Grace Kamera runs the HIV treatment program at St. Gabriel’s. She oversees atiretroviral therapy (ART) for the catchment area – which includes 250,000 people and an HIV prevalence rate of 15%. While there are a few government-run health centers in the area, St. Gabriel’s Hospital is the only facility offering HIV tests, and the only place to get treatment.
Many of the CHWs are ART monitors – they are trained to check in on HIV patients, to see if they’re complying with the treatment regimen. Noncompliance deducts from the treatment’s efficacy and contributes to drug resistence. Given a limited number of choices for drugs, patient adherence is critical.
Before FrontlineSMS and the accompanying cell phones arrived, Grace was receiving 25 paper reports, per month, from the ART monitors. With 21 ART monitors equipped with cell phones and trained in text messaging, she’s received 400 adherence updates since the outset of the project (15/week).
If the paper trail had continued, each report would have been hand-delivered by a CHW. The average round trip is about 6 hours, so the SMS program has saved ART monitors 900 hours of travel time.
If Grace receives an SMS regarding a patient’s missteps, she will counsel them when they return for more drugs. The patients are well aware that the CHWs have cell phones, and they’re grateful for the connection to the hospital (and Grace). Of all the patients who enroll in the ART program, 80% agree to be monitored. The remainder fear stigmatization within their communities.
Some patients do not turn up to receive their HIV medication. Grace says this is rare – “They usually come a day or two late” – but it happens. She’s used the SMS network to track 25 patients who have failed to show, asking the nearest CHWs to report on their status. Sometimes they’ve left, other times they’re unable to travel or they’ve passed away.
The hospital and the people it serves can’t afford a lack of connectivity. With Grace at the reigns, ART monitors will continue serving their communities, 160 characters at a time.
At the weekly ART meeting, the “Prevention of Mother-To-Child Transmission” (PMTCT) staff reported on the number of children from their program who have been confirmed HIV-positive.
Mothers are given a single dose of nevirapine, to be taken during labor (whether they deliver at home or in the hospital), and children born at the hospital to HIV-positive mothers receive short-course AZT, in an attempt to deter transmission of the virus. Each case that the PMTCT staff reported had a story. Some examples:
Mothers enrolled in the program for their first birth, but neglected to contact the hospital during a subsequent pregnancy
Faced with substantial travel costs, some mothers played their (rather, their children’s) chances – delivering without PMTCT ARVs
Mothers from a certain village failed to deliver at the hospital, afraid the care-seeking behavior would reveal their status
These mothers might bring in their children for testing after 18 months, or only if symptoms present. This delay in determining HIV-seropositivity dramatically decreases the child’s chances of survival. Because the drugs (single-dose at birth, followed by a one-week course) are so effective in halting vertical transmission of HIV, every child born HIV-positive to women enrolled in the PMTCT program is deeply troubling.
After talking with hospital staff, we’re going to integrate the new SMS network into the hospital’s Voluntary Counseling and Testing (VCT) services. As part of their post-test counseling, every client who tests positive will be paired with an HIV-positive CHW with a cell phone. Many of the CHWs we have trained to text are committed members of the HIV-positive community – leaders of support groups, impressively drug-adherent, and people who spread a ‘Positive Living’ message.
These CHWs, along with their mobiles, will provide HIV-positive individuals a link to hospital services, a way to privately ask questions, and someone to look over their health. It will also provide a means by which to track pregnancies for HIV-positive patients, and follow deliveries for mothers in the PMTCT program.
Above – the fourth group of CHWs. After the training session, Alex and I situated each CHW’s ID pin on the map of the catchment area. As promised, new colors appeared – youth counselors and reproductive health volunteers are now connected to the hospital. At the week’s medical meeting, a new category was reported – “SMS Follow-Ups” – for the TB and ART programs.
This week, another group of jubilant CHWs was trained in texting. Below, you can watch a one-minute excerpt of the training session – Alex is explaining the first steps in operating the phone. At the end, you’ll hear a chorus of ‘success sounds’ – all the phones turning on for the first time by their owners’ manipulations.
The week has gone very well, and the project’s initial success has been noticed by each arm of the hospital. I took a minibus into Lilongwe, which turned out to be a fruitful venture – I rode into Namitete on a bike taxi wielding extra maps, an assortment of push-pins, and a few surge protectors (which will establish a permanent location for CHWs to charge their phones at the hospital).
Each CHW we train and distribute a phone to will be placed on a map of the hospital’s catchment area, with a different color pin, depending on their program (Home Based Care, ART Monitors, Reproductive Health Volunteers, Counseling, or Youth Volunteers). Particularly committed volunteers assume multiple roles in their community – they’re distinguished by blue pins. The idea is to have the maps, with hundreds of CHWs’ locations marked, displayed clearly for the clinical staff at the hospital. This way, a clinician looking to track down a patient need only consult the map, find the nearest, appropriate CHW’s identifying number (written on the pin), and send out a text. Here are the new maps, along with the locations of the first 20 dispersed phones:
Tomorrow afternoon, I’m attending the staff meeting for those involved with the hospital’s antiretroviral therapy (ART) program. I’ll be explaining the project, and the group will determine a protocol for communicating with adherence monitors in the field. Below, you’ll see me, sitting with Grace, who coordinates the hospital’s ARV provision.
As always, thanks for reading. Any ideas, as this expands?