SummaryBackgroundAs mobile phone access continues to expand globally, opportunities exist to leverage these technologies to support demand for immunisation services and improve vaccine coverage. We aimed to assess whether short message service (SMS) reminders and monetary incentives can improve immunisation uptake in Kenya.MethodsIn this cluster-randomised controlled trial, villages were randomly and evenly allocated to four groups: control, SMS only, SMS plus a 75 Kenya Shilling (KES) incentive, and SMS plus 200 KES (85 KES = USD$1). Caregivers were eligible if they had a child younger than 5 weeks who had not yet received a first dose of pentavalent vaccine. Participants in the intervention groups received SMS reminders before scheduled pentavalent and measles immunisation visits. Participants in incentive groups, additionally, received money if their child was timely immunised (immunisation within 2 weeks of the due date). Caregivers and interviewers were not masked. The proportion of fully immunised children (receiving BCG, three doses of polio vaccine, three doses of pentavalent vaccine, and measles vaccine) by 12 months of age constituted the primary outcome and was analysed with log-binomial regression and General Estimating Equations to account for correlation within clusters. This trial is registered with ClinicalTrials.gov, number NCT01878435.FindingsBetween Oct 14, 2013, and Oct 17, 2014, we enrolled 2018 caregivers and their infants from 152 villages into the following four groups: control (n=489), SMS only (n=476), SMS plus 75 KES (n=562), and SMS plus 200 KES (n=491). Overall, 1375 (86%) of 1600 children who were successfully followed up achieved the primary outcome, full immunisation by 12 months of age (296 [82%] of 360 control participants, 332 [86%] of 388 SMS only participants, 383 [86%] of 446 SMS plus 75 KES participants, and 364 [90%] of 406 SMS plus 200 KES participants). Children in the SMS plus 200 KES group were significantly more likely to achieve full immunisation at 12 months of age (relative risk 1·09, 95% CI 1·02–1·16, p=0·014) than children in the control group.InterpretationIn a setting with high baseline immunisation coverage levels, SMS reminders coupled with incentives significantly improved immunisation coverage and timeliness. Given that global immunisation coverage levels have stagnated around 85%, the use of incentives might be one option to reach the remaining 15%.FundingBill & Melinda Gates Foundation.

BackgroundAn increasing burden of cardiovascular disease (CVD) in low-resource settings demands innovative public health approaches.ObjectivesTo design and test a novel mobile health (mHealth) tool for use by community health workers (CHWs) to identify individuals at high CVD risk who would benefit from education and/or pharmacologic interventions.MethodsWe designed and implemented a novel two-way mobile phone application, ‘AFYACHAT’, to rapidly screen for the CVD risk in rural Kenya. AFYACHAT collects and stores a short message system (SMS) text message data entered by a CHW on a subject’s age, sex, smoking, diabetes and systolic blood pressure, and returns as SMS text message the category of 10-year CVD risk: ‘GREEN’ (<10% 10 year risk of cardiovascular event), ‘YELLOW’ (from 10% to <20%), ‘ORANGE’ (from 20% to <30%), or ‘RED’ (≥30%). CHWs were equipped and trained to use an automated blood pressure device and the mHealth tool.ResultsFive CHWs screened 2865 subjects in remote rural communities in Kenya over a 22-month period (2015–2017). The median age of subjects was 50 (interquartile range 43–60) and 1581 (55%) were female. The point prevalence of hypertension (systolic blood pressure > 140 mmHg), diabetes and tobacco use were 23%, 3.2% and 22%, respectively. Overall, the 10-year risk of CVD among patients was <10% in 2778 (97%) patients, from 10% to <20% in 65 (2.3%), from 20% to <30% in 12 (0.4%) and ≥30% in 10 (0.2%).ConclusionsWe have developed a mHealth tool that can be used by CHWs to screen for CVD risk factors, demonstrating the proof of concept in rural Kenya.

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IntroductionSurveillance of recent HIV infections in national testing services has the potential to inform primary prevention programming activities. Focusing on procedures required to accurately determine recent infection, and the potential for recent infection surveillance to inform prevention efforts, we present the results of three independent but linked pilots of recency testing.MethodsTo distinguish recently acquired HIV infection from long‐standing infection, in 2018 we applied a Recent Infection Testing Algorithm that combined a laboratory‐based Limiting Antigen Avidity Enzyme Immunoassay with clinical information (viral‐load; history of prior HIV diagnosis; antiretroviral therapy‐exposure). We explored potential misclassification of test results and analysed the characteristics of participants with recent infection. We applied the algorithm in antenatal clinics providing prevention of mother‐to‐child transmission services in Siaya County, Kenya, outreach sites serving female sex workers in Zimbabwe, and routine HIV testing and counselling facilities in Nairobi, Kenya. In Nairobi, we also conducted recency testing among partners of HIV‐positive participants.ResultsIn Siaya County, 2.3% (10/426) of HIV‐positive pregnant women were classified as recent. A risk factor analysis comparing women testing recent with those testing HIV‐negative found women in their first trimester were significantly more likely to test recent than those in their second or third trimester. In Zimbabwe, 10.5% (33/313) of female sex workers testing HIV‐positive through the outreach programme were classified recent. A risk factor analysis of women testing recent versus those testing HIV‐negative, found no strong evidence of an association with recent infection. In Nairobi, among 532 HIV‐positive women and men, 8.6% (46) were classified recent. Among partners of participants, almost a quarter of those who tested HIV‐positive were classified as recent (23.8%; 5/21). In all three settings, the inclusion of clinical information helped improve the positive predictive value of recent infection testing by removing cases that were likely misclassified.ConclusionsWe successfully identified recently acquired infections among persons testing HIV‐positive in routine testing settings and highlight the importance of incorporating additional information to accurately classify recent infection. We identified a number of groups with a significantly higher proportion of recent infection, suggesting recent infection surveillance, when rolled‐out nationally, may help in further targeting primary prevention efforts.