A mobile health-facilitated behavioural intervention for community health workers improves exclusive breastfeeding and early infant HIV diagnosis in India: a cluster randomized trial

Abstract

Introduction: India's national AIDS Control Organization implemented World Health Organization's option B+ HIV prevention of mother-to-child transmission (PMTCT) guidelines in 2013. However, scalable strategies to improve uptake of new PMTCT guidelines to reduce new infection rates are needed. This study assessed impact of Mobile Health-Facilitated Behavioral Intervention on the uptake of PMTCT services.

Methods: A cluster-randomized trial of a mobile health (mHealth)-supported behavioural training intervention targeting outreach workers (ORWs) was conducted in four districts of Maharashtra, India. Clusters (one Integrated Counselling and Testing Center (ICTC, n = 119), all affiliated ORWs (n = 116) and their assigned HIV-positive pregnant/postpartum clients (n = 1191)) were randomized to standard-of-care (SOC) ORW training vs. the COMmunity home Based INDia (COMBIND) intervention - specialized behavioural training plus a tablet-based mHealth application to support ORW-patient communication and patient engagement in HIV care. Impact on uptake of maternal antiretroviral therapy at delivery, exclusive breastfeeding at six months, infant nevirapine prophylaxis, and early infant diagnosis at six months was assessed using multi-level random-effects logistic regression models.

Results: Of 1191 HIV-positive pregnant/postpartum women, 884 were eligible for primary outcome assessment; 487 were randomized to COMBIND. Multivariable analyses identified no statistically significant differences in any primary outcome by study arm. COMBIND was associated with higher uptake of exclusive breastfeeding at two months (adjusted Odds Ratio (aOR), 2.10; 95% CI 1.06 to 4.15) and early infant diagnosis at six weeks (aOR, 2.19; 95% CI 1.05 to 3.98) than SOC.

Conclusions: The COMBIND intervention was easily integrated into India's existing PMTCT programme and improved early uptake of two PMTCT components that require self-motivated health-seeking behaviour, thus providing preliminary evidence to support COMBIND as a potentially scalable PMTCT strategy. Further study would identify modifications needed to optimize other PMTCT outcomes.

Keywords: HIV; India; PMTCT uptake; behavioural intervention; mhealth; outreach workers.

Figure 1

Study districts in Maharashtra state, India. COMBIND study was conducted in four high HIV burden distrcits of Maharashtra state in India; Pune, Thane, Satara and Sangli.

Figure 2

Flow of clusters and participants in COMBIND study. The study clusters were ICTc centres (119), ORWs (121) and HIV‐positive pregnant and postpartum women (1256). Randomization included 119 ICTCS, 116 ORWs and 1191 enrolled HIV‐positive women. Fifty‐nine ICTCs, 60 ORWs and 640 HIV‐positive women were randomized in intervention arm. Notably, 153 HIV‐positive women from intervention arm and 154 from SOC arm had completed six months of breastfeeding at the time of study enrolment and could only be included in secondary outcome analysis. The remaining 884 pregnant/postpartum women were eligible for at least one primary outcome assessment; of these, 487 and 397 were in the Intervention and SOC arms respectively.

Figure 3

Effect of COMmunity Home Based INDia (COMBIND) intervention on the uptake of national PMTCT services in Maharashtra, India. This figure depicts that COMBIND intervention showed no statistically significant differences between study arms in any primary outcome after adjusting for maternal and ORW characteristics. However, Compared to SOC, the COMBIND arm had twofold higher uptake of both exclusive breastfeeding at two months (adjusted odds ratio (aOR), 2.10; 95% CI, 1.06 to 4.15) and early infant diagnosis at six weeks (aOR, 2.19; 95% CI, 1.05 to 3.98). No significant differences in maternal or infant death by study arm were observed.