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 people living with HIV/AIDS (PLHIV) in antiretroviral therapy (ART) is an increasing challenge. Retention is not stagnant: PLHIV cycle into and out of ART over time. Few mHealth innovations have been tested or proven effective in real-world, public SSA settings. mHealth innovations that successfully retain more clients 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) with a combined 36,000 ART clients. Both clinics employ a real-time electronic medical records system (EMRS) and implement a resource-intensive client retention program, Back to Care (B2C). B2C aims to trace clients who miss ART visits by >14 days. B2C demand, coupled with healthcare worker (HCW) constraints and poor data, results in tracing delays, interrupted treatment, and lost to follow-up (LTFU). 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, client retention system using two-way texting (2wT) between new ART clients and HCWs (R21/R33TW011658). 2wT aims to resolve potential retention issues before they occur and improve data quality (e.g. identifying transfers), reducing B2C workload. Initial 2wT results from the 468 clients in the parent study found that 86% were alive six months post ART initiation compared to 76% in standard of care with reminder calls from buddy supporters (SoC). The probability of being alive and on ART at 6 months was 93.9% (95% CI 89.8-95.1) for 2wT clients and 83.1% (95% CI 79.3-86.2%) in SoC. Patients in 2wT arm were 64% less likely to drop out compared to SoC clients (RR 0.36, 95% CI 0.23-0.55). 2wT appears to lower 12-month retention costs over SoC. This proposed supplement in R33 year 2, will amplify the implementation science (IS) focus and deepen understanding of for whom, where, how and at what cost can retention be optimized? This supplement aims to: 1) Use secondary EMRs and 2wT data to describe retention patterns and cycles in care among 2wT and LT's overall cohort over time and by client characteristic, building mathematical models to guide retention optimization over a 5-year period; 2) Qualitatively explore diverse LT client perspectives, preferences, and experiences with 2wT and complementary retention efforts, gaining understanding of differential retention support needs over time; and 3) Strengthen retention costing analysis to reflect actual cycles of 2wT care engagement, tracing, and reengagement (visit adherence and retention in ART) over time to advocate for appropriate resources and inform an optimized, cost-effective retention approach. We engage MoH and other stakeholders in a participatory approach, presenting preliminary results at 6 months to jointly define 12-month outcomes. At 12- months, we will deliver 2wT recommendations and a retention improvement package that balances scare resources, reflects client retention realities, and specifies retention strategy based on patient characteristics.