Two-way Texting (2wT) to Improve Patient Retention While Reducing the Healthcare Workload in High-Burden Public HIV Clinics in Malawi

In sub-Saharan Africa (SSA), antiretroviral therapy (ART) retention challenges threatens both individual health and HIV epidemic control. With significant healthcare system constraints and formidable healthcare worker (HCW) shortages, ART services in SSA are struggling to keep up with demand for, and continuity in, ART care. Within large-volume public ART clinics in SSA, mobile health (mHealth) innovations may prove critical to support retention of more patients on ART with reduced workload and lower cost.

Lighthouse Trust (LT) is a national ART Centre of Excellence in Lilongwe, Malawi, that operates with the Malawi Ministry of Health (MoH) to provide HIV care, treatment, and support across Malawi. In its two Lilongwe flagship clinics, 35,000 patients are on ART: 24,000 at Martin Preuse Centre (MPC) and 11,000 at Lighthouse (LH). Patients at both are managed via a real-time, point-of-care, electronic medical records system (EMRS). Despite its prominence, retention at MPC and LH clinics falls short: an average of 67% of ART patients are retained at 12-months, well below the 90% threshold needed for epidemic control. Since 2006, LH and MPC implemented a patient retention program, "Back-To-Care" (B2C), that traces ART patients by phone or home visit who miss a clinic visit by >14 days. B2C has been well-recognized for its success returning patients to care . Although early patient tracing increases likelihood of patient reengagement, tracing-based retention efforts are reactive -- waiting for clients to miss visits before intervention. B2C and other tracing programs are highly resource intensive, limiting scale. At MPC, there are over 7800 scheduled ART visits each month: of these, over 800 clients are presumed lost to follow up (LTFU) and referred to the 8 full-time B2C tracers. Program resource constraints cause B2C delays and tracing gaps, greatly diminishing B2C effectiveness and retention success. In July, 2019 only 33% of eligible clients were traced at MPC, a tracing gap found in other ART programs in SSA. Additional proactive retention efforts, within the existing limited resources, are needed to reduce LTFU before it happens.

Therefore, the University of Washington's International Training and Education Center for Health (I-TECH) and LT, with support from MoH and Medic Mobile implemented an innovative, proactive, patient retention system using two-way texting (2wT) between new ART patients and staff. 2wT aims to resolve potential retention issues before they occur and improve data quality (e.g. identifying transfers), reducing B2C workload. A comparison of retention (ART outcomes, visit adherence, VL) and B2C referrals among new MPC ART clients showed improved retention with possible lower costs.

The Malawi Ministry of Health Department of HIV/AIDS (DHA) requested a small-scale randomized control trial (RCT) to provide more rigorous evidence of the 2wT benefit for ART retention.

Study arms: