Review of mHealth evidence: what we know, what we don’t know Richard T. Lester, MD, FRCPC Associate Professor, Global Health, Division of Infectious Diseases Director, NGDI-UBC SESSION: mHealth and the Global HIV Response: Harnessing the Promise of Mobile Technologies for Effective Programme Implementation July 24, 2017, Paris richard.lester@ubc.ca

Conflict of Interest Associate Professor, University of British Columbia – Professional and commercial interests: WelTel International mHealth Society (www.weltel.org) Non-profit for mHealth service in Africa Co-founder, Chief Scientific Officer WelTel Incorporated Private company, mHealth product development and scaling Chief Scientific officer (non-paid) Previous grant/project/travel funding from BMS, Gilead, Merck, Sanofi. Other funding: NIH, CIHR, WHO, CDC, PEPFAR, CDC Foundation, BCCDC Foundation, Grand Challenges Canada, BCLA, CTN, .. Advising: WHO Task Force, mHealth Alliance, China CDC, BC MOH

Overlapping Pandemics Problem: People living with HIV Response: People on ART People with mobile phones All three pandemics overlap their focus in resource-limited settings

GOALS of Digital/mHealth in HIV care To improve: Effectiveness E.g. adherence/treatment outcomes Efficiency E.g. faster, lower cost +Quality E.g. less stigma, improved security CREDIT: http://linearityofexpectation.blogspot.it/2015 by James BonTempo

Promoting vs. Monitoring Adherence value Patient Care & Support Provider Monitoring & Evaluation Centered? Patient centered Provider centered

Different Ways Digital Adherence Interventions May Work Technology mode Approach/mechanism Care/support Reminders Monitoring Education (health literacy) Motivation Entertainment (Games) Financial incentives (mPESA) Alarms SMS Voice Online (internet) Apps (smartphones) Social media Video Devices (e.g EDM) And each of these can be used in different ways!

Adherence Promotion effectiveness

Key first studies What works? 2-way SMS and voice: “mambo?” *24% relative improvement in achieving 95% adherence *19% relative improvement in achieving viral suppression SMS reminders/motivation (one way): *Weekly (short) messages 32% improvement in 90% adherence (MEMS) *9% decrease in treatment interruptions *No adherence improvement with daily, longer reminders Effective at helping achieve viral suppression – the 3rd 90. Improves outpatient management efficiency Nov 27, 2010 January 2011 Cochrane review: Strong evidence (2012)

What works (mechanism): reminders or Support? Key early study – how? What works (mechanism): reminders or Support? Targeted adherence counselling persistent effect on adherence and viral suppression A medication reminder alarm device no effect on adherence or viral suppression Another trial in Kenya demonstrates support, not medication reminders, are the key driving factor in 3rd 90 Behaviour Change Wheel Chung et al. PLoS Med, March 2011

The key success = interactive? Evidence Reviews The key success = interactive? Am J Med. 2015 Oct;128(10):1139.e1-5

Trying to get the message out!

Consolidated ARV guidelines, June 2013 9.2.2 Interventions to optimize adherence to ART (part 2) Operations and service delivery Topic: Interventions to optimize adherence to ART Recommendations: Mobile phone text messages could be considered as a reminder tool for promoting adherence to ART as part of a package of adherence interventions (strong recommendation, moderate-quality evidence). oops! Strong recommendation for SMS support, but should have stated “communications” not “reminders”!

mHealth Reviews RESULTS: Of the 1504 articles found, 20 fulfilled the inclusion criteria [13 randomised clinical trials (RCT), one quasi-RCT, one non-randomised parallel group study and five studies with a pre-post design]. Nearly all the trials were conducted in high-income countries (80.0%). Articles were categorised depending on the target population into three different groups: (i) HIV-infected patients, n = 5; (ii) patients with other chronic diseases (asthma, coronary heart disease, dibetes mellitus, hypertension, infectious diseases, transplant recipients and psoriasis), n = 11; and (iii) healthy individuals, n = 4. Adherence improved in four of the studies on HIV-infected patients, in eight of the studies on patients with other chronic diseases, and in 1 study performed in healthy individuals. All studies reported sending SMS as medication reminders, healthy lifestyle reminders, or both. Only one trial (HIV-infected patients) had a low risk of bias. 22 March 2017 Dec 2014

Updated HIV Adherence Reviews Lancet HIV: Systematic Reviews, 2014, updated 2016 Weekly SMS support and adherence counseling improve HIV adherence Only 2 evidence-based adherence intervention types: SMS and adherence counseling support

Efficiency?

mHealth adherence: cost-effectiveness Medicine 2017: Very cost-effective at $15 pppy mHealth Summit 2011: Cost saving to PEPFAR within 3 years Figure . Costs of SMS Intervention vs. Costs Savings over 3 years for PEPFAR Global Cohort on ART (2.485M patients) Bella Hwang, mHealth Summit 2011 Anik R. Patel, RPh, MHA1,2 Jason Kessler, MD, MPH2 R. Scott Braithwaite, MD, MSc2 Kimberly A. Nucifora, MSc2 Harsha Thirumurthy, PhD,3 Qinlian Zhou, PhD2 Richard T. Lester, MD1 Carlo Marra, PharmD, PhD4

Helps triage= Differentiated Care! Only 3% of patients self-identify need for support each week (6% in first 3 months of Rx, 2% thereafter once stable) Clinicians felt it helped them prioritize triage and support

quality?

Quality? Digital health can help make the difference Hi acceptance, better management

Newer approaches? Front end? Back end? This Photo by Unknown Author is licensed under CC BY-SA

Use the evidence wisely, be careful! Hot off the Press: May 2017 compared the effect of “3 low-cost reminder devices” on medication adherence. 4-arm, block-randomized clinical trial, primary outcome optimal adherence (medication possession ratio ≥80%) ascertained using pharmacy claims data 53 480 enrollees randomized to 1) mail a pill bottle strip with toggles, 2) digital timer cap, 3) standard pillbox, or 4) standard care control. Results - 16.3% 15.1% 15.5%15.1% - no difference Conclusion: Don’t use reminders and gadgets for adherence promotion! Use the evidence wisely, be careful!

Globally, adherence has more in common than differences 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) Appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). Vancouver, BC

Why mHealth? In 2014 the number of mobile phone subscriptions surpassed the number of human beings Now 23 billion texts are sent worldwide every day Texts have a 99% open rate. (95% within 3 minutes) Text messaging is currently the most used data service in the world. Lester, IAS 2015 > https://www.textrequest.com/blog/texting-statistics-answer-questions/

TAKE HOME MESSAGES Goals: Effectiveness, Efficiency, and/or Quality of services mHealth can be used in many different ways E.g. SMS is not a thing, depends how its used Evidence has been strong since 2010/2011 to use weekly SMS to improve ART adherence (3rd 90) Similar evidence emerging for PrEP Use it! (correctly) – we are running out of time 90-90-90 by 2020, implement + evaluate

Do’s and Don’ts (to promote adherence and outcomes) Use mHealth to enhance patient care Be patient-centered (Ask) Use the most inclusive modality (e.g. SMS) Be evidence-based (2-way) Use scalable platforms Put the big data analytics on the back-end Keep it simple! Send medication reminders Send any one-way messaging that may compromise privacy Use expensive or complicated gadgetry Except in isolated conditions Try to reinvent the wheel

Thanks! Better care = Better adherence = Better outcomes mHealth Richard.lester@ubc.ca rich@weltel.org

Extra slide: WelTel SMS service, built for scale Our platform solution: built for scale patien Secure, server hosted, anywhere, any device, any connection, evidence based. REACH of SMS Digital Health Outreach & Patient Management Tool For Global Settings POWER & SCALABILITY of the cloud Currently operating in: Kenya, Canada, USA, South Africa Used in: HIV (care + PrEP) TB, MNCH, asthma, primary care Precision Public Health www.weltel.org https://demo.weltel.org/