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Using Mobile Phone Technology to Improve Antenatal and PMTCT

Service Delivery and Uptake in Kenya

Seble Kassaye, MD, MSElizabeth Glaser Pediatric AIDS Foundation

July 2012

Introduction

• Project developed in response to WHO call for implementation research– efficacious interventions to accelerate

progress towards MDGs 4,5,6• Substantial loss to follow-up during

PMTCT cascade despite initial high ANC uptake

Epidemiology

*Study districts: Rachuonyo and Homabay, Nyanza province†Excluding SD NVP

Kiarie et al.. Evaluation of utilization and effectiveness of PMTCT services in Kenya. Kenya National PMTCT Implementers Meeting. Nairobi, Kenya: July 18-20, 2011; DHS Kenya 2009

Kenya Nyanza Province*

HIV Prevalence 6.2% 14.9%

HIV Prevalence – pregnant women 17.7%(18.4% &18.9%*)

HTC in ANC 71%**

Women receiving ARVs during pregnancy for prophylaxis or treatment

81%

Facility-based deliveries 44%†

Infants receiving antiretrovirals for PMTCT

62.7%

Infants tested for HIV 39.6%

Why Use Mobile Phones

• Explore operational effectiveness of mobile phone technology for PMTCT

• Enable communication between health providers and patients, thus improving outreach for PMTCT service delivery – Reinforce key messages – Promote specific behaviors

• High mobile phone coverage in Kenya– National census Kenya 2010 – 63% of

households have mobile phone• Collaboration between EGPAF and Ministry of

Health, Kenya

Formative Research

• Focus group discussions (community health workers, peer educators, PMTCT program participants and their partners):– Topics

• Health seeking behaviors– ANC visits– Antiretrovirals and adherence– Facility deliveries– Infant feeding– Early infant diagnosis

• Current phone use and ownership• Preferred messaging/support for key PMTCT

Identified Challenges

Infant follow up – for immunizations but less so for HIV testing

Forget appointments

Miss doses of ARVs

Minimal support for Partner HTC

Limited ability to Communicate for Transport support

PMTCT

Essential Maternal Child

Health

Male Partner Involvement

Motivational Messages and Communication

Coordination/communication between CHWs and patients-

Challenges with communication/ stigma

Social environment does not encourage male participation in MCH

Objectives

Primary• To measure effect of PMTCT-focused structured SMS text

messaging and calls on completion of key PMTCT cascade milestones during pregnancy up to 6-8 weeks postpartum

• To determine acceptability of PMTCT-focused SMS text messaging among pregnant women and male partners

• To evaluate cost inputs and cost estimates for scale-up of the mobile phone intervention components

Secondary• To determine whether male partner involvement with

SMS intervention improves increased PMTCT cascade completion at six weeks postpartum.

Study Design

• Cluster randomized control study– Randomization:• stratified by district and facility type i.e.

hospital, health center and dispensary• accounts for different volumes

– Semi-automated SMS system• Functional for bidirectional communication

– Phone calls between health care providers and participants as appropriate

• Health facility• CHWs

• mHealth Platform• SMS• Phone calls

• PMTCT patient

• Male Partner

Intervention• Web-based and server• Semi-automated

-- Automated components-- Manual components

PMTCT

Male Partner

Involvement

Motivational Messages and Communication

Essential Maternal

Child Health

Drug Adherence

Appointment Reminders Infant HIV testing

Nutrition

Birth Planning

Warning Signs

Partner HIV Testing

Encouragement

Seek Support

SMS Thematic Areas

SMS Messages

Here's advice on timing of pregnancy medicines. Try to take them at the same time each day. It works better if you do! And it will help you not to forget.

Some women eat less food during pregnancy to avoid a large baby. However, this is a myth. Expectant moms should eat a little more than usual for good health!

After birth, give your baby only the very best, your breast milk ONLY, and no other foods or liquids for the first 6 months. Be strong against pressure.

Continue exclusive breastfeeding. Breast milk has all the necessary ingredients and at the correct temperature. Exclusive breastfeeding will avoid diarrhea.

Message of hope: There are women like you all over the world. They walk the same path that you do. Think of them. They will think of you. Don't lose hope.

All men should know their status. And women too. This gives you peace of mind. You'll be smart, strong, and well prepared. Tell a friend to get tested too.

Study Outcomes

Primary Outcome: proportion of women who successfully complete key PMTCT transition points from antenatal to six weeks postpartum

(i) Initiation of antiretrovirals during pregnancy

(ii) delivery at a health facility

(iii) Infant HIV testing at 6 weeks and receipt of

results

Study Outcomes (2)

Secondary Outcomes:(i) number of antenatal care visits (ii) maternal adherence to ARVs (iii) time to initiation of ARVs (iv) uptake of ARVs during labor, delivery, and

postpartum(v) exclusive breastfeeding (vi) uptake of family planning at 6 weeks

postpartum

Pilot: April – June 2012Total Intervention Control

Participants screened 259 155 104

Eligible 199 113 86

Eligible and enrolled 140 females7 males

74 females7 males

66 females0 males

Eligible but not enrolled

59 (29%) 39 (35%) 20 (23%)

*Reasons for non-enrollment (N=59):(i) Newly tested, needed time to decide:11 (19%)(ii) Lacked own mobile phones: 29 (49%)(iii) Went to consult with the partner:13 (22%)(iv) Refused: 6 (10%)

Baseline Characteristics

Age* 26 years (18-27 years)

Gestational age* 24 weeks (16-32 weeks)

Own phone 21/30 (70%)

Share phone 4/30 (13.3%)

Face to face discussion with health provider about PMTCT

15/30 (50%)

Used phone (SMS or voice) to discuss PMTCT with health provider

2/29 (7%)

*Median

HIV Status

28/30 women had been given ARVs for PMTCT during this pregnancy

Study Timeline

• July 2012 - February 2013 – enrollment• January-March 2013 – Focus group discussions

• CHWs and Study Participants

– Costing• November 2013 – complete data collection• December 2013 – February 2014 – Data analysis– Cost effectiveness analysis

• April 2014 – Final report

Study Limitations

• Factors not addressed by intervention that have an effect on PMTCT service delivery– high staff rotation and turnover

• lost contact with clients

– commodity stock-outs– transportation costs to health facilities– culturally influenced infant feeding practices– limited technical capacity of community health

workers within PMTCT– lack of male-friendly services

Acknowledgements

EGPAF Kenya Dr. John Ong’ech (PI)Dr. Judith KosePeter SavosnickRogers SimuyuRosemary OpiyoAggrey Mutimba

EGPAF Washington DCDr. Rhoderick MachekanoDr. Larissa JenningsSuzanne May

Ministry of Health - Kenya

Dr. Martin Sirengo(co-PI)

World Health OrganizationDr. Nigel Rollins

Funded by the World Health Organization