Results from a text message intervention for HIV treatment adherence highlight the challenges that remain around using mobile interventions for health, as study failed to have significant effect.
A text message intervention designed to promote antiretroviral treatment (ART) adherence failed to demonstrate a significant impact on rates of viral suppression among people living with HIV failing second line-treatment.
In this randomised control trial across nine low- and middle-income countries (LMICs), the mobile phone intervention over 48 weeks only marginally improved HIV-related outcomes compared to people receiving a standard of care (SOC) package. The study aimed to assess whether a two-way mobile phone-based communication intervention would increase HIV treatment success by improving treatment adherence, as measured by viral load readings.
Among those receiving the intervention, rates of viral suppression were 66% compared to 62% in the SOC arm, equating to a statistically insignificant absolute difference of just 3.6%. Viral failure rates fared slightly better, at a small but significant difference of 26% of patients in the intervention compared to 34% in the SOC arm with confirmed virological failure.
The study took place in 17 sites across countries in Africa, Asia and the Americas, and was embedded in an existing trial assessing strategies for ART after second-line failure. A total of 545 individuals were enrolled in the main study, of whom 521 (96%) were randomly assigned to the mobile phone intervention group (n=257) or the SOC group (n=264). The mobile intervention involved a text intervention asking the patient, “Everything OK?” in the local language, which were sent once daily for the first eight weeks and then weekly thereafter until 48 weeks after they entered the study.
Other studies previously indicated that patients preferred the weekly method, but the daily approach was used because investigators hypothesised that a more intensive intervention might be needed for this group of treatment experienced individuals with adherence challenges.
Patients were expected to call a central number upon receiving the text, which indicated that they were not experiencing any issues. This was called a flashback and was free for a participant to do. Failure to flashback more than three times over the intensive period and two times over the less intensive periods resulted in a call back from trained personnel. The personnel would then individualise adherence support through problem solving with the patient.
Investigators hypothesised that an absence of positive effect of the intervention may have been the result of insufficient training of the intervening personnel, a lack of time on their part to determine barriers to adherence and identify strategies for overcoming them, or logistical difficulties with delivering and receiving messaging and subsequent communication. Interaction was not monitored between the personnel and the patient.
Other limitations may be the fact that patients have had other reasons for treatment failure in the past besides being non-adherent (i.e. drug stock-outs), and so the intervention was not adequately designed to address these issues. In addition, the frequency of messaging may have impacted the overall effect of the results, with patients preferring weekly instead of daily messaging. We don’t have enough previous research into interventions that use the flashback approach to understand whether there are any limitations in the approach that could have affected efficacy.
Few studies have investigated the effect of text message interventions on adherence to ART, and just three have used viral load as an outcome. Notably, the WelTel Kenya One mobile phone-based intervention using two-way communication by text message found a higher proportion of patients adhered to medicine and had better viral outcomes than usual care. Other studies relied on indicators of treatment success including self-reported adherence, pill counts and electronic monitoring of medication package opening. The results from the current study are also the first data reported on individuals with multiple previous treatment failures.
“Despite the promise of mobile technology for health-care interventions in LMICs, they might be more difficult to implement than previously anticipated,” note the authors in their discussion.
“The amount of tracking, number of calls made, and the amount of time needed per participant might have been too burdensome for sites to implement fully. The logistics of implementing technological solutions in settings where power and mobile phone infrastructure are less robust might impede the ability of an intervention to fully take advantage of these solutions.”
Despite the surge in mobile use in low-resourced countries and the potential for their use in health settings, there remain significant unanswered questions regarding their efficacy for HIV adherence outcomes. The authors note that future research should focus on all factors that may be influencing treatment failure, and interventions that may depend less on infrastructure and staff time.
The study was published in the inaugural issue of a new Open Access journal by the Lancet, the Lancet Digital Health, which aims to release high-quality original research, comment, and correspondence contributing to promoting digital technologies in health practice worldwide.
By Caitlin Mahon