Improving Adherence to Antiretroviral Therapy for Youth Living with HIV/AIDS: A Pilot Study Using Personalised, Interactive, Daily Text Message Reminders

This prospective pilot study to "evaluate the feasibility, acceptability, and preliminary efficacy of short message service (SMS) or text message reminders to improve adherence to ART [antiretroviral therapy] for youth living with HIV/AIDS" was conducted from June to November 2009 at a community-based health centre providing clinical services to youth living with HIV/AIDS in the United States (US). Participants agreed to receive text messages reminding them to take their ARTs over a 24-week period and were given a US$40 incentive to cover time, transportation, and costs associated with receiving daily text messages.

Participants were recruited directly and with help from medical records based on: 1) missing more than 3 medication doses in the last month; or 2) missing any doses in the last month and not achieving viral suppression after 24 weeks of an appropriate regimen; or 3) being referred from a clinician who documented poor adherence in the medical record defined by a report of any missed doses to any member of the care team or not achieving viral suppression in the expected time period on an appropriate regimen.

Strategies to improve adherence included:

• The establishment of collaboration with a "Health Insurance Portability and Accountability Act"-  and "Health Information Technology for Economic and Clinical Health Act"-compliant vendor of SMS health-related reminder services;
• Patients worked with the study coordinator to design their own personalised SMS reminder messages which were then programmed through Intelcare's website to be delivered at specific times throughout the day as well as a follow-up message 1 hour later assessing whether they took the medication and asking them to respond via text with the number 1 if they took the medication and 2 if they did not;
• Patients were encouraged to consider developing messages that would respect their privacy if they did not want to disclose their HIV diagnosis;
• Participants could contact the study coordinator to change the message at any time and to reprogramme the message if their mobile service was interrupted; and
• Follow-up visits were conducted at 6, 12, 18, and 24 weeks and included assessments of adherence by visual analogue scale (VAS) and AIDS Clinical Trials Group (ACTG) adherence questionnaire and satisfaction surveys.

Participants were mostly male and of racial and ethnic minorities who had acquired HIV through unprotected sex. Of principal interest, the study found a change of adherence at the 12-week and 24-week follow-ups (in comparison with the baseline). Improvements in adherence measures were seen as early as 6 weeks and were sustained throughout the 24-week study period.

While none reported a change in cell phone services to the study coordinator, they did notify their medical provider, who then notified the study coordinator. 81% of participants who completed the study said they would like to continue to receive text messages.

Limitations of this study include the absence of a control group and lack of long-term follow up after completion of the intervention. Strengths of this particular trial in comparison to similar trials (text messages to improve adherence) with other populations are reported as: the daily, real-time interactive feature and messages created individually by participants. The study did find it feasible to use this method for a difficult-to-reach population using their own mobile phones, and it stated that there is hope that the unique interactive feature of this intervention may provide additional information about the timing of missed doses (other than forgetting) that medical providers and patients could use to overcome barriers to adherence. For example, algorithms could be programmed for real-time communication between the provider and the patient rather than waiting for the next routine clinic visit.