m-Africa: Building mobile phone-connected diagnostics and online care pathways to support HIV prevention and management in decentralised settings.

Lead Research Organisation: University College London
Department Name: London Centre for Nanotechnology

Abstract

m-Africa's long term vision is to build user-friendly, mobile phone-connected HIV tests which link to online pathways for prevention and medical care. These systems will be used by people within their own homes and communities and they can be set up quickly in South African communities hardest hit by HIV. This will enable people to take full advantage of recent breakthroughs in HIV care and ultimately empower those at greatest risk to manage their own health.

The United Nations aims to end the HIV/AIDS epidemic by 2030. Yet despite huge advances in HIV treatment, prevention and care, many countries lack the set up to roll them out on a large scale and many people remain afraid of testing and seeking care.

South Africa is the country most affected by HIV; almost seven million people are living with HIV and 300,000 people acquire HIV each year. The province of KwaZulu-Natal, home to The Africa Health Research Institute (AHRI), is particularly hard hit. Forty five percent of women attending antenatal clinics have HIV and only half of all people diagnosed with HIV go for medical care within the following year. AHRI research showed that regular home-based HIV testing and immediate treatment could reduce HIV and prolong lives, but getting young people into clinic once they had been diagnosed was hugely challenging. This was because young people felt judged and looked down on once others knew they had HIV. Also they simply couldn't afford to miss work in order to come for an appointment.

The aim of m-Africa is to build a new generation of mobile phone-connected HIV diagnostic tests together with an online app that allows a person, from within their home or local community, to get their test results and medical care online. This could even include getting HIV drugs for prevention or treatment. This would allow people to test with more privacy, avoiding the clinic visits they find so difficult. South Africans have more smartphones than people in almost any other African country. We want to take advantage of this to enable more people to get tested, especially those who have never tested before.

But in order for these exciting new ideas to succeed we have to develop solutions which people at risk of HIV, health care professionals and government find appealing. So our research will start by asking people from these groups for their opinions on our ideas. We will use focus groups, individual interviews and questions in a regular AHRI household survey of 100,000 people.

In parallel we will develop and ask people to test out diagnostic test prototypes, which will include looking at how new ultra-sensitive "nanomaterial" tests could best work. These can detect HIV at the very early stages of infection, when transmission is most likely and prevention most important. We will also design apps to interpret already available HIV tests, which could link results to a doctor for online care.

We will engage with key stakeholders from the outset, including the Community Advisory Board, Directorate of Health KwaZulu Natal, industry, policy makers and regulators, to ensure we develop solutions that will be quickly put into practice. This is important because the technologies we develop could be applied across a wide range of infections and medical conditions. This plan is very much in line with the South African mobile health strategy.

Our team brings together outstanding clinicians, scientists, engineers and public health researchers from South Africa and the UK, with the primary goal of improving HIV prevention and care to deliver major health and economic benefits at the global epicentre of HIV.

Technical Summary

Undiagnosed and untreated HIV can have devastating consequences for the individual and populations, leading to increased morbidity, mortality, and transmission. South Africa has a forward looking mHealth strategy to deliver improved HIV health services but this emerging field is still in its infancy, with currently no safe and acceptable online care pathways and very limited knowledge of the usability and performance of devices in care pathways in low and middle income countries.
With this Foundation Award we will assess facilitators and barriers to implementation of new mobile phone-connected diagnostics and online care pathways into the KwaZulu Natal health system for HIV prevention, diagnosis and clinical management. We will use mixed-method studies using qualitative (key informant interviews, focus groups) and quantitative methods (AHRI household survey of 100,000 residents) to: (i) map current HIV diagnostic capability and needs; (ii) explore smartphone/mobile phone and digital capability among service providers and users; (iii) explore ways mobile technologies are used and viewed; (iv) explore the acceptability and feasibility of integrating new diagnostics into a range of models, including health worker-led testing and self-tests. In parallel we will develop a range of innovative smartphone connected diagnostic tests, benchmark their performance to gold-standard tests (e.g. sensitivity, specificity, speed, cost compared ot laboratory ELISAs and PCR) and run small scale pilots of their usability in primary care and home settings. Technologies at our disposal span from apps to interpret commercial HIV tests to early stage assays utilizing advanced nanomaterials to detect p24 in acute infections and viral load. We will engage with a broad range of stakeholders to ensure we develop solutions allied to their needs. This work is pivotal to building a fit-for-purpose integrated mHealth diagnostic, prevention and clinical platform for HIV prevention in LMICs.

Planned Impact

Our long term vision is to build a fit for purpose integrated digital diagnostic, prevention and clinical platform for HIV to ultimately empower patients to self-diagnose and self-manage remote from traditional health services, using HIV as an example, with broad applicability across infections and non-communicable diseases. This will bring major impact in the following areas:

1. Population benefits - The major beneficiaries will of course be the populations in the HIV endemic region of KwaZulu-Natal who will benefit from a more person -centered approach to HIV testing, prevention and care. The convenience of self-testing within their home, providing more rapid and reliable diagnoses of their illness, and supporting community and home-based provision of HIV prevention and care, will lead to reduced morbidity and mortality, and improvements in quality of life. Wider public benefits include reduced risk of onwards transmission, particularly by those who are unaware of their status.

2. South African and global healthcare systems - will benefit from improved clinical practice and health service delivery by:
i. Widening access to testing for HIV in community settings and the home will enable more patients be tested and linked to care.
ii. A highly innovative opportunity to engage young people with HIV testing, prevention and care by shifting delivery from problematic facility-based care into a self-directed model of online, and supported community based services.
iii. Potential to support HIV self-testing, task shifting to the community care givers and to support virtual adherence-support groups, would allow this project to digitally support current innovations in health care delivery in South Africa i.e. the community care givers program and the use of MSF inspired adherence clubs to support on-going care in stable HIV patients.
iv. Reducing pressure on health facilities and workers - Online patient pathways will allow results, to be rapidly and securely transmitted into KwaZulu-Natal health electronic systems, potentially supporting virtual appointments and treatment to be dispensed in the community, reducing the enormous pressure on facility centres and the administrative burden on staff.
v. More timely public health interventions and new capabilities to monitor the impact of these interventions.
vi. Health-economic benefits - South Africa spends in excess of $1 billion on HIV/AIDS programmes and every case of HIV that is prevented would save a lifetime of antiretroviral costs.
3. Commercial opportunities - Beyond trained man/women power, the potential commercial benefits to South Africa accrue through better population testing, prevention and care, and new employment opportunities in the emerging mHealth sector. We will reach out to local industries, including diagnostic test manufacturers, mobile network providers, handset manufacturers, app developers, policy makers and regulators through our second Workshop, planned at the end of year 1, to communicate developments in our understanding of the needs, technology developments and seed new collaborations. South Africa is well placed to grow commercial opportunities in this space, given its high smartphone penetration (among the highest in Africa), a flourishing mobile industry ($51M investment in tech start ups 'GSMA The Mobile Economy - Africa 2016') and forward looking national mHealth strategy.
 
Description Invited Speaker and Particpant in FAST Workshop Going beyond the test: online care pathways for Sexual Health: http://www.fast-healthcare.org.uk/digital-health-workshop/ with input to workshop publication (pdf) http://www.fast-healthcare.org.uk/wp-content/uploads/2017/07/FAST-Digital-Health-Report.pdf
Geographic Reach Multiple continents/international 
Policy Influence Type Citation in other policy documents
URL http://www.fast-healthcare.org.uk/wp-content/uploads/2017/07/FAST-Digital-Health-Report.pdf
 
Description Invited speaker BASHH National Conference, 2017, Belfast. The Digital Divide: are we excluding the most vulnerable in the move to online sexual health care? Plenary,
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Prof. McKendry invited to Co-Chair of Digital Medicine stream of Topol Technology Review commissioned by Jeremy Hunt, the Secretary of State for Health and Social Care
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
 
Description UCL Global Engagement Grant to visit the Africa Health Research Institute (AHRI) in South Africa (2017)-Harriet Gliddon
Amount £1,530 (GBP)
Organisation University College London 
Department UCL Global Engagement Office
Sector Academic/University
Country United Kingdom
Start 07/2017 
End 11/2017
 
Description i-sense EPSRC IRC Next Steps Plus: A Smartphone Powered mRNA Sequence Detector
Amount £1,027,001 (GBP)
Funding ID EP/R018707/1 
Organisation Engineering and Physical Sciences Research Council (EPSRC) 
Sector Academic/University
Country United Kingdom
Start 10/2018 
End 09/2021
 
Description i-sense Next Steps Award: EPSRC IRC in Agile Early Warning Sensing Systems for Infectious Diseases and Antimicrobial Resistance
Amount £3,900,620 (GBP)
Funding ID EP/R00529X/1 
Organisation Engineering and Physical Sciences Research Council (EPSRC) 
Sector Academic/University
Country United Kingdom
Start 10/2018 
End 09/2022
 
Title Advanced nanomaterials for infectious disease diagnosis 
Description i-sense is developing a range of advanced nanomaterials for ultra-sensitive disease diagnosis 
Type Of Material Technology assay or reagent 
Year Produced 2017 
Provided To Others? No  
Impact Invention disclosure submitted to UCLB 
URL https://www.i-sense.org.uk/news/collaborative-research-explores-why-llamas-could-change-future-hiv-d...
 
Title Llama antibodies against HIV 
Description Llama antibodies have been developed against HIV and influenza biomarkers. Benchmarking studies to leading commercial antibodies show improved sensitivity and on rates. 
Type Of Material Antibody 
Year Produced 2017 
Provided To Others? Yes  
Impact Gray, E.R., Brookes, J.C., Caillat, C., Turbe, V., Webb, B.L., Granger, L.A., Miller, B.S., McCoy, L.E., El Khattabi, M., Verrips, C.T., Weiss, R.A., Duffy, D.M., Weissenhorn, W., McKendry, R.A. 'Unravelling the molecular basis of high affinity nanobodies against HIV p24: in vitro functional, structural and in silico insights.' ACS Infectious Diseases (2017); DOI: 10.1021/acsinfecdis.6b00189 ; Turbé, V., Gray, E. R., Lawson, V. E., Nastouli, E., Brookes, J. C., Weiss, R. A., Pillay, D., Emery, V. C., Verrips, C. T., Yatsuda, H., Athey, D., McKendry, R. A. 'Towards an ultra-rapid smartphone- connected test for infectious diseases' Scientific Reports 7, Article number: 11971 (2017); DOI:10.1038/s41598-017-11887-6 
URL https://www.i-sense.org.uk/news/collaborative-research-explores-why-llamas-could-change-future-hiv-d...
 
Title Machine learning algorithms to interpret rapid tests 
Description Machine Learning algorithms to interpret rapid tests. Models developed using library of images acquired in the field. 
Type Of Material Technology assay or reagent 
Year Produced 2017 
Provided To Others? No  
Impact Early stage development. Publications in preparation. 
 
Title prototype smartphone connected test for early HIV infections using ultra-sensitive nanozyme technology 
Description Prototypes tests under development based on ultra-sensitive nanozymes. Pilot study with clinical patient samples and benchmarking to gold-standard commercial tests. - Loynachan, C.N., Thomas, M.R., Gray, E.R., Richards, D.A., Kim, J., Miller, B.S., Brookes, J.C., Agarwal, S., Chudasama, V., McKendry, R.A., Stevens, M.M. 'Platinum Nanocatalyst Amplification: Redefining the Gold Standard for Lateral Flow Immunoassays with Ultrabroad Dynamic Range' ACS Nano (2017); DOI: 10.1021/acsnano.7b06229 
Type Of Material Technology assay or reagent 
Year Produced 2017 
Provided To Others? Yes  
Impact High impact publication ACS Nano; interest from commercial party; 
 
Title Library of rapid HIV test images under development in partnership with AHRI 
Description A library of photographs of HIV tests has been acquired in rural KwaZulu Natal in South Africa. Images acquired by m-africa and i-sense researchers and AHRI health workers. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact The library images are being used to support early stage machine learning models to interpret HIV test results. 
 
Description QVQ 
Organisation QVQ B.V.
Country Netherlands 
Sector Private 
PI Contribution Expertise in diagnostic test development, advanced nanomaterials, molecular modelling and virology
Collaborator Contribution QVQ bring a wealth of expertise in llama antibody development
Impact Loynachan, C.N., Thomas, M.R., Gray, E.R., Richards, D.A., Kim, J., Miller, B.S., Brookes, J.C., Agarwal, S., Chudasama, V., McKendry, R.A., Stevens, M.M. 'Platinum Nanocatalyst Amplification: Redefining the Gold Standard for Lateral Flow Immunoassays with Ultrabroad Dynamic Range' ACS Nano (2017); DOI: 10.1021/acsnano.7b06229; urbé, V., Gray, E. R., Lawson, V. E., Nastouli, E., Brookes, J. C., Weiss, R. A., Pillay, D., Emery, V. C., Verrips, C. T., Yatsuda, H., Athey, D., McKendry, R. A. 'Towards an ultra-rapid smartphone- connected test for infectious diseases' Scientific Reports 7, Article number: 11971 (2017); DOI:10.1038/s41598-017-11887-6; Gray, E.R., Brookes, J.C., Caillat, C., Turbe, V., Webb, B.L., Granger, L.A., Miller, B.S., McCoy, L.E., El Khattabi, M., Verrips, C.T., Weiss, R.A., Duffy, D.M., Weissenhorn, W., McKendry, R.A. 'Unravelling the molecular basis of high affinity nanobodies against HIV p24: in vitro functional, structural and in silico insights.' ACS Infectious Diseases (2017); DOI: 10.1021/acsinfecdis.6b00189
Start Year 2012
 
Description Strategic collaboration with Africa Health Research Institute (AHRI) 
Organisation Africa Health Research Institute
Country South Africa 
Sector Charity/Non Profit 
PI Contribution This strategic partnership with AHRI aims to build a digital test bed in the heart of the HIV and TB pandemic in KwaZulu Natal South Africa. Our contribution includes world-class expertise in nano sensors, telecommunications, big data and bioengineering.
Collaborator Contribution The Africa Health Research Institute is a £63M new institute in KwazuluNatal South Africa, and is a merger between Wellcome Trust funded Africa Centre and the Howard Hughes Medical Institute. AHRI brings a wealth of world-class expertise in HIV, state of the art research facilities in Durban, a demographic surveillance household survey of 100,000 people, and a biobank of patient samples.
Impact Turbé, V., Gray, E. R., Lawson, V. E., Nastouli, E., Brookes, J. C., Weiss, R. A., Pillay, D., Emery, V. C., Verrips, C. T., Yatsuda, H., Athey, D., McKendry, R. A. 'Towards an ultra-rapid smartphone- connected test for infectious diseases' Scientific Reports 7, Article number: 11971 (2017); DOI:10.1038/s41598-017-11887-6; Loynachan, C.N., Thomas, M.R., Gray, E.R., Richards, D.A., Kim, J., Miller, B.S., Brookes, J.C., Agarwal, S., Chudasama, V., McKendry, R.A., Stevens, M.M. 'Platinum Nanocatalyst Amplification: Redefining the Gold Standard for Lateral Flow Immunoassays with Ultrabroad Dynamic Range' ACS Nano (2017); DOI: 10.1021/acsnano.7b06229
Start Year 2015
 
Title Computer vision app to interpret rapid HIV tests 
Description The smartphone/tablet application guides the user step by step in the process of performing a RDT for HIV. It asks the user to take a picture of the RDT at the correct time, at which point the picture is fed to a deep learning-trained model embedded in the application which returns the interpretation of the test result. The model was trained with a large (approx. 10 000) library of images taken in field conditions, to account for variations in shadows, brightness levels and inherent imperfection (blurriness, angle, focal distance...). 
Type Of Technology Webtool/Application 
Year Produced 2017 
Impact Early stage development. 
 
Description BBC The Truth About HIV 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact In 2017, BBC created a documentary titled 'The Truth About HIV'. Part of the documentary saw presenter Dr van Tulleken visit KwaZulu-Natal, South Africa and speak with Prof Deenan Pillay about the Treatment as Prevention trial. During this interview, the i-sense data dashboards were showcased.
Year(s) Of Engagement Activity 2017
URL http://www.bbc.co.uk/programmes/b08rvdwp
 
Description Building Mobile Phone-connected Diagnostics and Online Pathways for HIV care: Early findings from the m-Africa Formative Study in KwaZulu-Natal, South Africa. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact In July 2018 (Adeagbo OA, Herbst C, Dlamini N, Mhlongo T, Luthuli M, Xulu S, Sonnenberg P, Estcourt C, Blandford A, Turbe V, Thomas M, Herbst K, Pillay D, McKendry RA, Shahmanesh M) presented their research at the 22nd International AIDS Conference, Amsterdam,
Year(s) Of Engagement Activity 2018
URL https://onlinelibrary.wiley.com/doi/full/10.1002/jia2.25148
 
Description Direcotorate of Health, KZN- in Durban South Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Health policy makers and researchers
Year(s) Of Engagement Activity 2018
 
Description Hong Kong University 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Phones, Drones & Disease Workshop organised by HKU
Year(s) Of Engagement Activity 2018
 
Description If she tests negative, it means I am also negative": Men's construction of HIV testing in KwaZulu-Natal, South Africa. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Abstract presented at HIV Research for Prevention (HIVR4P) 2018 Conference, Madrid, 23 October 2018 by Adeagbo OA, Herbst C, Dlamini N, Mhlongo T, Luthuli M, Xulu S, Sonnenberg P, Estcourt C, Blandford A, Turbe V, Thomas M, Herbst K, Pillay D, McKendry RA, Shahmanesh M.
Year(s) Of Engagement Activity 2018
URL https://www.hivsharespace.net/event/hiv-research-prevention-hivr4p-2018
 
Description New Scientist Live exhibition 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact i-sense and m-africa members attended the New Scientist live exhibition over four days. The purpose of having an exhibition space what to have the opportunity to engage with the general public about our research and gain ideas and insights from different audiences. We organised the booth into three spaces - track, test and treat - and had various elements of hands on engagement, including a model demonstration of our lateral flow tests and mobile app, and a 'wall of voices' for people to engage in discussions on how they felt about their health data being shared. This exhibit was highly beneficial for i-sense PhD students and postdocs to discuss their work with a very broad audience from young children to healthcare professionals. Following the event, we had a few students contact us to enquire about internships or work experience and one student who did a feature on our exhibit for their school project.
Year(s) Of Engagement Activity 2017
URL https://www.i-sense.org.uk/news/i-sense-science-bug-spreads-across-new-scientist-live
 
Description Science for a Successful Nation 2018 - EPSRC - Royal Society 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Presenting some of the ongoing projects of i-sense and mAfrica, including the HIV dashboards, smartphone app to read POCT for HIV and twitter-based early flu outbreaks prediction model.
Year(s) Of Engagement Activity 2018
URL https://www.epsrc.ac.uk/funding/calls/science-for-a-successful-nation-2018/
 
Description Stevens talk - 2018 MRS Fall Meeting, Boston, MA, USA 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Research talk given to international audience.
Year(s) Of Engagement Activity 2018
 
Description Stevens talk - 2018 MRS Spring Meeting & Exhibit, Phoenix, AZ, USA 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Research talk given to international audience.
Year(s) Of Engagement Activity 2018
 
Description Stevens talk - 255th ACS National Meeting and Exposition, New Orleans, LA, USA 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Research talk given to international audience.
Year(s) Of Engagement Activity 2018
 
Description Stevens talk - Israel Materials Engineering Conference (Plenary Lecture), Dead Sea, Israel 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Research talk given to international audience.
Year(s) Of Engagement Activity 2018
 
Description The 'Missing Middle' in HIV Treatment Cascade: Ensuring Men's and Young People's access to HIV Care in KwaZulu-Natal, South Africa.  
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Adeagbo OA, Herbst C, Dlamini N, Mhlongo T, Luthuli M, Xulu S, Sonnenberg P, Estcourt C, Blandford A, Turbe V, Thomas M, Herbst K, Pillay D, McKendry RA, Shahmanesh M. presented at the International ASSHH Conference, Amsterdam, July 2018
Year(s) Of Engagement Activity 2018
URL http://www.unaids.org/en/resources/campaigns/AIDS2018
 
Description eHealth Afro 2017 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact The eHealth Afro 2017 conference brought together healthcare professionals, government leaders and industry stakeholders to explore tangible eHealth opportunities and eHealth excellence in Southern Africa. It aimed to empower participants to advance eHealth in the region by showcasing proven strategies, best practice and real-world learning to realise measurable benefits for patients, communities, clinicians, and the industry as a whole.
Year(s) Of Engagement Activity 2017
URL https://www.ehealthafro.org/
 
Description i-sense/m-Africa in the EPSRC Pioneer 18 newsletter 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact In June 2017, an article about i-sense and the m-Africa project was featured in the EPSRC Pioneer 18 magazine. The piece was about EPSRC-supported researchers developing mobile phone-connected HIV tests, which link to online prevention and medical care for use in South African communities hardest hit by HIV.
Year(s) Of Engagement Activity 2017
URL https://www.epsrc.ac.uk/newsevents/pubs/pioneer18/