Two-way Texting (2wT) to Improve Patient Retention While Reducing the Healthcare Workload in High-Burden Public HIV Clinics in Malawi

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In sub-Saharan Africa (SSA), retention of HIV-infection people in antiretroviral therapy (ART) is an increasing challenge. With only 67% retained on ART in SSA, over 7.5 million people are out of care, threatening both individual health and HIV epidemic control. With significant healthcare system constraints and formidable healthcare worker (HCW) shortages, ART services in SSA struggle to meet ambitious global targets of 90% retained in care. In research settings, text-based mHealth innovations show promise to increase ART retention and, therefore, reduce viral load (VL). However, few mHealth innovations have been tested or proven effective in real-world settings with severe human and financial resource constraints. mHealth innovations that successfully retain more patients on ART, at lower cost, within large-volume public ART clinics in SSA are urgently needed. Lighthouse Trust (LT), the largest public provider of ART in Malawi, operates two large clinics in Lilongwe with the Malawi Ministry of Health (MoH), Lighthouse Clinic (LH) and Martin Preuss Center (MPC), with a combined 35,000 ART patients. 12-month retention at Lighthouse is 67%, below the 90% global target for epidemic control. Both clinics employ a real-time electronic medical records system (EMRS) and implement a resource-intensive patient retention program, Back to Care (B2C). B2C aims to trace patients who miss ART visits by >14 days. MPC has over 7800 monthly ART visits, and more than 10% of clients are B2C-eligible. B2C demand, coupled with HCW constraints, results in tracing of only 33% of target clients. Lack of, or delayed, tracing reduces ART retention. Moreover, over 50% of traced B2C clients are found on ART, 60% of whom had transferred, demonstrating significant unnecessary tracing. Poor data quality reduces B2C effectiveness. Therefore, the University of Washington’s International Training and Education Center for Health (I-TECH) and LT, with support from MoH and Medic Mobile, seek to implement an innovative, proactive, patient retention system using two-way texting (2wT) between new ART patients and staff. 2wT will resolve potential retention issues before they occur and improve data quality (e.g. identifying transfers), reducing B2C workload. Using a quasi-experimental, pre-post design, this R21 (Aim 1) will test a hybrid 2wT intervention to provide adherence support for, and visit-focused communication with, new ART initiates at MPC clinic, comparing retention (ART outcomes, visit adherence, VL) and B2C referrals among two groups of new MPC ART clients: 2wT-supported (prospective intervention) and matched pre-2wT (retrospective comparison). After demonstrating improved retention at lower cost (Aim 2) using research teams (R21: years 1-2), 2wT integration into the EMRS (R33: years 3-5) will automate enrollment and management of 2WT for new clients in both LH and MPC using routine HCWs (Aim 3), assessing the transition of research to practice. The proposed mHealth study will significantly increase ART retention in public ART clinics using routine HCWs, reducing workload and costs. This innovative approach in high-volume, public settings in Malawi sets the stage for national or regional scale-up.