globally , mother - to - child transmission of hiv-1 results in approximately 370  000 infant infections each year .
hiv-1 early infant diagnosis ( eid ) programs aims to detect hiv infection as early as possible in hiv - exposed infant and to link them to care and treatment .
eid of hiv confers substantial benefits to infants and families , both for hiv - infected and uninfected infants , as well as to programs providing prevention of parent - to - child transmission ( pptct ) services , including hiv counselling and testing , family centric approach , provision of care , support and lifelong treatment for hiv positive women , provision of arv and cotrimoxazole prophylaxis and early infant diagnosis services for hiv - exposed children , guidance on feeding and nutrition practices , and immunization services .
maharashtra is one of the high prevalent states in the country with hiv prevalence of 0.4% among antenatal women and 0.42% in adults   and ante natal case prevalence 0.40% .
early infant diagnosis was launched in the country in april 2010 , which entails follow - up of babies born to hiv positive women for hiv dna polymerase chain reaction ( pcr ) test and subsequently final hiv test at the age of 18 months of age .
a major priority for pptct services is ensuring pregnant women pursue their care and treatment , including testing of babies at regular intervals for eid .
the common barriers reported in qualitative studies regarding low uptake of pptct - eid services for mother and baby both include confidentiality , stigma , availability of testing facility , financial issues , behavior of health staff , fear of baby 's hiv test result , cultural barriers , long waiting time .
in addition , health workers are unable to monitor pregnant women because of inadequate data management system across the service continuum . who estimates that only 615% of hiv - exposed infants under 1 year of age accessed eid programs in 20082009 , highlighting that the implementation of effective eid programs has been challenging in resource - limited settings and demands careful attention .
although there are many reasons for the lack of continuity of care , there is a need to improve the adherence and retention in care and this may be improved by maintaining better communication between program officers and field staff .
mobile phone technology has the potential to serve as a strategic intervention medium to improve patient management .
owing to the widespread use and low cost of this technology , it pervades all age groups and many cultures and socioeconomic backgrounds .
but there is also a need for interactive program management by reacting promptly and effectively to deviations from program plans .
this may include operational decisions for short - term management of patient retention at individual care centers , tactical decisions such as reconfiguring the messaging based on performance , and strategic decisions such as data collection or preservation .
hence , an integrated mobile phone text messaging system was designed , developed , and implemented to follow the babies under eid in maharashtra ( excluding mumbai ) in june 2012 .
this study was conducted to assess the utility of web - based mobile technology monitoring tool , for ensuring linkages , and tracking of hiv - exposed child until 18 months of age .
maharashtra state aids control society developed a web - based system that provides support to eid program .
a broad set of usability requirements was identified during brainstorming design sessions between the researchers , program officers , and developer .
the program officers in maharashtra state aids control society , with strong program backgrounds and substantial experience in healthcare and understanding of the field problems , outlined the requirements that they anticipated the system should offer .
these requirements were then documented and elaborated in more detail as new ideas were exchanged within the design team ( two program officers and one computer experts ) and final design principles of the system were derived . the development team and the program officers assessed the responses from field staff in the current system , which were stored in a microsoft structured query language server , to identify patterns that could be used to define relevant answers .
the output was a list of possible automatic sms text message replies through symbian supported mobile .
eid follow - up system was designed as a web - based tool using java swing framework which generates automated sms and e - mails for reminding the field level staff for follow - up of hiv - exposed babies 7 days prior to the follow - up date .
the information was collected through field tested excel - based hiv positive pregnant women line - list format incorporating the major key indicators of pptct program .
this line list is generated at the hiv testing facilities where the pregnant woman is detected hiv positive .
format is then shared through e - mail with hiv treatment facilities to update the treatment details of the pregnant women .
the line list is further updated on periodic basis whenever the pregnant women is accessing the pptct services at hiv facilities .
the individual records in the line list are monitored and crossverified by district and state level officials during the supervisory visits to these centers on periodic basis .
the data collected through line list from different districts is then compiled by the state . for the software
, we used the variables like name of mother and child , date of birth of baby , mobile number of counsellor and district supervisor , email of district official , and name of the hiv testing facility .
database of hiv positive mother and her exposed child with date of birth was updated on monthly basis .
deliberation with various stakeholders on development of tracking system led to use of mobile technology in follow - up mechanism .
the software developed sends required information ( name of mother / child , facility name , and follow - up date ) to the counsellor of the respective facility and district supervisor as mobile text message alerts on daily basis and simultaneously , system generated e - mail is send to district officials for monitoring and following the baby for eid .
we used brainstorming techniques to solicit usability requirements , focus group meetings to discuss and define system architecture , and prototyping to test in real environments and to improve the system ( fig .
eid follow up system : development process and work flow . in this kind of system , there are telecommunication costs involved .
it is imperative to be able to make favorable bulk mobile text messaging contracts on the part of the healthcare provider , but also to be efficient in messaging so as to reduce the traffic . on a pilot basis , we have purchased sim card at state for sending mobile text message from the same number to counsellors and district supervisors .
the connection between the server and the client mobile is made using a web service .
a set of text messages was developed based on discussion involving the design team and the program officers .
suggestions for message formulations were reviewed and amended during team meetings , resulting in a final set of three messages , which were approved by all involved . in both sets , messages for testing of baby for eid were divided into four categories : 6-week follow - up reminders , 6-month follow - up reminders , 12-month follow - up , and 18-month follow - up reminders .
the messages did not include general information about the health status of the patient because such status information may be difficult to communicate in an unambiguous way .
as the mobile networks in maharashtra are often unreliable , especially in rural areas , we designed a mechanism of e - mail to district aids prevention and control unit ( dapcu ) and dapcu will follow - up at field level .
this way , we were able to , in most cases , get daily updates , although not necessarily at a predefined time every day . to accommodate the requirements , architecture
the main elements of this architecture include the following : the sms server , as shown in fig .
3 , interacts with feild staff that uses their mobile phone set and the sms messaging service to send messages to the system . at the lowest level , the sms server interfaces with a global system for mobile ( gsm ) modem that sends field staff sms text messages through an sms service provider ( mobile operator ) .
once the data are imported in software from excel sheet , the sms server performs checks on its content and responds to the field staff accordingly ( automatic reply feature ) .
safeguarding the privacy , confidentiality , and security of any public health information is an important undertaking .
the system only collects data necessary for the server to process and send text messages .
the system comprises an application layer for the capture and delivery of patient information , including date of next appointment and next date of testing , to a remote server by means of a gsm modem .
six sets of system requirements that need to be addressed for success are  data collection , telecommunication costs , privacy and data security , text message content , connectivity , and system scalability .
a text messaging system was designed and implemented in 578 hiv testing facilities and district supervisors in 33 districts in maharashtra .
these sites feed data into a central data repository , which was used for analysis of operations and decision support . based on the follow - up schedule
, the system automatically generates appointment reminders as mobile text message to counsellors and as emails to dapcu officers .
healthcare professionals , technical experts , and an interdisciplinary group of researchers were involved in the design , development , and implementation processes to enhance the utility and functionality of the system .
it is imperative to be able to make favorable bulk mobile text messaging contracts on the part of the healthcare provider , but also to be efficient in messaging so as to reduce the traffic . on a pilot basis , we have purchased sim card at state for sending mobile text message from the same number to counsellors and district supervisors .
the connection between the server and the client mobile is made using a web service .
a set of text messages was developed based on discussion involving the design team and the program officers .
suggestions for message formulations were reviewed and amended during team meetings , resulting in a final set of three messages , which were approved by all involved . in both sets , messages for testing of baby for eid were divided into four categories : 6-week follow - up reminders , 6-month follow - up reminders , 12-month follow - up , and 18-month follow - up reminders .
the messages did not include general information about the health status of the patient because such status information may be difficult to communicate in an unambiguous way .
as the mobile networks in maharashtra are often unreliable , especially in rural areas , we designed a mechanism of e - mail to district aids prevention and control unit ( dapcu ) and dapcu will follow - up at field level .
this way , we were able to , in most cases , get daily updates , although not necessarily at a predefined time every day . to accommodate the requirements , architecture
the main elements of this architecture include the following : the sms server , as shown in fig .
3 , interacts with feild staff that uses their mobile phone set and the sms messaging service to send messages to the system . at the lowest level , the sms server interfaces with a global system for mobile ( gsm ) modem that sends field staff sms text messages through an sms service provider ( mobile operator ) .
once the data are imported in software from excel sheet , the sms server performs checks on its content and responds to the field staff accordingly ( automatic reply feature ) .
safeguarding the privacy , confidentiality , and security of any public health information is an important undertaking .
the system only collects data necessary for the server to process and send text messages .
the system comprises an application layer for the capture and delivery of patient information , including date of next appointment and next date of testing , to a remote server by means of a gsm modem .
six sets of system requirements that need to be addressed for success are  data collection , telecommunication costs , privacy and data security , text message content , connectivity , and system scalability .
a text messaging system was designed and implemented in 578 hiv testing facilities and district supervisors in 33 districts in maharashtra .
these sites feed data into a central data repository , which was used for analysis of operations and decision support .
based on the follow - up schedule , the system automatically generates appointment reminders as mobile text message to counsellors and as emails to dapcu officers .
healthcare professionals , technical experts , and an interdisciplinary group of researchers were involved in the design , development , and implementation processes to enhance the utility and functionality of the system .
before the introduction of  eid follow - up system , only 55.9% ( 637/1139 ) of the hiv - exposed babies born were tested at 6 weeks for dna - pcr during april 2011march 2012 . however , after its introduction , 68.4% ( 1117/1631 ) of them were tested during april 2012march 2013 .
correspondingly , the 18 months confirmatory hiv testing in eligible babies increased from 45.6% ( 934/2044 ) to 54.7% ( 1118/2044 ) .
this study summarizes the processes of design , development , and implementation of a remote management system using mobile technologies to help field staff and supervisors to track mother and children for hiv testing .
our study endeavors to design , develop , and implement a tool to empower health staff in tracking hiv - exposed children .
mobile phones are available and are practical , low - cost tools that may facilitate and support health staff in follow - up of babies .
our study showed that mobile phone text messaging provides an effective communication mechanism between healthcare providers and supervisors , provided it is implemented well .
it has been shown that regular follow - up is possible through mobile technology intervention .
design of a system for follow - up of specific diseases like hiv / aids , based on mobile phone text message and e - mail technology , includes careful attention to not only the theoretical underpinning of the strategic intervention and associated content , but also the requirements for optimal design , including how each part of the system has to be placed together .
crucial parts of a successful text messaging intervention include how messages are tailored , how participants may be directed to different content based on their situation , and the intensity of the communication .
the system must also include cost - effective mechanisms so as to minimize costs of both technologies involved ( including costs for gsm network communication and gsm modems with its data plan ) and of sending messages to patients .
trust , usefulness , and usability are crucial issues for both health staff and professional users , and it is important that features installed also work properly and meet privacy standards .
therefore , it is better to move slowly in making the system more advanced and , at the same time , making sure to have users on board .
the basic input information required for system to generate the follow - up is being manually compiled through excel - based format on monthly basis leading to delay in updating the base data in the system .
this study demonstrated that it is possible to design , develop , and implement an integrated remote patient management system using the mobile phone 's text message feature to communicate with field staff regarding alerts on follow - up of children .
the study shows that it is necessary to address the following six different requirements : data collection , telecommunication costs , privacy and data security , the content of text messages , connectivity , and system scalability .
state may plan for an evaluation of the system , including a satisfaction survey of the health professionals and field staff that used it .
additionally , plan to perform a cost - benefit analysis and to implement the system permanently with advanced technology using android - based smart phone .
we thank all the ictc , dapcu , art and sacs staff of maharashtra state aids control society for their sincerity and hard work in facilitating this study .
 objectivethe purpose of this study is to assess the utility of web - based mobile technology monitoring tool , for ensuring linkages , and tracking of hiv - exposed child until 18 months of age.methodsthe  early infant diagnosis ( eid ) follow - up system was designed as a tool for reminding the field level staff for follow - up of hiv - exposed babies . using java swing framework , 
 software was developed which generates automatic advance sms alerts regarding patient information to the counsellor of the respective integrated counselling and testing center and district supervisor , 7 days prior to due dates . 
 simultaneously , system generated e - mail is sent to district program officer for monitoring and updating the line-list.resultsbefore the introduction of  eid follow - up system in june 2013 , only 55.9% ( 637/1139 ) of the hiv - exposed babies born were tested at 6 weeks for dna - polymerase chain reaction during april 2011march 2012 . however , after its introduction , 68.4% ( 1117/1631 ) of them were tested during april 2012march 2013 . 
 correspondingly , the 18 months confirmatory hiv testing in eligible babies increased from 45.6% ( 934/2044 ) to 54.7%(1118/2044 ) during the same period.conclusionthe replicable technology driven initiative would help in strengthening the follow - up mechanisms and reach every hiv - exposed child for eid . 
INTRODUCTION
METHODS
Telecommunication costs
Privacy and data security
Text message content
RESULTS
DISCUSSIONS
LIMITATION OF STUDY
CONCLUSION
RECOMMENDATIONS
Acknowledgements
Financial support and sponsorship
Conflicts of interest