mHealth to Improve Health:A weekly text messaging intervention to improve ART adherence and

HIV Viral Load in a Canadian Context: WelTel OAKTREE

K.Friesen, A.Qiu, O.Goktepe, E.Maan, N.Pick, A.Alimenti, M.Kestler,

K.Smillie, D.Money, R.Lester, M.Murray & WelTel OAKTREE Study Team

Relationships with commercial interests:

Grants/Research Support:

Bristol-Meyers-Squibb, Gilead Sciences

Other:

Telus (Has provided in-kind phone support)

WelTel (Has provided in-kind platform support)

Disclosure

Background

https://233livenews.wordpress.com/2015/02/25/unaids-welcomes-further-evidence-of-the-efficacy-of-

antiretroviral-medicines-in-preventing-new-hiv-infections/antiretroviral-drugs/

• RCT – WelTel Kenya 1

• Kenya, 538 participants

• SMS

• May 2007-Oct 2008

• FINDINGS:• 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

Background

Lester et. Al. Lancet 2010 Nov 27;376(9755):1838-45. Epub 2010 Nov 9.

Background

Oak Tree Clinic

•Provide optimal care,

treatment and support

for HIV positive women,

pregnant women,

children, youth and

partners.

Inter-disciplinary, collaborative clinic:

Oak Tree Clinic

• Front desk staff

• Clinic Aide

• Physicians(ID,OB,Peds)

• Dietitian

• Nurse Clinicians

• Psychiatrist

• Trauma & Addiction Counselor

• Part time child care provided by

Volunteers and a literacy

program

• Social Worker

• Nurse Practitioners

• Outreach Workers

• Pharmacists

• Research team

• Program Manager

• Repeated measures study of 85 participants from the

Oak Tree Clinic

Baseline year: 1 year prior to study enrollment

Study year: 1 year of receiving the intervention

Study Design

Enrollment period: April 2013 -May 2014

1) Attended clinic for ≥ 1 year prior to study entry

2) Age ≥14 years.

3) Indication for cART

4) Any viral load ≥200 copies/mL in the control year.

5) Vulnerable Population • poor engagement in care

• difficult to contact

• poor or non-adherence to ARV therapy

• advanced HIV infection/AIDS

• unstable housing situation

• recent/active problem substance use

• intimate partner violence

• mental health factors

Inclusion Criteria

1) Attended clinic for

• If patients have no cell phone….

• They are provided with a basic phone and unlimited texting for the duration of the study.

• They are taught to use the phone/text as required.

• If patients have a cell phone with unlimited texting….

• They are taught to use the phone/text as required.

The Intervention

• Weekly text message x 12 months using our

automated text messaging platform….

http://bell-canada.be.funpic.de/images/3-bell-canada-international-text-messaging.jpg

The Intervention

• Repeated measures mixed-effect regressions to

test for an effect of weekly SMS text messaging

on…

• VL

• CD4

• Clinic and other appointment attendance

• Adherence to ARV’s.

• QOL assessment and cost analysis

Analysis

TABLE 1Participant Demographics (n=81) N (%)

Gender Female

MaleTransgender

73 (90.1%)

6 (7.4%)2 (2.5%)

Age (years) Median (Range) 39.4 (15-61)

Ethnicity

Caucasian

Indigenous

African/Caribbean BlackSouth Asian

31 (38.3%)

27 (33.3%)

18 (22.2%)5 (6.2%)

IncomeSocial Assistance

EmployedOther

64 (79%)

4 (5.0%)13 (16.0%)

Cell phone ownership (baseline)

YesNo

43 (53.1%)38 (46.9%)

Baseline CD4 Median (Range) 350 (10-490)

23 (29%)

At study end:

35 participants VL

*repeated measures mixed effects linear regression@repeated measures mixed effects logistic regression

TABLE 2

Effectiveness Measure

Control Year

Intervention Year

Coefficient P-value

Mean log10 HIV

Viral Load*

2.92 2.57 -0.26 0.015

Mean CD4 Count (cells/mm3) *

345.2 356.5 0.005 0.74

ART Adherence

(predicted mean % doses taken)@

67.1% 70.0% 0.13

Box plots of median population log10 VL in the control year vs. study end. Using the

Wilcoxon rank sum test there is a significant decrease in log10 VL at study end (p=0.007)

What about texting

response rates?

0,00

0,10

0,20

0,30

0,40

0,50

0,60

0,70

0,80

1 6 11 16 21 26 31 36 41 46 51

Pro

po

rtio

n

Weeks

Response Rates for Duration of Study

Problem:

OK

No Response

• Median response rate: 51.9% (range: 0-98%)

• Mean response rate: 50%

• If we dichotomize based upon this….

• “responders” – 50% or greater response rate

• “non-responders” -

Response Rates

Pre-intervention Intervention

year

End VL Change

Responders

VL (median) 2.62 log 1.90 log 1.59 log -1.03 log

ARV Adherence

(median)

68.8% 82.5% +13.7%

Non-responders

VL (median) 3.00 log 2.90 log 2.61 log -0.39 log

ARV Adherence

(median)

50.7% 51.5% +0.8%

Adherence: Responder vs. Non-responders, p=0.008

VL between groups: p=0.03Kruskall-Wallis test

• WTOT-13:

“Having that, just having that knowing that that connection was there. And knowing that it was a

woman. And specific to my, MY needs, my

health care needs. Like, you don't feel like when

you're given those phones that there's 300 other

women out there. You feel like you’ve got one-to-one with your healthcare provider, 24/7.”

Benefits

What is the impact of the

intervention on the clinic?

Person A

Person B

Person C

Person D

Person E

Person F

Person

GPerson H

218 148348

376

270

172

21947

2451

284

Physician

Outreach

Nurse Practitioner

Social Work

Counsellor

Front Desk

Study RA

Dietician

Study Nurse

Pharmacy

Total Time: 75.5 hours (4533 minutes).

53 minutes/person enrolled for 1 year of coverage

Time Usage (minutes)

8

4,9

6,7 6,1 5,7

27

15

7,7 7,8

4,4

6

0

5

10

15

20

25

30

Mean Time per Interaction (minutes)

Study Nurse – 2451 minutesCheck-in

Social Work

Mental Health

Medical

Medication related

Test Results

Outside referral

Other

Other text

Appointmentreminders

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?

• Population VL decreased significantly from control to

intervention year, and from control year to study end.

• ART adherence improved significantly from control to

intervention year

• No change was seen in CD4 count or appointment

attendance.

• Those who actively participated in text-messaging had a

greater improvement in adherence and HIV VL.

• Results suggest the WelTel intervention is an effective

tool for reducing HIV VL load and improving ART

adherence in poorly engaged, vulnerable Canadian

populations.

Conclusions

Our Sponsors:

• WelTel

• Gilead Sciences

• Bristol-Myers-Squibb

• Telus

Our Team:

• Dr. Melanie Murray

• Dr. Richard Lester

• Evelyn Maan

• Annie Qiu

• Ozge Goktepe

• Kirsten Smillie

Our Team:

• Nancy Makela

• Sara O’Shaughnessy

• Jasmina Memetovich

• Jonathan Steif

• Dr. Neora Pick

• Dr. Mary Kestler

• Dr. Ariane Alimenti

• Dr. Laura Sauve

• Dr. Deborah Money

• Oak Tree Study Team

Acknowledgments

All of those who participated in the study

thank you!