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 Siedner, Data Santorino, Alexander J Lankowski, Michael Kanyesigye, Mwebesa B Bwana, Jessica E Haberer, David R Bangsberg, Mark J Siedner, Data Santorino, Alexander J Lankowski, Michael Kanyesigye, Mwebesa B Bwana, Jessica E Haberer, David R Bangsberg

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.

Figures

Fig. 1
Fig. 1
Study flowchart for a combination intervention to improve HIV linkage to care in rural Uganda. Participants in the pre-intervention period served as a control group. Participants in the intervention period with CD4 count below a clinician-selected threshold were randomized to receive one of three short message service (SMS) text messages to inform them of abnormal laboratory results: 1) a direct message which stated that test results were abnormal and they should return to clinic, 2) a personal identification number (PIN)-protected message that was otherwise identical to the direct message, and 3) a coded message reading “ABCDEFG” to deliver an abnormal result message confidentially. Those who returned to clinic within seven days received a transportation incentive
Fig. 2
Fig. 2
Kaplan-Meier plots demonstrating days from abnormal CD4 count result until return to clinic (a) and days from abnormal CD4 count result until ART initiation (b). The left panels compare results for participants in the pre-intervention period (control) versus all participants in the intervention period (SMS). The right panels compare results between the pre-intervention period (control) and each of the three randomized SMS message groups (direct, PIN, and coded)

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