MICA:Development of new paradigm in differentiated care for HIV patients; Community pharmacy drug refill using the ARTAccess Mobile phone application.

Lead Research Organisation: University of Cambridge
Department Name: Institute of Public Health

Abstract

We have made great progress in getting life saving medication to people living with HIV all over the world. However, there are still around 15 million people worldwide who need treatment. This treatment is essential to stop people living with HIV from getting sick and dying, but it also helps to prevent new infections happening. As there are no vaccines for HIV at the moment and no cure, this is a very important form of preventing the spread of the infection. However, in many setting such as Uganda the cost of treating patients with HIV puts a great strain on the health services, and as more patients need treatment this will increase. Therefore, we need to find different ways of providing HIV treatment which will enable the health services to cope. This could include reducing the need for patients to see a doctor or nurse every time they go to clinic and so reduce the burden on staff, to reduce the paperwork involved, to make it easier for the patients to access their medication near to their homes, so that they do not lose working hours, and many more. Lots of people have now been on medication for a number of years and are doing very well. At the moment they still need to come frequently (every 1-3 months) to their local clinic to pick up medication which adds burden to both them and their clinic.

We propose to use mobile phone technology to see if we can help to reduce this burden. Mobile phones are cheap and widely available in sub-Saharan Africa and very many people use them. In fact, many people use them to send money and do business, without the need for banks. We will use a mobile phone or tablet to link the patients records and their recent blood tests to community pharmacies, so that the patients can get their drugs from multiple sites, not just their clinic. As this approach is new we will need to see how the technology works, see what the patients, doctors and nurses, pharmacy staff and the government think about this system and to see what effect it is having on the delivery of services to the patients.

We will also plan for a much larger research study which will link these technologies with other mobile phone based tools, such as daily reminders to take pills, and see how we can link up a whole geographical area and streamline the services for people living with HIV. If this works, it may be used for very many hundreds of thousands of people on HIV treatment, and in future may be used for other conditions such as high blood pressure or diabetes in Uganda and elsewhere in sub-Saharan Africa.

Technical Summary

Can a set of interlinking mhealth technologies integrated into existing health systems improve and expand the care and treatment of people living with HIV in order to achieve the 90:90:90 UNAIDS goals?

Technologies based on cheap widely available mobile phones (mHeath) provide an opportunity to support health systems, but are so far understudied. In Uganda we have developed a range of models of care that have helped to differentiate care for people living with HIV (PLHIV). These allow intensified support for those who need it whilst safely reducing interactions with stable patients. We are now starting to evaluate mHealth interventions that will allow further streamlining of these models of HIV care delivery, so that more people can access ART within our limited resource envelope. We are working with community pharmacies to deliver anti-retroviral drugs (ART) with additional nursing support. This foundation grant will allow us to pilot the use of mHealth tools to link patient information on ART and viral load to an algorithm which guides a community pharmacy on ART delivery without additional staff needs. We ultimately aim to evaluate a complex intervention based on interlinking mHealth tools which support health service delivery, logistics and information management to improve outcomes in PLHIV whilst reducing the burden on human and financial resources. This will require a large multi-site research trial using creative approaches and development of new research methodologies. In this foundation grant we will conduct preliminary studies including feasibility, acceptability and evaluation of the impact of introduction into the health systems of 2 novel mHealth innovations. We will use descriptive, qualitative, quantitative and cost analysis methods to evaluate the effect of the pilot on the health system. We will develop methods to enable a multi-site trial of a complex intervention with multiple mHealth technologies supporting different health system functions.

Planned Impact

This research is designed to improve care for people living with HIV in Uganda and beyond. For the patients accessing the pilot, the aim is that they can access their anti-retroviral (ART) drug refills as quickly and conveniently as possible near to their home or work. HIV clinics in Uganda are so overburdened that often patients miss a whole day of work in a visit to the clinic. They may incur travel costs if the clinic is far. Due to limited supplies of ART, they often have to visit the clinic every 1-3 monthly to ensure that they have necessary medication. This pilot should reduce this burden and cost to the patient of accessing ART. If less patients who are stable on ART do not attend clinic, then patients who need more support be helped more effectively. More health care workers time may mean finding and engage or re-engage patients who are not currently in care. This may be patients who could be found and returned to care, patients who have not been tested, or patients who are in need to intensive support due to co-morbidities, adherence issues or new to medication. Health care workers may also have time to see other non-HIV patients attending the clinic.

The pilot should help to reduce the burden on health care workers, if patient numbers are eased. We will explore impacts stress and burn out, or if their time is then absorbed with other activities to the same extent. The participating community pharmacy staff will have the opportunity for professional development as they learn about ART delivery, and their business may benefit from an improved reputation or higher footfall.

If successful, policymakers and planners may be able to implement further pilots in other settings, and if cost effective this may release resources for other activities.

The impact of this pilot will be to cement the use of mhealth technologies as a health systems strengthening opportunity and allow policymakers, HIV care implementers such as NGOs, funding bodies and commerical companies, to creatively think what technologies they could employ at a health system or health care delivery level to a population as well as individuals. If we undertake a large multi-site study of interlinking mHealth technologies that shows improvement in care and greater access to care, this may help Uganda to acheive its targets of 90% HIV positive people knowing their status, 90% of these on ART and 90% of those on ART with an undetectable viral load. This care cascade is of vital public health importance as starting on ART treatment and reaching an undetectable HIV viral load through good adherence to ART reduces mortality and onwards transmission of HIV. Most recent global estimates suggest that only 37% of those in need of ART are accessing it, so there is an urgent and increasing need to increase coverage of ART. The burden of this is greatest in sub-Saharan Africa (SSA), where the treatment gap is estimated at 15 million people, and despite huge progress in Uganda around 300,000 people are still not on ART. If successful we may be able to close this gap, and so prevention onwards transmission of HIV as well as reducing mortality. The work may also be scaleable outside of Uganda, and so has the opportunity to benefit millions of people accessing HIV care in the region.

Early benefits (<1 year) will include pilot in 4 sites with around 300 patients, and stakeholder engagement
Medium term benefits (1-3 years) will include knowledge around methods for evaluating mHealth tools and increased comfort levels with stakeholders for mHealth technologies
Longer term (3-6) years could include a larger study with around 1000 patients and scale up to 100,000s patients if sucessful.
The Ugandan research staff on this project will be trained in qualitative data collection, eeconomics and health systems
strenghtening. This will alllow for work in many of the health and research sectors in Uganda; we aim that at least one staff progresses to a PhD

Publications

10 25 50
 
Description Invitation to join Ugandan Ministry of Health eTechnical Working Group
Geographic Reach Africa 
Policy Influence Type Participation in a national consultation
 
Description Training on Qualitative data collection and analysis
Geographic Reach Africa 
Policy Influence Type Influenced training of practitioners or researchers
Impact Study team have gained skills for analysis of qualitative data which has led to submission of an abstract to the International AIDS Society Conference 2019. 20 Masters students gained training in qualitative data collection methods and use of NVIVO software.
 
Description Training on health economics for early career researchers (25 - Masters and PhD). run by Centre for Health Economics University of York at IDI, Makerere University, Kampala
Geographic Reach Africa 
Policy Influence Type Influenced training of practitioners or researchers
Impact 25 early career researchers gained an introduction to health economics
 
Description Academic Collaborative agreement 
Organisation Makerere University College of Health Sciences
Department The Infectious Diseases Institute, Kampala
Country Uganda 
Sector Academic/University 
PI Contribution Developing and signing of collaborative agreement
Collaborator Contribution Reviewing and signing of collaborative agreement . University of York have now held a two day training workshop on Health Economics for 25 students (Masters/ PhD) in Uganda.
Impact Academic Collaborative agreement
Start Year 2017
 
Description Academic Collaborative agreement 
Organisation University of York
Department Centre for Health Economics (CHE)
Country United Kingdom 
Sector Academic/University 
PI Contribution Developing and signing of collaborative agreement
Collaborator Contribution Reviewing and signing of collaborative agreement . University of York have now held a two day training workshop on Health Economics for 25 students (Masters/ PhD) in Uganda.
Impact Academic Collaborative agreement
Start Year 2017
 
Title ART Access App 
Description We have developed the ART Access app which is being implemented in 5 community pharmacies. The app allows delivery of HIV medication - anti-retroviral therapy (ART) to patients in the community. This allows decongestion of public (government) health facilities and increases convenience for the patient. It replaces a laborious paper based system. We have so far registered 1000 patients on the tool and are collecting data on faesibility and safety. 
Type Support Tool - For Medical Intervention
Current Stage Of Development Early clinical assessment
Year Development Stage Completed 2018
Development Status Under active development/distribution
Impact We are still assessing the impact 
 
Title ART Access App 
Description This is a web and phone based app that allow patients to access their HIV medication at a community pharmacy instead of at their main government clinic. This has been described further under medical interventions 
Type Of Technology Webtool/Application 
Year Produced 2019 
Impact App is under pilot and evaluation 
 
Description Global Digital Health Forum 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact We presented the app as part of an "Appy Hour" at the Global Digital Health Forum in Washington DC. The app was well received and feedback was useful. There were opportunities to network with others in the field. We also learnt about machine learning and natural language processing for digital health tools at the meeting. This knowledge was useful in an application to the Cambridge Global Challenges Research Fund for a successful bid for accessing funding for an AI in Public Health for Low income settings workshop we will be holding in Cambridge in 2019
Year(s) Of Engagement Activity 2018
URL http://www.cvent.com/events/2018-global-digital-health-forum/event-summary-a8f2c247c810491ca434c825e...
 
Description Pharmacy and health care worker engagement 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact The study team engaged in 7 meetings with proposed end users of the study tool including government health care workers (nurses, doctors, data entry teams) in HIV clinics. They also interacted with nurses and pharmacy workers in the target community pharmacies. This led to 5 iterations and revisions of the ART Access tool which has led to an improved product. This also served as sensitization for the study to the possible study sites.
Year(s) Of Engagement Activity 2018
 
Description Presentation to Ministry of Health ETechnical Working Group 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The team presented the project to the Ministry of Health eTechnical Working Group. The project was well received and the Ministry of Health officials encouraged ongoing dialogue with the team as the project develops as well as presentation of results at study end. The MOH team have accepted to join the Scientific Advisory Board of the study and provided a letter of support for the follow on grant application we submitted to the HSRI funding call.
Year(s) Of Engagement Activity 2019