The use, adherence, and evaluation of interactive text-messaging among women admitted to prevention of mother-to-child transmission of HIV care in Kenya (WelTel PMTCT).

BACKGROUND: To improve future mobile health (mHealth) interventions in resource-limited settings, knowledge of participants' adherence to interactive interventions is needed, but previous studies are limited. We aimed to investigate how women in prevention of mother-to-child transmission of HIV (PMTCT) care in Kenya used, adhered to, and evaluated an interactive text-messaging intervention. METHODS: We conducted a cohort study nested within the WelTel PMTCT trial among 299 pregnant women living with HIV aged ≥ 18 years. They received weekly text messages from their first antenatal care visit until 24 months postpartum asking "How are you?". They were instructed to text within 48 h stating that they were "okay" or had a "problem". Healthcare workers phoned non-responders and problem-responders to manage any issue. We used multivariable-adjusted logistic and negative binomial regression to estimate adjusted odds ratios (aORs), rate ratios (aRRs) and 95% confidence intervals (CIs) to assess associations between baseline characteristics and text responses. Perceptions of the intervention were evaluated through interviewer-administered follow-up questionnaires at 24 months postpartum. RESULTS: The 299 participants sent 15,183 (48%) okay-responses and 438 (1%) problem-responses. There were 16,017 (51%) instances of non-response. The proportion of non-responses increased with time and exceeded 50% around 14 months from enrolment. Most reported problems were health related (84%). Having secondary education was associated with reporting a problem (aOR:1.88; 95%CI: 1.08-3.27) compared to having primary education or less. Younger age (18-24 years) was associated with responding to < 50% of messages (aOR:2.20; 95%CI: 1.03-4.72), compared to being 35-44 years. Women with higher than secondary education were less likely (aOR:0.28; 95%CI: 0.13-0.64), to respond to < 50% of messages compared to women with primary education or less. Women who had disclosed their HIV status had a lower rate of non-response (aRR:0.77; 95%CI: 0.60-0.97). In interviews with 176 women, 167 (95%) agreed or strongly agreed that the intervention had been helpful, mainly by improving access to and communication with their healthcare providers (43%). CONCLUSION: In this observational study, women of younger age, lower education, and who had not disclosed their HIV status were less likely to adhere to interactive text-messaging. The majority of those still enrolled at the end of the intervention reported that text-messaging had been helpful, mainly by improving access to healthcare providers. Future mHealth interventions aiming to improve PMTCT care need to be targeted to attract the attention of women with lower education and younger age.

Exploring Primary Healthcare Experiences and Interest in Mobile Technology Engagement Amongst an Urban Population Experiencing Barriers to Care.

Mobile phone-based engagement approaches provide potential platforms for improving access to primary healthcare (PHC) services for underserved populations. We held two focus groups (February 2020) with residents (n = 25) from a low-income urban neighbourhood (downtown Vancouver, Canada), to assess recent healthcare experiences and elicit interest in mobile phone-based healthcare engagement for underserved residents. Note-based analysis, guided by interpretative description, was used to explore emerging themes. Engagement in PHC was complicated by multiple, intersecting personal-level and socio-structural factors, and experiences of stigma and discrimination from care providers. Perceived inadequacy of PHC services and pervasive discrimination reported by participants indicate a significant and ongoing need to improve client-provider relationships to address unmet health needs. Mobile phone-based engagement was endorsed, highlighting phone ownership and client-provider text-messaging, facilitated by non-clinical staff such as peers, as helpful to strengthening retention and facilitating care team connection. Concerns raised included reliability, cost, and technology and language accessibility.

Experiences of the HIV Cascade of Care Among Indigenous Peoples: A Systematic Review.

Indigenous leaders remain concerned that systemic oppression and culturally unsafe care impede Indigenous peoples living with HIV from accessing health services that make up the HIV cascade of care. We conducted a systematic review to assess the evidence related to experiences of the HIV care cascade among Indigenous peoples in Australia, Canada, New Zealand, and United States. We identified 93 qualitative and quantitative articles published between 1996 and 2017 reporting primary data on cascade outcomes disaggregated by Indigenous identity. Twelve involved data from Australia, 52 from Canada, 3 from New Zealand and 26 from United States. The majority dealt with HIV testing/diagnosis (50). Relatively few addressed post-diagnosis experiences: linkage (14); retention (20); treatment initiation (21); adherence (23); and viral suppression (24). With the HIV cascade of care increasingly the focus of global, national, and local HIV agendas, it is critical that culturally-safe care for Indigenous peoples is available at all stages.

The effect of text messaging on latent tuberculosis treatment adherence: a randomised controlled trial.

There is limited high-quality evidence available to inform the use of text messaging to improve latent tuberculosis infection (LTBI) treatment adherence.We performed a parallel, randomised controlled trial at two sites to assess the effect of a two-way short message service on LTBI adherence. We enrolled adults initiating LTBI therapy from June 2012 to September 2015 in British Columbia, Canada. Participants were randomised in a 1:1 ratio to standard LTBI treatment (control) or standard LTBI treatment plus two-way weekly text messaging (intervention). The primary outcome was treatment completion, defined as taking ≥80% prescribed doses within 12 months (isoniazid) or 6 months (rifampin) of enrolment. The trial was unblinded except for the data analyst.A total of 358 participants were assigned to the intervention (n=170) and control (n=188) arms. In intention-to-treat analysis, the proportion of participants completing LTBI therapy in the intervention and control arms was 79.4% and 81.9%, respectively (RR 0.97, 95% CI 0.88-1.07; p=0.550). Results were similar for pre-specified secondary end-points, including time-to-completion of LTBI therapy, completion of >90% of prescribed LTBI doses and health-related quality of life.Weekly two-way text messaging did not improve LTBI completion rates compared to standard LTBI care; however, completion rates were high in both treatment arms.

Gender differences in health-related quality of life at the time of a positive HIV test - a cross-sectional study in a resource-poor, high prevalence setting in Nairobi, Kenya.

Few studies have examined gender differences in sub-Saharan Africa, where HIV disproportionately affects women. Objectives of this cross-sectional study were to determine gender differences in HRQoL at the time of a positive HIV test, and whether factors associated with HRQoL differed between men and women. Adults testing HIV-positive were recruited from two clinics located in informal settlements. HRQoL was measured with the SF-12. Multiple linear regression was used to test whether there were gender differences in physical (PCS) and mental composite summary (MCS) scores. Separate models were built for men and women to examine factors associated with HRQoL. Between April 2013 and June 2015, 775 individuals from were recruited. The mean PCS score was higher in women (adjusted mean difference 2.49, 95% CI 0.54 to 4.44, p = 0.012). There was no significant gender difference in MCS scores. Similar factors were associated with better physical HRQoL in men and women: secondary education, younger age, higher CD4, and employment. Employment was the only factor associated with MCS in men, while less social support and low CD4 were associated with poorer MCS scores in women. Gender differences in factors related to HRQoL should be considered in broader policy and interventions to improve the HRQoL in those diagnosed with HIV.

A pilot randomized controlled trial on the impact of text messaging check-ins and a web-based asthma action plan versus a written action plan on asthma exacerbations.

OBJECTIVE: We compared electronic asthma action plans (eAAP) supported by automated text messaging service (SMS) with written asthma action plans (AAP) on assessing acceptability and asthma control improvement. We hypothesized that the patients in eAAP group would have more improvements in their quality of life, asthma control and decreased asthma exacerbations. METHODS: Patients with physician-diagnosed asthma having at least one asthma exacerbation in the previous 12 months were recruited. Participants received individualized action plans and were randomly assigned into either the intervention (eAAP) or control (AAP) group. Intervention participants received weekly SMS, triggering assessment of asthma control and viewing their eAAP. We assessed applicability of Telehealth platform on asthma exacerbations, asthma control, and quality of life over a 12-month period. RESULTS: 106 patients were enrolled (eAAP = 52, AAP = 54). The cumulative response rate to all weekly SMS check-ins was 68.4%. Overall, 28% of patients checked into their eAAP during the intervention period. There were fewer exacerbations in the eAAP group (18%) compared to the AAP group (RR = 0.82 [95%CI 0.49, 1.36]), (P = 0.44). The mean scores for asthma control and quality of life were higher in the eAAP group compared to the AAP group by 4% (RR = 1.04 [95%CI 0.83, 1.30]), (P = 0.73) and 5.5% (RR = 1.06 [95%CI 0.87, 1.28]), (P = 0.59), respectively, but were not statistically significant. CONCLUSIONS: We demonstrated that the eAAP presented improved asthma control outcomes, but as expected the sample size was inadequate to show a significant difference, but based on this pilot study we plan a larger appropriately powered randomized controlled trial (RCT).

The validity of the SF-12 and SF-6D instruments in people living with HIV/AIDS in Kenya.

BACKGROUND: Health-related quality of life (HRQoL) and health state utility value (HSUV) measurements are vital components of healthcare clinical and economic evaluations. Accurate measurement of HSUV and HRQoL require validated instruments. The 12-item Short-Form Health Survey (SF-12) is one of few instruments that can evaluate both HRQoL and HSUV, but its validity has not been assessed in people living with HIV/AIDS (PLWHA) in east Africa, where the burden of HIV is high. METHODS: This cross-sectional study used baseline data from a randomized trial involving PLWHA in Kenya. Data included responses from a translated and adapted SF-12 survey as well as key demographic and clinical data. Construct validity of the survey was examined by testing the SF-12's ability to distinguish between groups known in advance to have differences in their health based on their disease severity. We classified disease severity based on established definitions from the US Center for Disease Control (CDC) and WHO, as well as a previously studied viral load threshold. T-tests and ANOVA were used to test for differences in HRQoL and HSUV scores. Area under the receive operator curve (AUC) was used to test the discriminative ability of the HRQoL and HSUV instruments. RESULTS: Differences in physical component scores met the minimum clinically important difference among participants with more advanced HIV when defined by CD4 count (4.3 units) and WHO criteria (compared to stage 1, stages 2, 3 and 4 were 2.0, 7.2 and 9.8 units lower respectively). Mental score differences met the minimum clinically important difference between WHO stage 1 and stage 4 patients (4.4). Differences in the HSUV were statistically lower in more advanced HIV by all three definitions of severity. The AUC showed poor to weak discriminatory ability in most analyses, but had fair discriminatory ability between WHO clinical stage 1 and clinical stage 4 individuals (AUC = 0.71). CONCLUSION: Our findings suggest that the Kiswahili translated and adapted version of the SF-12 could be used as an assessment tool for physical health, mental health and HSUV for Kiswahili-speaking PLHWA. TRIAL REGISTRATION: Clinical trials.gov identifier: NCT00830622 . Registered 26 January 2009.

Mobile Text Messaging to Improve Medication Adherence and Viral Load in a Vulnerable Canadian Population Living With Human Immunodeficiency Virus: A Repeated Measures Study.

BACKGROUND: Combination antiretroviral therapy (cART) as treatment for human immunodeficiency virus (HIV) infection is effective and available, but poor medication adherence limits benefits, particularly in vulnerable populations. In a Kenyan randomized controlled trial, a weekly text-messaging intervention (WelTel) improved cART adherence and HIV viral load (VL). Despite growing evidence for short message service (SMS) text-message interventions in HIV care, there is a paucity of data utilizing these interventions in marginalized or female cohorts. OBJECTIVE: This study was undertaken to assess whether the standardized WelTel SMS text-message intervention applied to a vulnerable, predominantly female, population improved cART adherence and VL. METHODS: We conducted a repeated measures study of the WelTel intervention in high-risk HIV-positive persons by measuring change in VL, CD4 count, and self-reported adherence 12 months before and 12 months after the WelTel intervention was introduced. Inclusion criteria included VL ≥200 copies/mL, indication for treatment, and meeting vulnerability criteria. Participants were given a mobile phone with unlimited texting (where required), and weekly check-in text messages were sent for one year from the WelTel computer platform. Clinical data were collected for control and intervention years. Participants were followed by a multidisciplinary team in a clinical setting. Outcomes were assessed using Wilcoxon signed ranks tests for change in CD4 and VL from control year to study end and mixed-effects logistic regressions for change in cART adherence and appointment attendance. A secondary analysis was conducted to assess the effect of response rate on the outcome by modeling final log10 VL by number of responses while controlling for mean log10 VL in the control year. RESULTS: Eighty-five participants enrolled in the study, but 5 withdrew (final N=80). Participants were predominantly female (90%, 72/80) with a variety of vulnerabilities. Mean VL decreased from 1098 copies/mL in the control year to 439 copies/mL at study end (P=.004). Adherence to cART significantly improved (OR 1.14, IQR 1.10-1.18; P<.001), whereas appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). A response was received for 46.57% (1753/3764) of messages sent and 9.62% (362/3764) of text messages sent were replied to with a problem. An outcome analysis examining relationship between reply rate and VL did not meet statistical significance (P=.07), but may be worthy of investigating further in a larger study. CONCLUSIONS: WelTel may be an effective tool for improving cART adherence and reducing VLs among high-risk, vulnerable HIV-positive persons. TRIAL REGISTRATION: Clinicaltrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/6qK57zCwv).

Sexually transmitted infection trends among gay or bisexual men from a clinic-based sentinel surveillance system in British Columbia, Canada.

INTRODUCTION: We described trends for sexually transmitted infections (STI) among gay/bisexual men in British Columbia, Canada, using a sentinel site surveillance approach. METHODS: Using data from an electronic charting system, we included gay/bisexual men who visited high-volume STI clinics from 2000 to 2013. Diagnosis rates and incidence density were calculated for chlamydia, gonorrhea, syphilis, HIV, hepatitis C, genital herpes, and genital warts. Incidence density was estimated among repeat testers who converted from a negative to positive test result. We also conducted Poisson regression analysis to determine factors that were associated with increased incidence rates. RESULTS: A total of 47,170 visits were identified for gay/bisexual men during our time frame. The median age was 34 years (interquartile range, 27-43 years), and most clients were seen in Vancouver. Although trends for most STI were stable, diagnoses of gonorrhea and syphilis have risen steadily in recent years. Coinfection with HIV was associated with higher gonorrhea and syphilis rates in the Poisson regression model. In addition, visiting a Vancouver clinic and younger age were associated with increased incidence. CONCLUSIONS: Our clinic-based sentinel surveillance system found increasing trends for gonorrhea and syphilis among gay/bisexual men but not for other STI in British Columbia. Further investigation is required to explore the syndemic effects of syphilis, gonorrhea, and HIV. This new platform will be a valuable tool for ongoing monitoring of STI and targeting prevention efforts.

Recent Evidence for Emerging Digital Technologies to Support Global HIV Engagement in Care.

Antiretroviral therapy is a powerful tool to reduce morbidity and mortality for the 35 million people living with HIV globally. However, availability of treatment alone is insufficient to meet new UNAIDS 90-90-90 targets calling for rapid scale-up of engagement in HIV care to end the epidemic in 2030. Digital technology interventions (mHealth, eHealth, and telehealth) are emerging as one approach to support lifelong engagement in HIV care. This review synthesizes recent reviews and primary studies published since January 2014 on digital technology interventions for engagement in HIV care after diagnosis. Technologies for health provide emerging and proven solutions to support achievement of the United Nations targets for the generalized HIV-affected population. Much of the existing evidence addresses antiretroviral therapy (ART) adherence; however, studies have begun to investigate programs to support linkage and retention in care as well as interventions to engage key populations facing extensive barriers to care.

Test uptake and case detection of syphilis, HIV, and hepatitis C among women undergoing prenatal screening in British Columbia, 2007 to 2011.

OBJECTIVE: Test uptake and case detection trends for rubella, syphilis, HIV, and hepatitis C (HCV) were compared among the 2007 to 2011 cohort of women undergoing prenatal testing in British Columbia. Analysis involved linkage of provincially centralized laboratory and surveillance data to assess prenatal test uptake and rates of newly diagnosed versus prevalent infections. METHODS: We included prenatal specimens submitted from BC women aged 16 to 45 years in 2007 to 2011. Laboratory records were linked to provincial surveillance systems to identify confirmed maternal syphilis and HIV cases. Previous positive status was determined for HIV and HCV if a prior confirmed case was identified from laboratory records. We determined rates of HIV and HCV newly identified at prenatal screening (new diagnoses per 100 000 per year). Prevalence for HIV and HCV was the sum of all new and prior diagnoses (prevalence per 100 000 per year). RESULTS: Of 233 203 women, 96.9% were screened for rubella, 93.3% for syphilis, 93.8% for HIV, and 21.5% for HCV. From 2007 to 2011, the overall rates of new diagnoses were 15.4, 5.1, and 82.8 cases per 100 000 per year for syphilis, HIV, and HCV, respectively. The overall prevalence was 45.9 and 551.5 cases per 100 000 per year for HIV and HCV, respectively (0.05% and 0.6%). From 2007 to 2011, new diagnoses of HCV decreased 40% from 106.0 to 62.1 cases per 100 000 per year. HCV prevalence did not change and increased with maternal age. CONCLUSION: This study links surveillance and laboratory data to provide a provincial picture of prenatal screening test uptake and case detection, with the advantage of distinguishing new from prior diagnoses. This information can help guide prenatal communicable disease screening policy.

Objectif : La mesure dans laquelle les tests de dépistage de la rubéole, de la syphilis, du VIH et de l'hépatite C (VHC) ont été utilisés et les tendances en ce qui concerne la détection de cas de ces maladies ont été comparées, entre 2007 et 2011, chez les cohortes de femmes faisant l'objet d'un dépistage prénatal en Colombie-Britannique. L'analyse a mis en jeu le croisement de données de surveillance et de laboratoire centralisées à l'échelle provinciale, afin de déterminer la mesure dans laquelle les tests de dépistage prénatal ont été utilisés et de comparer le taux d'infections nouvellement diagnostiquées au taux d'infections prévalentes. Méthodes : Nous avons inclus les prélèvements prénataux, issus de Britanno-colombiennes âgées de 16 à 45 ans, qui ont été soumis au cours de la période allant de 2007 à 2011. Les dossiers de laboratoire ont été liés aux systèmes de surveillance provinciaux en vue d'identifier les cas maternels confirmés de syphilis et de VIH. La présence d'un statut de séropositivité préalable a été établie, pour ce qui est du VIH et du VHC, en ce qui concerne les cas préalablement confirmés ayant été identifiés à partir des dossiers de laboratoire. Nous avons déterminé les taux d'infections au VIH et au VHC nouvellement identifiées au moment du dépistage prénatal (nouveaux diagnostics par 100 000 par année). La prévalence du VIH et du VHC équivalait à la somme de tous les diagnostics, tant nouveaux que préalables (prévalence par 100 000 par année). Résultats : Chez 233 203 femmes, 96,9 % ont fait l'objet d'un dépistage visant la rubéole, 93,3 % ont fait l'objet d'un dépistage visant la syphilis, 93,8 % ont fait l'objet d'un dépistage visant le VIH et 21,5 % ont fait l'objet d'un dépistage visant le VHC. Entre 2007 et 2011, les taux globaux de nouveaux diagnostics ont été de 15,4, de 5,1 et de 82,8 cas par 100 000 par année pour ce qui est de la syphilis, du VIH et du VHC, respectivement. La prévalence globale était de 45,9 et de 551,5 cas par 100 000 par année pour ce qui est du VIH et du VCH, respectivement (0,05 % et 0,6 %). Entre 2007 et 2011, les nouveaux diagnostics de VHC ont connu une baisse de 40 % en passant de 106,0 à 62,1 cas par 100 000 par année. La prévalence du VHC n'a pas connu de fluctuation et nous avons constaté que celle des anticorps anti-VHC augmentait en fonction de l'âge maternel. Conclusion : Cette étude a procédé au croisement des données de surveillance et de laboratoire afin de pouvoir brosser un tableau provincial de la mesure dans laquelle les tests de dépistage prénatal ont été utilisés et de la détection de cas qui s'en est suivie, le tout s'accompagnant de l'avantage de pouvoir distinguer les nouveaux diagnostics des diagnostics préalables. Ces renseignements pourront contribuer à orienter la politique de dépistage prénatal des maladies transmissibles.

Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel Retain).

Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis.

Alignment and specifics of Brazilian health agencies in relation to the international premises for the implementation of digital health in primary health care: a rhetorical analysis.

Digital health and sustainable development goals have had strong impacts with the COVID-19 pandemic. In Brazil, the health crisis scenario required changes in social welfare programs and policies, based on recommendations from international agencies, such as the UN and WHO. This study aims to analyze the alignment of the arguments of Brazilian and international organizations for the adoption of digital health in Primary Health Care based on the COVID-19 pandemic. This is a qualitative documentary study of the rhetorical analysis type, based on Perelman and Obrechts-Tyteca's Theory of Argumentation. The search for documents was carried out by two independent researchers, between December 2021 and June 2022, through the websites of the World Health Organization, the Pan American Health Organization, the Brazilian Ministry of Health, and the Federal Councils of Medicine and Brazilian nursing, with the terms "digital health," "telehealth," "telemedicine," "e-health," "telehealth," "telenursing," "telemedicine," and "digital health." Twenty official documents were analyzed and identified in terms of context, authorship, authenticity, reliability, nature, and key concepts. The international and Brazilian arguments emphasize the applicability of Information and Communication Technologies (ICTs) in the health field. In logical arguments, based on the structure of reality, international agencies emphasize the overlap between health needs and the conditions for the applicability of ICTs. In Brazil, however, there was a need to regulate the digital practices of health professionals. In the international discourse, in the structuring of reality, there are illustrations of the relationship between the context of the health crisis caused by COVID-19 and the concrete conditions for the applicability of digital health; while in the Brazilian discourse, the need to strengthen an environment conducive to digital health is explicit. The Brazilian alignment in relation to the international premises is evident. Yet, there is a need, socially and economically sustainable, to strengthen the inclusion of digital health in PHC policy.

Cephalosporin and azithromycin susceptibility in Neisseria gonorrhoeae isolates by site of infection, British Columbia, 2006 to 2011.

BACKGROUND: Widespread resistance of Neisseria gonorrhoeae to penicillin, tetracycline, and fluoroquinolones has challenged effective treatment and control; recent international case reports of cefixime, ceftriaxone, and azithromycin resistance suggest that the remaining treatment options are now additionally threatened. To explore trends in antimicrobial susceptibility of N. gonorrhoeae, we reviewed provincial laboratory data from British Columbia, 2006 to 2011. METHODS: Susceptibility testing was performed for all N. gonorrhoeae isolates detected in-house or forwarded to the reference laboratory. Resistance or intermediate resistance (nonsusceptibility) was defined by standard breakpoints for penicillin, tetracycline, ciprofloxacin, and spectinomycin. Elevated minimum inhibitory concentrations (MICs) at serial dilutions of 0.064 µg/mL or greater were explored for cefixime/ceftriaxone and 0.5 µg/mL or greater for azithromycin. Nonsusceptibility/elevated MIC was compared by year, site of infection, sex, and age. RESULTS: A total of 1837 isolates representing 22% of all reported gonorrhea cases were analyzed. Nonsusceptibility to penicillin was established at baseline. Nonsusceptibility to tetracycline and ciprofloxacin increased over the study period, reaching 96% and 36%, respectively, in 2011. Sixteen isolates (1%) had a cefixime MIC of 0.25 µg/mL (none ≥0.5), none had a ceftriaxone MIC of 0.25 µg/mL or greater, and 15 (1%) had an azithromycin MIC of 2.0 µg/mL or greater. Elevated MIC of these agents showed an increasing trend over time. Nonsusceptibility and elevated MIC were consistently highest at the rectal and pharyngeal sites and higher in isolates from males, including when stratified to the pharyngeal site. INTERPRETATION: Increases in elevated MIC of cefixime/ceftriaxone/azithromycin were superimposed on a background of established resistance to penicillin, tetracycline, and ciprofloxacin and may signal impending gonococcal resistance to first-line treatments. Ongoing surveillance will inform timely shifts in treatment recommendations.

The effect of an interactive weekly text-messaging intervention on retention in prevention of mother-to-child transmission of HIV care: a randomised controlled trial (WelTel PMTCT).

Retention in prevention of mother-to-child transmission (PMTCT) care is critical to prevent vertical HIV transmission and reduce morbidity and mortality of mother-infant pairs. We investigated whether weekly, interactive text-messaging improved 18-month postpartum retention in PMTCT care. This randomised, two-armed, parallel trial was conducted at six PMTCT clinics in western Kenya. Pregnant women with HIV at least 18 years of age with access to a mobile phone, able to text-message, or had somebody who could text on their behalf, were eligible. Participants were randomly assigned at a 1:1 ratio in block sizes of four to the intervention or control group. The intervention group received weekly text messages asking "How are you?" ("Mambo?" in Swahili) and were requested to respond within 48 h. Healthcare workers called women who indicated a problem or did not respond. The intervention was administered up to 24 months after delivery. Both groups received standard care. The primary outcome was retention in care at 18 months postpartum (i.e., clinic attendance 16-24 months after delivery based on data from patient files, patient registers and Kenya's National AIDS and STI Control Programme database), which was analysed by intention-to-treat. Researchers and data collectors were masked to group assignment, while healthcare workers were not. Between June 25th, 2015, and July 5th, 2016, we randomly assigned 299 women to the intervention and 301 to standard care only. Follow-up concluded on July 26th, 2019. The proportion of women retained in PMTCT care at 18 months postpartum was not significantly different between the intervention (n = 210/299) and control groups (n = 207/301) (risk ratio 1.02, 95% confidence interval 0.92-1.14, p = 0.697). No adverse events related to the mobile phone intervention were reported. Weekly, interactive text-messaging was not associated with improved retention in PMTCT care at 18 months postpartum or linkage to care up to 30 months postpartum in this setting. (ISRCTN No. 98818734).

SMS-based digital health intervention in Rwanda's home-based care program for remote management of COVID-19 cases and contacts: A qualitative study of sustainability and scalability.

Background: COVID-19 pandemic resulted in unprecedented global health challenges. Rwanda identified its first COVID-19 case on March 14, 2020 and subsequently introduced Home-Base Care (HBC) Program in August 2020 following community transmission of the virus and to alleviate logistical and financial strain on the healthcare system. Cases and contacts eligible for HBC were remotely supported by WelTel, an SMS-based mHealth intervention that was successfully implemented before for HIV epidemic in Rwanda. Enrolled cases and contacts were supported and monitored daily via their cell and/or mobile phones until they complete isolation/quarantine period. This study explored the rationale, perspectives, and experiences of key informants (KIs) during the implementation WelTel's mHealth tool for HBC in Rwanda. Methods: Semi-structured one-on-one virtual interviews were conducted with KIs in this qualitative study. The KIs were classified into 2 major categories: (A) Senior staff including policymakers, directors, and senior managers; (B) Technical teams including case managers, and other staff supporting the implementation of WelTel (e.g., IT staff). Interviews were audio-recorded, transcribed, and analyzed in NVivo. Thematic analysis was conducted using a hybrid approach. A topic guide was developed using the Modified Consolidated Framework for Implementation Research and feedback from local stakeholders. Results: 7 KIs were interviewed. Five themes emerged following thematic analysis including: SMS-Based mHealth for Home-Isolation; Facilitators for Intervention Adoption; Barriers for Intervention Adoption; Infection prevention and control for Home-Isolation; and SMS-Based mHealth for Future Pandemics and Epidemics. Based on interviews, strong political commitment and advanced digital infrastructure were major facilitators for adopting WelTel for HBC. A major barrier to adopting WelTel was identified as technical-based issues. This was followed by local communication culture. All participates agreed on the significance of using WelTel to improve access and adherence to infection prevention and control measures, understand transmission dynamics, and inform public health decision-making regarding HBC. Conclusions: Rwanda successfully adopted WelTel for supporting and monitoring COVID-19 cases and contacts in home-isolation and the implementation was instrumental to the country's effort to manage the pandemic. Experiences and perspectives of cases and contacts enrolled into WelTel must be explored to understand the appropriateness and effectiveness of the intervention.

Mobile phone access and preferences among medical inpatients at an urban Canadian hospital for post-discharge planning: A pre-COVID-19 cross-sectional survey.

Background: Digital health interventions are increasingly used for patient care, yet little data is available on the phone access type and usage preferences amongst medical ward inpatients to inform the most appropriate digital interventions post-discharge. Methods: To identify mobile phone ownership, internet access, and cellular use preferences among medical inpatients, we conducted a researcher-administered survey of patients admitted to five internal medicine units at Vancouver General Hospital (VGH) in January 2020. The survey was administered over 2 days separated by a 2-week period. Results: A total of 81 inpatients completed the questionnaire. Survey found that 85.2% of survey respondents had mobile phone access where 63.0% owned their own mobile phone, and 22.2% had access to a mobile phone via a proxy (or an authorized third-party) such as a family member. All participants with mobile phone access had cellular plans (i.e., phone and text); however, a quarter of respondents did not have data plans with internet access. Survey showed that 71.1% of males owned a mobile phone compared to only 52.8% of females. All participants at a "high" risk of readmission had access to a mobile phone, either as phone-owners or proxy-dependent users. Conclusion: Access to mobile phones among medical ward inpatients, 85.2%, was comparable to smartphone penetration rates amongst Canadians in 2019, 85.1%. More patients had cellular than data plans (i.e., internet and applications). Understanding patient-specific access is key to informing potential uptake of digital health interventions aimed at using patients' mobile phones (mHealth) from an effectiveness and equity lens.

Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial.

BACKGROUND: Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. METHODS: WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients were randomised (1:1) by simple randomisation with a random number generating program to a mobile phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h. Randomisation, laboratory assays, and analyses were done by investigators masked to treatment allocation; however, study participants and clinic staff were not masked to treatment. Primary outcomes were self-reported ART adherence (>95% of prescribed doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma HIV-1 viral RNA load suppression (<400 copies per mL) at 12 months. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00830622. FINDINGS: Between May, 2007, and October, 2008, we randomly assigned 538 participants to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk [RR] for non-adherence 0·81, 95% CI 0·69-0·94; p=0·006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0·84, 95% CI 0·71-0·99; p=0·04). The number needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI 5·0-29·5) and the NNT to achieve viral load suppression was 11 (5·8-227·3). INTERPRETATION: Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcome in resource-limited settings. FUNDING: US President's Emergency Plan for AIDS Relief.

The effect of weekly interactive text-messaging on early infant HIV testing in Kenya: a randomised controlled trial (WelTel PMTCT).

Mother-to-child transmission of HIV remains a significant concern in Africa despite earlier progress. Early infant diagnosis (EID) of HIV is crucial to reduce mortality among infected infants through early treatment initiation. However, a large proportion of HIV-exposed infants are still not tested in Kenya. Our objective was to investigate whether weekly interactive text-messages improved prevention of mother-to-child transmission (PMTCT) of HIV care outcomes including EID HIV testing. This multicentre, parallel-group, randomised, open-label trial included six antenatal care clinics across western Kenya. Pregnant women living with HIV, aged 18 years or older, with mobile phone access, were randomised in a 1:1 ratio to weekly text messages that continued until 24 months postpartum, asking "How are you?" ("Mambo?") to which they were asked to respond within 48 h, or a control group. Healthcare workers contacted participants reporting problems and non-responders by phone. Participants in both groups received routine PMTCT care. The prespecified secondary outcome reported in this paper is EID HIV testing by eight weeks of age (blinded outcome assessment). Final 24-months trial results will be published separately. We estimated risk ratios using Poisson regression with robust standard errors. Between June 2015-July 2016, we screened 735 pregnant women, of whom 600 were enrolled: 299 were allocated to the intervention and 301 to the control group. By eight weeks of age, the uptake of EID HIV testing out of recorded live births was 85.5% in the intervention and 84.7% in the control group (71.2% vs. 71.8% of participants randomised, including miscarriages, stillbirths, etc.). The intention-to-treat risk ratio was 0.99; 95% CI: 0.90-1.10; p = 0.89. The proportion of infants diagnosed with HIV was 0.8% in the intervention and 1.2% in the control group. No adverse events were reported. We found no evidence to support that the WelTel intervention improved EID HIV testing. A higher uptake of EID testing than expected in both groups may be a result of lower barriers to EID testing and improved PMTCT care in western Kenya, including the broader standard use of mobile phone communication between healthcare workers and patients. (ISRCTN No. 98818734. Funded by the European-Developing Countries Clinical Trial Partnership and others).