Mobile Text Messaging to Improve Medication Adherence and Viral Load in a Vulnerable Canadian Population Living With Human Immunodeficiency Virus: A Repeated Measures Study

Abstract

BackgroundCombination antiretroviral therapy (cART) as treatment for human immunodeficiency virus (HIV) infection is effective and available, but poor medication adherence limits benefits, particularly in vulnerable populations. In a Kenyan randomized controlled trial, a weekly text-messaging intervention (WelTel) improved cART adherence and HIV viral load (VL). Despite growing evidence for short message service (SMS) text-message interventions in HIV care, there is a paucity of data utilizing these interventions in marginalized or female cohorts.ObjectiveThis study was undertaken to assess whether the standardized WelTel SMS text-message intervention applied to a vulnerable, predominantly female, population improved cART adherence and VL.MethodsWe conducted a repeated measures study of the WelTel intervention in high-risk HIV-positive persons by measuring change in VL, CD4 count, and self-reported adherence 12 months before and 12 months after the WelTel intervention was introduced. Inclusion criteria included VL ≥200 copies/mL, indication for treatment, and meeting vulnerability criteria. Participants were given a mobile phone with unlimited texting (where required), and weekly check-in text messages were sent for one year from the WelTel computer platform. Clinical data were collected for control and intervention years. Participants were followed by a multidisciplinary team in a clinical setting. Outcomes were assessed using Wilcoxon signed ranks tests for change in CD4 and VL from control year to study end and mixed-effects logistic regressions for change in cART adherence and appointment attendance. A secondary analysis was conducted to assess the effect of response rate on the outcome by modeling final log10 VL by number of responses while controlling for mean log10 VL in the control year.ResultsEighty-five participants enrolled in the study, but 5 withdrew (final N=80). Participants were predominantly female (90%, 72/80) with a variety of vulnerabilities. Mean VL decreased from 1098 copies/mL in the control year to 439 copies/mL at study end (P=.004). Adherence to cART significantly improved (OR 1.14, IQR 1.10-1.18; P<.001), whereas appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). A response was received for 46.57% (1753/3764) of messages sent and 9.62% (362/3764) of text messages sent were replied to with a problem. An outcome analysis examining relationship between reply rate and VL did not meet statistical significance (P=.07), but may be worthy of investigating further in a larger study.ConclusionsWelTel may be an effective tool for improving cART adherence and reducing VLs among high-risk, vulnerable HIV-positive persons.Trial RegistrationClinicaltrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/6qK57zCwv)

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

“…There is a significant body of literature on text messaging as a means of, for instance, supporting people with chronic illness; [46][47][48] facilitating adherence and/or attendance; [49][50][51][52] conveying results of tests; 53 or sending health promotion messages. [54][55][56][57] Systematic reviews have indicated that text messaging can be effective in facilitating short-term behaviour and medication adherence in particular.…”

A Systematic Review on Promoting Adherence to Antiretroviral Therapy in HIV-infected Patients Using Mobile Phone Technology

“…8, Of these 26 studies, 23 studies used SMS alone for reminders, and 3 used SMS plus counseling as noted in ►Table 1. Six reports were from the United States; [35][36][37][42][43][44] three each from Kenya 8,31,40 and South Africa; 28,39,48 two each from Uganda, 38,45 China, 34,47 and Cameroon; 30,41 and one each from Italy, 26 Brazil, 29 Nigeria, 32 New Zealand, 27 India, 33 Argentina, 46 Canada, 49 and Malaysia. 50 The types of studies included 19 RCTs, 8,27,[29][30][31][32][34][35][36]38,39,[41][42][43][44][45]47,50 three prospective cohort studies, 26,37,46 two ambidirectional studies (retrospective/prospective cohort study...…”

“…The primary outcomes addressed in the studies included one ART usage among study participants, 40 one adherence measured through prescription refills, 48 two viral load adherences, 37,46 six adherences over time, 31,33,34,38,39,43 and 16 self-reported adherences (►Table 2). 8,[26][27][28][29][30]32,35,36,41,42,44,45,47,49,50 Adherence interventions were measured as self-report, ART usage, adherence over time using a medication event monitoring system (MEMS) or an electronic adherence monitoring device, such as Wisepill, pharmacy refills, pill count, and clinical outcomes (viral load, HIV-ribonucleic acid [RNA] suppression, and cluster of differentiation 4 [CD4] count). Additionally, a summary of the outcome data, adherence assessment, metrics, relative effect (risk and odds ratios [OR]), and a measure of precision (95% confidence interval [CI]) for each study are shown in ►Table 2.…”

Preliminary Efficacy of a Cognitive Behavioral Therapy Text Messaging Intervention Targeting Alcohol Use and Antiretroviral Therapy Adherence: A Randomized Clinical Trial

“…Despite advances in the development of text messaging approaches to promoting adherence to various aspect of HIV care, there is a paucity of behavioral mHealth interventions research on people living with HIV and comorbid alcohol and other substance use disorders [52][53][54]. While at least one recent study addressed this gap by recruiting vulnerable populations with one or more risk factors for disengagement from HIV care (e.g., mental illness, active substance use, poor baseline ART adherence) to receive a text messaging intervention [55], the intervention content addressed ART adherence, but not alcohol or drug use. Correspondingly, improvements were observed in ART adherence, but not substance use.…”