A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study

Siedner et al. BMC Medicine (2015) 13:160 DOI 10.1186/s12916-015-0397-1 Medicine for Global Health RESEARCH ARTICLE Open Access A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study Mark J. Siedner1*, Data Santorino2, Alexander J. Lankowski3, Michael Kanyesigye2, Mwebesa B. Bwana2, Jessica E. Haberer4 and David R. Bangsberg1 Abstract Background: Up to 50 % of HIV-infected persons in sub-Saharan Africa are lost from care between HIV diagnosis and antiretroviral therapy (ART) initiation. Structural barriers, including cost of transportation to clinic and poor communication systems, are major contributors. Methods: We conducted a prospective, pragmatic, before-and-after clinical trial to evaluate a combination mobile health and transportation reimbursement intervention to improve care at a publicly operated HIV clinic in Uganda. Patients undergoing CD4 count testing were enrolled, and clinicians selected a result threshold that would prompt early return for ART initiation or further care. Participants enrolled in the pre-intervention period (January – August 2012) served as a control group. Participants in the intervention period (September 2012 – November 2013) were randomized to receive daily short message service (SMS) messages for up to seven days in one of three formats: 1) messages reporting an abnormal result directly, 2) personal identification number-protected messages reporting an abnormal result, or 3) messages reading “ABCDEFG” to confidentially convey an abnormal result. Participants returning within seven days of their first message received transportation reimbursements (about $6USD). Our primary outcomes of interest were time to return to clinic and time to ART initiation. Results: There were 45 participants in the pre-intervention period and 138 participants in the intervention period (46, 49, and 43 in the direct, PIN, and coded groups, respectively) with low CD4 count results. Median time to clinic return was 33 days (IQR 11–49) in the pre-intervention period and 6 days (IQR 3–16) in the intervention period (P < 0.001); and median time to ART initiation was 47 days (IQR 11–75) versus 12 days (IQR 5–19), (P < 0.001). In multivariable models, participants in the intervention period had earlier return to clinic (AHR 2.32, 95 %CI 1.53 to 3.51) and earlier time to ART initiation (AHR 2.27, 95 %CI 1.38 to 3.72). All three randomized message formats improved time to return to clinic and time to ART initiation (P < 0.01 for all comparisons versus the pre-intervention period). Conclusions: A combination of an SMS laboratory result communication system and transportation reimbursements significantly decreased time to clinic return and time to ART initiation after abnormal CD4 test results. Trial registrations: Clinicaltrials.gov NCT01579214, approved 13 April 2012. Keywords: HIV/AIDS, Sub-Saharan Africa, Clinical trial, Short message service, Financial incentive, Antiretroviral therapy * Correspondence: 1 Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA Full list of author information is available at the end of the article © 2015 Siedner et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Siedner et al. BMC Medicine (2015) 13:160 Background Despite expanded access to antiretroviral therapy (ART) [1], programs in resource-limited settings continue to document high mortality rates during early stages of disease [2–4]. An important contributor to poor outcomes is suboptimal retention of patients between HIV diagnosis and ART initiation [5], when mortality rates are highest [6, 7], and approximately 20–50 % of patients are lost to care [8–10]. Structural barriers to care in resource-limited settings, including transportation costs and absence of communication between providers and patients, are major contributors to poor linkage [11–14]. Communication of critical clinical information to patients in the community represents a particular challenge. For example, reporting and responding to abnormal clinical investigations typically requires patients to return for a repeat clinical visit, which comes at significant cost and time away from economic activity for patients [15]. In cases of an indication for ART initiation, treatment failure, severe treatment complications, or evidence of opportunistic infection, such reporting and intervention delays result in adverse outcomes and/or compromise future treatment options. Scalable interventions that mitigate structural barriers to clinical care in resource-limited settings are urgently needed. Mobile health (mHealth) applications hold promise in this area by leveraging existing cellular phone infrastructure to improve patient-provider communication and prioritize care delivery for those most in need. Cellular phone coverage in sub-Saharan Africa increased from 5 to 70 % of the population during the past decade, while personal subscriptions increased from 16 to 380 million [16, 17]. While short message service (SMS) reminders have been shown to improve ART adherence [18, 19], there has been limited data to evaluate the efficacy of mHealth interventions to improve clinical care. We previously reported results of a survey to assess the acceptability of an SMS-based laboratory results notification system to communicate abnormal laboratory results to patients at a publicly operated HIV clinic in rural, southwestern Uganda [20]. We found that acceptance was nearly 100 % and that benefits of improved patient-provider communication outweighed potential concerns about breaches of confidentiality. We now report results of a follow-up intervention trial to evaluate an mHealth laboratory result notification system coupled with transportation stipends to improve care for people living with HIV undergoing critical laboratory tests in rural Uganda. We hypothesized that the mHealth application coupled with transportation reimbursements would reduce time to clinic return and time to ART initiation for patients with low CD4 count results. Page 2 of 11 Methods Study population and eligibility criteria Study participants were enrolled from a publicly operated President’s Emergency Plan for HIV/AIDS Relief (PEPFAR)-supported HIV clinic at the Mbarara Regional Referral Hospital in Mbarara, Uganda. Eligibility criteria included: a) current enrollment at the adult HIV clinic, b) self-rep (...truncated)