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Feldacker C, Klabbers RE, Huwa J, Kiruthu-Kamamia C, Thawani A, Tembo P, Chintedza J, Chiwaya G, Kudzala A, Bisani P, Ndhlovu D, Seyani J, Tweya H. The effect of proactive, interactive, two-way texting on 12-month retention in antiretroviral therapy: Findings from a quasi-experimental study in Lilongwe, Malawi. PLoS One 2024; 19:e0298494. [PMID: 39208237 PMCID: PMC11361596 DOI: 10.1371/journal.pone.0298494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 07/15/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Retaining clients on antiretroviral therapy (ART) is challenging, especially during the first year on ART. Mobile health (mHealth) interventions show promise to close retention gaps. We aimed to assess reach (who received the intervention?) and effectiveness (did it work?) of a hybrid two-way texting (2wT) intervention to improve ART retention at a large public clinic in Lilongwe, Malawi. METHODS Between August 2021-June 2023, in a quasi-experimental study, outcomes were compared between two cohorts of new ART clients: 1) those opting into 2wT who received automated, weekly motivation short messaging service (SMS) messages and response-requested appointment reminders; and 2) a matched historical cohort receiving standard of care (SoC). Reach was defined as "the proportion clients ≤6 months of ART initiation eligible for 2wT". 2wT effectiveness was assessed in time-to-event analysis. Retention was presented in a Kaplan-Meier plot and compared between 2wT and SoC using a log-rank test. The effect of 2wT on ART dropout (lost to follow-up or stopped ART) was estimated using Fine-Gray competing risk regression models, adjusting for sex, age and WHO HIV stage at ART initiation. RESULTS Of 1,146 clients screened, 501 were eligible for 2wT, a reach of 44%. Lack of phone (393/645; 61%) and illiteracy (149/645; 23%) were the most common ineligibility reasons. Among 468 participants exposed to 2wT, 12-month probability of ART retention was 91% (95% CI: 88% - 94%) compared to 76% (95% CI: 72% - 80%) among 468 SoC participants (p<0.001). Compared to SoC, 2wT participants had a 65% lower hazard of ART dropout at any timepoint (sub-distribution hazard ratio 0.35, 95% CI: 0.24-0.51; p<0.001). CONCLUSIONS 2wT did not reach all clients. For those who opted-in, 2wT significantly increased 12-month ART retention. Expansion of 2wT as a complement to other retention interventions should be considered in other low-resource, routine ART settings.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Robin E. Klabbers
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States of America
| | | | - Christine Kiruthu-Kamamia
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Lighthouse Trust, Lilongwe, Malawi
| | | | | | | | | | | | | | | | | | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
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Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Feldacker C, Klabbers RE, Huwa J, Kiruthu-Kamamia C, Thawani A, Tembo P, Chintedza J, Chiwaya G, Kudzala A, Bisani P, Ndhlovu D, Seyani J, Tweya H. The effect of proactive, interactive, two-way texting on 12-month retention in antiretroviral therapy: findings from a quasi-experimental study in Lilongwe, Malawi. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.26.24301855. [PMID: 38352345 PMCID: PMC10863037 DOI: 10.1101/2024.01.26.24301855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Background Retaining clients on antiretroviral therapy (ART) is challenging especially during the first year on ART. Mobile health (mHealth) interventions show promise to close retention gaps. We aimed to assess reach (who received the intervention?) and effectiveness (did it work?) of a hybrid two-way texting (2wT) intervention to improve ART retention at a large public clinic in Lilongwe, Malawi. Methods Between August 2021 - June 2023, a quasi-experimental study compared outcomes between two cohorts of new ART clients: 1) those opting into 2wT with combined automated, weekly motivation short messaging service (SMS) messages and response-requested appointment reminders; and 2) a matched historical cohort receiving standard of care (SoC). Reach was defined as "the proportion clients ≤6 months of ART initiation eligible for 2wT". 2wT effectiveness was assessed in time-to-event analysis comparing Kaplan-Meier plots of 6- and 12-month retention between 2wT and SoC using a log-rank test. The effect of 2wT on ART drop out was estimated using multivariable Cox proportional hazard models, adjusting for sex, age and WHO stage at ART initiation. Results Of the 1,146 clients screened, 645 were ineligible (56%) largely due to lack of phone access (393/645; 61%) and illiteracy (149/645; 23%): a reach of 44%. Among 468 2wT participants, the 12-month probability of ART retention was 91% (95%CI: 88% - 93%) compared to 75% (95%CI: 71% - 79%) among 468 SoC participants (p<0.0001). Compared to SoC participants, 2wT participants had a 62% lower hazard of dropping out of ART care at all time points (hazard ratio 0.38, 95% CI: 0.26-0.54; p<0.001). Conclusions Not all clients were reached with 2wT. For those who opted-in, 2wT reduced drop out throughout the first year on ART and significantly increased 12-month retention. The proactive 2wT approach should be expanded as a complement to other interventions in routine, low-resource settings to improve ART retention.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
| | - Robin E. Klabbers
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Christine Kiruthu-Kamamia
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Lighthouse Trust, Lilongwe, Malawi
| | | | | | | | | | | | | | | | | | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
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Knox J, Schwartz S, Duncan DT, Curran G, Schneider J, Stephenson R, Wilson P, Nash D, Sullivan P, Geng E. Proposing the observational-implementation hybrid approach: designing observational research for rapid translation. Ann Epidemiol 2023; 85:45-50. [PMID: 37015306 PMCID: PMC10936213 DOI: 10.1016/j.annepidem.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/24/2023] [Indexed: 04/04/2023]
Abstract
We propose the observational-implementation hybrid approach-the incorporation of implementation science methods and measures into observational studies to collect information that would allow researchers to anticipate, estimate, or infer the effects of interventions and implementation strategies. Essentially, we propose that researchers collect implementation data early in the research pipeline, in situations where they might not typically be thinking about implementation science. We describe three broad contextual scenarios through which the observational-implementation hybrid approach would most productively be applied. The first application is for observational cohorts that individually enroll participants-either for existing (to which implementation concepts could be added) or for newly planned studies. The second application is with routinely collected program data, at either the individual or aggregate levels. The third application is to the collection of data from study participants enrolled in an observational cohort study who are also involved in interventions linked to that study (e.g., collecting data about their experiences with those interventions). Examples of relevant implementation data that could be collected as part of observational studies include factors relevant to transportability, participant preferences, and participant/provider perspectives regarding interventions and implementation strategies. The observational-implementation hybrid model provides a practical approach to make the research pipeline more efficient and to decrease the time from observational research to health impact. If this approach is widely adopted, observational and implementation science studies will become more integrated; this will likely lead to new collaborations, will encourage the expansion of epidemiological training, and, we hope, will push both epidemiologists and implementation scientists to increase the public health impact of their work.
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Affiliation(s)
- Justin Knox
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY; HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York; Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY.
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Dustin T Duncan
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Geoff Curran
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock
| | - John Schneider
- Department of Medicine, University of Chicago, Chicago, IL
| | - Rob Stephenson
- The Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor
| | - Patrick Wilson
- Department of Psychology, University of California, Los Angeles
| | - Denis Nash
- Department of Epidemiology, School of Public Health, City University of New York, New York
| | - Patrick Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Elvin Geng
- Washington University School of Medicine, St. Louis, MO
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Mirzazadeh A, Eshun-Wilson I, Thompson RR, Bonyani A, Kahn JG, Baral SD, Schwartz S, Rutherford G, Geng EH. Interventions to reengage people living with HIV who are lost to follow-up from HIV treatment programs: A systematic review and meta-analysis. PLoS Med 2022; 19:e1003940. [PMID: 35290369 PMCID: PMC8923443 DOI: 10.1371/journal.pmed.1003940] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 02/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Optimizing services to facilitate engagement and retention in care of people living with HIV (PLWH) on antiretroviral therapies (ARTs) is critical to decrease HIV-related morbidity and mortality and HIV transmission. We systematically reviewed the literature for the effectiveness of implementation strategies to reestablish and subsequently retain clinical contact, improve viral load suppression, and reduce mortality among patients who had been lost to follow-up (LTFU) from HIV services. METHODS AND FINDINGS We searched 7 databases (PubMed, Cochrane, ERIC, PsycINFO, EMBASE, Web of Science, and the WHO regional databases) and 3 conference abstract archives (CROI, IAC, and IAS) to find randomized trials and observational studies published through 13 April 2020. Eligible studies included those involving children and adults who were diagnosed with HIV, had initiated ART, and were subsequently lost to care and that reported at least one review outcome (return to care, retention, viral suppression, or mortality). Data were extracted by 2 reviewers, with discrepancies resolved by a third. We characterized reengagement strategies according to how, where, and by whom tracing was conducted. We explored effects, first, among all categorized as LTFU from the HIV program (reengagement program effect) and second among those found to be alive and out of care (reengagement contact outcome). We used random-effect models for meta-analysis and conducted subgroup analyses to explore heterogeneity. Searches yielded 4,244 titles, resulting in 37 included studies (6 randomized trials and 31 observational studies). In low- and middle-income countries (LMICs) (N = 16), tracing most frequently involved identification of LTFU from the electronic medical record (EMR) and paper records followed by a combination of telephone calls and field tracing (including home visits), by a team of outreach workers within 3 months of becoming LTFU (N = 7), with few incorporating additional strategies to support reengagement beyond contact (N = 2). In high-income countries (HICs) (N = 21 studies), LTFU were similarly identified through EMR systems, at times matched with other public health records (N = 4), followed by telephone calls and letters sent by mail or email and conducted by outreach specialist teams. Home visits were less common (N = 7) than in LMICs, and additional reengagement support was similarly infrequent (N = 5). Overall, reengagement programs were able to return 39% (95% CI: 31% to 47%) of all patients who were characterized as LTFU (n = 29). Reengagement contact resulted in 58% (95% CI: 51% to 65%) return among those found to be alive and out of care (N = 17). In 9 studies that had a control condition, the return was higher among those in the reengagement intervention group than the standard of care group (RR: 1.20 (95% CI: 1.08 to 1.32, P < 0.001). There were insufficient data to generate pooled estimates of retention, viral suppression, or mortality after the return. CONCLUSIONS While the types of interventions are markedly heterogeneity, reengagement interventions increase return to care. HIV programs should consider investing in systems to better characterize LTFU to identify those who are alive and out of care, and further research on the optimum time to initiate reengagement efforts after missed visits and how to best support sustained reengagement could improve efficiency and effectiveness.
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Affiliation(s)
- Ali Mirzazadeh
- Division of Infectious Disease and Global Epidemiology, Department of Epidemiology and Biostatistics, and Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University at St Louis, St Louis, Missouri, United States of America
| | - Ryan R. Thompson
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
| | | | - James G. Kahn
- University of California San Francisco, San Francisco, California, United States of America
| | - Stefan D. Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - George Rutherford
- Division of Infectious Disease and Global Epidemiology, Department of Epidemiology and Biostatistics, and Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, School of Medicine, Washington University at St Louis, St Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St Louis, Missouri, United States of America
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