# Mobile phone infrastructure provides evidence of improved HIV viral load monitoring in Malawi

## TL;DR

A mobile phone app in Malawi significantly reduced the time it takes to get HIV test results, improving care and saving money.

## Contribution

The implementation of a digital SMS/USSD platform for returning HIV viral load results, reducing turnaround time by over 60%.

## Key findings

- Clients received results in 128 days before and 48.5 days after using the digital system, a 62.4% improvement.
- The digital results open rate was 60%, and nearly all users wanted the application to continue.
- National scaling of the system could save $1.8-6.7 million USD annually.

## Abstract

Malawi has 991,600 people living with HIV and has expanded access to annual HIV viral load testing to enhance care quality for clients. However, significant delays persist in returning viral load (VL) results back to facilities and to clients. To address this, we implemented a digital VL results return (VLRR) application, using existing mobile phone platforms to expedite results return to clients and healthcare providers (HCPs).VLRR is a digital SMS/USSD platform leveraging mobile phones to reduce turnaround time (TAT) and improve access to VL results. To evaluate the VLRR intervention, we: (1) estimated the TAT for digital results return, (2) calculated open rates of digital results, (3) conducted a mixed methods evaluation with VLRR users, and (4) estimated the potential cost savings from avoiding unnecessary sample redraws. From April 2022 to June 2024, HCPs registered 4,067 clients. For each client, TAT was calculated separately for the periods before and after enrollment in the VLRR system. On average during this period, clients received results in 128 days before VLRR enrollment and 48.5 days after enrollment, reflecting a 62.4% improvement. By July 2023, VLRR clients and HCPs received results in an average of 30 and 38 days. The overall open rate for digital results (opened by either a client or HCP) was 60% and nearly 100% of clients and HCPs indicated they wanted to the application to continue. Lastly, if VLRR were scaled nationally, it has the potential cost savings of $1.8-6.7 million USD.VLRR is effective in reducing TAT and improving access to VL results. To enhance uptake and achieve national scale, VLRR can be integrated into Malawi’s existing EMR systems, further reducing TAT and enabling HCPs to deliver higher quality care and improve clinical outcomes.

The digital VLRR application uses SMS and USSD on a mobile phone to deliver viral load test results back to clients and healthcare providers for those clients who opt into receive their results digitally. A major challenge for HIV positive clients in low-income settings is monitoring their care properly due to long turnaround times from blood sample to receiving their paper test results back at a facility. The option to receive results digitally reduces the turnaround time of results by more than 60% because it cuts out the time it takes to deliver paper results from lab to clinic and clinic to client. This has both positive clinical and monetary implications for clients because they can have more agency to monitor their care in a timely manner.