Effects of a Mobile Phone Short Effects of a Mobile Phone Short Message Service (SMS) on Message Service (SMS) on Antiretroviral Treatment Adherence in Antiretroviral Treatment Adherence in Kenya (WelTel Kenya1): A Randomized Kenya (WelTel Kenya1): A Randomized TrialTrial

Jesse ColemanUniversity of British Columbia, BC Centre for Disease Control

ICIUM, Antalya, Turkey Nov 14, 2011

Original research by Dr. Richard Lester et al.

Your health, in your hands

Kenya Clinic Survey, July 2005

• Despite often making <$2/day…

• Most patients Most patients attending HIV clinics had cell phone access had cell phone access

• Used for almost everything…• But not used for health

management

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

The Unfortunate Gap

... Compared to the current standard of care (SOC)

The PHE: WelTel Kenya1Clinical Trial (NCT00830622)

*Protocol: SMS (text messaging)

SMS: “Mambo?= How RU?”

“Sawa” = Fine “Shida” = ProblemMonday

<48h

If necessary

HealthHealthAdviceAdvice

SMS ‘check-in’SMS ‘check-in’

SMS responseSMS response

*Derived from focused group discussions with HCW and patients

Study Participants and RandomizationStudy Participants and Randomization

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

Patient Characteristics

=Equity• 65% women65% women• Median age 36• Oldest age = 82Oldest age = 82• 30% unemployed30% unemployed• 4.5% had no formal no formal

education education (26% at rural site)• CD4 = 164• 19% ‘rural’• 30% make < $1 per day30% make < $1 per day

=Access• Cell phone access

– 84% owned 84% owned cell phone– 16% shared 16% shared a phone– 0.3% had a land line– Distance from clinic

• 83% never called clinic before study...

Weekly (SMS) Patient Response RatesWeekly (SMS) Patient Response Rates

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’)

Feedback

Positive feedback Challenges

• “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?Scalability?• Why Why does it work?

– Behavior change?– Reminders?

Lester & Karanja Lancet Infectious Diseases Vol 8 December 2008

Study Conclusions• 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 equitable access to care

• Implications for developing health systems (horizontal?)http://www.scientificamerican.com/podcast/episode.cfm?id=text-message-outreach-improves-hiv-10-11-10

Example Kenya

PEPFAR investment in HIV /AIDS (2010)

• $548,119,441$548,119,441• (includes treatment and

prevention efforts)

• 410,300 individuals on ART410,300 individuals on ART

Apply WelTel = Apply WelTel = 37,30037,300 extra people with fully suppressed HIV load

Cost, est. <1% of PEPFAR spending

Kenya Government Investment in Health

• $513,000,000 on health$513,000,000 on health• HIV prevalence 6.3% • WelTel 24% improvement in

ART adherence (19% in VL)• = 1.2-7% reduction in 1.2-7% reduction in

TOTAL health services cost TOTAL health services cost • WelTel = WelTel = gov’t savings of gov’t savings of

$5-36,000,000 USD$5-36,000,000 USD

• Model REF: Freedberg K et al. Cote d’Ivoire, PLoS Model REF: Freedberg K et al. Cote d’Ivoire, PLoS Med 2009Med 2009

PEPFAR: Costs and savings from WelTel (draft)

ARV Patients on Weltel Year 1 Year 2 Year 3 Percent of

total 60% 70% 80%

Numbers 1,491,180.00

1,739,710.00

1,988,240.00

Year 1 Year 2 Year 3 Total Costs

Saved $

49,192,687.76 $

53,685,886.76 $

95,234,908.75 Costs of Weltel

$ 30,051,663.56

$ 23,759,930.39

$ 23,430,641.39

Year 1 Year 2 Year 3

Costs Saved of 2nd Line therapy

$ 16,036,363.64

$ 18,709,090.91

$ 21,381,818.18

Costs Saved of Opportunistic

Infections $

49,090,909.09 $

57,272,727.27 $

65,454,545.45 Costs Saved for

Clinic Time Needed

$ 53,633,491.20

$ 53,626,406.40

$ 143,079,321.60

Total Costs Saved

$ 118,760,764

$ 129,608,225

$ 229,915,685

Concluding statements

• mHealth (Cell Phone SMS support) support) can improve HIV treatment outcomesimprove HIV treatment outcomes in resource-limited settings

• May benefit HIV pandemic control (helps Treatment as Prevention)

• Global AIDS response cost-containmentcost-containment• Post – trial obligation to implement.