By Martha Henry
Problem
Time is critical in much of medicine. This is especially true for pregnant HIV-infected women who want their children to be born HIV-free. About 1.4 million women with HIV become pregnant annually. If these expectant mothers begin taking antiretroviral drugs (ARVs) before the third trimester of pregnancy, their risk of passing HIV to their babies can be reduced to as low as 1%. Without ARVs, the rate of infant infection is between 25-40%.
We have the knowledge and medications, yet less than one third of eligible women worldwide begin taking ARVs prior to delivery. In Botswana, where 29% of pregnant women are HIV positive, researchers want to do better.
“We were trying to figure out what the gaps were and whether we could fix that problem so that women who needed therapy for their own health could be on it and also reduce the risk of transmission to their children,” said Dr. Scott Dryden-Peterson, an HAI clinician and researcher. “Most women don’t come into antenatal care until they’re midway through their second trimester. It’s a race to get them onto treatment for that treatment to be effective—to block transmission to their child.”
Hypothesis
Pregnant women in Botswana are required to have a CD4 test before beginning treatment. “CD4 is one of the cells that fights infection,” said Dryden-Peterson. “It’s good to have a lot of them.” Getting CD4 test results back quickly from the lab was identified as an obstacle to quickly putting women on treatment.
Most health clinics in Botswana don’t have Internet access, so there were two ways to get CD4 test results. In most clinics, every week or two a nurse would take a bus to a place with a computer terminal, look up the results online, write them in a book, go back to the clinic, and wait for the pregnant women to return. Or else the lab would print out the result, send the printouts via ambulance to the clinic along with other lab results where they would sit in a stack. If a woman came back to the clinic to request results, a staff member would go through the stack to try to find the result.
Dryden-Peterson and colleagues proposed a simpler solution. The lab would send test result directly to the antenatal clinic via SMS (Short Messaging Service) message. Using a cell phone frequency, the test results would be transmitted to the lab and printed on a small printer the size of an old adding machine.
Trial
The SMS system was rolled out in twenty antenatal clinics in Gaborone, Botswana from July 2011 to April 2012. Equipment and training was provided to both lab and clinic staff. During the trial, 366 ART naïve women were included—189 women got results from the new system, 177 women got results in the standard way.
Results
Without the intervention, the time from when blood was drawn for the CD4 test to when the clinic received the result was a median of sixteen days. With the SMS-based intervention, the time was cut to six days. The SMS method was also cheaper and more efficient. Great news, right? Yes and no.
Though Dryden-Peterson and colleagues were able to dramatically reduce the time it took for test results to reach the clinic, their intervention did not improve the time it took for pregnant women to initiate ART. “The study was successful in getting key results back to the clinics and to the patients much faster and cheaper, but when we solved that problem, other problems emerged, so the end result was that the intervention didn’t help,” explained Dryden-Peterson.
Conclusion
A CD4 test is one step in the “Cascade of Care,” the sequence of events necessary for a patient to successfully receive needed treatment. For HIV, that includes being tested, counseled, treated, and retained in care.
“The big problem is that we have made things quite complicated with too many steps,” said Dryden-Peterson. We have implemented a long process that is not commensurate with the few week window in pregnancy.”
“We focused the intervention of improving communication and coordination within the antenatal clinic, as this was where the most apparent problems were. However, this didn’t improve communication with the ART clinic or help the women get off work to go there. One of the main recommendations from the project was to train midwives to start ART in the antenatal clinic, rather than referring elsewhere. The Botswana Harvard Partnership is helping make that happen.”
“There’s a lot of enthusiasm about mHealth [mobile health technology] interventions for low-income countries, but very limited information about whether they work,” said Dryden-Peterson. “The results of this study emphasizes the promise of these technologies, but also that we still need to learn more about how best to use them to realize their promise for health”
The study was funded by the U.S. National Institutes of Health.
To read the paper: An Augmented SMS Intervention to Improve Access to Antenatal CD4 Testing and ART Initiation in HIV-Infected Pregnant Women: A Cluster Randomized Trial