Text messaging can improve treatment adherence in HIV patients


NOVEMBER 9, 2010

A trial in Kenya has shown that using text messages to help patients adhere to their treatment improves absolute adherence rates by 12% and numbers achieving viral load suppression by 9%. The results of the WelTel Kenya1 study are reported in an Article Online First and in an upcoming Lancet, written by Dr Richard Lester, British Columbia Centre for Disease Control, Vancouver, BC, Canada, and colleagues. The study is being presented at the 2010 ‘m Health’ Summit in Washington, DC, USA.

The number of cell phone users is rapidly expanding (4•5 billion cell phone subscribers are expected worldwide by 2012), mainly because of free market forces (ie, capitalism) and the demand for rapid wireless communications for personal use and to aid multisector economic development (eg, trade, tourism, and infrastructure); thus, mobile technology has the potential to be used in health systems worldwide. A wide range of medical services could be improved by providing patient-focused support and anagement
through the health-care system.

This study aimed to assess whether cell phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. The randomised trial assessed HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients received a cell phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h.


Patients in the control group received standard follow-up without text messages. (The standard of care, which includes limited in person counselling with each clinic visit). 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 per mL) at 12 months.


Typically, the slogan “Mambo?” was sent, which is Kiswahili for “How are you?” The health workers used multiple recipient (bulk) messaging functions to improve efficiency. Patients in the intervention group were instructed to respond within 48h that either they were doing well (“Sawa”) or that they had a problem (“Shida”). The clinician then called patients who said they had a problem or who failed to respond within 2 days.

Between May, 2007, and October, 2008, a total of 538 participants were allocated either to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 (62%) patients receiving the SMS intervention compared with 132 of 265 (50%) in the control group. Suppressed viral loads were reported in 156 of 273 patients (57%) in the SMS group and 128 of 265 (48%) in the control group. One extra patient would achieve adherence for every nine patients using the SMS service; while one extra person would achieve viral suppression for every 12 treated in the SMS group.

The authors say: “This study shows that mobile health innovations can improve HIV treatment outcomes. Patients who received the SMS support were more likely to report adherence to ART and were more likely to have their viral load suppressed below detection levels than patients who received the standard care alone.”

Furthermore, they point out that, because only 3•3% of the weekly text messages identified a definitive requirement for follow-up (Shida), one nurse could potentially manage 1000 patients by SMS and expect to call only 33 patients per week.  The authors point out The SMS intervention is inexpensive (each SMS costs about US$0•05, equivalent to $20 per 100 patients per month, and follow-up voice calls averaged $3•75 per nurse per month) and the cell phone protocol uses existing infrastructure. This protocol is also probably less expensive than in-person community adherence interventions, on the basis of travel costs alone.

The authors conclude: “The applicability of this study to other countries and other diseases remains to be assessed. Factors that influence adherence are often common within Africa and other global settings. Although the uptake of wireless telecommunication devices is becoming ubiquitous, introduction of mobile health initiatives is variable. We believe that the patient-centred communication effect, in
particular the timely support of a patient by a health professional, is universal and can be improved by mobile telecommunication.”

In a linked Comment Dr Benjamin H Chi and Dr Jeffrey S A Stringer, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia and University of Alabama School of Medicine, Birmingham, AL, USA, say: “In sub-Saharan Africa, the science of implementation—particularly focusing on patients’ adherence and retention—has understandably lagged behind the rapid pace of programme expansion. In this regard,
WelTel is an important step forward, one that shows the promise of technology to assist in settings where high-disease burden and resource constraints threaten a programme’s success. However, technology-based approaches represent only one of many effective means that should be considered by policy makers and health providers to improve adherence to antiretrovirals. A comprehensive multipronged approach tailored to the specific needs of individual local settings must be used if maximum gains in patients’ health are to be realised.”

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