Objectives To evaluate the impact of a short message service (SMS) reminder system on HIV/sexually transmitted infection (STI) re-testing rates among men who have sex with men (MSM).
Methods The SMS reminder programme started in late 2008 at a large Australian sexual health clinic. SMS reminders were recommended 3–6 monthly for MSM considered high-risk based on self-reported sexual behaviour. The evaluation compared HIV negative MSM who had a HIV/STI test between 1 January and 31 August 2010 and received a SMS reminder (SMS group) with those tested in the same time period (comparison group) and pre-SMS period (pre-SMS group, 1 January 2008 and 31 August 2008) who did not receive the SMS. HIV/STI re-testing rates were measured within 9 months for each group. Baseline characteristics were compared between study groups and multivariate logistic regression used to assess the association between SMS and re-testing and control for any imbalances in the study groups.
Results There were 714 HIV negative MSM in the SMS group, 1084 in the comparison group and 1753 in the pre-SMS group. In the SMS group, 64% were re-tested within 9 months compared to 30% in the comparison group (p<0.001) and 31% in the pre-SMS group (p<0.001). After adjusting for baseline differences, re-testing was 4.4 times more likely (95% CI 3.5 to 5.5) in the SMS group than the comparison group and 3.1 times more likely (95% CI 2.5 to 3.8) than the pre-SMS group.
Conclusion SMS reminders increased HIV/STI re-testing among HIV negative MSM. SMS offers a cheap, efficient system to increase HIV/STI re-testing in a busy clinical setting.
- service delivery
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HIV and syphilis are concentrated among men who have sex with men (MSM) in Australia.1 Australian testing guidelines recommend MSM have annual HIV/sexually transmitted infection (STI) testing and 3–6 monthly testing for ‘high-risk’ MSM;2 mathematical modelling shows that testing at this frequency may substantially reduce HIV/STI incidence.3 4 However, in practice, it appears that only about a quarter of high-risk men are having two or more HIV/STI tests per year.5 We describe the impact of a new short message service (SMS) reminder system implemented at the Sydney Sexual Health Centre (SSHC), a large sexual health clinic, which aimed to increase HIV/STI re-testing rates among MSM.
In late 2008, clinicians at the SSHC were encouraged to offer SMS reminders for HIV/STI re-testing in MSM tailored to the patient's risk behaviour and ability to return for testing. A SMS reminder template was added to the patient electronic database and enabled clinicians to record the date of a SMS stating: ‘You are due for your next screening. Please call SSHC on 93827440 to make an appointment’. Each SMS cost $0.05 to send. No other types of HIV/STI re-testing reminders were sent to MSM during the study period. In total, 93% of MSM provided a mobile telephone number during the study period.
Study group definitions
The SMS group included MSM who underwent HIV/STI testing between 1 January 2009 and 31 August 2009 and received a SMS reminder. The comparison group included MSM who underwent HIV/STI testing in the same time period and did not receive a SMS reminder. The pre-SMS group included all MSM who underwent HIV/STI testing between 1 January 2008 and 31 August 2008 (prior to the SMS programme implementation). SMS reminders were sent 4 months, on average, after the baseline test.
Re-testing was calculated as the first of one or more HIV/STI tests in the study period and the second test within 9 months. Subsequent tests were excluded from the analysis.
MSM with HIV infection were excluded as they have routine management plans. MSM living outside of or arriving in New South Wales (NSW) in the last 12 months were excluded as they may have been travellers.
We compared the baseline characteristics of MSM in the SMS group, comparison group and pre-SMS group using a χ2 test. Characteristics found to be significantly different between the SMS group and other study groups were included in the multivariate logistic regression analysis to examine the association between re-testing in the SMS group compared to the comparison group and pre-SMS group.
The evaluation was approved by the South Eastern Sydney and Illawarra Area Health Service ethical committee.
There were 714 HIV negative MSM in the SMS group, 1084 men in the comparison group and 1753 men in the pre-SMS group.
Baseline characteristics of the SMS and comparison groups are shown in table 1. Men in the SMS group were significantly more likely to be new clients, younger, have less than 5 partners in the last 3 months, used condoms inconsistently in the last 3 months, reported ano-genital symptoms, be diagnosed with rectal or uro-genital chlamydia and have different reasons for presentation (p<0.001) (table 1). The same differences were also observed between the SMS group and pre-SMS group (data not shown).
HIV/STI re-testing was significantly higher in the SMS (64%) than the comparison group (30%; p<0.001) and the pre-SMS group (31%; p<0.001).
On univariate analysis, the OR associated with HIV/STI re-testing in the SMS group was 4.3 (95% CI 3.5 to 5.2; p<0.001) compared to the comparison group and 3.0 (95% CI 2.4 to 3.7; p<0.001) compared to the pre-SMS group.
After adjusting for differences in baseline characteristics, the OR associated with HIV/STI re-testing in the SMS group was 4.4 (95% CI 3.5 to 5.5; p<0.001) compared to the comparison group and 3.1 (95% CI 2.5 to 3.8; p<0.001) compared to the pre-SMS group.
The HIV/STI re-testing rate was more than double among MSM who received SMS reminders compared to those who did not receive a SMS. After adjusting for differences in baseline characteristics, HIV/STI re-testing was three to four times more likely in the SMS group than the comparison groups.
To our knowledge, this is the first published study to demonstrate improved HIV/STI re-testing in MSM through SMS reminders.6 7 The SMS programme had a number of favourable attributes: it allowed large numbers of messages to be sent simultaneously and automatically, reminders were direct, immediate and cheap to send and required minimal labour. Other studies have shown that SMS reminders reduce labour costs considerably compared to telephone or postal reminder systems.8 Also, as a third of MSM in Sydney attend a sexual health clinic for STI testing (Zablotska I, personal communications, 2010), this simple reminder strategy could substantially increase population-level HIV/STI re-testing rates and have an impact on the STI epidemics in MSM.3 4
Despite the SMS reminders successfully increasing HIV/STI re-testing, only 40% of MSM who were tested for HIV/STI had SMS reminders established in the 9-month period. Reasons for this may include clinicians simply forgetting, the SMS template being separate from their main clinical data entry portal and, also, some patients may have refused a SMS reminder. SSHC plans to introduce electronic prompts for clinicians to remind them to establish the reminders and encourage patients to self-select SMS reminders through computer-assisted survey.
Our evaluation study has a number of limitations. The study was not a randomised controlled trial and, therefore, could have been biased by patient and external factors influencing HIV/STI re-testing rates, including a higher motivation to re-attend within the SMS group. We attempted to overcome some biases by comparing HIV/STI re-testing rates in the SMS group to two comparison groups and adjusted for potential biases in the multivariate analysis. Also, we were unable to establish if MSM re-tested elsewhere.
Our evaluation demonstrates that in a large sexual health clinic, SMS reminders increased HIV/STI re-testing rates and if adopted more widely have great potential to reduce HIV/STI infections in the MSM community. More randomised trials in other sexual health clinics and primary care settings are needed to assess if there is a similar effect to that seen at SSHC.
Short message service (SMS) reminders increased re-testing rates for HIV/sexually transmitted infections in men who have sex with men to 64% at a sexual health clinic compared to 30% in a comparison group who did not receive any reminders.
The reminders were automated, convenient, immediate, confidential and cheap.
Future SMS programmes at the clinic will include prompts to remind clinicians to offer the reminders and maximise the uptake of the initiative.
Competing interests None declared.
Ethics approval This study was conducted with the approval of the South Eastern Sydney Area Health Service research ethics committee.
Provenance and peer review Not commissioned; externally peer reviewed.