1. Review on current technology HIV/AIDS care and control Will Mobile Technology "Do It"? Review on current technology Richard Lester, MD, FRCPC BCCDC / University of British Columbia University of Nairobi, WelTel July 25, 2012

2. CREDIT: http://www.armybase.us/2009/04/air-force-yields-in-f-22-fighter-dispute/

3. Can mobile (communication) technologies “Do it”?

4. mHealth-Hype? Problem Problem: People living with HIV Response Response: People on ARTPeople with mobile phones

5. HIV Cascade of care PreventionTesting Access/ Linkage to care Access to treatments (supply chain) AdherenceRetention

6. HIV Care & Prevention = prevention Access (Uptake) = prevention Adherence = prevention Retention Access + Adherence + Retention = Engagement

7. Two Randomized Controlled Trials (Kenya) March 27, 2011Nov 27, 2010 WelTel weekly SMS check-ins (two way): *24% improvement in achieving 95% adherence over 1y *19% improvement in achieving viral suppression at 1y (NNT = 9 & 11) SMS reminders/motivation (one way): *Weekly (short) messages 32% improvement in 90% adherence (MEMS) over 1y *9% decrease in treatment interruptions *No adherence improvement with daily, longer reminders *No viral load/clinical outcomes

9. 243 references ID’d to Nov 2011:

10. Bella Hwang – mHealth Summit 2011 WelTel: PEPFAR (2.485M people) Figure. Costs of SMS Intervention vs. Costs Savings over 3 years for PEPFAR Global Cohort on ART (2.485M patients) +230,000 suppressed

11. What doesn’t work?

12. Reminders or Support? adherence counselling Targeted adherence counselling persistent effect on adherence and viral suppression reminder alarm device A medication reminder alarm device no effect on adherence or viral suppression Chung et al. PLoS Med, March 2011 Lancet ID, Feb 2012 Adherence to antiretroviral therapy: supervision or support? Lancet ID, Feb 2012 http://www.thelancet.com/journals/laninf/article/ PIIS1473-3099(11)70354-1/fulltext

13. Monitoring Adherence & Results Challenges in Using Mobile Phones for Collection of Antiretroviral Therapy Adherence Data in a Resource- Limited Setting SMS and IVR Adherence Real Time Monitoring in Uganda Jessica E. Haberer 1, 2, 3, Julius Kiwanuka 4, Denis Nansera 4, Ira B. Wilson 5 and David R. Bangsberg 2, 3, 6 (1) Department of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA(2) Harvard Initiative for Global Health, Mbarara University of Science and Technology, Kampala, Uganda, online: 8 June 2010 High acceptability for cell phone text messages to improve communication of laboratory results with HIV-infected patients in rural Uganda: a crosssectional survey study. BMC Med Inform Decis Mak. 2012 Jun 21;12(1):56. [Epub ahead of print] Siedner MJ, Haberer JE, Bwana MB, Ware NC, Bangsberg DR.

15. Other cell phone studies AIDS Patient Care STDS. 2011 Mar;25(3):153-61. Epub 2011 Feb 16. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. N=19 adults Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR Trials. 2011 Jun 9;12:145. The challenges and opportunities of conducting a clinical trial in a low resource setting: the case of the Cameroon mobile phone SMS (CAMPS) trial, an investigator initiated trial. N=198 adults Mbuagbaw L, Thabane L, Ongolo-Zogo P, Lang T. AIDS Patient Care STDS. 2011 May;25(5):303-10. Epub 2011 Apr 2. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. N=40 adults Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Lancet. 2011 Aug 27;378(9793):795-803. Epub 2011 Aug 3. The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial. N=2269 children Zurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, Snow RW.

19. “mobile phone HIV” publications

20. AIDS 2012: mHealth abstracts 27 abstracts “mobile/cell phones, text message”

21. AIDS 2012: RCT2 TUPE673 - Poster Exhibition SMS messaging improves treatment outcome among the HIV-positive Mayan population in rural Guatemala » J.M. Ikeda 1, R. Barrios 2, J.B. Lopez Lopez 3, N. Hearst 4 – 226 HIV positive clients from the Integrated Care Clinic in Quetzaltenango – The mean time to viral load suppression: 7 months intervention group and 10 months control group.

22. Summary of RCT Evidence on mHealth Interventions to improve ART outcomes Adherence monitoring by SMS? - ? – not yet known if effective for adherence promotion – Challenging to implement, cost, compliance, stigma? Targeted adherence counselling? - Y – improves adherence and viral suppression (1yr) Digital alarm reminders? - N – No improvement on adherence or VL (1yr) One way cell phone SMS reminders? – N/Y – no improvement in adherence (by MEMS), for daily reminders – effective with short weekly messages. (1yr) Two-way cell phone SMS çheck-ins’/access to HCW? -Y – Improves adherence and viral suppression (1yr) Level of Evidence: Level of Evidence: Grade A (weekly SMS) Support (access to care) > Reminders?

23. My take home messages Keep it simple – Every extra step (complexity) loses someone Keep it low cost – Resource limited settings, vulnerable groups Conduct controlled studies – What really works, and what doesn’t? Seize the opportunity – mHealth is a gift

24. Can mobile (communication) technologies “Do it”?

25. Future Direction Grand Challenges Canada WelTel International mHealth SocietyFormed a non-profit organization to assist implementing the WelTel model globally (WelTel International mHealth Society). PMTCT in Kenya PMTCT in Kenya – Supported by IDRC/GHRI Current Research Projects: WelTel HAARTBC1 WelTel HAARTBC1 – Oak Tree Clinic, Vancouver – Supported by BCCDC foundation and Bristol-Myers-Squibb WelTel LTBI WelTel LTBI – BCCDC TB clinics, latent TB infection support (RCT) – Supported by BCLA, CIHR WelTel Retain WelTel Retain – Pre-ART retention in care with AMREF in Kenya – Supported by NIMH EPIC – PrEP in San Francisco – Supported by NIMH

26. Thank you www.weltel.org The future is now.