SMS to promote retention
About the project
In recent years, it has been observed that many patients who begin antiretroviral therapy (ART) do not continue beyond the first two years. This is despite the fact that ART is a lifelong treatment course and that stoppages or breaks in treatment will likely to lead to a rapid deterioration in health. In Sub-Saharan Africa, rates of attrition from ART programmes are particularly high. One systematic review found that 40% of patients are lost from after two years, 21% of these in just the first six months of treatment (Rosen and Fox, 2007).
SMS messages as support to HIV/AIDS patients
The intervention to be evaluated takes aim at these high rates of patient attrition and employs an everyday technology, the mobile phone, to promote healthy behaviours. Specifically, the intervention is an SMS support system for patients beginning or in the early years of treatment.
Randomly selected participants recruited from health centres across the country will receive weekly SMS reminders. These SMS will encourage patients to take their pills and remind them of the importance of ART for their health.
The intention is to serve as an immediate and consistent means of patient follow-up. In regions where contact with health personnel is limited and distances to health centres may be considerable, this follow-up has high impact potential.
The immediate intended outcomes are enhanced retention and adherence (i.e. pill-taking) to antiretroviral therapy. Ultimately, improvements in patient health are also desired. The intervention will run for an initial period of two years.
This evaluation will address the following questions:
- Do SMS reminders promote retention in HIV treatment programmes and encourage adherence to antiretroviral regimens?
- Are health outcomes improved as patients receive SMS reminders?
- Are subjective health outcomes improved as patients receive SMS reminders?
- Can message fatigue be observed in the medium to long-term?
- Do the type (text versus picture) and the frequency (once a week versus twice a week) of the SMS have a differential impact?
- Are patients receiving the SMS messages more likely to work?
- Have patients receiving the messages a better nutritional status?
The primary outcomes of the study will thus be retention in care (measured as the proportion of patients who remain in treatment programmes), adherence to treatment (measured as the proportion of pills taken of those prescribed), and patient health. Patient health will be monitored by two biomarkers —CD4 counts and BMI—as well as by incidence of co-infection, mortality, and subjective health ratings.
The experiment itself
Treatment arms will vary by message content. Formal versus informal messages and reminders framed in terms of health gains versus health risks will be evaluated. Participants will thus be randomly assigned to one of five groups:
- Group 0 serves as the control and will not receive any SMS reminders
- Group 1 receives one SMS text message per week. The message content varies over time.
- Group 2 receives two SMS text messages per week with varying message content.
- Group 3 receives one SMS text message every Monday and one SMS ASCII picture based message every Friday
- Group 4 receives one SMS ASCII picture based message per week.
All groups will receive the same standard of care. Along with periodic clinical check-ups and treatment counseling, this includes routine monitoring of patient CD4 cells and viral load as measures of disease progression. Adherence support and/or additional treatment counseling may also be provided at the community level. This will be assessed during follow-up surveys (see below).
For groups 1-4, messages will be sent on a weekly basis. A total of 4-8 monthly text messages will thus be sent to each participant assigned to groups 1-4.
The study started with the baseline survey in February 2015. Patients on antiretroviral regimen were enrolled in the study from February to March 2015. More than 3,800 people living with HIV across Burkina Faso are participating in the study.
The participants were randomly assigned to one of the four SMS interventions or a control group with the first text messages being sent out on Monday, October 5, 2015.
We conducted the first follow-up survey between April and May 2016, i.e. roughly six months after the start of the intervention. A second follow up survey was conducted between October and December 2016 and a third follow up survey between October and December 2017.