Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa

The Implementation and Costs To Deliver a youth-friendly multi-component Program Addressing Stigma, HIV, and Linkage To Care for Adolescent Girls and Young Women in Lusaka, Zambia

Community-centered HIV prevention is most effective among adolescent girls and young women (AGYW) when integrated with youth-friendly health care services; yet gaps in the literature remain about the costs and the processes of these services. We describe the implementation and costs of two intervention components: (1) the Support for HIV Integrated Education, Linkages to care, and Destigmatization (SHIELD) program, which includes a monthly group session for AGYW with content on social support, stigma, and self-efficacy in health care seeking-behaviors; and (2) the Integrated Wellness Care (IWC) clinic that provided HIV testing along with other sexual and reproductive health services in a youth-friendly clinical setting. Data (e.g., youth club attendance, daily time reporting) come from a cluster randomized trial (ClinicalTrials.gov NCT03995953) conducted in four communities in Lusaka, Zambia. The economic cost of the SHIELD component per client was approximately twice that of the IWC component per client; the greatest costs for SHIELD included participant follow-up (scheduling and session reminders). Those receiving only the SHIELD component attended an average of 7.4 group sessions and those receiving both SHIELD and IWC components attended an average of 6.6 group sessions. Understanding the processes for implementation and delivery costs of behavioral interventions integrated with existing health care models is needed to inform scale-up and adaptation, particularly for policymakers who require understanding intervention costs to make such decisions. By capturing labor and efforts to navigate clients into care we better understand the full cost of sustaining health programs and long-term health care needs of populations.

Results of the Sukuma Ndoda ("Stand up, Man") HIV Self-Screening and Assisted Linkage to Care Project in Johannesburg: A Quasi-Experimental Pre-Post Evaluation

BACKGROUND

HIV testing rates among South African men lag behind rates for women and national targets. Community-based HIV self-screening (HIVSS) distribution and follow-up by community health workers (CHWs) is a scalable option to increase testing coverage, diagnosis, and treatment initiation. We provided HIVSS and assisted linkage to care to men not recently tested (within the past 12 months) residing in high-HIV-burden areas of Johannesburg.

METHODS

CHWs distributed HIVSS in 6 clinic catchment areas. Follow-up to encourage confirmatory testing and antiretroviral therapy initiation was conducted through personal support (PS) or an automated short message service (SMS) follow-up and linkage system in 3 clinic areas each. Using a quasi-experimental pre-post design, we compared differences in the proportion of men testing in the clinic catchment areas during the HIVSS campaign (June-August 2019) to the 3 months prior (March-May 2019) and compared treatment initiations by assisted linkage strategy.

RESULTS

Among 4793 participants accepting HIVSS, 62% had never tested. Among 3993 participants with follow-up data, 90.6% reported using their HIVSS kit. Testing coverage among men increased by 156%, from under 4% when only clinic-based HIV testing services were available to 9.5% when HIVSS and HIV testing services were available (z = -11.6; P < 0.01). Reported test use was higher for men followed through PS (99% vs. 68% in SMS); however, significantly more men reported reactive self-test results in the SMS group compared with PS (6.4% vs. 2.0%), resulting in more antiretroviral therapy initiations in the SMS group compared with PS (23 vs. 9; P < 0.01).

CONCLUSIONS

CHW HIVSS distribution significantly increases testing among men. While PS enabled personalized follow-up, reporting differences indicate SMS is more acceptable and better aligned with expectations of privacy associated with HIVSS.

A randomized trial of 'fresh start' text messaging to improve return to care in people with HIV who missed appointments in South Africa

OBJECTIVE

Treatment interruptions are a barrier to successful antiretroviral therapy (ART). 'Fresh start messages', which leverage significant days on the calendar (e.g., new year, public holiday) in order to prompt action, have the potential to encourage people with HIV (PWH) to return to care. We evaluated a 'fresh start' intervention (text messages) to increase return to care in PWH who had missed their last appointment.

DESIGN

A three arm 1 : 1:1 individual randomised controlled trial.

METHODS

We randomized adults in Capricorn District who had missed ART appointments by >28 days to: no text message; unframed messages (fresh start not mentioned); or framed messages (fresh start mentioned). Randomization was stratified by treatment interruption duration and across two holidays (Youth Day, Mandela Day). The primary outcome was an ART-related clinic visit at ≤45 days of the first message.

RESULTS

9143 participants were randomised. For Youth Day, 1474 and 1468 were sent unframed and framed messages respectively, with 13.4% sent these messages having an ART visit vs. 11.9% not sent a message [adjusted odds ratio (aOR) 1.2; 95% confidence interval (CI): 1.0-1.4, P -value = 0.075]. For Mandela Day, 1336 and 1334 were sent unframed and framed messages respectively, with 6.7% sent these messages having an ART-related clinic visit vs. 5.4% not sent a message (aOR 1.2; 95% CI: 1.0-1.6; P -value = 0.100).

CONCLUSIONS

Low-cost text messages sent around a 'fresh start' date may increase the likelihood that patients who miss appointments return to care. This study suggests the potential of text messaging for motivating return to care.

Cost Analysis of Short Messaging Service and Peer Navigator Interventions for Linking and Retaining Adults Recently Diagnosed With HIV in Care in South Africa

INTRODUCTION

Large proportions of people living with HIV (PLHIV) in sub-Saharan Africa are not linked to or retained in HIV care. There is a critical need for cost-effective interventions to improve engagement and retention in care and inform optimal allocation of resources.

METHODS

We estimated costs associated with a short message service (SMS) plus peer navigation (SMS+PN) intervention; an SMS-only intervention; and standard of care (SOC), within the I-Care cluster-randomized trial to improve HIV care engagement for recently diagnosed PLHIV. We employed a uniform cost data-collection protocol to quantify resources used and associated costs for each intervention.

RESULTS

Compared with SOC, the SMS+PN intervention cost $1284 ($828-$2859) more per additional patient linked to care within 30 days and $1904 ($1158-$5343) more per additional patient retained in care at 12 months, while improving linkage by 24% (95% CI: 11 to 36) and retention by 16% (95% CI: 6 to 26). By contrast, the SMS-only intervention cost $198 ($93-dominated) more per additional patient linked to care and $697 ($171-dominated) more per additional patient retained in care but was not significantly associated with improvements in linkage (12%; 95% CI: -1 to 25) or retention (3%; 95% CI: -7 to 14) compared with SOC. The efficiency of the SMS+PN intervention could be improved by 46%, to $690 more per additional patient linked and $1023 more per additional patient retained in care, if implemented within the Department of Health using more efficient distribution of staff resources.

DISCUSSION

Findings suggest that scale-up of the SMS+PN intervention could benefit patients, improving care and health outcomes while being cost-effective.