The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
...
HIV Unplugged: Advances in Mobile Health
Ankita Kadakia, MD
Assistant Clinical Professor
Owen Clinic
Objectives
 Discuss mobile health (mHealth) technology specifically
for resource limited settings
 How mHealth technolog...
http://www.who.int/mediacentre/factsheets/fs310/en/index1.html
http://www.unaids.org/en/resources/campaigns/globalreport2013/factsheet/
Doctors, Nurses, Midwives / 10 Million
Population
Crisp N, Chen L. N Engl J Med 2014;370:950-957
Global HealthWorkforce and Burden of
Disease byWHO Region
Crisp N, Chen L. N Engl J Med 2014;370:950-957
BURDEN OF DISEASE
HEALTH CARE WORKERS
The healthcare delivery gap
DIAGNOSIS TREATMENT
Harvard Department of Global Health and Social Medicine
“Despite unprecede...
“The Know-Do gap , the often
neglected work of getting
effective therapies (the know)
to the people who need them
(the do)...
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 ...
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 ...
Factors Affecting Adherence in
Resource Limited Areas
 Transportations issues
 Payment for services and
medications
 Il...
Factors Affecting Adherence in
Resource Limited Areas
 Transportations issues
 Payment for services and
medications
 Il...
2014Winner of theWorld Press Photo Award: African migrants in Dijbouti
A Global Connection
http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014
http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014
Connectivity
 The most rapidly
growing global
cellular market!
http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICT...
Can mHealth Bridge the Delivery Gap?
DIAGNOSIS TREATMENT
Convenient,Mobile,Cheap,EfficientandFitsinYour
Pocket…MobileDoctor
mHealth Point of Care Diagnostics
Why do POC diagnostics improve healthcare
delivery in resource limited settings?
 Impro...
Bridging the Human Delivery Gap with mHealth in
Health Care Delivery Systems of Resource Limited
Areas
Study Investigators...
Kabale Uganda
 1 hospital system
 >600,000 people
 200 beds
 300 patient visits/day
 13 doctors
Average time to CD4/VL
 Flow Cytometry for CD4 count
 CD4 count performed twice per year
 Samples are grouped and proce...
Implementation of POC in
Resource Limited Areas
1. Identify the major disease burdens in the community
 Choose a POC base...
Study Objectives
1
• How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital l...
Study Objectives
1
• Creating a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital litera...
mHealth Hospital Clinic
Creatinga ruralmHealthClinicCreatingaruralmHealthClinic
CreatingaruralmHealthClinic
Creating a rural mHealth Clinic
Creating a rural mHealth Clinic
Point-of-Care ECG
Point-of-Care Pediatric Cardiac Ultrasound
Study Objectives
1
• How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital l...
Digital Literacy
 Sophistication of
cellphone use
 Do you own a
cellphone?
 Is it a smartphone?
 Do you use the
camera...
Cellphone Penetration
Cellphone Penetration
What % of people in Kabale own a
cellphone?
 20%
 50%
 70%
 100?
Cellphone Penetration
75
25
0
10
20
30
40
50
60
70
80
Non-Smartphone Smartphone
Cellphone Penetration
N~300
Percent(%)
Cellphone Penetration
75
25
0
10
20
30
40
50
60
70
80
Non-Smartphone Smartphone
Cellphone Penetration
N~300
Percent(%)
Digital Literacy
100%
70%
85% 85%
100%
85%
90%
33%
100%
50%
88%
40%
Cellphone
ownership
Smartphone SMS text Camera
usage
M...
Digital Literacy
100%
70%
85% 85%
100%
85%
90%
33%
100%
50%
88%
40%
Cellphone
ownership
Smarphone SMS text Camera
usage
Mo...
Digital Literacy
100%
70%
85% 85%
100%
85%
90%
33%
100%
50%
88%
40%
Cellphone
ownership
Smarphone SMS text Camera
usage
Mo...
Study Objectives
1
• How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital l...
Community Based Research
Horowitz CR et al. Community Based Participatory Research From the Margin to the Mainstream. Are ...
Community Based Participatory Research
Horowitz CR et al. Community Based Participatory Research From the Margin to the Ma...
Community Advisory Board
Community
Social
Organizations
School
System
Physician
CaregiversPatients
Adminstration
Healthcare
System
Community Based ...
Community Based Healthcare
Needs
70%
50%
50%
60%
General Examinations
Vaccinations
Healthy Lifestyle Education
Postpartum ...
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 Practitio...
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 Practitio...
Study Objectives
1
• How to create a rural mHealth clinic
2
• Determine the cellphone penetration and assess
the digital l...
mHealth Usability
mHealth Usability
WHO HealthTechnology Assessment
World HealthOrganization: HealthTechnology Assessment of Medical Devices
1. Clinical effec...
mHealth Usability
mHealth Usability
mHealthUsability
World HealthOrganization: HealthTechnology Assessment of Medical Devices
Local mHealth Usability
Local mHealth Usability
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Can these
devices
work?
Easy to use? Useful
features?
...
Rapid Connectivity!
Point-of-Care Implementation
Identify key gaps in rural healthcare
delivery
Select POC diagnostics appropriate
for resourc...
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 Practitio...
mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future D...
mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future D...
How can the Cellphone help with
medication adherence?
mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future D...
Lab-on-a-Chip
Lab on a Chip
•Clinical trial in Muhima Hospital, Kigali, Rwanda
•Commercially available sera/ plasma samples of HIV /Syphilis tested in...
m-ELISA CD4 count
mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future D...
•Tested 17 HIV/AIDS patients and 18 transplant patients
on immunosuppression
•Compared with Flow cytometry as gold standar...
HIVViral Load Pipeline
www.aslm.org
Simple Amplification Based
Assay(SAMBA)
Lee, Helen et al, J Infect Dis. (2010) 201 (supplement 1): s65-s71
•HIV-1 viral nu...
mHealth HIV
 Text messaging for medication adherence
 Lab-on-a-Chip and Microfluidics
 Mobile-Elisa (mElisa)
 Future D...
HIV Patient
Eye
Cardiac
HepatitisSkin
TB
mHealth HIV
HIV Patient
Sensing
Dissemination
MonitoringEducation
Prevention
The Future Now
Necessity is the mother of Innovation
Thank you
HIV Unplugged: Advances in Mobile Health
HIV Unplugged: Advances in Mobile Health
HIV Unplugged: Advances in Mobile Health
HIV Unplugged: Advances in Mobile Health
HIV Unplugged: Advances in Mobile Health
HIV Unplugged: Advances in Mobile Health
HIV Unplugged: Advances in Mobile Health
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Ankita Kadakia, M.D., of UC San Diego Owen Clinic, presents "HIV Unplugged: Advances in Mobile Health" at AIDS Clinical Rounds

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HIV Unplugged: Advances in Mobile Health

  1. 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. 2. HIV Unplugged: Advances in Mobile Health Ankita Kadakia, MD Assistant Clinical Professor Owen Clinic
  3. 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. 4. http://www.who.int/mediacentre/factsheets/fs310/en/index1.html
  5. 5. http://www.unaids.org/en/resources/campaigns/globalreport2013/factsheet/
  6. 6. Doctors, Nurses, Midwives / 10 Million Population Crisp N, Chen L. N Engl J Med 2014;370:950-957
  7. 7. Global HealthWorkforce and Burden of Disease byWHO Region Crisp N, Chen L. N Engl J Med 2014;370:950-957
  8. 8. BURDEN OF DISEASE HEALTH CARE WORKERS
  9. 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. 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. 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. 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. 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. 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. 15. 2014Winner of theWorld Press Photo Award: African migrants in Dijbouti A Global Connection
  16. 16. http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014
  17. 17. http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014
  18. 18. Connectivity  The most rapidly growing global cellular market! http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014
  19. 19. Can mHealth Bridge the Delivery Gap? DIAGNOSIS TREATMENT
  20. 20. Convenient,Mobile,Cheap,EfficientandFitsinYour Pocket…MobileDoctor
  21. 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. 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)
  23. 23. Kabale Uganda  1 hospital system  >600,000 people  200 beds  300 patient visits/day  13 doctors
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. mHealth Hospital Clinic
  29. 29. Creatinga ruralmHealthClinicCreatingaruralmHealthClinic
  30. 30. CreatingaruralmHealthClinic
  31. 31. Creating a rural mHealth Clinic
  32. 32. Creating a rural mHealth Clinic
  33. 33. Point-of-Care ECG
  34. 34. Point-of-Care Pediatric Cardiac Ultrasound
  35. 35. 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
  36. 36. 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?
  37. 37. Cellphone Penetration
  38. 38. Cellphone Penetration
  39. 39. What % of people in Kabale own a cellphone?  20%  50%  70%  100?
  40. 40. Cellphone Penetration 75 25 0 10 20 30 40 50 60 70 80 Non-Smartphone Smartphone Cellphone Penetration N~300 Percent(%)
  41. 41. Cellphone Penetration 75 25 0 10 20 30 40 50 60 70 80 Non-Smartphone Smartphone Cellphone Penetration N~300 Percent(%)
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. Community Advisory Board
  49. 49. Community Social Organizations School System Physician CaregiversPatients Adminstration Healthcare System Community Based mHealth Research
  50. 50. Community Based Healthcare Needs 70% 50% 50% 60% General Examinations Vaccinations Healthy Lifestyle Education Postpartum Education Patient Assessment
  51. 51. 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
  52. 52. 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
  53. 53. 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
  54. 54. mHealth Usability
  55. 55. mHealth Usability
  56. 56. 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?
  57. 57. mHealth Usability
  58. 58. mHealth Usability
  59. 59. mHealthUsability World HealthOrganization: HealthTechnology Assessment of Medical Devices
  60. 60. Local mHealth Usability
  61. 61. 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
  62. 62. Rapid Connectivity!
  63. 63. 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?
  64. 64. 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
  65. 65. mHealth HIV  Text messaging for medication adherence  Lab-on-a-Chip and Microfluidics  Mobile-Elisa (mElisa)  Future Directions
  66. 66. mHealth HIV  Text messaging for medication adherence  Lab-on-a-Chip and Microfluidics  Mobile-Elisa (mElisa)  Future Directions
  67. 67. How can the Cellphone help with medication adherence?
  68. 68. mHealth HIV  Text messaging for medication adherence  Lab-on-a-Chip and Microfluidics  Mobile-Elisa (mElisa)  Future Directions
  69. 69. Lab-on-a-Chip
  70. 70. Lab on a Chip
  71. 71. •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
  72. 72. m-ELISA CD4 count
  73. 73. mHealth HIV  Text messaging for medication adherence  Lab-on-a-Chip and Microfluidics  Mobile-Elisa (mElisa)  Future Directions
  74. 74. •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
  75. 75. HIVViral Load Pipeline www.aslm.org
  76. 76. 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
  77. 77. mHealth HIV  Text messaging for medication adherence  Lab-on-a-Chip and Microfluidics  Mobile-Elisa (mElisa)  Future Directions
  78. 78. HIV Patient Eye Cardiac HepatitisSkin TB mHealth HIV
  79. 79. HIV Patient Sensing Dissemination MonitoringEducation Prevention The Future Now
  80. 80. Necessity is the mother of Innovation
  81. 81. Thank you

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