Evaluating the effect of interactive two-way texting on 6-month antiretroviral therapy outcomes: Findings from a randomized controlled trial in Lilongwe, Malawi

Retention on antiretroviral therapy (ART) 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 compliance to ART refill appointments, early retention, and VLS among new ART initiates. After receiving routine ART initiation counseling, 442 clients with mobile phones on ART ≤ six months were randomized to 2wT or standard of care (SoC). The 2wT group received weekly motivational messages, appointment reminders, and access to an open-ended SMS communication channel with retention officers. The SoC group received peer support at clinic visits and reminder calls, pre-visit and for missed appointments. All participants were traced if they missed an appointment by >14 days. Study outcomes ascertained six months post ART initiation included: ART appointment compliance (attending within 2 days), retention in care (alive on ART), and VLS (