Digitally-supported Decentralized Diagnostics to Combat AMR

Digitally supporting health providers and patients to use rapid diagnostics at the point of care to radically improve antibiotic use, patient communication, and epidemic surveillance.

Luke Shankland

Globally almost 5 million deaths were associated with bacterial AMR. The death rate attributable to AMR was highest in west Africa, at 27.3 deaths per 100,000, followed by Eastern, Central and Southern Africa. AMR is relevant across multiple types of infections:  Urinary Tract Infections (UTIs)-resistance-associated deaths, for example, were even higher than Tuberculosis-resistance-associated deaths. Globally, 404 million cases led to 236,790 UTI-related deaths, estimated in 2019, with a  growing trend. Studies in Africa show a high resistance to common first line antibiotics; and the diagnosis of UTIs by clinical criteria alone has an error rate of ~33%.

Rapid Diagnostic (RDT) kits at the point of care can dramatically improve diagnosis in real-time, increase the possibility of test and treat approaches, and ultimately reduce syndromic management and potential overuse of antibiotics. There is an increasing pipeline of diagnostic innovations designed for point-of-care testing for bacterial infections, but decentralized testing comes with key challenges. Beyond ensuring that the cost and care models are viable, it is critical to address the perception that antibiotics are “faster and easier” interventions than a test-and-treat approach. Incorporating RDT into existing treatment algorithms requires significant patient and provider reorientation for it to be successfully adopted. 

Pocket Clinic is currently serving multiple demographics in Africa. Our current implementation partners working in HIV focus on high-risk groups who do not traditionally access facility-based HIV testing services: Youth and adolescent girls in particular, Men aged 25-40, First-time HIV testers, and key population groups (men who have sex with men (MSM); lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI); sex workers). We anticipate working with similar target groups in mind, given the high incidence of sexually transmitted infections such as gonorrhea and chlamydia.

Pocket Clinic is specifically designed with the target groups in mind and provides them with custom experiences tailored to their needs. This is achieved by incorporating principles of systematic user-centered design throughout the design and customization process. Post design and into implementation, we do data-driven improvements to the system based on the results of monitoring and through structured planned experiments in alpha/beta (A/B) testing. 

Aviro has consistently ensured that assessments and white-papers are made publicly available. Beyond dissemination of results and processes, we also believe that universal access to the information, education and communication materials and health flows are essential (ie even to patients or healthworkers who do not have access to the Pocket Clinic platform the platform in their operations). To this end, in our HIV testing support programs, Aviro has built and maintains a free universally accessible web version of the platform https://www.aviropocketclinic.co.za/ that anyone can access.  We would propose to do the same for AMR to ensure maximum accessibility.

Aviro Pocket Clinic is conceptually aligned with the Social Ecological model, believing that successful interventions 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, includes:

1. Identify Key Users: Pocket Clinic is designed with the target groups in mind and provides them with custom experiences. 

2. Innovate Service Delivery: Pocket Clinic addresses three key aspects of  the screening pathway:

• AMR awareness through customized content and messaging

• Counseling content both pre-and post-testing

• Facilitating journeys and decisions

Collaborate with Health Provider Partners: Aviro Pocket Clinic is implemented through health organisations that adapt the product and implementation programme through rapid cycles of improvement and user testing guided by data and insights.

Intervene to Improve in Service Delivery: The crux of the intervention involves registered Pocket Clinic users being guided through testing, reporting of results, diagnosis, and linkage to care for positive and negative results.

Leading to Improved Health Outcomes: The combination of the product and programmes is expected to produce the two main health outcomes: 

• Improved uptake and reporting from RDTs prior to diagnosis for infectious diseases (in particular UTIs)

• Improved accuracy of antibiotic usage

Aviro aims to reach 10 million citizens in Africa s in the coming 5 years, and show verified health improvements with 2 million.

In the coming 24 months, we will be adapting the service to the AMR use case and trialing with key research partners in Senegal, South Africa, and potentially elsewhere.  Based on the results and a clearly established value value of the service, we will be in a position to scale and make the intervention sustainable, by engaging with the health-system stakeholders that pay for service delivery and diagnostic innovations in Africa.

In the Public Sector, Departments of Health, NGO’s and global funders see Aviro Pocket Clinic’s value as improving testing/treatment efficiency and accuracy, while providing extensive new insights into epidemic spread and antibiotic use/mis-use. NGOs and global funders see additional value in 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. This pathway will need to be established for AMR stakeholders. 

We are now also in the process of engaging with Private Sector payers and expect to test our proposition in that sector in the coming year.

Aviro’s M&E goals for the intervention are:

• To strategically direct resources and effort 

• To monitor progress against goals and objectives

• To evaluate the outcomes, impact and effectiveness of the 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, dashboards)

• Programme: refers to the delivery of the intervention with implementation partners

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

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 level, these translate into a few key metrics that guide our daily operations and decision-making:

• 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.

We anticipate addressing three main barriers:

• Behaviour Change and introduction of new protocols is challenging. By guiding patients and providers through a clear and optimized workflow that has been designed with stakeholders (including behaviour change experts) to fit into existing procedures, with carefully designed communication materials and supportive training, we can increase adherence rates to new management algorithms and ultimately limit overutilization of antibiotics. 

• Lack of awareness around the AMR challenge and generating demand for new diagnostic tools.  A lack of awareness can create resistance to change at all levels (patients, providers, regulators), so strong and well-supported tools are not themselves sufficient - education and training on the risk of AMR and misuse of antibiotics among all stakeholders will be required.

• Costs may be perceived as high for introducing diagnostics and digital support tools versus the status quo. It will be necessary to carefully control the prices of both through subsidisation and scale, as well as clearly demonstrate, through robust health economic research, the cost-benefit of these solutions.

We recognises the unique opportunity offered by the Trinity Challenge to facilitate the formation of the connections and partnerships required to make the Pocket Clinic available across Africa, and to profoundly increase the impact that the solution can have on individual users. 

In particular, as the platform expands, it will be essential to have technology partners that can help us to ensure that our AI can safely and maximally support unique users, and yield the most value from our data sets. 

Access to global leaders in health will also be essential, in terms of supporting uptake of the solution in the varied contexts of Africa. Through a great network of partners, we hope to gain expertise, partnerships and investment opportunities that will help us to scale our impact.

We are especially interested in support and connections in the following fields: 

• Technology (Meta, Google): support with scaling our solution to benefit from new technologies, especially around AI applications to better manage patient interactions, and machine learning applications to improve data analysis and epidemiological reporting.

• Health Networks: connections with partners who can facilitate the navigation of health system and relevant regulators, in both public sector (Foundations) and private sector (Pharma)

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

• Regulators: ability to engage with Africa CDC, etc