1. Effects of a Mobile Phone Short Message Service (SMS) on Antiretroviral Treatment Adherence in Kenya (WelTel Kenya1): A Randomized Trial Jesse Coleman University of British Columbia, BC Centre for Disease Control ICIUM, Antalya, Turkey Nov 14, 2011 Original research by Dr. Richard Lester et al. Your health, in your hands

2. Kenya Clinic Survey, July 2005 Despite often making <$2/day… Most patients had cell phone access Most patients attending HIV clinics had cell phone access Used for almost everything… But not used for health management Lester et al. AIDS Vol 20, 17 Nov, 2006 The Unfortunate Gap

3. Hypothesis: cell phone communicationwill improve: The cell phone intervention (SMS), through regular communication with patients, will improve: ART adherence (30 day self-report at 6 and 12m) HIV plasma viral suppression (<400 copies/ml) at 12m Also, health, social, and economic outcomes... Compared to the current standard of care (SOC) The PHE: WelTel Kenya1 Clinical Trial (NCT00830622)

4. *Protocol: SMS (text messaging) SMS: “Mambo? = How RU?” “Sawa” = Fine “Shida” = Problem Monday <48h If necessary HealthAdvice SMS ‘check-in’ SMS response *Derived from focused group discussions with HCW and patients

5. Study Participants and Randomization Screening (581+) Randomized (538) Pumwani (251) SMS (120) Follow-up control (131) Follow-up Coptic (209) SMS (117) Follow-up control (92) Follow-up Kajiado (78) SMS (36) Follow-up control (42) Follow-up Inclusion Adults (> 18 years) starting ART Adequate phone access (owned/shared) Informed consent Randomization Baseline survey 6 month 12 month Powered to show 10% improvement in adherence Exclusion (44) Inadequate phone access Refused/Unable SMS n=273 Control n=265

6. Patient Characteristics =Equity 65% women 65% women Median age 36 Oldest age = 82 Oldest age = 82 30% unemployed 30% unemployed no formal education 4.5% had no formal education (26% at rural site) CD4 = 164 19% ‘rural’ 30% make < $1 per day 30% make < $1 per day =Access Cell phone access – 84% owned – 84% owned cell phone – 16% shared – 16% shared a phone – 0.3% had a land line – Distance from clinic 83% never called clinic before study...

7. Weekly (SMS) Patient Response Rates Weekly (SMS) Patient Response Rates n=11,983 SMS logs (6.1% ‘SHIDA’) (2.0% ‘SHIDA’)

8. Feedback Positive feedbackChallenges “Feels like someone cares” 98% want the program to continue 97% would recommend it to a friend SMS response rates Changes in phone ownership Crisis management Scalability? Scalability? Why Why does it work? – Behavior change? – Reminders? Lester & Karanja Lancet Infectious Diseases Vol 8 December 2008

9. Study Conclusions Cell phones useful for HIV/AIDS management SMS patient support significantly improved ART adherence and rates of viral suppression (First report) – SMS patients 24% more likely to be adherent to ART – SMS patients 19% more likely to have suppressed VL Logistical challenges can be overcome equitable access May enhance equitable access to care Implications for developing health systems (horizontal?) http://www.scientificamerican.com/podcast/episode.cfm?id=text-message- outreach-improves-hiv-10-11-10

10. Example Kenya PEPFAR investment in HIV /AIDS (2010) $548,119,441 $548,119,441 (includes treatment and prevention efforts) 410,300 individuals on ART 410,300 individuals on ART Apply WelTel = 37,300 Apply WelTel = 37,300 extra people with fully suppressed HIV load Cost, est. <1% of PEPFAR spending Kenya Government Investment in Health $513,000,000 on health $513,000,000 on health HIV prevalence 6.3% WelTel 24% improvement in ART adherence (19% in VL) 1.2-7% reduction in TOTAL health services cost = 1.2-7% reduction in TOTAL health services cost WelTel = gov’t savings of $5-36,000,000 USD WelTel = gov’t savings of $5-36,000,000 USD Model REF: Freedberg K et al. Cote d’Ivoire, PLoS Med 2009 Model REF: Freedberg K et al. Cote d’Ivoire, PLoS Med 2009

11. PEPFAR: Costs and savings from WelTel (draft) ARV Patients on WeltelYear 1Year 2Year 3 Percent of total60%70%80% Numbers 1,491,180.00 1,739,710.00 1,988,240.00 Year 1Year 2Year 3 Total Costs Saved $ 49,192,687.76 $ 53,685,886.76 $ 95,234,908.75 Costs of Weltel $ 30,051,663.56 $ 23,759,930.39 $ 23,430,641.39 Year 1Year 2Year 3 Costs Saved of 2nd Line therapy $ 16,036,363.64 $ 18,709,090.91 $ 21,381,818.18 Costs Saved of Opportunistic Infections $ 49,090,909.09 $ 57,272,727.27 $ 65,454,545.45 Costs Saved for Clinic Time Needed $ 53,633,491.20 $ 53,626,406.40 $ 143,079,321.60 Total Costs Saved $ 118,760,764 $ 129,608,225 $ 229,915,685

12. Concluding statements support) improve HIV treatment outcomes mHealth (Cell Phone SMS support) can improve HIV treatment outcomes in resource- limited settings May benefit HIV pandemic control (helps Treatment as Prevention) cost-containment Global AIDS response cost-containment Post – trial obligation to implement.