title: An augmented SMS intervention to improve access to antenatal CD4 testing and ART initiation in HIV-infected pregnant women: a cluster randomized trial.
abstract: BACKGROUND
  Less than one-third of HIV-infected pregnant women eligible for combination antiretroviral therapy (ART) globally initiate treatment prior to delivery, with lack of access to timely CD4 results being a principal barrier. We evaluated the effectiveness of an SMS-based intervention to improve access to timely antenatal ART.
  
  
  METHODS
  We conducted a stepped-wedge cluster randomized trial of a low-cost programmatic intervention in 20 antenatal clinics in Gaborone, Botswana. From July 2011-April 2012, 2 clinics were randomly selected every 4 weeks to receive an ongoing clinic-based educational intervention to improve CD4 collection and to receive CD4 results via an automated SMS platform with active patient tracing. CD4 testing before 26 weeks gestation and ART initiation before 30 weeks gestation were assessed.
  
  
  RESULTS
  Three-hundred-sixty-six ART-naïve women were included, 189 registering for antenatal care under Intervention and 177 under Usual Care periods. Of CD4-eligible women, 100 (59.2%) women under Intervention and 79 (50.6%) women under Usual Care completed CD4 phlebotomy before 26 weeks gestation, adjusted odds ratio (aOR, adjusted for time that a clinic initiated Intervention) 0.87 (95% confidence interval [CI]0.47-1.63, P = 0.67). The SMS-based platform reduced time to clinic receipt of CD4 test result from median of 16 to 6 days (P<0.001), was appreciated by clinic staff, and was associated with reduced operational cost. However, rates of ART initiation remained low, with 56 (36.4%) women registering under Intervention versus 37 (24.2%) women under Usual Care initiating ART prior to 30 weeks gestation, aOR 1.06 (95%CI 0.53-2.13, P = 0.87).
  
  
  CONCLUSIONS
  The augmented SMS-based intervention delivered CD4 results more rapidly and efficiently, and this type of SMS-based results delivery platform may be useful for a variety of tests and settings. However, the intervention did not appear to improve access to timely antenatal CD4 testing or ART initiation, as obstacles other than CD4 impeded ART initiation during pregnancy.
authors.affiliation: Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Scott
authors.initials: S
authors.lastname: Dryden-Peterson
authors.affiliation: Bennett Statistical Consulting, Inc., Ballston Lake, New York, United States of America.
authors.forename: Kara
authors.initials: K
authors.lastname: Bennett
authors.affiliation: Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hughes
authors.affiliation: Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Adrian
authors.initials: A
authors.lastname: Veres
authors.affiliation: Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
authors.forename: Oaitse
authors.initials: O
authors.lastname: John
authors.affiliation: Yale School of Public Health, New Haven, Connecticut, United States of America.
authors.forename: Rosina
authors.initials: R
authors.lastname: Pradhananga
authors.affiliation: Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America.
authors.forename: Matthew
authors.initials: M
authors.lastname: Boyer
authors.affiliation: John's Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Brown
authors.affiliation: Ministry of Health, Gaborone, Botswana.
authors.forename: Bright
authors.initials: B
authors.lastname: Sakyi
authors.affiliation: Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
authors.forename: Erik
authors.initials: E
authors.lastname: van Widenfelt
authors.affiliation: Ministry of Health, Gaborone, Botswana.
authors.forename: Koona
authors.initials: K
authors.lastname: Keapoletswe
authors.affiliation: Ministry of Health, Gaborone, Botswana.
authors.forename: Madisa
authors.initials: M
authors.lastname: Mine
authors.affiliation: Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
authors.forename: Sikhulile
authors.initials: S
authors.lastname: Moyo
authors.affiliation: Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
authors.forename: Aida
authors.initials: A
authors.lastname: Asmelash
authors.affiliation: Harvard Medical School, Boston, Massachusetts, United States of America; Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Mark
authors.initials: M
authors.lastname: Siedner
authors.affiliation: Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
authors.forename: Mompati
authors.initials: M
authors.lastname: Mmalane
authors.affiliation: Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America.
authors.forename: Roger L
authors.initials: RL
authors.lastname: Shapiro
authors.affiliation: Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Shahin
authors.initials: S
authors.lastname: Lockman
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology* / Q000635:transmission; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control; D018962:Phlebotomy; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy / Q000276:immunology; D011296:Prenatal Diagnosis; D017216:Telemedicine / Q000191:economics / Q000379:methods*; D060145:Text Messaging; D013997:Time Factors
chemical_list: D019380:Anti-HIV Agents