Objective There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. Design A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. Methods Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. Results In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P=0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). Conclusion These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.

Summary Background Identifying interventions to increase men’s uptake of HIV testing in sub-Saharan Africa is essential for the success of combination HIV prevention. HIV self-testing is an emerging approach with high acceptability, but limited evidence exists on optimal strategies for distributing self-tests. We explored a novel approach of providing multiple self-tests to women at high risk of HIV acquisition in order to promote partner HIV testing and facilitate safer sexual decision-making. Methods HIV-uninfected women aged 18–39 years were recruited at two sites in Kisumu, Kenya: a health facility with antenatal (ANC) and postpartum (PPC) clinics, and a drop-in center for female sex workers (FSW). Following informed consent and instructions on using the OraQuick Rapid HIV 1/2 Test, index participants (IPs) enrolled at the health facility and drop-in center received 3 and 5 self-tests, respectively. Structured interviews were conducted with IPs at enrollment and over 3 months to determine how self-tests were used. Key outcomes included the number of self-tests distributed by IPs, the proportion of IPs whose sexual partners used a self-test, couples testing, and sexual behavior following self-testing. Findings Between January 14, 2015 and March 13, 2015, 280 IPs were enrolled (61 ANC, 117 PPC, 102 FSW). Follow-up interviews were completed with 265 IPs (96%). Most IPs with a primary sexual partner distributed a self-test to that partner (53/58, 91% ANC; 91/106, 86% PPC; 64/85, 75% FSW). A vast majority of FSW IPs also distributed ≥1 self-tests to commercial sex clients (82/101, 81%). Among self-tests distributed to and used by IPs’ primary sexual partners, couples testing occurred frequently (27/53, 51% ANC; 62/91, 68% PPC; and 53/64; 83% FSW). Among self-tests distributed to and used by IPs’ sexual partners, an HIV-positive result was obtained for 3.8% (2/53), 2.2% (2/91), and 13.8% (41/298) of the tests in the ANC, PPC, and FSW participant groups, respectively. Sexual intercourse was significantly less likely after a sexual partner tested HIV-positive versus HIV-negative (18% vs. 62%, p<0.0001), while condom use was significantly more likely (100% vs. 44%, p=0.0018). Of 265 IPs with follow-up data, four reported intimate partner violence as a result of self-test distribution. No other adverse events were reported. Interpretation Provision of multiple HIV self-tests to women at high risk of HIV infection was successful in promoting HIV testing among their sexual partners and in facilitating safer sexual decisions. This novel strategy warrants further consideration as countries develop self-testing policies and programs.

BackgroundAchieving higher rates of partner HIV testing and couples testing among pregnant and postpartum women in sub-Saharan Africa is essential for the success of combination HIV prevention, including the prevention of mother-to-child transmission. We aimed to determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing.Methods and FindingsWe conducted a randomized trial in Kisumu, Kenya, between June 11, 2015, and January 15, 2016. Six hundred antenatal and postpartum women aged 18–39 y were randomized to an HIV self-testing (HIVST) group or a comparison group. Participants in the HIVST group were given two oral-fluid-based HIV test kits, instructed on how to use them, and encouraged to distribute a test kit to their male partner or use both kits for testing as a couple. Participants in the comparison group were given an invitation card for clinic-based HIV testing and encouraged to distribute the card to their male partner, a routine practice in many health clinics. The primary outcome was partner testing within 3 mo of enrollment. Among 570 participants analyzed, partner HIV testing was more likely in the HIVST group (90.8%, 258/284) than the comparison group (51.7%, 148/286; difference = 39.1%, 95% CI 32.4% to 45.8%, p < 0.001). Couples testing was also more likely in the HIVST group than the comparison group (75.4% versus 33.2%, difference = 42.1%, 95% CI 34.7% to 49.6%, p < 0.001). No participants reported intimate partner violence due to HIV testing. This study was limited by self-reported outcomes, a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used.ConclusionsProvision of multiple HIV self-tests to women seeking antenatal and postpartum care was successful in promoting partner testing and couples testing. This approach warrants further consideration as countries develop HIVST policies and seek new ways to increase awareness of HIV status among men and promote couples testing.Trial RegistrationClinicalTrials.gov NCT02386215.

Voluntary physical distancing is essential for preventing the spread of COVID-19. We assessed the role of political partisanship in individuals’ compliance with physical distancing recommendations of political leaders using data on mobility from a sample of mobile phones in 3,100 counties in the United States during March 2020, county-level partisan preferences, information about the political affiliation of state governors, and the timing of their communications about COVID-19 prevention. Regression analyses examined how political preferences influenced the association between governors’ COVID-19 communications and residents’ mobility patterns. Governors’ recommendations for residents to stay at home preceded stay-at-home orders and led to a significant reduction in mobility that was comparable to the effect of the orders themselves. Effects were larger in Democratic- than in Republican-leaning counties, a pattern more pronounced under Republican governors. Democratic-leaning counties also responded more strongly to recommendations from Republican than from Democratic governors. Political partisanship influences citizens’ decisions to voluntarily engage in physical distancing in response to communications by their governor.