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mHealth to Improve Health:A weekly text messaging intervention to improve ART adherence and
HIV Viral Load in a Canadian Context: WelTel OAKTREE
K.Friesen, A.Qiu, O.Goktepe, E.Maan, N.Pick, A.Alimenti, M.Kestler,
K.Smillie, D.Money, R.Lester, M.Murray & WelTel OAKTREE Study Team
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Relationships with commercial interests:
Grants/Research Support:
Bristol-Meyers-Squibb, Gilead Sciences
Other:
Telus (Has provided in-kind phone support)
WelTel (Has provided in-kind platform support)
Disclosure
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Background
https://233livenews.wordpress.com/2015/02/25/unaids-welcomes-further-evidence-of-the-efficacy-of-
antiretroviral-medicines-in-preventing-new-hiv-infections/antiretroviral-drugs/
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• RCT – WelTel Kenya 1
• Kenya, 538 participants
• SMS
• May 2007-Oct 2008
• FINDINGS:• SMS patient support
significantly improved ART adherence and rates of viral suppression (First report)
• SMS patients: 24% more likely to be adherent to ART
• SMS patients 19% more likely to have suppressed VL
Background
Lester et. Al. Lancet 2010 Nov 27;376(9755):1838-45. Epub 2010 Nov 9.
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Background
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Oak Tree Clinic
•Provide optimal care,
treatment and support
for HIV positive women,
pregnant women,
children, youth and
partners.
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Inter-disciplinary, collaborative clinic:
Oak Tree Clinic
• Front desk staff
• Clinic Aide
• Physicians(ID,OB,Peds)
• Dietitian
• Nurse Clinicians
• Psychiatrist
• Trauma & Addiction Counselor
• Part time child care provided by
Volunteers and a literacy
program
• Social Worker
• Nurse Practitioners
• Outreach Workers
• Pharmacists
• Research team
• Program Manager
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• Repeated measures study of 85 participants from the
Oak Tree Clinic
Baseline year: 1 year prior to study enrollment
Study year: 1 year of receiving the intervention
Study Design
Enrollment period: April 2013 -May 2014
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1) Attended clinic for ≥ 1 year prior to study entry
2) Age ≥14 years.
3) Indication for cART
4) Any viral load ≥200 copies/mL in the control year.
5) Vulnerable Population • poor engagement in care
• difficult to contact
• poor or non-adherence to ARV therapy
• advanced HIV infection/AIDS
• unstable housing situation
• recent/active problem substance use
• intimate partner violence
• mental health factors
Inclusion Criteria
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1) Attended clinic for
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• If patients have no cell phone….
• They are provided with a basic phone and unlimited texting for the duration of the study.
• They are taught to use the phone/text as required.
• If patients have a cell phone with unlimited texting….
• They are taught to use the phone/text as required.
The Intervention
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• Weekly text message x 12 months using our
automated text messaging platform….
http://bell-canada.be.funpic.de/images/3-bell-canada-international-text-messaging.jpg
The Intervention
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• Repeated measures mixed-effect regressions to
test for an effect of weekly SMS text messaging
on…
• VL
• CD4
• Clinic and other appointment attendance
• Adherence to ARV’s.
• QOL assessment and cost analysis
Analysis
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TABLE 1Participant Demographics (n=81) N (%)
Gender Female
MaleTransgender
73 (90.1%)
6 (7.4%)2 (2.5%)
Age (years) Median (Range) 39.4 (15-61)
Ethnicity
Caucasian
Indigenous
African/Caribbean BlackSouth Asian
31 (38.3%)
27 (33.3%)
18 (22.2%)5 (6.2%)
IncomeSocial Assistance
EmployedOther
64 (79%)
4 (5.0%)13 (16.0%)
Cell phone ownership (baseline)
YesNo
43 (53.1%)38 (46.9%)
Baseline CD4 Median (Range) 350 (10-490)
23 (29%)
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At study end:
35 participants VL
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*repeated measures mixed effects linear regression@repeated measures mixed effects logistic regression
TABLE 2
Effectiveness Measure
Control Year
Intervention Year
Coefficient P-value
Mean log10 HIV
Viral Load*
2.92 2.57 -0.26 0.015
Mean CD4 Count (cells/mm3) *
345.2 356.5 0.005 0.74
ART Adherence
(predicted mean % doses taken)@
67.1% 70.0% 0.13
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Box plots of median population log10 VL in the control year vs. study end. Using the
Wilcoxon rank sum test there is a significant decrease in log10 VL at study end (p=0.007)
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What about texting
response rates?
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0,00
0,10
0,20
0,30
0,40
0,50
0,60
0,70
0,80
1 6 11 16 21 26 31 36 41 46 51
Pro
po
rtio
n
Weeks
Response Rates for Duration of Study
Problem:
OK
No Response
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• Median response rate: 51.9% (range: 0-98%)
• Mean response rate: 50%
• If we dichotomize based upon this….
• “responders” – 50% or greater response rate
• “non-responders” -
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Response Rates
Pre-intervention Intervention
year
End VL Change
Responders
VL (median) 2.62 log 1.90 log 1.59 log -1.03 log
ARV Adherence
(median)
68.8% 82.5% +13.7%
Non-responders
VL (median) 3.00 log 2.90 log 2.61 log -0.39 log
ARV Adherence
(median)
50.7% 51.5% +0.8%
Adherence: Responder vs. Non-responders, p=0.008
VL between groups: p=0.03Kruskall-Wallis test
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• WTOT-13:
“Having that, just having that knowing that that connection was there. And knowing that it was a
woman. And specific to my, MY needs, my
health care needs. Like, you don't feel like when
you're given those phones that there's 300 other
women out there. You feel like you’ve got one-to-one with your healthcare provider, 24/7.”
Benefits
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What is the impact of the
intervention on the clinic?
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Person A
Person B
Person C
Person D
Person E
Person F
Person
GPerson H
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218 148348
376
270
172
21947
2451
284
Physician
Outreach
Nurse Practitioner
Social Work
Counsellor
Front Desk
Study RA
Dietician
Study Nurse
Pharmacy
Total Time: 75.5 hours (4533 minutes).
53 minutes/person enrolled for 1 year of coverage
Time Usage (minutes)
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8
4,9
6,7 6,1 5,7
27
15
7,7 7,8
4,4
6
0
5
10
15
20
25
30
Mean Time per Interaction (minutes)
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Study Nurse – 2451 minutesCheck-in
Social Work
Mental Health
Medical
Medication related
Test Results
Outside referral
Other
Other text
Appointmentreminders
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Nursing PracticeHi! This is Karen, we changed the ultrasound appt to thurs at 10am. There r a couple of instructions. Is
there a number I can call u on?
Thurs at 10am at [location]. U have to eat a fat free supper on Wed and
then fast from midnight on.
When is the appt?
Dr. M wants to ask how your breathing is these days. Have u
been able to take the septra?
How are you?
I’m ok I missed my ultrasound yesterday can
u rebook please?
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• Population VL decreased significantly from control to
intervention year, and from control year to study end.
• ART adherence improved significantly from control to
intervention year
• No change was seen in CD4 count or appointment
attendance.
• Those who actively participated in text-messaging had a
greater improvement in adherence and HIV VL.
• Results suggest the WelTel intervention is an effective
tool for reducing HIV VL load and improving ART
adherence in poorly engaged, vulnerable Canadian
populations.
Conclusions
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Our Sponsors:
• WelTel
• Gilead Sciences
• Bristol-Myers-Squibb
• Telus
Our Team:
• Dr. Melanie Murray
• Dr. Richard Lester
• Evelyn Maan
• Annie Qiu
• Ozge Goktepe
• Kirsten Smillie
Our Team:
• Nancy Makela
• Sara O’Shaughnessy
• Jasmina Memetovich
• Jonathan Steif
• Dr. Neora Pick
• Dr. Mary Kestler
• Dr. Ariane Alimenti
• Dr. Laura Sauve
• Dr. Deborah Money
• Oak Tree Study Team
Acknowledgments
All of those who participated in the study
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thank you!