Supporting Adherence to Antiretroviral Therapy with Mobile Phone Reminders: Results from a Cohort in South India

et al. (2012) Supporting Adherence to Antiretroviral Therapy with Mobile Phone Reminders: Results from a Cohort in South India. PLoS ONE 7(8): e40723. doi:10.1371/journal.pone.0040723 Supporting Adherence to Antiretroviral Therapy with Mobile Phone Reminders: Results from a Cohort in South India Rashmi Rodrigues 0 Anita Shet 0 Jimmy Antony 0 Kristi Sidney 0 Karthika Arumugam 0 Shubha Krishnamurthy 0 George D'Souza 0 Ayesha DeCosta 0 Landon Myer, University of Cape Town, South Africa 0 1 Division of Global Health, Karolinska Institutet, Stockholm, Sweden, 2 Department of Community Health, St. John's National Academy of Health Sciences , Bangalore , India , 3 The HIVIND project, St. John's National Academy of Health Sciences , Bangalore , India , 4 Division of Chest Disease, St. John's National Academy of Health Sciences , Bangalore , India , 5 Department of Pediatrics, St. John's National Academy of Health Sciences , Bangalore , India Background: Adherence is central to the success of antiretroviral therapy. Supporting adherence has gained importance in HIV care in many national treatment programs. The ubiquity of mobile phones, even in resource-constrained settings, has provided an opportunity to utilize an inexpensive, contextually feasible technology for adherence support in HIV in these settings. We aimed to assess the influence of mobile phone reminders on adherence to antiretroviral therapy in South India. Participant experiences with the intervention were also studied. This is the first report of such an intervention for antiretroviral adherence from India, a country with over 800 million mobile connections. Methods: Study design: Quasi-experimental cohort study involving 150 HIV-infected individuals from Bangalore, India, who were on antiretroviral therapy between April and July 2010. The intervention: All participants received two types of adherence reminders on their mobile phones, (i) an automated interactive voice response (IVR) call and (ii) A non-interactive neutral picture short messaging service (SMS), once a week for 6 months. Adherence measured by pill count, was assessed at study recruitment and at months one, three, six, nine and twelve. Participant experiences were assessed at the end of the intervention period. Results: The mean age of the participants was 38 years, 27% were female and 90% urban. Overall, 3,895 IVRs and 3,073 SMSs were sent to the participants over 6 months. Complete case analysis revealed that the proportion of participants with optimal adherence increased from 85% to 91% patients during the intervention period, an effect that was maintained 6 months after the intervention was discontinued (p = 0.016). Both, IVR calls and SMS reminders were considered nonintrusive and not a threat to privacy. A significantly higher proportion agreed that the IVR was helpful compared to the SMS (p,0.001). Conclusion: Mobile phone reminders may improve medication adherence in HIV infected individuals in this setting, the effect of which was found to persist for at least 6 months after cessation of the intervention. - Funding: This work was funded by a European Commission FP7 grant for the HIVIND project. [URL: http://cordis.europa.eu/fetch?CALLER = FP7_PROJ_ EN&ACTION=D&DOC=1&CAT=PROJ&QUERY=0132a68e52ee:51ac:213dc128&RCN=90123]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors declare that no competing interests exist. Adherence to treatment in HIV is a complex phenomenon influenced by the illness, patient characteristics; healthcare system; treatment regimen and environment [1,2,3,4]. As adherence is critical to treatment success in HIV [5], a number of interventions to support adherence have been implemented. Some of the interventions used to support adherence to antiretroviral therapy (ART) include directly administered ART [6,7]; financial incentives [8]; education, counseling and social support [9]; electronic and phone reminders [10,11,12]. The popularity of mobile phones and their low cost, even in resource constrained settings, has resulted in the use of the technology in healthcare delivery. Examples of evolving uses of this technology in healthcare include data collection, behavior counseling for adherence, disease outbreak tracking and training healthcare workers in remote settings [13,14]. Of these, recent reports of the use of mobile phones for HIV disease management, including adherence, are available from the Americas and sub Saharan Africa [11,12,15,16,17]. With 800 million mobile phone connections and the relatively low cost of mobile handsets and services in India [18], mobile communication technology provides a contextually suitable opportunity for antiretroviral adherence support. Approximately 240,000 Indian HIV infected individuals receive first line ART under the National AIDS Control Program [19]. Given the prohibitive costs of second line ART, it is important that the efficacy of first-line regimens is preserved for as long as possible [20] by supporting adherence. We aimed to assess the influence of weekly mobile phone reminders on adherence to antiretroviral therapy in South India and to study their post intervention effects on adherence. Participant experiences with the intervention were also studied. To our knowledge, this is the first such report on mobile phone reminders for adherence support in India. The study was implemented at the Infectious Disease Clinic, St. Johns National Academy of Health Sciences, Bangalore, South India. This is a tertiary level, non profit, private healthcare facility. The clinic provides routine care and treatment to approximately 2,000 HIV infected individuals from within the province of Karnataka and the neighboring provinces of Andhra Pradesh, Tamil Nadu and Kerala. This quasi-experimental cohort study was conducted between March 2010 and July 2011. The participants included were (i) HIV infected adults who followed up at the clinic as outpatients (ii) had access to a mobile phone and (iii) were on ART for at least a month prior to enrollment. Patients who were participants of other adherence studies were excluded. First line ART in the setting of Indias National AIDS Control Program consists of zidovudine or stavudine, plus lamivudine plus nevirapine (or efavirenz in patients on anti tuberculosis treatment) to be taken by the patient twice daily [21]. These antiretrovirals are available free of cost to HIV infected individuals through a network of public healthcare facilities and public private partnerships. Our intervention was restricted to individuals on such first line regimens. The intervention studied was adherence support with mobile phone reminders. Each reminder comprised of two components, (i) an interactive voice response (IVR) call and (ii) a non interactive neutral picture delivered as a short message service (SMS). All participants received both com (...truncated)