Mahsa Abassi



Nominated From: University of Minnesota

Research Site: Uganda

Research Area: Infectious Disease

Primary Mentor: David Boulware

Research Project

Utilization of Mobile Health Technology to Improve Cryptococcal Antigen Screening in Uganda

Cryptococcal meningitis is one of the leading causes of death among AIDS patients throughout Sub-Saharan Africa. The prevention of cryptococcal meningitis includes early initiation of antiretroviral therapy, screening for cryptococcal antigenemia (CRAG) in persons with CD4 less than 100, and preemptive fluconazole treatment for persons found to be CRAG positive in the blood (1). As previously identified, pre-antiretroviral therapy (ART) screening in persons with CD4 less than 100 cells/μL is highly cost-effective (1-3). Most recently, Pre-ART CRAG screening has been adopted into WHO and PEPFAR guidelines (4,5).

In an effort to improve retention in care and decrease mortality in persons with cryptococcal antigenemia, it is important to understand why patients are lost to follow-up, experience delays in initiating or completing fluconazole therapy and/or antiretroviral therapy, as well as any knowledge barriers that exist for patients or health care providers.

Specific Aims:

Specific Aim 1: Retention in Care
Primary Endpoint:

  • Retention in care at 6 months and 1-year follow-up. Secondary Endpoints:
  • Proportion of Participants who return for their CD4 results within 14 days.
  • Proportion of clinic appointments made on time at 6 months and 1-year follow-up.
  • Proportion of missed clinic appointments made within 5-7 days at the end of 6 months and 1-year follow-up.

Specific Aim 2: Adherence to CRAG screening and treatment guidelines. Primary Endpoint:

  • Proportion of patients with a CD4 count < 100 who receive CRAG screening. Secondary Endpoints
  • Timely initiation and continuation of Fluconazole therapy for CRAG positive participants within 1 week of CRAG results.
  • Timely initiation of ART within 2 weeks of receiving their CD4 results.

Specific Aim 3: Qualitative assessment of text-messaging services and participant attitudes. Primary Endpoint:

  • Participants attitudes regarding the incorporation of mobile technology into their clinical care. Secondary Endpoints:
  • Attitudes regarding the use of mobile technology and feelings of empowerment as assessed by increased level of engagement with the health care system, improved knowledge regarding when to seek care, and better relationship with health care providers.


Research Significance

We propose an innovative, sustainable, and locally lead initiative to disseminate CRAG screening throughout Uganda, evaluate barriers to CRAG screening, and assess the risk factors for lack of fluconazole therapy. We propose incorporating the use of the rapidly growing telecommunications system in Uganda to accomplish our objectives outlined above, specifically the utilization of mobile technology to improve health outcomes.

The use of mobile technology to improve health outcomes is an increasing area of interest, both in research and clinical care. Current estimates predict that 90% of the population over 6 years of age will own a mobile phone by 2020 (6). Smartphone subscriptions have continued to see rapid growth and are predicted to reach 70% of the world’s population by 2020. Africa has seen the highest growth rate in mobile broadband subscriptions, increasing from 2% penetration in 2010 to 11% in 2013. With increasing access to affordable phones, 55% of new mobile phone subscriptions, globally, will be in the Middle East and Africa by 2020. There have been several studies trying to assess the efficacy of mobile health in improving medication adherence and linkage to care. A cross-sectional study conducted in Uganda of patients presenting to health clinics in two rural districts, utilized either text or voice messages to remind patients of their clinic appointment for ARV refill (7). It was found that mobile phone access was high, reaching 64%, in the rural districts, despite socioeconomic status. In addition, medication adherence was higher during the period of mobile phone intervention as well as clinic attendance.

Another study conducted in Uganda, participants were enrolled into a study assessing the effects of SMS message reporting of low CD4 counts and transportation reimbursement on clinic return and timing to ART initiation (8). Compared to a pre-intervention cohort of participants, those receiving SMS messages and transportation reimbursement had statically significantly decreased time to clinic follow-up and ART initiation.

In developed countries, the use of smartphone technology has become pervasive throughout the health care community. A 2012 study conducted by the Manhattan Research/Physician Channel Adoption Study found that 87% of doctors used either a smartphone or tablet device in their workplace (9). In the same survey, mobile phone apps were used for information gathering, clinical decision making, medical education and training. In low-income countries, although the use of smartphone technology is not yet widely available, the rapidly growing market makes it an attractive option as a method for disseminating CRAG screening in Uganda.





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