New research shows that interactive, mobile technology safely improves male circumcision care quality at lower cost than standard post-operative visits.

Voluntary medical male circumcision (MC) safely reduces the risk of female-to-male HIV transmission by up to 60%. Few men have any post-operative MC complication. However, current practice in Zimbabwe and throughout most of sub-Saharan Africa requires MC patients to return for multiple, in-person post-operative visits. With low complication rates, and severe healthcare worker shortages, these required visits are a burden for providers and patients – threatening achievement of critical HIV prevention targets.  A two-way texting model studied by University of Washington researchers in Zimbabwe offers a new way to address this barrier by reducing provider workload while also safeguarding patient safety.

“These visits can be a barrier to male circumcision uptake and expansion in countries with severe healthcare worker shortages, as well as negatively impacting patients who needlessly pay for transport, miss work, and wait for unnecessary reviews,” said Caryl Feldacker, International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington.

The study included 721 MC patients in two locations in urban Zimbabwe. In the study, patients communicated directly with a healthcare worker through interactive text messaging for the critical 13 days post-MC, rather than returning for required in-person visits. By giving men the option to heal safely at home, or return to care when desired or if complications arise, the method dramatically reduced in-person visits by 85%. Texting also reduced follow-up costs by about one-third while improving the quality of care.

As compared to routine in-person care, the study  yielded twice the number of reported complications. “This increased identification and reporting is a positive result that is likely attributable to improved counseling and men’s engagement in care. Through texting, men were empowered to observe their healing and report potential issues promptly, before they worsened” said Feldacker.

Currently, most text-based healthcare efforts blast pre-defined messages to many people simultaneously, removing patients’ ability to communicate back with healthcare workers.  In contrast, two-way texting between providers and patients provides interactive care and the short timeframe heightened participation: in the study, 93% of men responded to texts. Both providers and clients reported confidence in the texting option, feeling safe, and highly recommending it for scale.

“With the current system, Zimbabwe could perform millions of unnecessary follow-up visits over the coming 5 years. The workload burden for healthcare workers and time lost for patients who are healing without complication is a significant burden for healthcare workers and clients, alike,” said Feldacker, “Potential gains in efficiency and reduced costs through using two-way messaging are large.”

With funding from Centers for Disease Control and Prevention, and partnership with Society for Family Health, the model will soon be tested in urban South Africa. The new, field-based research will further test two-way texting in a different geographical and patient context to better inform the model for adaptation and widespread scale-up.

Feldacker added that “while our findings are grounded in studies on male circumcision, our results are largely attributable to the methods rather than to a specific disease or condition.  With minimal adaptation, two-way texting could streamline other post-operative care contexts or be re-configured for other similarly acute, episodic conditions where continuity of care within a short period is critical for patients, such as short-course TB treatment, post-operative healing, post-natal care or early childhood illnesses (diarrhea, pneumonia, malaria), laying the foundation for generalizing to other diseases and contexts.”

For more on the study, see the paper pre-published in the JAIDS Journal of Acquired Immune Deficiency Syndromes:

Reducing provider workload while preserving patient safety: a randomized control trial using 2-way texting for post-operative follow-up in Zimbabwe’s voluntary medical male circumcision program

The study was led by Caryl Feldacker and  co-investigators are Vernon Murenje (International Training and Education Center for Health (I-TECH), Harare, Zimbabwe); Mufuta Tshimanga (Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe); Scott Barnhart, Isaac Holeman, and Joseph B. Babigumira (Department of Global Health, University of Washington); Sinokuthemba Xaba (Ministry of Health and Child Care, Harare, Zimbabwe); and, technology partner, Medic Mobile (Nairobi, Kenya).

The Zimbabwe 2wT study was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW010583.