Nearly everyone on earth now has access to a mobile phone, according to the latest surveys. From remote villages in Kenya to large cities in the United States, these new “toys” are becoming tools to overcome some of the greatest challenges in HIV—prevention, screening, and treatment adherence.
The use of cell phones in health care is often called mHealth (for mobile health), and it’s one of the fastest growing technological areas in medicine, particularly in the developing world. The National Institutes of Health Consensus Group describes mHealth as “the use of mobile and wireless devices to improve health outcomes, healthcare services and health research.” The mHealth Alliance, [www.mhealthalliance.org] devoted to spreading the use of mHealth globally, says that it “presents the opportunity to improve health outcomes through the delivery of innovative medical and health services with information and communication technologies to the farthest reaches of the globe."
mHealth is a logical outgrowth of the sheer numbers of people with cell phones. A 2012 survey from the Pew Internet and American Life Project found that 85% of adults in the US owned cellphones, half of them smart phones, and that about a third of cell phone owners use their devices to research health or medical information online.1 The United Nation’s Telecommunication Union (ITU) estimates that almost as many people in the developing world—80%--have a mobile phone subscription.2
For HIV prevention efforts in the developing world, these small phones are proving powerful communication devices:
• In rural Uganda, 64% of 176 HIV-infected patients with access to cell phones received reminders via voice calls or text messages about missed clinic appointments. Patients missed 11% of visits, but nearly 80% of those contacted via cell phone came in for their visit within two days of the contact.3
• A randomized clinical trial in Kenya involving 538 patients starting antiretroviral therapy (ART) found that patients who received a weekly text message from a nurse and were required to respond within 48 hours had an adherence rate 19% higher (P=0.006) than the control group. They were also significantly more likely to demonstrate suppressed viral loads (P=0.04).3
• In another study in Kenya, participants received daily or weekly texts to improve adherence. Of those receiving weekly text reminders, 53% achieved adherence rates of at least 90% during the 48-week study, compared with 40% of the control group (P = 0.03). Those receiving weekly reminders were also significantly less likely than the control group to experience treatment interruptions exceeding 48 hours (P = 0.03).4
Policy makers should consider funding programs of this type, recommended authors of a Cochrane meta analysis of two randomized, controlled studies using text messaging to improve ART adherence, and clinics and hospitals should consider implementing them.5
Improving Prevention and Screening
The primary reason that HIV-infected people do not receive treatment isn’t because the treatment isn’t available; but because they either aren’t tested or aren’t educated about the disease and need for treatment.6
A program called Text to Change doubled the number of people who received HIV tests in northern Uganda in one month. The Dutch organization that developed the program produced radio spots asking people to subscribe to the Text for Change SMS quiz. The broadcasts reached more than 145,000 people, among whom 7,000 registered. Just 44% of them had ever been tested. Within a week, the AIDS Information Centre in the city of Lira had conducted 398 HIV tests, compared to 185 the previous week.7
The efficacy of such programs is not limited to developing countries. In Australia, adolescents who received text messages about sexually transmitted diseases demonstrated increased knowledge about STDs and had fewer sexual partners compared to a group that only received texts about sun safety.8
And in the United States, researchers sent three HIV-prevention text messages a week for 12 weeks to 16- to 20-year-old African Americans in Philadelphia, stressing the importance of condom use and reducing the number of sexual partners. Those receiving the messages were more likely to become monogamous than those in the control group.9
Another US study used text messages and YouTube videos about HIV to reach adolescent girls. One participant said the intervention prompted her to take three friends with her for HIV testing, during which one girl learned she was pregnant.10
There’s an App for That
For people in quite different social networks, interventions via apps can offer more sophisticated means of prevention. For instance, consider MEDXSafe, an app that allows users to “bump” phones and exchange not just their contact details but also their STD status in a completely HIPAA-compliant manner. Doctors sign up for the program, usually at their patient’s request, and can provide the information about negative tests to MedXSafe. Only licensed doctors participate and all communication is strongly encrypted.
Another app designed for people worried they might have an STD allows users to snap a picture of their genitals, include notes about their symptoms, and send it off to dermatologists. For a $10 fee, the doctors evaluate the symptoms and photos within 24 hours and send back possible diagnoses and recommendations for treatment. STDTriage, available for $9.99 on the iTunes store, also displays a map of nearby STD clinics.
In New York, Columbia University researchers have developed a handheld mobile device that checks patients’ HIV status with a finger prick, diagnoses the patient within 15 minutes, and immediately sends the results into the patient’s electronic health record using cellular and satellite networks. They tested the low-cost device in Rwanda, where it demonstrated 100% diagnostic sensitivity and specificity. It even detected samples that existing rapid tests missed, and consumed as little power as a mobile phone.
Addressing the Barriers
mHealth is not without challenges, particularly in the developing world. Among them are poor infrastructure, low literacy, limited access to electricity to charge phones and tablets, and cultural issues. Where men control all phones in the family, for instance, they may deny women access as well as confidentiality around issues such as contraception and HIV status. Thus purveyors of mHealth are challenged to find ways around these barriers, such as solar-powered phones.
"At the end of the day, mHealth is not about smartphones, gadgets or even apps,” says Rick Cnossen, director of worldwide health information technology at Intel. “It's about holistically driving transformation . . . about distributing care beyond clinics and hospitals and enabling new information-rich relationships between patients, clinicians and caregivers to drive better decisions and behaviors."11