A Single-blind, Randomized, Parallel Design Study to Assess the Effectiveness of SMS Reminders in Improving ART Adherence Among Adolescents Living With HIV in Nigeria (STARTA Trial-Adolescents)

BACKGROUND In Nigeria, approximately 3.2 million people were living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in Nigeria. Nigeria has about 196,000 adolescents (10-19 years) living with HIV with an estimated 17,000 new infections and 11,000 AIDS-related deaths per year in the age group. Adolescents aged 15 to 19 years constitute 8.8% of Nigeria's over 173 million people and have an HIV prevalence rate of 2.9%.

Non-adherence to antiretroviral therapy (ART) increases the risk of non-suppression of HIV, secondary HIV transmission, and development of drug resistance; it has a negative impact on treatment outcomes, leads to decreased survival and worsened quality of life. Adolescents on ART have lower viral suppression rates (49%) when compared with both adults and younger children (72.8% and 57%) and this is one of the most frequent causes of lower adherence to ART.

The non-maintained ART adherence is a major barrier to the achievement of optimal treatment outcomes among adolescents living with HIV. ART adherence is a challenge among adolescents living with HIV because of lack of appropriate information, their unique emotional state and lifestyles. Religious, cultural, social and health services related factors have also been recognized as a source of non-adherence to ART treatment. Other known barriers to ART adherence include difficult dosing schedule, side effects, food restrictions and pill burden but the most commonly quoted challenge to adherence is forgetting to take antiretroviral drugs. Many strategies, including directly observed drug use, adherence counselling, telephone calls and reminder devices adopted to enhance ART adherence have turned out to be time-consuming, costly and intrusive.

With over 148 million active mobile lines, short message service (SMS) has become a common means of communication in Nigeria. SMS is used commonly by teenagers, including those who are economically disadvantaged. SMS has been applied in a variety of healthcare setting because of its low-cost and convenient technology and has proved to be an effective tool for behavioural change interventions. There is evidence to suggest that SMS interventions may enhance drug compliance among adolescents living with other chronic diseases such as asthma and diabetes. An RCT showed that text-messaging system increased adherence to medication among adolescents by about 7%. While studies have evaluated the effectiveness of SMS reminders on ART adherence among PLHIV in some low-resource settings, to the best of our knowledge studies that evaluated SMS reminders for adolescents living with HIV have not yet been published. Indeed, a Cochrane systematic review of randomized controlled trials (RCTs) that assessed the effectiveness of SMS for improving ART adherence among people living with HIV infection identified the need of RCTs for this intervention among adolescents.

Mobile technology communicates interventions to people in real-time and in their natural habitat. A review of the literature on SMS interventions for behavioural change in health care settings identified key characteristics for success such as interactivity and tailored messages.