SXT-CVT

Our solutions boost manual contact tracing effectiveness to address pandemic infection spread.  We delivering anonymous contact tracing using SMS and email, digital triage contacts to access testing & treatment and then our booking module supports linkage to care. 

Over four years we developed our solutions for HIV and other sexually transmitted infections and compared with standard of care we are able to boost manual contract tracing effectiveness six times.  For covid-19 we have repurposed our solution and added in new features to support mass notification (e.g. to inform all passengers on a plane) as well as a social media tool and we are confident that we can boost covid-19 contact tracing by ten times.

In addition to covid-19 there are a range of other pandemics that claim millions of lives such as HIV, tuberculosis, Hepatitis C and sexually transmitted infections.  Our solution boosts healthcare worker impact for public health.

Manual contact tracing is the mainstay of public health programs to address infectious diseases; however, delivering this work is time consuming and inefficient.  The healthcare worker has to interview the patient with the infection and then ask them to provide the details of the people they have been in contact with so that they can be informed.  

Many patients are reluctant to give the details of their contacts because of shame, stigma, fear of reprisal, embarrassment etc; consequently, contacts at risk of infection are unaware of their risk and the infection is then unwittingly transmitted on to other members of the population.

Covid-19 has infected over 8 million people to date and 440 thousand deaths have been associated with this virus.  Similarly the HIV pandemic kills 770 thousand young people whilst tuberculosis affects one third of the global population and kills one million people per year.  Syphilis is the most common infectious cause of stillbirth. 

Those with the highest burden of infectious disease are the poorer people across the world because of the density of their housing, their nutrition status and access to healthcare.  Contact tracing improves testing efficiency,  saves lives and improves the health of the community.

The SXT solution (www.sxt.org.uk) started after meeting patients who suffered from untreated infections because they could not identify a local appropriate service.  We created a clinic controlled signposting tool to help clients find the right service, in the right place at the right time.

We then realized that patients and staff were using SXT to inform contacts, 'at risk' from the infection, and to support them to identify a local testing service.  Working with patients and staff we created a contact tracing solution that is anonymous and uses SMS and email to communicate with contacts.

Once this was launched we heard back from contacts that after they were being alerted of their risk and identified a local service they were then unable to be seen because demand was greater than capacity at these clinics.  Again working with patients and staff we created a booking module that supports linkage to care for key 'at risk' patients.

In CVT (http://cvt.health) we repurposed SXT to work for covid-19 contact tracing and enhanced its functionality to support mass notification (e.g. airline, religious leader, event organizer, etc) as well as a link for use in social media.  The real-time dashboards of both services show impact.

The target population are the contacts of an infection.  Many who are exposed and infected (up to 50%) have no symptoms and unaware that they potentially pose a risk to others.  

In the case of HIV and sexually transmitted infections the contacts are part of the sexual network and individuals are usually unaware if they are a core transmitter at the center of the network or on the edge of the group of infected people.

In the case of covid-19 and tuberculosis transmission is associated with close exposure such as being in the same room for 15+ minutes, less than two meters for a similar duration or closer contact.

Effectively alerting contacts of their risk, digitally triaging them to find a local appropriate venue for testing and then ensuring linkage to care with targeted appointments are essential steps to reduce transmission.  After creating SXT with stakeholders over the years we have supported contact tracing with over 40 thousand patients diagnosed with sexually transmitted infections including HIV.  We have data showing that we half the staff time to deliver three times the impact.

For covid-19 working with public health professionals we developed a solution that further boosts manual contact tracing. 

The ability to diagnose infections and then deliver effective contact tracing services is key to manage the current and future pandemics.  Our solution supports a network of clinics to work effectively together and amplifies the manual contact tracing process.

The ability to effectively inform contacts of their risk, digitally triage them to an appropriate service and then support linkage to care does more than manage infection spread.  In addition. this approach supports the clinic to increase the diagnostic yield, as up to 50% of contacts will have the infection, as well as support research into diagnostics, prophylaxis and treatment.

A number of digital solutions have been created to support the delivery of contact tracing such as TellYourPartner (https://tellyourpartner.org) or InSpot (https://www.inspot.org).  These platforms are self service by the patient with the infection and provide rudimentary signposting services.

The SXT solution is the first that enables contact tracing by both the healthcare worker and the patient, signposts contacts to clinics who control what hours and services they provide and are able to support linkage to care of key 'at risk' patients through the provision of targeted appointments.

Initiating contact tracing from the clinic was chosen to ensure that the patient is aware of how far they should look back to inform contacts (e.g. two days before symptoms for covid-19 and three months for patients with gonorrhoea and no symptoms).  

Supporting both the health care worker and patient to deliver contact tracing was chosen to support the patient to deliver this important service in private.  We know that 12% of patients inform more contacts than were declared when they were in the clinic. 

Clinic controlled signposting was created to ensure that contacts were only signposted to providers who were able to delivery the service required by the contact.

The booking  module was created to support linkage to care for key 'at risk' patients because we heard back from contacts that they were unable to access clinics as demand normally exceeded their capacity.  The booking module ensures we can digitally curate the full journey for the contact. 

Our software as a service model has evolved over time using a design-led agile methodology.  The software has been coded in Ruby on Rails and we are hosted on an Amazon Web Server and we use Gov.UK notify as our SMS and Email provider.

Most of our patients use SMS to communicate with contacts.  The first SMS offers the contact the ability to opt-out in line with the General Data Protection Regulations of 2017.  The second SMS informs the contact of their infection risk and the URL in the text takes them to a bespoke webpage.  

On the webpage we provide information about the infection, a button to find a local appropriate clinic, a button to support communication with the reception team when the contact arrives at the clinic and a button to self-verify that the contact has already been seen and tested.  

When a contact books an appointment they provide their name and their mobile number.  A text confirms the booking and the patient and the clinic are able to cancel & reschedule.  If the patient does not show up for the appointment, they are automatically texted a link to rebook. All names are redacted to their initials once the appointment time has passed.

Privacy is key to our solution.  All personal information is encrypted and hidden until the final reminder is sent and then the personal information is deleted.  We are compliant with all 14 principles of Technology-Assisted Contact Tracing white paper published by the ACLU (https://www.aclu.org/report/ac...)

SXT has hospitals, small clinics, online providers and primary care physicians that are customers of the contact tracing tool and the booking module.  The customers login using their PC, tablet or mobile phone to deliver the contact tracing service.

The communication with contacts and patients using SMS and email is quick and effective.  The data from the backend of SXT enables us to fully understand how the contact tracing solution is working and the behavior of the contacts.  When a contact is informed by text, three quarters open the link with the majority doing so within the first few hours.  Contacts are being told on one day and booking and being seen on the next day.

The real-time dashboard provides an up to date key performance indicator of the number of contacts informed and tested within four weeks.  Our database is able to distinguish between the contacts who were already aware of the patient's diagnoses and those who were prospectively informed after the diagnosis and if they self-verified or were seen and tested in a clinic.

Public Health England published 2018 data in September 2019 showing the effectiveness of contact tracing for sexually transmitted infections.  Clinics using SXT reported nearly three times the number of contacts of Gonorrhoea seen and tested versus the standard of care using half the staff time.  The ability to boost manual contact tracing effectiveness six times in 2018 resulted from the combination of anonymous contact tracing, digital triage and targeted appointments. 

Our theory of change has been informed from patient stories, public health analysis, engagement with staff and feedback from payers.

Signposting

SXT started after meeting patients who had missed out on timely clinical interventions to treat infections or provide prevention services such as post exposure prophylaxis or emergency contraception.  At that time most clinic websites were rudimentary and limited information was provided about what services were available, where and when.

We assumed that the mobile phone platform would continue to grow and develop more features and that detailed information about service provision would be valuable for patients looking to access care.

Anonymous contact tracing

We could see from the SXT database that patients and clinical staff were using links from our signposting services to direct contacts to get tested and this encouraged us to focus on building a contact tracing solution that would work for both patients and staff.  We discovered from speaking with patients that many would like to inform contacts themselves and they were not always keen to do it when they were in clinic.  When patients were asked if they would like to be informed if they were a contact responded 'Yes'.  Face-to-face was the preferred method to tell contacts and be informed as a contact and SMS was the second choice for both groups too.  When we analyzed the number of contacts actually told we realized that we needed to support SMS communication to ensure that the job was done.  Giving the patient the opportunity to inform contacts enabled additional people to be informed.

Targeted appointments

Contacts were reporting to SXT that they were unable to access clinics after being informed because the demand for services was so high.  We tested if the provision of targeted appointments would resolve this and improve contact tracing metrics and we found that contact tracing outcomes jumped 20% in just three weeks.  

Real-time dashboard

We assumed that transparent reporting would improve engagement. The provision of simple metrics and filters to generate detailed reports stimulated the workforce to deliver more effective contact tracing, enabled training and the management of colleagues.

The SXT contact tracing tool was used with over 18,000 diagnosed with a sexually transmitted infection (STI) in 2019.  The booking module was used with more than 30,000 patients in that year.

In the first part of the first quarter of 2020 clinic attendance was normal and clinics were delivering comparable activity; however, as the covid-19 pandemic hit the UK the number of staff diverted, staff unwell and changes in clinic provision led to a drop in attendance.

Contact Virus Tracker (CVT) for covid-19 started to be built in March and was first demonstrated in late April 2020. We are hoping to sign up our first clinic to use this software in June 2020 and the data will immediately be generate an understanding of the tool performance and this will be used to market to other clinics over the year.

With the drop in STI diagnoses and the development time to create CVT we are estimating that 2020 will be equivalent to 2019; however, once we start to be used in the USA (NYC Health, Tampa General, MA Department of Public Health) then we expect to have significant growth.

Our aim is that all the HIV, Syphilis, Gonorrhoea and Chlamydia contact tracing in half the US states will be achieved in the next five years.  In June, SXT is submitting a Development Innovation Venture USAID grant to support scaling up in 10 Sub-Saharan African countries with milestone payments linked to increasing the HIV diagnosis rate by 20% over the baseline.  

It is hard to know how the covid-19 pandemic will evolve over time; however, if Iran is a harbinger for all the countries that remove the lockdown early then a second higher peak is likely.  The USA is currently diagnosing a steady 20,000 cases per day whilst the UK has fallen to 2,000 cases a day and the lockdown is being lifted in both countries.

We are keen to go live with CVT to prove our estimate of being able to boost manual contact tracing efficiency by ten times from the standard of care.  Once we can do that then we will be in a strong position within the year to support the growing number of contact tracing teams that have been employed to do this work.

In five years time it is not clear if covid-19 will still be circulating in the population; however, based on the high number of the population who are still susceptible, the infectivity of the virus, the lack of a vaccine and the need to restart economies it is possible that it will be with us for a few years.

In the UK and USA three million sexually transmitted infections are diagnosed each year.  Over the next year we have plans to streamline the onboarding of clinics to start using SXT.  The use of our UK infrastructure by US and New Zealand clinics will make it easier to reassure and scale on the African continent where two thirds of the HIV epidemic exists.

Information governance

The biggest barrier to scaling the SXT solution has been the information governance sign-off steps that need to be undertaken by providers.  The typical onboarding procedure involves being contacted by a champion of contact tracing in the clinic, after the demonstration and agreement to proceed we then need to speak with the digital security officer, complete a data privacy impact assessment and provide our IT certificates.   

Smartphone

SXT was initially developed with just two-way SMS; however, with the rapid adoption of the smartphone we switched to supporting this popular tool.  Even though the number of smartphone users is growing rapidly there are still a substantial fraction of the population who only have a feature phone as well as a smaller fraction who have no mobile phone.  

Language

SXT and CVT have been created in English; however, contact tracing is required worldwide and we will need to start creating non-English versions of the software.

Information governance

At the time of applying for MIT Solve, SXT-CVT has undergone evaluation evaluation by the Cyber Team in NYC Health and Compass Health in Wellington, New Zealand.  Similar questions were asked, documents requested and tests done to gain approval.  NYC Health have accepted our approach to contact tracing, our privacy by design approach and signed off our UK infrastructure to deliver contact tracing for patients diagnosed with HIV.  Once we have sign-off from New Zealand then that will support our approach to deliver one global solution and then we will focus on expediting the approval through the creation of relevant material in one place and active engagement with the IT teams for each clinic during onboarding.

Smartphones

For the USAID grant application we plan to deliver SXT in Ghana to support diagnosing HIV.  The initial project will start in Accra, where there is high smartphone penetration, and once we demonstrate that we can increase the HIV diagnosis by 20% we will then ask for support to rekindle our old code for two way SMS so that it can be used on feature phones before we expand across Ghana.

Language

We are currently only targeting English speaking countries; however, when we are in Ghana we will have a help page in Twi to support engagement.  Similarly, as we expand across English speaking countries in Sub-Saharan African countries we will do the same.  The first translations by SXT-CVT will be into Spanish, Portuguese and French. 

SXT Health CIC is a community interest company limited by guarantee that was founded by Dr Menon-Johansson in 2010.  This social enterprise was created with a mission to improve access to Sexual & Reproductive Health (SRH) care services and over the years we have focused on access for patients 'at risk' for an infection, requiring time sensitive services or falling pregnant.

SXT was incubated within the SRH Department of Guy's & St Thomas' and partners.  Over the last four years, since we have had the contact tracing tool and booking module, we have significantly increased the contacts informed and tested.

SXT was founded by Dr Menon-Johansson after winning an entrepreneurial grant to create a SMS solution to signpost patients to local appropriate services. 

Nearly nine years ago, SXT started to work with the digital design company BitZesty (http://bitzesty.com) and grant funding has been used to build and refine this tool with stakeholder engagement.

SXT has employed on a contractual basis a dozen staff over the years and currently has two part-time staff, the BitZesty team, an eight person advisory board team and two behavioral and data scientists. 

Dr. Anatole Menon-Johansson is an attending physician working in Sexual & Reproductive Health at Guy's & St Thomas' NHS Foundation Trust and recent Sloan & Legatum Fellow at MIT.  Dr Menon-Johansson read an MPH at the Harvard T H Chan School of Public Health in 2008 and since then has focused on using digital tools to improve healthcare delivery.  Dr Menon-Johansson has an extensive network of colleagues working in public health, microbiology and entrepreneurial ventures in the UK and the USA. 

Matthew Ford & Laura Paplauskaite are cofounders of the digital design company BitZesty and are the advising CTO and digital service strategist respectively.  Their company has worked on a number of Government Digital Service projects, for profit companies, charities and they have worked with SXT for nine years.  

Dr. Tomas Folke provides data analytics and behavioral science input.  He obtained his PhD in Behavioural Psychology from the University of Cambridge and is currently working as a data scientist at Columbia University using R to analyse hospital data and differential access to service by disadvantaged groups. 

Prav Menon-Johansson will provide stakeholder engagement and support. Prior to joining CVT, Prav was a fringe theatre producer in London.  Her academic achievements are having a law degree from University of London and a Masters in Child Psychology. 

In addition to Dr. Folke, a connection has been made with Dr. Erez Yoeli (Applied Cooperation Team at MIT) who has extensive experience using behavioral science approaches to improving software usage and impact.

SXT currently has a number of customers for its contact tracing tool and booking module, these include:

• Guy's & St Thomas' NHS Foundation Trust
• Homerton University Hospital
• Brook 
• SH:24
• Kent Community Health
• Hackney GP Federation
• Salisbury NHS Foundation Trust
• Imperial Healthcare
• Brighton & Sussex University Hospital
• Central and North West London NHS Foundation Trust
• The Royal Liverpool and Broadgreen University Hospitals
• Western Health and Social Care Trust

SXT is currently in the final stages of signing up the following providers to be customers 

• King's College Hospital NHS Foundation Trust
• Central Middlesex NHS Foundation Trust
• Compass Health, Wellington, New Zealand
• New York City Health, NYC, USA
• Tampa General & University South Florida (the latter will be the first to use CVT)

SXT-CVT has four key stakeholders:

• Patients diagnosed with the infection are provided with a convenient way to inform contacts without the risk of stigma, shame or the fear of violence
• Contacts have three benefits from our services: the first is being informed, the second is signposting to service and the third is access to care through the provision of targeted appointments
• Healthcare workers benefit from a tool that supports them to deliver effective contact tracing in half the time and to see in real-time outcomes that are significantly better than the standard of care
• Payers are able to see a clear improvement in their contact tracing service, the ability to increase their diagnosis rate and considerable savings in staff time delivering an improved service.

Our customers are healthcare providers who test for infectious diseases.  Our contact tracing tool requires less staff time to deliver better outcomes.  In the UK half the staff time is worth $10 per patient.  Up to half the contacts who test will have the infection and this is significantly higher than standard testing of a disease.  The SXT booking module has a 3% no show rate for popular appointments and this is three times better than comparable booking modules.  We achieve this though automated canceling, rebooking and reminders.

SXT Health CIC is a social enterprise that is limited by guarantee.

Our initial focus was on raising grant funds to development of features as well as taking out a Big Issue Invest Corporate Social Venture loan to build the contact tracing tool.

Since 2016, SXT has been trading and in 2018 we were selling two services to healthcare providers (terrestrial and online).

As we acquire more customers we learn and co-create new features with our users; consequently, we are still developing features and services and the cost for this work is a significant fraction of our revenue stream.

SXT has to date only traded in the United Kingdom.  In January a Legatum Fellowship trip to Ghana was done to explore the utility of taking SXT to that country to address their HIV epidemic. In order to deliver SXT in Ghana and other sub-Saharan countries we are looking for a grant to initiate testing and scaling within those lower income countries; however, once we show impact we plan to charge in this countries adjusted for local salaries.

SXT is close to having revenue streams that already exceed our expenses & development costs. 

For the last year I have been a Sloan & Legatum Fellow at MIT and during this time I have focussed on applied management tools, analytics and entrepreneurship.  Over the year the social enterprise SXT has grown slowly in the UK and cultivated customers in the USA and New Zealand.

The Legatum Fellowship trip to Ghana in January 2020 cemented my desire to take SXT to the African Continent to address the HIV pandemic that claims 770 thousand lives a year.

I am applying to be an MIT Solver because over this year I have really experienced the value of team work, the energy from an entrepreneurial ecosystem, access to mentors and the focus on experimentation and the application of technology to solve problems.

The barriers SXT faces with information governance, expanding the solution to work on feature phones and translating the site into other languages are the most pressing challenges; however, there will be other challenges that arise and I would really value developing SXT-CVT alongside other Solvers as well as getting support from mentors, students and MIT Faculty to ensure that our solution excels and takes contact tracing to a level that genuinely addresses current and future pandemics.

SXT-CVT currently has a transparent pricing structure and clear steps to onboarding healthcare providers to use the software.

Over the last year we have identified that different countries have similar steps to evaluate and authorize the use of the software for contact tracing.  

We are keen to use this next year to review and refine the onboarding process so that we can take new users through the key regulatory steps to start delivering effective contact tracing.

As we start to trade in other countries we are keen to partner with services that can support the legal and regulatory aspects and work with experts in B2B sales.

Working with data scientists across our website, contact tracing and booking databases highlights the possibility in the future of using machine learning as a solution technology to adjust appointments provided based on the demand from users, infections diagnosed and contacts informed. 

In addition to applying the USAID, SXT is keen to explore opportunities to support PEPFAR to identify patients with HIV so that they can be engaged with care, started on treatment and become health and uninfectious.

In Ghana the current HIV testing program diagnoses 20,000 people a year after performing 2 million tests (1 % positivity rate).  When an HIV contact tests up to 33% are found to have an infection.  The ability to boost manual contact tracing effectiveness is a key increase the diagnostic rate.

In the context of the Hepatitis C pandemic, we know have treatment that is able to eradicate this viral infection.  There are estimated to be one million people with Hepatitis C in the USA and yet case finding is the challenge to deliver this life saving treatment.

Over the last six months I have been in discussion with Dr Erez Yoeli (Applied Cooperation Team at MIT) to make changes to the SXT software using a step wedge design so that we can effectively unpick what changes are the most effective to ensure that contacts are informed of their risk.

Over the last four years we have demonstrated that SXT is able to bring a network of providers together to maximise their public health impact through the provision of anonymous contact tracing, digital triaging and targeted appointments. SXT (www.sxt.org.uk) is able to amplify manual contact tracing effectiveness up to six times for HIV and other sexually transmitted infections and the modifications we have made for COVID-19 (http://cvt.health) have the potential to amplify this key Public Health Service ten times. Even though our service is anonymous we are able to demonstrate real-time metrics of contacts being informed and tested. HIV and Tuberculosis pandemics currently claim nearly two million lives a year and COVID-19 is one of a number of zoonotic infections (Ebola, H1N1, SARS) that have emerged and led to human-to-human transmission this century. As the human population rises, global trade resumes and we encroach into new natural habitats then the risk of additional pandemic challenges will increase. We would use The Elevate Prize to bring SXT-CVT into a single solution to support healthcare services around the world to address current and future pandemics. Your support would ensure that our solution optimised for Smartphones can be used on all mobile phones to mitigate against a digital divide, create non-English services to support scale across the globe and, real-time dashboards to show public health impact.