Feasibility & Acceptability of a Real Time Adherence Device among HIV Positive IDU Patients in China

7182019 Feasibility amp Acceptability of a Real Time Adherence Device among HIV Positive IDU Patients in China

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Hindawi Publishing CorporationAIDS Research and reatmentVolume 983090983088983089983091 Article ID 983097983093983095983096983094983090 983094 pageshttpdxdoiorg983089983088983089983089983093983093983090983088983089983091983097983093983095983096983094983090

Research ArticleFeasibility and Acceptability of a Real-Time AdherenceDevice among HIV-Positive IDU Patients in China

Mary Bachman DeSilva1 Allen L Gifford2 Xu Keyi3 Zhong Li4 Cheng Feng5

Mohamad Brooks1 Mark Harrold1 Hu Yueying6 Christopher J Gill1 Xie Wubin4

Taryn Vian1 Jessica Haberer7 David Bangsberg7 and Lora Sabin1

983089 Center for Global Health and Development Boston University School of Public Health 983096983088983089 Massachusetts Avenue Crosstown

983091rd Floor Boston MA 983088983090983089983089983096 USA983090 Department of Health Policy and Management Boston University School of Public Health albot Building 983091983092983096W Boston MA 983088983090983089983089983096 USA

983091 Ditan Hospital 983089983091 Ditan Park Andingmen Outer Street Beijing 983089983088983088983088983089983089 China983092 FHI 983091983094983088 Asia-Paci1047297c Regional Office 983089983097th Floor ower 983091 Sindhorn Building 983089983091983088-983089983091983090 Wireless Road Kwaeng Lumpini

Khet Phathumwan Bangkok 983089983088983091983091983088 Tailand 983093 Global Health Strategies Manila Room 983089983095th Floor Ping an International Financial Plaza ower B No 983089-983091 Xinyuan South Road

Chaoyang District Beijing 983089983088983088983088983090983090 China983094 Guangxi CDC AR Clinic 983089983096 Jinzhou Road Nanning Guangxi 983093983091983088983088983090983096 China983095 Center for Global Health Massachusetts General Hospital 983089983088983088 Cambridge Street 983089983093th Floor Boston MA 983088983090983089983089983092 USA

Correspondence should be addressed to Mary Bachman DeSilva marybdbuedu

Received 983091983088 March 983090983088983089983091 Accepted 983090983094 June 983090983088983089983091

Academic Editor Curt Beckwith

Copyright copy 983090983088983089983091 Mary Bachman DeSilva et al Tis is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

We collected data on easibility and acceptability o a real-time web-linked adherence monitoring container among HIV-positiveinjection drug users (IDU) in China ldquoWisepillrdquo uses wireless technology to track on-time medication dosing en patients onantiretroviral therapy (AR) at the Guangxi CDC HIV clinic in Nanning China used Wisepill or one AR medication or onemonth We monitored device use and adherence and explored acceptability o the device among patients Mean adherence was983096983097983090 (SD 983089983088983094) Hal o the subjects reported a positive overall experience with Wisepill Seven said that it was inconvenientsupported by comments that it was large and conspicuous Five worried about disclosure o HIV status due to the device nodisclosures were reported welve signal lapses occurred (983093983092 o prescribed doses) o which one was due to technical reasonsnine to behavioral reasons (both intentional and unintentional) and two to unclear reasons Although the technical components

mustbe monitored careully and acceptabilityto patientspresents challengeswhich warrant urtherexploration the Wisepilldevicehas potential or adherence interventions that deliver rapid adherence-support behavioral eedback directly to patients includingIDU Te use o wireless technology appears uniquely promising or providing time-sensitive communication on patient behaviorthat can be harnessed to maximize the bene1047297ts o HIV treatment

1 Introduction

Interventions to improve adherence to antiretroviral therapy (AR) are urgentlyneededamong HIV-positive patientspar-ticularly in developing countries where most o the worldrsquosHIV-inected population lives China has experienced amajor HIVAIDS epidemic since the 983089983097983097983088s with an estimated983095983096983088983088983088983088 persons living with HIV in 983090983088983089983089 [983089] Free AR is

available nationwide and over 983089983090983094983088983088983088 Chinese patients arenow on treatment However ew AR adherence studies havebeen conducted in China As it is elsewhere in the worldAR adherence is suboptimal in China in large part becauseHIVAIDS is highly stigmatized [983090 983091]

Recently wireless technology has emerged as a potentialtool or monitoring medication adherence in real time [983092ndash983096]Tis is noteworthy given the recognized association between



983090 AIDS Research and reatment

late dose-timing and loss o viral suppression [983097] Onepromising tool the Wisepill personal medication container(Wisepill echnologies Cape own South Arica) detectsthe exact date and time whenever the patient opens it toaccess medication It then transmits a real-time signal by general packet radio service (GPRS) to a central server where

the data are recorded securely and accessible to appropriateclinicians or researchers Wisepill and other similar devicesare currently being pilot tested in various countries ordifferent uses such as inection control and oral hygiene[983089983088 983089983089] Although these devices have the potential to supportadherence monitoring and counseling ew studies haveassessed easibility and acceptability among AR patientsparticularly in developing countries [983089983090 983089983091]

In a previous intervention study (Adherence or Lie(AFL)) which tested the use o electronic drug monitoring(EDM) data as an inormation and counseling tool amongprimarily injection drug using (IDU) AR patients in ChinarsquosYunnan province we ound that monthly EDM-inormedcounseling signi1047297cantly improved mean AR adherenceand CD983092 counts [983089983092] Tese 1047297ndings indicate that use o electronic data-collecting pill containers is easible in Chinaand offer proo o concept that providing Chinese patientsand providers with adherence data can positively impactpatientsrsquo adherence

o lay the groundwork or a larger intervention study inChina using wireless technology to monitor adherence andintervene in real time among injection drug users (IDU) weconducted an in-depth easibility and acceptability study onthe use o the device in a small cohort o IDU patients Tisapproach allowed us to glean important inormation aboutthe potential or use o the device given the socioculturalcircumstances o provision o AR in China including theollowing HIV is highly stigmatized AR is relatively newand policies on provision have changed in recent years useo cellphone technology while ubiquitous and amiliar is inrapid transition and the clinician-patient relationship par-ticularly whenthe patient is an IDU is extremely hierarchical

2 Materials and Methods

983090983089 Study Site and Population Te study was led by BostonUniversityrsquos Center or Global Health and Development(CGHD) with enrollment at the Guangxi Centers or Dis-ease Control (CDC) antiretroviral therapy (AR) clinic in

Nanning China a large clinic that currently treats over 983089983092983088983088patients including 983089983088983092983088 adults 983091983095983088 children and a highproportion o IDU among the adult patients We providedten current or ormer IDU patients who were being treatedwith AR at the clinic with a Wisepill device or one ormore o their AR medications We then monitored their useo the device or one month without the subjects receivingany inormation about their adherence data Tis allowedus to collect pilot data on (983089) acceptability o use o theWisepill device among a Chinese patient population and (983090)easibility o monitoring patient adherence using the devicein China We limited the sample size to ten subjects due tobudget constraints and to permit a rapid assessment prior

F983145983143983157983154983141 983089 Te Wisepill device

to initiating the larger study but ofen ormative easibility studies o this type have used similar sample size [983089983090 983089983093]

983090983090 Data Te study involvedthe ollowing sources o patientdata (983089) a baseline sociodemographic and health history questionnaire (983090) a brie sel-report o adherence and use o Wisepill rom subjects afer 983089 month o use (983091) continuousadherence data rom the Wisepill device (983092) continuous dataon reasons or signal lapses and (983093) CD983092 and VL test resultsrom patientsrsquo medical charts

983090983091 Sociodemographic and Wisepill Experience Data Tebaseline and monthly interviews were administered in Man-darin Chinese by trained clinic staff In addition to sociode-mographic inormation and health history the baselineinstrument also covered route and duration o HIV inectionhistory o depression and alcoholdrug use Besides sel-reported adherence the monthly orm included quantita-tive and open-ended questions covering acceptability andusability o the Wisepill device (easeconvenience o usedifficulties using the device device storage and potentialstigmaloss o con1047297dentiality) as well as perceptions o apossible intervention that makes use o Wisepill

983090983092 Wisepill Medication Dispenser and Adherence Monitoring Device Te Wisepill device measures 30 times 60times 130 mm andholds up to 983094983088 small pills in two inner compartments (seeFigure 983089) It is powered by one rechargeable 983091983095 volt 983089983089983088983088 mAhlithium polymer battery and contains a Subscriber Identity Module (SIM) card Te device creates a date and time stampeach time it is opened and transers this inormation by general packet radio service (GPRS) to a central server inSouth Arica Te data are then available to research clinicand program personnel via a secure internet-based interace

983090983093 Adherence Data and Measures Data on Wisepill open-ings were transmitted automatically and continuously over



AIDS Research and reatment 983091

the month as described previously Investigators downloadedthe data rom a password-protected account on the Wisepillwebsite From these data we calculated mean adherence overthe one-month period using the ollowing ormula (numbero doses taken plusmn one hour o dose time)(number o pre-scribed doses) the approach used in the AFL study based on

the adherence measure that was most signi1047297cantly associatedwith viral load [983089983094] We also analyzed the adherence datasel-reported by subjects in the monthly orm using a visualanalog scale (VAS) that indicates the proportion o total dosespatient took and compared this with the adherence datagenerated by the Wisepill device

983090983094 Signal Lapses We investigated all Wisepill signal lapsesby a phone call to the subject within 983090-983091 days to determinewhether a lapse was due to technical ailure (battery ailureorwarder malunction) or had a behavioral cause (misseddose intentional nonuse) Tis inormation was recorded in aldquosignal lapserdquo report that we created or each subject over the

month o data collection We then calculated separately theproportion o technical issues and behavioral reasons amongall expected Wisepill signal lapses

983090983095 Clinical Data CD983092 and viral load test results werecollected rom subjectsrsquo medical charts as background inor-mation on subjects no additional blood draws were requiredor the study

983090983096 Data Analysis For all quantitative data we calculateddescriptive statistics (means ranges standard deviations orcontinuous variables and requencies or categorical vari-

ables) Qualitative data rom the open-ended questions wereanalyzed using a thematic approach All quantitative analyseswere conducted using SAS 983097983089 (Te SAS Institute Cary NCUSA)

Te study was approved by the Institutional Review Boards at Boston University Medical Center and the GuangxiProvincial Center or Disease Control Nanning ChinaAll subjects provided written inormed consent prior toenrollment Because it was not a clinical trial registrationwith httpClinicalrialsgov was not required

3 Results

983091983089 Participants Te ten subjects were current and ormerinjection drug users and most (983095) reported that they hadbeen inected via shared needles Te mean age o the samplewas 983091983090983095 years (SD = 983093983091) seven o the ten were men andsix were married On average the subjects had been on AR983092983088983097 months (SD = 983090983097983092) and had a mean baseline CD983092 counto 983091983096983091cellsL (SD = 983089983095983088 cellsL) Seven had a history o depression and two were alcoholic Four reported havinghepatitis C and two reported having had syphilis Nine o the ten had an educational level o middle school or lowerMost subjects had a low monthly income typical o IDU inChina While one did not know and one reported a monthly income o 983089983088983088983089ndash983093983088983088983088 Yuan (approximately 983076 983089983093983097ndash983095983097983092) eight

had a monthly income o 983089983088983088983088 Yuan (approximately 983076 983089983093983094) orless

983091983090 Wisepill Data ransmission and Adherence Lapses Tetotal prescribed (expected) number o device openings was983094983089983092 or the month o study welve lapses occurred over the

month (983091983091 total doses) thus 983091983091983094983089983092 or 983093983092 o prescribeddoses were not recorded in real time Te mean duration o real-time lapses was 983090983095983093 doses (range 983089 dosendash983090983089 doses)

O the lapses one was due to technical reasons nineto behavioral reasons and two to unclear reason Tetechnical problem was a lack o airtime on the SIM cardbut this resulted in 983090983089 consecutive openings missed becausethe subject could not be contacted Afer the SIM cardwas reactivated these initially missed doses were eventually received by the server so they could be included in thesubjectrsquos adherence calculation I these 983090983089 openings notrecordedin real time are includedthe proportion o openingsnot measured by the device was 983090983088 (983089983090983094983089983092) O the nine

behavioral lapses seven were due to a subject orgetting totake a dose and one was due to a subject orgetting to closethe device afer use Te 1047297nal behavioral lapse was due to apatient purposely not using the box (reportedly taking a doseout early and actually taking the medicine later at work)

983091983091 Adherence Levels Using Wisepill data adherence was983097983095983090 (SD = 983091983093) o prescribed doses taken and 983096983097983090(SD = 983089983088983094) using a measure that incorporates dose timing(detailed previously) Using a visual analogue scale at themonthly visit sel-reported adherence was 983097983096983093 (SD =983091983090)

983091983092 Acceptability of Wisepill Device In quantitative ques-tions hal o the subjects reported a positive or very positiveoverall experience with Wisepill the other 1047297ve reported aldquosomewhat negativerdquo overall experience Seven were willingor very willing to participate in a larger intervention studyEight ound the device very easy to use However sevensaid that it was inconvenient or very inconvenient Five weresomewhat or very worried about disclosure o their HIVstatus due to the device no disclosures were reported

983091983092983089 Ease and Convenience of Use In the open-endedquestions exploring acceptability and usability o the Wisepilldevice (easeconvenience o use difficulties using the device

device storage and potential stigmaloss o con1047297dentiality)six patients reported a positive eeling about the deviceo whom our said knowing that someone was monitoringtheir adherence helped them take their medications moreregularly As two subjects explained

Knowing that someone is monitoring my medicationspurs me to take my medication better Te pill box is

just a normal drug container there is nothing good orbad about it

I like the pill box because 1047297rsto all there is no speciallabel on the pillbox (comparing with the medicinebottle on the instruction label there is inormation




about HIV medicine) so no one will know whatmedicine I am taking second it records the time o medicine taking which helps me take doses better

Tree reported a negative experience Onesaid the device wasinconvenient to carry andthereore a burden andone did notlike the eeling o being watched (this one had both positiveand negative eelings as heshe also said using the device wasa helpul reminder)

983091983092983090 Difficulties of Use Including Potential Stigma and Loss of Con1047297dentiality When asked about difficulties encounteredusing the Wisepill device one subject reported having noproblem with the device at all while another had no majorproblem because heshe ldquoalways carried it in a bagrdquo Howevereight indicated that the device was inconvenient or eltuncomortable using it Many ound it too big one patientthought it should be wider Additional eedback included theollowing two subjects did not like that it could only holdone drug two worried that drugs would be damaged whilecarrying the device two were concerned about others seeingit Tese were typical statements

It is too big to carry I have a eeling o unease usingthe Wisepill in ront o other people I never take thepillbox outside

Te pillbox is too big I have a big concern that usingthis pill box could disclose my HIV status

983091983092983091 Device Management and Storage Strategies Subjectsreported a variety o ways to manage their use o the deviceOne compensated or the inconvenience by always takingdoses at home another changed hisher dose time to avoidcarrying the device to work and one told riends thatthe drugs were a hepatitis medicine instead o HIV-relatedmedications Seven o the patients reported keeping theirdevice at home exclusively six seemed to keep it hiddenwhether at home or outside Patients were also asked whatthey did with the device when they traveled Hal reportednever taking the device away rom home the other hal reported having ound ways to travel with the device One o the ormer elaborated that

I have no job in the past one month I always takemy medicine at home Even when I go to parties ormeeting riends I did not bring the pill box with me

Tatrsquos why sometimes when I returned home late Ialso took my medications late

983091983092983092 Reminder Messages and Willingness to Participate in aLarger Study When asked speci1047297cally about text messagesonly our patients thought reminder messages would behelpul O the six who did not one was a truck driver andcould not read messages while driving one did not readtext messages at work and one thought that text messagereminders are not much more useul than an alarm

When asked about possibly participating in a larger study using Wisepill with text message reminders six said they would be willing to participate o whom our said it would

help them take their AR medications on time As twoexplained

Yes the reminder message could help I usually readshort messages I hope the message could be as simpleas possible like a symbol would be good

Yes the reminder message could help Te SMS could just be ldquoItrsquos time to take your medication do notorgetrdquo I do not worry about other people (knowing)my health status through this message

Tree subjects were not willing to participate in a subsequentlarger study All three did not think text messages wouldwork two said the box was too inconvenient One wasconcerned about possible disclosure o status via messagesand one did not use text messages

4 Discussion

Tis study has demonstrated that use o a real-time SMS-enabled web-linked AR adherence monitoring system istechnically easible in an urban Chinese clinical settingamong predominantly IDU HIV patients Only a ew minortechnical difficulties were encountered and easily addressedthe issue o acceptability is more complex

Te technical lapses due to inadequate time on theSIM card bear some discussion In terms o adherencemeasurement these types o lapses do not represent a majorconcern as long as there is adequate battery power in thedevice the openings are recorded but are just not transmittedto the server until the airtime on the SIM card is replenishedIn other words the transer o inormation is delayed butthe data needed or characterizing adherence rates are notaffected Because the system did not work perectly orcapture o data in real time however this presumably wouldhave an impact on its effectiveness as a tool or promotingadherence including triggered SMS reminders Moreoveri an intervention was designed to send an SMS messagewhen the server does not receive a signal within a set timewindow then the server would send an SMS reminder to theparticipant regardless o the reason or the lapse In such anintervention context the subject with the lapse o 983090983089 doses inthe present study would have received 983090983089 reminder messageseven though shehe actually used the device correctly andtook all o the doses on time Readers in the USA shouldalso note that in most other countries including China a

mobile phone that has run out o SIM card airtime can stillreceive text messages Te main risk here is that patientsmight become annoyed In short the logistical requirementso the device are real (airtime out o range issues andbattery power) and can cause some problems A technicallapse due to the airtime issue does not preclude us rommeasuring and understanding adherence behavior but totake ull advantage o the technical capacity o the deviceresearchers and clinicians must pay close attention to theselogistical requirements

Te study raises greater concerns about the acceptability o the device to patients Several subjects complained aboutthe size and inconvenience o the device o overcome these




concerns consideration should be given to the design andappearance o the device Some ideas might include devisinga carrying case or bag to make the device less conspicuous orcreating a cell phone case thatwould hold both the phone andthe monitoring device A smaller less conspicuous box per-haps retaining the removable pill containers or easy re1047297lling

that Wisepill currently offers might also be considered Inaddition although no disclosures were reported during thepilot subjects did raise concerns about disclosure and stigmadue to the device in both closed and open-ended questionsTis is a potential problem with the device which deservesurther attention [983096] Tat said the extent to which even oursmall sample o patients devised a variety o ways o using thedevice is striking Input rom patients with experience withthe device will be critical to thinking about how to make iteasier and potentially less stigmatizing to use in daily lie

A limitation o the study is the small sample o tenindividuals who used the device with no accompanyingintervention that might oster more positive eelings aboutthe device Te ull wireless capabilities o the device werenot tested and could not be appreciated It is possible thatsubjectsrsquo attitudes mightchange aferhaving the experience o receiving SMS reminders particularly i they could see theiradherence increase or their health improve as a result

Te technical 1047297ndings rom the study are more persua-sive but the qualitative aspects are by de1047297nition limited andsubjective Tereore we revised aspects o the subsequentlarger randomized controlled trial currently underway inthe same clinic including our data collection instrumentsto allow more extensive collection o qualitative data Tiswill allow us to obtain more conclusive data rom the largerstudy in which intervention subjects receive a tailored SMSreminder message i they are more than 983091983088 minutes latetaking a dose Tose who are suboptimal adherers (lt983097983093)also review a printout o their adherence behavior over theprevious month in counseling sessions Te design o thislarger study will permit us to collect quantitative and qual-itative data on acceptability over time or both interventionand control groups and thereby gain a deeper understandingo the evolution o acceptability o the device over time in thisChinese patient population

5 Conclusions

Although the technical logistical requirements mustbe moni-

tored careully and acceptability to patients is not perect theWisepill device shows potential or adherence interventionsthat deliver rapid adherence-support behavioral eedback directly to patients including IDU as well as in clinicalsettings Te act is that each current adherence monitoringdevice or technology has its advantages and disadvantagesas well as a certain measure o intrusion or patientsWisepill involves a high degree o intrusion but also a highdegree o accuracy as well as the unique bene1047297t o real-time monitoring which allows or real-time interventions toimprove adherence beore the substantial negative impact o poor adherence can accumulate to cause substantial harmOther adherence measures (sel-report pill count pharmacy

re1047297ll eg) may involve a lesser burden or patients but they are less accurate and do not permit real-time interventionsElectronic drug monitoring reviewed at the timeo clinic visit(such as the Medication Event Monitoring System (MEMS))imposes a similar degree o intrusion on patients comparedto Wisepill but again there is no opportunity to intervene

in real time Tus while the Wisepill delivery system isnot perect we believe that it holds substantial advantagesover other currently available adherence monitoring optionsJust as so many recent technological advances offer thepossibility o client-centered approaches the use o wirelesstechnology appears uniquely promising or providing time-sensitive communication on patient behavior that can beharnessed to maximize the bene1047297ts o HIV treatment

Acknowledgments

Te authors are grateul or support rom the Small PilotFunding program at the Boston University School o Pub-

lic Health and to Roberta White in particular We thank Mary Dangora Sherley Brice and Deirdre Pierotti or theirsteadast help with various aspects o this body o researchTe authors also thank Jessica Chung and Gampo Dorji ortheir generous help preparing study documents Te authorsacknowledge Lloyd Marshall and the entire Wisepill Incstaff along with personnel at the ormer FHI 983091983094983088 Beijingoffice or their assistance and support implementing thisproject Finally the authors thank the patients in Nanningwho participated in this study and the entire staff o theGuangxi CDC SIAIDS clinic in Nanning Te authors areespecially grateul or their productive partnership with theircollaborator the late Dr ang Zhirong director o the study

clinic Tis work would not have been possible without his vision and dedication to seeking ways to improve the healtho his patients

References

[983089] Ministry o Health and Peoplersquos Republic o China 983090983088983089983090 China AIDS Response Progress Ministry o Health and Peoplersquos Repub-lic o China Beijing China 983090983088983089983090

[983090] H Wang G He X Li et al ldquoSel-reported adherence to anti-retroviral treatment among HIV-inected people in CentralChinardquo AIDS Patient Care and SDs vol 983090983090 no 983089 pp 983095983089ndash983096983088983090983088983088983096

[983091] L L Sabin M BDeSilva D HHamer etalldquoBarriers toadher-ence to antiretroviral medications among patients living withHIV in southern China a qualitative studyrdquo AIDS Care vol983090983088no 983089983088 pp 983089983090983092983090ndash983089983090983093983088 983090983088983088983096

[983092] K E Charlton L Bourne K Steyn andJ A Laubscher ldquoPoornutritional status in older black South Aricansrdquo Asia Paci1047297c Journal of Clinical Nutrition vol 983089983088 no 983089 pp 983091983089ndash983091983096 983090983088983088983089

[983093] Horvath H Azman G E Kennedy and G W RutherordldquoMobile phone text messaging or promoting adherence toantiretroviral therapy in patients with HIV inectionrdquo CochraneDatabase of Systematic Reviews vol 983091 Article ID CD983088983088983097983095983093983094983090983088983089983090

[983094] B X ran and S Houston ldquoMobile phone-based antiretroviraladherence support in Vietnam easibility patientrsquos preerence




and willingness-to-payrdquo AIDS and Behavior vol 983089983094 no 983095 pp983089983097983096983096ndash983089983097983097983090 983090983088983089983090

[983095] R Rodrigues A Shet J Antony et al ldquoSupporting adherenceto antiretroviral therapy with mobile phone reminders resultsrom a cohort in South Indiardquo PLoS ONE vol 983095 no 983096 ArticleID e983092983088983095983090983091 983090983088983089983090

[983096] M L Scanlon and R C Vreeman ldquoCurrent strategies orimproving access and adherence to antiretroviral therapies inresource-limited settingsrdquo HIV AIDS vol 983093 pp 983089ndash983089983095 983090983088983089983091

[983097] J Parienti M Das-Douglas V Massari et al ldquoNot all misseddoses are the same sustained NNRI treatment interruptionspredict HIV rebound at low-to-moderate adherence levelsrdquoPLoS ONE vol 983091 no 983095 Article ID e983090983095983096983091 983090983088983088983096

[983089983088] J M Boyce Cooper and M J Dolan ldquoEvaluation o anelectronic device or real-time measurement o alcohol-basedhand rub userdquo Infection Control and Hospital Epidemiology vol983091983088 no 983089983089 pp 983089983088983097983088ndash983089983088983097983093 983090983088983088983097

[983089983089] M F Walji O Coker J A Valenza H Henson D Warren-Morris andL Zhong ldquoA persuasive toothbrush to enhance oralhygiene adherencerdquo AMIA Annual Symposium Proceedings p

983089983089983094983095 983090983088983088983096[983089983090] J E Haberer J Kahane I Kigozi et al ldquoReal-time adherence

monitoring or HIV antiretroviral therapyrdquo AIDS and Behavior vol 983089983092 no 983094 pp 983089983091983092983088ndash983089983091983092983094 983090983088983089983088

[983089983091] M J Siedner A Lankowski D Musinga et al ldquoOptimizingnetwork connectivity or mobile health technologies in sub-Saharan Aricardquo PLoSONE vol 983095 no 983097Article ID e983092983093983094983092983091 983090983088983089983090

[983089983092] L L Sabin M B DeSilva D H Hamer et al ldquoUsing electronicdrug monitor eedback to improve adherence to antiretroviraltherapy among HIV-positive patients in Chinardquo AIDS and Behavior vol 983089983092 no 983091 pp 983093983096983088ndash983093983096983097 983090983088983089983088

[983089983093] M N Burns M Begale J Duffecy et al ldquoHarnessing contextsensing to develop a mobile intervention or depressionrdquo Journal of Medical Internet Research vol 983089983091 no 983091 p e983093983093 983090983088983089983089

[983089983094] C J Gill L L Sabin D H Hamer et al ldquoImportance o dose timing to achieving undetectable viral loadsrdquo AIDS and Behavior vol 983089983092 no 983092 pp 983095983096983093ndash983095983097983091 983090983088983089983088



C o p y r i g h t o f A I D S R e s e a r c h amp T r e a t m e n t i s t h e p r o p e r t y o f H i n d a w i P u b l i s h i n g C o r p o r a t i o n

a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a l i s t s e r v w i t h o u t

t h e c o p y r i g h t h o l d e r s e x p r e s s w r i t t e n p e r m i s s i o n H o w e v e r u s e r s m a y p r i n t d o w n l o a d o r

e m a i l a r t i c l e s f o r i n d i v i d u a l u s e




late dose-timing and loss o viral suppression [983097] Onepromising tool the Wisepill personal medication container(Wisepill echnologies Cape own South Arica) detectsthe exact date and time whenever the patient opens it toaccess medication It then transmits a real-time signal by general packet radio service (GPRS) to a central server where

the data are recorded securely and accessible to appropriateclinicians or researchers Wisepill and other similar devicesare currently being pilot tested in various countries ordifferent uses such as inection control and oral hygiene[983089983088 983089983089] Although these devices have the potential to supportadherence monitoring and counseling ew studies haveassessed easibility and acceptability among AR patientsparticularly in developing countries [983089983090 983089983091]

In a previous intervention study (Adherence or Lie(AFL)) which tested the use o electronic drug monitoring(EDM) data as an inormation and counseling tool amongprimarily injection drug using (IDU) AR patients in ChinarsquosYunnan province we ound that monthly EDM-inormedcounseling signi1047297cantly improved mean AR adherenceand CD983092 counts [983089983092] Tese 1047297ndings indicate that use o electronic data-collecting pill containers is easible in Chinaand offer proo o concept that providing Chinese patientsand providers with adherence data can positively impactpatientsrsquo adherence

o lay the groundwork or a larger intervention study inChina using wireless technology to monitor adherence andintervene in real time among injection drug users (IDU) weconducted an in-depth easibility and acceptability study onthe use o the device in a small cohort o IDU patients Tisapproach allowed us to glean important inormation aboutthe potential or use o the device given the socioculturalcircumstances o provision o AR in China including theollowing HIV is highly stigmatized AR is relatively newand policies on provision have changed in recent years useo cellphone technology while ubiquitous and amiliar is inrapid transition and the clinician-patient relationship par-ticularly whenthe patient is an IDU is extremely hierarchical

2 Materials and Methods

983090983089 Study Site and Population Te study was led by BostonUniversityrsquos Center or Global Health and Development(CGHD) with enrollment at the Guangxi Centers or Dis-ease Control (CDC) antiretroviral therapy (AR) clinic in

Nanning China a large clinic that currently treats over 983089983092983088983088patients including 983089983088983092983088 adults 983091983095983088 children and a highproportion o IDU among the adult patients We providedten current or ormer IDU patients who were being treatedwith AR at the clinic with a Wisepill device or one ormore o their AR medications We then monitored their useo the device or one month without the subjects receivingany inormation about their adherence data Tis allowedus to collect pilot data on (983089) acceptability o use o theWisepill device among a Chinese patient population and (983090)easibility o monitoring patient adherence using the devicein China We limited the sample size to ten subjects due tobudget constraints and to permit a rapid assessment prior

F983145983143983157983154983141 983089 Te Wisepill device

to initiating the larger study but ofen ormative easibility studies o this type have used similar sample size [983089983090 983089983093]

983090983090 Data Te study involvedthe ollowing sources o patientdata (983089) a baseline sociodemographic and health history questionnaire (983090) a brie sel-report o adherence and use o Wisepill rom subjects afer 983089 month o use (983091) continuousadherence data rom the Wisepill device (983092) continuous dataon reasons or signal lapses and (983093) CD983092 and VL test resultsrom patientsrsquo medical charts

983090983091 Sociodemographic and Wisepill Experience Data Tebaseline and monthly interviews were administered in Man-darin Chinese by trained clinic staff In addition to sociode-mographic inormation and health history the baselineinstrument also covered route and duration o HIV inectionhistory o depression and alcoholdrug use Besides sel-reported adherence the monthly orm included quantita-tive and open-ended questions covering acceptability andusability o the Wisepill device (easeconvenience o usedifficulties using the device device storage and potentialstigmaloss o con1047297dentiality) as well as perceptions o apossible intervention that makes use o Wisepill

983090983092 Wisepill Medication Dispenser and Adherence Monitoring Device Te Wisepill device measures 30 times 60times 130 mm andholds up to 983094983088 small pills in two inner compartments (seeFigure 983089) It is powered by one rechargeable 983091983095 volt 983089983089983088983088 mAhlithium polymer battery and contains a Subscriber Identity Module (SIM) card Te device creates a date and time stampeach time it is opened and transers this inormation by general packet radio service (GPRS) to a central server inSouth Arica Te data are then available to research clinicand program personnel via a secure internet-based interace

983090983093 Adherence Data and Measures Data on Wisepill open-ings were transmitted automatically and continuously over












3 Results































4 Discussion












5 Conclusions





Acknowledgments




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3 Results































4 Discussion












5 Conclusions





Acknowledgments




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4 Discussion












5 Conclusions





Acknowledgments




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5 Conclusions





Acknowledgments




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Documents

Feasibility & Acceptability of a Real Time Adherence Device among HIV Positive IDU Patients in China