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，将艾滋病毒感染者保留在抗逆转录病毒疗法(ART)中是一个日益严峻的挑战。 然而，很少有移动医疗创新在现实世界中经过测试或证明有效， 人力和财力方面的限制。成功留住更多患者接受抗逆转录病毒治疗的移动健康创新， 在SSA的大容量公共艺术诊所内降低成本是迫切需要的。灯塔信托(LT)，最大的 马拉维的公共抗逆转录病毒治疗提供商，在利隆圭(LighTower(LH)和Martin Preuss)经营着两家大型诊所 与马拉维卫生部(MoH)合作)，总共有35,000名抗逆转录病毒治疗患者。12个月保留期 在灯塔是72%，低于90%的全球疫情控制目标。这两家诊所都使用了实时电子 医疗记录系统(EMRS)和实施资源密集型患者保留计划，Back to Care (B2C)。B2C的目标是追踪错过抗逆转录病毒治疗14天的患者。它每月有超过7800次艺术访问，而且 超过10%的客户符合B2C标准。B2C需求，加上医护人员的限制，导致 仅跟踪33%的目标客户。此外，糟糕的数据质量会降低B2C的有效性。因此，LT和 华盛顿大学国际卫生培训和教育中心(i-tech)，在支持下 来自卫生部和医疗部，实施了使用双向短信的创新、主动的患者保留系统(2wT) 新的抗逆转录病毒治疗患者和工作人员之间的联系(1R21TW011658-01)。2wT旨在解决潜在的保留问题 并提高数据质量(例如识别传输)，从而减少B2C工作负载。2wt参与者 与非2wt相比，ART启动后3个月的保留率估计值(95%，95%CI 91-975)更高 2例(86%，95%可信区间82-89%)。R21的保留率改进和工作负载减少的初步结果 在MPC阶段，卫生部对此表示欢迎。为了支持广泛采用和扩展，卫生部要求严格 来自2wt随机对照试验(RCT)的证据。在R33年第1年，建议的移动健康研究补充 将利用已建立的2WT系统和现有的2WT操作，在LH和MPC诊所进行随机对照试验 团队，最大限度地减少成本，同时最大限度地增加证据生成。RCT比较了410种新ART的结果 患者按1：1随机分为2wT(干预组)和对照组(标准B2C组)。RCT结果反映了缩短的结果 时间表(6个月与12个月)，但结果相同：保留(ART结果，访问依从性)和B2C转介。 同时，母公司R33准试验性、开机前设计(R33 TW011658)将专注于2wt/EMR 互操作性(Y3)和MPC(3年级)的2wT注册，然后扩展到LH(3-4年级)。RCT将做出贡献 到R33注册，并生成严格的证据以响应MoH请求，而无需更改经过验证的 2WT干预或R33时间线。这一小补充在证据生成和 加强卫生部伙伴关系。 。

In sub-Saharan Africa, retention of HIV-infection people in antiretroviral therapy (ART) is an increasing challenge. However, few mobile health 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 (Lighthouse (LH) and Martin Preuss Clinic (MPC)) with the Malawi Ministry of Health (MoH) with a combined 35,000 ART patients. 12-month retention at Lighthouse is 72%, 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. LT has over 7800 monthly ART visits, and more than 10% of clients are B2C-eligible. B2C demand, coupled with healthcare worker constraints, results in tracing of only 33% of target clients. Moreover, poor data quality reduces B2C effectiveness. Therefore, LT and the University of Washington’s International Training and Education Center for Health (I-TECH), with support from MoH and Medic, implemented an innovative, proactive, patient retention system using two-way texting (2wT) between new ART patients and staff (1R21TW011658-01). 2wT aimed to resolve potential retention issues before they occur and improve data quality (e.g. identifying transfers), reducing B2C workload. 2wT participants had higher retention estimates (95%, 95% CI 91-975) at 3 months post ART initiation compared to non 2wT patients (86%, 95% CI 82-89%). Preliminary results on retention improvements and workload reduction from R21 phase at MPC were welcomed by MoH. In support of widespread adoption and scale up, MoH requests rigorous evidence from a 2wT randomized control trial (RCT). In R33 year 1, the proposed mHealth study supplement will conduct an RCT at LH and MPC clinics, using the established 2wT system and the existing 2wT operations team, minimizing costs while maximizing evidence generation. RCT compares outcomes among 410 new ART patients randomized 1:1 into 2wT (intervention) and control (standard B2C). RCT outcomes reflect shortened timeline (6- vs. 12-months), but same outcomes: retention (ART outcomes, visit adherence) and B2C referrals. In parallel, parent R33 quasi-experimental, pre-post design (R33 TW011658) will focus on 2wT/EMRs interoperability (Y3) and 2wT enrollments at MPC (Year 3) before expanding to LH (Year 3-4). RCT will contribute to R33 enrollments and generate rigorous evidence in response to MoH requests without changing the proven 2wT intervention or the R33 timeline. This small supplement brings large gains in evidence generation and strengthened MoH partnership. .