Acceptability, effect, and cost-effectiveness of mobile-health on antiretroviral therapy adherence among youth : a mixed methods sequential study in Kiryandongo District, Western Uganda

Abstract

Introduction: Adherence to antiretroviral therapy is the principal determinant for achieving and sustaining viral suppression, which decreases progression to Acquired immunodeficiency syndrome (AIDS) and reduces the risk of mortality. Few studies have evaluated mHealth adherence tools among youth in resource-limited settings. This study aimed to evaluate the barriers, enablers, acceptability, effect, and cost-effectiveness of an mHealth tool (Call for Life) on antiretroviral therapy (ART) adherence outcomes among youth in Kiryandongo, Uganda. Methods: This was a mixed-methods sequential design with four studies: qualitative studies conducted before (paper 1), a randomized clinical trial (paper 2), a cost-effectiveness analysis study (paper 3) and endline qualitative study (paper 4). The second study involved 206 youth initiating ART or on ART for ≤ six months who were randomized to either the Standard of Care or the mHealth tool plus the Standard of Care .The qualitative analyses were guided by socio-ecological model and information motivation behavioral modes with support from Nvivo 14.0 software. The primary end point was viral load suppression at 12 months and secondary endpoint was viral suppression at 6 months and retention in care. Log binomial analysis through STATA software was performed. The cost-effectiveness analysis outcome was the incremental cost-effectiveness ratio of the intervention in comparison to the standard of care per disability-adjusted life-years. Results: The qualitative results showed multiple barriers to ART adherence at individual and social levels, with travels from home, forgetfulness, stigma, noise from pill bottle, unintended disclosure being the common barriers. The enablers included social support, repacking ART into drug envelopes other than pill bottles and disclosure. The Call for Life interactive voice response tool showed 21.7% more effective on adherence leading to higher proportions of youth with virological suppression. The tool is cost-effective in improving retention and viral suppression in this age group and has an incremental cost-effectiveness ratio of $17 per disability adjusted life year (DALY) averted. The Call for life system was highly acceptable, informative and easy to use among the youth. Conclusion: The major barriers were at individual level and enablers at relationship level. The call for life intervention was effective in viral suppression and retention in care, it was cost-effective compared to usual care, easy to use and acceptable in improving ART adherence, viral suppression and retention in care. Discussion: This project is among a few that have assessed barriers and enablers of ART adherence, acceptability, effectiveness, and cost-effectiveness of mHealth on viral suppression. The tool is cost-effective in this setting and should be considered by policymakers for the improvement of health outcomes in youth living with HIV.