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2g. HIV/AIDS, TB: Use of Technology to Improve Patient Management in Resource Poor Settings
Computer Alert System and Telephone Support to Improve Antiretroviral Therapy Adherence
1Helios Salud, Argentina; 2Universidad de Buenos Aires; 3Infhos
Problem statement: Poor adherence to antiretroviral therapy (ART) is a major obstacle to successful treatment outcomes. There is evidence that telephone support improves adherence. In developing countries, mobile phones are widely used and are emerging as a new tool in health care communication. The registry of medication dispensed is an indirect method to assess adherence with acceptable sensitivity and specificity.
Objectives: To evaluate the efficacy of strategies of a computer alarm system and telephone support implemented to increase and maintain ART adherence
Design: Retrospective intervention comparative cohort study; the comparator referred to is year 2006. In 2007, a newly installed computer alert system began to identify any delay of ART dispensing. Adherence strategies of telephone support were applied. Results for 2007, 2008, and 2009 were compared to 2006. The rates of dispensed ART were compared as indirect indicators of adherence.
Setting: This study was realized at a private, specialized, medical center in Buenos Aires City and affiliates in the provinces where interdisciplinary HIV/AIDS attention is provided.
Study population: The whole population in follow-up was retrospectively studied from 2006 to 2009. At baseline year 2006, there were 3,319 patients being followed up: mean age (SD) 37.0 (11.5) years, male 67.8%, ART 75.5%. In 2007 3,430 patients, 37.3 (11.3) years, male 66.9%, ART 77.5%; in 2008, 4,040 patients, 37.7(11.2) years, male 67.7%, 76.5% on ART; in 2009, 4,584 patients, 38.4 (11.4) years, male 67.5%, ART 77.2%.
Intervention: A computer program was designed to alert health staff about a delay in patients’ visits for medication dispense for the following period. Psychologists, social workers, and peer support were trained to contact those patients.
Outcome measure: To assess efficacy of intervention in the yearly rate of pharmacy dispensing visits with respect to baseline
Results: The rate of medication dispensing visits showed a statistically significant increase with respect to baseline in 2007 (81.4%; 95% CI: 80.97-81.88; p = 0.001), 2008 (81.0%; CI: 95%: 80.52 - 81.37; p = 0.004), 2009 (83.2%; CI: 95%: 82.85-83.60, p < 0.001), and the first 4 months in 2010 (88.9%; CI: 95%: 88.33-89.40, p < 0.0001). The rate of viral load was < 50 copies/mL; lab results showed a statistically significant increase with respect to the baseline. The rate of CD4 T-cell count remained stable or slightly increased with no statistical significance.
Conclusions: Findings show that centralized data generation of pharmacy dispensing, computer alarm for any delay and telephone support improves long-term adherence to ART and clinical outcomes.
Funding sources: Helios Salud
Effects of a Mobile Phone Short Message Service (SMS) on Antiretroviral Treatment Adherence in Kenya (WelTel Kenya1): A Randomized Trial
1University of British Columbia, Canada; 2University of Nairobi, WHO Collaborative Centre for HIV/STD Research and Training, Kenya; 3US Centers for Disease Control and Prevention, Kenya Branch; 4University of Manitoba, Canada
Problem statement: Mobile (cell) phone communication has been suggested as a method to improve delivery of health services; however, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited.
Objectives: We aimed to assess whether mobile phone communication between health care workers and patients starting antiretroviral therapy in Kenya improved medicine adherence and suppression of plasma HIV-1 RNA load.
Design: We conducted a multisite 1:1 randomized controlled adherence-support intervention trial.
Setting: Three different HIV clinics in Kenya were recruited. One university clinic serves a very low-income population in Nairobi. A second operates out of a faith-based hospital located in a higher income area of Nairobi. The third is a government health centre in a large rural district.
Study population: Patients were eligible to participate if they were initiating ART and if they owned a cell phone or shared access with a consenting partner. Consecutive enrolment was attempted. Between May 2007 and October 2008, 581 patients were screened, and we randomly assigned 538 to the SMS intervention (n = 273) or to standard care (n = 265). Of these, 222/275 (81%) and 204/265 (77%), respectively, completed the study.
Intervention: Patients in the intervention group received weekly SMS message inquiries from a clinic nurse and were required to respond within 48 hours. Patients that indicated a problem or did not respond were called to help triage any problem. Advice was given when appropriate.
Policy: Routine cell phone communication with patients was not part of standard care.
Outcome measures: Primary outcomes were self-reported ART adherence (>95% of prescribed doses in the past 30 days at both 6- and 12-month follow-up visits) and plasma HIV-1 viral RNA load suppression (<400 copies/mL) at 12 months. The primary analysis was by intention to treat.
Results: Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk [RR] for nonadherence 0.81, 95% CI 0.69–0.94; p = 0.006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0.84, 95% CI 0.71–0.99; p = 0.04). The number needed to treat (NNT) to achieve greater than 95% adherence was 9 (95% CI 5.0–29.5), and the NNT to achieve viral load suppression was 11 (5.8–227.3).
Conclusions: Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcomes in resource-limited settings.
Funding source(s): US President’s Emergency Plan for AIDS Relief
Using Mobile Technology to Strengthen HIV/AIDS Management in Remote Areas
1Management Sciences for Health/Strengthening Pharmaceutical Systems (MSH/SPS).; 2Ministry of Health and Social Services (MoHSS)
Problem Statement: Namibia is the second most sparsely inhabited country in the world. Vast distances have to be travelled to district hospitals which can greatly compromise quality of care and services resulting in patients being non-adherent in attending clinic appointments and medicine collection. To improve access to antiretroviral therapy (ART) services, the MoHSS has decentralized ART services to clinics and health centers in remote areas of Namibia. Data capturing and management at outreach sites was a challenge resulting in duplication of work. The staff at the outreach site had to use paper records and then use those records to update the Electronic Dispensing Tool (EDT) upon return to the main antiretroviral therapy (ART) facility site. Furthermore, data for outreach sites would often be missing or incomplete and therefore monitoring patients and quantifying medicines presented challenges.
Intervention: SPS supported the MoHSS in developing the EDT mobile using a hand-held scanner. The device has the same functionality of the EDT in that it enables dispensing, monitoring adherence through pill counts, setting patient appointments, and managing stock. Data from the EDT is uploaded onto the scanner at the main site before an outreach visit is done. The scanner is then used to dispense medicines at the outreach site, and upon return to the main site, the primary EDT is updated with information from the scanner. At this stage, patient and stock records are updated.
Results: (1)14 % (12,320) of all ART patients are serviced at outreach sites through the EDT-mobile; (2) Speed and accuracy of dispensing at outreach sites increased as dispensing is automated and labels printed. The need for double recording was eliminated thus freeing staff to perform other critical tasks. (3) Improved stock control at outreach sites due to accurate data on quantities of each antiretroviral (ARV) dispensed at the outreach site; (4) Improved patient and data management at outreach sites allowed for patient monitoring, stock management, and quantification of ARVs; (5) The need to computerize smaller outreach sites as had been envisaged was eliminated, thus saving on costs; and (6) Pill counts could be recorded which helps to objectively assess patient adherence as well as the facility average adherence.
Conclusion: The EDT mobile scanner is a fast, cost-effective and efficient way to manage ART records in remote settings. Because it uses batteries, the scanner can be employed in areas where there is no electricity. The record holding capacity of the scanner enables use for multiple outreach sites and eliminates the need to update the EDT daily (updates can be done monthly or quarterly). EDT mobile is effective to use where record management is essential, but installation of a desktop computer is not feasible. This novel concept is recommended for data management in sparsely populated and resource limited countries like Namibia.
Funding Source: US Agency for International Development/Namibia
Supporting Adherence to Antiretroviral Therapy Using Mobile Phone Reminders In South India
1St Johns National Academy of Health Sciences, India; 2Division of Global Health, Karolinska Institutet, Stockholm, Sweden
Problem statement: The success of antiretroviral therapy (ART) is compromised by poor adherence leading to resistance and treatment failure. In India, 0.3 million HIV-positive patients are on ART and up to 40% are reported not to be optimally adherent to treatment. Therefore, interventions that are contextually feasible to promote adherence are necessary to prevent resistance and prolong life. Given the ubiquity of mobile phones in India, mobile phone based interventions for improving adherence hold promise.
Objective: (1) To test the hypothesis that mobile phone reminders improve adherence to medication in HIV-positive patients on ART, (2) To assess participant experiences with the intervention over a period of 6 months.
Study Design and Sample: Quasi-experimental time series design involving 150 HIV positive patients aged 18–60years who have been on ART for at least one month and have a mobile phone.
Study Setting: The infectious disease clinic, St. John’s National Academy of Health Sciences from April to November 2010.
Intervention: All participants received two types of adherence reminders on their mobile phones, i.e., an automated interactive voice call (IVR) and a non-interactive neutral picture short message service (SMS) once a week for 6months. Participants adherence was assessed at baseline followed by months 1, 3, 6, 9, and 12 using the pill count. All participants were trained to receive the IVRs and SMS. Adequate adherence was defined as an adherence rate 95%. An interviewer administered questionnaire assessed participant experiences at week 24.
Outcome Measure: Change in adherence over time during the intervention, suatainability of this effect for 6months post intervention and participant experiences at the end of the intervention period. Statistical analysis involved frequencies, measures of central tendency and dispersion, Wilcoxon signed rank test, and Cochran’s Q.
Results: The mean age of the participants was 39±7.7yrs, 27% were female and 90% urban. The median duration of ART was 65 weeks. Over the 24-week period, 4,103 IVRs and 3,073 SMSs were sent to the 150 participants. Of the IVRs, 87% were accessed by the participants while 59% of the participants reported viewing the SMSs at least once in the 6th month of the intervention. The proportion of participants adequately adherent to medication was 86%, 93%, 94%, 92%, 95%, 94% at baseline, months1, 3, 6, 9, and 12, respectively (p=0.001). At the end of 6 months, 74% of the participants preferred voice calls with or without the SMS, 10% preferred only the SMS and 16% preferred neither. The IVR was considered more helpful than the SMS (p<0.001). Both components of the intervention were not perceived as intrusive by the participants (p>0.05).
Conclusion: Mobile phone reminders were found acceptable for adherence support in the context of HIV in South India. Interactive voice calls were preferred over SMSs. The proportion of participants adherent to medication increased during the study. Improvement in adherence persisted even after the cessation of the intervention.
Funding Source: EU-FP 7, HIVIND grant
Monitoring Drug Resistant Tuberculosis Treatment in Brazil through an Innovative Web-Based Information System
1Projeto MSH (Management Sciences for Health), SPS (Strengthening Pharmaceutical Systems), Brazil; 2Centro de Referência Professor Hélio Fraga, Fiocruz, Ministry of Health, Brazil
Setting: All patients with multidrug-resistant tuberculosis (MDR-TB) cases treated in Brazil have been notified and followed-up through the web-based management information system (e-TB Manager) accessed by all references health facilities and TB coordinations countrywide. Since 1999, all MDR-TB patients have been treated for a 18-24-months duration by a standardized regimen of quality-assured amikacin, ofloxacin (changed to levofloxacin in 2009), ethambutol, terizidone, and clofazimine (changed to pyrazinamide in 2004) provided free of charge by the Ministry of Health.
Methods: The e-TB Manager was developed and implemented by the partnership between Projeto MSH and Centro de Referência Prof. Hélio Fraga since 2004, allowing online extraction of epidemiological reports, such as incidence, prior treatment history, treatments outcomes, adverse reactions, co-morbidities, and clinical and radiological presentation, among others.
Results: From January 2000 to December 2010, 4,049 new MDR-TB cases (and 437 retreatment cases) were notified in Brazil. Among them, 15% referred one previous TB treatment, 34% referred two, 47% referred three or more, and only 4% referred no previous TB treatment. Of these cases, 98% were pulmonary; 65% bilateral cavitary, and 17% unilateral cavitary. Related adverse reactions were experienced by 43.5% of registered patients, with the following frequency: 60% skin hyperpigmentation, 38% joint pain, 22% gastrointestinal intolerance, 18% hearing disorders, 17% insomnia, 14% headache, and 14% psyche disorder; 33% related comorbidities were recorded, among them, 15% alcoholism, 8% diabetes, 7% AIDS, and 6% use of illicit drugs; 99% were tested for HIV with 8% positive results. Treatments outcomes registered from 2000 to 2008 for 3,053 cases show a significant increase of cure rate from 47 to 62%, while the death rate was reduced from 24 to 11%. The failure rate was reduced from 20 to 10%, but the default rate remains around 9%—probably related to adverse drug effects, diverse co-morbidities, and other risk factors. Based on survival analysis, MDR-TB patients not treated with directly observed therapy (DOT) presented almost 3 times more treatment default than those treated with DOT.
Conclusions: The e-TB Manager is an innovative tool that provides a rapid extraction of key data and epidemiologic reports so action can be rapidly taken and resources strategically allocated. Data collected show the severity of the pulmonary disorders after many irregular previous treatments for TB. Regular monitoring of adverse reactions, such as hearing and psyche disorders were crossed with data recorded by physician for adequate drug substitutions. Alcoholism and use of illicit drugs contributed to lower patients’ adherence. Treatments outcomes are improving progressively, a consequence of permanent assistance network strengthening for better diagnosis, clinical practices, and information sharing at all levels. DOT could reduce substantially the treatment default, and appears as a crucial element to increase treatment efficacy in MDR-TB.
Funding source: Information not provided