Exploring how mHealth interventions are improving retention in prevention of mother-to-child HIV transmission services
In Kenya, where approximately 890,000 women live with HIV, the threat of mother-to-child transmission (MTCT) remains a persistent public health challenge. Despite significant progress, Kenya still records an unacceptably high MTCT rate of 8.9%, with about 5,200 children newly infected with HIV annually5 . What makes these statistics particularly troubling is that modern interventions can reduce transmission rates to below 2% when properly implemented5 . The heartbreaking reality is that most of these infections could be prevented—but a critical gap exists in keeping mothers and infants consistently engaged with healthcare services after delivery.
MTCT rate in Kenya
Children newly infected with HIV annually
Achievable MTCT rate with proper interventions
Enter an unexpectedly simple tool: the text message. In a country with explosive growth in mobile phone connectivity, researchers wondered if this everyday technology could help solve one of Kenya's most stubborn healthcare challenges. This is the story of how scientists are testing text messaging as a lifeline to keep mother-baby pairs connected to vital HIV prevention services.
The use of mobile technology for health (mHealth) represents an innovative approach to addressing systemic healthcare challenges. In Kenya, where text messaging has become ubiquitous, researchers recognized an opportunity to leverage this technology to improve retention in Prevention of Mother-to-Child Transmission (PMTCT) programs.
About clinic appointments and medication schedules to ensure consistent care.
Addressing recipients by name and using preferred languages for better engagement.
Allowing women to ask questions and report problems directly to healthcare providers.
Throughout pregnancy and the postpartum period when dropout rates are highest.
These interventions are particularly crucial in the context of PMTCT programs, where research has identified a troubling pattern: approximately 50% of mother-infant pairs are lost to follow-up during the critical postpartum period4 . This dropout rate represents a devastating break in the healthcare continuum that can lead to preventable HIV infections in infants.
To rigorously test whether text messaging could improve retention, researchers conducted what's known as a pragmatic, cluster-randomized, stepped-wedge trial—considered the gold standard for evaluating real-world healthcare interventions1 4 . This sophisticated design involved:
Randomly allocated to implement the intervention at different times
Participating in the study between February 2015 and December 2016
To reflect real-world conditions as closely as possible
The TextIT system was carefully designed based on extensive preliminary research:
Messages were developed using constructs from the Health Belief Model, which explains how people make health decisions based on perceived susceptibility, severity, benefits, and barriers8 .
Women could respond to messages, call, or send inquiries to a designated clinic phone.
Messages were sent at each woman's preferred time of day to maximize engagement.
Content was developed through focus group discussions with health workers and women attending ANC, postnatal care, and PMTCT clinics8 .
This thoughtful, comprehensive approach distinguished TextIT from simple reminder systems, creating a genuine communication channel between healthcare providers and pregnant women living with HIV.
The findings from the TextIT trial revealed several important patterns. While the improvements associated with the text messaging intervention didn't always reach statistical significance, they consistently pointed in a positive direction:
| Outcome Measure | Intervention Group | Control Group | Adjusted Relative Risk |
|---|---|---|---|
| Infant HIV testing by 8 weeks | 90.9% (1,466/1,613) | 85.4% (609/713) | 1.03 (95% CI: 0.97-1.10) |
| Maternal retention at 8 weeks postpartum | 90% (1,548/1,725) | 76% (571/747) | 1.12 (95% CI: 0.97-1.30) |
The results demonstrate a promising trend—with more infants receiving crucial early HIV testing and more mothers staying in care during the critical early postpartum period when they typically drop out of the healthcare system.
| Characteristic | SMS Group (n=195) | Control Group (n=193) |
|---|---|---|
| Median age | 27 years | 27 years |
| Married or with partner | 86.7% | 88.6% |
| On ART for own health | 51.8% | 52.8% |
| Shared phone | 26.2% | 25.9% |
| Education (primary or less) | 60.5% | 58.6% |
These balanced baseline characteristics strengthen the validity of the trial results, showing that the randomization process created comparable groups at the start of the study.
While the TextIT trial provided valuable quantitative data, a separate case report illustrates the very real human consequences when PMTCT care breaks down5 . The story of "Susan" (a pseudonym) demonstrates the multiple system failures that can lead to mother-to-child transmission despite the existence of prevention programs:
Susan didn't begin prenatal care until her third trimester, resulting in delayed HIV diagnosis and treatment5 .
The hospital where she delivered wasn't the same facility where she received HIV care, leading to a failure to administer infant HIV prophylaxis medications5 .
Susan's struggles with medication adherence went unnoticed until routine viral load monitoring three months after treatment initiation5 .
Susan initiated breastfeeding before her baby received prophylaxis, potentially increasing transmission risk5 .
This case highlights how text messaging interventions could help address these system failures by maintaining continuous engagement, identifying adherence challenges earlier, and providing crucial guidance at critical moments.
Implementing successful mHealth interventions for PMTCT requires several essential components:
| Component | Function | Example from TextIT |
|---|---|---|
| Automated messaging platform | Sends scheduled messages without manual effort | Custom-built software sent messages based on gestational age and delivery date4 |
| Two-way communication system | Enables participants to respond and ask questions | Designated clinic phone with option to request callbacks8 |
| Personalization capabilities | Tailors content to individual characteristics | Messages included recipient's name, preferred language, and infant's name after birth4 |
| Behavioral theory foundation | Guides content development based on psychological principles | Health Belief Model informed message content8 |
| Integration with healthcare system | Connects digital interventions with clinical care | Healthcare workers followed up on problems reported via text |
The mixed results from various texting interventions suggest that text messaging alone isn't a silver bullet for the complex challenge of PMTCT retention. The WelTel PMTCT trial, which tested a weekly "How are you?" message with healthcare worker follow-up, found no significant improvement in 18-month postpartum retention. This indicates that more intensive or differently designed interventions might be necessary for long-term retention.
Phone ownership among participants in the TextIT trial1
However, the consistently high rates of phone ownership among participants confirm that the infrastructure for these interventions already exists. As one analysis noted, "The promise of scientific breakthroughs can only be fulfilled through systems that ensure equitable access"3 .
AI-powered diagnostic tools to enhance decision-making3
Addressing structural barriers like transportation or stigma
Responding to individual patient behaviors and needs
Between different healthcare facilities and services
The research on text messaging for PMTCT retention tells a compelling story of innovation and persistence. While the results have been mixed, the consistent trend toward improved outcomes suggests that well-designed mHealth interventions can contribute meaningfully to keeping mother-baby pairs engaged in care.
Perhaps the most important lesson from this body of research is that improving routine care through basic enhancements may be as important as technological innovations. As the TextIT researchers concluded, "Improving the implementation of usual care may have been sufficient to substantially improve infant HIV testing rates"1 .
As Kenya continues its journey toward eliminating mother-to-child HIV transmission, text messaging remains a promising tool in the broader arsenal of interventions. In the battle against HIV, sometimes the most sophisticated solutions come in the simplest packages—and for many mothers, a timely, caring text message might make all the difference.