Programming Connection


British Columbia
2018

WelTel is a mobile health (mHealth) intervention for people with HIV that uses two-way text messaging to connect people with healthcare providers. The WelTel program at the Oak Tree Clinic (OTC) in Vancouver, British Columbia, was modelled after WelTelKenya1, which was shown to significantly improve adherence to antiretroviral therapy (ART) and viral load suppression in a randomized controlled trial in Kenya. Study results from Vancouver indicate that WelTel has significantly improved adherence to ART and viral load suppression in a sample of predominantly vulnerable women.1

WelTel program description1,2

The WelTel program is run through the OTC, a provincial referral centre for women and families living with HIV in British Columbia. The clinic has an interdisciplinary care team to address the holistic health needs of clients in one setting.

The WelTel program provides clients with a basic mobile phone with unlimited text messaging (if they do not have one), as well as training on how to use text messages, if needed. Every week, automated text messages are sent to participants asking “How are you?” Participants either respond “ok” or “not ok,” with the latter response indicating that they have a problem. If the participant indicates a problem, a nurse follows up by telephone. The nurse then provides the needed support or advice (if appropriate) or refers the client to another healthcare provider (e.g., physician, pharmacist, dietician, counsellor, social worker, or nurse practitioner) or service (e.g., clinic-based service, hospital-based service, counselling) either within or outside of the OTC.

If a participant does not respond to the first automated text message, a follow-up text message is sent. If there is no response to the follow-up text message, a nurse telephones the participant. Participants who were unreachable by text message or telephone will receive the weekly-automated text message the following week when the process starts again.

Problems that participants commonly report include the need for medical advice, the need for ART prescription refills/pick-ups, and requests for information on medication side effects. The approach used in the WelTel intervention is meant to increase timely responses to issues and allow clients to maintain personal contact with clinic staff while maintaining confidentiality. No HIV information is communicated via text message unless the client requested it specifically.

Results

The current study recruited 85 participants (90% women); 76% of participants experienced vulnerabilities (e.g., mental health illness, substance use, unstable housing). Participants continued to receive interdisciplinary care through the OTC throughout the study period, including follow-up appointments every one to four months.

The participant’s medical records in the 12 months before their participation in the WelTel program were used to enable clinical outcomes (e.g., viral load, CD4 counts, medication adherence) to be compared. The study found that 47% of text messages received an “ok” reply, 10% received a “not ok” reply and 42% received no reply. The study nurse was able to solve 65% of problems on their own.1 Other findings included the following:

  • Average viral loads of participants significantly decreased from 1098 copies/mL in the control year to 439 copies/mL after 12 months in the study, and ART adherence significantly increased from 60.3% in the control year to 62.2% in the intervention year.
  • Attendance at clinic appointments significantly decreased from 52% in the control year to 47% attendance in the intervention year. The researchers postulate this could be because common issues traditionally solved in clinic were being solved via the WelTel intervention.
  • There was no significant change in CD4 count, substance use, ART regimen and hospital admission.

The authors of the study suggest that the quick identification of problems and close connection with care or a support network could have prevented treatment interruptions and that the connection between participants and healthcare providers provided through WelTel may improve medication adherence and therefore viral load.1

The cost of the intervention was determined by calculating the cost associated with the number of hours that each healthcare provider spent engaging with participants and the cost of the mobile phone provided to clients (i.e., cost of phone and phone plans). The median cost of the intervention was $347.74 per year per participant. The median cost associated with the time healthcare providers spent on the intervention was $36.72 per year per participant that responded with at least one problem.2

What does this mean for service providers?

mHealth is a growing area of research in HIV care and treatment, with studies showing improved viral load suppressions (among other outcomes) (e.g., see PositiveLinks evidence brief). This specific study shows that a low-tech (i.e., no smart phone required) approach to engaging predominantly vulnerable female participants in weekly two-way communication with a nurse and other healthcare providers can have positive outcomes.

The analysis of costing information could help organizations to determine if this intervention is feasible within their local context. If mobile phones are not being provided as part of the initiative, the costs of delivering the program are less than $50 per year per participant.

Interventions such as WelTel could potentially be used to supplement other programs or to enhance engagement between vulnerable clients and healthcare providers using a low-cost approach.

Related resources

PositiveLinks – evidence brief

References

  1. King E, Kinvig K, Steif J, et al. Mobile text messaging to improve medication adherence and viral load in a vulnerable Canadian population living with human immunodeficiency virus: a repeated measures study. Journal of Medical Internet Research. 2017;19(6):e190.
  2. Campbell AR, Kinvig K, Côté HCF, et al. Health care provider utilization and cost of an mHealth intervention in vulnerable people living with HIV in Vancouver, Canada: prospective study. JMIR mHealth and uHealth. 2018;6(7):e152.