Medication Adherence and Quality of Life Support by Interactive Voice Response (IVR) Calls among People Living with HIV in India
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Abstract
Background: Anti-Retroviral Therapy (ART) for HIV/AIDS treatment requires 95% adherence to achieve viral suppression to maintain health and reduce transmission risks. High adherence remains a challenge for people living with HIV (PLH) globally. Non-adherence to ART is linked to depression, stigma, social isolation, substance use, and sexual risk behaviors. India has high numbers of PLH but low resources to provide behavioral counseling approaches to support adherence and related factors. Simple, massively scalable, mobile phone delivered messaging interventions are potential disruptive innovations that can meet the essential needs of most PLH at minimal costs. Recently, several text-messaging interventions for ART reminders have demonstrated efficacy in controlled trials, and others have had null results, but these interventions have taken a focused only on medication and appointment reminders. In addition, text-messaging (SMS) is not universally acceptable, particularly in India, where another recent ART adherence study found Interactive Voice Response (IVR) to be more acceptable than SMS and MMS picture messages.
Objective: A two-phase study was initiated in 2012 to design, pilot, refine, and test an automated mobile phone ART adherence and prevention support intervention among PLH in Kolkata, India.
Methods: Phase 1 was a formative mixed-methods study involving a PLH Community Advisory Board to inform initial intervention development, which was then tested in a one-month pre-post no control pilot study (n=46) culminating with focus groups to guide the further intervention development based on experienced user preferences. The intervention consists of two IVR calls each day at each individual’s specified ART dosing schedule, and three appointment reminders for each monthly ART center visit. Phase 2 consists of a six-month RCT (n=400), launched in April 2014, with a baseline and three 2-month follow-up assessments, medical chart abstraction, and weekly IVR brief assessments (4 yes/no questions). The control condition (n=200) receives only weekly IVR assessments. IVR messages, in Bengali and Hindi and voices matched to gender, focus on nutrition, hygiene, mental health (i.e., cognitive-behavioral strategies), stress, social support, entitlements, and adherence. The IVR system and assessment tools were built by Dimagi Inc. on the CommConnect messaging and CommCare case management platforms.
Results: Phase 1 results demonstrated that: 1) SMS is not feasible in this context due to low reading literacy (39% illiterate) and technology literacy, while IVR is common; 2) depression, hopelessness, and stigma are significant concerns; 3) Nutrition/diet, mental health, and social support messages were highly desired; 4) messages mentioning HIV/AIDS, condoms, STIs, sex, or substance use were not acceptable due to confidentiality concerns if others answered or overheard a call, particularly for PLH with children or living with others who were not aware of HIV status; and 5) IVR calls functioned as ART reminders even if unanswered or unintelligible due to poor reception. The Phase 1 pilot found significant reductions in self-report non-adherence (p = 0.016) over one month. Phase 2 RCT is currently in progress.
Conclusions: Engaging and tailored message content is critical to sustained participation in phone messaging interventions, which are likely to be cost-effective disruptive innovations compared to in-person counseling modalities.
Objective: A two-phase study was initiated in 2012 to design, pilot, refine, and test an automated mobile phone ART adherence and prevention support intervention among PLH in Kolkata, India.
Methods: Phase 1 was a formative mixed-methods study involving a PLH Community Advisory Board to inform initial intervention development, which was then tested in a one-month pre-post no control pilot study (n=46) culminating with focus groups to guide the further intervention development based on experienced user preferences. The intervention consists of two IVR calls each day at each individual’s specified ART dosing schedule, and three appointment reminders for each monthly ART center visit. Phase 2 consists of a six-month RCT (n=400), launched in April 2014, with a baseline and three 2-month follow-up assessments, medical chart abstraction, and weekly IVR brief assessments (4 yes/no questions). The control condition (n=200) receives only weekly IVR assessments. IVR messages, in Bengali and Hindi and voices matched to gender, focus on nutrition, hygiene, mental health (i.e., cognitive-behavioral strategies), stress, social support, entitlements, and adherence. The IVR system and assessment tools were built by Dimagi Inc. on the CommConnect messaging and CommCare case management platforms.
Results: Phase 1 results demonstrated that: 1) SMS is not feasible in this context due to low reading literacy (39% illiterate) and technology literacy, while IVR is common; 2) depression, hopelessness, and stigma are significant concerns; 3) Nutrition/diet, mental health, and social support messages were highly desired; 4) messages mentioning HIV/AIDS, condoms, STIs, sex, or substance use were not acceptable due to confidentiality concerns if others answered or overheard a call, particularly for PLH with children or living with others who were not aware of HIV status; and 5) IVR calls functioned as ART reminders even if unanswered or unintelligible due to poor reception. The Phase 1 pilot found significant reductions in self-report non-adherence (p = 0.016) over one month. Phase 2 RCT is currently in progress.
Conclusions: Engaging and tailored message content is critical to sustained participation in phone messaging interventions, which are likely to be cost-effective disruptive innovations compared to in-person counseling modalities.
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