Aviro Pocket Clinic

Due to the global COVID-19 pandemic, HIV testing is down by 22% and new ARV initiations are down by 12% in Southern Africa. This means that approximately 200 thousand people that were expected to be on ARVs this year are not. As a result, millions more people are likely to be infected. HIV is the leading cause of mortality in Southern Africa and the second leading cause of death among youth worldwide. Only 62% of the ten million people living with HIV in Southern Africa know their status and only 45% are on treatment. 

HIV Self-Testing (HST) allows individuals to test themselves confidentially, anonymously and conveniently and is especially attractive for marginalised  populations that struggle to access traditional services. These very attributes make patient support and disease surveillance very difficult however, limiting health provider support for scaling these solutions and making them available to patients.

Health workers need innovative solutions to overcome these challenges, and make health systems more efficient, resilient, and accessible. We must find ways to make it easy for health workers to promote and manage self-screening for HIV (and other conditions over time), or we will see another generation in which millions suffer with diseases that, like HIV, can be prevented or managed.

Aviro Pocket Clinic smartly combines digitally-assisted self-care with linkages to live people and services. The Pocket Clinic uses data, design and behavioural science to deliver a semi-automated but robust and holistic experience that guides patients along common health pathways. Our carefully crafted medical content and proven user flows, managed and delivered through a multi-channel platform (Web app and WhatsApp chatbots at home, and tablets in facilities) have been proven to reduce the barriers and costs of providing effective screening for populations that struggle to access traditional care, and to empower patients to achieve key health outcomes for various HIV use cases (testing, initiation, linkage to care, prevention). 

Pocket Clinic is provided to patients by health workers using a custom interface built with busy health workers in mind, and Aviro supports its integration into care settings. The secure platform, featuring robust data and analytics capabilities, provides key support to patients along the care pathway (learning and counselling, reminders and appointment booking, results reporting, linkages to health workers) while giving visibility on progress to health workers, reducing the burden of coordination of care and improving economics and outcomes. Studies by Johns Hopkins, Wits University, and London School of Hygiene (as well as feedback from users) confirms that the platform is easy to use, attractive to populations, effective at driving outcomes, and introduces efficiencies. The tool has been endorsed by both the NDOH in South Africa and provincial health departments.  By carefully listening to the needs of patients and providers, Aviro Pocket Clinic reduces the demands on physical facilities and health workers'  time, so that counsellors can focus on the cases that require specialised  in-person support.

Aviro Pocket Clinic is currently serving multiple self-testing demographics in South Africa and Kenya. Our implementation partners focus on high-risk groups who do not traditionally access facility-based HIV testing  services:

• Undiagnosed People Living with HIV 

• Youth and adolescent girls in particular 

• Men aged 25-40 and First-time HIV testers

• Key population groups (men who have sex with men (MSM); lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI); sex workers) 

Aviro Pocket Clinic is the self-care partner for these populations.  We understand that navigating healthcare can be confusing and intimidating, especially for those from marginalised  backgrounds. Empowering and supporting people to manage their own health benefits everybody.

 We give people what they need to perform important health checks like regular HIV self-testing or insulin initiation and connect them to experts and services who can offer hands-on and supported care when needed. This increases feelings of empowerment and autonomy and helps all users overcome the barriers they may experience (stigma, cost, distance, etc.) in accessing the care that they need and want. We help people  find good health easily, every day.

Aviro Health is a South African-based company supporting a global team currently working on projects in South Africa and Kenya. Aviro is a diverse, multidisciplinary team of 15 people with extensive experience in mHealth. We are  committed to upskilling and training Africans from previously disadvantaged backgrounds. With extensive experience in all aspects of digital health, our mission is to help healthcare workers focus on more complicated cases by providing technology-enabled services that automate workflows, improve access to quality medical information, and provide digitally-enabled counselling services. Aviro is led by:

CEO - Musaed Abrahams musaed@avirohealth.com 

A  medical doctor with a specialization in HIV/TB, Musaed is the former MSF HIV Training Director, with over 10 years of experience in public health. He is also the  editor of the MSF HIV Handbook, developer of an HIV eLearning course, and creator of the MedMentor decision support tool. 

COO - Luke Shankland luke@avirohealth.com 

Luke is a former country manager and board member at MSF; a manager of business and strategy development at Praekelt.org; and the African lead for EFL, a financial services startup working with major banks. Luke is an MBA with proven experience in scaling technology businesses throughout Africa.

CTO - Ahmed Bhamjee  ahmed@avirohealth.com 

With three  decades of software engineering experience, Ahmed has worked in a range of industries, including healthcare, software security, insurance and IT consultancy, working on diverse software projects including large integration, data engineering and reporting systems. Ahmed has a post-graduate diploma in computing from The Open University, UK. 

Aviro has developed robust internal business and scaling policies and established an agile workflow and team organisation to allow for greater autonomy for teams and individuals. Aviro has an established board of directors that provides strategic governance and oversight, and including independent board member, Ting Shih.

At Aviro Health, we are people-centred  and data-informed. We believe in centering people for engagement and trust and using data to inform decisions for efficiency.  Together, this creates measurable impact. 

Aviro recognises  the unique opportunity offered by Solve to facilitate the formation of the connections and partnerships required to make the Pocket Clinic available globally, and to profoundly increase the impact that the solution can have on individual users. As the platform expands to cater to other conditions and to other countries, access to global leaders in the industry will become essential. Through Solve’s great network of partners, we hope to gain expertise, partnerships and investment opportunities that will help us to scale our impact, especially in the following fields: 

• Technology: support with  scaling our solution to new channels and technologies, especially around Blockchain applications to better manage patient data, and machine learning applications to improve patient experience and data analysis.

• Health Networks: connections with partners who can facilitate the navigation of health system buyers and relevant regulators.

• Academia: establishing systems to complement our M&E plan with robust research and publication of findings. 

Aviro Pocket Clinic combines several existing technologies into a new application and new clinical process that meets pressing and unmet health needs. Specifically. it includes a progressive web app, chat messaging, gamification, and continuous optimisation /customisation in order to create a convenient and accessible experience for patients. The platform is carefully designed to meet patient needs by using innovative tools such as interactive video and unique patient paths to engage and monitor patients. This reduces the burden on health workers so that they can concentrate on high-value health services.

In  addition, the model of engaging with providers via a B2B2C model is innovative for the public sector. While some providers want to “build their own”, most or many public health providers are not able or interested in running  and optimizing  their own digitally supported programs, and know that it will be years (if ever) before  they are  able to make something that delivers results. Aviro has the most proven “off the shelf” complete self-testing and self-care solution for emerging markets, and is showing how these types of private sector solutions and business models can transform access to care for much of the population. 

Aviro will reach 10 million  patients in emerging markets in the coming 5 years and show verified health improvements with 2 million.

In the coming 12 months, we will be scaling this service across South Africa and Kenya and establishing it in 10 provinces (we are currently in 4); launch with 4 new health providers; and reach 200,000 patients with testing in order to get 10,000 HIV-positive patients on ARVs. We will be specifically targeting at-risk and marginalised populations that do not have access to traditional services. 

We are also currently exploring partnerships to support other types of self-testing services, specifically in COVID and other STIs, as well as in diabetes. Although these are in the early stages, we expect that these directions are easily leveraged with our current setup  and can increase our impact significantly. 

Operational success is ultimately linked to getting the maximum number of users drawn to the platform to optimize  output (engagement, linkage to care, monitoring, adherence) and  establish the health outcomes (improved self-management of disease) that will have a meaningful impact, resulting in a healthier population.

Aviro’s approach to the Monitoring and Evalution (M&E) framework for the Pocket Clinic is based on guidelines, evidence and key strategic digital health policies that inform our activities and help us measure and demonstrate attributable changes in the health system (or impact on clients) occurring as a result of the intervention. The M&E goals are:

• To strategically direct resources and effort 

• To monitor progress against APC’s goals and objectives

• To evaluate the outcomes, impact and effectiveness of the APC platform

A logic model has been used to outline the relationships between inputs, processes, outputs and outcomes at a high-level, while a results framework has been used to identify the specific goals and objectives of the Aviro Pocket Clinic platform. The logic model and results framework describe the structured approach to M&E in three levels of intervention: 

• Product: refers to Pocket Clinic systems (WhatsApp, web application, offline app)

• Programme: refers to the delivery of the intervention which involves collaboration with service  and implementation partners

• Population: refers to the target  population, users and beneficiaries of the product and the programme.

At each of these levels of intervention, Aviro has a robust set of metrics that are continuously tracked to ensure program quality and impact. At the highest business level, these translate into a few key metrics that we use throughout our daily operations and decision-making (and which feed into and guide our business OKRs) especially:

• Number of users/mo

• % of users reporting health outcomes

• % of users taking health-worker-verified health actions

• Provider partners retaining Pocket services

• Cost/patient to provide services.

Aviro Pocket Clinic is conceptually aligned with the Social Ecological model, which recognises that successful HIV intervention strategies for key populations require effective integration of evidence-based biomedical, behavioral and structural interventions.  As such, our Theory of Change, which aligns Aviro Pocket Clinic programme activities to the health outcomes of interest, has multiple change components at different intervention levels.

Overall, the aim of the user journey on Aviro Pocket Clinic is to convert a need for improved health (either perceived or unrecognized) into a demand for healthcare services. We achieve this through the following: 

1. Identify Key Users: Pocket Clinic is specifically designed with the target groups in mind and provides them with custom experiences tailored to their needs, against the background of over 270 000 new HIV infections annually. This is achieved by incorporating principles of systematic user-centered design and data-driven improvements to the system based on the results of monitoring and through structured planned experiments in alpha/beta (A/B) testing. 

2. Innovate Service Delivery: Pocket Clinic addresses four key aspects of  the self-screening journey:

• HIV awareness through customized  content and messaging

• Autonomy and privacy through decision support in pre-counselling, result interpretation and reporting, as well as in areas of data management.

• Counseling is offered using tailored video content both pre-and post-testing for reactive and non-reactive test results 

• Linkages to Care that facilitates referral of users testing positive to health facilities for confirmation, baseline investigations and treatment initiation; and negatives to preventative services.

Collaborate with Health Provider Partners: Aviro Pocket Clinic has been implemented through strategic collaborations with organisations such as Wits Reproductive Health Institute (WRHI), the Aurum Institute, Johns Hopkins University, Biomedical Research and Training Institute (BRTI), London School of Hygiene and Tropical Medicine (LSHTM), Population Science International (PSI) Kenya, and the Western Cape Provincial Department of Health. These partnerships have led to the adaptation of the product and implementation programme through rapid cycles of improvement and user acceptability testing. 

Intervene to Improve in Service Delivery: The crux of the intervention involves registered Pocket Clinic users being guided through self-testing, voluntary disclosure, reporting of results and linkage to care for positive and negative results. Future additions are expected to further support users through initiation and adherence. 

Leading to Improved Health Outcomes: The combination of the product (the Pocket Clinic digital platform that identifies needs and provides innovative experiences) and programmes (through partnerships/collaborations for health systems’ strengthening) is expected to produce the two main health outcomes: 

• Improved uptake and reporting from voluntary counseling and testing in undiagnosed People Living with HIV (PLHIV)

• Improved initiation of ART (HIV treatment) in diagnosed PLHIV

Aviro Pocket Clinic supports patients to achieve concrete health outcomes through carefully crafted medical content and proven user flows, managed and delivered through a multi-channel platform (Web App, offline app, and WhatsApp chatbots) with robust data and analytics capabilities, so that counsellors can focus on the cases that require specialised in-person support. The technology that supports delivery includes:

• Clients are guided through custom multi-language pre- and post-test counselling  content and optimised flows accessed via web, chatbot, or tablet application at a facility. They can also speak to a live counsellor through our helpdesk and access services such as finding a clinic, getting a certificate, booking an appointment or ordering a self-care product. 

• Providers have a simple online/offline tool for managing their clients and tracking results. Beyond initiation and tracking of patient journeys, the tool includes counselling and health information, support for patient handovers, and assistance with communicating with patients for reminders and follow-ups. 

• Administrators, whether in management or analysis, have access to real-time data through our dashboards. This helps them  monitor and manage healthcare workers and operations by providing insights into what is working (and what is not) and by streamlining data collection and outcomes reporting. 

Aviro Health uses several services to securely and in a GDPR-compliant manner support the collection, storage and analysis of HIV data across the countries it operates in, with most of the stack built on AWS cloud servers. Client authentication is done using Cognito and all APIs are routed via API Gateway to “microservices,” which are implemented as Lambda functions. These Lambda functions in turn interact with Aurora Postgres Serverless, which is used as an operational store. This architecture is replicated for each of the Aviro partners and provides segregation of data and execution so that each partner can be individually costed and have their data secured. Operational data is then anonymised and pushed to a data warehouse, also in Aurora Postgres Serverless. This data is initially analysed using QuickSight, and the intention is to use the machine learning services available in AWS to gain further insight into the data. There is also a strong interest to pursue the use of blockchain technology in the coming year to improve the management of patient records, for instance by improving portability, security, etc.

As Aviro Health works in health innovation and is specifically addressing the needs of communities of people preventing and living with HIV, it is crucial that we maintain an  internal culture that addresses and is aware of inclusivity and diversity dynamics. Beyond internal culture and processes, if we are to successfully  identify and effectively respond to the health needs of communities and stakeholders, it is also essential to have a critical lens and approach to how partners, clients and the communities are engaged. The level of effort in terms of inclusivity is a major determinant of the success and impact of the company and its products and programs. Aviro’s ethos also centres  around empathy, making it important to acknowledge the systemic marginalisation of women, girls, transgender people , non-binary and gender-queer folks in their diversity.

 In view of this dynamic, Aviro has conducted workshops to construct and then implement a gender and inclusivity strategy that outlines our strategic and philosophical commitments to inclusivity and that is focused (in the short term) on improving in the following 3 key directions:  business processes, especially hiring and security;  user-facing tech/content and engagement processes;  metrics and goals. Since creation of this strategy in 2020 Aviro has made numerous adjustments to operations to align to this strategy, for instance by:

1. Making changes to hiring, promotion and security policies, as well as appointing two  females in senior executive positions and hiring a female board director

2. Making changes to strategic direction and product roadmap towards inclusion

3. Prioritizing changes to user experience in terms of how gender is framed and communicated

4. Adjusting the M&E plan to be able to analyze key indicators by key diversity and inclusion metrics

5. Holding regular diversity sensitization workshops for the entire team.

We have shown that Aviro Pocket Clinic is preferable to a significant portion of patients and front-line health providers. In order to scale and make it sustainable, we need to understand clearly the value of adding the service to existing screening programs to those health-system stakeholders that actually pay for service delivery, and ensure we have a clear value proposition for them.

In the Public Sector, Departments of Health, NGO’s and global funders see Aviro Pocket Clinic’s value as (1) increasing positive yield and linkages to care by accessing clients who would not otherwise test; and (2) improving testing efficiency by reducing per patient counsellor costs. NGOs and global  funders see additional value in (3) implementing innovative programs that yield data/platforms for ongoing innovations/experiments.  This sector is where we have had the most traction to date and clearly demonstrated willingness to pay to have Aviro Pocket Clinic implemented.

We are now also  in the process of engaging with Private Sector payers and expect to run trials to test our Customer Value Proposition in the sector in the coming year. We do however have initial feedback from potential buyers that:

• Life  insurers see value in (1) increasing throughput on underwriting by simplifying the health screening process; and (2) improving policyholder loyalty and experience.

• Pharmacies see value in offering self-screening in order to (1) increase foot traffic and associated opportunities for x-sells and up-sells; (2) improve loyalty and referral.

• Employers (for example mining/trucking operations) see value in improving the effectiveness and efficiency of their employee health screening programs, (1) reducing the cost of these programs and also (2) decreasing downtime and sick days.

Aviro has to date had a B2B2C/B2G2C SAAS model with Aviro charging the payer for a supported implementation followed by a monthly subscription fee that covers training, support, upgrades, etc. Our objective has been to shift as much revenue as possible to per-user subscription fees in order to drive scalable and recurring revenue. However, we are not confident in the details and how various segments, especially in the private sector, will respond to our current pricing, so in 2022, Aviro plans to:

• Create and prioritize viable pricing/engagement models, potentially including:

  • Software license + services

  • SAAS based on per user (current model) or per HCW, per facility, etc

  • Fee-for-service model

• Test models in key markets (Pharma, life insurance, govt) and determine viability via feedback, contracts and pilots

• Construct and start to implement a scaling plan based on the most scalable/profitable model(s), 

As the pricing and revenue models solidify, in order to scale, it is also critical that we establish clear internal milestones around things needed to support the scale of those models, specifically: establishing proof points to de-risk engagement and ease partnerships; developing internal capabilities to sell to and serve particular segments; and securing funding with the right profile that will allow us to build up these proof points and capabilities.

Required for the Public Sector:

• Proof points to demonstrate: low-cost and quick uptake of the service; ability to reach patient types not traditionally reached;

• Capabilities to be built/expanded: public sector sales, marketing, and account management; integrations to public sector data systems (DHIS2, TIER.NET, etc); compliance specialists; financial capabilities to manage long RFP- and grant- based cycles.

• Funders to secure: patient impact investment to fund proof points and capabilities with a view to driving scale and adoption (and less need for strong financial return).

Required for the Private Sector:

• Proof points to demonstrate: private sector patient/customer satisfaction, x-sells/up-sells of products/services through the platform, and linkages to care.

• Capabilities to be built/expanded: private sector sales and account management; integrations with  private sector systems; Machine Learning data management capabilities; competitive marketing capabilities.

• Funders: VC-type investment to fund these proof points and capabilities with a view to driving margins and financial return.

• Signed, built and launched 7 paid instances of Aviro Pocket Clinic with NGOs and governments in SA and Kenya, with total revenue of 950k$ to date.

• Raised 1.4M$ from South African VC investors for scaling private sector models + 300k$ and 500k$ from Grand Challenges and Madiro Foundation respectively to support scaling in public sector.

• Official endorsement from NDOH; support from WC and KZN DOHs and NASCOP in Kenya

• Opened conversations with >60 potential clients in both the private and public sectors.