• Treatment adherence
  • An HIV-free future: improving adherence to antiretroviral treatment

    It is common knowledge that HIV and AIDS has long been an overwhelming challenge in Africa. East and sub-Saharan Africa is the most affected region in the world.  Statistics indicate that at least 19.4 million people are living with HIV in this part of the continent. South Africa alone has the biggest HIV epidemic in the world with 7.1 million people living with HIV.  In 2016, there were at least 270 000 new infections and 110 000 AIDS-related deaths in the country.

    These statistics are worrying, but there is hope. It is estimated that 61% of adults and 51% of children in East and Southern Africa are on anti-retroviral therapy (ART). Antiretroviral medications (ARVs) are life-saving drugs that have turned HIV into a manageable chronic condition. The disease is no longer a death-sentence and when HIV-positive people take their ARVs responsibly and strictly.

    Adherence to ART is often an overlooked issue despite its incredible importance. In order for an HIV-positive person to achieve an effective level of viral suppression, adherence to ARVs needs to be more than 95%. This means that there is very little room for those living with HIV to skip their ARVs.

    Remembering when to take medication on time can be challenging for many reasons. People use different methods to remind themselves, but in most cases, these methods are not always reliable or effective.

    MyTherapy, a medication reminder and health tracker app designed in Germany, is an effective and easy-to-use app that has been proven to raise adherence levels significantly. In a short space of time, the app has improved adherence by over 45% and currently has over 500,000 users.

    While the app’s main function is to help its users keep track of their medication intake, it has also been designed to improve their overall health and sense of wellbeing. Users can record important measurements, like blood pressure and weight, and track their symptoms, and for those living with HIV, the app allows users to enter lab-results data, such as blood tests, kidney-function tests and viral load.

    The app is easy-to-use and all users have to do is enter the relevant data and set alarm times. The app is designed to handle complex medication regimens, perfect for ART which requires multiple medication intake per day, and all recorded data can be printed out at the end of each month in easy-to-read graphs, which is useful for the user’s doctor. Furthermore, while the app does rely on self-efficacy and self-discipline, users can invite family and friends on the app to help them stick to their treatment plans, ensuring that various parties are involved to promote adherence further. MyTherapy also takes data protection and privacy seriously, and users also have the option to use a passcode to prevent others from accessing the app and seeing personal data.

    ARVs are exceptional drugs that have changed the face of HIV and AIDS forever.  There is potential for an HIV-free future, only if those living with the virus are responsible and take their ART strictly.

    Knowledge of HIV/AIDS is continuously expanding. Information in the article's taken from Avert and the NCBI. 

  • Three mHealth apps help with treatment adherence

    Adherence to medication is an increasing problem in primary health care in Africa. It is important for many things, from birth control to antibiotics to ARTs. When medications are forgotten or skipped, most treatments are no longer as effective.  This becomes both costly for the healthcare system and detrimental to a patient’s health.

    Factors impacting adherence are multifaceted and include social, economic and psychological motives.  A sub-Saharan study in 2017 reported the most common barriers to adherence were;

    ForgettingLack of access to adequate foodStigma and discriminationSide-effects of the medicationTraveling

    With the uptake of smartphones in Africa, mHealth apps targeting treatment adherence could be a simple solution.  Here are the top 3 downloaded treatment adherence apps on Google Play Store. 

    PatientPartner

    This app turns patient education into an adventure game and shows patients the importance of sticking to a treatment schedule.

    Medisafe

    In addition to medication reminders, this app will notify friends and family if the user defaults. Medisafe also launched a low-tech version that sends reminders through automated phone calls and text messages. 

    MyTherapy

    After logging their medications on the MyTherapy app, users will receive reminders and alerts to take their medications.  Other features on the app include symptom tracking, healthy lifestyle tips and friends and family support groups.

    Improved adherence means a healthier society and ultimately, a reduced burden on healthcare systems.  Moreover, access to adherence data from these apps could help doctors and policy makers make better informed decisions about how to improve the healthcare system.

  • eHealth for medication compliance made no difference

    Complying with drug prescriptions can be a challenge. Using eHealth has considerable potential to help. The reality might be different. A study reported in the Journal of the American Medical Association (JAMA) Internal Medicine of wireless technology and behavioural economic approaches to vascular re-hospitalization and medication adherence for Acute Myocardial Infarction (AMI) survivors found no statistically significant differences for three variables. They were times to first re-hospitalisation for a vascular event or death, medication adherence and cost.

    The 1,509 AMI patients in the study were prescribed at least two of four medications, statins, aspirins, ?-blockers and antiplatelet agents. They’d spent between one to 180 days as inpatients and discharged home with a principal AMI diagnosis. The control group didn’t have smart pill bottles. The other group did, but the eHealth group had no significant benefits. 

    The findings are a salutary reminder that eHealth’s potential benefits don’t always translate into actual benefits. Rigorous attention to other variables are needed to maximise eHealth’s probable benefits, and the study has considerable value in emphasising that eHealth’s much more than the just the technology.

    Studies that show eHealth’s limitations can offer more insights than successful projects. Africa’s health systems have to address this to maximise their own eHealth benefits.

  • Some EHRs may have medication benefit barriers

    EHRs can have a wide range of benefits. In Africa, medication adherence is often seen as a high eHealth and mHealth priority. A research team led by Duke University in the USA has found some persistent barriers in EHRs helping to improve patient’s medication adherence. 

    In the Journal for Medical Informatics Research, the team set out its study. There are four persistent eHealth barriers to medication adherence. They are:

    Underdeveloped of data reciprocity across clinical, community, and home settings, limiting the data capture needed for clinical care Inconsistent data definitions and lack of harmonised patient-focused data standards, making existing data difficult to use for patient-centred outcomes research Inability to use the national drug code information effectively from EHRs and claims datasets for adherence purposes Lack of data capture for medication management interventions in EHRs, such as medication management therapy.

    Limited semantic interoperability’s seen as an underlying constraint in removing or minimising these barriers. It’s been a longstanding issue.

    Poor medication adherence data reciprocity across systems has two characteristics:

    Data complexity, coding syntax, and the transmission infrastructure on which data resides Output, such as medication history, refill rates or patients’ experiences of side effects.

    Common to both features, data’s not accessible, timely, nor easily understood by healthcare systems. Consequently, providers, patients, family members, and community support often lack adequate communication about using medication. 

    The study highlights the role of mHealth in medication adherence, which is important for Africa’s health systems. Barriers identified for EHRs can apply to mHealth too, so all need assessing rigorously as part of mHealth medication adherence projects. Just having an app doesn’t seem to be enough.

  • Good SMS results have some limitations

    Reminding patients to take their drugs is a good idea. It’s especially important for patients with chronic conditions. SMSs are ideally suited to the task. An international team from the Cardiology Department at Westmead Hospital, Sydney, Sydney University, Johns Hopkins Bloomberg School of Public Health and the George Institutes for Global Health at Oxford and Sydney Universities has reviewed evaluation literature and found improved compliance, but two limitations that are helpful to Africa’s health systems.

    Its report from 16 Randomised Clinical Trials (RCT) of 2,742 patients, in the Journal of the American Medical Association, JAMA Internal Medicine, had services from five using personalised services, eight using two-way communication, and eight using daily SMSs. The findings showed that SMS significantly improved medication adherence, almost 18%. It wasn’t sensitive to the different types of patients’ chronic diseases and approximately doubles the odds of compliance.

    There are two big buts. One’s the short duration of RCT’s. The other’s reliance on self-reported medication adherence. These combine to create an important caution in using the findings. They need including in future studies of SMS effectiveness to identify the SMSs that improve success, patient populations that can benefit most, the sustained effects, and influences on clinical outcomes.

    An extra theme can be added to these. SMSs studies are needed to show their cost-effectiveness or costs and benefits over time. There may be better ways to improve compliance, or SMSs are the best way. It’d be good for African health systems to know.

  • Patient portals are effective

    Should patients have access to their medical records? It’s an important decision for Africa’s eHealth if it increases the benefits of EHRs. There may be trend emerging.

    In 2012, a study in the Journal of Internet Medical Research (JMIR) of patient portals’ effectiveness by and Austrian team found:

    Five papers presenting found studies No statistically significant changes between intervention and control group in the two randomised controlled trials investigating the effect of patient portals on health outcomes Significant changes in the patient portal group, compared to a control group for: Quicker decrease in office visit rates Slower increase in telephone contacts Increase in the number of messages sent Changes of the medication regimen Better adherence to treatment.

    A USA study in 2015, also reported in the JMIR, found the availability of notes following visits to GPs was associated with improved adherence by patients to prescribed antihypertensive medications, used to treat high blood pressure. It didn’t find an improvement for antihyperlipidemic medications, used as cholesterol busters.

    Surveys, interviews, and focus groups have shown that patients taking medications and offered portal access to their GPs notes reported better adherence to their regimens. There’s a big but. The study says that objective confirmation hasn’t been reported, so the team completed a retrospective comparative analysis at a site of the OpenNotes quasi-experimental trial. Quasi-experimental research has similarities with the randomised controlled trials, but they don’t have a random assignment to treatment or control.

    Patients in Danville, Pennsylvania, older than 17, in the Geisinger Health Plan insurance, and taking at least one antihypertensive or antihyperlipidemic agent from March 2009 to June 2011, provided data for the study. From 2010, patients were invited and reminded to use the portal to read their GPs notes. Control patients had portal access too, but their GPs notes weren’t available. There were 2,147 patients, 756, 35%, in the intervention group, and 1,391, 65%, in the control group.

    The 756 patients with access to their GPs notes were more compliant to antihypertensive medications regimens. The rates were nearly 80% compared to 75% for the control group. For antihyperlipidemic medication, the rates were about 77% for both groups.

    The study says as the “Use of fully transparent records spreads, patients invited to read their clinicians’ notes may modify their behaviours in clinically valuable ways.” How can Africa’s eHealth take advantage of it?

  • Diálisis 24H's app helps kidney treatment adherence

    Two nurses and an IT engineer joined forces to create the Diálisis 24H app, to improve adherence to kidney treatments. The team worked closely with renal patients to ensure the app design is user friendly and provides benefits.

    An article in Healthcocreation says Diálisis 24H is innovative in the way it supports kidney patients. It aims to motivate patients to manage their health and take control of their care. The app’s free and can be downloaded for iOS and Android.

    It has a number of self-monitoring features. First, it has a calculator for hydric balance, a crucial value for renal self-care. Most people aren’t aware of the influence of specific foods and liquids and the importance of maintaining a healthy balance to achieve an appropriate water flow. The app helps to address this. It includes a food catalogue that informs patients about the amounts of potassium, sodium and water, certain foods contain. In an interview with Healthcocreation, the team says “We want our dialysis patients to be able to eat all kinds of food but in a healthy manner. It is not about prohibiting, it is about giving the tools to allow patients to eat what they like taking into account the quantity and the portions.”

    Diálisis 24H has a gaming component to encourage learning. Users can play the quiz alone or with other users to solve challenges. There’s a digital pillbox too, to remind users to take their medications.

    The healthcare advice section provides patients and relatives with information on nutrition, lifestyles, dialysis, care on vascular accesses, vaccines and many other issues. It’s updated regularly to keep up with latest findings and developments.

    Historical dialysis records also promote treatment success. With this information patients get a powerful tool for self-care, and can share the information with their healthcare professionals. 

    The app’s currently available in Spanish, but’s easily translated. Renal patients in Africa, who don’t have easy access to clinics or healthcare facilities, could benefit from it. Diálisis 24H would allow them to monitor and manage their care from home and could reduce the frequency of the need to see health workers.  

  • More eHealth to stop TB

    TB incidence in Africa is unacceptably high. So are its mortality and drug resistance rates. Both are fueled by poor treatment adherence.

    For the vast majority of cases, TB is treatable. Success needs a few simple things to work: early diagnosis, access to treatment, and adherence for at least six months. This is the nub. Most of us aren’t good at following a treatment regimen, even if it’s simply a daily dose. Compliance deteriorates if we have to do it for months. So, well-trained health workers help. They’re called Directly Observed Treatment Short-course (DOTS) supporters, part of WHO’s DOTS programme.

    DOTS has five components:

    Political commitment with increased and sustained financing Case detection through quality-assured bacteriology Standardised treatment, with supervision and patient support An effective drug supply and management system Monitoring and evaluation and impact measurement.

    eHealth and other technologies have an important role too. They’re emerging as a sustainable solution.

    In India, uNotify supports text messages, fingerprint scanners and intelligent pill dispensers to support treatment adherence. uNotify devices send information to a centralised server that monitors programme activity and alerts administrators when a patient misses a dose. In South Africa, On Cue Compliance does much the same. It uses specially designed pill bottles fastened with a SIM card and transmitter. When the pill bottle’s opened, the transmitter relays a text message to a designated healthcare worker. If patients don’t open pill bottles on time, they receive a text message reminding them to take their medication. According to the programme’s reported results in the CHMI database, 90% of patients complied with their medication regimen, compared to a compliance rate of 22 to 60% without the system. Similar results have been achieved by SIMpill and Wisepill reported in eHNA.

    Protecting the drug supply chain is also important, since gaps in supply don’t do treatment adhernce any good. TexTB, in the Philippines, and the Uganda Health Information Network help to monitor and manage the supply of TB meds. The Ugandan programme reports 24% improvements in efficiency when compared with paper-based data management, where officials in five districts monitor drug and supply levels at health centers via PDAs.

    The MOTECH Suit, using Dimagi CommCare mobile phone-based tools for community health workers, provides health workers with text messages, electronic forms, job aids, medical protocols, alerts, and other features to identify and respond to symptoms for high-burden health issues like TB. World Health Partners uses text messages included in the MOTECH Suite to enable rural medical providers and consumers alike in Bihar, India to better manage their TB. D-tree International is developing a TB module to help health workers in Tanzania identify TB among HIV-infected clients; the module suggests diagnostic tests even when clients miss a visit.

    Africa’s healthcare is moving its eHealth role in TB treatment forward. There’s still plenty to do.

  • mHealth to encourage treatment adherence in Tanzania

    The Vodacom Foundation has donated mobile phones to the Sickle Cell Foundation of Tanzania to support treatment adherence among patients. About 150 sickle cell patients are set to receive mobile phones that will simplify monitoring of their health condition says an article in BIZTECH Africa. 

    Sickle cell disease rate in Tanzania keeps rising, as 11,000 babies are born with the disease each year. The Sickle Cell Foundation is committed to supporting prevention, care and effective management of disease in Tanzania. It’s working with Muhimbili University on the Mighty Dots (MDOTS) project that uses graphic screen designs for mobile phones to improve adherence to medication.

    The pilot will see 150 patients on long-term medication receive mobile phones. These patients will be monitored daily by recording themselves ingesting the medication and sending the video to the clinic using the new phones.

    MDOTS Programme Coordinator, Dr. Robert Mongi said, “We prescribe medication for different strains of sickle cell. Patients with severe sickle cell disease are prescribed medication that must be taken daily however, not all patients observe these instructions. This project will help us determine whether monitoring intake of medication is effective in ensuring adherence to medication on a daily basis.” Many long term patients tend to skip taking their medication based on lack of symptoms. The accountability aspects of the initiative should help improve adherence.

    Tanzania ranks fourth in the world for the highest number of sickle cell disease births a year, after Nigeria, India and DRC. Sickle cell disease is manageable with comprehensive care, but needs diligent treatment adherence. This basic mHealth initiative could help patients manage their disease better.

  • Treatment adherence is never easy

    When was the last time that you completed a full course of medication prescribed by your GP, taking each pill as prescribed, on time, every time? The truth is very few of us comply, which creates all kinds of problems both small, when it takes longer for us to recover, and big, when we help drug-resistant super bugs to take hold even more.

    It seems that South Africans know a thing or two about treatment adherence. This is not surprising, given the long, hard battle being fought in South Africa to bring challenges such as Tuberculosis and HIV, and their nefarious combination, under control, without creating escalating problems associated with poor treatment adherence, particularly drug resistance.

    Over the last decade South Africans have made valuable contributions to real-time support for treatment adherence. Dr David Green, as inventor and innovator of Simpill, and Ricci and Lloyd Marshall, a husband and wife team, as entrepreneurs and owners at Wisepill Technologies are good examples. Both use a portable medication dispenser with a GSM communicator, connected to Internet software that drives adherence services customized to patients’ unique medication regimens.

    Simpill was a pioneering concept, invented in the early 2000’s by Dr David Green to help TB patients remain compliant. It’s now used in a number of countries to help patients manage their chronic conditions and avoid costly and unpleasant hospital admissions needed to deal with poor treatment adherence.

    Wisepill was founded in 2007, contributing a suite of solutions to the real time adherence support. Wisepill’s been selected by Family Health International (FHI360) for their trials of antiretroviral agent Truvada and used by Massachusetts General Hospital (MGH), Harvard and Columbia Universities in HIV research in Uganda and in South Africa.

    In 2011, Wisepill won South Africa’s Department of Trade and Industry (DTI) Technology Award in the category of small businesses. Director and owner Ricci Marshall said, “Our focus has been on providing innovative products and service excellence in the field of medication adherence. It is gratifying to see our solutions being used more and more for personal adherence management as well as in clinical trials internationally.”

    So why don’t we see more of these technology solutions helping people stay healthy and avoid running up unnecessary costs? There are probably a number of reasons, though cost, often regarded as the key deterrent to serious scale-up, should not be one of them.

    When I first came across these devices I was curious about the cost question, so produced a cost minimisation assessment of a SIMpill pilot, with Prof Maurice Mars of University of KwaZulu-Natal. Our assessment published in January 2012 found that the discounted net present value, the estimated value for money quantified by the accumulated economic benefits less costs over a project cycle, was nearly half a million US dollars. It also showed substantial improvements in health outcomes.

    So either “if it sounds too good to be true it is” or something else is the limiting factor to their increased use, not costs. The real difficulty is that pilots do not deal with a wide range of additional, complicated issues necessary for wider implementation. Important factors such as integrating the new solution into regular working arrangements and dealing with affordability and the extra cash needed to finance the project.

    Economic assessments usually don’t address these issues, though they do help to point in the right direction, so that more substantial cost benefit analyses, or eHealth impact assessments can be applied to tease out the hard work that’s needed to realise real benefits.

    Without a doubt, real-time treatment adherence support is here to stay, and sound economic assessment methods will be critical tools to help position them properly. On both of these topics, South Africans are likely to continue to contribute, helping eHealth improve health and healthcare in Africa and elsewhere.