Engagement in care is critical to meeting UNAIDS 90-90-90 goals. South Africa has improved access to antiretroviral therapy (ART) through expanded ART initiation and monitoring at primary health clinics, however nearly half of HIV-positive clients are still lost to care. To improve retention in care, we designed and implemented short message service (SMS) reminders and peer navigation (PN) to address barriers to HIV care.
The I-Care Trial (registration: NCT02417233) used a cluster randomized design to assign primary health clinics in North West Province, South Africa, to: 1) SMS check-in messages, along with appointment and healthy living reminders (6 clinics); 2) SMS reminders plus PN services (SMS+PN) to address personal barriers to care (7 clinics); and 3) standard of care (SOC; 4 clinics). From October, 2014, to April, 2015, we enrolled 752 recently HIV-diagnosed, consenting adults (292 men, 460 women) in SMS, SMS+PN, or SOC assigned clinics and followed them for up to 1 year. We extracted clinical record data and conducted intention-to-treat analyses of 12-month retention outcomes using generalized estimating equations (GEE). Retention in care was defined as: 1) an average of at least 1 clinic visit every 3 months for participants on ART, which corresponded to the minimum frequency with which ART was dispensed at the facilities; or 2) an average of at least 1 clinic visit every 6 months for pre-ART participants (those not yet eligible for ART at the time of the study). The trial is complete and results are final.
Participants receiving SMS+PN services had nearly 3 times the odds of being retained in care compared to SOC participants (Table 1). SMS services alone did not significantly improve outcomes relative to SOC, although SMS demonstrated protective trends for those on ART. When analyzed by gender, men (OR=3.34, 95% CI: 1.37-8.14) and women (OR=2.64, 95% CI: 1.60-4.37) had greater odds of being retained in care when receiving SMS+PN services than when receiving SOC. There were no differences between SMS and SOC conditions for men or women in stratified analyses.
Peer navigation paired with SMS reminders substantially improves retention in HIV care at South African primary health clinics. The intervention offers a valuable strategy for meeting 90-90-90 campaign targets. Efforts are now needed to identify feasible strategies for wider-scale implementation in resource-constrained clinics.