Telephone delivered interventions for preventing HIV infection in HIV-negative persons

  • Review
  • Intervention

Authors

  • Michelle HMMT van-Velthoven,

    1. Imperial College London, Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, London, UK
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  • Lorainne Tudor Car,

    1. University of Split, Split, Croatia
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  • Sarah Gentry,

    1. Peninsula College of Medicine and Dentistry, Exeter, UK
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  • Josip Car

    Corresponding author
    1. Imperial College London, Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, London, UK
    2. University of Ljubljana, Department of Family Medicine, Faculty of Medicine, Ljubljana, Slovenia
    • Josip Car, Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, St. Dunstans Road, Hammersmith, London, W6 8RP, UK. josip.car@imperial.ac.uk.

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Abstract

Background

This is one of the three Cochrane reviews that examine the role of the telephone in HIV/AIDS services. Although HIV infection can be prevented, still a large number of new infections occur. More effective HIV prevention interventions are needed to reduce the number of people newly infected with HIV. Phone calls can be used to potentially more effectively deliver HIV prevention interventions. They have the potential to save time, reduce costs and facilitate easier access.

Objectives

To assess the effectiveness of voice landline and mobile telephone delivered HIV prevention interventions in HIV-negative persons.

Search methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed Central, EMBASE, PsycINFO, Web of Science, Cumulative Index to Nursing & Allied Health, the World Health Organization's Global Health Library and Current Controlled Trials from 1980 to June 2011. We searched the following grey literature sources: Dissertation Abstracts International and the Centre for Agricultural Bioscience International Direct Global Health database, the System for Information on Grey Literature Europe, The Healthcare Management Information Consortium, Google Scholar, Conference on Retroviruses and Opportunistic Infections database, International AIDS Society conference database, AIDS Education Global Information System and reference lists of articles.

Selection criteria

Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before and after studies, and interrupted time series studies comparing the effectiveness of delivering HIV prevention by phone calls to usual care in HIV-negative people regardless of their demographic characteristics and in all settings.

Data collection and analysis

Two reviewers independently searched databases, screened citations, assessed study quality and extracted data. A third reviewer resolved any disagreement. Primary outcomes were knowledge about the causes and consequences of HIV/AIDS, change in behaviour, healthcare uptake and clinical outcomes. Secondary outcomes were users' and providers' views on the intervention, economic outcomes and adverse outcomes.

Main results

Out of 14,717 citations, only one study met the inclusion criteria. The included RCT recruited women and girl children who received post-exposure prophylaxis (PEP) after rape from sexual assault services in South Africa between August 2007 and May 2008.

Participants (n (number) =274) were randomised into a telephone support (n=136) and control (n=138) group. Control group participants received usual care (an interactive information session) from the sexual assault service during the 28 days in which they had to take PEP, with no further contact from the study staff. Telephone support group participants received standard care and phone calls from a counsellor throughout the 28 days when they had to take PEP.

Overall, adherence to PEP was not significantly (P=0.13) different between the intervention (38.2%) and control (31.9 %) groups. Also, the proportion of participants who read a pamphlet, did not return to collect medication or with a depression were not significantly different between the intervention and control groups (P=0.006, P=0.42, P=0.72 respectively). The proportion of participants who used a diary was significantly (P=0.001) higher in the intervention group (78.8%) versus the control group (69.9%). The study authors reported that there were no recorded adverse events. The RCT did not provide information about participants’ and providers’ evaluation outcomes, or economic outcomes. The study had a moderate risk of bias.

Authors' conclusions

We found only one RCT, with a moderate risk of bias, which showed that providing PEP support by phone calls did not result in higher adherence to PEP. However, the RCT was conducted in an upper-middle-income country with high HIV prevalence, on a high-risk population and the applicability of its results on other settings and contexts is unclear. There is a need for robust evidence from various settings on the effectiveness of using phone calls for providing PEP support and for other HIV prevention interventions.

Résumé scientifique

Interventions réalisées par téléphone pour prévenir l'infection par le VIH chez les personnes séronégatives

Contexte

La présente revue fait partie de l'une des trois revues Cochrane qui examinent le rôle du téléphone dans les services dédiés au VIH/SIDA. Bien qu'il soit possible de prévenir l'infection par le VIH, un grand nombre de nouvelles infections se produisent toujours. Des interventions de prévention du VIH plus efficaces sont nécessaires pour réduire le nombre de personnes nouvellement infectées par le VIH. Les appels téléphoniques peuvent être utilisés pour réaliser des interventions de prévention du VIH potentiellement plus efficaces. Ils permettent de gagner du temps, de réduire les coûts et de faciliter l'accès aux soins.

Objectifs

Évaluer l'efficacité des interventions de prévention du VIH réalisées par téléphone fixe et portable chez les personnes séronégatives.

Stratégie de recherche documentaire

Nous avons effectué une recherche dans le registre Cochrane des essais contrôlés - Cochrane Central Register of Controlled Trials, MEDLINE, PubMed Central, EMBASE, PsycINFO, Web of Science, Cumulative Index to Nursing & Allied Health, the World Health Organization's Global Health Library et Current Controlled Trials de 1980 à juin 2011. Nous avons effectué une recherche dans les sources de la littérature grise suivantes : Dissertation Abstracts International and the Centre for Agricultural Bioscience International Direct Global Health database, the System for Information on Grey Literature Europe, The Healthcare Management Information Consortium, Google Scholar, Conference on Retroviruses and Opportunistic Infections database, International AIDS Society conference database, AIDS Education Global Information System et les listes bibliographiques d'articles.

Critères de sélection

Essais contrôlés randomisés (ECR), essais contrôlés quasi-randomisés, études contrôlées avant et après, et études de séries temporelles interrompues comparant l'efficacité des interventions de prévention du VIH par appels téléphoniques aux soins habituels chez les personnes séronégatives quelles que soient leurs caractéristiques démographiques et dans tous les cadres.

Recueil et analyse des données

Deux relecteurs ont effectué des recherches dans les bases de données, passé au crible les références bibliographiques, évalué la qualité méthodologique des études et extrait des données de manière indépendante. Un troisième relecteur a permis de résoudre tout désaccord. Les principaux résultats portaient sur les connaissances sur les causes et les conséquences du VIH/SIDA, le changement du comportement, le recours aux soins de santé et les résultats cliniques. Les résultats secondaires portaient sur la perception des utilisateurs et des prestataires sur l'intervention, les résultats économiques et les résultats négatifs.

Résultats principaux

Sur 14 717 références bibliographiques, seule une étude remplissait les critères d'inclusion. L'ECR inclus portait sur des femmes et des filles recevant une prophylaxie post-exposition (PPE) suite à un viol dans des services aux victimes d'agression sexuelle en Afrique du Sud entre août 2007 et mai 2008.

Les participantes (n (nombre) = 274) étaient randomisées dans un groupe recevant un soutien téléphonique (n = 136) et un groupe témoin (n = 138). Les participantes du groupe témoin recevaient les soins habituels (une séance d'information interactive) de la part des services aux victimes d'agression sexuelle pendant les 28 jours durant lesquels elles devaient prendre la PPE, sans autre contact avec le personnel de l'étude. Les participantes du groupe recevant le soutien par téléphone recevaient les soins standard et des appels téléphoniques de la part d'un conseiller pendant les 28 jours durant lesquels elles devaient prendre la PPE.

Globalement, l'observance de la PPE n'était pas significativement (P = 0,13) différente entre les groupes recevant l'intervention (38,2 %) et témoin (31,9 %). Par ailleurs, la proportion de participantes qui lisaient une brochure, qui ne retournaient pas prendre leur traitement ou qui souffraient de dépression n'était pas significativement différente entre les groupes recevant l'intervention et témoin (P = 0,006, P = 0,42, P = 0,72 respectivement). La proportion de participantes qui utilisaient un carnet de traitement était significativement plus élevée (P = 0,001) dans le groupe recevant l'intervention (78,8 %) que dans le groupe témoin (69,9 %). Les auteurs de l'étude ont indiqué qu'aucun événement indésirable n'avait été signalé. L'ECR ne fournissait pas d'informations sur les résultats relatifs à l'évaluation par les participantes et les prestataires, ou les résultats économiques. L'étude présentait un risque de biais modéré.

Conclusions des auteurs

Nous n'avons trouvé qu'un seul ECR, présentant un risque de biais modéré, qui indiquait que l'apport de soutien à la PPE à l'aide d'appels téléphoniques ne se traduisait pas par une meilleure observance de la PPE. Cependant, l'ECR a été réalisé dans un pays à revenu moyen supérieur où la prévalence du VIH est élevée, sur une population à haut risque, et la généralisabilité de ses résultats à d'autres cadres et contextes est incertaine. Il est nécessaire d'obtenir des données solides dans divers cadres sur l'efficacité des appels téléphoniques pour fournir un soutien à la PPE et pour d'autres interventions de prévention du VIH.

Plain language summary

The use of the telephone for the delivery of HIV prevention interventions

Although HIV infection can be prevented, every year a large number of people become newly infected with HIV. Interventions that teach people about HIV can change their attitudes and behaviour, and thereby prevent new HIV infections. These interventions often require people to go to health facilities, but barriers such as a lack of money, transport problems or stigma attached to HIV-positive serostatus can limit people's access to HIV prevention interventions. Landline or mobile phones calls can be used to potentially more effectively deliver HIV prevention interventions, because they may save people's time, reduce costs and give people easier access to healthcare.

The aim of this review was to assess the effectiveness HIV prevention interventions delivered by phone calls compared to the standard way of delivering care. After a comprehensive search of various scientific databases and other resources, we found only one relevant study. This study was done in sexual assault services in South Africa. Study participants were women and girls who were given medication to prevent HIV infection (so called 'post-exposure prophylaxis' or 'PEP') after they had been raped. The participants were divided into two groups: one group of participants only received standard care and participants in the other group were given standard care and support via telephone calls to help them take their HIV prevention medication. Overall, only about one third of the participants took their HIV prevention medication for 28 days. The participants who received the phone calls were not more likely to take their medication than participants who only received standard care. Also, the phone calls did not decrease the number of participants with depression and did not increase the number of participants who read an information pamphlet or returned to collect HIV prevention medication. Only a higher percentage of participants who received the calls used a medication diary compared to the participants who did not receive the calls. No harmful effects of this intervention were reported. We could not find any information about other relevant outcomes, such as participants’ and healthcare providers’ satisfaction with the telephone intervention or costs. We urgently need more studies conducted in various settings comparing the effectiveness of the phone calls to other ways of delivering HIV prevention interventions to prevent new HIV infections.

Résumé simplifié

Utilisation du téléphone pour réaliser des interventions de prévention du VIH

Bien qu'il soit possible de prévenir l'infection par le VIH, chaque année un grand nombre de personnes deviennent nouvellement séropositives. Les interventions qui informent le public sur le VIH peuvent modifier leurs attitudes et leur comportement, et ainsi prévenir de nouvelles infections par le VIH. Ces interventions nécessitent souvent que les personnes se rendent dans des établissements de santé, mais les obstacles tels que le manque d'argent, les problèmes de transport ou la stigmatisation autour de la séropositivité par le VIH peuvent limiter l'accès du public aux interventions de prévention du VIH. Les appels sur des lignes fixes ou mobiles peuvent être utilisés pour réaliser des interventions de prévention du VIH potentiellement plus efficaces, parce qu'ils peuvent faire gagner du temps aux personnes, réduire les coûts et faciliter l'accès aux soins de santé.

L'objectif de la présente revue était d'évaluer l’efficacité des interventions de prévention du VIH réalisées par appels téléphoniques en comparaison avec le moyen standard de fournir des soins. Après avoir effectué des recherches exhaustives dans plusieurs bases de données scientifiques et d'autres ressources, nous n'avons trouvé qu'une seule étude pertinente. Cette étude a été menée dans des services aux victimes d'agression sexuelle en Afrique du Sud. Les participants à l'étude étaient des femmes et des filles recevant un traitement destiné à prévenir l'infection par le VIH (dit « prophylaxie post-exposition » ou « PPE ») suite à un viol. Les participantes étaient divisées en deux groupes : un groupe de participantes ne recevaient que les soins standard et les participantes de l'autre groupe recevaient les soins standard et un soutien par des appels téléphoniques ayant pour but de les aider à prendre leur traitement de prévention contre le VIH. Globalement, seules environ un tiers des participantes prenaient leur traitement de prévention contre le VIH pendant 28 jours. Les participantes qui recevaient les appels téléphoniques n'étaient pas davantage susceptibles de prendre leur traitement que les participantes qui ne recevaient que les soins standard. Par ailleurs, les appels téléphoniques ne réduisaient pas le nombre de participantes souffrant de dépression et n'augmentaient pas le nombre de participantes qui lisaient une brochure d'information ou qui retournaient prendre leur traitement de prévention contre le VIH. On peut seulement noter qu'un pourcentage plus élevé de participantes qui recevaient les appels utilisaient un carnet de traitement par rapport aux participantes ne recevant pas les appels. Aucun effet nocif de cette intervention n'a été signalé. Nous n'avons pas pu trouver d'informations sur les autres résultats pertinents, tels que la satisfaction des participantes et des prestataires de soins de santé quant à l'intervention téléphonique et aux coûts. Nous avons un besoin urgent d'études supplémentaires réalisées dans divers cadres, comparant l'efficacité des appels téléphoniques aux autres moyens de réaliser des interventions de prévention du VIH pour prévenir les nouvelles infections par le VIH.

Notes de traduction

Traduit par: French Cochrane Centre 3rd June, 2013
Traduction financée par: Pour la France : Minist�re de la Sant�. Pour le Canada : Instituts de recherche en sant� du Canada, minist�re de la Sant� du Qu�bec, Fonds de recherche de Qu�bec-Sant� et Institut national d'excellence en sant� et en services sociaux.

Background

This review is one of three Cochrane reviews that examine the role of the telephone in HIV/AIDS services. The other two reviews are entitled 'Telephone delivered interventions for reducing morbidity and mortality in people with HIV infection' (Gentry 2013) and 'Telephone communication of HIV testing results for improving knowledge of HIV infection status' (Tudor Car 2013). The titles emerged from a preliminary overview of the literature (van Velthoven 2012). While the preliminary systematic review focused on people living with HIV, people recently being tested for HIV, and people at risk for HIV, it was felt that the population of interest was too broadly defined as those three groups are not necessarily the same groups of people. Therefore, we decided to conduct three reviews with distinct populations by which we aimed to make results more cohesive and valuable. The reviews will provide a comprehensive synthesis of the evidence of the use of voice telephone interventions in HIV/AIDS services.

Description of the condition

In 2010, more than 34 million people were living with HIV (WHO 2011). The estimated number of newly infected people with HIV in one year decreased by 21% from 3.4 million [range 3.1 million–3.6 million] in 1997 (the year when the number of people newly infected with HIV peaked) to 2.7 million [2.4 million–2.9 million] in 2010 (WHO 2011). Despite this decline, the number of newly infected people is large, and some regions and countries, such as North Africa and the Middle East, have seen rises in their annual number of people newly infected with HIV (WHO 2011). Strenghtening primary prevention of HIV infection is essential for controlling the pandemic.

Primary prevention includes implementation of a wide range of interventions. Effective biomedical HIV prevention interventions that can reduce the risk of HIV infection include condom use, prevention of-mother-to-child transmission (PMTCT) of HIV interventions, male circumcision, pre-exposure prophylaxis (PrEP) in high-risk populations (Okwundu 2012) and post-exposure prophylaxis (PEP) (Young 2007). According to the World Health Organization (WHO) HIV prevention in the health sector should include interventions aimed at changing individuals’ behaviour and addressing cultural norms, social attitudes and behaviour that may increase people’s vulnerability to HIV infection" (WHO 2010a). Successful behavioural HIV prevention interventions include those focussed on reducing sexual transmission of HIV among high-risk populations (Johnson 2008; Wariki 2012).

Description of the intervention

Several behavioral interventions to reduce HIV-related sexual risk behaviour in different populations have been developed and evaluated in recent years (Noar 2008). Technology-based interventions, such as telephone calls, can be used to deliver HIV prevention interventions. Helplines have, both in developed (Bos 2004) and developing countries (UNAIDS 2002), been used for addressing HIV/AIDS related questions. Studies have evaluated using the telephone for delivery of HIV prevention behavioural interventions. For example, a cognitive-behavioral group counselling intervention delivered to men who have sex with men by telephone showed effectiveness in reducing risk of HIV transmission over the year following the intervention (Roffman 1997a). Motivational enhancement therapy delivered by telephone to men who have sex with men did not increase readiness to adopt safer sex behaviours, but increased intentions to use condoms in the intervention group compared to the control group (Picciano 2001).

How the intervention might work

HIV prevention behavioural interventions can enhance knowledge, understanding and self-efficacy of people, thereby changing emotions and behaviours (Fishbein 2000). This could change the uptake of healthcare (e.g. seeking sexually transmitted infection testing including HIV testing) and encourage people to adopt healthier behaviours (e.g. reduce risky behavior), which could prevent HIV infection and ultimately reduce infection rates.

Telephone compared to face-to-face delivery of interventions can possibly reduce costs, is faster and may be more convenient for users (Car 2003). Using telephones can also deal with issues such as stigma and psychological factors. People can decide whether to disclose their identity and avoid being intimidated by face-to-face contact, which might add to a degree of emotional safety. Transport and infrastructure barriers can be overcome as people do not have to travel to their healthcare provider. Healthcare workers could be able to deal with more patients in a given time (Bunn 2005). However, healthcare workers may be concerned about medical risks (Car 2003). Moreover, approaches to minimize the problem of confidentiality in telephone consultations need to be considered (Sokol 2006).

HIV prevention interventions delivered by phone calls are most feasible for specifically targeted populations, such as sex workers, men who have sex with men or adolescents and young adults (Djossa 2011). HIV-negative individuals could be offered a telephone intervention when they visit healthcare or community services, or they can be reached via other channels including radio, television or the internet.

Mobile phones have become ubiquitous, with an estimated 6 billion users globally and approximately 3.8 billion users in developing countries at the end of 2011 (ITU-D 2011). Mobile phone messaging is very popular and shows promise as a simple and cost-effective mode of communication for HIV (Noar 2012; van Velthoven 2013), for example for improving antiretroviral medication adherence in Sub-Saharan Africa (Horvath 2012). Mobile phone messaging has the advantage of easy delivery of information to a large number of people. However, the use of mobile phone messaging for HIV prevention may be limited by illiteracy and the short space available in a message. Mobile phone calling can overcome these barriers and be used to deliver HIV prevention interventions.Toll-free numbers offer a solution for the potential costs of calling that many people living in low- and middle-income countries may not be able to afford.

Why it is important to do this review

There is a large gap between theoretically and empirically proven effects of the use of information and communication technology for healthcare, including telephone-delivered interventions (Black 2011). The evidence about the feasibility and effectiveness of the telephone for HIV prevention is inconclusive (Bunn 2005; van Velthoven 2012). Little is known about the quality of the advice given by telephone in comparison with face-to-face consulting (Car 2004). Safe and effective telephone interventions require good training of healthcare personnel (Higgs 2003). The key approaches for healthcare workers have to be defined and the skills required of them for efficient practice also need to be ascertained. Considering the potential that telephone interventions can offer to improve HIV/AIDS prevention, it is important to assess the effectiveness. This review synthesized evidence from studies investigating interventions delivered by telephone calls for HIV prevention in HIV-negative persons and will inform current and new initiatives to focus on the best interventions. We aimed to contribute to an evidence base for the effective and safe use of this intervention.

Objectives

Primary objective

To assess the effectiveness of voice landline and mobile telephone delivered interventions for preventing HIV infection in HIV-negative persons.

Secondary objective

To assess user and provider evaluation, costs and adverse events associated with telephone delivered interventions for HIV-negative persons.

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs), quasi-randomised controlled trials (qRCTs), controlled before and after studies (CBAs) with at least two intervention and two control groups and interrupted time series studies (ITS) studies with at least three time points before and after the intervention. We considered qRCTs, CBAs and ITS studies, because our preliminary search showed that there was a limited number of RCTs. The other study types can provide additional evidence; for example including ITS studies can be valuable in assessing the ongoing qualities of a new technology requiring an introduction period. We also planned to evaluate relevant trials with economic evaluations.

Types of participants

People not infected with HIV who receive telephone delivered interventions for HIV prevention, regardless of any demographic characteristic (e.g. age, gender, education, marital status, employment status, income) in all settings (e.g. community settings, primary care settings, outpatient settings, hospital settings).

Types of interventions

We considered studies using a telephone or mobile phone for delivering the intervention. The comparison group had to receive a face-to-face intervention or usual care. Outcome measures for people who received interventions delivered by telephone were compared to outcomes of people assigned to the usual care or control group. We only included studies where telephone delivered intervention happened between the healthcare provider and the HIV-negative persons. Studies using mobile phones for calling were included.

Studies using mobile phone messaging (SMS, MMS) were excluded as another Cochrane review is focusing on mobile phone messaging for preventive healthcare (Vodopivec-Jamsek 2012). Studies using automated calls were excluded as another Cochrane review is evaluating automated telephone communication for preventive healthcare (Cash-Gibson 2012). Studies using telephones only as a part of their intervention were excluded when the telephone component could not be separately evaluated. Studies in which a telephone voice intervention was used in combination with mobile phone text messaging were excluded when the voice component could not be evaluated separately. Studies which focused on any telephone delivered intervention for HIV prevention, not only restricted to an intervention specific to HIV prevention, were excluded when the effectiveness of the telephone intervention specific for HIV prevention could not be separately evaluated.

Types of outcome measures

We included studies if they reported on at least one of the following primary or secondary outcomes.

Primary outcomes

To evaluate the effectiveness of telephone delivered interventions, we were interested in whether those interventions can improve knowledge, change behaviour, enhance healthcare uptake and ultimately change clinical outcomes. We searched for the following outcomes:

  1. Knowledge about the causes and consequences of HIV/AIDS

  2. Behaviour outcomes (e.g. risky substance use behaviour, risky sexual behaviour (e.g. self-reported abstinence or intentions regarding abstinence, condom use, unprotected intercourse))

  3. Healthcare uptake related outcomes (e.g. proportion of people seeking care when needed)

  4. Clinical outcomes (e.g. HIV infection, sexually transmitted infections, pregnancy)

Secondary outcomes

To evaluate whether the telephone is an appropriate mode of communication for HIV prevention interventions, we looked at the following outcomes:

  1. User evaluation outcomes (e.g. acceptability of service, user-reported communication with the healthcare provider, ease and timeliness with which people are able to obtain and maintain services they needed, barriers to services, perceived confidentiality, privacy)

  2. Provider evaluation outcomes (e.g. readiness to use, timeliness, convenience, satisfaction, barriers to using the intervention)

  3. Economic outcomes (e.g. cost-effectiveness, cost-benefit, resources used)

  4. Adverse outcomes regarding the communication mode (e.g. lower quality of telephone interventions, increased out-of hours contact for the provider, breach of confidentiality, misinterpretation of information)

Search methods for identification of studies

We used terms specific to the telephone and HIV/AIDS to create a general search for all three reviews. We consulted a librarian and the Cochrane's HIV/AIDS Review Group's Trial Search Coordinator for developing the search strategy. We did not manually search specialized journals. We included both peer-reviewed studies and grey literature, regardless of publication year. We included articles from journals in the English language and from journals in foreign languages;articles in all languages but with an English abstract, were included. Two reviewers independently performed the searches in June 2011. The detailed search strategies for all databases searched are presented in the appendices (Appendix 1; Appendix 2; Appendix 3; Appendix 4; Appendix 5; Appendix 6; Appendix 7; Appendix 8; Appendix 9; Appendix 10; Appendix 11; Appendix 12; Appendix 13; Appendix 14; Appendix 15; Appendix 16; Appendix 17).

Electronic searches

  • The Cochrane Central Register of Controlled Trials

  • MEDLINE (Ovid); 1980 - June 2011

  • PubMed Central (PMC)

  • EMBASE (Ovid); 1980 - June 2011 

  • PsycINFO (Ovid); 1980 - June 2011      

  • ISI Web of Science which includes: Social Sciences Citation Index, Conference Proceedings Citation Index- Science, Science Citation Index Expanded, Arts & Humanities Citation Index      

  • Cumulative Index to Nursing & Allied Health; 1981 - June 2011        

  • WHOs The Global Health Library (regional indexes)

Searching other resources

Trial registers

We searched online trial registers for ongoing and recently completed studies (current controlled trials: www.controlled-trials.com). This database contains the following registers:

  • Action Medical Research United Kingdom (UK) - subset from the International Standard Randomised Controlled Trial Number (ISRCTN) Register

  • Medical Research Council UK - subset from the ISRCTN Register

  • National Institutes of Health ClinicalTrials.gov Register (International) - subset of randomised trial records

  • National Institutes of Health Research Health Technology Assessment Programme UK - subset from ISRCTN Register

  • The Wellcome Trust UK - subset from the ISRCTN Register

  • UK trials - subset from the ISRCTN Register, UK trials only

Reference lists

We searched reference lists of the RCT which was included in the review, relevant systematic reviews and key articles in this area (as described or referred to by experts in the field).

Grey literature

We also searched Dissertation Abstracts International and the Centre for Agricultural Bioscience International, Direct Global Health database, the System for Information on Grey Literature Europe and the Healthcare Management Information Consortium database . A preliminary Google Scholar search showed a large number of hits, so we screened the first 500 results.

Conference proceedings

We searched the following conference databases:

  • Conference on Retroviruses and Opportunistic Infections

  • International AIDS Society

  • AIDS Education Global Information System

Data collection and analysis

Selection of studies

We merged search results across databases using Endnote (Endnote X4), and removed duplicate records of the same citations. Two groups of two authors (Sarah Gentry (SG) and Lorainne Tudor Car (LTC), Michelle van Velthoven (MvV) and SG) independently examined titles and abstracts according to pre-specified inclusion criteria to determine study eligibility. Studies for which eligibility was uncertain on the basis of the title and abstract alone were examined with the full text. Study authors were contacted if the information contained in the abstract or full text was not sufficient to make a judgement. The authors discussed which studies were to be finally included.

Data extraction and management

Two authors (MvV and LTC) independently retrieved details of the study and intervention characteristics with a standardised data extraction form (EPOC 2002). We resolved any disagreements by discussion.

Data extracted included:

  • Study citation

  • Methods: study aims, design, duration, recruitment method and setting, inclusion and exclusion criteria, control or comparison group, incentives for participation and duration of follow-up

  • Participants: demographic characteristics, diagnostic criteria, location of study centre(s), intervention setting, power calculation details, number recruited/excluded/declined and number randomised/withdrawn/lost to follow-up with reasons

  • Intervention: intervention content, intervention target, frequency of delivery, duration of intervention, who delivered the intervention, number of providers, training for users and providers, initiator of the intervention, adherence, exposure, quality of delivery, participant responsiveness, mode of delivery, behaviour change theory used, implementation fidelity, program differentiation and security arrangements

  • Outcomes: outcomes collected, outcomes reported, outcome definition, method of assessing outcome, time points for assessment, measurements involved and adverse effects.

  • Results: quantitative data for all relevant outcomes and qualitative data on health economics, adverse effects, acceptability to users and providers, user knowledge and understanding and social outcomes.

  • Key conclusions of the study.

  • Risk of bias data in order to perform risk of bias assessment as outlined below.

Assessment of risk of bias in included studies

Two authors (MvV and LTC) independently assessed the trial, performed risk of bias assessment and resolved disagreement by consensus.

We assessed bias in the included RCT as described by Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2009) and EPOC group (EPOC 2009) for six domains:

  1. Sequence generation; whether the study used a mechanism that ensured that the same sorts of participants were allocated to the intervention and control groups

  2. Allocation sequence concealment; whether the study made sure that those who admitted participants to the intervention and control groups did not know in which intervention the participants were randomised, before the intervention started

  3. Blinding; whether personnel and people assessing outcomes were being kept unaware of the allocation of the intervention after inclusion of participants (blinding of participants was not feasible in this context)

  4. Incomplete outcome data; whether the study addressed attrition, reasons for attrition and how this was handled during analysis

  5. Selective outcome reporting; whether all pre-specified outcomes, described in the methods or the outcomes one would expect, were reported in the results

  6. Other potential biases; relevant for this review were comparability of intervention and control group characteristics at baseline, imbalance of outcome measures at baseline and protection against contamination.

Data synthesis

We wrote a narrative description of outcomes presented in the included study.

Results

Description of studies

Results of the search

The joint search strategy for the three Cochrane reviews on use of telephone delivered interventions for HIV resulted in 14,717 citations. We found only one relevant RCT focused on the use of telephone calls for preventing HIV in HIV-negative persons. We did not find any relevant conference proceedings or ongoing trials. We present the search process in the form of a study flow diagram, which can be found in Figure 1.

Figure 1.

Study flow diagram.

Included studies

We included one eligible RCT in this review (Abrahams 2010a) (See Characteristics of included studies). The participants were women and girl children who received PEP after rape. The RCT was conducted between August 2007 and May 2008 in the Eastern and Western Cape Province in South Africa. South Africa’s HIV epidemic is the largest in the world, with approximately 5.6 million [range 5.4 – 5.8 million] people living with HIV in 2009 (Department of Health South Africa 2010) and an estimated prevalence of 17.8% (WHO 2010b).

Women and girl children of all ages (if children, they were accompanied by a guardian) were eligible for inclusion. The study excluded rape victims who did not get PEP (because they did not test for HIV or were HIV-positive), those who were unable to give informed consent because they had severe injury or severe mental distress and those who could not be contacted by a telephone or mobile phone. There were 2011 participants assessed for eligibility and 1737 were excluded for the following reasons: they did not meet the inclusion criteria (n (number) =1701); they refused participation (n=31); or they spoke a language other than English, Afrikaans or Xhosa (n=5). Rape victims were recruited from one day-time sexual assault service in Mthatha in the Eastern Cape (rural) and three 24-hour urban sexual assault services in Cape Town in the Western Cape (urban). At the initial visit after rape, the services provided rape victims with PEP medication for a period varying from three to seven days. Then victims were to return to the health centre to receive PEP for the remaining 28 days, which was required to complete the course. A recruiter assessed participants for their eligibility after they received standard care. Standard care comprised of psychological support, medical examination, HIV testing with pre- and post-test counselling, provision of emergency contraception, treatment of sexually transmitted infections and PEP. The recruiters obtained informed consent, collected contact details and baseline information and had an interactive information session with the participant or guardian in which recruiters explained the information pamphlet and showed participants how to use a medication diary.

Participants were randomised into a telephone support (n=136) or control (n=138) group. Control group participants received standard care from the sexual assault service during the 28-day period of taking PEP, with no further contact from the study staff after the interactive information session. Telephone support group participants received telephone calls from a counsellor throughout the 28 days when they had to take PEP. The counsellor called the participants four times in the first week; three times in the second and third week and two times in the last week. More calls could be made if necessary. The focus of the calls was to encourage the participants to take PEP, to seek support from family and friends, to attend counselling services, to read the information pamphlet, to use the medication diary and to return to the clinic for the follow-up medication. The counsellors were skilled in providing psychosocial support to rape victims, were knowledgeable about PEP and its side-effects and had experience of referral counselling services.

All participants were to visit the clinic within five days after completion of their 28 day PEP period. A fieldworker assessed their adherence and other outcomes during this visit. The outcomes of interest were the proportion of participants who completed the PEP treatment of 56 doses, used their pamphlet and medication diary, returned to collect medication and had depressive symptomatology four weeks after the rape. Non-adherence was defined as missing three or more doses of PEP (that was 94% adherence), which could have been consecutive or non-consecutive doses. Depression symptomatology was only measured in adults using the Centre for Epidemiological Studies Depression Scale (CES-D Scale) (Weissman 1977).

Excluded studies

Seven studies were excluded at the full-text screening stage (Orellana 2006; Picciano 2001; Picciano 2007; Roffman 1997a; Roffman 1997b; Roffman 1998; Rutledge 2001). The reasons for exclusion are given in Characteristics of excluded studies.

Risk of bias in included studies

Overall, we judged the included RCT to have a moderate risk of bias. Figure 2 and Figure 3 show a 'Risk of bias' graph and summary. For selection bias, we judged the risk of sequence generation bias to be low as a study statistician created a computer-generated randomisation list. However, we judged allocation concealment as unclear, because the study only reported that the study coordinator allocated the participants to an arm after the data had been collected. We were unsure whether concealment of the upcoming allocations from those involved in enrolment into the trial was done. Fieldworkers who did the final interview were blinded to study arm, though this may have been disclosed by the participants during the final interviews. Blinding of participants to the study arm was not possible. However, we believe this did not influence outcomes and therefore we judged the risk of performance bias to be low. We judged the risk of detection bias to be unclear, since we could not find any information in the study about blinding of the outcome assessors and we were unsure whether this could have influenced the outcomes. We judged the risk of attrition bias to be low as follow-up was high in both the intervention group (91.9%) and control group (92.7%). Furthermore, we judged the study to have an unclear risk of reporting bias, because the study protocol was unavailable to us. We judged the study to have high risk of reliable tools bias as the assessment of adherence could have been flawed. Self-reports of medication remaining may have been unreliable. Contamination between the arms may have biased the results, but recruitment over nine months at a rate of four or fewer patients per week per site makes this less likely. Therefore, we judged the risk of bias for contamination to be low.

Figure 2.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Effects of interventions

Overall, the proportion of participants adhering to PEP was 31.9 % in the control versus 38.2% in the intervention group. The estimated intervention effect of telephone counselling was 6.5% (95% CI: 4.6 to 17.6%) and not statistically significant (P=0.13). In Cape Town, adherence was 34% in the intervention and 26% in the control group. This was significantly (P=0.01) lower than in Mthatha where adherence was 47.6% in the intervention vs. 45.2% in the control group. However, the intervention effect was not statistically significant across sites (P=0.50).

The proportion of participants who read the pamphlet was not significantly (P=0.06) different between the intervention (72.8%) and control group (61.7%). The proportion of participants who used the diary was significantly (P=0.001) higher in the intervention group (78.8%) versus the control group (69.9%). Participants who reported reading the pamphlet and using the diary were more likely to adhere to PEP than those who did not report reading the pamphlet or using the diary (odds ratio: 2.5 (95% confidence interval (CI): 0.99 to 6.5) P=0.05).

The proportion of participants who did not return to collect their medication (between three and seven days after their initial visit to the sexual assault service) was not significantly (P=0.42) different between the intervention (23.2%) and control group (30.5%).

The proportion of participants with depression (CES-D score > 21) was not significantly (P=0.73) different between the intervention group (60.9%) and control group (55.8%).

The study reported that there were no recorded adverse events.

Discussion

Summary of main results

The only included RCT, which had a moderate risk of bias, showed that the psychosocial support delivered by telephone was not a significantly more effective method for supporting rape victims to adhere to PEP compared to usual care.

Overall completeness and applicability of evidence

We performed a thorough search of an extensive range of databases and considered all experimental study designs accepted by The Cochrane Collaboration. Nevertheless, we only found one eligible trial that assessed the effectiveness of telephone delivered HIV prevention interventions compared to usual care. Due to the scarcity of evidence, the results of this systematic review are not generalizable and the conclusions have to be interpreted with caution.

The study was performed in South Africa and recruited women and girls from one sexual assault service in the town Mthatha in Eastern Cape (predominantly impoverished Xhosa-speaking Black African_ and from three urban sexual assault services in Western Cape. Although the included study did not show that telephone psycho-social counselling was more effective than usual care, it was focused on a specific group of participants in an upper-middle-income country with high HIV prevalence (17.8%). Therefore, the applicability of these results to other participants and settings, particularly to low-income or high-income countries with a lower HIV prevalence, is unclear. The study excluded a large number of participants; 2011 participants were assessed for eligibility and 1737 were excluded. This was mainly because they did not meet the inclusion criteria (n=1653) for receiving PEP because they did not test for HIV or were HIV positive or had severe mental distress (the specific numbers for each reason is unknown). This suggests that telephone delivered HIV prevention is not suitable for a large proportion of the study population and this limits its use. The included study did not provide any information about patients’ and providers’ acceptability of using the telephone for PEP support, or its cost-effectiveness.

The rapid increase in use of mobile phones, both in developed and developing countries (ITU-D 2011), at least theoretically provides a great opportunity for improvement of healthcare in resource-limited settings. In the included RCT in South Africa, only 48 participants out of 2011 had to be excluded because they could not be reached by a telephone or mobile phone. Given the high prevalence and poor treatment outcomes of HIV infection in developing countries, this technology could prove to be highly beneficial in diagnosis, prevention and treatment of HIV. However, the existing evidence does not offer sufficient information on the effects of using telephones or mobile phones for supporting women to adhere to PEP either in developed or developing countries. The included RCT did not provide information on whether participants received calls via a telephone or mobile phone and what the implications of this were.

Quality of the evidence

The only included study in this review with 274 participants had a moderate risk of bias due unclear allocation concealment, blinding and selective reporting and possible unreliability of the assessment tools. The available evidence is weak.

Potential biases in the review process

This review has a number of strengths. We followed the rigorous Cochrane methodology, performed a comprehensive search and included all Cochrane accepted experimental study designs. We believe it is unlikely that we missed any other relevant studies.

Agreements and disagreements with other studies or reviews

At our protocol stage we identified another Cochrane protocol evaluating information and communication technologies for promoting sexual and reproductive health and preventing HIV infection in adolescents and young adults (Djossa 2011). This protocol also includes telephone interventions for HIV prevention and overlaps with our review. However, this protocol only aimed to include adolescents and young adults, whereas our review includes all HIV-negative persons. At the time of submission of our review, this protocol was not published as a review (Djossa 2011).

A meta-analysis showed that HIV prevention interventions aimed at increasing condom use delivered by computers have similar efficacy to traditional human delivered interventions (Noar 2009), but currently computer interventions may not be feasible in many low- and middle-income countries.

A systematic review assessed adherence to PEP for the prevention of HIV infection in victims of sexual assault and included studies with different designs (Chacko 2012). The RCT which we included in our review was also the only included RCT in that review (Chacko 2012). The review included only two other intervention studies with prospective designs; the studies evaluated different models of nurse-driven care to improve adherence to PEP in South Africa. In addition, the review included 23 cohort studies (2166 patients) and the overall proportion of patients adhering to PEP was 40.3% (95% CI 32.5% to 48.1%). Adherence was found to be higher in developing countries compared to developed countries, which may have been due to a higher awareness of HIV in high prevalence settings. However, the overall PEP adherence in the included South African RCT was lower (38.2% in the intervention group and 31.9% in the control group) than the overall PEP adherence in the cohort studies (40.3%) .

Another study by the authors of the included RCT in this review examined participants' barriers to PEP completion after rape (Abrahams 2010b). The qualitative study involved in-depth interviews with 29 women attending sexual assault services in the Eastern and Western Cape in South Africa in 2005 and 2006. Only nine women adhered to PEP. The study showed that the barriers to adherence of PEP after rape in this setting are complex. Rape stigma and fear of HIV negatively influenced women's adherence to PEP. Feelings of blame and a lack of social support had a severely negative psychological impact. However, the study concluded that more evidence is needed to better guide possible interventions to address these issues.

Authors' conclusions

Implications for practice

Due to the scarcity of evidence, we cannot recommend the use of the telephone for HIV prevention interventions. In this review, we could only find one eligible study showing that telephone psycho-social calls compared to usual care did not result in significantly more patients adhering to PEP.

Implications for research

There is a lack of evidence on the effectiveness of telephone use for HIV prevention. The only eligible study we found used telephone psycho-social counselling to support PEP. The study had a moderate risk of bias, was performed in a upper-middle-income country, on a high-risk, high HIV prevalence population. It is questionable if the findings from the included study are applicable to settings with lower HIV prevalence, or in a high- or low-income country. Women and girls who attend sexual assault services are likely to be only a small percentage of those who experience sexual assault and are at risk of HIV infection. We need interventions which reach victims who do not present at health facilities as well. Telephones and mobile phones could be a potential medium for reaching them, but currently there is no evidence on this. Future studies need to generate high-quality evidence on different HIV prevention interventions in various settings and contexts. This research should not only focus on behaviour and health outcomes, but also on implementation outcomes such as intervention acceptability and economic outcomes.

Acknowledgements

We are very grateful to Joy Oliver from the Cochrane HIV/AIDS Review Group for helping us develop the search strategy. We also would like to thank Tara Horvath, Gavrilah Wells and the rest of the Cochrane HIV/AIDS Review Group for their support and guidance.

Data and analyses

Download statistical data

This review has no analyses.

Appendices

Appendix 1. MEDLINE search strategy

NumberSearch terms
#1phone*
#2telephon*
#3telefon*
#4telephone intervention
#5call  
#6calls
#7calling
#8telemedicine
#9teleconsult*
#10telecounsel*
#11Telephone[MeSH]
#12Hotlines[MeSH]
#13Cellular phone[MeSH]
#14Cellular phone
#15Mobile phone
#16Cell phone
#17#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16
#18HIV Infections[MeSH]
#19HIV[MeSH]
#20hiv[tw]
#21hiv-1*[tw]
#22hiv-2*[tw]
#23hiv1[tw]
#24hiv2[tw]
#25hiv infect*[tw]
#26human immunodeficiency virus[tw]
#27human immunedeficiency virus[tw]
#28human immune-deficiency virus[tw]
#29((human immun*) AND(deficiency virus[tw]))
#30“Acquired Immunodeficiency Syndrome”[MeSH]
#31acquired immunodeficiency syndrome[tw]
#32acquired immunedeficiency syndrome[tw]
#33acquired immuno-deficiency syndrome[tw]
#34acquired immune-deficiency syndrome[tw]
#35((acquired immun*) AND (deficiency syndrome[tw]))
#36#18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35
#37# 17 AND # 36

Appendix 2. Pubmed Central (PMC) search strategy

Choose ‘Advanced search’ from the list of terms above the search box.

On the Advanced search interface, enter the following search string into the search box:

(TELEPHONE OR PHONE[Body - Key Terms]) AND HIV OR AIDS[Body - Key Terms]

Click on limits from the list of terms above the search box and enter:

01/01/1980-13/06/2011, into dates

Appendix 3. EMBASE search strategy

No.Query
#9 #1 AND #7 AND [humans]/lim AND [embase]/lim AND [1980-2011]/py
#8 #1 AND #7
#7 #2 OR #3 OR #6
#6 'telemedicine'/syn OR teleconsult* OR 'remote consulting' OR 'remote consultation'/syn OR 'remote consultations' OR telecounsel*
#3 telephon* OR phone* OR telefon* OR hotline*
#2 'telephone'/syn OR 'mobile phone'/syn
#1 'human immunodeficiency virus infection'/exp OR 'human immunodeficiency virus infection'/de OR 'human immunodeficiency virus infection' OR 'human immunodeficiency virus'/exp OR 'human immunodeficiency virus'/de OR 'human immunodeficiency virus' OR hiv:ti OR hiv:ab OR 'hiv-1':ti OR 'hiv-1':ab OR 'hiv-2':ti OR 'hiv-2':ab OR 'human immunodeficiency virus':ti OR 'human immunodeficiency virus':ab OR 'human immuno-deficiency virus':ti OR 'human immuno-deficiency virus':ab OR 'human immunedeficiency virus':ti OR 'human immunedeficiency virus':ab OR 'human immune-deficiency virus':ti OR 'human immune-deficiency virus':ab OR 'acquired immune-deficiency syndrome':ti OR 'acquired immune-deficiency syndrome':ab OR 'acquired immunedeficiency syndrome':ti OR 'acquired immunedeficiency syndrome':ab OR 'acquired immunodeficiency syndrome':ti OR 'acquired immunodeficiency syndrome':ab OR 'acquired immuno-deficiency syndrome':ti OR 'acquired immuno-deficiency syndrome':ab

Appendix 4. PsycINFO search strategy

NumberSearch terms
1phone*.af.
2Telephon*.af.
3telefon*.af.
4telephone intervention.af.
5call.af.
6calls.af.
7calling.af.
8teleconsult*.af.
9telecounsel*.af.
10Hotline.af.
11Telephone Hotlines.af.
12Hotline, Telephone.af.
13Telephone Hotline.af.
14Phone, Cellular.af.
15Cellular Telephone.af.
16Cellular Telephones.af.
17Cell Phone.af.
18Phone, Cell.af.
19Phones, Cell.af.
20Mobile Phone.af.
21Phone, Mobile.af.
22Phones, Mobile.af.
23Car Phone.af.
24Car Phones.af.
25exp Telephone Systems /
26exp Cellular Phones /
27exp Hot Line Services/
28exp telemedicine /
291 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28
30exp hiv/
31exp hiv testing/
32hiv.ti. OR hiv.ab.
33hiv-1.ti. OR hiv-1.ab.
34hiv-2.ti. OR hiv-2.ab.
35human immunodeficiency virus.ti. OR human immuno deficiency.ab.
36human immuno-deficiency virus.ti. OR human immuno-deficiency virus.ab.
37human immunedeficiency virus.ti. OR human immune deficiency virus.ab.
38human immune-deficiency virus.ti. OR human immune-deficiency virus.ab.
39acquired immune-deficiency syndrome.ti. OR acquired immune-deficiency syndrome.ab.
40acquired immunodeficiency syndrome.ti. OR acquired immunodeficiency syndrome.ab.
41acquired immuno-deficiency syndrome.ti. OR acquired immuno-deficiency syndrome.ab.
42exp aids/
4330 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42
4429 AND 43

Appendix 5. ISI Web of Science search strategy

NumberSearch terms
1TS=phone*
2TS=Telephon*
3TS=telefon*
4TS=telephone intervention
5TS=call
6TS=calls
7TS=calling
8TS=telecounsel*
9TS=Hotline
10TS=Telephone Hotlin*
11TS=Cellular Phon*
12TS=Cellular Telephon*
13TS=Cell Phon*
14TS=Portable Cellular Phon*
15TS=Mobile Phon*
16TS=Car Phon*
17TS=telemedicine
18TS=teleconsult*
19TS=teletherapy
20TS=telehealth
211 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20
22TS=AIDS
23TS=HIV
24TS=HIV-1*
25TS=HIV-2*
26TS=HIV1
27TS=HIV2
28TS=HIV INFECT*
29TS=HUMAN IMMUNODEFICIENCY VIRUS
30TS=HUMAN IMMUNEDEFICIENCY VIRUS
31TS=HUMAN IMMUNO DEFICIENCY VIRUS
32TS=HUMAN IMMUNE-DEFICIENCY VIRUS
33(TS=HUMAN IMMUN*) AND (TS=DEFICIENCY VIRUS)
34TS=ACQUIRED IMMUNODEFICIENCY SYNDROME
35TS=ACQUIRED IMMUNEDEFICIENCY SYNDROME
36TS=ACQUIRED IMMUNO-DEFICIENCY SYNDROME
37TS=ACQUIRED IMMUNE-DEFICIENCY SYNDROME
38(TS=ACQUIRED IMMUN*) AND (TS=DEFICIENCY SYNDROME)
39TS=VIRAL SEXUALLY TRANSMITTED DISEASES
4022 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39
4121 and 40

Appendix 6. CINAHL search strategy

NumberSearch terms
1phone*
2Telephon*
3telefon*
4telephone intervention
5call
6calls
7calling
8telecounsel*
9Hotline
10Telephone Hotlines
11Hotline, Telephone
12Hotlines, Telephone
13Telephone Hotline
14Cellular Phones
15Phone, Cellular
16Cellular Telephone
17Cellular Telephones
18Telephones, Cellular
19Cell Phone
20Cell Phones
21Phone, Cell
22Phones, Cell
23Portable Cellular Phone
24Portable Cellular Phones
25Cellular Phone, Portable
26Cellular Phones, Portable
27Portable Cellular Phones
28Cellular Phone, Transportable
29Cellular Phones, Transportable
30Mobile Phone
31Mobile Phones
32Phone, Mobile
33Phones, Mobile
34Car Phone
35Car Phones
36Phone, Car
37Phones, Car
38Phones, Cellular
39Telephone, Cellular
40telemedicine
41teleconsult*
42teletherapy
43telehealth
441 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43
45AIDS
46HIV
47HIV-1*
48HIV-2*
49HIV1
50HIV2
51(HIV INFECT*)
52(HUMAN IMMUNODEFICIENCY VIRUS)
53(HUMAN IMMUNEDEFICIENCY VIRUS)
54(HUMAN IMMUNO-DEFICIENCY VIRUS)
55(HUMAN IMMUNE-DEFICIENCY VIRUS)
56((HUMAN IMMUN*) AND (DEFICIENCY VIRUS) )
57(ACQUIRED IMMUNODEFICIENCY SYNDROME)
58(ACQUIRED IMMUNEDEFICIENCY SYNDROME)
59(ACQUIRED IMMUNO-DEFICIENCY SYNDROME)
60(ACQUIRED IMMUNE-DEFICIENCY SYNDROME)
61((ACQUIRED IMMUN*) AND (DEFICIENCY SYNDROME))
62(VIRAL SEXUALLY TRANSMITTED DISEASES)
6345 OR 46 OR 47 OR 48 OR 49 OR 50 OR 51 OR 52 OR 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR 59 OR 60 OR 61 OR 62
6444 AND 63

Appendix 7. WHOs The Global Health Library search strategy

Search for: Title in Regional indexes with the following terms:

(phone* or telephon* or telefon* or telephone intervention or call  or calls or calling or telemedicine or teleconsult* OR telecounsel* or "Telephone" OR "Telephone Hotlines" OR "Telephone, Cellular") AND ( hiv or hiv-1* or hiv-2* or hiv-1 or hiv-2 or (human immunodeficiency virus) or (human immunedeficiency virus) or (human immune-deficiency virus) or ((human immun*) AND (deficiency virus)) or (acquired immunodeficiency syndrome) or (acquired immunedeficiency syndrome) or (acquired immuno-deficiency syndrome) or (acquired immune-deficiency syndrome) or ((acquired immun*) AND (deficiency syndrome)) or hiv infect* or aids or "HIV" OR "AIDS" OR "HIV Infections")

Appendix 8. CENTRAL search strategy

Appendix 9. DAI search strategy

cabs(phone* or telephon* or telefon* or "telephone intervention" or call or calls or calling or telecounsel* or Hotline or "Mobile Phon*" or telemedicine or teleconsult* or teletherapy or telehealth) AND cabs((HIV OR "AIDS" OR "HIV infect*" OR "human immunodeficiency virus" OR "acquired immunodeficiency syndrome"))

LIMIT FOR: SINCE 1980

Appendix 10. CABI search strategy

NumberSearch terms
1phone*
2Telephon*
3telefon*
4telephone intervention
5call
6calls
7calling
8telecounsel*
9Hotline
10Telephone Hotlines
11Hotline, Telephone
12Hotlines, Telephone
13Telephone Hotline
14Cellular Phones
15Phone, Cellular
16Cellular Telephone
17Cellular Telephones
18Telephones, Cellular
19Cell Phone
20Cell Phones
21Phone, Cell
22Phones, Cell
23Portable Cellular Phone
24Portable Cellular Phones
25Cellular Phone, Portable
26Cellular Phones, Portable
27Portable Cellular Phones
28Cellular Phone, Transportable
29Cellular Phones, Transportable
30Mobile Phone
31Mobile Phones
32Phone, Mobile
33Phones, Mobile
34Car Phone
35Car Phones
36Phone, Car
37Phones, Car
38Phones, Cellular
39Telephone, Cellular
40telemedicine
41teleconsult*
42teletherapy
43telehealth
441 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43
45AIDS
46(HIV INFECTIONS)
47HIV
48HIV-1*
49HIV-2*
50HIV1
51HIV2
52(HIV INFECT*)
53(HUMAN IMMUNODEFICIENCY VIRUS)
54(HUMAN IMMUNEDEFICIENCY VIRUS)
55(HUMAN IMMUNO-DEFICIENCY VIRUS)
56(HUMAN IMMUNE-DEFICIENCY VIRUS)
57((HUMAN IMMUN*) AND (DEFICIENCY VIRUS) )
58(ACQUIRED IMMUNODEFICIENCY SYNDROME)
59(ACQUIRED IMMUNEDEFICIENCY SYNDROME)
60(ACQUIRED IMMUNO-DEFICIENCY SYNDROME)
61(ACQUIRED IMMUNE-DEFICIENCY SYNDROME)
62((ACQUIRED IMMUN*) AND (DEFICIENCY SYNDROME))
63(VIRAL SEXUALLY TRANSMITTED DISEASES)
6445 OR 46 OR 47 OR 48 OR 49 OR 50 OR 51 OR 52 OR 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR 59 OR 60 OR 61 OR 62 OR 63
6544 AND 64

Appendix 11. OpenSIGLE search strategy

Simple search required:

((telephon*) AND (hiv OR aids))

Appendix 12. HMIC search strategy

NumberSearch terms
1phone*.af.
2Telephon*.af.
3telefon*.af.
4telephone intervention.af.
5call.af.
6calls.af.
7calling.af.
8Hotline.af.
9Telephone Hotlines.af.
10Telephone Hotline.af.
11Cellular Phones.af.
12Cellular Telephone.af.
13Cellular Telephones.af.
14Cell Phones.af.
15Mobile Phones.af.
16Phones, Mobile.af.
17exp telephone/
18exp telemedicine/
19exp teletherapy /
201 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19
21exp human immunodeficiency virus/
22hiv.ti. OR hiv.ab.
23hiv-1.ti. OR hiv-1.ab.
24hiv-2.ti. OR hiv-2.ab.
25human immunodeficiency virus.ti. OR human immuno deficiency.ab.
26human immuno-deficiency virus.ti. OR human immuno-deficiency virus.ab.
27human immune-deficiency virus.ti. OR human immune-deficiency virus.ab.
28acquired immune-deficiency syndrome.ti. OR acquired immune-deficiency syndrome.ab.
29acquired immunedeficiency syndrome.ti. OR acquired immunedeficiency syndrome.ab.
30acquired immunodeficiency syndrome.ti. OR acquired immunodeficiency syndrome.ab.
31acquired immuno-deficiency syndrome.ti. OR acquired immuno-deficiency syndrome.ab.
32exp acquired immune deficiency syndrome/
3321 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32
3420 AND 33

Appendix 13. Google Scholar search strategy

((telephon*) AND (hiv OR aids))

Appendix 14. Conference on Retroviruses and Opportunistic Infections (CROI)

Source: http://www.retroconference.org/AbstractSearch/default.aspx

Search strategy: telephone HIV AIDS

Match on all words entered

Include Prior 14 Conferences (1997 - 2011)

Appendix 15. International AIDS Society (IAS)

Source: http://www.iasociety.org/Default.aspx?pageId=7

Search strategy: telephone phone

Search conference IAS 2009

Search conference AIDS 2010

Appendix 16. AEGIS search strategy

telephon* OR phone* OR hotline* OR telecounsel* OR telemedicine OR teleconsult*

Appendix 17. Current Controlled Trials search strategy

hiv AND (telephone OR phone OR hotline OR text message OR messaging OR telemedicine OR telecounseling)

Contributions of authors

JC conceived the idea for the review. MvV, SG and LTC performed the searches, screening of citations, data extraction and risk of bias assessment. MvV wrote the review. JC, LTC and SG provided comments on the review.

Declarations of interest

None to declare.

Sources of support

Internal sources

  • National Institute for Health Research, UK.

    The Department of Primary Care and Public Health at Imperial College London is grateful for support from the National Institute for Health Research Collaboration for Leadership in Applied Health Research & Care Scheme, the NIHR Biomedical Research Centre scheme and the Imperial College London Centre for Patient Safety and Service Quality.

External sources

  • No sources of support supplied

Differences between protocol and review

There are a number of differences between the protocol and the present review. These differences are mainly due to the fact that only one study met the inclusion criteria, thus they are mainly in the data analysis section. 

  1. Assessment of risk of bias in included studies: we did not find any eligible studies with study designs other than a RCT design, so using other tools to assess risk of bias (EPOC 1998; EPOC 2009) as previously stated in the protocol, was not necessary.

  2. Data analysis: if we found more than one study meeting our criteria we would have presented a summary of the treatment effect by study design, type of intervention and setting. Moreover, we would have analysed the outcomes using RevMan and the intention-to-treat principle of analysis. If sufficient quality had been available, we would have summarised data statistically. We planned to calculate dichotomous data as a relative risk with 95% CIs. For continuous outcomes we wanted to calculate the mean differences and the weighted mean differences with 95% CI. For ITS studies we would have reported mean differences in before and after values. We would also report each study design separately. We wanted to calculate the overall results based on a fixed model. If heterogeneity had been detected and it had been appropriate to combine the trials, we would have used a random-effects model.

  3. Dealing with missing data: missing data (e.g. studies, outcomes, summary data, individuals) would have been obtained from original investigators. We would not have performed imputation for missing data. Attrition rates, for example drop-outs, losses to follow-up and withdrawals would also have been investigated.

  4. Assessment of heterogeneity: we would have qualitatively examined the degree of heterogeneity between the included studies in terms of intervention characteristics, type of provider of the intervention, characteristics of subjects, the context of study population and outcomes. We would have looked at the extent to which each of these parameters overlapped between the studies. When relevant, we would have statistically tested for heterogeneity using the I2 statistic with significance set at >50% and the chi-squared statistic with significance set at P<0.10. Possible sources of heterogeneity would have been evaluated by sensitivity analysis (Higgins 2011) and a random-effects model would have used if heterogeneity was detected.

  5. Reporting bias: we would have used funnel plots and tests for funnel plot asymmetry to assess the presence of reporting bias.

  6. Data synthesis: we would have performed a meta-analysis if a group of included studies was sufficiently homogenous. We would have separately analysed the results of different study types and of different outcomes. If statistical pooling of results had been inappropriate, we would have undertaken a narrative overview of the results. We would have systematically described each included study according to design, setting, participants, control and outcomes. We would have also provided additional information such as intervention integrity if available. We would have grouped the included studies according to intervention types. We would have presented each included study in a Characteristics of included studies table and we would have provided a risk of bias assessment and quality assessment of the included studies.

  7. Subgroup analysis and investigation of heterogeneity: subgroup analyses would have been performed if one of the primary outcomes demonstrated statistically significant differences between intervention groups. We would have considered subgroup analyses based on demographic outcomes such as race/ethnicity/nationality, age, gender and HIV risk factors.

  8. Sensitivity analyses: we would have considered factors such as lower quality studies, studies with a higher or lower risk of bias (as specified above), studies of low statistical power, unpublished studies, studies in languages other than English, research undertaken in different countries, source of funding (industry versus other) and different statistical models (fixed- and random-effects models). 

  9. Assessment of quality of evidence across studies: we would have used the GRADE approach to evaluate the aggregate quality of the evidence (Higgins 2011) for the primary outcomes.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Abrahams 2010a

MethodsRandomised controlled trial conducted between August 2007 and May 2008.
Participants274 women and girl children who got post-exposure prophylaxis (PEP) after rape from one sexual assault service in the Eastern Cape and three urban sexual assault services in the Western Cape in South Africa.
InterventionsThe 274 participants were randomised into a telephone support (n=136) and control (n=138) group. Control group participants received standard care from the sexual assault service during the 28-day period of taking PEP, with no further contact from the study staff after an interactive information session. Telephone support group participants received standard care and telephone support from a counsellor throughout the 28 days when they had to take PEP.
Outcomes

The study examined the proportion of participants who completed the PEP treatment of 56 doses, used the pamphlet and diary , returned to collect medication and had depressive symptomatology four weeks after the rape.

Overall, adherence to PEP was 31.9 % in the control versus the 38.2% intervention group, which was not significantly different between the groups (P=0.13). The proportions of participants who read the pamphlet, who did not return to collect medication or with depression were not significantly different between the intervention and control group (P=0.006, P=0.42, P=0.72 respectively). The proportion of participants who used the diary was significantly (P=0.001) higher in the intervention group (78.8%) versus the control group (69.9%). The study reported that there were no recorded adverse events.

Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskStudy quote: "A computer-generated randomisation list was generated by the study statistician and random block sizes of four, six and eight were used to ensure balance in the two arms".
Allocation concealment (selection bias)Unclear riskThe only information provided was: "Participants were allocated to an arm by the study coordinator after the initial data had been collected and leaflet explained".
Blinding of participants and personnel (performance bias)
All outcomes
Low riskStudy quote: "Fieldworkers who did the final interview were blinded to study arm, but this may have been disclosed by the participants during the final interviews. Participants could not be blinded to the study arm.' We judged that this is unlikely to have influenced the study results".
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskWe could not identify information on blinding of outcome assessment in the study and we are unsure if this could have influenced the study results.
Incomplete outcome data (attrition bias)
All outcomes
Low riskWe judged the risk of attrition bias to be low as follow-up was high in both the intervention group (91.9%) and control group (92.7%).
Selective reporting (reporting bias)Unclear riskThe study protocol was unavailable.
Other biasHigh riskWe judged the study to have high risk of reliable tools bias as the assessment of adherence could have been flawed. Self-reports of medication which was not taken may have been unreliable.

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Orellana 2006This study assessed factors associated with nonparticipation among high–risk, sexually active men who have sex with men and participated in a brief, telephone–delivered HIV prevention trial designed to evaluate the efficacy of motivational enhancement therapy. It did not assess the effectiveness of using the telephone for HIV prevention.
Picciano 2001This pilot RCT assessed the efficacy of a telephone-based brief counselling intervention to reduce sexual risk taking among men who have sex with men. Men were randomly assigned to immediate counselling or to a delayed counselling control condition. We excluded the study because there was no control group that received usual care or only the assessments.
Picciano 2007This RCT tested a brief theory-based counselling intervention delivered by telephone for men who have unprotected sex with men. Men were randomly assigned to Motivational Enhancement Therapy or to a delayed counselling control condition. We excluded the study because there was no control group that received usual care or only the assessments.
Roffman 1997aThis study assessed efficacy outcomes of a safer-sex group counselling program delivered by telephone that was offered to men who had sex with men and sought support in lowering their risk of HIV transmission. Men were randomised to treatment or to a wait-list control condition. We excluded the study, because there was no control group that received usual care or only the assessments.
Roffman 1997bThis study assessed factors associated with participation and the attainment of HIV prevention behavioral outcomes in gay and bisexual men who participated in a HIV prevention group counselling program delivered by telephone. It did not assess the effectiveness of using the telephone for HIV prevention.
Roffman 1998This study evaluated the use of anonymous enrolment as a technique for engaging and retaining gay and bisexual men in an AIDS prevention counselling intervention delivered by telephone. It did not assess the effectiveness of using the telephone for HIV prevention.
Rutledge 2001This study discusses the use of motivation interviewing, drawing on experiences from a pilot trial of a telephone delivered brief motivational enhancement therapy for HIV risk reduction with men who have sex with men. It did not assess the effectiveness of using the telephone for HIV prevention.

Ancillary