An Interactive Text Messaging Intervention to Improve Adherence to Option B+ Prevention of Mother-to-Child HIV Transmission in Kenya: Cost Analysis

Cost-effectiveness analysis of two-way texting (2wT) intervention to improve ART retention among newly-initiated antiretroviral therapy clients in Malawi

Background

Retention in HIV care is crucial for improved health outcomes. Malawi has a high HIV prevalence and struggles with retention despite significant progress in controlling the epidemic. Mobile health (mHealth) interventions, such as two-way texting (2wT), have shown promise in improving anti-retroviral therapy (ART) retention. We explore the cost-effectiveness of a 2wT intervention in Lighthouse Trust's Martin Preuss Center (MPC) in Lilongwe, Malawi, that sends automated SMS visit reminders, weekly motivational messages, and supports direct communication between clients and healthcare workers.

Methods

Costs and retention rates were compared between 2wT and standard of care (SOC) for 468 clients enrolled in each. Incremental cost-effectiveness ratios (ICERs) were calculated. Scenario analyses were conducted to estimate costs if 2wT expanded.

Results

The 2wT group had higher retention (80%) than SOC (67%) at 12 months post-ART initiation. For 468 clients, the total annual costs for 2wT were $36,670.38 as compared to SOC costs at $33,458.72, resulting in an ICER of $24,705. Among scenarios, the ICER was -$105,315 if 2wT expanded to all new clients (2678 at MPC and -$723,739 as 2wT expanded to other four high-burden facilities (2901 clients), suggesting high cost savings if 2wT was effectively scaled.

Conclusion

The 2wT intervention appears cost-effective to improve ART retention among new ART initiates in a high-burden ART clinic. While mHealth interventions have potential limitations, their benefits in improving patient outcomes and cost savings support their integration into HIV care programs.

Assessing preferences for HIV pre-exposure prophylaxis (PrEP) delivery services via online pharmacies in Kenya: protocol for a discrete choice experiment

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition, but coverage remains low in high prevalence settings. Initiating and continuing PrEP via online pharmacies is a promising strategy to expand PrEP uptake but little is known about user preferences for this strategy. We describe methods for a discrete choice experiment (DCE) to assess preferences for PrEP delivery from an online pharmacy.

METHODS AND ANALYSIS

This cross-sectional study is conducted in Nairobi, Kenya, in partnership with MYDAWA, a private online pharmacy retailer with a planned sample size of >400 participants. Eligibility criteria are: ≥18 years, not known HIV-positive and interested in PrEP. Initial DCE attributes and levels were developed via literature review and stakeholder meetings. We conducted cognitive interviews to assess participant understanding of the DCE survey and refined the design. The final DCE used a D-efficient design and contained four attributes: PrEP eligibility assessment, HIV test type, clinical consultation type and user support options. Participants are presented with eight scenarios consisting of two hypothetical PrEP delivery services. The survey was piloted among 20 participants before being advertised on the MYDAWA website on pages displaying products indicating HIV risk (eg, HIV self-test kits). Interested participants call a study number and those screened eligible meet a research assistant in a convenient location to complete the survey. The DCE will be analysed using a conditional logit model to assess average preferences and mixed logit and latent class models to evaluate preference heterogeneity among subgroups.

ETHICS AND DISSEMINATION

This study was approved by the University of Washington Human Research Ethics Committee (STUDY00014011), the Kenya Medical Research Institute, Nairobi County (EOP/NMS/HS/128) and the Scientific and Ethics Review Unit in Kenya (KEMRI/RES/7/3/1). Participation in the DCE is voluntary and subject to completion of an electronic informed consent. Findings will be shared at international conferences and peer-reviewed publications, and via engagement meetings with stakeholders.

Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa

OBJECTIVE

We examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART).

DESIGN

I-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation.

METHODS

Eighteen primary care clinics were randomized to automated SMS ( n  = 7), automated and tailored SMS + PN ( n  = 7), or standard of care (SOC; n  = 4). Recently HIV diagnosed adults ( n  = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n  = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status.

RESULTS

Overall, SMS ( n  = 132) and SMS + PN ( n  = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n  = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC.

CONCLUSION

Results suggest SMS and peer navigation services significantly reduce time to linkage to HIV care in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs.

TRIAL REGISTRATION

NCT02417233, registered 12 December 2014; closed to accrual 17 April 2015.

Multi-level Interventions to Promote Oral Pre-exposure Prophylaxis Use Among Adolescent Girls and Young Women: a Review of Recent Research

Purpose of review

This review summarizes interventions to promote HIV pre-exposure prophylaxis (PrEP) use among adolescent girls and young women (AGYW) in HIV endemic settings, while also highlighting gaps in our current measures of PrEP intervention success.

Recent findings

AGYW report challenges with PrEP use, although the field is currently grappling with defining metrics of optimal PrEP use applicable for AGYW with dynamic HIV prevention needs. Ongoing studies are exploring multilevel interventions to address barriers to PrEP use for AGYW. At the individual and interpersonal levels, mHealth, drug-level feedback, adherence counseling, peer groups, and PrEP decision-support interventions are acceptable and feasible for AGYW although limited effectiveness data are available. At the health facility and community levels, PrEP demand creation, modified PrEP refill schedules, and integrated PrEP and reproductive health services are also promising options to support PrEP use for AGYW.

Summary

As PrEP delivery continues to expand, improved metrics of success and evidence on the effectiveness of multi-level adherence support interventions are needed to maximize the impact of PrEP for AGYW in HIV endemic settings. We present case studies of these intervention approaches but limited data are currently available on the effectiveness of these approaches. We will look toward forthcoming study results on the impact of PrEP interventions, including mHealth, drug-level feedback and other enhanced counseling, peer support, decision-support tools, PrEP demand creation, modified refills, and integrated service delivery, to determine the ideal package of PrEP support approaches for AGYW.