Comparative Effectiveness Trial for Retention, Adherence and Health

This application proposes to evaluate the implementation of a theory-based HIV care enhancement and alcohol treatment intervention delivered by cell phone to patients in urban and rural areas. Engagement, retention, and adherence to care are necessary to achieve HIV suppression and antiretroviral therapy (ART) non-adherence can lead to treatment resistant genetic variants of HIV. People living with HIV often experience difficulty sustaining high-levels of treatment adherence and alcohol use is known to impede HIV care. Most factors that interfere with adherence to care are unanticipated and occur between clinical visits, including depression, ART side effects, and substance use. We will conduct a comparative effectiveness study to evaluate the implementation of a cell phone-delivered theory-based alcohol treatment and HIV care adherence counseling intervention. The intervention is grounded in the Behavioral Self-Regulation Model and utilizes brief cell phone counseling that includes monitoring adherence, provider support, and guided corrective feedback as well as interactive text message check-ins. This proactive approach with patients who drink is intended to increase engagement in care and facilitate reductions in drinking thereby improving retention to care and health outcomes. Brief counseling conducted via cell phones allows providers to detect and correct patient slippage from their care plan within a timeframe that can head-off missed appointments, ART non-adherence, and viral resistance. The intervention also includes interactive text (SMS) messaging that begins weekly and tappers off to further enhance engagement in care. Participants are 200 men and 200 women living in high-HIV prevalence remote communities who actively use alcohol and are receiving HIV treatment. Following screening, informed consent, and baseline assessments, participants will be allocated to either (a) the mobile alcohol behavioral self-regulation counseling enhancement to their usual care or (b) routine services provided in their usual care. Participants will be followed for 12-months post-intervention. The primary endpoints are retention to care, medication adherence assessed by unannounced pill counts and HIV RNA (viral load). The study will also evaluate the implementation processes including facilitators and barriers to engagement in care and a cost accounting of resources expended to achieve optimal outcomes. A team of internationally recognized experts in HIV treatment and behavioral research will form a working group to guide an in-depth implementation and cost evaluation. This study will inform the implementation of low-cost evidence-based care retention and adherence interventions in resource limited settings.