An Adaptive Strategy for Preventing and Treating Lapses of Retention in Adult HIV Care (AdaPT-R) in Nyanza, Kenya
- Conditions
- HIV
- Interventions
- Behavioral: REC; SMS + Voucher if FailureBehavioral: REC; Navigator if FailureBehavioral: SMS; Navigator if FailureBehavioral: SMS; Outreach if FailureBehavioral: SMS; Navigator if Failure; Stop SMS if SuccessBehavioral: REC; Outreach if FailureBehavioral: SMS; SMS+Voucher if FailureBehavioral: Voucher; Outreach if Failure; Stop Voucher if SuccessBehavioral: Voucher; Navigator if Failure; Stop Voucher if SuccessBehavioral: SMS; SMS+Voucher if Failure; Stop SMS if SuccessBehavioral: Voucher; Outreach if FailureBehavioral: Voucher; SMS+Voucher if FailureBehavioral: Voucher; SMS+Voucher if Failure; Stop Voucher if SuccessBehavioral: SMS; Outreach if Failure; Stop SMS if SuccessBehavioral: Voucher; Navigator if Failure
- Registration Number
- NCT02338739
- Lead Sponsor
- University of California, San Francisco
- Brief Summary
Retaining HIV-infected patients in care is critical, but loss to follow-up after enrolment often reaches 20%-40% by two years, placing millions of patients at risk of poor outcomes. A strategy to optimize retention within resource constraints is urgently needed. Sequential adaptive strategies - a novel class of public health approaches - may offer a solution. A candidate sequential adaptive strategy would start with a less expensive intervention (e.g., SMS) in all patients and then apply a more costly and intensive one (e.g., navigator) only to patients who show early signs of poor retention. This study involves a sequential multiple assignment randomized trial to evaluate a family of such strategies. the investigators will randomize 1,800 adults newly initiating antiretroviral treatment (ART) at 4 HIV clinics in the Nyanza region of Kenya to (1) standard of care routine education and counselling (REC), (2) SMS text messages, or (3) transport vouchers. Patients with early signs of weakening retention (defined as the first time a patient is 14 days late for an appointment) will be re-randomized to (1) a single episode of outreach (standard of care), (2) SMS combined with vouchers, or (3) a peer navigator. Patients not successfully contacted by 28 days after missed visit (and not verified to have left the area or transferred to another clinic) will also be rerandomized to of one the same three re-engagement interventions. Individuals randomized at first stage to SMS or voucher that do not miss a visit by at least 14 days in the first 12 months of follow up will be re-randomized at 12 months to stop first stage intervention or continue with that same intervention to 24 months. The investigators primary objective is to assess the comparative effectiveness of sequenced intervention strategies to prevent initial lapses in retention and to treat those that occur. The investigators primary endpoint is fraction of time retained in care two years after enrolment. In addition, the investigators will assess the comparative effectiveness of first-stage strategies (REC, SMS, voucher) to prevent lapses in retention, and the comparative effectiveness of second stage strategies (outreach, SMS + voucher, navigator) to re-engage patients after initial lapse. This study will also compare outcomes among patients who continue versus discontinue the SMS and voucher interventions, including a small complementarity component utilizing qualitative methods to examine the voucher approach and the effects of discontinuing this approach after success among a subset of participants. At study conclusion the investigators output will be a menu of adaptive strategies for retention, accompanied by estimates of cost and effectiveness, which policy makers in different settings can use to advance the impact of HIV care and treatment programs in Africa.
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 1816
- HIV-infection
- 18 years old
- Planning to remain in the study area (Nyanza region) for the duration of the study, capable of informed consent
- Newly initiating ART (within past 90 days)
- Access to a cell phone
- Ability to read or be read SMS messages
- And willingness to be contacted by clinic upon missed appointment.
- Plans to move out of Nyanza region or acutely ill and requiring hospitalization.
- Hospitalized patients who later recover will be eligible for enrolment at the first post-hospitalization clinic visit during which eligibility criteria are met.
- No access to a cell phone.
- Involvement in studies with the potential to influence retention behaviors.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description REC; SMS + Voucher if Failure REC; SMS + Voucher if Failure - REC; Navigator if Failure REC; Navigator if Failure - SMS; Navigator if Failure SMS; Navigator if Failure - SMS; Outreach if Failure SMS; Outreach if Failure - SMS; Navigator if Failure; Stop SMS if Success SMS; Navigator if Failure; Stop SMS if Success - REC; Outreach if Failure REC; Outreach if Failure - SMS; SMS+Voucher if Failure SMS; SMS+Voucher if Failure - Voucher; Outreach if Failure; Stop Voucher if Success Voucher; Outreach if Failure; Stop Voucher if Success - Voucher; Navigator if Failure; Stop Voucher if Success Voucher; Navigator if Failure; Stop Voucher if Success - SMS; SMS+Voucher if Failure; Stop SMS if Success SMS; SMS+Voucher if Failure; Stop SMS if Success - Voucher; Outreach if Failure Voucher; Outreach if Failure - Voucher; SMS+Voucher if Failure Voucher; SMS+Voucher if Failure - Voucher; SMS+Voucher if Failure; Stop Voucher if Success Voucher; SMS+Voucher if Failure; Stop Voucher if Success - SMS; Outreach if Failure; Stop SMS if Success SMS; Outreach if Failure; Stop SMS if Success - Voucher; Navigator if Failure Voucher; Navigator if Failure -
- Primary Outcome Measures
Name Time Method Retention Up to two years after enrollment Fraction of time in care
- Secondary Outcome Measures
Name Time Method Fraction on-time pharmacy pick-ups for antiretroviral drugs Two years after enrollment Proportion of prescriptions filled and picked up by participants to prescriptions written
Alive with suppressed HIV RNA level (<400 copies/ml) Two years after study enrollment Number of subjects alive with suppressed HIV RNA levels (\<400 copies/ml)
Time from second randomization to return to clinic after initial retention lapse Up to two years after enrollment Time from second randomization to re-engagement; re-engagement is defined as first visit back to clinic
Mean visit adherence (% visits made) Two years after study enrollment Proportion of kept scheduled appointments (range=0-100%), with kept visits being those attended by the patient and with the denominator excluding canceled visits
Cost effectiveness After two years of enrollment Cost per failure (virological failure (HIV RNA\>=400 copies/ml) or death averted
Retention Two years after enrollment Fraction of time in care
Patient-reported barriers to engagement At years one and two after study enrollment Self-reported by questionnaire
Trial Locations
- Locations (1)
Kenya Medical Research Institute
🇰🇪Kisumu, Nyanza, Kenya