Two-Way Short Message Service (SMS) Communication May Increase Pre-Exposure Prophylaxis Continuation and Adherence Among Pregnant and Postpartum Women in Kenya

Jillian Pintye; Zoe Rogers; John Kinuthia; Kenneth K. Mugwanya; Felix Abuna; Harison Lagat; Joseph Sila; Valarie Kemunto; Jared M. Baeten; Grace John-Stewart; Jennifer A. Unger

doi:10.9745/GHSP-D-19-00347

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Interface of mWACh-PrEP System With Mock Data© 2019 Jillian Pintye
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FIGURE 1
Enrollment of Women in mWACh Program at PrEP Initiation Visits, Kusumu County, Kenya
Abbreviations: mWACh, Mobile WACh; PrEP, pre-exposure prophylaxis.
^a From 2 sites that participated in the mWACh-PrEP program.
^b PrEP initiators who were not screened for mWACh-PrEP initiated PrEP in January 2018 before mWACh-PrEP implementation, which began in February 2018.
^c PrEP initiators who were screened for mWACh-PrEP initiated PrEP between February and October 2018.
^d PrEP discontinuation was defined as either not returning for a follow-up visit or not refilling a PrEP prescription at a follow-up visit.
^e PrEP continuation was defined as attending a follow-up visit and refilling a PrEP prescription.
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FIGURE 2a
Women's Response Frequency to Automated SMS Over Time Since PrEP Initiation and Enrollment in mWACh-PrEP Program, Kusumu County, Kenya^a
Abbreviations: mWACh, Mobile WACh; PrEP, pre-exposure prophylaxis; SMS, short message service.
^a Full SMS transcripts were available and analyzed for 170/190 (90%) of women who enrolled into mWACh-PrEP.
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FIGURE 2b
Frequency Distribution of Unprompted Question and Concern Topics Sent by Women Who Initiated PrEP to Remote Nurses Using the mWACh-PrEP Platform, Kusumu County, Kenya (N=183)^a
Abbreviations: mWACh, Mobile WACh; PrEP, pre-exposure prophylaxis; SMS, short message service.
^a Overall, 170 participants who initiated PrEP were enrolled in the mWACh-PrEP program had full transcripts available for analysis and 74 (44%) ever sent an unprompted question to a remote nurse during follow-up. Remote nurses received and responded to 183 unprompted questions in total from 74 women.

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TABLE 1.

Characteristics of Women Screened for mWACH-PrEP and Women Who Initiated PrEP Before mWACh-PrEP,^{^a,^b} by Enrollment, Kusumu County, Kenya

	Screened for mWACh			Initiated PrEP Before mWACh (n=166)
	Enrolled (n=190)	Ineligible or Declined^a (n=144)	P Value^b		P Value^c
Age, years, median (IQR)	25 (22–30)	23 (20–27)	<.001	24 (21–28)	.006
Age category, No. (%)
<18 years	3 (1.6%)	9 (6.3%)	.04	11 (6.6%)	.06
18–24 years	89 (46.8%)	80 (55.6%)		77 (46.4%)
25–29 years	46 (24.2%)	28 (19.4%)		47 (28.3%)
30–34 years	38 (20.0%)	18 (12.5%)		22 (13.3%)
≥35 years	14 (7.4%)	9 (6.3%)		9 (5.4%)
Client recruitment clinic, No. (%)
Antenatal care	78 (41.1%)	63 (43.8%)	.84	80 (48.2%)	.19
Postnatal care	95 (50.0%)	70 (48.6%)		78 (47.0%)
Family planning	17 (9.0%)	11 (7.6%)		8 (4.8%)
Married, No. (%)	171 (90.0%)	125 (86.8%)	.36	134 (81.2%)	.02
Male partner HIV status, No. (%)
HIV-negative	89 (46.8%)	55 (38.2%)	.04	75 (45.5%)	.81
HIV-positive	19 (10.0%)	8 (5.6%)		14 (8.5%)
Unknown	823 (43.2%)	81 (56.3%)		76 (46.1%)
Gestational age, years, median (IQR)	25 (20–28)	26.5 (20–32.5)	.25	24.5 (20–32)	.51
First antenatal care visit, No. (%)	24 (34.3%)	16 (27.6%)	.42	38 (52.1%)	.03
Behavioral risk factors (last 6 months), No. (%)
Had sex without a condom	187 (98.4%)	144 (100.0%)	.13	164 (98.8%)	.77
Exchanged sex for money or other favors	0 (0.0%)	2 (1.4%)	.10	1 (0.6%)	.28
Diagnosed with or treated for a sexually transmitted infection	1 (0.5%)	2 (1.4%)	.41	0 (0.0%)	.35
Forced to have sex against will	5 (2.6%)	4 (2.8%)	.93	8 (4.8%)	.27
Experienced intimate partner violence	4 (2.1%)	3 (2.1%)	.99	8 (4.8%)	.16

Abbreviations: mWACh, Mobile WACh; PrEP, pr-exposure prophylaxis.
↵a Overall, 3 women were eligible for mWACh-PrEP and declined participation; 141 women were ineligible.
↵b Chi-sqared tests for proportions or Kruskal-Wallis tests for continuous measures, comparing women who were eligible and enrolled with women who were ineligible/declined among those screened for mWACh-PrEP.
↵c Chi-sqared tests for proportions or Kruskal-Wallis tests for continuous measures, comparing women who were eligible and enrolled with women who initiated PrEP in the month before mWACh-PrEP implementation.

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TABLE 2.

Representative Quotations Pertaining to Each Main Topic of Questions or Concerns and Correponding Responses, mWACh-PrEP Platform^a

Topic	Unprompted Question or Concern Sent by Participants by SMS	Nurse's Response to Participant (Time to Response From SMS Receipt)
PrEP dis/continuation	Thanks, nurse, for the concern. Just want to know the duration of taking PrEP? Because in my case, we are a discordant couple.	Hello {Name}. It is important that you continue taking PrEP until your partner's viral load is suppressed. You can incorporate condoms during sexual intercourse to protect you further. We encourage that you freely share health information related to your partners care. (14 hours; participant sent SMS in the evening, nurse responded the next morning)
	Hi, I separated with my husband because of mistrust. He felt ill and was taken to the hospital, where he tested HIV-negative and malaria-positive. Should I continue using this drug? I am not a sex worker.	Hello {Name}. You can continue taking your medication. But should you desire to discontinue, please come back to our clinic for further advice. I would also like to tell you that PrEP is not ONLY used by sex workers, but also those who feel they are at risk of becoming infected. (3 hours)
	Hi {Nurse's name}. If I'm abstaining from sex and I also stay alone, should I continue to use this drug?	Hello {Name}. If you feel you are no longer at risk of being infected, you may stop PrEP. However, you should continue taking the drug 1 pill daily for 28 days from the last risk period. (1 hour)
Side effects	After taking it (PrEP), and I vomit once a day.	Nausea and vomiting is common in pregnancy and could also be a side effect of PrEP. Minor side effects like nausea and vomiting are manageable. Avoiding fatty food, eating smaller meals, and limiting spicy foods may help. PrEP minor side effects subside after a short period of time. (20 minutes)
PrEP clarification	Hey, is it true that PrEP is a type of ARV? They say it is given to HIV+ and HIV- individuals.	Hello {Name}. PrEP is classified as one of the antiretroviral medications used to protect someone from HIV/AIDS. PrEP medication is given to different people depending on the substantial risks involved. Discordant couples, unknown HIV status of your sexual partner, and individuals with multiple sexual partners are some of the people at risk who could be eligible to use PrEP. (2 hours)
	Does PrEP prevent someone from conceiving?	Morning {Name}. PrEP does not prevent someone from conceiving. It is safe for pregnancy as well. It can have side effects like headache, nausea, and vomiting that subsidize with time. (1 hour)
	I abide by what you people told me at the clinic, but some information I was told elsewhere is different. I heard it is not good to use this medication (PrEP) until I know my partner's status. Another issue is that PrEP is an antiretroviral medication. Can I get HIV/AIDS if I use PrEP medication for long periods?	Hello, {Name}. PrEP medication helps to prevent HIV/AIDS acquisition. Not knowing your partners status is one of the risks that may lead to an individual acquiring HIV/AIDS. It is important to know your partner's status because it helps to reduce the risk of HIV acquisition. In case you want to stop PrEP, it is advisable to come back to the clinic for discontinuation. (2 hours)
PrEP logistics	Hello, Nurse. I would like to ask if it is good to take my medications before taking my meals?	Hello, {Name}. It is good to take the medications after meals to avoid side effects such as nausea and vomiting. (10 minutes)
	Is it a must that I should take it (PrEP) at bedtime?	Hello, it is not a must to take at bedtime. PrEP can be taken one tablet daily either in the morning, afternoon or evening. It is also advisable to be strict on the time you take the medication. In case you decide its morning hours, then every day you should take it in the morning. (19 hours; participant sent SMS in the evening, nurse responded the next morning)
	In case I forget to take PrEP medication today and then I remember the next day, can I take the medicine then?	Hello, at that point in time when you remember to take medication, you should swallow 1 tablet. It is not advisable to swallow 2 tablets at once because you forgot taking the medication the previous day. You can set an alarm on your phone to act as a reminder when to take the medication. (20 hours; participant sent SMS in the evening, nurse responded the next morning)
HIV risk	I am inquiring if I have 2 partners, 1 has HIV and the other one is HIV-negative. If it happens that I have sex with the negative partner, can he get HIV because the other one is positive?	How are you, {Name}. You can't transmit HIV to him because you are negative and you are on PrEP taking them faithfully. Again, if your positive partner is taking antiretrovirals as prescribed, he can't transmit HIV to you…..However, you should also use condoms when you are meeting your negative partner because you don't know if he is having multiple partners. (4 hours)
MCH/family planning	Hello, I have been using Depo Provera for a long time until I stopped because of excess bleeding…I haven't experienced any of these side effects since I stopped using the injection. My monthly periods have resumed normally, 5 days, with 3 heavy days and lighter 2 days. Which method of family planning can I use without side effects?	Hello, I would kindly advise you to find time and come to the hospital so that we can talk more on the other methods of family planning, so that you can be able to decide and choose one of the family planning methods that you would want to use. (2 hours)
MCH/family planning	Now is when the baby is breastfeeding too much because she had mouth rash, she was not feeding.	Hello {Name}. Breastfeeding is important for the baby because it helps in growth and development. Did you bring the child for review at the clinic regarding the oral thrush? When the baby has lesions in the mouth it can affect how the baby breastfeeds and feeding orally. (16 hours; participant sent SMS in the evening, nurse responded the next morning)
Other (not related to PrEP)	I have a problem when having sex with my husband with a condom. I experience bloating and abdominal pain. What can I do please? Should I stop having sex?	Hi {Name}. You can stop having sex, but I would like you to see a doctor for further management and instructions. (23 hours; participant sent SMS on the weekend, nurse responded on Monday)