1. 1 Using Mobile Phone Technology to Improve Antenatal and PMTCT Service Delivery and Uptake in Kenya Seble Kassaye, MD, MS Elizabeth Glaser Pediatric AIDS Foundation July 2012

2. Introduction Project developed in response to WHO call for implementation research – efficacious interventions to accelerate progress towards MDGs 4,5,6 Substantial loss to follow-up during PMTCT cascade despite initial high ANC uptake

3. Epidemiology *Study districts: Rachuonyo and Homabay, Nyanza province Excluding SD NVP Kiarie et al.. Evaluation of utilization and effectiveness of PMTCT services in Kenya. Kenya National PMTCT Implementers Meeting. Nairobi, Kenya: July 18-20, 2011; DHS Kenya 2009 KenyaNyanza Province* HIV Prevalence6.2%14.9% HIV Prevalence – pregnant women17.7% (18.4% &18.9%*) HTC in ANC71%** Women receiving ARVs during pregnancy for prophylaxis or treatment 81% Facility-based deliveries44% Infants receiving antiretrovirals for PMTCT 62.7% Infants tested for HIV39.6%

4. Why Use Mobile Phones Explore operational effectiveness of mobile phone technology for PMTCT Enable communication between health providers and patients, thus improving outreach for PMTCT service delivery – Reinforce key messages – Promote specific behaviors High mobile phone coverage in Kenya – National census Kenya 2010 – 63% of households have mobile phone Collaboration between EGPAF and Ministry of Health, Kenya

5. Formative Research Focus group discussions (community health workers, peer educators, PMTCT program participants and their partners): – Topics Health seeking behaviors – ANC visits – Antiretrovirals and adherence – Facility deliveries – Infant feeding – Early infant diagnosis Current phone use and ownership Preferred messaging/support for key PMTCT

6. Identified Challenges Infant follow up – for immunizations but less so for HIV testing Forget appointments Miss doses of ARVs Minimal support for Partner HTC Limited ability to Communicate for Transport support PMTCT Essential Maternal Child Health Male Partner Involvement Motivational Messages and Communication Coordination/ communication between CHWs and patients- Challenges with communication/ stigma Social environment does not encourage male participation in MCH

7. Objectives Primary To measure effect of PMTCT-focused structured SMS text messaging and calls on completion of key PMTCT cascade milestones during pregnancy up to 6-8 weeks postpartum To determine acceptability of PMTCT-focused SMS text messaging among pregnant women and male partners To evaluate cost inputs and cost estimates for scale-up of the mobile phone intervention components Secondary To determine whether male partner involvement with SMS intervention improves increased PMTCT cascade completion at six weeks postpartum.

8. Study Design Cluster randomized control study – Randomization: stratified by district and facility type i.e. hospital, health center and dispensary accounts for different volumes – Semi-automated SMS system Functional for bidirectional communication – Phone calls between health care providers and participants as appropriate

9. Health facility CHWs mHealth Platform SMS Phone calls PMTCT patient Male Partner Intervention Web-based and server Semi-automated -- Automated components -- Manual components

10. PMTCT Male Partner Involvement Motivational Messages and Communication Essential Maternal Child Health SMS Thematic Areas

11. SMS Messages Here's advice on timing of pregnancy medicines. Try to take them at the same time each day. It works better if you do! And it will help you not to forget. Some women eat less food during pregnancy to avoid a large baby. However, this is a myth. Expectant moms should eat a little more than usual for good health! After birth, give your baby only the very best, your breast milk ONLY, and no other foods or liquids for the first 6 months. Be strong against pressure. Continue exclusive breastfeeding. Breast milk has all the necessary ingredients and at the correct temperature. Exclusive breastfeeding will avoid diarrhea. Message of hope: There are women like you all over the world. They walk the same path that you do. Think of them. They will think of you. Don't lose hope. All men should know their status. And women too. This gives you peace of mind. You'll be smart, strong, and well prepared. Tell a friend to get tested too.

12. Study Outcomes Primary Outcome: proportion of women who successfully complete key PMTCT transition points from antenatal to six weeks postpartum (i) Initiation of antiretrovirals during pregnancy (ii) delivery at a health facility (iii) Infant HIV testing at 6 weeks and receipt of results

13. Study Outcomes (2) Secondary Outcomes: (i) number of antenatal care visits (ii) maternal adherence to ARVs (iii) time to initiation of ARVs (iv) uptake of ARVs during labor, delivery, and postpartum (v) exclusive breastfeeding (vi) uptake of family planning at 6 weeks postpartum

14. Pilot: April – June 2012 TotalInterventionControl Participants screened259155104 Eligible19911386 Eligible and enrolled 140 females 7 males 74 females 7 males 66 females 0 males Eligible but not enrolled 59 (29%)39 (35%)20 (23%) *Reasons for non-enrollment (N=59): (i) Newly tested, needed time to decide:11 (19%) (ii) Lacked own mobile phones: 29 (49%) (iii) Went to consult with the partner:13 (22%) (iv) Refused: 6 (10%)

15. Baseline Characteristics Age*26 years (18-27 years) Gestational age*24 weeks (16-32 weeks) Own phone21/30 (70%) Share phone4/30 (13.3%) Face to face discussion with health provider about PMTCT 15/30 (50%) Used phone (SMS or voice) to discuss PMTCT with health provider 2/29 (7%) *Median

16. HIV Status 28/30 women had been given ARVs for PMTCT during this pregnancy

17. Study Timeline July 2012 - February 2013 – enrollment January-March 2013 – Focus group discussions CHWs and Study Participants – Costing November 2013 – complete data collection December 2013 – February 2014 – Data analysis – Cost effectiveness analysis April 2014 – Final report

18. Study Limitations Factors not addressed by intervention that have an effect on PMTCT service delivery – high staff rotation and turnover lost contact with clients – commodity stock-outs – transportation costs to health facilities – culturally influenced infant feeding practices – limited technical capacity of community health workers within PMTCT – lack of male-friendly services

19. Acknowledgements EGPAF Kenya Dr. John Ongech (PI) Dr. Judith Kose Peter Savosnick Rogers Simuyu Rosemary Opiyo Aggrey Mutimba EGPAF Washington DC Dr. Rhoderick Machekano Dr. Larissa Jennings Suzanne May Ministry of Health - Kenya Dr. Martin Sirengo(co-PI) World Health Organization Dr. Nigel Rollins Funded by the World Health Organization