Nearly 36 000 young Mozambicans have signed up for SMS-based health counselling but will the new technology curb HIV infections?
“When I was younger, like 17, I was shy to talk to my parents so I would end up talking to my friends about sex. They used to tease me saying, ‘you are late, you should start having sex,’ ” says Alfabeto Chiloveque.
“They were always bragging about sleeping with different girls, and called me weak.”
He was not convinced. “Their reasoning didn’t make sense to me. Then I spoke to a counsellor at school who told me more about sex and relationships.”
Sitting in the office he shares with his colleagues in the Mozambican capital of Maputo, Chiloveque (20) shakes his head, laughing.
“My friends were wrong. The reason they could not tell me why I was supposed to start having sex at that age was because they also didn’t know,” he says.
“Now they are the ones coming to talk to me.”
Chiloveque is one of a dozen counsellors who respond to questions from young people through SMS BIZ, an interactive short message service (SMS) that provides counselling on sexual and reproductive health issues, including HIV.
Today, his friends are not the only ones coming to him for advice. More than 250km away in Chibuto, Soares Mutambe (20) recently signed up to SMS BIZ.
“I used to wake up wet and I didn’t know why. I thought it was a disease,” says the grade 10 learner, shyly describing night-time ejaculations (wet dreams) that can be common during adolescence and early adulthood.
“I sent a message to SMS BIZ and learnt that it is normal.”
Health goes mobile
Globally, about 80% of countries are using mobile and wireless technologies to support the achievement of health objectives (mHealth), according to a 2011 World Health Organisation (WHO) survey. The huge growth in cellular network coverage has helped fuel mHealth’s rise. The WHO report notes that the bulk of the world’s more than five billion cellphone users are in low and middle income countries.
Many countries are using the technology to tackle culturally sensitive matters such as sexual and reproductive health.
“We have seen that young people are shy to talk about issues of sexual and reproductive health. This is worse in rural areas where they have limited access to information,” says Francelino Murela, from the United Nations Children’s Fund (Unicef), which supports the programme that now reaches about 36 000 young people.
“SMS BIZ does not require a smart phone with access to the internet (so) anyone who has a mobile phone can use the service. All they have to do is register, then they can send their texts to our counsellors for free.”
The programme targets people between the ages of 10 and 24 and “especially girls, because they are most affected by HIV”.
Mozambique has an HIV prevalence rate of 11% among adults aged 15 to 49, according to UNAids. This rate is higher in women (13%) than in men, who only have a 9% prevalence rate.
Women also typically get infected earlier than men do. HIV prevalence among young women aged 15 to 24 is almost three times higher (11.1%) than that among men in the same age group (3.7%).
Unicef supports similar SMS programmes in other countries, including Swaziland, Zimbabwe and Nigeria, where the platform shares information about diseases such as Ebola and polio.
Measuring the impact
The direct effect of SMS programmes is unclear. Unicef’s 2015 annual report notes that an evaluation found that Zambian SMS-based campaigns had no “significant impact” on the uptake of medical male circumcision. Medical male circumcision can reduce a man’s risk of contracting HIV through vaginal sex by about 60%, according to UNAids.
A 2014 article in the journal Global Health Action, which reviewed studies of several mHealth programmes in low and middle income countries, calls for more detailed studies on the effect of mobile technologies on health outcomes.
The review finds that, when it comes to mHealth, “evidence of effectiveness is both mixed and scant”. For example, the article describes an SMS-based support group in South Africa for women with diabetes. It notes that while women were linked with buddies to support their treatment and care through SMS, the project was unable to demonstrate significant changes in the women’s health after six months.
Researchers also argue that while some SMS systems have helped HIV patients stay on treatment, text-based messages have largely failed to curb HIV risk behaviours such as unsafe sex. The Global Health Action article also shows that gender disparities in mobile phone ownership can restrict access to SMS mHealth programmes. In Uganda, for example, “women were less likely to own a mobile phone, so were less likely to directly benefit from SMS education”.
Data collected since the SMS BIZ programme was launched in Mozambique in October last year, show low levels of HIV knowledge among users. These levels are similar to UNAids figures that show only 48% of women and 63% of men aged 15 to 49 had accurate knowledge about how HIV was spread.
In cases where data showed SMS BIZ users had correct HIV knowledge, this did not translate into behaviour change, says Murela. “Although they knew that HIV can be transmitted through sexual intercourse, some of the users indicated that they still engaged in unprotected sex.”
Murela is hopeful. Judging by the high rate of engagement with users on the programme, he believes that, in time, the service will lead more young people to make informed choices when it comes to their sexual health.