Text messages to mothers improve early infant HIV diagnosis rates in Kenya and Mozambique

Use of text messaging significantly improved the rate of early infant diagnosis (EID) among HIV-positive pregnant women enrolled in a prevention of mother-to-child transmission (PMTCT) programme in Kenya, researchers reported in a poster at the 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention last week in Kuala Lumpur, Malaysia.

In this randomised controlled trial, postpartum retention also improved significantly in the intervention group compared to the control group: 19.6% (38/194) and 11.8% (22/187) respectively, yet the overall proportion of women attending remained low.

The availability of effective antiretroviral treatment (ART) for prevention of mother-to-child transmission and expansion of ART and access to PMTCT services in many countries in sub-Saharan Africa has resulted in considerable declines in transmission rates. For example, Botswana and South Africa have reduced transmission rates to under 5%; without any intervention, transmission rates would range between 25 and 40%.

Even with better access to ART, PMTCT services are still under used. For PMTCT services to be effective, an integrated continuum of care comprising maternal counselling and testing, CD4 count to determine ART eligibility, starting and monitoring ART, care at labour and delivery, infant ART and cotrimoxazole prophylaxis, early infant diagnosis (EID) and ART for HIV-positive infants are all needed.

Overall, the numbers of children in need of ART and getting it have increased. Yet, in most resource-poor settings, only three-in-ten children eligible for ART are getting it.

Women are often diagnosed late in pregnancy – maternal diagnosis is the key to access to PMTCT services and prevention of new paediatric HIV infections. Yet only an estimated 35% of pregnant women in low- and middle-income countries get an HIV test.

EID is a key step to linking children born to HIV-positive mothers to care and treatment, so reducing death and disease. Retaining mothers and their infants in care, especially after birth, is a singularly critical issue. Studies have reported loss-to-follow-up (LTFU) from PMTCT programmes ranging from 43% to as high as 75%.

According to the latest UNAIDS progress report, only four countries – Namibia, South Africa, Swaziland and Zambia – provided EID to over 50% of children born to HIV-positive women. Five – Angola, Chad, the Democratic Republic of Congo, Malawi and Nigeria – had coverage under 10%.

The researchers wanted to see whether interactive text messaging would improve rates of clinic attendance and early infant diagnosis.

HIV-positive pregnant women over 18 years of age enrolled in a PMTCT programme were randomised to receive either SMS text messages (195) or the usual care (193).

Messages were developed according to the constructs of the Health Belief Model:

• Perceived susceptibility – an individual’s assessment of the risk of the medical consequences of not attending clinic and infant not being tested.
• Perceived severity – individual’s assessment of seriousness of this and consequences.
• Perceived barriers – an individual's assessment of the influences that facilitate or discourage adoption of the promoted behaviour.
• Perceived benefits - an individual's assessment of the positive consequences of adopting the behavior.

Depending on gestational age those in the SMS group received up to eight text messages before delivery and six after. Primary outcomes were maternal attendance at the clinic after giving birth and infant HIV testing by DNA PCR by eight weeks after birth.

In total, there were outcome data for 381 (98.2%) women, with a median age of 27 years. At baseline, median gestational age was 34 weeks (IQR: 32-36). 

Close to 20% (38/194) of those in the SMS group attended a maternal postpartum clinic, compared to 11.8% (22/187) in the control. Those in the control group had over one and half times the increased risk of not attending clinic after giving birth, RR 1.66, 95% CI: 1.02-2.70.

Altogether, 92% (172/187) of infants in the SMS group were tested within eight weeks, compared to 85.1% (154/181) in the control group, RR, 1.08, 95% CI: 1.00-1.16.

Similarly, in another randomised controlled trial, researchers found a structured series of SMS reminders sent to HIV-positive pregnant women, followed for twelve months while attending five clinics in Maputo Province (one urban, two peri-urban and two rural), resulted in a significant uptake of EID at eight weeks, 77.1% compared to 70.9%, p=0.026.

Of the 1012 HIV-positive pregnant women interviewed, 490 (47%) were ineligible: either they did not own a cell phone (35%) or they were illiterate (21%). Of the 468 births (90%), only 315 infants were followed up until eight weeks.

Institutional births in peri-urban sites also increased significantly, compared to the control group, at 97 and 88%, p=0.018, respectively.

Mothers getting SMS reminders whose child was born anywhere other than at the study centres were more likely to bring their infants for EID: 75% compared to 38%, p=0.034.

These findings lend further support to mobile technology as a cost-effective, easily accessible tool with a potential for increased adherence and improved EID. In addition, the researchers from the Maputo study highlight the need for more research into how best to reach rural, illiterate women with such health interventions.