James Habyarimana

Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial

BACKGROUND Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. METHODS WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients were randomised (1:1) by simple randomisation with a random number generating program to a mobile phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h. Randomisation, laboratory assays, and analyses were done by investigators masked to treatment allocation; however, study participants and clinic staff were not masked to treatment. Primary outcomes were self-reported ART adherence (>95% of prescribed doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma HIV-1 viral RNA load suppression (<400 copies per mL) at 12 months. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00830622. FINDINGS Between May, 2007, and October, 2008, we randomly assigned 538 participants to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk [RR] for non-adherence 0·81, 95% CI 0·69-0·94; p=0·006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0·84, 95% CI 0·71-0·99; p=0·04). The number needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI 5·0-29·5) and the NNT to achieve viral load suppression was 11 (5·8-227·3). INTERPRETATION Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcome in resource-limited settings. FUNDING US Presidents Emergency Plan for AIDS Relief.

Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.

Objective:There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. Design:A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. Methods:Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. Results:In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P = 0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). Conclusion:These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.

Why Does Ethnic Diversity Undermine Public Goods Provision

A large and growing literature links high levels of ethnic diversity to low levels of public goods provision. Yet although the empirical connection between ethnic heterogeneity and the underprovision of public goods is widely accepted, there is little consensus on the specific mechanisms through which this relationship operates. We identify three families of mechanisms that link diversity to public goods provision—what we term “preferences,” “technology,” and “strategy selection” mechanisms—and run a series of experimental games that permit us to compare the explanatory power of distinct mechanisms within each of these three families. Results from games conducted with a random sample of 300 subjects from a slum neighborhood of Kampala, Uganda, suggest that successful public goods provision in homogenous ethnic communities can be attributed to a strategy selection mechanism: in similar settings, co-ethnics play cooperative equilibria, whereas non-co-ethnics do not. In addition, we find evidence for a technology mechanism: co-ethnics are more closely linked on social networks and thus plausibly better able to support cooperation through the threat of social sanction. We find no evidence for prominent preference mechanisms that emphasize the commonality of tastes within ethnic groups or a greater degree of altruism toward co-ethnics, and only weak evidence for technology mechanisms that focus on the impact of shared ethnicity on the productivity of teams.

The Impact of HIV/AIDS and ARV Treatment on Worker Absenteeism: Implications for African Firms.

We characterize medium and long-run labor market impacts of HIV/AIDS and ARV treatment using unique panel data of worker absenteeism and information from an AIDS treatment program at a large mining firm in Botswana. We present robust evidence of an inverse-V shaped pattern in worker absenteeism around the time of ARV treatment inception. Absenteeism one to four years after treatment start is low and similar to nonenrolled workers at the firm. Furthermore, our analysis suggests that for the typical manufacturing firm in Africa, the benefits of treatment to the firm cover 8-22 percent of the cost of treatment.

When can school inputs improve test scores

The relationship between school inputs and educational outcomes is critical for educational policy. The authors recognize that households will respond optimally to changes in school inputs and study how such responses affect the link between school inputs and cognitive achievement. To incorporate the forward-looking behavior of households, the authors present a household optimization model relating household resources and cognitive achievement to school inputs. In this framework, if household and school inputs are technical substitutes in the production function for cognitive achievement, the impact of unanticipated inputs is larger than that of anticipated inputs. The authors test the predictions of the model for nonsalary cash grants to schools using a unique data set from Zambia. They find that household educational expenditures and school cash grants are substitutes with a coefficient of elasticity between -0.35 and -0.52. Consistent with the optimization model, anticipated funds have no impact on cognitive achievement, but unanticipated funds lead to significant improvements in learning. This methodology has important implications for educational research and policy.

Differences between self-reported and electronically monitored adherence among patients receiving antiretroviral therapy in a resource-limited setting.

Background:Measurement of adherence to antiretroviral therapy (ART) by patient self-report is common in resource-limited settings but widely believed to overstate actual adherence. The extent to which these measures overstate adherence has not been examined among a large patient population. Methods:HIV-infected adult patients in Kenya who initiated ART within the past 3 months were followed for 6 months. Adherence was measured by participants’ self-reports of doses missed in the past 7 days during monthly clinic visits and by continuous Medication Event Monitoring System (MEMS) in participants’ pill bottles. Seven-day self-reported adherence was compared to 7-day MEMS adherence, 30-day MEMS adherence, and adherence more than 90% during each of the first 6 months. Results:Self-reported and MEMS adherence measures were linked for 669 participants. Mean 7-day self-reported adherence was 98.7% and mean 7-day MEMS adherence was 86.0%, a difference of 12.7% (P < 0.01). The difference between the two adherence measures increased over time due to a decline in 7-day MEMS adherence. However, patients with lower MEMS adherence were in fact more likely to self-report missed doses and the difference between self-reported and MEMS adherence was similar for each number of self-reported missed doses. When analysis was limited to patients who reported rarely or never removing multiple doses at the same time, mean difference was 10.5% (P < 0.01). Conclusion:There is a sizable and significant difference between self-reported and MEMS adherence. However, a strong relationship between the measures suggests that self-reported adherence is informative for clinical monitoring and program evaluation.

An Assessment of the Investment Climate in South Africa

The objective of the South Africa Investment Climate Assessment (ICA) is to evaluate the investment climate in South Africa in all its operational dimensions and to promote policies to strengthen the private sector. The investment climate is made up of the many location-specific factors that shape opportunities and incentives for firms to invest productively, create jobs, and expand. These factors include macroeconomic and regulatory policies, the security of property rights and the rule of law, and the quality of supporting institutions such as physical and financial infrastructure. The main source of information for the ICA is a survey of over 800 formal private enterprises. The survey includes data on firm productivity, the cost of doing business, the regulatory environment, the labor market, the financial sector, the trade regime, and levels of investment. The analysis links business environment constraints to firm-level costs and productivity. Also, the investment climate and performance of firms in South Africa can be compared with those of firms in the more than 70 low- and middle income countries in which Investment Climate Surveys (ICSs) have been conducted.

Behavioral Responses of Patients in AIDS Treatment Programs: Sexual Behavior in Kenya

We estimate changes in sexual behavior for HIV-positive individuals enrolled in an AIDS treatment program using longitudinal household survey data collected in western Kenya. We find that sexual activity is lowest at the time that treatment is initiated and increases significantly in the subsequent six months, consistent with the health improvements that result from ART treatment. More importantly, we find large and significant increases of 10 to 30 percentage points in the reported use of condoms during last sexual intercourse. The increases in condom use appear to be driven primarily by a program effect, applying to all HIV clinic patients regardless of treatment status.

Improving Learning in Uganda, Volume III : School-based Management, Policy and Functionality

Uganda is one of the few African countries with a functional national assessment system. Established in 2003, the National Assessment of Progress in Education (NAPE) Program is executed by the Uganda National Examination Board (UNEB). The program uses a learning outcomes measurement framework to annually measure achievement in literacy and numeracy proficiency on the basis of a cross-sectional, nationally representative sample of learners from the primary three (P3) and primary six (P6) grades. In 2008, the framework was extended to the senior two (S2) grade of lower secondary education for English, math, and biology. However, use of national assessment results to inform improvements in student learning remains weak. These data can nevertheless be used to search for solutions to the challenge of low-quality education in Uganda. The objective of this study is to generate a comprehensive, consolidated evidence base about student learning outcomes and teacher effectiveness in primary and secondary schools Uganda, grounded in existing, nationally owned NAPE assessment data. In specific terms, this analytical work attempts to establish the following: (a) the performance levels and patterns of students in P3, P6, and S2; (b) problematic curriculum areas in the respective grades; (c) teacher competency; and (d) predictors of student and teacher performance levels. The goal is not to reanalyze existing data, but rather, provide additional analysis that can help complement the very useful summary reports provided by NAPE for individual years. This analysis is also supported by findings from the qualitative end-of-cycle (EOC) curriculum examination reports generated by UNEB chief examiners.

Child diarrhoea and nutritional status in rural Rwanda: a cross-sectional study to explore contributing environmental and demographic factors

To explore associations of environmental and demographic factors with diarrhoea and nutritional status among children in Rusizi district, Rwanda.