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

在撒哈拉以南非洲，艾滋病毒感染者继续接受抗逆转录病毒治疗的人数正在增加， 挑战.在撒哈拉以南非洲，只有67%的人继续接受抗逆转录病毒治疗，超过750万人得不到护理， 个人健康和艾滋病毒流行控制。由于医疗保健系统的严重限制和强大的 卫生保健工作者（HCW）短缺，撒哈拉以南非洲的ART服务难以实现90%的雄心勃勃的全球目标 保持在护理。在研究环境中，基于文本的mHealth创新显示出增加ART保留率的前景 从而降低病毒载量（VL）。然而，很少有移动健康创新经过测试或证明有效 在人力和财力资源严重受限的现实环境中。移动健康创新， 在撒哈拉以南非洲，在大规模公共抗逆转录病毒治疗诊所内以较低费用成功地留住更多接受抗逆转录病毒治疗的病人， 迫切需要。马拉维最大的公共抗逆转录病毒疗法提供者灯塔信托基金会（LT）经营着两家大型诊所 在利隆圭与马拉维卫生部（MoH），灯塔诊所（LH）和马丁·普鲁斯中心（MPC）， 总共有35,000名ART患者。12-Lighthouse的月留存率为67%，低于90%的全球目标， 疫情控制。两家诊所均采用实时电子病历系统（EMRS），并实施 资源密集型患者保留计划，回到护理（B2C）。B2C旨在追踪错过ART的患者 访问>14天MPC每月有超过7800次ART访问，超过10%的客户符合B2C资格。B2c 需求，加上HCW的限制，导致只能追踪到33%的目标客户。缺乏或延迟， 追踪减少了抗逆转录病毒疗法的保留。此外，超过50%的B2C客户被发现在ART上，其中60%的人 转移，显示重大不必要的追踪。数据质量差会降低B2C的效率。 因此，华盛顿大学的国际健康培训和教育中心（I-TECH）和 LT在卫生部和Medic移动的的支持下，寻求实施一种创新的、主动的、患者保留的 新的ART患者和工作人员之间使用双向短信（2 wT）的系统。2 wT将解决潜在的滞留 在问题发生之前就发现问题，提高数据质量（例如识别传输），减少B2C工作量。使用 准实验、前后设计，本R21（目标1）将测试混合2 wT干预以提供依从性 支持MPC诊所的新ART发起者，并与他们进行以访问为重点的沟通，比较保留率（ART 结果，访问依从性，VL）和B2C转介两组新的MPC ART客户：2 wT支持 （前瞻性干预）和匹配的2 wT前（回顾性比较）。在证明改进后， 以较低的成本保留（目标2），使用研究团队（R21：1-2年），2 wT集成到EMRS（R33： 3-5年）将使用常规方法为LH和MPC中的新客户自动登记和管理2 WT HCWs（目标3），评估研究向实践的过渡。拟议的mHealth研究将大大 增加公共抗逆转录病毒治疗诊所使用常规保健工作人员的抗逆转录病毒治疗保留率，减少工作量和成本。这一创新 在马拉维的高容量公共环境中采用这种方法为国家或区域扩大规模奠定了基础。

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.