hiv unplugged: advances in mobile health
DESCRIPTION
Ankita Kadakia, M.D., of UC San Diego Owen Clinic, presents "HIV Unplugged: Advances in Mobile Health" at AIDS Clinical RoundsTRANSCRIPT
The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission.
AIDS CLINICAL ROUNDS
HIV Unplugged: Advances in Mobile Health
Ankita Kadakia, MD Assistant Clinical Professor Owen Clinic
Objectives
Discuss mobile health (mHealth) technology specifically for resource limited settings
How mHealth technology can be used to bridge the health care delivery gap specifically for HIV/AIDS care
Using mHealth technology targeted towards the Ugandan healthcare system
http://www.who.int/mediacentre/factsheets/fs310/en/index1.html
http://www.unaids.org/en/resources/campaigns/globalreport2013/factsheet/
Doctors, Nurses, Midwives / 10 Million Population
Crisp N, Chen L. N Engl J Med 2014;370:950-957
Global Health Workforce and Burden of Disease by WHO Region
Crisp N, Chen L. N Engl J Med 2014;370:950-957
BURDEN OF DISEASE
HEALTH CARE WORKERS
The healthcare delivery gap
DIAGNOSIS TREATMENT
Harvard Department of Global Health and Social Medicine
“Despite unprecedented financial resources and medical advances care is prevented from consistently reaching the patients who need it.”
“The Know-Do gap , the often neglected work of getting effective therapies (the know) to the people who need them (the do)” -Paul Farmer, MD
What is the adherence rate to ARVS in sub-saharan Africa?
A) 10%
B) 33%
C) 55%
D) 77%
E) 95%
Mills Edward J. et al JAMA August 6,2009 Vol 290, No 679-690
What is the adherence rate to ARVS in sub-saharan Africa?
A) 10%
B) 33%
C) 55%
D) 77%
E) 95%
Mills Edward J. et al JAMA August 6,2009 Vol 290, No 679-690
Factors Affecting Adherence in Resource Limited Areas
Transportations issues Payment for services and
medications Illness and co-morbid
conditions Inability to obtain
consistent supplies of medication
Food insecurity Alcohol use Religious beliefs and
stigma Higher CD4 counts and
complacency Increased adherence with
cell phone users
Magutu D et al, Factors affecting first month adherence to antiretroviral therapy for HIV positive adults in South Africal; Afr J AIDS Res. 2010 Millis EJ et al, J Acquir Immune Defic Syndrome. 2013 May 1;63(1)e:23-7
Factors Affecting Adherence in Resource Limited Areas
Transportations issues Payment for services and
medications Illness and co-morbid
conditions Inability to obtain
consistent supplies of medication
Food insecurity Alcohol use Religious beliefs and
stigma Higher CD4 counts and
complacency Increased adherence with
cell phone users
Magutu D et al, Factors affecting first month adherence to antiretroviral therapy for HIV positive adults in South Africal; Afr J AIDS Res. 2010 Millis EJ et al, J Acquir Immune Defic Syndrome. 2013 May 1;63(1)e:23-7
2014 Winner of the World Press Photo Award: African migrants in Dijbouti
A Global Connection
http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014
http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014
Connectivity The most rapidly
growing global cellular market!
http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014
Can mHealth Bridge the Delivery Gap?
DIAGNOSIS TREATMENT
Convenient, Mobile, Cheap, Efficient and Fits in Your Pocket … Mobile Doctor
mHealth Point of Care Diagnostics
Why do POC diagnostics improve healthcare delivery in resource limited settings? Improve scalability: shifting health delivery to the local
level (healthcare community worker) Reduce cost Improve early detection: increasing the yield of disease
diagnosis Improve access to previously underserved populations Improve treatment rates
Bridging the Human Delivery Gap with mHealth in Health Care Delivery Systems of Resource Limited
Areas
Study Investigators and Collaborators Ankita Kadakia MD Sanjeev Bhavnani MD (The Scripps Research Institute) Rakhi Sharma MA (Disaster Relief, The World Bank) James Saturday BSc (Kabale Regional Medical Center) Elizabeth Ekirapa-Kiracho PhD (Makerere University School of Public Health) Peterson Kyebambe MD (Nagaru Hospital, Kampala Uganda)
Kabale Uganda 1 hospital system >600,000 people 200 beds 300 patient visits/day 13 doctors
Average time to CD4/VL
Flow Cytometry for CD4 count
CD4 count performed twice per year
Samples are grouped and processed at central facility distant from the collection site (9hours by bus once weekly)
Viral load results take 60-90 days
Galiwango RM et al. (2014) Field Evaluation of PIMA Point-of-Care CD4 Testing in Rakai, Uganda. PLoS ONE 9(3): e88928. doi:10.1371/journal.pone.0088928
Implementation of POC in Resource Limited Areas
1. Identify the major disease burdens in the community Choose a POC based on community based needs Specific factors leading to the delivery-care gap
2. Is the POC diagnostic suitable for use in rural areas? Diagnostic robustness, ease of use, accuracy and cost Is the POC an improvement over the current method of
diagnosis?
3. Organizational infrastructure Adequate medical, financial, human and technological
resources?
http://globalhealth.mit.edu/wp-content/uploads/2011/07/Assessing-POC-diagnostics.pdf
Study Objectives
1 • How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess the digital literacy rates among users in a rural setting
3 • Create a community based mHealth research
model
Study Objectives
1 • Creating a rural mHealth clinic
2 • Determine the cellphone penetration and assess
the digital literacy rates among users
3 • Create a community based mHealth research
model
mHealth Hospital Clinic
Creating a rural mHealth Clinic Creating a rural mHealth Clinic
Creating a rural mHealth Clinic
Creating a rural mHealth Clinic
Creating a rural mHealth Clinic
Point-of-Care ECG
Point-of-Care Pediatric Cardiac Ultrasound
Study Objectives
1 • How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess the digital literacy rates among users in a rural setting
3 • Create a community based mHealth research model
Digital Literacy
Sophistication of cellphone use Do you own a
cellphone? Is it a smartphone? Do you use the
camera? Do you text message? Do you use mobile
payments? Do you use the
internet?
Cellphone Penetration
Cellphone Penetration
What % of people in Kabale own a cellphone?
20%
50%
70%
100?
Cellphone Penetration
75
25
0
10
20
30
40
50
60
70
80
Non-Smartphone Smartphone
Cellphone Penetration
N~300
Perc
ent (
%)
Cellphone Penetration
75
25
0
10
20
30
40
50
60
70
80
Non-Smartphone Smartphone
Cellphone Penetration
N~300
Perc
ent (
%)
Digital Literacy
100%
70%
85% 85%
100%
85% 90%
33%
100%
50%
88%
40%
Cellphoneownership
Smartphone SMS text Camerausage
Mobilepayments
Internetusage
Healthcare Worker (n=14) Patient (n=24)
% o
f Res
pond
ents
Digital Literacy
100%
70%
85% 85%
100%
85% 90%
33%
100%
50%
88%
40%
Cellphoneownership
Smarphone SMS text Camerausage
Mobilepayments
Internetusage
Healthcare Worker (n=14) Patient (n=24)
% o
f Res
pond
ents
Digital Literacy
100%
70%
85% 85%
100%
85% 90%
33%
100%
50%
88%
40%
Cellphoneownership
Smarphone SMS text Camerausage
Mobilepayments
Internetusage
Healthcare Worker (n=14) Patient (n=24)
% o
f Res
pond
ents
Study Objectives
1 • How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess the digital literacy rates among users in a rural setting
3 • Create a community based mHealth research model
Community Based Research
Horowitz CR et al. Community Based Participatory Research From the Margin to the Mainstream. Are Researchers Prepared? Circulation 2009;119:2633-2642
Community Based Participatory Research
Horowitz CR et al. Community Based Participatory Research From the Margin to the Mainstream. Are Researchers Prepared? Circulation 2009;119:2633-2642
Community Advisory Board
Community
Social Organizations
School System
Physician
Caregivers Patients
Adminstration
Healthcare System
Community Based mHealth Research
Community Based Healthcare Needs
70%
50%
50%
60%
General Examinations
Vaccinations
Healthy Lifestyle Education
Postpartum Education
Patient Assessment
Community Based Healthcare Needs
40
25
60 70
40
60
40
10 0
60
80
60 70
0 0
102030405060708090 Healthcare Practitioner Patient
% o
f Res
pond
ents
Community Based Healthcare Needs
40
25
60 70
40
60
40
10 0
60
80
60 70
0 0
102030405060708090 Healthcare Practitioner Patient
% o
f Res
pond
ents
Study Objectives
1 • How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess the digital literacy rates among users in a rural setting
3 • Create a community based mHealth research model • mHealth device usability and barriers to use
mHealth Usability
mHealth Usability
WHO Health Technology Assessment
World Health Organization: Health Technology Assessment of Medical Devices
1. Clinical effectiveness 2. Appropriateness 3. Implementation
Can the technology work? Can the technology work in this setting? How and should the technology be implemented in
this setting? By physicians? By all healthcare workers? By patients?
mHealth Usability
mHealth Usability
mHealth Usability
World Health Organization: Health Technology Assessment of Medical Devices
Local mHealth Usability
Local mHealth Usability
0%10%20%30%40%50%60%70%80%90%
100%
Can thesedeviceswork?
Easy to use? Usefulfeatures?
Increaseefficiency of
caredelivery?
Use by allhealthcareworkers?
90% 100%
80%
100% 100%
% o
f Res
pond
ents
Rapid Connectivity!
Point-of-Care Implementation Identify key gaps in rural healthcare
delivery
Select POC diagnostics appropriate for resource limited settings
Ensure effective training, treatment and support
Improved Health Outcomes?
Community Based Healthcare Needs
40
25
60 70
40
60
40
10 0
60
80
60 70
0 0
102030405060708090 Healthcare Practitioner Patient
% o
f Res
pond
ents
mHealth HIV
Text messaging for medication adherence
Lab-on-a-Chip and Microfluidics
Mobile-Elisa (mElisa)
Future Directions
mHealth HIV
Text messaging for medication adherence
Lab-on-a-Chip and Microfluidics
Mobile-Elisa (mElisa)
Future Directions
How can the Cellphone help with medication adherence?
mHealth HIV
Text messaging for medication adherence
Lab-on-a-Chip and Microfluidics
Mobile-Elisa (mElisa)
Future Directions
Lab-on-a-Chip
Lab on a Chip
•Clinical trial in Muhima Hospital, Kigali, Rwanda •Commercially available sera/ plasma samples of HIV /Syphilis tested in the mChip at Columbia University, HIV sensitivity 100%, specificity 95%, Syphilis 100%, 81% •Commercial ELISA HIV 100/98-100% and Syphilis ab 82-100/97-100% •70 specimens collected from known HIV positive men and women •1 out of 70 specimens tested was falsely negative, 98-100% sensitivity/88-100 specificity •67 samples for duplex HIV/Syphilis mChip yielded 100%/94% sensitivity and 100%/76% specificity
m-ELISA CD4 count
mHealth HIV
Text messaging for medication adherence
Lab-on-a-Chip and Microfluidics
Mobile-Elisa (mElisa)
Future Directions
•Tested 17 HIV/AIDS patients and 18 transplant patients on immunosuppression •Compared with Flow cytometry as gold standard •97% accuracy rate compared with flow cytometry
HIV Viral Load Pipeline
www.aslm.org
Simple Amplification Based Assay(SAMBA)
Lee, Helen et al, J Infect Dis. (2010) 201 (supplement 1): s65-s71
•HIV-1 viral nucleic acid based assay for dipstick, 2 hours for result •Sample prep for extraction of viral RNA, isothermal amplification of viral nucleic acid, rapid visual detection of amplification products by dipstick •Tests subtype B and Non-B strains •63 positive /6 negative samples from Royal College of London, 100% reproducible resultscompared with the same samples tested with Roche Taqman HIV-1 assay
mHealth HIV
Text messaging for medication adherence
Lab-on-a-Chip and Microfluidics
Mobile-Elisa (mElisa)
Future Directions
HIV Patient
Eye
Cardiac
Hepatitis Skin
TB
mHealth HIV
HIV Patient
Sensing
Dissemination
Monitoring Education
Prevention
The Future Now
Necessity is the mother of Innovation
Thank you