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Response to Kelly and Giordano

Thirumurthy, Harshaa,b; Haberer, Jessicac,d; Habyarimana, James Pe; Pop-Eleches, Cristianf,g; Bangsberg, David Rh,i

doi: 10.1097/QAD.0b013e328346715f

aDepartment of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

bThe World Bank, Washington, District of Columbia, USA

cDepartment of Medicine, Massachusetts General Hospital, USA

dMassachusetts General Hospital Center for Global Health, Boston, Massachusetts, USA

ePublic Policy Institute, Georgetown University, Washington, District of Columbia, USA

fSchool of International and Public Affairs, USA

gDepartment of Economics, Columbia University, New York, New York, USA

hRagon Institute of MGH, MIT and Harvard, Boston, Massachusetts, USA

iMbarara University of Science and Technology, Mbarara, Uganda.

Received 28 February, 2011

Accepted 4 March, 2011

Correspondence to Harsha Thirumurthy, PhD, The World Bank, 1818 H Street NW, Washington, DC 20433, USA. E-mail:,

We agree with Kelly and Giordano [1] that social support is critical to supporting adherence to antiretroviral therapy (ART), particularly in resource-limited settings (RLSs). The senior investigator of our group was among the first to explain how individuals taking ART in RLS utilize social support to overcome structural and economic barriers to adherence and also how HIV stigma prevents individuals from accessing social support to sustain adherence [2,3]. Although the lack of an effect for the longer, more supportive text messages in our study may indicate that those messages did not provide additional social support (over and above what is provided by the short text messages as well as the standard of care), the overall increase in Medication Event Monitoring System adherence among study participants receiving weekly text messages may well be because those messages provided some social support [4]. The messages may have also facilitated adherence by serving as a periodic reminder to take medications.

Directly observed therapy (DOT) has been associated with improved adherence and survival in many settings and clearly social support through an accompagnateur or peer health worker contributes to this benefit. However, DOT may be unnecessary and, in some cases, could cause social harm or place unnecessary burdens on individuals and healthcare systems [5]. Some cautioned against the ART roll-out at all unless we could make sure that every dose for people living in extreme poverty was directly observed to prevent antiretroviral anarchy and drug resistance [6]. The evidence, however, is that most people in RLS achieve superb adherence even without daily contact from a peer health worker [7].

As ART roll-out continues and concerns about suboptimal adherence arise, wireless technology is an inexpensive and highly scalable method of providing reminders and regular contact to individuals taking ART [8,9]. Although two randomized controlled trials have now demonstrated that wireless communication can improve adherence and viral suppression, the optimal content, frequency, and type of communication (such as one-way or two-way text messaging) remain to be determined [4,10]. Coupled with real-time adherence monitoring, wireless communication also has the potential to strategically direct adherence support specifically to those individuals when and where they miss doses prior to virologic treatment failure [11]. Moreover, wireless communication can be used as a triage-style support system in which text messages are sent both as reminders for all or most individuals in a given population and as a means for connecting individuals with community health workers when needed [10]. Many, if not most, of the settings for which this paper is relevant do not have the economic, human, or organizational resources for high quality community health worker programs, and wireless communication offers options for effective and efficient resource allocation.

The ART roll-out in RLS is relatively new and we still have much to learn. Many were convinced that adherence success was unlikely, if not impossible. These concerns delayed the ART roll-out that has since saved millions of lives. As we test innovative ways to provide adherence support, we recommend open and innovative approaches to enhancing social support and tackling other barriers to adherence. All options, including wireless communication, should be on the table.

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© 2011 Lippincott Williams & Wilkins, Inc.