Two-Way Short Message Service (SMS) Communication May Increase Pre-Exposure Prophylaxis Continuation and Adherence Among Pregnant and Postpartum Women in Kenya

Abstract

Introduction: We evaluated a 2-way short message service (SMS) communication platform to improve continuation of pre-exposure prophylaxis (PrEP) for HIV prevention among Kenyan women who initiated PrEP within routine maternal child health (MCH) and family planning clinics.

Methods: We adapted an existing SMS platform (Mobile WACh [mWACh]) to send PrEP-tailored, theory-based SMS and allow clients to communicate with a remote nurse. Women who did not have HIV and who were initiating PrEP at 2 MCH/family planning clinics in Kisumu County, Kenya, from February to October 2018, were offered enrollment into the mWACh-PrEP program; SMS communication was free. We evaluated acceptability, satisfaction, and implementation metrics. In a pre/postevaluation, we compared PrEP continuation at 1-month postinitiation among women who initiated PrEP in the period before (n=166) versus after mWACh-PrEP implementation, adjusting for baseline differences.

Results: Of the 334 women who were screened for enrollment into the mWACh-PrEP program; 193 (58%) were eligible and of those, 190 (98%) accepted enrollment. Reasons for ineligibility (n=141) included no phone access (29%) and shared SIM cards (25%). Median age was 25 years (interquartile range=22-30), and 91% were MCH clients. Compared to women who initiated PrEP in the month before mWACh-PrEP implementation, women who enrolled in mWACh-PrEP were more likely to return for their first PrEP follow-up visit (40% vs. 53%; adjusted risk ratio [aRR]=1.26; 95% confidence interval [CI]= 1.06, 1.50; P=.008) and more likely to continue PrEP (22% vs. 43%; aRR=1.75; 95% CI=1.21, 2.55; P=.003). Among those who returned, 99% reported successful receipt of SMS through the mWACh-PrEP system and 94% reported that mWACh-PrEP helped them understand PrEP better. Concerns about PrEP use, how it works, and side effects accounted for the majority (80%) of issues raised by participants using SMS.

Conclusions: Two-way SMS expanded support for PrEP and opportunities for dialogue beyond the clinic and enabled women to ask and receive answers in real time regarding PrEP, which facilitated its continued use.

Interface of mWACh-PrEP System With Mock Data© 2019 Jillian Pintye

FIGURE 1

Enrollment of Women in mWACh Program at PrEP Initiation Visits, Kusumu County, Kenya Abbreviations: mWACh, Mobile WACh; PrEP, pre-exposure prophylaxis. ^a From 2 sites that participated in the mWACh-PrEP program. ^b PrEP initiators who were not screened for mWACh-PrEP initiated PrEP in January 2018 before mWACh-PrEP implementation, which began in February 2018. ^c PrEP initiators who were screened for mWACh-PrEP initiated PrEP between February and October 2018. ^d PrEP discontinuation was defined as either not returning for a follow-up visit or not refilling a PrEP prescription at a follow-up visit. ^e PrEP continuation was defined as attending a follow-up visit and refilling a PrEP prescription.

FIGURE 2a

Women's Response Frequency to Automated SMS Over Time Since PrEP Initiation and Enrollment in mWACh-PrEP Program, Kusumu County, Kenya^a Abbreviations: mWACh, Mobile WACh; PrEP, pre-exposure prophylaxis; SMS, short message service. ^a Full SMS transcripts were available and analyzed for 170/190 (90%) of women who enrolled into mWACh-PrEP.

FIGURE 2b

Frequency Distribution of Unprompted Question and Concern Topics Sent by Women Who Initiated PrEP to Remote Nurses Using the mWACh-PrEP Platform, Kusumu County, Kenya (N=183)^a Abbreviations: mWACh, Mobile WACh; PrEP, pre-exposure prophylaxis; SMS, short message service. ^a Overall, 170 participants who initiated PrEP were enrolled in the mWACh-PrEP program had full transcripts available for analysis and 74 (44%) ever sent an unprompted question to a remote nurse during follow-up. Remote nurses received and responded to 183 unprompted questions in total from 74 women.