This randomized controlled trial (RCT) tested the feasibility and efficacy of text-messaging to promote follow-up care among otherwise healthy trauma patients screened for HIV at an Emergency Department in a limited income country. We found that most patients approached were willing to be tested and receive SMS messages. Follow up with recommended care was significantly greater in those who received the text messages compared to those who did not, RR= 3.4.
Previous studies globally evaluating the effect of SMS in promotion of patient care not only in HIV but other illnesses have also found this method to improve compliance with care (7,8,11–17). A 2017 systemic review by Daher et al including 99 studies in Africa, Asia, Europe and America assessed whether digital innovations were feasible, acceptable and had a general impact on promotion of care in HIV and other sexual transmitted diseases. The review concluded that not only were these innovations feasible, but they were also acceptable and had general impact in promotion of care (13). Likewise, in our study we were able to verify that SMS intervention does significantly increase follow up visits in patients screened for HIV. A 2017 meta-analysis by Fontelo et al which analysed 34 different studies globally, showed that text message was a valuable tool to increase general HIV related compliance not only in attendance but also in medication and adherence (14). All of the studies in these reviews involved symptomatic patients.
Our study had a number of unique aspects. While prior RCT’s have been conducted using digital interventions like text message via SMS to improve the care of HIV patients in LMIC countries (7,8,10,15), most of these studies were confined to patients known to have or suspected to have HIV due to symptoms, while our study assessed the value of this intervention in asymptomatic patients who had not sought out HIV screening. This study also looked at the impact of SMS on individuals testing negative for HIV and found that the SMS was helpful in compliance with repeat testing in three months. A Kenyan study by Mugo et al (8) comparing the impact of text message, phone call and in-person appointment reminders on rate of repeat screening of HIV also found that text message increased likelihood of accessing follow up services. However, that study included only patients who had presented to a clinic because of their medical symptoms.
Another unique aspect of our study was the use of pre-programmed, automated SMS. advantage of automated SMS is that messages can be programmed to be sent to specific individuals at specified times. The intervention does not require an individual to remember or physically send these messages since the computer programme does this. The intervention had high fidelity: 381 messages were logged as sent, participants in the intervention arm remembered receiving a message, and no patients in the control arm reported receiving the SMS.
This study also shows the importance of provider-initiated counselling and testing for every patient entering the hospital in our study. Among patients without medical complaints, and who would have not presented to a medical facility other than for trauma, we found an incidence of HIV of 3.5%. This is substantially higher than in many ED-based screening programs in high income countries. While we only included patients who were willing to be tested for HIV, the cohort study by Ramadhan et al (5) at our emergency department enrolled participants first, and then asked if they were willing to be tested and receive their results. In that study, 250 (76.7%) patients accepted testing for HIV, and among them 98.8% were ready to receive their test results, demonstrating again the willingness of people who are asymptomatic to be tested.
The success of this intervention in Tanzania can be explained by the wide availability of mobile phones in limited and middle-income countries which has allowed communication even in remote areas. The use of SMS (as opposed to email) meant that patients did not need to have internet access or incur any cost to receive the messages, eliminating the burden of buying internet data packages. All of the participants when asked if they would be okay with receiving an SMS accepted, showing the method is acceptable to most individuals.
A total of $20,000 was used in research tool development and $170 used for domain name registration, sending messages and hosting the research app online. The number needed to treat suggests this is a small cost compared to the cost the individual and government will incur to treat advanced HIV or AIDS and its opportunistic infections. Used broadly, this type of technology would have significant impact on the transmission and treatment of HIV.
The overall rate of follow up for care in our cohort was 39.2%, which is certainly suboptimal. This shows the need for some type of intervention to increase compliance with care. Follow up was significantly higher in the intervention group compared to control group overall. The majority of the patients were HIV negative and were much more likely to follow up for repeat screening if they received the SMS than if they were in the control group. HIV positive patients had good follow up in both groups, but with only 9 people in the total group, the uncertainty surrounding the impact of the intervention in those who are HIV+ is quite large. We would recommend that the Ministry of Health, Community Development, Gender, Elderly and Children plus the Government and other stakeholders as a whole should look at employing and funding SMS based innovation as means to remind patients of important follow up visits not only in HIV but other chronic diseases
4.2) Study Limitationsand Mitigation
Our assessment of following up with recommended care was based on self-report. Self-reporting can be affected by social desirability bias. However, we would not expect the intervention group to be more likely to provide positive answers than control group. Secondly it was a single center study, our results may not be generalizable to other hospitals in Tanzania. However, Muhimbili National hospital is a tertiary level referral hospital, receiving patients from all over the country. And lastly, the small number of HIV positive participants prohibited useful statistical testing on the effect of the intervention in this group.
In conclusion, text message is a feasible and efficient way to increase follow up visits among individuals tested for HIV in a limited income country. This study was able to show a very significant difference between the groups that receive reminder text to those that don’t. This relatively low-cost method can help in decreasing the burden of disease from HIV in LMIC’s, as well as other chronic illnesses.