Enhancing retention on antiretroviral therapy at 6 months using interactive two-way texting: findings from a randomized controlled trial in Lilongwe, Malawi

Antiretroviral therapy (ART) retention is critical for achieving viral load suppression (VLS) among people living with HIV (PLHIV). Retention remains challenging in high-prevalence settings like Malawi. Short messaging service (SMS) interventions, particularly hybrid two-way texting (2wT), show promise in improving ART retention. We conducted a randomized control trial (RCT) at Lighthouse Trust in Lilongwe, Malawi, to evaluate the effectiveness of a hybrid 2wT system to improve early retention, appointment attendance, and VLS among new ART initiates within six months of ART initiation. After receiving routine ART initiation counseling, 452 new ART clients with mobile phones were randomized to 2wT or standard of care (SoC). The 2wT group received weekly motivational messages, appointment reminders, and had access to an open-ended SMS communication channel with healthcare workers. The SoC group received peer support at clinic visits and visit reminder phone calls. All participants were traced if they missed a clinic appointment by 14 days. Study outcomes included: retention in care (alive on ART), appointment adherence (attending within 2 days), and VLS (< 200 copies) at six months. Data from electronic medical records were analyzed using Chi-square tests and multivariable logistic regression. At six months post ART initiation, the 2wT group demonstrated significantly higher appointment adherence (59.6% vs. 46.8%, p = 0.008) and VLS (97.5% vs. 93.2%, p=0.007) compared to SoC. Among both 2wT and SoC, 91% remained in care (p=0.68). Although retention among 2wT and SoC at 6 months did not differ, 2wT clients were more likely to attend clinic visits on time and reach VLS in the first six months. The low-tech 2wT approach offers a scalable, appropriate intervention to enhance visit compliance and VLS among PLHIV with mobile phones. Implementing 2wT study over a longer time frame and among more clients would likely provide evidence for scaling 2wT more broadly.