title: Effect of mobile phone reminders on follow-up medical care of children exposed to or infected with HIV in Cameroon (MORE CARE): a multicentre, single-blind, factorial, randomised controlled trial.
abstract: BACKGROUND
  Missed scheduled HIV appointments lead to increased mortality, resistance to antiretroviral therapy, and suboptimum virological response. We aimed to assess whether reminders sent to carers by text message, mobile phone call, or concomitant text message and mobile phone call increase attendance at medical appointments for HIV care in a population of children infected with or exposed to HIV in Cameroon. We also aimed to ascertain the most cost-effective method of mobile-phone-based reminder.
  
  
  METHODS
  MORE CARE was a multicentre, single-blind, factorial, randomised controlled trial in urban, semi-urban, and rural settings in Cameroon. Carers of children who were infected with or had been exposed to HIV were randomly assigned electronically in blocks of four and allocated (1:1:1:1) sequentially to receive a text message and a call, a text message only, a call only, or no reminder (control). Investigators were masked to group assignment. Text messages were sent and calls made 2 or 3 days before a scheduled follow-up appointment. The primary outcomes were efficacy (the proportion of patients attending a previously scheduled appointment) and efficiency (attendance/[measures of staff working time × cost of the reminders]), as a measure of cost-effectiveness. The primary analysis was by intention to treat. This study is registered with the Pan African Clinical Trials Register, number PACTR201304000528276.
  
  
  RESULTS
  The study took place between Jan 28 and May 24, 2013. We randomly assigned 242 adult-child (carer-patient) pairs into four groups: text message plus call (n=61), call (n=60), text message (n=60), and control (n=61). 54 participants (89%) in the text message plus call group, 51 (85%) in the call group, 45 (75%) in the text message group, and 31 (51%) in the control group attended their scheduled appointment. Compared with control, the odds ratios for improvement in the primary efficacy outcome were 7·5 (95% CI 2·9-19·0; p<0·0001) for text message plus call, 5·5 (2·3-13·1; p=0·0002) for call, and 2·9 (1·3-6·3; p=0·012) for text message. No significant differences were seen in comparisons of the three intervention groups with each other, and there was no synergism between text messages and calls. For the primary efficiency outcome, the mean difference for text message versus text message plus call was 1·5 (95% CI 0·7 to 2·4; p=0·002), for call versus text message plus call was 1·2 (0·7 to 1·6; p<0·0001), and for call versus text message was 0·4 (-1·3 to 0·6; p=0·47).
  
  
  CONCLUSIONS
  Mobile-phone-based reminders of scheduled HIV appointments for carers of paediatric patients in low-resource settings can increase attendance. The most effective method of reminder was text message plus phone call, but text messaging alone was the most efficient (ie, cost-effective) method.
  
  
  BACKGROUND
  No external funding.
authors.affiliation: Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon; Faculty of Medicine, University of Montpellier 1, Montpellier, France; Preventing Mother to Child Transmission Unit, Goulfey District Hospital, Goulfey, Cameroon. Electronic address: bignarimjj@yahoo.fr.
authors.forename: Jean Joel R
authors.initials: JJ
authors.lastname: Bigna
authors.affiliation: Internal Medicine Unit, Edéa Regional Hospital, Edéa, Cameroon.
authors.forename: Jean Jacques N
authors.initials: JJ
authors.lastname: Noubiap
authors.affiliation: Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon; Accredited Treatment Centre, Yaoundé Central Hospital, Yaoundé, Cameroon.
authors.forename: Charles
authors.initials: C
authors.lastname: Kouanfack
authors.affiliation: Department of Medicine, New York University Langone Medical Center, New York, NY, USA.
authors.forename: Claudia S
authors.initials: CS
authors.lastname: Plottel
authors.affiliation: Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon; Infectious Disease Unit, Yaoundé Central Hospital, Yaoundé, Cameroon.
authors.forename: Sinata
authors.initials: S
authors.lastname: Koulla-Shiro
mesh_terms: D000328:Adult; D001071:Appointments and Schedules; D002163:Cameroon; D040421:Cell Phone; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D017010:Reminder Systems; D016037:Single-Blind Method; D060145:Text Messaging