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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.
The PrEP Implementation for Young Women and Adolescents (PrIYA) Program was a 2-year implementation project in Kusumu County, Kenya, a region where adult HIV prevalence is 19.9% (up to 28% among pregnant women).22–24 The program was designed to reach adolescents and young women at high risk for HIV acquisition through integrated delivery of PrEP within routine MCH and family planning systems.9 Conducted in collaboration with the Kisumu County Department of Health and Sanitation and the National AIDS and STI Control Programme, PrIYA was first implemented in 16 facilities (11 public, 4 faith-based, and 1 private) followed by a PrEP mentorship program in 20 additional sites. The 16 highest volume (based on monthly number of new antenatal care ANC clients) facilities in Kisumu County were selected to be in the PrIYA Program. The current evaluation focuses on the implementation of a 2-way SMS intervention among a subset of participants in the PrIYA Program. The SMS intervention was conducted at 2 public-sector sites purposively selected based on the highest monthly enrollment of new PrEP clients. In the PrIYA Program, 40 program-supported nurses were trained on PrEP delivery per national guidelines as previously described.25 Briefly, nurses screened women who did not have HIV for behavioral risk factors, including male partner HIV status and willingness to consider PrEP. Behavioral risk factors were assessed using a standardized risk assessment tool.8 Women who wanted to initiate PrEP and were medically eligible received same-day PrEP and were scheduled for a 1-month follow-up visit.9 This mixed-methods evaluation of the SMS communication program for supporting PrEP adherence and continuation had 3 primary aims: (1) describe implementation metrics (e.g., eligibility, acceptability, satisfaction, and utilization); (2) compare frequency of PrEP continuation and self-reported adherence before and after the introduction of the SMS program; and (3) identify issues and concerns among new PrEP initiators by qualitatively analyzing transcripts of SMS conversations. Our team previously developed mWACh, a user-friendly bidirectional interactive SMS platform, that enables efficient communication between women attending MCH clinics and nurses.19 The mWACh platform sends timed preprogrammed SMS messages that clients can respond to and allows clients to send messages with questions or concerns. A trained nurse-counselor receives and responds to messages from women, providing a mechanism for women to interact with nurses in real-time and an opportunity for medication adherence support.9 mWACh has been shown to be feasible, acceptable, and effective in improving MCH outcomes.20,21 Interface of mWACh-PrEP System With Mock Data© 2019 Jillian Pintye We adapted the mWACh platform to send weekly PrEP-tailored, theory-based SMS and to allow MCH and family planning clients who initiate PrEP to communicate with a nurse about their individual needs. SMS messages incorporated behavioral theory-informed counseling framed in the informational-motivational-behavioral skills model, specifically tailored to women receiving PrEP in the context of MCH/family planning services (Box). The intervention was field-tested by PrIYA nurses with more than 6 months of experience delivering PrEP to MCH and family planning clients before implementation. During field-testing, we elicited feedback from PrEP providers on the utility, frequency, and content of SMS messages to refine the tool. The final message bank was translated and back translated from English to Kiswahili and Dhuluo (a prevalent local language in western Kenya). PrIYA nurses were trained on using the mWACH-PrEP system and responding to SMS messages from clients based on behavioral counseling principles including informational-motivational-behavioral skills, motivational interviewing, and positive reinforcement. We also developed and tested quality assurance/quality control systems that reviewed and discussed responses to SMS with medical and research teams in Kenya and Seattle to ensure consistency and accuracy of nurses’ responses to women. Motivational Interviewing (e.g., goal-oriented action plans) {name}, this is {nurse} from {clinic}. It can be difficult to take medications every day especially if you are trying to be discrete. Many people ask a friend to help remind them, set a timer on their phone, or take it with a meal. You can also put it in a different container you can carry with you in private. How do you remember to take your medication? Do you have any challenges taking it every day? Theory of Planned Behavior (e.g., perceived behavioral control) {name}, this is {nurse} from {clinic}. Side effects from PrEP affect each person differently. Most side effects lessen after the first few weeks of use, once the body is used to the medication. Please let us know if you are having any side effects. We can help you manage them or know if it is okay to continue. Health Belief Model (e.g., perceived barriers) {name}, this is {nurse} from {clinic}. You are doing a great job taking care of yourself. PrEP is very effective at preventing you from getting HIV if you take it every day. It also helps prevent HIV infection to your baby if you are pregnant. If you miss too many doses it may not work. Are you having any challenges taking the medication? Social-Cognitive Theory (e.g., positive reinforcement) Good job coming in for your visit! You will receive weekly SMS to help support taking your medication. Please SMS back and tell us any questions or concerns you have. Please tell us if you need assistance with your prevention medication. If you have any challenges or stop PrEP, please let us know. From February to October 2018, we approached women on the same day they initiated PrEP at the 2 selected MCH/family planning clinics and offered them participation in the mWACH-PrEP program. Women were eligible if they initiated PrEP that day, had a functioning cellphone in-hand that they did not share with anyone, and had an active SIM card on the Safaricom network (Kenya’s largest network provider). Reasons for ineligibility were captured. We did not exclude women who expressed confidentiality concerns related to their PrEP use or content of the SMS. All women were free to decline enrollment and welcome to stop receiving SMS at anytime. Women registered into the mWACh-PrEP platform indicated their preferences for message delivery including a preferred name for messaging, language (English, Kiswahili, or Dholuo), and day of the week and time for SMS delivery. All automated push messages included participant nickname, clinic, and nurse name, an educational message or actionable advice targeting PrEP adherence and continuation and/or MCH/family planning topics, and a question related to the content. SMS topics included adherence encouragement, PrEP efficacy and safety, self-efficacy for prevention of HIV, support for potential PrEP side effects, behavioral skills (tips for remembering PrEP medications), and visit reminders. During enrollment, the program nurse explained that replies to the automated SMS questions were voluntary, though women were enrouraged to reply. Women were also encouraged to send SMS with their concerns or questions whenever they arose. The program nurse was available to answer SMS during normal business hours on weekdays. All messaging was free of charge to the participant using a reverse billed short code. SMS were sent from enrollment until December 2018. Participants could voluntarily and autonomously exit the program by texting “STOP,” which would end all platform communication. All SMS communication was conducted through our custom web application designed for 3‐way communication between the automated push system, program staff, and participants. SMS data were downloaded biweekly by program data managers to track SMS outages and data on implementation activity (e.g., new enrollments, sucessful automated SMS delivery, participant responses, voluntary exits). When a participant sent an unprompted question or sent a reply to an automated message that was not in English, program nurses translated the SMS into English within the system daily to ensure interpretation consistency and allow for quality assurance/quality control. We defined utilization using 2 metrics: responding to automated push messages and sending an unprompted question or concern using SMS. Program nurses administered questionnaires to women enrolled in mWACh-PrEP at routine 1-month PrEP follow-up visits to assess satisfaction using a series of items on a 5-point Likert scale (e.g., I would recommend the SMS program to other women who use PrEP; strongly agree, agree, neutral, disagree, strongly disagree). Closed-ended items assessed self-reported utilization experiences with the platform (e.g., I took action based on the nurse’s advice; yes/no). We also abstracted PrEP indicators from the Kenya Ministry of Health client encounter form that included data on attendance of a PrEP follow-up visit, self-reported adherence (number of missed PrEP doses in the past month), and PrEP refills. We defined PrEP continuation as confirmed dispensation of a PrEP refill at an attended follow-up visit. PrEP discontinuation was defined as no PrEP refill or no attendance at a follow-up visit. Data from PrEP follow-up visits were abstracted for all women who initiated PrEP in the month before implementation of the mWACh-PrEP program and from all women who were screened for mWACh-PrEP enrollment. We used descriptive statistics to summarize acceptability, satisfaction, and utilization indicators. We used Chi-squared tests for proportions and Kruskall-Wallis tests for continous measures to compare baseline demographic and behavioral characteristics of women who were eligible and enrolled in the mWACh-PrEP program with (1) women who initiated PrEP in the month before implementation of mWACh-PrEP and (2) women who were screened for enrollment but were ineligible/declined. We compared PrEP continuation and self-reported adherence among women who enrolled in mWACh-PrEP with women in the other 2 groups using Chi-squared tests and multivariate Poisson regression models with robust error variance, an approach used when the outcome prevalence is not rare (e.g., >10%).26,27 Final multivariate Poisson models were adjusted for age and marital status because these characteristics were significantly different between women who enrolled in the mWACh-PrEP program and those who initiated PrEP before mWACh-PrEP implementation. All statistical analyses were performed by using StataSE 15.0 (StataCorp, College Station, TX). Statistical comparisons were 2-sided and were considered significant at the P<.05 level. At the completion of the mWACh-PrEP program, transcripts of SMS conversations were analyzed using a modified constant comparative approach. Our primary goal was to identify issues raised by women who initiated PrEP through unprompted questions or concerns sent to nurses using the mWACh-PrEP system. We developed an initial codebook based on a review of a subset of transcripts and input from nurses who responded to participants' messages, and the codebook was iteratively refined. SMS transcripts were transferred into Microsoft Excel for data management. All transcripts were coded by 2 research team members (ZR and JP), and coding disagreements were resolved through discussion. Key issues raised by women who enrolled in mWACh-PrEP were identified by reading transcripts to identify similarities and differences across conversations, and codes were subsequently organized within thematic categories to identify trends. We also selected representative quotations pertaining to each main category. Our primary qualitative analysis goal was to identify issues that women who initiated PrEP raised through unprompted messages. Protocols were reviewed and approved by the Kenyatta National Hospital-University of Nairobi Ethics Research Committee and University of Washington Human Subjects Review Committee. In addition, approval was obtained from the Kisumu County Department of Health and administrators in respective health facilities. Women provided informed consent for all activities.
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