Discussion
hepatitis C
ADVERSE EVENTS, HEPATITIS C, CROSS
This study established the functionality of the Guaral +ST app for monitoring of treatment under the conditions evaluated: use by CHV in rural settings with poor access to mobile networks. This approach to active monitoring yielded a significant gain in information on adverse events, adherence to, and outcome of treatment, supporting the feasibility of active monitoring of treatment and outcome by CHV using this mHealth app. CHV, particularly those who were members of the civil defense and had permits and a distinguishing uniform, were able to move more freely, providing outreach to dispersed communities including some affected by the resurgence of violence. Nevertheless, insecurity did constrain the functional range of the CHV and the proportion of patients that were evaluated or lost to follow-up. Even in the intervention arm, 46.9% had been lost to follow-up by week 26, reflecting difficulty in mobility in the study area for geographical and socioeconomic reasons. However, in the intervention arm, retention was notably greater (approximately 75%) at week 13, and this time point is considered an acceptable time to define outcome [This RCT experience evaluating mHealth underscored the importance of contextual awareness and engagement and articulation of CHVs with peripheral health facilities and other entities working with the communities such as civil defense, Red Cross, Doctors Without Borders, and community councils. These organizations and their personnel provided a network of communication and support in locating and monitoring individuals with CL.Connectivity presented challenges to the use of the Guaral +ST app and has been reported and recognized as a potential barrier for other mHealth strategies in dispersed rural communities where internet coverage is patchy and unstable [Based on this and prior experience with mHealth for community empowerment [The people-centered design of the Guaral +ST app included embedded instructions and educational components [The combination of mHealth and empowerment of CHV through training to effectively utilize the app, responded to an unmet patient need and provided previously unavailable information to the health system on the effectiveness of the treatments administered as standard of care. This approach shifts responsibility for active monitoring of patients during treatment to communities in alliance with health professionals and institutions, similar to the ECHO model which is effective for hepatitis C [In conclusion, this study provides proof of concept for mHealth monitoring of CL treatment in remote and complex settings by community health volunteers, deliver of improved care, and provision of previously unavailable information to the health system on effectiveness of treatment.