Ankita Kadakia, M.D., of UC San Diego Owen Clinic, presents "HIV Unplugged: Advances in Mobile Health" at AIDS Clinical Rounds

1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS

2. HIV Unplugged: Advances in Mobile Health
Ankita Kadakia, MD
Assistant Clinical Professor
Owen Clinic

3. Objectives
 Discuss mobile health (mHealth) technology specifically
for resource limited settings
 How mHealth technology can be used to bridge the health
care delivery gap specifically for HIV/AIDS care
 Using mHealth technology targeted towards the Ugandan
healthcare system

4. http://www.who.int/mediacentre/factsheets/fs310/en/index1.html

5. http://www.unaids.org/en/resources/campaigns/globalreport2013/factsheet/

6. Doctors, Nurses, Midwives / 10 Million
Population
Crisp N, Chen L. N Engl J Med 2014;370:950-957

7. Global HealthWorkforce and Burden of
Disease byWHO Region
Crisp N, Chen L. N Engl J Med 2014;370:950-957

8. BURDEN OF DISEASE
HEALTH CARE WORKERS

9. The healthcare delivery gap
DIAGNOSIS TREATMENT
Harvard Department of Global Health and Social Medicine
“Despite unprecedented financial resources
and medical advances care is prevented from
consistently reaching the patients who need
it.”

10. “The Know-Do gap , the often
neglected work of getting
effective therapies (the know)
to the people who need them
(the do)”
-Paul Farmer, MD

11. What is the adherence rate to
ARVS in sub-saharan Africa?
 A) 10%
 B) 33%
 C) 55%
 D) 77%
 E) 95%
Mills Edward J. et al JAMA August 6,2009Vol 290, No 679-690

12. What is the adherence rate to
ARVS in sub-saharan Africa?
 A) 10%
 B) 33%
 C) 55%
 D) 77%
 E) 95%
Mills Edward J. et al JAMA August 6,2009Vol 290, No 679-690

13. Factors Affecting Adherence in
Resource Limited Areas
 Transportations issues
 Payment for services and
medications
 Illness and co-morbid
conditions
 Inability to obtain
consistent supplies of
medication
 Food insecurity
 Alcohol use
 Religious beliefs and
stigma
 Higher CD4 counts and
complacency
 Increased adherence with
cell phone users
Magutu D et al, Factors affecting first month adherence to antiretroviral therapy for HIV
positive adults in South Africal;Afr J AIDS Res. 2010
Millis EJ et al, J Acquir Immune Defic Syndrome. 2013 May 1;63(1)e:23-7

14. Factors Affecting Adherence in
Resource Limited Areas
 Transportations issues
 Payment for services and
medications
 Illness and co-morbid
conditions
 Inability to obtain
consistent supplies of
medication
 Food insecurity
 Alcohol use
 Religious beliefs and
stigma
 Higher CD4 counts and
complacency
 Increased adherence with
cell phone users
Magutu D et al, Factors affecting first month adherence to antiretroviral therapy for HIV
positive adults in South Africal;Afr J AIDS Res. 2010
Millis EJ et al, J Acquir Immune Defic Syndrome. 2013 May 1;63(1)e:23-7

15. 2014Winner of theWorld Press Photo Award: African migrants in Dijbouti
A Global Connection

16. http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014

17. http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014

18. Connectivity
 The most rapidly
growing global
cellular market!
http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014

19. Can mHealth Bridge the Delivery Gap?
DIAGNOSIS TREATMENT

20. Convenient,Mobile,Cheap,EfficientandFitsinYour
Pocket…MobileDoctor

21. mHealth Point of Care Diagnostics
Why do POC diagnostics improve healthcare
delivery in resource limited settings?
 Improve scalability: shifting health delivery to the local
level (healthcare community worker)
 Reduce cost
 Improve early detection: increasing the yield of disease
diagnosis
 Improve access to previously underserved populations
 Improve treatment rates

22. Bridging the Human Delivery Gap with mHealth in
Health Care Delivery Systems of Resource Limited
Areas
Study Investigators and Collaborators
Ankita Kadakia MD
Sanjeev Bhavnani MD (The Scripps
Research Institute)
Rakhi Sharma MA (Disaster Relief,The
World Bank)
James Saturday BSc (Kabale Regional
Medical Center)
Elizabeth Ekirapa-Kiracho PhD (Makerere
University School of Public Health)
Peterson Kyebambe MD (Nagaru
Hospital, Kampala Uganda)

24. Kabale Uganda
 1 hospital system
 >600,000 people
 200 beds
 300 patient visits/day
 13 doctors

27. Average time to CD4/VL
 Flow Cytometry for CD4 count
 CD4 count performed twice per year
 Samples are grouped and processed at central facility
distant from the collection site (9hours by bus once
weekly)
 Viral load results take 60-90 days
Galiwango RM et al. (2014) Field Evaluation of PIMA Point-of-Care CD4Testing in Rakai,
Uganda. PLoS ONE 9(3): e88928. doi:10.1371/journal.pone.0088928

28. Implementation of POC in
Resource Limited Areas
1. Identify the major disease burdens in the community
 Choose a POC based on community based needs
 Specific factors leading to the delivery-care gap
2. Is the POC diagnostic suitable for use in rural areas?
 Diagnostic robustness, ease of use, accuracy and cost
 Is the POC an improvement over the current method of
diagnosis?
3. Organizational infrastructure
 Adequate medical, financial, human and technological
resources?
http://globalhealth.mit.edu/wp-content/uploads/2011/07/Assessing-POC-diagnostics.pdf

29. Study Objectives
1
• How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital literacy rates among users in a rural
setting
3
• Create a community based mHealth research
model

30. Study Objectives
1
• Creating a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital literacy rates among users
3
• Create a community based mHealth research
model

31. mHealth Hospital Clinic

35. Creatinga ruralmHealthClinicCreatingaruralmHealthClinic

36. CreatingaruralmHealthClinic

37. Creating a rural mHealth Clinic

38. Creating a rural mHealth Clinic

40. Point-of-Care ECG

41. Point-of-Care Pediatric Cardiac Ultrasound

42. Study Objectives
1
• How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital literacy rates among users in a rural
setting
3
• Create a community based mHealth research model

43. Digital Literacy
 Sophistication of
cellphone use
 Do you own a
cellphone?
 Is it a smartphone?
 Do you use the
camera?
 Do you text message?
 Do you use mobile
payments?
 Do you use the
internet?

44. Cellphone Penetration

45. Cellphone Penetration

46. What % of people in Kabale own a
cellphone?
 20%
 50%
 70%
 100?

47. Cellphone Penetration
75
25
0
10
20
30
40
50
60
70
80
Non-Smartphone Smartphone
Cellphone Penetration
N~300
Percent(%)

48. Cellphone Penetration
75
25
0
10
20
30
40
50
60
70
80
Non-Smartphone Smartphone
Cellphone Penetration
N~300
Percent(%)

49. Digital Literacy
100%
70%
85% 85%
100%
85%
90%
33%
100%
50%
88%
40%
Cellphone
ownership
Smartphone SMS text Camera
usage
Mobile
payments
Internet
usage
Healthcare Worker (n=14) Patient (n=24)
%ofRespondents

50. Digital Literacy
100%
70%
85% 85%
100%
85%
90%
33%
100%
50%
88%
40%
Cellphone
ownership
Smarphone SMS text Camera
usage
Mobile
payments
Internet
usage
Healthcare Worker (n=14) Patient (n=24)
%ofRespondents

51. Digital Literacy
100%
70%
85% 85%
100%
85%
90%
33%
100%
50%
88%
40%
Cellphone
ownership
Smarphone SMS text Camera
usage
Mobile
payments
Internet
usage
Healthcare Worker (n=14) Patient (n=24)
%ofRespondents

52. Study Objectives
1
• How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital literacy rates among users in a rural
setting
3
• Create a community based mHealth research model

53. Community Based Research
Horowitz CR et al. Community Based Participatory Research From the Margin to the Mainstream. Are Researchers Prepared? Circulation 2009;119:2633-2642

54. Community Based Participatory Research
Horowitz CR et al. Community Based Participatory Research From the Margin to the Mainstream. Are Researchers Prepared? Circulation 2009;119:2633-2642

55. Community Advisory Board

56. Community
Social
Organizations
School
System
Physician
CaregiversPatients
Adminstration
Healthcare
System
Community Based mHealth Research

57. Community Based Healthcare
Needs
70%
50%
50%
60%
General Examinations
Vaccinations
Healthy Lifestyle Education
Postpartum Education
Patient Assessment

58. Community Based Healthcare
Needs
40
25
60
70
40
60
40
10
0
60
80
60
70
0
0
10
20
30
40
50
60
70
80
90 Healthcare Practitioner Patient
%ofRespondents

59. Community Based Healthcare
Needs
40
25
60
70
40
60
40
10
0
60
80
60
70
0
0
10
20
30
40
50
60
70
80
90 Healthcare Practitioner Patient
%ofRespondents

60. Study Objectives
1
• How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital literacy rates among users in a rural
setting
3
• Create a community based mHealth research model
• mHealth device usability and barriers to use

61. mHealth Usability

62. mHealth Usability

63. WHO HealthTechnology Assessment
World HealthOrganization: HealthTechnology Assessment of Medical Devices
1. Clinical effectiveness
2. Appropriateness
3. Implementation
 Can the technology work?
 Can the technology work in this setting?
 How and should the technology be implemented in
this setting? By physicians? By all healthcare
workers? By patients?

64. mHealth Usability

65. mHealth Usability

66. mHealthUsability
World HealthOrganization: HealthTechnology Assessment of Medical Devices

67. Local mHealth Usability

68. Local mHealth Usability
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Can these
devices
work?
Easy to use? Useful
features?
Increase
efficiency of
care
delivery?
Use by all
healthcare
workers?
90%
100%
80%
100% 100%
%ofRespondents

69. Rapid Connectivity!

70. Point-of-Care Implementation
Identify key gaps in rural healthcare
delivery
Select POC diagnostics appropriate
for resource limited settings
Ensure effective training, treatment
and support
Improved Health Outcomes?

71. Community Based Healthcare
Needs
40
25
60
70
40
60
40
10
0
60
80
60
70
0
0
10
20
30
40
50
60
70
80
90 Healthcare Practitioner Patient
%ofRespondents

72. mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future Directions

73. mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future Directions

74. How can the Cellphone help with
medication adherence?

75. mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future Directions

76. Lab-on-a-Chip

77. Lab on a Chip

78. •Clinical trial in Muhima Hospital, Kigali, Rwanda
•Commercially available sera/ plasma samples of HIV /Syphilis tested in the mChip at
Columbia University, HIV sensitivity 100%, specificity 95%, Syphilis 100%, 81%
•Commercial ELISA HIV 100/98-100% and Syphilis ab 82-100/97-100%
•70 specimens collected from known HIV positive men and women
•1 out of 70 specimens tested was falsely negative, 98-100% sensitivity/88-100 specificity
•67 samples for duplex HIV/Syphilis mChip yielded 100%/94% sensitivity and 100%/76%
specificity

79. m-ELISA CD4 count

80. mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future Directions

81. •Tested 17 HIV/AIDS patients and 18 transplant patients
on immunosuppression
•Compared with Flow cytometry as gold standard
•97% accuracy rate compared with flow cytometry

82. HIVViral Load Pipeline
www.aslm.org

83. Simple Amplification Based
Assay(SAMBA)
Lee, Helen et al, J Infect Dis. (2010) 201 (supplement 1): s65-s71
•HIV-1 viral nucleic acid based assay for dipstick, 2 hours for result
•Sample prep for extraction of viral RNA, isothermal amplification of viral nucleic acid,
rapid visual detection of amplification products by dipstick
•Tests subtype B and Non-B strains
•63 positive /6 negative samples from Royal College of London, 100% reproducible
resultscompared with the same samples tested with Roche Taqman HIV-1 assay

84. mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future Directions

85. HIV Patient
Eye
Cardiac
HepatitisSkin
TB
mHealth HIV

86. HIV Patient
Sensing
Dissemination
MonitoringEducation
Prevention
The Future Now

87. Necessity is the mother of Innovation

88. Thank you