Dr. Caryl Feldacker
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A new five-year research project will study two-way texting as a means of communication between healthcare providers and male circumcision (MC) patients in South Africa. It will build on previous research conducted in Zimbabwe.

Caryl Feldacker is the Principal Investigator on this RO1, which will support research through 2025. The multi-stage implementation science study is based out of the International Training and Education Center for Health (I-TECH), and will be implemented with Dr. Geoffrey Setswe, PI for South Africa partner, Aurum Institute, and with technology partner, Medic Mobile.

“Previous research shows that healthcare workers waste a lot of time and money reviewing MC clients without complications,” Feldacker said. “So, in partnership with Medic Mobile, we developed a two-way texting (2wT) system to identify and refer men with potential medical issues to in-person care while allowing the vast majority to opt-out of routine post-operative visits.”

Programs providing voluntary medical male circumcision (MC) in sub-Saharan Africa are struggling to meet the annual goal of 5 million MCs. However, chronic human and financial resource shortages threaten achievement of MC targets, reducing impact of this effective HIV prevention intervention. Although MC is safe with an adverse event (AE) rate of less than 2% , global MC guidelines require one or more in-person, post-operative visits within 14 days of MC for timely AE identification. With low AE rates, overstretched clinic staff likely waste invaluable resources conducting unnecessary routine reviews for MC clients without complications while men healing well needlessly pay for transport, miss work, and wait for reviews, discouraging MC uptake.

With this background, Dr. Feldacker’s prior randomized controlled trial (RCT) in Zimbabwe tested whether 2wT between patients and providers during the critical 13-day post-operative period (instead of routine in-person reviews) could ensure patient safety while reducing provider workload. 2wT safely reduced client visits by 85%, increased AE identification, and cut follow-up costs, suggesting that 2wT could make a dramatic difference in MC programs operating at scale. Plus, providers and patients found the 2wT follow-up approach highly usable and acceptable. “These daily text exchanges really empowered men to be partners in their healing process, creating a win-win for providers and patients.”

Whether the successes of 2wT within the RCT context in Zimbabwe can be replicated and scaled in routine program settings in South Africa is the question the new NIH-funded study seeks to answer. Like in Zimbabwe, the combination of high MC-volume urban clinics and challenging remote service delivery threaten MC program quality and scale-up in South Africa. In urban MC clinics, post-operative reviews cause service delivery bottlenecks while multi-hour trips to conduct follow-ups can slow productivity and raise MC costs in rural areas. Feldacker and her team think that 2wT could ultimately provide continuity of care for over 500,000 MC clients each year, reducing in person visits without compromising safety. Demonstrating that 2wT works to reduce provider workload and preserve patient safety in these areas – areas already severely constrained from a health services perspective – “would be a significant advancement for MC care quality and efficiency in a time of decreasing global funding,” Dr. Feldacker says.

“We want to take the initial lessons learned on 2wT safety and workload from Zimbabwe and conduct rigorous research on the implementation and optimization of 2wT in South Africa,” noted Feldacker. “We want to create the evidence needed to bring this intervention to scale and make a positive difference in the quality of MC programs.” In the South Africa study, the 2wT research will be locally-led, “hopefully strengthening and speeding efforts to move from research to routine practice.”

Outside of the 2wT technology itself, the research is unique for several other reasons. First, after an initial RCT to provide strong evidence for safety and workload reductions of 2wT, Drs. Feldacker and Setswe will employ robust implementation science methods to study the implementation, adaptation, and maintenance of 2wT, identifying critical local barriers and facilitators that affect the transition from research to routine practice. Second, costing will be a central component of both the RCT and scale-up phases, quantifying the potential cost savings of 2wT over in-person follow-up from the payer (Aurum or Ministry of Health) perspective. Lastly, the open-source software used for 2wT will be optimized for the routine MC program and patient context in South Africa; transfer of the 2wT technology to local ownership is a critical study outcome.

“Ultimately, we want to establish the local evidence-base and provide timely information to support the further adaptation, adoption, and spread of 2wT for MC in RSA and beyond,” Dr. Feldacker said. “This would increase public health impact – which is the goal of global health practice.”

In addition to Dr. Feldacker, DGH faculty Dr. Scott Barnhart (Professor), Dr. Ruanne Barnabas (Associate Professor), Dr. Kenneth Gimbel-Sherr (Professor), Dr. Isaac Holeman (Clinical Assistant Professor) and Dr. Bryan Weiner (Professor) are also included as personnel on this project, which will begin in July 2020.

The research will be funded by a $2.5 million grant from the National Institutes for Health’s (NIH) National Institute of Nursing Research. The full title of the grant is “Expanding and Scaling Two-Way Texting (2wT) to Reduce Unnecessary Follow-Up and Improve Adverse Event Identification Among Voluntary Medical Male Circumcision (VMMC) Clients in the Republic of South Africa”.