9.2 Guidance on operations and service delivery: adherence to ART

Consolidated ARV guidelines, June 2013

9.2.2 Interventions to optimize adherence to ART (part 2)

New recommendation

Mobile phone text messages could be considered as a reminder tool for promoting adherence to ART as part of a package of adherence interventions (strong recommendation, moderate-quality evidence).


Forgetfulness and changes in daily routines are often cited as the main reason for poor adherence to ART in most settings, although the specific reasons for forgetting to take medication could vary. Reminders and communication that engage people in taking ARV drugs could be an important intervention to improve adherence through behavioural change.

The use of mobile text messages for supporting adherence and in health care delivery in general has increased as access to phone technology expands (28). Using this, however, requires adequate national regulations to protect the privacy of the people receiving text messages (29,30). Programmes may explore public-private partnerships to accelerate the scaling up of mobile phone–based interventions.

Rationale and supporting evidence

Mobile phone technology may be a convenient reminder mechanism to engage people living with HIV in care. Moreover, since mobile phones are widely used globally, using them may not require major changes to people’s daily routines. Mobile phone text messaging is also relatively inexpensive or without marginal cost, is a succinct way of sending a message without the need to talk and offers a record of messages.

The systematic review identified five randomized trials and two observational studies on mobile phone text messaging for improving adherence to ART. High-quality evidence from two randomized trials found that text messages contributed to reduced unsuppressed viral loads after one year (31,32). This finding was consistent with high-quality evidence from three randomized trials that found reduced non-adherence levels after one year (31,33,34).

Four observational studies evaluated the use of text messaging for less than one year. Very-low- quality evidence from one observational study found reduced unsuppressed viral loads after nine months (35). Although moderate-quality evidence from two randomized trials showed similar non-adherence levels after 4–6 months (36,37), very-low-quality evidence from two observational studies suggests reduced non-adherence levels after 6–9 months (35,38). Overall, the systematic review supports the use of text message reminders, although the quality of the data was variable and duration of follow-up short (up to one year).

Other patient reminders

Other patient reminder tools include alarms, phone calls, diaries and calendars and are used to send brief reminders about the timing of ARV drugs, drug dosage and appointments. The evidence does not demonstrate that these interventions support treatment adherence better than the standard of care.

The systematic review identified four randomized trials. Moderate-quality evidence from one randomized trial found that the risk of unsuppressed viral loads was similar after 18 months of follow-up using alarms versus the standard of care (19). Low-quality evidence from one randomized trial also found that rates of non-adherence and unsuppressed viral loads were similar after three months using phone calls compared with the standard of care (39). Very-low-quality evidence from one randomized trial further found that the risk of unsuppressed viral load and non-adherence was similar after 15 months using diaries relative to the standard of care (40). Finally, low-quality evidence from one randomized trial found that non-adherence was similar using calendars relative to the standard of care after one year of follow-up (41). Using these interventions requires further exploration among different populations and settings.