title: A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study.
abstract: BACKGROUND
  Up to 50 % of HIV-infected persons in sub-Saharan Africa are lost from care between HIV diagnosis and antiretroviral therapy (ART) initiation. Structural barriers, including cost of transportation to clinic and poor communication systems, are major contributors.
  
  
  METHODS
  We conducted a prospective, pragmatic, before-and-after clinical trial to evaluate a combination mobile health and transportation reimbursement intervention to improve care at a publicly operated HIV clinic in Uganda. Patients undergoing CD4 count testing were enrolled, and clinicians selected a result threshold that would prompt early return for ART initiation or further care. Participants enrolled in the pre-intervention period (January - August 2012) served as a control group. Participants in the intervention period (September 2012 - November 2013) were randomized to receive daily short message service (SMS) messages for up to seven days in one of three formats: 1) messages reporting an abnormal result directly, 2) personal identification number-protected messages reporting an abnormal result, or 3) messages reading "ABCDEFG" to confidentially convey an abnormal result. Participants returning within seven days of their first message received transportation reimbursements (about $6USD). Our primary outcomes of interest were time to return to clinic and time to ART initiation.
  
  
  RESULTS
  There were 45 participants in the pre-intervention period and 138 participants in the intervention period (46, 49, and 43 in the direct, PIN, and coded groups, respectively) with low CD4 count results. Median time to clinic return was 33 days (IQR 11-49) in the pre-intervention period and 6 days (IQR 3-16) in the intervention period (P < 0.001); and median time to ART initiation was 47 days (IQR 11-75) versus 12 days (IQR 5-19), (P < 0.001). In multivariable models, participants in the intervention period had earlier return to clinic (AHR 2.32, 95 %CI 1.53 to 3.51) and earlier time to ART initiation (AHR 2.27, 95 %CI 1.38 to 3.72). All three randomized message formats improved time to return to clinic and time to ART initiation (P < 0.01 for all comparisons versus the pre-intervention period).
  
  
  CONCLUSIONS
  A combination of an SMS laboratory result communication system and transportation reimbursements significantly decreased time to clinic return and time to ART initiation after abnormal CD4 test results.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT01579214 , approved 13 April 2012.
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA. msiedner@mgh.harvard.edu.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Siedner
authors.affiliation: Mbarara University of Science and Technology, Mbarara, Uganda. boymukedata@gmail.com.
authors.forename: Data
authors.initials: D
authors.lastname: Santorino
authors.affiliation: Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA. alexlankowski@gmail.com.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Lankowski
authors.affiliation: Mbarara University of Science and Technology, Mbarara, Uganda. mkanyesigye2010@gmail.com.
authors.forename: Michael
authors.initials: M
authors.lastname: Kanyesigye
authors.affiliation: Mbarara University of Science and Technology, Mbarara, Uganda. mwebesa_bwana@yahoo.com.
authors.forename: Mwebesa B
authors.initials: MB
authors.lastname: Bwana
authors.affiliation: Department of Medicine, Massachusetts General Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, MA, 02114, USA. jhaberer@mgh.harvard.edu.
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Haberer
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA. dbangsberg@mgh.harvard.edu.
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data; D019380:Anti-HIV Agents / Q000627:therapeutic use; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012051:Reimbursement Mechanisms / Q000706:statistics & numerical data*; D012424:Rural Population / Q000706:statistics & numerical data*; D060145:Text Messaging / Q000706:statistics & numerical data*; D014186:Transportation / Q000191:economics* / Q000706:statistics & numerical data; D014454:Uganda
chemical_list: D019380:Anti-HIV Agents