distance from clinic 83% never called clinic before study... • 65% women • Median age 36 • Oldest age = 82 • 30% unemployed • 4.5% had no formal education (26% at rural site) • CD4 = 164 • 19% ‘rural’ • 30% make < $1 per day

7. Weekly (SMS) Patient Response Rates (6.1% ‘SHIDA’) (2.0% ‘SHIDA’) n=11,983 SMS logs

8. Challenges Feedback Positive feedback “Feels like someone cares” 98% want the program to continue 97% would recommend it to a friend SMS response rates Changes in phone ownership Crisis management Scalability? Why does it work? Behavior change? Reminders? Lester & Karanja Lancet Infectious Diseases Vol 8 December 2008

9. Study Conclusions • http://www.scientificamerican.com/podcast/episode.cfm?id=text-message-outreach-improves-hiv-10-11-10 • Cell phones useful for HIV/AIDS management • SMS patient support significantly improved ART adherence and rates of viral suppression (First report) • SMS patients 24% more likely to be adherent to ART • SMS patients 19% more likely to have suppressed VL • Logistical challenges can be overcome • May enhance equitable access to care • Implications for developing health systems (horizontal?)

10. Example Kenya PEPFAR investment in HIV /AIDS (2010) Kenya Government Investment in Health $513,000,000 on health HIV prevalence 6.3% WelTel 24% improvement in ART adherence (19% in VL) = 1.2-7% reduction in TOTAL health services cost WelTel = gov’t savings of $5-36,000,000 USD Model REF: Freedberg K et al. Cote d’Ivoire, PLoS Med 2009 • $548,119,441 • (includes treatment and prevention efforts) • 410,300 individuals on ART Apply WelTel = 37,300 extra people with fully suppressed HIV load Cost, est. <1% of PEPFAR spending

11. PEPFAR: Costs and savings from WelTel (draft)

12. Concluding statements • mHealth (Cell Phone SMS support) can improve HIV treatment outcomes in resource-limited settings • May benefit HIV pandemic control (helps Treatment as Prevention) • Global AIDS response cost-containment • Post – trial obligation to implement.