1. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Improved retention in HIV care following SMS reminders in Mozambique Authors: D. Joseph Davey*, W. Ponce*, O. Augusto**, E. Jetha**, D. Traca*, S. Mazivile***, C. Palha de Sousa** *ARK, Mozambique ** University of Eduardo Mondlane, Mozambique *** Provincial Director of Health, Maputo Province

2. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Background Only 74% of people who started ART in 2011 were still on treatment after 12-months (MoH). Despite various interventions to improve patient adherence the number of patients defaulting from treatment is still increasing ARK launched a study, SMSaúde or ‘SMS for health’, to test the hypothesis that sending regular SMS reminders would improve retention in HIV care among an adult population in Mozambique.

3. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 ART Cohort: Assessed for eligibility Nov 2011- Mar 2012 417 Allocated to SMS intervention 366 (31%) Exclusion criteria: 140 (38%) illiterate 99 (27%) didn’t own cell phone 106 (29%) illiterate + no phone 21 (6%) other reasons 413 Allocated to control (standard of care) Randomized (n=830) Follow-up : (mean 16 months) Nov, 2011 - May, 2013 5 (<1%) declined to participate Screened (n=1,201)

4. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 SMSaúde Study Sites HC. Machava 2 (Urban) 349 ART patients HC. Machava 2 (Urban) 349 ART patients HC. Matola (Urban) 349 ART Patients HC. Matola (Urban) 349 ART Patients HC. Namaacha (Rural) 132 ART patients HC. Namaacha (Rural) 132 ART patients

5. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 How do the SMS reminders work? 5 Electronic patient record database is connected to the SMSaúde Platform to send automatic regular reminders to patients Modem in health facility used to send SMSs over Vodacom network Patients received regular SMSs reminding them of appointments (1 week and 2 days before and 2 days after missed appointments) HIV+ pregnant women also received educational messages about the importance of antenatal & post-natal care, institutional birth and infant testing for HIV

6. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Results: Demographic information * P<0.05 ControlSMSTotalp-value Gender Female243 (58.8%)253 (60.7%)496 (59.8%) 0.59 Male170 (41.2%)164 (39.3%)334 (40.1%) Education Primary307 (74%)302 (72%)609 (73.4%) 0.479 Secondary94 (23%)102 (24%)196 (23.6%) Marital status Cohabiting212 (51%)217 (52%)429 (51.7%) 0.508 Single140 (34%)147 (35%)187 (34.6%) Married29 (7%)19 (5%)48 (5.8%) Widow32 (8%) 64 (7.7%)

7. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Incidence of loss to follow up* at 12-months per 100 person years * Loss to follow up: Patients who didn’t come in for drug pick up or clinical visit for >60 days (MoH Definition) ControlInterventionRRp-value All patients7.2 (5.2-9.9)5.2 (3.6-7.6)0.71 (0.439-1.178)0.180 Urban patients7.7 (5.5-10.9)4.2 (2.7-6.7)0.56 (0.319-0.969)0.035 Recently initiated on ART (<3 months) 13.1 (7.6-22.5)4.9 (2.0-11.7)0.37 (0.138-1.00)0.045 Urban recently initiated (<3 months) 14.9 (8.7-25.7)4.5 (1.7-12)0.30 (0.105-0.866)0.021

8. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Accumulated risk among urban patients

9. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Accumulated risk among urban, recent ART initiated (< 3 months)

10. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Stratified multivariate Cox regression analysis (urban) URBAN < 3 months on ART > 3 months on ART Factor (at enrolment)RRRR CIpRRRR CIp Receive SMS 0.240.072 - 0.767**1.240.569 - 2.685 Male 1.140.411 - 3.1692.070.937 - 4.555* > 30 years old 0.570.165 - 1.9660.600.234 - 1.545 At least secondary education 1.410.432 - 4.5900.380.127 - 1.125* Single 1.590.308 - 8.2282.351.054 - 5.249** BMI < 20 1.040.291 - 3.7343.881.743 - 8.623*** Absolute CD4 count <200 4.841.358-17.236**1.650.664 - 4.077 Live far (>5 km) 0.350.089 - 1.3880.940.350 - 2.534 *p<0.1; **p<0.05; ***p<0.01

11. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Stratified multivariate Cox regression analysis (rural) RURAL Factor (at enrolment)RRRR CIp Receive SMS 1.080.228 - 5.114 Male 3.360.677 - 16.727 > 30 years old 0.860.145 - 5.083 At least secondary education 2.460.612 - 9.892 Single 0.820.082 - 8.275 BMI < 20 1.780.383 - 8.314 Absolute CD4 count <200 2.230.517 - 9.624 Live far (>5 km) 4.661.004 - 21.612** *p<0.1; **p<0.05; ***p<0.01

12. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Summary of findings SMS reminders did not have an overall impact on retention in care, however, subgroup analysis shows that there is impact in: – Retention in ART care among urban patients – Retention in ART care among early ART patients (<3 months on treatment)

13. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Discussion SMS reminders can have a significant impact on improving retention in care, especially among urban and early-initiated ART patients. Women were less likely to own their own cell phone and were less literate, which prevented them from participating in the study. Designing m-Health strategies in rural contexts remains a challenge due to weak infrastructure, illiteracy, and cell-phone ownership.

14. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Next steps Further analysis need on: – the lack of impact in rural health facilities – cost effectiveness of intervention Continue ART follow up: for 24 months with support from USAID Test SMSaude on a larger scale: in 16 facilities in Gaza Province (rural area), targeting >70,000 patients with support from DFID

15. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Obrigada & Kanimambo! Acknowledgements: Study funded by ARK, implemented in partnership with the Ministry of Health, University of Eduardo Mondlane with support from Vodacom Thank you to: Dr Samu Dube and Sabina Morley, ARK, Ministry of Health, Mozambique Doctors, Nurses, Counselors and Data Entry staff & Patients who participated in the study.

16. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 The total number of African mobile telephone subscribers -2009