inafu6212-001-2012-3



By: Neil Mirochnick


A Global Epidemic
aids ribbon.png
(Creative Commons)

More than 30 years after the first cases were reported, HIV remains one of the most serious health challenges in the world and a significant barrier to development. Although new infections have declined by 20 percent since 2001, there were 2.5 million new infections, more than 7,000 a day, in 2011.[i] Despite substantial HIV/AIDS funding, as high as $15.6 billion in 2008,[ii] almost half of patients eligible for treatment worldwide were not receiving anti-retroviral therapy in 2011.[iii]

Successful mHealth HIV/AIDS Projects
HIV/AIDS mHealth projects have aimed to improve care and treatment for HIV-positive patients and provide information about the disease and the benefits of testing to potentially at-risk populations.

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(Text to Change)

Text to Change, the first program of its kind in Africa when it started in Uganda in 2008, aims to increase participation in voluntary HIV counseling and testing and increase patient knowledge of available health services by sending SMS quizzes.[v] The program claimsan increase of up to 40 percent in HIV counseling and testing services in partnering clinics. The program’s founder Bas Hoefman credits the success to Text to Change’s accessibility, saying “Text to Change is about reaching out to people with something they already have in their pockets.”[vi]

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(Fotopedia.com/Creative Commons)

Mwana, a UNICEF project in Zambia, has been working to improve HIV/AIDS testing by accelerating the transmission of lab results for early infants. SMS results delivery has increased turnaround times by an average of 50 percent, with an even greater improvement in rural communities. Although UNICEF admits they have not yet established whether the faster turnaround leads to earlier access to anti-retroviral therapy, Mwana will expand from a pilot in 13 districts to national scale-up in 2013.
The program aims to address a serious problem in Zambia: half of infants who contract HIV die before the age of two if no interventions for care and support are provided. In comparison, when HIV-positive newborns are diagnosed and receive treatment during their first 12 weeks survival rates are up to 75 percent higher.

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(Photopedia.com/Creative Commons)

The Praekelt Foundation’s program TXT Alert in South Africa aims to increase appointment attendance of HIV patients by notifying patients of upcoming appointments via SMS and requesting they reschedule if they cannot attend. For those participating in the project, missed appointments have fallen from 30 percent to 4 percent and lost-follow-up rates have declined from 27 percent to 4 percent. One drawback however is that TXT Alert requires health centers with electronic patient databases. Most rural health centers do not have electronic databases and so far TXT Alert is only operating in Johannesburg.

Field Experiences
As mHealth continues to expand, programs are becoming more elaborate. A project in Brazil sponsored by Nokia is addressing adherence to antiretroviral therapy by creating a social network where HIV-positive youth can interact.

There is a stigma attached to HIV/AIDS in Brazil and especially for youth it can be difficult to deal with. The project’s goal is to create a social network where youth with HIV can interact, share experiences and provide each other with positive reinforcement. The project is currently preparing for “a proof of concept trial” and in January, three groups of eight to ten patients will participate in the pilot.

“I’m very optimistic this could be the next step. The youth love their phones and interact so much through them,” Dr. Jorge Pinto, a pediatrician in Belo Horizonte who specializes in HIV/AIDS and directs the Nokia project, said in an interview via Skype. “Our expectation is that once we have a stable and reliable application we can move to a much larger trial and ultimately provide this as an effective tool to improve adherence for youth and young adults.”

While simpler SMS based projects have worked well in Africa, the Nokia project in Brazil uses a more complex application to not only remind youth when they should take anti-retrovirals and record adherence over time, but also provide remote access to lab results showing patients’ viral load and CD4 count and a mobile platform for youth to interact over a distance.

One of the obstacles that could affect the project’s scalability is the cost of the phones. Windows phones that support the program cost around $120. The pilot phase is funded by the Brazilian Ministry of Health, but expanding beyond the initial 24-30 participants will require a cheaper phone, which Nokia has been working on, or a considerably larger budget.

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(N. Kishore)

While the Nokia project in Brazil uses a complex platform to target a specific population, ChatSalud, an education and awareness mHealth initiative in Nicarauga, targets a mass audience with simple technology. ChatSalud is a mobile database using Frontline SMS to provide hundreds of
pre-programmed answers to sexual health questions related to HIV, STIs and safe sex. Although HIV prevalence rates in Nicaragua are estimated to be relatively low, around 0.2 percent, the reported statistics are based on very limited data and the Nicaraguan Ministry of Health predicted an 11.2 percent increase in the number of new cases in 2010.[vii]

ChatSalud’s founder Nishant Kishore, a Peace Corps volunteer living in Quilali, Nicarauga, believes one of the main causes of the increased of new HIV cases is a lack of knowledge due to cultural taboos associated with talking about sex. “People have such a difficult time talking about these themes. They don’t want to speak to a medical rofessional or family member about sex and HIV so they go to the streets where myths get propagated,” Kishore said in an interview via Skype.[viii]


In Nicaragua, 151 out of 153 municipalities have cell phone service and mobile penetration will top 80 percent by 2015.[ix] The majority of cell phone activity is SMS. When ChatSalud launches its pilot campaign in three cities in January, SMS responses will be free but users will pay for the initial text. Kishore does not believe the small fees will be a barrier.

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(N. Kishore)

“It’s technological leapfrogging. Most of these people never had a landline. Some of them live in places where you don’t have a health post and you don’t have police,” Kishore said. “There are some cybercafés and internet use is growing, but there still isn’t etiquette for internet. Searching and Google isn’t part of the culture the way it is in the U.S. People here are not using the internet to seek out information on these topics.”

ChatSalud is the third and most ambitious HIV-related mHealth initiative Kishore has been involved with during his two years as a community health promoter in Nicaragua. Kishore started a respondent group for at-risk populations for HIV, such as sex workers and men-who-have-sex-with-men, who receive weekly messages about HIV and the importance of getting tested. Kishore also led a mobile phone survey of 1,000 migrant coffee workers to investigate the relationship between high-risk behavior and HIV awareness. Last year, Kishore undertook a similar survey by hand. It took weeks to organize the data from a much smaller sample. This year, the results were available instantly, with no coding errors.
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(ChatSalud/N. Kishore)



“With 1,000 people and 50 questions, that would have been 50,000 entries to plug into Excel. There would have been lots of room for error,” Kishore said. “mHealth is all about removing barriers. Removing barriers to access to communication and using this massive amount of data for health reasons. Mobile phones are making communication easier. Everyone has one. It’s such a great way to get a message to the population so quickly. MHealth is the wave of the future. It has to be.”

Looking Ahead
In a list of the top 10 lessons learned on mHealth, Dr. Patricia Mechael, executive director of the mHealth Alliance and an adjunct professor at Columbia University’s School of International and Public Affairs, claims “it is not about the technology.”[x] While the software is important, mHealth is really about people and processes. The technology “is an enabler, but it is one part of a much larger puzzle.”[xi] mHealth scalability requires the right combination of government ownership and meaningful private sector engagement. Projects that include local end user input will be more effective than interventions that invest in technology for the sake of technology, without truly understanding how people will use it. There is growing evidence that mHealth communication will be more likely to succeed when programs connect or extend existing health resources, making human contact more efficient, not replacing it.[xii]

It is more likely that confronting diseases such as HIV with mobile technology will require thousands of locally relevant interventions of modest impact as opposed to a small number of high-impact worldwide interventions that carry the field.[xiii] Successful mHealth projects will require not just innovation, but reasonable expectations and honest evaluation. Although there are issues to be worked out – the need for more collaboration and greater emphasis on long-term scalability – a detailed look at both the success of first wave mHealth HIV projects and the potential of initiatives currently in the works provides reason to believe that mHealth is and will continue to be an effective tool in the fight against HIV.

Additional Information:
1) mHealth for HIV Treatment & Prevention: International AIDS Conference 2012 (www.InSTEDD.org)


2) Global Health Story: mHealth and Early Infant Diagnosis (www.clintonfoundation.org)


[i] U.S. Global Health Policy, F. S. (2012). The Global HIV/AIDS Epidemic.
[ii] Funding for HIV and AIDS. (n.d.). AVERT. Retrieved December 18, 2012, from http://www.avert.org/aids-funding.htm
[iii] WHO | HIV/AIDS. (November 2012).
[iv] What we do | Text to Change. (n.d.). Retrieved December 18, 2012, from http://www.texttochange.org/what-we-do
[v] Vital Wave Consulting (2009). mHealth for Development: The Opportunity of Mobile Technology for Healthcare
in the Developing World. Washington, D.C. and Berkshire, UK: UN Foundation-Vodafone Foundation
Partnership.
[vi] What we do | Text to Change. (n.d.). Retrieved December 18, 2012, from http://www.texttochange.org/what-we-do
[vii] Espinoza, H., Sequeira, M., Domingo, G., Amador, J. J., Quintanilla, M., & de los Santos, T. (2011). Management of the HIV epidemic in Nicaragua: the need to improve information systems and access to affordable diagnostics. Bulletin of the World Health Organization, 89(8), 619–620. doi:10.2471/BLT.11.086124
[viii] Kishore, N. (2012, December 9). Personal Interview with Nishant Kishore.
[ix] Pyramid Finds. (July 21 2012). Mobile Penetration in Nicaragua will Exceed 80 Percent by 2015. Retrieved December 18, 2012, from http://www.prnewswire.com/news-releases/mobile-penetration-in-nicaragua-will-exceed-80-percent-by-2015-pyramid-finds-98916189.html
[x] Mechael, P. (November 15 2010). Top Ten Lessons Learned on mHealth – State of the Planet. Retrieved December 18, 2012, from http://blogs.ei.columbia.edu/2010/11/15/mhealth-summit/
[xi] Mechael, P. (November 15 2010).
[xii] Sherry, J. & Ratzan, S. (2012). Measurement and Evaluation
Outcomes for mHealth Communication: Don't We Have an App for That?, Journal of Health
Communication: International Perspectives, 17:sup1, 1-3
[xiii] Sherry, J. & Ratzan, S. (2012).