Evaluating a Mobile Phone-Delivered Text Message Reminder Intervention to Reduce Infant Vaccination Dropout in Arua, Uganda: Protocol for a Randomized Controlled Trial.

BACKGROUND: Globally, suboptimal vaccine coverage is a public health concern. According to Uganda's 2016 Demographic and Health Survey, only 49% of 12- to 23-month-old children received all recommended vaccinations by 12 months of age. Innovative ways are needed to increase coverage, reduce dropout, and increase awareness among caregivers to bring children for timely vaccination. OBJECTIVE: This study evaluates a personalized, automated caregiver mobile phone-delivered text message reminder intervention to reduce the proportion of children who start but do not complete the vaccination series for children aged 12 months and younger in select health facilities in Arua district. METHODS: A two-arm, multicenter, parallel group randomized controlled trial was conducted in four health facilities providing vaccination services in and around the town of Arua. Caregivers of children between 6 weeks and 6 months of age at the time of their first dose of pentavalent vaccine (Penta1; containing diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b antigens) were recruited and interviewed. All participants received the standard of care, defined as the health worker providing child vaccination home-based records to caregivers as available and providing verbal instruction of when to return for the next visit. At the end of each day, caregivers and their children were randomized by computer either to receive or not receive personalized, automated text message reminders for their subsequent vaccination visits according to the national schedule. Text message reminders for Penta2 were sent 2 days before, on the day of, and 2 days after the scheduled vaccination visit. Reminders for Penta3 and the measles-containing vaccine were sent on the scheduled day of vaccination and 5 and 7 days after the scheduled day. Study personnel conducted postintervention follow-up interviews with participants at the health facilities during the children's measles-containing vaccine visit. In addition, focus group discussions were conducted to assess caregiver acceptability of the intervention, economic data were collected to evaluate the incremental costs and cost-effectiveness of the intervention, and health facility record review forms were completed to capture service delivery process indicators. RESULTS: Of the 3485 screened participants, 1961 were enrolled from a sample size of 1962. Enrollment concluded in August 2016. Follow-up interviews of study participants, including data extraction from the children's vaccination cards, data extraction from the health facility immunization registers, completion of the health facility record review forms, and focus group discussions were completed by December 2017. The results are expected to be released in 2021. CONCLUSIONS: Prompting health-seeking behavior with reminders has been shown to improve health intervention uptake. Mobile phone ownership continues to grow in Uganda, so their use in vaccination interventions such as this study is logical and should be evaluated with scientifically rigorous study designs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04177485; https://clinicaltrials.gov/ct2/show/NCT04177485. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17262.

HIV prevalence in voluntary counseling and testing centers compared with national HIV serosurvey data in Uganda.

OBJECTIVES: To compare HIV prevalence from routine voluntary counseling and testing (VCT) data with a population-based serosurvey in Uganda and to assess the utility of VCT data as a supplemental data source for HIV surveillance. METHODS: We analyzed HIV testing data from 75,640 unique VCT clients aged 15-59 years collected from August 2004 to January 2005 at 160 VCT sites. We excluded clients who reported illness as the reason for testing. During the same time period, 18,525 adults aged 15-59 years were tested for HIV in the Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS). We compared UHSBS HIV prevalence with age-standardized VCT prevalence, overall and among stand-alone and facility-based VCT sites. RESULTS: HIV prevalence in urban areas was similar overall [UHSBS: 9.7%, 95% confidence interval (CI) 8.6 to 10.7; VCT: 10.1%, CI 9.8 to 10.5] and for both men (UHSBS: 6.3%, CI 4.9 to 7.6; VCT: 7.1, CI 6.6 to 7.5) and women (UHSBS: 12.2%, CI 10.6 to 13.7; VCT: 12.9%, CI 12.3 to 13.4). Urban prevalence from UHSBS (9.7%, CI 8.6 to 10.7), VCT stand-alone sites (10.3% CI 9.8 to 10.8), and VCT sites in health facility settings (10.0%, CI 9.5 to 10.4) was similar. However, in rural areas where VCT coverage is much lower than in urban areas (10% versus 31%), HIV prevalence was much higher among rural VCT clients (8.2%, CI 7.9% to 8.4%) than among rural UHSBS participants (5.2%, CI 4.8% to 5.5%). This resulted in overall higher HIV prevalence among all VCT clients (8.8%, CI 8.7 to 9.1) compared with all survey participants (5.9%, CI 5.6 to 6.2). CONCLUSIONS: After excluding clients who give illness as a reason for testing, VCT data may be used without further adjustment to monitor the HIV epidemic among urban Ugandans using either VCT data from stand-alone or health facility-based sites. However, monitoring rural and overall HIV prevalence using VCT data may not be appropriate until the uptake of VCT in rural areas is significantly improved or an adjustment factor is applied.

Estimating HIV incidence in voluntary counseling and testing clients in Uganda (1992-2003).

OBJECTIVES: To estimate HIV incidence from first-time testers among voluntary counseling and testing (VCT) clients in Uganda. METHODS: Data on 203,000 VCT clients tested from 1992 through 2003 were adjusted for temporal changes in the testing population. Differential mortality rates by HIV status were used to derive expected prevalence at future times from baseline prevalence within 5-year birth cohorts. Incidence was computed as the proportion of HIV-uninfected persons who seroconverted divided by the proportion negative at baseline. RESULTS: Annual HIV incidence per 100 uninfected persons increased from 0.9 (95% confidence interval [CI]: 0.8 to 1.1) in 1993 to 2.3 (95% CI: 2.2 to 2.5) in 2003 (chi test for trend, P < 0.001). Prevalence decreased from 23% to 13% in 1999 to 2000 and increased to 15% in 2003. Women had a higher incidence. Peak incidence shifted to older age groups over time. CONCLUSIONS: Estimating incidence from routine data presents a practical way of tracking HIV incidence and is a useful tool in targeting and evaluating the impact of prevention programs. Our analysis reveals a new phase of the HIV epidemic in Uganda: decreasing prevalence and increasing incidence, especially among middle-aged persons. These findings support the need for intensified prevention interventions among middle-aged persons in Uganda.

Using HIV voluntary counseling and testing data for monitoring the Uganda HIV epidemic, 1992-2000.

OBJECTIVE: To assess trends in the prevalence of HIV infection among voluntary counseling and testing (VCT) clients in Uganda and to describe the utility of VCT data for monitoring the HIV epidemic in 1992-2000. METHODS: We analyzed routinely collected data from first-time VCT clients not reporting illness as a reason for testing. We developed a model adjusting for test site, couple testing, and premarital testing, assessed trends in adjusted prevalence of HIV infection and shifts in age-specific peak prevalence, and compared antenatal clinic (ANC) surveillance data and VCT prevalence trends. RESULTS: Among 201,741 clients, adjusted prevalence of HIV infection declined from 23% in 1992 to 13% in 2000 (P < 0.001) (men, 17%-9% [P < 0.001]; women, 31%-18% [P < 0.001]). The prevalence declined for all age groups except men older than 39 years and women older than 34 years. The prevalence increased for women older than 39 years (P < 0.003). Between 1992 and 2000, peak prevalence declined for both men (31% to 24%) and women (44% to 41%), whereas the age at which the peak occurred increased for both men (36 to 41 years) and women (31 to 36 years). VCT and ANC prevalence trends were similar. CONCLUSION: In Uganda, the prevalence of HIV infection among male and female VCT clients declined from 1992 to 2000, similar to ANC surveillance data, but did not decline in older age groups. In regions with well-established VCT programs, VCT data may provide a useful and convenient tool for monitoring the HIV epidemic.