A number of studies
presented at the 19th International AIDS Conference (AIDS 2012) in
Washington DC highlighted potentially important roles for mobile phone
technology in the delivery of HIV services.
Interest in the
use of mobile technology has soared among public health practitioners and
researchers in recent years, and there is a growing body of evidence regarding different
kinds of programmatic experiences. A recently published Cochrane
Review focusing specifically on text messaging to support antiretroviral
adherence reported strong evidence of the effectiveness of this intervention.
At a conference session
devoted to mobile technology, researchers considered the use of mobile phones
as an adherence tool on both the local and national level, and also reported on
how mobile phone systems might aid health personnel with clinical
decision-making and record-keeping.
One study was
implemented within the context of a healthcare program for HIV-positive
infants in Haiti. It was hoped that phone communication between health clinic
staff and the mothers of the infants would increase clinic attendance, improve
treatment adherence and facilitate the monitoring of infant health.
intervention provided donated phones to 70 women; another 38 women in the study
group had their own phones. Approximately once per week, clinic staff called
women to discuss appointments, medication and the children’s health.
At the time of
evaluation, a total of 76 women from the two groups had functioning phones. The
HIV-positive children of these women had been brought to all of their last six-monthly
clinic appointments. All of the women reported having positive feelings about
being called by the clinic staff, and many reported that the calls were helpful
reminders in relation to appointments and medication.
The study also
concluded that the use of phones could reduce loss to follow-up, which is a
considerable problem for many PMTCT programs.
team reported on the cost of scaling up an existing mobile phone antiretroviral
adherence system to the national level in India, where the national AIDS
programme anticipates having 800,000 people on antiretroviral treatment by 2017.
The team based its estimates on an existing program that delivers weekly mobile
phone reminders – a picture message and an interactive voice response call – to
1600 people who receive HIV care at a clinic in Bangalore.
The current cost
per person is US$2.82 annually. Researchers calculated that expanding the
programme to serve everyone who is expected to be taking ART by 2017 would cost US$0.68 per person. At that rate, bringing the programme to scale nationally would
require less than one-fifth of one per cent of India’s current five-year AIDS
looked at how mobile phone technology might be utilised to improve the
performance of community health workers (CHWs). A small study provided 17 CHWs
at a public HIV clinic in Nairobi with access to a mobile telephone system
known as ClinipakMobile. Phones given to the CHWs featured electronic surveys
to support clinical decision-making, and were also linked to an electronic
patient information database.
one-day training and a baseline assessment, CHWs underwent follow-up
assessments at three weeks and six weeks. The assessment indicated that CHWs
retained the skills required to use ClinipakMobile and that they were highly
satisfied with this tool.
When CHWs used
ClinipakMobile during home visits with clients living with HIV, the system
recorded 'red flag' answers relating to treatment adherence, side effects and
opportunistic infections. Thirty per cent of clients received health facility
referrals based on ClinipakMobile recommendations.
A client chart
review indicated that at follow-up visits, clinicians often failed to note the
problems that had prompted the referrals. This led researchers to recommend
that the ClinipakMobile system could be improved by directly informing clinicians
about the content of client records uploaded to the central database.
small Tanzanian non-governmental organisation had mixed results when it sought
to use a mobile phone system as a reporting tool for community health workers
in rural villages. The system was designed to replace a monthly paper-based
reporting system, with the phones transmitting data to a central database via
CHWs received training on how to use the phones for monthly reporting. The
study compared outcomes for this group to outcomes for other CHWs who continued
to follow paper-based reporting procedures.
One month after
the programme was initiated, CHWs using mobile phones had carried out reporting
for 37% of their clients, while the other CHWs had only submitted information
for 6% of clients.
At three months,
outcomes were different: 79% of paper records had been submitted compared to
45% of electronic records. However, paper records were two-and-a-half times as
likely to have missing information.
conference presentation, research team member Kati Regan said that mobile phone
reporting sharply declined after six months, and that “by eight or nine months,
community health workers had stopped sending texts altogether”.
The study called
attention to two factors preventing higher levels of reporting via mobile
phone: challenges with system maintenance and CHW misunderstandings about the
phone credit reimbursement system.
delegates that human resources were crucial for both establishing and
maintaining a mobile phone data collection system. Her organisation’s system
was put into place by someone working on a short-term fellowship, and when
those human resources were lost, it became much more difficult to maintain the
Regan noted that
her organisation’s annual budget is less than US$400,000, and that there are
only 12 full-time staff and 182 CHWs. “As a small NGO, I think what we learned
is that some fundamental questions need to be asked if you want to try to do
data collection with mobile phones,” she said. “The first question is can you do it – the issue is
maintenance. If you can’t maintain a system after you’ve set it up, then it’s
not very useful.
“I think the
area where we probably most underestimated the challenges was with training and
supervision time,” she added.
study presented in the same session can be seen as a compelling example of why
it is important to overcome obstacles that may limit the use of mobile
technology by CHWs. In her presentation of study findings, researcher Jennifer
Cohn noted the potential gravity of the clinical issues that CHWs reported.
Cohn said that
CHWs recorded a high number of 'red flags', during patient visits, such as
noting when a patient reported a cough lasting for two weeks or longer – a
possible sign of tuberculosis. CHWs referred five patients for follow-up visits
because of this issue, but the chart review indicated that clinicians only
noted coughing in three of these cases and apparently failed in all cases to
screen for tuberculosis.
CHWs recorded 'red flags' for eleven patients for antiretroviral adherence-related reasons.
The chart review only found adherence to be a concern of note in one follow-up
“It’s clear that
CHWs are able to access and generate very important clinical information,” Cohn
said. “The CHWs were able to identify patient complaints and problems that were
not actually identified by the clinicians.”
that reasons for this might include clinicians’ time constraints, as well as
patients feeling more trusting of CHWs since they were community members.
She added that a
next step in the project is to link the CHW data to clinics, enabling
clinicians who see patients at follow-up visits to know about the concerns noted