Sms Messaging To Improve Retention And Viral Suppression In Prevention Of Mother-To-Child Hiv Transmission (Pmtct) Programs In Kenya: A 3-Arm Randomized Clinical Trial

Background Pregnant and postpartum women living with HIV (WLWH) need support for HIV and maternal child health (MCH) care, which could be provided using short message service (SMS).Methods and findings We compared 2-way (interactive) and 1-way SMS messaging to no SMS in a 3-arm randomized trial in 6 MCH clinics in Kenya. Messages were developed using the Health Belief Model and Social Cognitive Theory; HIV messages were integrated into an existing MCH SMS platform. Intervention participants received visit reminder and prespecified weekly SMS on antiretroviral therapy (ART) adherence and MCH, tailored to their characteristics and timing. Two-way participants could message nurses as needed. Clinic attendance, viral load (VL), and infant HIV results were abstracted from program records. Primary outcomes were viral nonsuppression (VL >= 1,000 c/ml), on-time clinic attendance, loss to follow-up from clinical care, and infant HIV-free survival. Among 824 pregnant women randomized between November 2015 and May 2017, median age was 27 years, gestational age was 24.3 weeks, and time since initiation of ART was 1.0 year. During follow-up to 2 years postpartum, 9.8% of 3,150 VL assessments and 19.6% of women were ever nonsuppressed, with no significant difference in 1-way versus control (11.2% versus 9.6%, adjusted risk ratio (aRR) 1.02 [95% confidence interval (CI) 0.67 to 1.54], p = 0.94) or 2-way versus control (8.5% versus 9.6%, aRR 0.80 [95% CI 0.52 to 1.23], p = 0.31). Median ART adherence and incident ART resistance did not significantly differ by arm. Overall, 88.9% (95% CI 76.5 to 95.7) of visits were on time, with no significant differences between arms (88.2% in control versus 88.6% in 1-way and 88.8% in 2-way). Incidence of infant HIV or death was 3.01/100 person-years (py), with no significant difference between arms; risk of infant HIV infection was 0.94%. Time to postpartum contraception was significantly shorter in the 2-way arm than control. Study limitations include limited ability to detect improvement due to high viral suppression and visit attendance and imperfect synchronization of SMS reminders to clinic visits.Conclusions Integrated HIV/MCH messaging did not improve HIV outcomes but was associated with improved initiation of postpartum contraception. In programs where most women are virally suppressed, targeted SMS informed by VL data may improve effectiveness. Rigorous evaluation remains important to optimize mobile health (mHealth) interventions.Trial registration ClinicalTrials.gov number NCT02400671.Author summaryWhy was this study done?Interactive short message service (SMS) text messaging has the potential to provide remote support and information about HIV care to peripartum women living with HIV (WLWH) in resource-limited settings. Prevention of mother-to-child HIV transmission (PMTCT) programs have observed declining retention and treatment adherence over the postpartum period, which results in persistent risk of infant HIV infection. Previous research has shown that interactive SMS can improve early retention in perinatal women, but it is unknown whether long-term interactive SMS systems can durably improve retention and viral suppression in PMTCT. We hypothesized that a holistic SMS platform that addressed relevant HIV care and maternal child health (MCH) care issues and incorporated comprehensive input from WLWH regarding their preferences would improve HIV care outcomes.What did the researchers do and find?We integrated messages about HIV treatment, guided by input from WLWH who had previously attended PMTCT programs into an existing interactive SMS platform for MCH. We conducted a randomized controlled trial among 824 pregnant WLWH in Kenya, comparing 1-way SMS (in which participants could receive SMS but not respond) and 2-way SMS (in which participants could receive and send SMS to nurses) to no treatment control. We followed WLWH from pregnancy to 2 years postpartum and evaluated impact of SMS on long-term timely attendance at clinic visits, retention, viral suppression, and infant HIV-free survival. We found no significant effect of 1-way or 2-way SMS on HIV viral load (VL) nonsuppression (9.6% in control versus 11.2% in 1-way and 8.5% in 2-way), on-time clinic appointment attendance (88.2% in control versus 88.6% in 1-way and 88.8% in 2-way), and infant HIV or death (2.6/100 person-years (py) in control versus 2.3/100 py in 1-way and 4.1/100 py in 2-way).What do these findings mean?Integrated SMS messaging on HIV treatment and MCH did not improve HIV outcomes, but the previously reported apparent effect on initiation of postpartum contraception was preserved. Study limitations included limited ability to detect outcome improvements due to high treatment success in the control arm and lack of systematic integration of intervention with medical records. In HIV treatment programs that achieve high levels of retention in care and viral suppression, targeted SMS informed by VL data though health record integration may improve effectiveness. As mobile health (mHealth) programs continue to gain popularity and increase in scale, rigorous evaluation of clinical effect remains important to optimize interventions.