Discussion
death, viral suppression, groupOur
HIV DISEASE PROGRESSION, MISCARRIAGE
To our knowledge, our study is the first RCT in PMTCT care with follow-up up to 30 months postpartum to investigate the effect of a text-messaging intervention. Our trial did not find that this weekly text-messaging intervention improved retention in PMTCT care at 18 months postpartum. Further, we observed no significant effect of the WelTel intervention on retention in PMTCT care between 6 and 12 months postpartum, delivery at a facility, postpartum linkage to chronic HIV care, or dropping out of care by 30 months from enrolment. There was no evidence of an intervention effect among subgroups. After excluding women who had died, had a miscarriage, stillbirth, infant death, or had transferred to another clinic, retention in PMTCT care at 18 months postpartum was 81%, substantially higher than expected in both study groups compared to pre-trial estimates of 30% in the control groupOur findings are consistent with a 2021 three-armed RCT of 824 women in PMTCT care in Kenya that reported no effect of either one-way or two-way text-messaging on loss to follow-up from PMTCT care up to 2 years postpartumOur results add to a small but growing body of evidence from RCTs published between 2016 and 2022 that reported no effect of text-messaging interventions on early postpartum (up to 8 weeks)We observed that retention in PMTCT care at 18 months postpartum was substantially higher than expected based on data available at the start of this trial across both groupsMobile phone access was high in our study setting. Only 7% of pregnant women screened were excluded due to a lack of mobile phone access. In 2015, coinciding with the beginning of our trial, Kenya launched new guidelines for ART providers, recommending increased use of telecommunication to improve adherence to clinic visits and ARTAt the end of 2019 when follow-up was completed, 98% of Kenyans had a mobile connectionLess discrimination towards people living with HIV in KenyaTo our knowledge, this is the first RCT that has investigated whether a text-messaging intervention improved long-term retention including women’s postpartum linkage to chronic HIV care. Linkage to chronic HIV care with sustained ART to ensure viral suppression is an important goal of the Option B+ recommendations to prevent HIV disease progression among postpartum women and sexual transmission of HIV to partnersA key strength of this trial is its long duration of follow-up, from the first appointment in antenatal care up to 30 months postpartum. In addition, the participation rate was high and included both rural and urban study sites spread over a large area in western Kenya, contributing to the generalisability of our results. We designed the intervention to resemble real-life conditions, with no incentives given to the participants. In addition, we used multiple sources of data including patient files, patient registers, and a national database to maximise the validity of our outcomes. Using a national database improved the accuracy of our retention in care estimate compared to using clinical records alone, since women who had a viral load test outside of their study clinic were also captured.Trial limitations include the open-label design necessitating healthcare workers’ awareness of the intervention to call women who reported a problem. Despite instructions to healthcare workers not to implement the components of the intervention in the control group, increased mobile phone communication with clients in general was reported by both clinic staff and peer mothers in our post-trial facility evaluation interviews (data unpublished), possibly improving retention for all study participants, undermining the possibility to observe an effect of the intervention. We were unable to quantitatively assess the frequency of all types of tele-communication between participants and healthcare providers. There was, however, no report of WelTel text messages sent to participants in the control group. The overall increase in mobile phone use was most likely due to national and local initiatives to improve HIV and PMTCT care outcomesIn 2012, the WHO recommended text-messaging and more efficient patient tracking to improve retention throughout the continuum of care for people living with HIV