Evaluating the effect of interactive two-way texting on 6-month antiretroviral therapy outcomes: Findings from a randomized controlled trial in Lilongwe, Malawi.

Retention on antiretroviral therapy (ART) is critical for achieving viral load suppression (VLS) among people living with HIV (PLHIV). Retention remains challenging in high-prevalence settings like Malawi. Short messaging service (SMS) interventions, particularly hybrid two-way texting (2wT), show promise in improving ART retention. We conducted a randomized control trial (RCT) at Lighthouse Trust in Lilongwe, Malawi, to evaluate the effectiveness of a hybrid 2wT system to improve compliance to ART refill appointments, early retention, and VLS among new ART initiates. After receiving routine ART initiation counseling, 442 clients with mobile phones on ART ≤ six months were randomized to 2wT or standard of care (SoC). The 2wT group received weekly motivational messages, appointment reminders, and access to an open-ended SMS communication channel with retention officers. The SoC group received peer support at clinic visits and reminder calls, pre-visit and for missed appointments. All participants were traced if they missed an appointment by >14 days. Study outcomes ascertained six months post ART initiation included: ART appointment compliance (attending within 2 days), retention in care (alive on ART), and VLS (< 200 copies). Data from electronic medical records were analyzed using Chi-square tests and multivariable logistic regression. Data on 2wT participation were extracted from the 2wT database and summarized using Microsoft Excel. At six months, the 2wT group demonstrated higher compliance to ART refill visits compared to SoC (59.6% vs. 46.8%, p = 0.008). Among 2wT participants, 86% responded to ≥ 1 message, suggesting strong engagement with 2wT. The platform sent 1,645 reminders: all participants received visit reminders with the majority receiving multiple pre-appointment and follow-up messages. However, 2wT did not significantly improve retention or VLS at 6 months. Over 91% of both 2wT and SoC were retained in care (p = 0.969), and higher VLS among 2wT (97.5%) vs. SoC (93.2%) was not significant (p = 0.07). Implementing a larger 2wT study over 12-24 months and among more clients could provide evidence of 2wT impact on retention and VLS. Overall, the enhanced ART visit compliance and high care engagement among 2wT participants suggests that the low-tech, highly-accepted, 2wT approach could provide a scalable, appropriate complement to existing retention interventions in low-resource settings.