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      Supporting Adherence to Antiretroviral Therapy with Mobile Phone Reminders: Results from a Cohort in South India

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          Abstract

          Background

          Adherence is central to the success of antiretroviral therapy. Supporting adherence has gained importance in HIV care in many national treatment programs. The ubiquity of mobile phones, even in resource-constrained settings, has provided an opportunity to utilize an inexpensive, contextually feasible technology for adherence support in HIV in these settings. We aimed to assess the influence of mobile phone reminders on adherence to antiretroviral therapy in South India. Participant experiences with the intervention were also studied. This is the first report of such an intervention for antiretroviral adherence from India, a country with over 800 million mobile connections.

          Methods

          Study design: Quasi-experimental cohort study involving 150 HIV-infected individuals from Bangalore, India, who were on antiretroviral therapy between April and July 2010. The intervention: All participants received two types of adherence reminders on their mobile phones, (i) an automated interactive voice response (IVR) call and (ii) A non-interactive neutral picture short messaging service (SMS), once a week for 6 months. Adherence measured by pill count, was assessed at study recruitment and at months one, three, six, nine and twelve. Participant experiences were assessed at the end of the intervention period.

          Results

          The mean age of the participants was 38 years, 27% were female and 90% urban. Overall, 3,895 IVRs and 3,073 SMSs were sent to the participants over 6 months. Complete case analysis revealed that the proportion of participants with optimal adherence increased from 85% to 91% patients during the intervention period, an effect that was maintained 6 months after the intervention was discontinued (p = 0.016). Both, IVR calls and SMS reminders were considered non-intrusive and not a threat to privacy. A significantly higher proportion agreed that the IVR was helpful compared to the SMS (p<0.001).

          Conclusion

          Mobile phone reminders may improve medication adherence in HIV infected individuals in this setting, the effect of which was found to persist for at least 6 months after cessation of the intervention.

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          Most cited references38

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          Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries?

          Warren A. Kaplan (2006)
          Background The ongoing policy debate about the value of communications technology in promoting development objectives is diverse. Some view computer/web/phone communications technology as insufficient to solve development problems while others view communications technology as assisting all sections of the population. This paper looks at evidence to support or refute the idea that fixed and mobile telephones is, or could be, an effective healthcare intervention in developing countries. Methods A Web-based and library database search was undertaken including the following databases: MEDLINE, CINAHL, (nursing & allied health), Evidence Based Medicine (EBM), POPLINE, BIOSIS, and Web of Science, AIDSearch (MEDLINE AIDS/HIV Subset, AIDSTRIALS & AIDSDRUGS) databases. Results Evidence can be found to both support and refute the proposition that fixed and mobile telephones is, or could be, an effective healthcare intervention in developing countries. It is difficult to generalize because of the different outcome measurements and the small number of controlled studies. There is almost no literature on using mobile telephones as a healthcare intervention for HIV, TB, malaria, and chronic conditions in developing countries. Clinical outcomes are rarely measured. Convincing evidence regarding the overall cost-effectiveness of mobile phone " telemedicine" is still limited and good-quality studies are rare. Evidence of the cost effectiveness of such interventions to improve adherence to medicines is also quite weak. Conclusion The developed world model of personal ownership of a phone may not be appropriate to the developing world in which shared mobile telephone use is important. Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy, but its magnitude is unknown. One advantage, however, of telephones with respect to adherence to medicine in chronic care models is its ability to create a multi-way interaction between patient and provider(s) and thus facilitate the dynamic nature of this relationship. Regulatory reforms required for proper operation of basic and value-added telecommunications services are a priority if mobile telecommunications are to be used for healthcare initiatives.
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            The use and interpretation of quasi-experimental studies in infectious diseases.

            Ilene H Zuckerman, Douglas Bradham, Eli Perencevich … (2004)
            Quasi-experimental study designs, sometimes called nonrandomized, pre-post-intervention study designs, are ubiquitous in the infectious diseases literature, particularly in the area of interventions aimed at decreasing the spread of antibiotic-resistant bacteria. Little has been written about the benefits and limitations of the quasi-experimental approach. This article outlines a hierarchy of quasi-experimental study design that is applicable to infectious diseases studies and that, if applied, may lead to sounder research and more-convincing causal links between infectious diseases interventions and outcomes.
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              Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy.

              Elke S. Backman, Paul R Skolnik, Anela Stanic … (2011)
              Adherence to antiretroviral therapy (ART) represents one of the strongest predictors of progression to AIDS, yet it is difficult for most patients to sustain high levels of adherence. This study compares the efficacy of a personalized cell phone reminder system (ARemind) in enhancing adherence to ART versus a beeper. Twenty-three HIV-infected subjects on ART with self-reported adherence less than 85% were randomized to a cellular phone (CP) or beeper (BP). CP subjects received personalized text messages daily; in contrast, BP subjects received a reminder beep at the time of dosing. Interviews were scheduled at weeks 3 and 6. Adherence to ART was measured by self-report (SR, 7-day recall), pill count (PC, past 30 days at baseline, then past 3 weeks), Medication Event Monitoring System (MEMS; cumulatively at 3 and 6 weeks), and via a composite adherence score constructed by combining MEMS, pill count, and self report. A mixed effects model adjusting for baseline adherence was used to compare adherence rates between the intervention groups at 3 and 6 weeks. Nineteen subjects completed all visits, 10 men and 9 females. The mean age was 42.7 ± 6.5 years, 37% of subjects were Caucasian and 89% acquired HIV heterosexually. The average adherence to ART was 79% by SR and 65% by PC at baseline in both arms; over 6 weeks adherence increased and remained significantly higher in the ARemind group using multiple measures of adherence. A larger and longer prospective study is needed to confirm these findings and to better understand optimal reminder messages and user fatigue.
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 27 August 2012
                Volume: 7
                Issue: 8
                Electronic Location Identifier: e40723
                Affiliations
                [1 ]Division of Global Health, Karolinska Institutet, Stockholm, Sweden
                [2 ]Department of Community Health, St. John's National Academy of Health Sciences, Bangalore, India
                [3 ]The HIVIND project, St. John's National Academy of Health Sciences, Bangalore, India
                [4 ]Division of Chest Disease, St. John's National Academy of Health Sciences, Bangalore, India
                [5 ]Department of Pediatrics, St. John's National Academy of Health Sciences, Bangalore, India
                University of Cape Town, South Africa
                Author notes

                Competing Interests: The authors declare that no competing interests exist.

                Conceived and designed the experiments: RR AD AS GD KS. Performed the experiments: AD AS RR JA KS SK. Analyzed the data: RR AS KA. Contributed reagents/materials/analysis tools: GD AS. Wrote the paper: RR AS JA KS KA SK GD AD.

                Article
                Publisher ID: PONE-D-11-19032
                DOI: 10.1371/journal.pone.0040723
                PMC ID: 3428344
                PubMed ID: 22952574
                SO-VID: 58ca5c88-52b2-4577-bfb8-98df0e5ca4e2
                Copyright statement: Copyright @ 2012
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 26 September 2011
                Date accepted : 13 June 2012
                Page count
                Pages: 7
                Funding
                This work was funded by a European Commission FP7 grant for the HIVIND project. [URL: http://cordis.europa.eu/fetch?CALLER=FP7_PROJ_EN&ACTION=D&DOC=1&CAT=PROJ&QUERY=0132a68e52ee:51ac:213dc128&RCN=90123]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Subject: Medicine
                Subject: Clinical Research Design
                Subject: Cohort Studies
                Subject: Epidemiology
                Subject: Longitudinal Studies
                Subject: Prospective Studies
                Subject: Global Health
                Subject: Infectious Diseases
                Subject: Sexually Transmitted Diseases
                Subject: AIDS
                Subject: Viral Diseases
                Subject: HIV
                Subject: HIV diagnosis and management
                Subject: HIV epidemiology
                Subject: Public Health
                Subject: Behavioral and Social Aspects of Health

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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