Text Messaging Intervention to Improve Antiretroviral Adherence among HIV-Positive Youth: E2i

The Text Messaging Intervention to Improve Antiretroviral Adherence among HIV-Positive Youth (TXTXT) is designed to keep young people, particularly young, Black, gay, bisexual, same-gender loving, and other men who have sex with men, engaged in HIV medical care, by delivering personalized, daily, interactive text messages that remind them to take their antiretroviral therapy as prescribed. Two sites implemented TXTXT as part of E2i, an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017–2021. The intervention resulted in a statistically significant improvement in engagement in HIV care.

Detroit, MI

Brooklyn, NY

Evidence-Informed Intervention
Use of technology and mobile health
Retention in HIV medical care; Viral suppression
Treat
Black gay and bisexual men; Youth ages 13 to 24
RWHAP SPNS
RWHAP-funded clinic or organization
Need Addressed

Among people with HIV who take ART, an estimated 40% miss at least one dose a month.1 Medication adherence may be more difficult for young people who may have hectic schedules or a lack of daily routine. The low cost, convenience, and pervasiveness of text messaging makes it well-suited to helping people with HIV remember to take their medications. Although TXTXT was initially designed and evaluated for young, Black MSM it can be adapted to meet the needs of local communities or other populations of focus.

“One of the E2i sites decided to enroll all of their Black MSM clients in TXTXT, regardless of their viral load or medication adherence. They did this because they know that even when current adherence is going well, life stressors can unexpectedly get in the way of remembering to take medications.”

Core Elements
Daily two-way personalized text message medication reminders

Clients received daily personalized and interactive text messages. During the initial visit with the TXTXT specialist, clients personalized and customized the SMS text messages that they received. Clients received three personalized text messages each day, timed to coincide with medication dosing. Clients chose messages from a library of options or wrote their own. 

  • Message #1 reminds the client, in their own words, to take their medication.
  • Message #2 (sent 15 minutes later) asks if they have taken their medication (personalized using the client’s own words). The client can respond “yes” or “no.”
  • Message #3 automatically responds to the client’s message with either a positive affirmation or an encouragement to take their medication.
Medication adherence counseling and education

During the initial visit with the TXTXT specialist, clients received treatment adherence counseling and education on the importance of taking medications, how and when to take them, and how to safely store their medications. It is important that the TXTXT specialist be trained on how to provide basic HIV education, treatment adherence counseling, and referrals to supportive services.

Biopsychosocial assessments

Clients met with the TXTXT specialist at the initial visit and during the three- and six-month follow-ups.  During these visits, TXTXT specialists assessed clients for viral load values, medication dosage, adherence, medication self-efficacy, substance use, mental health, and HIV-associated stigma. The TXTXT specialists used this information to make referrals to supportive services, and for program evaluation.

Outcomes

The two sites enrolled 40 Black MSM aged 22–27 years into TXTXT and collected HIV care continuum outcomes for each client at the beginning and end of the 12-month project period. There was a statistically significant improvement in engagement in HIV care, defined as having at least one HIV care visit in the last 12 months. Of the 40 enrolled clients, 100% received SMS text message reminders over 12 months and 80% of participants replied to at least one text message.

Category Information
Evaluation data
Client HIV care continuum data, medical chart review
Measures
Engagement in HIV care, prescription of ART, retention in HIV care, viral suppression

Results

  • Engagement in care increased from 78% to 97%*
  • Retention in care increased from 64% to 79% 
  • Viral suppression increased from 74% to 80%

*statistically significant

Source: Text Messaging Intervention to Improve Antiretroviral Adherence among HIV-Positive Youth (TXTXT): E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.

“According to the E2i sites, clients who chose to remain in TXTXT after the six-month follow-up visit expressed that receiving daily text reminders helped them continue to take their HIV medications on time.”

Planning & Implementation

Assess use of text messaging in the priority population. Although TXTXT was initially developed for and evaluated in young, Black gay and bisexual men, the intervention may be adapted to serve other clients with HIV. An important first step in the planning process is to assess text message use among the priority population. This will help reduce technology and uptake-related barriers prior to implementation. 

Choose a text messaging vendor. There are several vendors that provide SMS text messaging gateway services, but not all have the capacity to personalize text messages in a way that is critical to the success of TXTXT. It is also important to select a platform that is simple and intuitive for clinic staff to use, including those with limited technology knowledge. An information technology staff member can help with the vendor selection, setup, and testing process. 

Establish eligibility criteria. TXTXT is intended to support clients with newly diagnosed HIV or who are struggling to adhere to ART. Agencies may establish additional criteria based on the needs of the community and the population of focus. Additionally, agencies should adopt clear definitions of suboptimal medication adherence, such as number of missed doses per week. Definitions for engagement and retention in care are also be important to consider.

Core Staff for implementing TXTXT

  • TXTXT specialist. This may be a stand-alone role, or the role may be incorporated into existing positions such as a peer navigator, case manager, or outreach specialist, depending on the needs and structure of the implementing organization. This individual is responsible for screening, recruiting, and enrolling clients into TXTXT, providing treatment adherence education and counseling, and regularly checking in with clients to coordinate referrals to supportive services as needed. 
  • Program manager or supervisor. This individual oversees program implementation and evaluation and provides direct supervision to TXTXT staff. 
  • Information technology specialist. This individual is responsible for selecting and coordinating with a text message delivery platform in conjunction with testing and troubleshooting the platform throughout its use. 
  • Additional recommended staff. TXTXT clients should have access to a full range of supportive services offered by the implementing agency. Case managers, clinicians, and other supportive staff should work together to refer and support clients while they participate in TXTXT.

“Having the whole clinic involved in TXTXT is really important to making this intervention work—it can’t just be the specialist working alone. The team must do their best to work together to support each other and their clients.”


Two sites participated in the TXTXT E2i initiative. Learn more about their implementations below.

State University of New York (SUNY) Downstate Medical Center, Health & Education Alternatives for Teens (HEAT) Program (Brooklyn, NY)

UNIFIED-HIV Health and Beyond (Detroit, MI)

Sustainability
  • TXTXT was successful as a short-term intervention. The original intervention model ended text messages after six months, having found that six months was enough time for adherence behaviors to become ingrained and continue beyond the intervention period. 
  • TXTXT is a low-cost intervention, using automated systems to provide daily medication reminders. The costs associated with TXTXT were related to planning, recruitment, implementation, and supervision and management. See the implementation guide for more information.
  • Organizations using peers to deliver services as part of TXTXT may be able to cover all or part of the services through their state’s Medicaid program. Organizations receiving RWHAP funding may also be able to cover TXTXT services under their treatment adherence service category. TXTXT lends itself to integration into existing roles and workflows, making sustainability easier. 

“The word of mouth about TXTXT has been: ‘No one’s heard of such a thing before.’ ‘Where can we sign up?’ ‘And this is amazing!’” 

Lessons Learned
  • Both implementation sites experienced technical difficulties while using the texting platform. It is important to select a vendor with responsive and effective technical support. 
  • Selecting the right TXTXT specialist is crucial. Ideally, the candidate is a member of the community of focus, in this case a young Black gay man. It is also preferable for the TXTXT specialist to have at least some technical knowhow. 
  • One of the implementation sites struggled with recruitment into TXTXT. It is important to develop a clear recruitment strategy, including both inreach and outreach, and to allow enough time to recruit participants.
Contact
The Research Foundation for the State University of New York, HEAT Program
UNIFIED-HIV Health and Beyond

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