Technical feasibility and uptake of tailored mobile health support for people with HIV in Lesotho

doi:10.21203/rs.3.rs-8214790/v1

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Research Article

Technical feasibility and uptake of tailored mobile health support for people with HIV in Lesotho

https://doi.org/10.21203/rs.3.rs-8214790/v1

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Background

Mobile health (mHealth) interventions may improve HIV care in the context of healthcare professional shortages. Here, we evaluate the performance of four mHealth components implemented during the Viral Load Triggered ART Care in Lesotho (VITAL) cluster randomised trial. VITAL enrolled adults with HIV receiving antiretroviral therapy (ART) at rural nurse-led clinics in Lesotho, southern Africa. This secondary analysis includes the nine intervention clinics where participants were offered the following tailored mHealth support: 1) short message services (SMS): viral load result communication, visit and adherence reminders; 2) adherence counselling by phone; 3) callback service; and 4) automated remote tuberculosis screening. We assessed the technical success and uptake of these four mHealth support options.

Results

Between 14 October 2020 and 7 August 2024, 376,168 SMS notifications were sent to 2,520 participants, with 288,786 (76.8%) successfully delivered messages. Among those, 277,061 (73.7%) were adherence reminders, 6,949 (1.8%) were clinic visit reminders, and 4,776 (1.3%) were viral load result notifications. Among 435 participants with viremia, 316 (72.6%) were successfully informed by SMS, 11 (2.5%) completed remote adherence counselling via phone. Of 129 nurse callback requests from 114 participants, most related to questions regarding ART intake 49 (37.9%) and questions about the VITAL trial 48 (37.2%), followed by other medical issues such as COVID-19 or body pains 9 (7.0%). Of 1,654 automated tuberculosis symptom calls triggered to participants, 31 (1.9%) were answered. Among these, 11 (35.5%) reported tuberculosis symptoms.

Conclusions

Automated SMS notifications to communicate viral load results and provide reminders for ART adherence and clinic visits encountered high uptake and were technically successful. However, uptake of other phone-based services was low, and technical challenges hindered the implementation of automated remote tuberculosis symptom screening calls. Trial Registration: ClinicalTrials.gov: NCT04527874 (registered 31 August 2020).

digital health

eHealth

mHealth

HIV/Tuberculosis

Lesotho

Southern Africa

Mobile phone ownership has reached 80% in some African countries by 2020, with the use of information and communications technology growing substantially over the past two decades(1, 2). For settings where access to clinics is difficult this trend may offer opportunities to simplify health service delivery. To alleviate the workload of health care providers and ease access to information and counselling, mobile health (mHealth) has been proposed for HIV programs in low- and middle-income countries where ever-growing numbers of people receiving antiretroviral therapy (ART) contrast with stagnating funding (3). In several studies, person-centered short message service (SMS) and phone call-based interventions showed encouraging results both globally and in southern Africa (3–10). In the current HIV funding crisis, with expected aggravation of the health workforce shortage, mHealth may help alleviate some of the consequences (11).

For people with HIV taking ART, mHealth may be particularly helpful in supporting adherence, rapid communication of viral load results, facilitating management in case of viremia and early identification of tuberculosis symptoms, allowing for early investigation for tuberculosis that remains a leading cause of death among people with HIV in southern Africa (12–15). Evidence on the effectiveness and generalisability of mHealth interventions among people with HIV remains mixed, with contradictory findings particularly in low- and middle income settings (1).

In case of viremia while taking ART, the World Health Organization (WHO) recommends enhanced adherence counselling to address barriers to adherence and a follow-up viral load thereafter (4, 16). Randomised controlled trials from Malaysia and India have demonstrated the effectiveness of remote counselling calls in improving ART adherence (17, 18). Similarly, remote telephonic counselling and motivational interviewing by trained nurses showed promising results in the United States of America (19–21). However, evidence on mHealth support beyond SMS for adherence and visit reminders for people with HIV in southern Africa remains limited.

In this secondary analysis of the VITAL trial, we report on the technical feasibility and acceptance of the following mHealth support offered to people with HIV taking ART at nine rural clinics in Lesotho: Viral load result notification SMS, clinic visit reminder SMS, ART adherence reminder SMS, nurse callback services, enhanced adherence counselling by phone and automated remote tuberculosis symptom screening calls.

Study design

This study is a preplanned secondary analysis from the VITAL trial(22, 23). The VITAL trial enrolled adults who were receiving ART at 18 rural nurse-led clinics in two districts of Lesotho. At the nine intervention clinics included in this secondary analysis, participants were offered four types of mHealth support: 1) SMS notifications (notifications of viral load results, clinic visit reminders, and adherence reminders); 2) enhanced adherence counselling via phone; 3) possibility to request a callback from the study nurse; and 4) automated remote tuberculosis symptom screening phone calls. In this analysis, we describe uptake of the offered mHealth support options and technical success in delivering over the 24-month follow-up period. Reporting follows the STROBE statement (24).

Setting and participants and enrolment

This study was conducted at the nine VITAL trial intervention clinics between 14 October 2020 and 7 August 2024. These are rural nurse-led clinics in the districts of Butha-Buthe and Mokhotlong, located in north-east Lesotho, Fig. 1a (Map of Lesotho showing all 18 VITAL clinics in 2 northern districts of Butha-Buthe and Mokhotlong) and Fig. 2b (Map of Lesotho in relation to the Southern Africa Region) (Supplementary information A). Lesotho is a mountainous country surrounded by South Africa. Its adult HIV prevalence was estimated at 17.1% in 2024 (25). VITAL trial participants at one of the nine VITAL intervention clinics who reported to have access to a cellphone were eligible for this secondary analysis.

Study procedures

The following four mHealth components were offered at the VITAL intervention clinics 1) automated short message service (SMS) notifications (information of viral load results; clinic visit reminders sent at one month, one week, and one day before the appointment; and adherence reminders); 2) enhanced adherence counselling by a nurse via phone in case of viremia, 3) VITAL nurse callback service in case a participant had a health related question; and 4) automated remote tuberculosis symptom screening calls. Each intervention was designed in close collaboration with health care professionals and people with HIV in Lesotho and provided in both the official language Sesotho and English. At enrolment, participants who had access to a cell phone to receive confidential information were informed about the different mHealth options and could choose among those according to their preferences. Participants specified their preferred weekday and daytime.

Short Message Service (SMS)

An overview of all SMS support options offered is displayed in Table 1(Short messages services text sent to participants cell phones). All SMS notifications were sent automatically according to the time and weekday chosen by participants. The mobile network provider reported on successful or unsuccessful delivery of each SMS sent. However, information on whether an SMS message was opened and read was not available (Supplementary information B).

Table 1
Short messages services text sent to participants cell phones. *All SMS were sent at the preferred weekday and time after the respective events.
Type	Timing*	Message Options (Sesotho)	Message Options (English)
Welcome SMS	Enrolment	Rea u amohela boithutong ba VITAL!!	Welcome to VITAL!!
ART intake reminder^#	Preference-based	Nako ea lithlare Nka matla! Bophelo bo botle! Nna le bophelo bo botle! Nako e nepahetseng	Med’s time Recharge! Healthy living! Me and good health! Right time!
Clinic visit reminders	30 days, 7 days, and 1 day prior to appointments	Hopola hotla setsing sa hau ka nako ea khoeli. Rea leboha Clinic name* Hopola hotla setsing sa hau ka nako ea beke. Rea leboha Clinic name* Hopola hotla setsing sa hau tsatsi le latelang. Rea leboha Clinic name*	Remember to report at your clinic in 28 days. Thank you, clinic, name Remember to report at your clinic in 7 days. Thank you clinic name. Remember to report at your clinic in the next day. Thank you clinic name.
HIV viral load result SMS	New HIV viral load result available	VL < 20. Rea u lebohela, sepetho sa hao se hantle haholo,Tsoara joalo. Litumeliso ho tsoa setsing sa hao. Clinic name VL 20–999 Sephetho sa hau se tlameha ho phethoa ka mora khoeli tse tharo.Litumeliso ho tsoa setsing sa hao. Clinic name VL ≥ 1’000 Sephetho sa hau se tsuile, re kopa u itlhalehe setsing kapele hau fumana molaetsa. Litumeliso ho tsoa setsing sa hao. Clinic name Sephetho sa hau se tlameha ho phethoa, itlalehe setsing kapele hau fumana molaetsa. Re kopa tsâoarelo ka tsitiso. Litumeliso ho tsoa setsing sa hao. Clinic name	VL < 20 Congratulations on good test ([result])! Keep it up! Discuss long-term supply! Greetings, [clinic name] 1st VL 20–999 Your test ([result]) needs to be repeated in 3 months. Greetings, [clinic name] 2nd VL 20–999 Your test ([result]) is out, please come and see us as soon as possible to discuss support options. Greetings, [clinic name] b. 3rd VL 20–999 Your test ([result]) is. out, please come and see us as soon as possible to discuss a switch. Greetings, [clinic name] a. 1st VL ≥ 1’000 Your test ([result]) is out, please come and see us as soon as possible to discuss support options. Greetings, [clinic name] b. 2nd VL ≥ 1’000 Your test ([result]) is out, please come and see us as soon as possible to discuss a switch. Greetings, [clinic name] Your test should be repeated, please come back as soon as possible, sorry for inconvenience. Greetings, [clinic name]
^# After an initial period of 12 months, participants were asked to confirm if they wanted to continue to receive ART intake reminders at the same frequency.

Table 1. To be put here/ref.

Enhanced Adherence Counselling

Participants in the intervention arm who had viremia were offered the option of receiving enhanced adherence counselling either face-to-face at the clinic (as per standard of care) or remotely via phone from the VITAL study nurse. Eligibility criteria for enhanced adherence counselling followed the national guidelines of Lesotho (26, 27).

VITAL nurse callbacks service

Participants in the intervention arm were provided with the option to request a callback from the VITAL study nurse for any reason. After the call, the study nurse recorded the reason for the callback request. Cellular service providers in Lesotho offer a messaging service known as "callback", which enables users to send a message displaying their caller ID without costs. This service is widely used in the general population (28).

Automated remote tuberculosis screening calls

Participants who received ART supply for more than 3 months were offered an automated tuberculosis screening phone call three months after their clinic visit, and every three months thereafter. Unanswered calls were repeated three times with one-day intervals before being marked as unsuccessful. If a participant had two known phone numbers, the first two calls were directed to the first number, followed by subsequent calls to the second number. During these automated phone calls, participants were asked in Sesotho about the four symptoms usually asked for when screening for tuberculosis: cough, fever, night sweats, and weight loss. Participants had to respond by dialling '1' for yes or '2' for no for each symptom. A USSD (Unstructured Supplementary Service Data) platform was used, which is a technology that enables interactive, real-time communication between a mobile phone and a service application, also in settings with limited internet connectivity. A positive screening result for any symptom triggered an invitation SMS for the participant to visit the clinic for further tuberculosis work-up as per national guidelines (Supplementary information D).

Data collection

Data were collected through the VITAL App and the Viral Load Cohort North-East Lesotho (VICONEL) database. The VITAL App was a custom-built App where health centre nurses and study staff could enter participant data and receive laboratory information for participants. The VITALapp was linked to the VICONEL database, which collects all viral load results in the study districts (29). Data on mHealth preferences including choice and frequency of adherence reminders, as well as preferred weekday and time of day were collected at the enrolment visit for the VITAL trial and could optionally be updated at any clinic visit through the VITALapp as previously reported (22) or remotely by requesting a callback. From the VITAL App, the information was uploaded to the VICONEL database, from where the personalised mHealth support was automatically dispatched at the predefined time points. Viral load results were sent from VICONEL to participants and to the VITAL App to inform the nurses in charge. The VITAL study nurse directly entered and reported data on remote enhanced adherence counselling sessions on the VICONEL database.

Data analysis

Descriptive statistics was applied in reporting these findings. Variables are summarised as frequencies, percentages, median, interquartile ranges, and categorical variables where applicable. All analyses were done using STATA version 16.0.

Sociodemographic details of participants and study population

A total of 3,401 participants were enrolled at one of the nine VITAL intervention clinics. Among these, 2,534 (74.5%) had access to a phone to receive confidential messages. Characteristics of participants with access to a phone at enrollment are displayed in Table 2 (Sociodemographic characteristics of study participants with access to a phone). The majority was female (67.9%) with median age of 42.06 years (IQR: 33.0-49.9), married (50.5%), unemployed (20.4%), and with at least primary education (45.2%).

Table 2

Sociodemographic characteristics of study participants with access to a phone, N = 2,534.
Categories	n (%)
Age at enrolment, in years (Median, IQR) 18–24 25–39 40–59 60+	40.62 years (IQR 33.7–49.3) 141(5.6) 1,021(40.3) 1,131 (44.6) 241 (9.5)
Sex Female Male	1,721(67.9) 813(32.1)
Marital status Married/Domestic partnership Not married Divorced/Separated Widowed *Missing	1,279 (50.5) 178 (7.0) 193(7.6) 432 (17.0) 452 (17.8)
Education level Primary Secondary or Tertiary Informal/other *Missing	1,146 (45.2) 511 (20.2) 486 (19.2) 391(15.4)
Employment status Unemployed Employed in Lesotho Employed in South Africa Self-employed/Housewife/other *Missing	516 (20.4) 219 (8.6) 174 (6.9) 321 (12.7) 1,304 (51.4)

Table 2 to be put here/ref.

SMS notifications to study participants

A sum of 376,168 SMS notifications were sent to 2,520 participants, with a total of 288,786 (76.8%) messages delivered successfully. Of those, 277,061 (73.7%) were ART adherence reminders, 6,949 (1.8%) were clinic visit reminders, and 4,776 (1.3%) viral load result notifications. Among the viral load results notifications, 4,560 (95.5%) reported undetectable, and 316 (4.5%) messages detectable results (Table 3).

Table 3
Offered mHealth support options and delivery status during the study.
Variable	Total (N)	Delivered n (%)	Not delivered n (%)
SMS
ART intake reminder	360,033	277,061 (76.9)	82,972 (23.1)
Clinic visit reminder
Day 1 before appointment	3,156	2,297 (72.8)	859 (27.2)
Day 7 before appointment	3,211	2,346 (73.1)	865 (26.9)
Day 28 before appointment	3,258	2,306 (70.8)	952 (29.2)
Viral load results (VL)
VL undetectable	6,075	4,560 (75.1)	1,515 (24.9)
VL detectable	435	316 (72.6.)	119 (27.4)
Phone calls
Remote enhanced adherence counselling calls	28	24 (85.7)	4 (14.3)
Automated tuberculosis symptoms screening calls	1654	87 (5.2)	1,567 (94.8)
VITAL nurse callback service
Callback calls done	129	129 (100)	0 (0.0)

An SMS notification is categorized as “delivered” if it was sent successfully to the phone.

Remote enhanced adherence counselling

Among 435 participants eligible for enhanced adherence counselling due to detectable viral load in the study period, 11 (2.5%) chose to receive remote enhanced adherence counselling by phone and all 11 completed it with a median of 2 calls and (IQR: 1–3) per person. The median duration of a call was 6.5 minutes (IQR: 6–9) per session (Supplementary information C).

VITAL nurse callback service

Overall, 112 participants received 129 callback calls from the nurse. Reasons for callback requests are summarised in Table 4. The median duration of calls with the nurse was 2 minutes (IQR: 2–3) with a maximum of four call attempts to get hold of a participant.

Table 4
Frequency of VITAL nurse callback reasons to participants, **N = 129**
Reason for callback	Frequency n (%)
VITAL study related reasons	49 (37.9)
ART intake related reasons	48 (37.2)
COVID-19	9 (7.0)
Body pains	9 (7.0)
General Enquiries	9 (7.0)
Viral load	5 (3.9)

Vital tuberculosis calls

Remote automated tuberculosis symptom screening calls

Thirty-one (1.7%) participants completed automated tuberculosis symptoms screening calls. Among these, 11 participants (35.5%) reported at least one tuberculosis symptom (7 reported cough, 6 fever, 5-night sweats and 7 weight loss). Eight out of the 11 requested a personal callback from the study nurse and 5 were reached by the nurse. None of the 11 accessed the clinic for further tuberculosis work-up. Fifty-five participants (3.9%) requested to receive the automated tuberculosis screening at another time, one participant (0.1%) started the tuberculosis screening but did not complete the screening. There were substantial interoperability technical problems with the mobile network providers, which only allowed for remote automated tuberculosis call screening between May 2023 and August 2024 among participants with a phone contract at one of two mobile network providers in Lesotho. Over that time, a total of 1,654 automated tuberculosis screening calls were dispatched to 1,394 participants. Among them, 1,567 (94.8%) did not reach the participant or were not completed by the participant (Table 3).

In this secondary analysis of the VITAL trial, we assessed feasibility and uptake of mHealth support options to people with HIV taking ART in Lesotho. Both the uptake of SMS support options and the technical success rate of SMS delivery were high. Uptake of other telemedical support, such as enhanced adherence counseling via phone or callbacks by a nurse for any medical concerns were relatively low. Success-rate of automated tuberculosis symptoms screening calls were extremely low due to technical problems making it impossible to conclude on their acceptability in our study. Overall, our findings show that for a majority, using SMS notifications as adherence and visit reminder and to directly communicate viral load results to patients appears to be highly acceptable and feasible in the rural context of Lesotho.

Our findings regarding SMS communication align with previous studies from low and middle income countries, demonstrating the feasibility and acceptance of SMS-based communication in delivering HIV-related health information, particularly in supporting adherence to ART and attendance at pharmacy visits in HIV care (1, 3, 30). Evidence across diverse settings, including Lesotho, South Africa, and Kenya show that ART adherence SMS reminders have been found to be feasible and acceptable(3, 17, 30–32). There is less evidence on direct viral load results communication to people with HIV. This approach was reported to be acceptable in small explorative studies in southern Africa (3, 33, 34). To our knowledge, this is the largest scale study testing this approach in such a setting. Considering that viral load results may often get lost, not communicated to patients or communicated too lately, reporting it automatically directly to the patient may potentially increase result awareness and make sure unsuppressed viral loads are followed by an action (35).

Enhanced adherence counselling through a phone call was not widely utilised, with only 11 (2.5%) of participants with viremia opting for this service. This is in contrast to a previous pilot study where participants were asked hypothetically about preferred enhanced adherence counselling mode and all participants requested adherence counselling by phone (36). Further studies report voice and interactive calls in HIV management to be popular (1, 10, 37). For instance, a study in Nigeria with 484 participants from key populations with HIV found that phone-based enhanced adherence counselling was slightly more effective than conventional in-person enhanced adherence counseling in achieving viral re-suppression (38). In contrast, in our study the anticipated benefits of remote counselling, such as reduced travel time and cost savings, may not have been significant enough to influence participants’ choices. Furthermore, phone co-ownership might have limited the utilisation of remote enhanced adherence counselling. Finally, there is a possibility that clinic nurses deviated from VITAL guidelines/protocol by not offering remote enhanced adherence counselling as an option to eligible participants, resulting in low uptake of the remote counselling interventions.

Similarly, the callback service option to the study nurse was not used very frequently. This is in contrast to the findings of the VITAL pilot study, where 97% of participants stated that they would like a callback option in the future (36). A cross-sectional study conducted at an HIV clinic in Durban, used an opt-out process enabling participants to send a free "Please Call Me" message to a specific clinic mobile phone. Participants of this study reported that the approach was easy to use (31). Similarly, to our study, a trial in Kenya established two-way SMS communication with professional nurses, but only 3.3% of participants per week actively requested a call from the nurse (39).

Automated remote tuberculosis screening calls have the potential to identify individuals with tuberculosis symptoms for further clinical evaluation and diagnosis. However, in our study, technical constraints do not allow to conclude on their acceptability or usefulness. Among 31 successfully contacted participants, almost 40% self-reported symptoms. But among those identified to have tuberculosis symptoms, none thereafter attended the clinic for tuberculosis work-up, indicating a potential large gap in the diagnostic cascade. Cell phone turnover, as observed at an HIV clinic in South Africa (31), could have impacted the accessibility of our remote tuberculosis screening calls, which underscores the importance of regularly updating participants contact information to maintain the feasibility of mobile health interventions. Another way to leverage the success of the SMS uptake would be to propose providing TB symptom screens by SMS instead of automated calls.

Limitations of the study

This study had several limitations. First, we were unable to verify whether delivered SMS messages were read by participants. Second, automated tuberculosis screening calls faced significant technical challenges, which did not allow us to evaluate their uptake. Third, this study only assessed technical feasibility and uptake, thus not allowing to conclude on the effectiveness of these mHealth interventions in improving health outcomes.

Our study demonstrates that SMS based mHealth interventions are technically feasible for integration into HIV care in southern Africa settings. SMS notifications such as adherence reminders, visit reminders and direct communication of viral load results, had high uptake and high technical success rates. To translate the technical feasibility of SMS-based support into broader mHealth impact, an enabling environment—spanning infrastructure, human resources, and patient trust—will be crucial, and should be examined in future large-scale and long-term evaluations.

ART Antiretroviral therapy

HIV Human immunodeficiency virus

mHealth Mobile health

STROBE STrengthening the Reporting of Observational Studies in Epidemiology

SMS Short Message Service

USSD Unstructured Supplementary Service Data

VICONEL Viral Load Cohort North-East Lesotho

VITAL Viral Load Triggered ART Care in Lesotho

WHO World Health Organization

Ethics approval and consent to participants

The study protocol was approved by National Health Research Ethics Committee (NH-REC) in Lesotho (ID 220–2019). The VITAL trial was registered on the 31/08/2020 with ClinicalTrials, https://clinicaltrials.gov/study/NCT04527874 - Viral Load Triggered ART Care in Lesotho. This study adhered to the Helsinki declaration. Written informed consent was obtained from all participants at enrolment. Illiterate participants were provided a thumb print and a witness co-signed the informed consent form.

Consent for publication

N/A

Availability of data and materials

The dataset used and /or analysed during the current study is available from the corresponding author on reasonable request.

Competing interest

The authors declare that they have no conflict of interest.

Funding

This study nested within the VITAL trial which was funded through grants from the Moritz Straus Foundation and an SNSF Eccellenza Professorship grant to NDL (PCEFP3_181355). The funders had no role in the study’s design, data collection and analysis, decision or publish, or preparation of the manuscript.

Authors contributions

Conceptualisation ML, NT, NDL. Data curation ML, NT, Formal analysis ML, NT. Funding acquisition NDL, Literature review ML. Methodology ML. Supervision NT, NDL, MSW. Writing original draft ML. Writing-review & editing ML, MKo, MKa, LM, MM,NC,MC,BN,BL,IY,MN,TT,AES,MSW,NT and NDL. All authors read and approved the final manuscript.

Acknowledgments

We wish to acknowledge all VITAL participants and staff at participating clinics. A special thanks goes to the SolidarMed Lesotho team and the Ministry of Health Lesotho for their ongoing collaborative support and dedication. We further wish to acknowledge Life4me+ for the development of the VITALapp and Visible Impact for the development and integration of the underlying VICONEL database.

Author details

¹University Hospital Basel, Totengässlein 3, Basel 4051 Switzerland, +41 61 326 5524,

[email protected] and ¹⁵University Hospital Basel, Totengässlein 3, Basel 4051 Switzerland, +41 61 328 5524, [email protected]

E-mail addresses of authors:

ML: [email protected]

MKo: [email protected]

MKa: [email protected]

LM: [email protected]

MM: [email protected]

NC: [email protected]

MC: [email protected]

BN: [email protected]

BL: [email protected]

IY: [email protected]

MN: [email protected]

TT: [email protected]

AES: [email protected]

MSW: [email protected]

NDL: [email protected]

NT: [email protected]

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Technical feasibility and uptake of tailored mobile health support for people with HIV in Lesotho

Status:

Version 1

Abstract

Background

Results

Conclusions

Introduction

Methodology

Study design

Setting and participants and enrolment

Study procedures

Short Message Service (SMS)

Enhanced Adherence Counselling

VITAL nurse callbacks service

Automated remote tuberculosis screening calls

Data collection

Data analysis

Results

Sociodemographic details of participants and study population

SMS notifications to study participants

Remote enhanced adherence counselling

VITAL nurse callback service

Vital tuberculosis calls

Remote automated tuberculosis symptom screening calls

Discussions

Limitations of the study

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1