The passage of another World AIDS Day on Dec. 1 provides a fitting occasion to take stock of the disease’s toll, but also the progress we’ve made in combating it.
The development of antiretroviral medication ranks as one of modern medicine’s great achievements. But we are far from declaring victory.
Unlike the polio vaccine, which effectively eradicated the disease in places where it was widely distributed, antiretroviral therapy requires an infected person’s lifelong adherence to an extensive medication regimen. Moreover, the people most affected by HIV—those living in Africa—also face the greatest challenges adhering to the medication.
Even if the cost of the treatment is covered, as the US President’s Emergency Plan for AIDS Relief has largely done in Africa, HIV-infected Africans often live far from clinics, or find themselves at the mercy of food shortages, economic hardship and wars that undermine the stability necessary for ongoing treatment.
But as I discovered during a five-year research fellowship at a Kenyan HIV clinic while I was at the University of Manitoba, there is at least one simple, low-cost method of countering those seemingly overwhelming challenges: mobile phone text messages.
I had never used my mobile phone for text-messaging until my arrival in Kenya. I quickly realized that the primary language to learn was not Swahili, but Short Message Service (SMS). As with the rest of the African continent, Kenyans were taking up cell phones at a rate faster than anywhere else in the world, and text messaging is inexpensive, rapid and convenient.
Our clinic staff and some patient volunteers brainstormed how to harness the cellular phone “epidemic” to increase the odds of maintaining their medication. The system we created was simple: Our nurses or clinical officers sent weekly check-ins—“How are you?” (“Mambo?” in Kiswahili)—that required patients to respond by texting either that they were doing fine (“Sawa”) or had a problem (“Shida”). Those with a problem, or who didn’t respond, were followed promptly with a call from the clinic to provide advice or triage for any problems. For patients who sometimes traveled up to 600 kilometres to attend the clinic, this access to a medical expert was a hit.
To ascertain if it truly made a difference in patient outcomes, we conducted a randomized clinical trial. The results, recently reported in The Lancet, showed that patients who received weekly SMS “check-ins” were 12 per cent more likely than a control group to have an undetectable level of the HIV virus a year after starting antiretroviral treatment. We estimated our text-messaging program would cost $8 per person per year, and if scaled up in Kenya would result in an extra 26,000 people with HIV levels suppressed to undetectable levels. I had the opportunity to present this evidence, on behalf of our team, at a conference last month devoted to such mobile health strategies. The mHealth Summit in Washington, D.C., attracted 2,400 delegates from the private sector, governments and non-governmental organizations, and included keynote sessions from Bill Gates, Ted Turner and John Holdren, the Chief Technology Advisor to the White House. The themes that arose at the conference—the need for hard evidence, the emphasis on ground-up innovation and the importance of using existing, low-cost technologies—bolstered my conviction that our experiment was worth replicating.
We are now undertaking a pilot study to take what we’ve learned in Kenya and apply it here in British Columbia, not only with people infected with HIV, but those with tuberculosis, a disease that also requires ongoing medication. Cell phones provide an opportunity to foster the patient-caregiver relationship in tangible ways that can ultimately improve human health. There is a long way to go, but perhaps technology is on our side.
Richard Lester is an assistant clinical professor in the Division of Infectious Diseases in the UBC Faculty of Medicine, and Lead Physician in the Division of Sexually Transmitted Infections/HIV Control at the BC Centre for Disease Control.
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