October 4, 2010

Can Mobile Phones Revolutionize the Clinical Care of People Living with AIDS In Resource Poor Settings?

By Setor Kunutsor
Institute of Health Sciences, Leeds University
The World Health Organization has urged the use of cell phones and other mobile communication technology to improve the quality of health care delivered in resource-poor countries. 
Mobile phones are one of the most promising emerging health tools, with the potential to address many of the challenges facing access to care and adherence to antiretroviral treatment among people living with HIV/AIDS in these settings. Africa has the highest rate of mobile phone uptake among developing regions and there is rapid continuous expansion of cell phone use across all socio-demographic groups. Our research examined the potential for mobile phones to enhance HIV/AIDS care in southern Africa.

What We Did
Our study aimed to assess mobile phone access and the patterns of their use among patients on antiretroviral treatment in two rural sites in Uganda. We wanted to know whether voice calls or short message service (SMS, text messaging) contact was a feasible tool for improving attendance to clinic appointments as well as adherence to antiretroviral therapy. To answer this question we conducted a cross-sectional survey with a random sample of 276 adults receiving HIV/AIDS care.

The survey focused on  access to mobile phones, and patterns of use. Eligible participants included all adults who had been receiving antiretroviral therapy for at least three months at the beginning of the study. Patients were identified during their routine clinic visits and invited to participate. We used the survey to identify 176 patients as having access to mobile phones, including having their own mobile phone or having access to a relative or friend's mobile phone, and willingness to be contacted by the clinic via voice calls or text messages.
Medication adherence was defined as the percentage of prescribed medication doses taken every 4 weeks during the study period using a clinic-based pill count method. To see if pill counts improved adherence prior to implementation of the mobile phone recall intervention.

What We Learned
Of the 276 participants who completed the survey, 177 (64%) had access to mobile phones. With the exception of one respondent, all those who had access even through a relative or friend’s phone, were willing to be contacted to alert them about missed appointments.
Nearly half of mobile phone owners had been using their phones for 2 years and over. Also among phone owners, one in three reported sharing their phones with somebody in the household. There was a gender difference, with men having greater access to mobile phones than women, Nearly all participants (94%) preferred being contacted via voice calls rather than text SMS.

Of the 560 scheduled clinic appointments, only 11% were missed visits. Of the 62 missed visits, 49 were returned following mobile phone recall. In 79% of episodes in which visits were missed, patients presented for treatment within an average duration of 2 days after mobile phone recall.
Patients reported that the primary reason given for missed visits was forgetfulness. Total cost for voice calls made and SMS text message sent during the entire duration of the study was approximately $14 USD. The rates for the calls and SMS were standard costs for the networks used and were not part of a negotiated contract. Network outages were also not a problem during the study period. Average medication adherence improved from 96.3% at baseline to 98.4% after mobile phone recall intervention.

What is Next?
The results presented showed that overall access to mobile phones was relatively high in this resource-poor setting, which is not surprising given the high rate of mobile phone uptake in Africa and the findings from similar studies which report high rural access to mobile phones. Privacy and confidentiality issues were also not deterrents to the use of mobile phone technology in our setting. The majority of patients reappeared at the clinic following mobile phone recall and within just two days. Medication adherence also improved significantly after the mobile phone intervention.

Considering the increasing availability of mobile phones and their  relatively low cost in resource-poor settings, mobile phone communications should become a ‘must use’ tool in HIV/AIDS treatment programs in resource poor settings.

Read the research report online at AIDS & Behavior


  1. This is an exciting area of research and very promising. I'm a little concerned, however, with terms like "revolutionize" and "must use" based on a cross-sectional study with an absolute increase in adherence of 2.1%. We really need RCTs to look at the impact of mobile phones on adherence and retention in care. I know Richard Lester will be presenting some data in this area soon at the mHealth Summit in Washington DC. Perhaps there are other such studies in the pipeline as well. I personally anticipate positive results, but want to make sure the science is there to back up the excitement.

    Jessica Haberer, Massachusetts General Hospital

  2. It's really a nice concept to improve HIV care and support system by using easily available modern communication in developing nations. More RCTs should be done to make a coordinated backup system involving HIV care providers, information technology and NGOs.

    Dhruba Mahajan, GHTM,Chennai, India

  3. It's really a nice concept to improve HIV care and support system by using easily available modern communications in developing nations. More RCTS are needed to make a coordinated backup system involving HIV care providers, Information technology and Non governmental organization.

    Dhruba Mahajan,GHTM,Chennai,India

  4. Dhruba,
    Thanks for commenting.
    I agree that more RCTs are needed. This technology is definitely emerging. I am excited about more work from e-health researchers is coming to AIDS and Behavior. Keep an eye on the papers published Online First, more will be posted soon.
    Thanks again