Research Article: Patient and health-care worker experiences of an HIV viral load intervention using SMS: A qualitative study

Date Published: April 11, 2019

Publisher: Public Library of Science

Author(s): Emilie Venables, Zibusiso Ndlovu, Dhodho Munyaradzi, Guillermo Martínez-Pérez, Elton Mbofana, Ponesai Nyika, Henry Chidawanyika, Daniela B. Garone, Helen Bygrave, Webster Mavhu.


Mobile Health or mHealth interventions, including Short Message Service (SMS), can help increase access to care, enhance the efficiency of health service delivery and improve diagnosis and treatment for HIV. Text messaging, or SMS, allows for the low cost transmission of information, and has been used to send appointment reminders, information about HIV counselling and treatment, messages to encourage adherence and information on nutrition and side-effects. HIV Viral Load (VL) monitoring is recommended by the WHO and has been progressively adopted in many settings. In Zimbabwe, implementation of VL is routine and has been rolled out with support of Médecins Sans Frontières (MSF) since 2012. An SMS intervention to assist with the management of VL results was introduced in two rural districts of Zimbabwe. After completion of the HIV VL testing at the National Microbiology Reference Laboratory in Harare, results were sent to health facilities via SMS. Consenting patients were also sent an SMS informing them that their viral load results were ready for collection at their nearest health facilities. No actual VL results were sent to patients.

A qualitative study was conducted in seven health-care facilities using in-depth interviews (n = 32) and focus group discussions (n = 5) to explore patient and health-care worker experiences of the SMS intervention. Purposive sampling was used to select participants to ensure that male and female patients, as well as those with differing VL results and who lived differing distances from the clinics were included. Data were transcribed, translated from Shona into English, coded and thematically analysed using NVivo software.

The VL SMS intervention was considered acceptable to patients and health-care workers despite some challenges in implementation. The intervention was perceived by health-care workers as improving adherence and well-being of patients as well as improving the management of VL results at health facilities. However, there were some concerns from participants about the intervention, including challenges in understanding the purpose and language of the messages and patients coming to their health facility unnecessarily. Health-care workers were more concerned than patients about unintentional HIV disclosure relating to the content of the messages or phone-sharing.

This was an innovative intervention in Zimbabwe, in which SMS was used to send VL results to health-care facilities, and notifications of the availability of VL results to patients. Interventions such as this have the potential to reduce unnecessary clinic visits and ensure patients with high VL results receive timely support, but they need to be properly explained, alongside routine counselling, for patients to fully benefit. The findings of this study also have potential policy implications, as if implemented well, such an SMS intervention has the potential to help patients adopt a more active role in the self-management of their HIV disease, become more aware of the importance of adherence and VL monitoring and seek follow-up at clinics when results are high.

Partial Text

Mobile Health, or mHealth, relates to the use of telecommunications infrastructure and uptake of mobile phones and other devices to support the provision of health services and help achieve global, community and individual level health targets [1]. By the end of 2014, mobile phone technology penetration was reported to be 90% worldwide [2]. In 2017, an estimated 85% of Zimbabweans per 100 inhabitants had mobile cellular subscriptions, suggesting that an mHealth intervention could be appropriate within this context [3].

This was a qualitative study, in which data was collected using in-depth interviews (IDIs) and focus group discussions (FGDs). The study was conducted during April 2015 in seven health centres across the districts of Gutu and Buhera in rural Zimbabwe.

Of the 43 patients who participated in the study, 23 were female. The median distance from participants’ homes to their health facilities was 2km. Only 25.6% of the patient participants had a suppressed VL (<1000 copies/ml). The key informants consisted of nurses, counsellors and nurse aides. Most of the participants were employed and reported being married (90% and 85% respectively). Types of employment included farming, transport and fishing. Amongst patients who were interviewed, the length of time since HIV diagnosis ranged from six months to thirteen years, with a median of 66 months since diagnosis. mHealth interventions such as the one described above show how SMS is an acceptable form of communication for patients to receive information about the availability of their VL results. This study described an innovative SMS intervention from the perspective of HCWs implementing it and the patients who opted in to receive messages. The main perceived benefits of the intervention included being able to give patients information about their VL results without them having to come to the clinic, and ensuring that those who needed to come to the clinic because of a high VL did so more quickly. Implementation can be challenging, however, if infrastructure and clear responsibility for explaining the SMS system to patients and for acting on the information sent by SMS are not put in place. Challenges also occur if the patients do not fully understand the messages and the action they are required to take when receiving them, suggesting that similar interventions would need to focus more time explaining the intervention and its purpose. This study described a unique intervention in which SMS technology was used to send messages to patients about the availability of their VL results in a rural context in Zimbabwe. HCWs and patients found the intervention acceptable, and there were relatively few concerns from patients. More emphasis needs to be placed on explaining the purpose and content of messages, so that patients understand why they are going to be receiving messages, what the messages mean and what—if any—action should be taken. Messages such as those described above have the potential to empower patients through giving them more control over when they come to the clinic, as well as reducing congestion and waiting times in clinics, but SMS alone will not bring a drastic change in turnaround time for patients to start EAC.   Source: