Background Pregnant and postpartum women living with HIV (WLWH) need support for HIV and maternal child health (MCH) care, which could be provided using short message service (SMS). Methods and findings We compared 2-way (interactive) and 1-way SMS messaging to no SMS in a 3-arm randomized trial in 6 MCH clinics in Kenya. Messages were developed using the Health Belief Model and Social Cognitive Theory; HIV messages were integrated into an existing MCH SMS platform. Intervention participants received visit reminder and prespecified weekly SMS on antiretroviral therapy (ART) adherence and MCH, tailored to their characteristics and timing. Two-way participants could message nurses as needed. Clinic attendance, viral load (VL), and infant HIV results were abstracted from program records. Primary outcomes were viral nonsuppression (VL ≥1,000 c/ml), on-time clinic attendance, loss to follow-up from clinical care, and infant HIV-free survival. Among 824 pregnant women randomized between November 2015 and May 2017, median age was 27 years, gestational age was 24.3 weeks, and time since initiation of ART was 1.0 year. During follow-up to 2 years postpartum, 9.8% of 3,150 VL assessments and 19.6% of women were ever nonsuppressed, with no significant difference in 1-way versus control (11.2% versus 9.6%, adjusted risk ratio (aRR) 1.02 [95% confidence interval (CI) 0.67 to 1.54], p = 0.94) or 2-way versus control (8.5% versus 9.6%, aRR 0.80 [95% CI 0.52 to 1.23], p = 0.31). Median ART adherence and incident ART resistance did not significantly differ by arm. Overall, 88.9% (95% CI 76.5 to 95.7) of visits were on time, with no significant differences between arms (88.2% in control versus 88.6% in 1-way and 88.8% in 2-way). Incidence of infant HIV or death was 3.01/100 person-years (py), with no significant difference between arms; risk of infant HIV infection was 0.94%. Time to postpartum contraception was significantly shorter in the 2-way arm than control. Study limitations include limited ability to detect improvement due to high viral suppression and visit attendance and imperfect synchronization of SMS reminders to clinic visits. Conclusions Integrated HIV/MCH messaging did not improve HIV outcomes but was associated with improved initiation of postpartum contraception. In programs where most women are virally suppressed, targeted SMS informed by VL data may improve effectiveness. Rigorous evaluation remains important to optimize mobile health (mHealth) interventions. Trial registration ClinicalTrials.gov number NCT02400671.

Globally, 2.5 million neonates die and 2 million more are stillborn each year; the vast majority occur where access to life-saving care is limited. High quality, feasible interventions are needed to reach, educate and empower pregnant women and new mothers to improve care-seeking behaviors. Mobile WACh (Mobile solutions for Women’s and Children’s health) NEO is a human-computer hybrid mobile health (mHealth) system that allows for two-way short message service (SMS) communication between women and healthcare workers during the peripartum period. We performed a secondary prospective cohort analysis of data from the Mobile WACh NEO pilot study to determine maternal characteristics associated with neonatal death and stillbirth and examine participant messaging associated with these events. Pregnant women were enrolled at two Kenyan public health clinics between 28–36 weeks gestation. They received personalized, educational, action-oriented SMS messages during pregnancy and through 14 weeks postpartum. Participants could message the study at any time and study nurses responded. Standardized questionnaires assessed participant characteristics at baseline and 14 weeks postpartum. Outcomes were ascertained at study visits or by SMS report. Among 798 pregnant women enrolled, median age was 24 years [IQR 21, 29], 37% were primiparous and 92% used SMS as a primary mode of communication. Seventeen neonatal deaths and 13 stillbirths occurred. Older maternal age was associated with increased risk of stillbirth [aRR 1.12 (CI 1.02–1.24), p <0.05]. We found no significant predictors of neonatal death. Participant messaging to study nurse about concerns in the week preceding death was less common prior to infant death after discharge home from facility birth (9%) than prior to stillbirth (23%). We found limited predictors of neonatal death and stillbirth, suggesting identifying women prenatally for targeted support may not be a feasible strategy. Scarce messaging from mothers whose neonates died may reflect difficulties identifying illness or rapid deterioration and needs to be better understood to design and test interventions for this high-risk period. Messaging prior to stillbirth, while at similar levels as other periods, does not appear to have an impact as most women do not experience identifiable signs or symptoms prior to the event.

Purpose of Review Short message system (SMS) communication is widespread in low-and middle-income countries (LMICs), and may be a viable approach to address challenges with in-person data collection for HIV-related research and monitoring and evaluation. We reviewed the literature to characterize potential benefits and challenges with using SMS for remote data capture, including examples from HIV and sexual and reproductive health. Recent Findings In our review, we found that studies that have used SMS to capture sensitive, self-reported data found this was an acceptable and feasible strategy, and may reduce social desirability bias of self-reported data; but studies are limited. Shared phones and privacy concerns have been described as challenges, but can be addressed with enhanced security features. Response rates to SMS surveys varied significantly by topic, population, and setting. Summary SMS may improve generalizability and precision of health and behavior data for HIV in research and programs, but use in LMICs is limited. SMS systems should be carefully designed to overcome potential implementation hurdles.