Implementation of eHealth Interventions Across the HIV Care Cascade: a Review of Recent Research

Effects of telehealth-assisted interventions among people living with HIV/AIDS: A systematic review and meta-analysis of randomized controlled studies

INTRODUCTION

Taking antiretroviral therapy (ART) is a daily necessity for people living with HIV but these individuals experience multiple barriers and challenges to medication adherence. Interventions to support medication adherence have yielded effects in the expected direction, but the extent to which telehealth or virtually delivered interventions to promote adherence are effective among people living with HIV/AIDS remains unknown. We aimed to address this knowledge gap and inform future research and practice that promotes the well-being of people living with HIV/AIDs through telehealth interventions addressing medication use.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted using the following databases: Academic Search Complete, Cochrane library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, MEDLINE, PubMed, OVID (UpToDate), and the Web of Science. Relevant full-text articles published through September 2021 were retrieved. The revised Cochrane risk of bias tool for randomized trials was used to assess the methodological quality of the included studies. A meta-analysis was performed using a random-effects model to calculate the pooled effects of telehealth-assisted interventions for people living with HIV/AIDS. Stata 16.0 was used for statistical analysis.

RESULTS

A total of 12 studies (N = 3557 participants) that used telehealth-assisted interventions for people living with HIV/AIDS were included. Telehealth interventions were found to increase the adherence to treatment (standardized mean difference [SMD]: 0.21; 95% confidence interval (CI): 0.03 to 0.40), to reduce depressive symptoms (SMD: -2,74; 95% CI: -3.39 to -2.09), and to improve perceived quality of life (SMD: 0.74; 95% CI: 0.37 to 1.10).

DISCUSSION

The meta-effects of telehealth-assisted interventions include significantly enhanced adherence to treatment, improved quality of life, and reduced depressive symptoms among people living with HIV/AIDS. These findings suggesting that delivering health management interventions remotely through telehealth-assisted modalities was both feasible and effective in yielding health benefits for people living with HIV/AIDS. Integrating telehealth-assisted interventions as a modality in HIV/AIDS care might support continuity of care and sustained well-being. Future research should evaluate telehealth intervention outcomes and examine mediating, moderating, or other tailorable variables affecting intervention effectiveness.

The effect of proactive, interactive, two-way texting on 12-month retention in antiretroviral therapy: findings from a quasi-experimental study in Lilongwe, Malawi

Background

Retaining clients on antiretroviral therapy (ART) is challenging especially during the first year on ART. Mobile health (mHealth) interventions show promise to close retention gaps. We aimed to assess reach (who received the intervention?) and effectiveness (did it work?) of a hybrid two-way texting (2wT) intervention to improve ART retention at a large public clinic in Lilongwe, Malawi.

Methods

Between August 2021 - June 2023, a quasi-experimental study compared outcomes between two cohorts of new ART clients: 1) those opting into 2wT with combined automated, weekly motivation short messaging service (SMS) messages and response-requested appointment reminders; and 2) a matched historical cohort receiving standard of care (SoC). Reach was defined as "the proportion clients ≤6 months of ART initiation eligible for 2wT". 2wT effectiveness was assessed in time-to-event analysis comparing Kaplan-Meier plots of 6- and 12-month retention between 2wT and SoC using a log-rank test. The effect of 2wT on ART drop out was estimated using multivariable Cox proportional hazard models, adjusting for sex, age and WHO stage at ART initiation.

Results

Of the 1,146 clients screened, 645 were ineligible (56%) largely due to lack of phone access (393/645; 61%) and illiteracy (149/645; 23%): a reach of 44%. Among 468 2wT participants, the 12-month probability of ART retention was 91% (95%CI: 88% - 93%) compared to 75% (95%CI: 71% - 79%) among 468 SoC participants (p<0.0001). Compared to SoC participants, 2wT participants had a 62% lower hazard of dropping out of ART care at all time points (hazard ratio 0.38, 95% CI: 0.26-0.54; p<0.001).

Conclusions

Not all clients were reached with 2wT. For those who opted-in, 2wT reduced drop out throughout the first year on ART and significantly increased 12-month retention. The proactive 2wT approach should be expanded as a complement to other interventions in routine, low-resource settings to improve ART retention.

Development of text messages for primary prevention of cardiovascular disease in persons with HIV

Objective

Persons with HIV (PWH) have increased risk for atherosclerotic cardiovascular disease (CVD). Despite this increased risk, perceived cardiovascular risk among PWH is low, and interventions that are known to be beneficial in the general population, such as statins, have low uptake in this population. We sought to develop a bank of text messages about (1) the association between HIV and CVD and (2) advice on reducing cardiovascular risk.

Methods

We developed an initial bank of 162 messages. We solicited feedback from 29 PWH recruited from outpatient clinics providing HIV care at a large urban tertiary medical center and a public hospital in San Francisco, California. Participants reviewed 7-10 messages each and rated message usefulness, readability, and potential impact on behavior on a scale from 1 (least) to 5 (most). We also collected open-ended feedback on the messages and data on preferences about message timing.

Results

The average score for the messages was 4.4/5 for usefulness, 4.4/5 for readability, and 4.0/5 for potential impact on behavior. The text messages were iteratively revised based on participant feedback, and lowest-rated messages were removed from the message bank. The final message bank included 116 messages on diet (30.2%), physical activity (24.8%), tobacco (11.2%), the association between HIV and cardiovascular disease (9.5%), general heart health (6.9%), cholesterol (5.2%), blood pressure (4.3%), blood sugar (2.6%), sleep (2.6%), and weight (2.6%).

Conclusion

We describe an approach for developing educational text messages on primary prevention of cardiovascular disease among PWH.

Association between eHealth literacy, diabetic behavior rating, and burden among caregivers of children with type 1 diabetes: Cross-sectional survey study

OBJECTIVE

The purpose of this study was to clarify the relationship between eHealth literacy, diabetic behavior rating, and caregiving burden among caregivers of children with type 1 diabetes mellitus (T1DM).

METHODS

A questionnaire-based cross-sectional study of 143 primary caregivers of T1DM was conducted. Electronic health literacy was quantified using the Chinese version of the eHealth Literacy Scale (eHEALS). Their diabetic management behavior rating and caregiving burden were measured by Diabetes Behavior Rating Scale-Parent Version (DBRS-P) and Zarit Burden Interview (ZBI), respectively. Pearson correlation analysis was used to estimate the relationship between the above variables.

RESULTS

Only 54 (37.76%) caregivers qualified by eHEALS scale, with a total score of 30.07 ± 4.54 out of 40. A positive correlation between DRBS-P scores and the scores of eHEALS (Pearson correlation coefficient r = 0.226, P = 0.007) and a negative correlation between ZBI and eHEALS scores (r = -0.166, P = 0.047) were observed.

CONCLUSIONS

The eHealth literacy level of caregivers of children with T1DM in China remains to be improved. Caregivers with higher eHealth literacy had better diabetic management behaviors and less caregiving burden.

IMPLICATIONS TO PRACTICE

This study suggests that hierarchical electronic health-based interventions should be designed according to the different levels of eHealth literacy of individuals, to enhance the ability of caregivers with different eHealth literacy levels to fully utilize eHealth resources to improve their daily disease management skills and reduce their burden when caring for T1DM children. In addition, improving eHealth literacy of caregivers for children with T1DM can be one of the important ways to enhance the effectiveness of electronic health-based programs designed for them.

Keep It Up! 3.0: Study protocol for a type III hybrid implementation-effectiveness cluster-randomized trial

BACKGROUND

Despite evidence that eHealth approaches can be effective in reducing HIV risk, their implementation requirements for public health scale up are not well established, and effective strategies to bring these programs into practice are still unknown. Keep It Up! (KIU!) is an online program proven to reduce HIV risk among young men who have sex with men (YMSM) and ideal candidate to develop and evaluate novel strategies for implementing eHealth HIV prevention programs. KIU! 3.0 is a Type III Hybrid Effectiveness-Implementation cluster randomized trial designed to 1) compare two strategies for implementing KIU!: community-based organizations (CBO) versus centralized direct-to-consumer (DTC) recruitment; 2) examine the effect of strategies and determinants on variability in implementation success; and 3) develop materials for sustainment of KIU! after the trial concludes. In this article, we describe the approaches used to achieve these aims.

METHODS

Using county-level population estimates of YMSM, 66 counties were selected and randomized 2:1 to the CBO and DTC approaches. The RE-AIM model was used to drive outcome measurements, which were collected from CBO staff, YMSM, and technology providers. Mixed-methods research mapped onto the domains of the Consolidated Framework for Implementation Research will examine determinants and their relationship with implementation outcomes.

DISCUSSION

In comparing our implementation recruitment models, we are examining two strategies which have shown effectiveness in delivering health technology interventions in the past, yet little is known about their comparative advantages and disadvantages in implementation. The results of the trial will further the understanding of eHealth prevention intervention implementation.

Using the Exploration-Preparation-Implementation-Sustainment (EPIS) Framework to prepare for the implementation of evidence-based practices into adolescent HIV settings

Despite advances in evidence-based practices (EBP) to support HIV prevention and treatment, youth ages 13-24 experience significant disparities in HIV risk and outcomes. An important factor in this disparity is poor EBP implementation, yet implementation research is limited, particularly in youth-serving settings. This study used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide the implementation of four Motivational Interviewing (MI) and MI-framed interventions into youth-serving HIV prevention and treatment settings. Key stakeholders (n = 153) across 13 sites completed pre-implementation interviews. Stakeholders' comments identified two critical factors for effective implementation: fit with the patient population and provider receptivity, including concerns about scope of practice, buy-in, and time. Stakeholders recommended strategies for structuring training, fidelity monitoring, and facilitating implementation including engaging informal leaders, collaboratively developing the implementation strategy, and site-wide implementation. Results highlight the importance of pre-implementation contextual assessment and strategic planning for identifying provider concerns and developing responsive implementation strategies.

A Longitudinal Mixed-Methods Examination of Positive Health Check: Implementation Results From a Type 1 Effectiveness-Implementation Hybrid Trial

BACKGROUND

Positive Health Check is an evidence-based video doctor intervention developed for improving the medication adherence, retention in care, and viral load suppression of people with HIV receiving clinical care.

SETTING

Four HIV primary care clinics within the United States.

METHODS

As part of a type 1 hybrid trial, a mixed-methods approach was used to longitudinally assess the following 3 key implementation constructs over a 23-month period: innovation-values fit (ie, the extent to which staff perceive innovation use will foster the fulfillment of their values), organizational readiness for change (ie, the extent to which organizational members are psychologically and behaviorally prepared to implement organizational change), and implementation climate (ie, the extent to which implementation is expected, supported, and rewarded). Quantitative mixed-effects regression analyses were conducted to assess changes over time in these constructs. Qualitative analyses were integrated to help provide validation and understanding.

RESULTS

Innovation-values fit and organizational readiness for change were found to be high and relatively stable. However, significant curvilinear change over time was found for implementation climate. Based on the qualitative data, implementation climate declined toward the end of implementation because of decreased engagement from clinic champions and differences in priorities between research and clinic staff.

CONCLUSIONS

The Positive Health Check intervention was found to fit within HIV primary care service settings, but there were some logistical challenges that needed to be addressed. Additionally, even within the context of an effectiveness trial, significant and nonlinear change in implementation climate should be expected over time.

Assessment of a viral load result-triggered automated differentiated service delivery model for people taking ART in Lesotho (the VITAL study): Study protocol of a cluster-randomized trial

INTRODUCTION

To sustainably provide good quality care to increasing numbers of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in resource-limited settings, care delivery must shift from a "one-size-fits-all" approach to differentiated service delivery models. Such models should reallocate resources from PLHIV who are doing well to groups of PLHIV who may need more attention, such as those with treatment failure. The VIral load Triggered ART care Lesotho (VITAL) trial assesses a viral load (VL)-, participant's preference-informed, electronic health (eHealth)-supported, automated differentiated service delivery model (VITAL model). With VITAL, we aim to assess if the VITAL model is at least non-inferior to the standard of care in the proportion of participants engaged in care with viral suppression at 24 months follow-up and if it is cost-saving.

METHODS

The VITAL trial is a pragmatic, multicenter, cluster-randomized, non-blinded, non-inferiority trial with 1:1 allocation conducted at 18 nurse-led, rural health facilities in two districts of northern Lesotho, enrolling adult PLHIV taking ART. In intervention clinics, providers are trained to implement the VITAL model and are guided by a clinical decision support tool, the VITALapp. VITAL differentiates care according to VL results, clinical characteristics, sub-population and participants' and health care providers' preferences.

EXPECTED OUTCOMES

Evidence on the effect of differentiated service delivery for PLHIV on treatment outcomes is still limited. This pragmatic cluster-randomized trial will assess if the VITAL model is at least non-inferior to the standard of care and if it is cost saving.

TRIAL REGISTRATION

The study has been registered with clinicaltrials.gov (Registration number NCT04527874; August 27, 2020).

eHealth supported multi-months dispensing of antiretroviral therapy: a mixed-methods preference assessment in rural Lesotho

BACKGROUND

Multi-month dispensing (MMD) of antiretroviral therapy (ART) represents one approach of differentiated service delivery (DSD) aiming to improve quality and cost-effectiveness for HIV services in resource-limited settings. However, reduction in clinic visits for people living with HIV (PLWH) should go along with out-of-clinic care tailored to PLWH`s preferences and comorbidities to maintain quality of care. eHealth supported MMD offers a potential solution.

METHODS

Between October 2019 and January 2020 we assessed preferences on an eHealth supported MMD package among adult PLWH attending routine ART care at a rural clinic in Lesotho using a mixed-methods approach. Participants reported their preferences among different refill and eHealth options. They were invited to test automated text messages (SMS) informing about their viral load results, an automated tuberculosis symptoms screening call and telemedical support by an expert nurse. Telemedical service comprised a call-back option if participants required any additional support and adherence counselling for closer follow-up of participants with unsuppressed viral loads. After 6 weeks, participants were followed-up to assess perception of the chosen eHealth support using a qualitative approach.

RESULTS

Among 112 participants (median age = 43 years; 74% female), 83/112 (75%) preferred MMD for 6-12 months (median = 9 months, IQR = [5, 12]). Neither sex, age, employment, costs and time for travel to clinic, nor the duration of taking ART correlated with the MMD preference. All 17 participants attending routine viral load measurement wished to receive the result via SMS. Fifteen (19.2%) participants requested a telemedical nurse call-back during the study period. All participants with recent unsuppressed viral load (N = 13) requested telemedical adherence counselling for closer follow-up. Among 78 participants followed-up, 76 (97%) would appreciate having the call-back option in future. Seventy-five participants (67%) received and evaluated the automated symptomatic tuberculosis screening call, overall 71 (95%) appreciated it.

CONCLUSIONS

The great majority of PLWH in this study preferred 6-12 months MMD and appreciated the additional eHealth support, including viral load results via SMS, telemedical nurse consultations and automated tuberculosis symptom screening calls. eHealth supported MMD packages appear to be a promising approach for DSD models and should be assessed for clinical endpoints and cost-effectiveness in larger studies.

Adapting digital health interventions for the evolving HIV landscape: examples to support prevention and treatment research

PURPOSE OF REVIEW

Although many HIV prevention and/or treatment digital health interventions (DHIs) have shown feasibility and acceptability, fewer have indicated efficacy, and only a subset have been adapted for new contexts. Adaptation is a key element of pragmatic implementation science research. Adaptation is cost effective and time efficient compared with new development. Leveraging adaptation can lead to accelerated scale-up and enhanced public health impact. Considering the value of adaptation, the purpose of this piece is to present examples of DHI to DHI adaptation sequences to inform future HIV prevention and/or treatment research.

RECENT FINDINGS

From an examination of recent academic articles (01 November 2016 to 31 October 2021), we identified adaptation sequences that included an original DHI with at least two adaptations. Four models are presented herein; examples consist of adapted DHIs for new population, health outcome, geography, or a combination thereof.

SUMMARY

Adaptation is a promising scientific approach to expeditiously respond to the evolving HIV landscape. We present examples of DHI adaptations alongside considerations for each type of adaptation; we also present adaptation challenges with responsive strategies. We suggest when conducted with attention to rigor (leveraging adaptation frameworks, community engagement, and tailoring content), adaptation is a powerful tool to pragmatically address the HIV epidemic.

Effectiveness of eHealth Interventions for HIV Prevention and Management in Sub-Saharan Africa: Systematic Review and Meta-analyses

HIV is still the leading cause of death in Sub-Saharan Africa (SSA), despite medical advances. eHealth interventions are effective for HIV prevention and management, but it is unclear whether this can be generalised to resource-poor settings. This systematic review aimed to establish the effectiveness of eHealth interventions in SSA. Six electronic databases were screened to identify randomised controlled trials (RCTs) published between 2000 and 2020. Meta-analyses were performed, following Cochrane methodology, to assess the impact of eHealth interventions on HIV-related behaviours and biological outcomes. 25 RCTs were included in the review. Meta-analyses show that eHealth interventions significantly improved HIV management behaviours (OR 1.21; 95% CI 1.05-1.40; Z = 2.67; p = 0.008), but not HIV prevention behaviours (OR 1.02; 95% CI 0.78-1.34; Z = 0.17; p = 0.86) or biological outcomes (OR 1.17; 95% CI 0.89-1.54; Z = 1.10; p = 0.27) compared with minimal intervention control groups. It is a hugely important finding that eHealth interventions can improve HIV management behaviours as this is a low-cost way of improving HIV outcomes and reducing the spread of HIV in SSA. PROSPERO registration number: CRD42020186025.

Mobile health interventions for HIV/STI prevention among youth in low- and middle-income countries (LMICs): a systematic review of studies reporting implementation outcomes

BACKGROUND

Advances and proliferation of technologies such as mobile phones may provide opportunities to improve access to HIV/STI services and reach young people with high risk for HIV and STI. However, the reach, uptake, and sustainability of mobile health (mHealth) HIV/STI interventions targeting young people aged 10-24 years in low- and middle-income countries (LMICs) are largely unknown. To address this gap and to inform implementation science research, a review was conducted to summarize what is known, and what we need to know about implementing mhealth interventions for HIV/STI prevention targeting young people in LMICs.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this review. Drawing upon Proctor's eight implementation outcome measures, we evaluated the acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability of  m-health HIV/STI interventions targeting young people in LMICs. The search was performed from September 2020-January 2021 and updated on March 1, 2021, in Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, SCOPUS, Global Health, and Web of Science. Eligible studies were required to include an HIV/STI prevention outcome, target young people aged 10-24 years, include a comparison/control group, and reporting of atleast one implementation outcome as outlined by Proctor.

RESULTS

A total of 1386 articles were located, and their titles and abstracts were screened. Of these, 57 full-text articles were reviewed and subsequently, and 11 articles representing 6 unique interventions were included in the systematic review. Acceptability 6 (100%), appropriateness 6 (100%), and feasibility 5(83%) were the most frequently evaluated implementation outcomes. Adoption 2 (33%), fidelity 1 (17%), and cost 1 (17%) were rarely reported; penetration and sustainability were not reported.

CONCLUSIONS

This review contributes to implementation science literature by synthesizing key implementation outcomes of mHealth HIV/STI interventions targeting young people in LMICs. Future research is needed on m-health HIV/STI implementation outcomes, particularly the penetration, cost, and long-term sustainability of these interventions. Doing so will enhance the field's understanding of the mechanisms by which these interventions lead or do not lead to changes in high HIV/STI risk and vulnerability among young people in LMICs.

Patient-Provider Text Messaging and Video Calling Among Case-Managed Patients Living With HIV: Formative Acceptability and Feasibility Study

Background

Patient-provider communication is critical for engaging and retaining people living with HIV in care, especially among medically case-managed patients in need of service coordination and adherence support. Expanding patient-provider communication channels to include mobile health modalities, such as text messaging and video calling, has the potential to facilitate communication and ultimately improve clinical outcomes. However, the implementation of these communication modalities in clinical settings has not been well characterized.

Objective

The purpose of this study is to understand patient and provider perspectives on the acceptability of and preferences for using text messaging and video calling as a means of communication; perceived factors relevant to adoption, appropriateness, and feasibility; and organizational perspectives on implementation within an HIV clinic in South Carolina.

Methods

We conducted 26 semistructured in-depth interviews among patients receiving case management services (n=12) and clinic providers (n=14) using interview guides and content analysis informed by the Proctor taxonomy of implementation outcomes and the Consolidated Framework for Implementation Research. Participants were purposefully sampled to obtain maximum variation in terms of age and gender for patients and clinic roles for providers. The data were analyzed using quantitative and qualitative content analyses.

Results

Most patients (11/12, 92%) and providers (12/14, 86%) agreed that they should have the capacity to text message and/or video call each other. Although consensus was not reached, most preferred using a secure messaging app rather than standard text messaging because of the enhanced security features. Perceived benefits to adoption included the added convenience of text messaging, and potential barriers included the cost and access of smartphone-based technology for patients. From an organizational perspective, some providers were concerned that offering text messaging could lead to unreasonable expectations of instant access and increased workload.

Conclusions

Patients and providers perceived text messaging and video calling as acceptable, appropriate, and feasible and felt that these expanded modes of communication could help meet patients’ needs while being safe and not excessively burdensome. Although patients and providers mostly agreed on implementation barriers and facilitators, several differences emerged. Taking both perspectives into account when using implementation frameworks is critical for expanding mobile health–based communication, especially as implementation requires active participation from providers and patients.

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

Ethical Implications of eHealth Tools for Delivering STI/HIV Laboratory Results and Partner Notifications

Purpose of Review

eHealth tools are increasingly utilized for communication with patients. Although efficacious and cost-effective, these tools face several barriers that challenge their ethical use in sexual health. We reviewed literature from the past decade to pick illustrative studies of eHealth tools that deliver results of laboratory tests for sexually transmitted infections, including the human immunodeficiency virus, as well as partner notifications. We describe ethical implications for such technologies.

Recent Findings

Our review found that despite widespread research on the use of eHealth tools in delivering laboratory results and partner notifications, these studies rarely measured or reported on the ethical implications. Such implications can be organized according to the four major principles in bioethics: beneficence, patient autonomy, non-maleficence, and justice. The beneficence of eHealth typically measures efficacy in comparison to existing standards of care. Patient autonomy includes the ability to opt in or out of eHealth tools, right-based principles of consent, and sovereignty over healthcare data. To adhere to the principle of non-maleficence, relevant harms must be identified and measured—such as unintentional disclosure of illness, sexual orientation, or sexual activity. Justice must also be considered to accommodate all users equally, irrespective of their literacy level, with easy-to-use platforms that provide clear messages.

Summary

Based on case studies from this review, we developed a list of recommendations for the ethical development and evaluation of eHealth platforms to deliver STI/HIV results to patients and notifications to partners.

A systematic review of early adoption of implementation science for HIV prevention or treatment in the United States

OBJECTIVE

To provide the first systematic review of the early adoption of implementation science for HIV prevention or treatment in the United States. We identified primary research studies that addressed implementation of HIV prevention or treatment in the United States and qualitatively assessed the reporting of implementation outcomes and intervention descriptions.

METHODS

We searched PubMed, PsycInfo, and CINAHL databases for evaluations of HIV prevention or treatment interventions that at least reported one implementation outcome and were published between 2014 and 2018. We used the 12-item Template for Intervention Description and Replication to assess study interventions.

RESULTS

A total of 2275 articles were identified. Thirty-nine studies met inclusion criteria. Of these, 84.6% used quantitative methods with 5% being hybrid effectiveness-implementation studies and 15% used qualitative methods. No studies cited a formal theoretical framework for implementation science. Acceptability and feasibility were the most frequently reported implementation outcomes. Eligible studies were diverse with regard to demographic categories. Most interventions focused on HIV prevention, particularly risk-reduction strategies. HIV treatment interventions targeted linkage to care and adherence to medications. Key implementation outcome findings indicated that these interventions are feasible and acceptable in the real world.

CONCLUSION

HIV implementation science could support dissemination of HIV prevention or treatment in the United States, although HIV treatment interventions are limited. Theoretical frameworks and key implementation outcomes like fidelity, penetration, and appropriateness could promote the rigor of future HIV treatment implementation research, helping the field deliver the promise of HIV prevention or treatment efforts in the United States.

Scale up mHealth HIV interventions: site and public health perspectives and lessons learned from P3

A number of mobile health (mHealth) interventions have been shown to be effective and highly acceptable tools for improving human immunodeficiency virus (HIV) prevention and care for youth. Scale-up of efficacious technology-based interventions is challenging and best practices for scale-up have not been clearly established. Developers of mHealth interventions should have plans in mind for wide scale implementation throughout all stages of development including planning, during trials and during analysis and dissemination. We discuss an approach of focus on researchers, funders and potential implementers including members of the community, public health practitioners and policymakers during initial planning, trials, analysis and dissemination, and planning for scale-up. Development of the P3 (Prepared, Protected, emPowered) mobile application (app), an intervention built to encourage and increase pre-exposure prophylaxis (PrEP) adherence among young men who have sex with men (YMSM) and young transgender women who have sex with men (YTWSM), is discussed in terms of designing for scale-up and lessons learned.

Care manager perspectives on integrating an mHealth app system into clinical workflows: A mixed methods study

OBJECTIVE

mHealth can be a valuable means of monitoring symptoms and supporting care for rural patients, but barriers to implementation remain. This study aimed to examine care manager perspectives on the adoption, use and impact of an mHealth system deployed within a pragmatic Collaborative Care trial for rural patients with PTSD and/or Bipolar Disorder.

METHOD

Sixteen care managers at 12 Federally Qualified Health Centers in 3 states participated in semi-structured interviews. Interviews were transcribed, coded, and thematically analyzed using the Unified Theory of Adoption and Use of Technology as a conceptual framework. App metadata was used to assess the frequency of a care manager reported phenomenon, clinically disengaged app use.

RESULTS

4 themes were identified: infrastructural limitations; redundant and incompatible clinical and mHealth workflows; cross platform and web access; and patient engagement and clinically disengaged app use. Most users had a period of consistently submitting symptom measures via the app while disengaged from care for >4 weeks.

Secure Delivery of HIV-Related and Tuberculosis Laboratory Results to Patient Cell Phones: A Pilot Comparative Study

South Africa processes 5.1 million HIV CD4, viral load (VL), and tuberculosis (TB) tests annually. This pilot non-randomized trial in South Africa explored an intervention ("MatlaMobile") to deliver laboratory results via mobile phone. Adults completing CD4, VL, and/or TB laboratory tests were enrolled-either receiving results by returning to clinic (control, n = 174) or mobile phone (intervention, n = 226). Study staff instructed control participants to return within 6 days (standard-of-care). MatlaMobile instructed intervention participants with clinically actionable results requiring intervention or treatment change (i.e., < 200 CD4 cells per milliliter, ≥ 400 viral copies per milliliter, or TB positive) to return immediately. A greater proportion of intervention participants than controls saw their results within 7 days of enrollment (73% vs. 8.6%, p < 0.001). Among participants instructed to return, more intervention participants (20%, n = 14/70) returned than controls (8.6%, n = 15/174, p = 0.02). MatlaMobile demonstrated that patients can quickly receive and respond appropriately to digital delivery of health information.

Patient's Perspectives of Telepsychiatry: The Past, Present and Future

Access to mental health care has significant disparities due to treatment gap, more so particularly for the remotely residing, physically vulnerable, aging populations. Adoption of technology will enable more people to receive specialty care addressing distance, transportation and cost-related barriers to treatment engagement from the comfort of home. Telemedicine has been regarded as "electronic personal protective equipment" by reducing the number of physical contacts and risk contamination for patients during COVID-19 crisis. This review aimed to give a broad view of patients' perception of the use of telepsychiatry in terms of clinical outcome, cost-effectiveness, and solutions to address patients' challenges with the adoption of technology. Over the years, telepsychiatry, both in synchronous and asynchronous modalities, had shown to improve patients' adherence to treatment, follow-up rates, and clinical symptoms, overcome stigma and discrimination, and save cost expenses accessing health care with better satisfaction and usability outcomes. Its utility is widespread such as in delivering care emergency evaluation, crisis intervention, conducting neuropsychological assessments, psychotherapy, promoting lifestyle modification, enhancing self-efficacy, and overcoming patients' linguistic and cultural barriers to care. However, patients' privacy and confidentiality and psychiatrists' legal liability remain as matter of major concern in digital platform. To keep up with the pace of technology and patients' expectations, a more agile approach is essential to develop, improve, and evaluate telepsychiatric interventions.

Positive Health Check evaluation: A type 1 hybrid design randomized trial to decrease HIV viral loads in patients seen in HIV primary care

For people with HIV, important transmission prevention strategies include early initiation and adherence to antiretroviral therapy and retention in clinical care with the goal of reducing viral loads as quickly as possible. Consequently, at this point in the HIV epidemic, innovative and effective strategies are urgently needed to engage and retain people in health care to support medication adherence. To address this gap, the Positive Health Check Evaluation Trial uses a type 1 hybrid randomized trial design to test whether the use of a highly tailored video doctor intervention will reduce HIV viral load and retain people with HIV in health care. Eligible and consenting patients from four HIV primary care clinical sites are randomly assigned to receive either the Positive Health Check intervention in addition to the standard of care or the standard of care only. The primary aim is to determine the effectiveness of the intervention. A second aim is to understand the implementation potential of the intervention in clinic workflows, and a third aim is to assess the costs of intervention implementation. The trial findings will have important real-world applicability for understanding how digital interventions that take the form of video doctors can be used to decrease viral load and to support retention in care among diverse patients attending HIV primary care clinics.

Understanding and Preventing Health Concerns About Emerging Mobile Health Technologies

New technologies and innovations have often improved population well-being and societal function; however, these are also often initially accompanied by worry and fear. In some cases, such worries can impede, or even prevent entirely, the adoption of the technology. Mobile health (mHealth), a discipline broadly focused on employing ambulatory technologies to improve the affordability, reach, and effectiveness of health promotion and clinical intervention approaches, offers new innovations and opportunities. Despite emerging evidence supporting mHealth efficacy (eg, for improving health outcomes), some individuals have concerns about mHealth technology that may impede scalability, efficacy, and, ultimately, the public health benefits of mHealth. We present a review and conceptual framework to examine these issues, focusing on three overarching themes: biophysiological, psychological, and societal concerns. There are features of mHealth that lead to worries about the potential negative effects on an individual’s health (eg, due to exposure to electromagnetic or radio waves), despite evidence supporting the safety of these technologies. When present, such beliefs can lead to worry that gives rise to the experience of unpleasant and concerning physical symptoms—the nocebo effect. This may represent an important implementational barrier because of apprehension toward beneficial mHealth products (or features thereof, such as wireless charging, wearable or implantable sensors, etc) and may also have broader ramifications (eg, leading to economic, governmental, and legislative actions). In addition to reviewing evidence on these points, we provide a broad three-step model of implementation research in mHealth that focuses on understanding and preventing health concerns to facilitate the safe and effective scalability of mHealth (and that may be generalizable and applied to similar technologies): (1) evaluating and better discerning public perceptions and misperceptions (and how these may differ between populations), (2) developing theory-based public health communication strategies regarding the safety of mHealth, and (3) disseminating this messaging using evidence-based methods. Collectively, these steps converge on reviewing evidence regarding the potential role of worry and nocebo in mHealth and providing a model for understanding and changing attitudes and preventing unfounded negative perceptions related to mHealth technology.

An Internet-Based, Peer-Delivered Messaging Intervention for HIV Testing and Condom Use Among Men Who Have Sex With Men in India (CHALO!): Pilot Randomized Comparative Trial

Background

Leveraging internet-based communication tools (eg, messaging apps, SMS text messaging, and email) may be an effective avenue for delivery of HIV prevention messages to men who have sex with men (MSM) in India, but there are limited models for such internet-based interventions.

Objective

The CHALO! pilot was an online educational and behavioral intervention aimed to determine the feasibility, acceptability, and preliminary impact of a peer-delivered, internet-based messaging intervention for HIV testing and consistent condom use for MSM in India. The messages addressed barriers to HIV testing and condom use and were theoretically based on the information-motivation-behavioral skills model.

Methods

Between February and March 2015, we recruited, enrolled, and randomized 244 participants via online advertisements on mobile dating apps and Facebook. Eligible men (18 years or older, sexually active with other men, and self-reported HIV-negative or unknown status) were randomized to receive educational and motivational messages framed as either approach (ie, a desirable outcome to be achieved) or avoidance (an undesirable outcome to be avoided) over 12 weeks via internet-based messaging platforms. Participants completed online surveys at baseline and immediately postintervention.

Results

Participants were similar across arms with respect to sociodemographic and behavioral characteristics. Over 82.0% (200/244) of participants were retained (ie, viewed final messages), and 52.3% (130/244) of them completed the follow-up survey. Of those completing the follow-up survey, 82.3% (107/130) liked or strongly liked participating in CHALO!. The results showed a significant increase in self-reported HIV testing in the past 6 months from baseline to follow-up (41/130, 31.5% to 57/130, 43.8%; P=.04). When including those who reported intentions to test, this percentage increased from 44.6% (58/130) at baseline to 65.4% (85/130) at follow-up (P<.01). When examining intentions to test among those without prior HIV testing, intentions increased from 32% (16/50) of the sample at baseline to 56% (28/50) of the sample at follow-up (P=.02). Condom use during anal sex did not significantly change from baseline to follow-up. HIV testing and condom use did not significantly differ between approach and avoidance conditions at follow-up.

Conclusions

As one of the first studies of an online HIV prevention intervention for Indian MSM, CHALO! was feasible to implement by a community-based organization, was acceptable to participants, and demonstrated potential to improve HIV testing rates.

Design Considerations for Implementing eHealth Behavioral Interventions for HIV Prevention in Evolving Sociotechnical Landscapes

PURPOSE OF REVIEW

Despite tremendous potential for public health impact and continued investments in development and evaluation, it is rare for eHealth behavioral interventions to be implemented broadly in practice. Intervention developers may not be planning for implementation when designing technology-enabled interventions, thus creating greater challenges for real-world deployment following a research trial. To facilitate faster translation to practice, we aimed to provide researchers and developers with an implementation-focused approach and set of design considerations as they develop new eHealth programs.

RECENT FINDINGS

Using the Accelerated Creation-to-Sustainment model as a lens, we examined challenges and successes experienced during the development and evaluation of four diverse eHealth HIV prevention programs for young men who have sex with men: Keep It Up!, Harnessing Online Peer Education, Guy2Guy, and HealthMindr. HIV is useful for studying eHealth implementation because of the substantial proliferation of diverse eHealth interventions with strong evidence of reach and efficacy and the responsiveness to rapid and radical disruptions in the field. Rather than locked-down products to be disseminated, eHealth interventions are complex sociotechnical systems that require continual optimization, vigilance to monitor and troubleshoot technological issues, and decision rules to refresh content and functionality while maintaining fidelity to core intervention principles. Platform choice and sociotechnical relationships (among end users, implementers, and the technology) heavily influence implementation needs and challenges. We present a checklist of critical implementation questions to address during intervention development. In the absence of a clear path forward for eHealth implementation, deliberate design of an eHealth intervention's service and technological components in tandem with their implementation plans is critical to mitigating barriers to widespread use. The design considerations presented can be used by developers, evaluators, reviewers, and funders to prioritize the pragmatic scalability of eHealth interventions in research.

Economic evaluation studies in the field of HIV/AIDS: bibliometric analysis on research development and scopes (GAPRESEARCH)

Background

The rapid decrease in international funding for HIV/AIDS has been challenging for many nations to effectively mobilize and allocate their limited resources for HIV/AIDS programs. Economic evaluations can help inform decisions and strategic planning. This study aims to examine the trends and patterns in economic evaluation studies in the field of HIV/AIDS and determine their research landscapes.

Methods

Using the Web of Science databases, we synthesized the number of papers and citations on HIV/AIDS and economic evaluation from 1990 to 2017. Collaborations between authors and countries, networks of keywords and research topics were visualized using frequency of co-occurrence and Jaccards’ similarity index. A Latent Dirichlet Allocation (LDA) analysis to categorize papers into different topics/themes.

Results

A total of 372 economic evaluation papers were selected, including 351 cost-effectiveness analyses (CEA), 11 cost-utility analyses (CUA), 12 cost-benefit analyses (CBA). The growth of publications, their citations and usages have increased remarkably over the years. Major research topics in economic evaluation studies consisted of antiretroviral therapy (ART) initiation and treatment; drug use prevention interventions and prevention of mother-to-child transmission interventions. Moreover, lack of contextualized evidence was found in specific settings with high burden HIV epidemics, as well as emerging most-at-risk populations such as trans-genders or migrants.

Conclusion

This study highlights the knowledge and geographical discrepancies in HIV/AIDS economic evaluation literature. Future research directions are also informed for advancing economic evaluation in HIV/AIDS research.

An mHealth pilot designed to increase the reach of prevention of mother-to-child transmission of HIV (PMTCT) across the treatment cascade in a resource-constrained setting in Tanzania

BACKGROUND

Data collection and integrated reporting between the multiple health facilities for supporting more efficient care linkages is an indispensable element for prevention of mother-to-child transmission of HIV (PMTCT) by fostering continuity of patient care and improving the treatment cascade for HIV-infected pregnant women. mHealth potentially presents timely solutions to the data challenges related to efficient and effective care delivery in resource-constrained settings, particularly in low- and middle-income countries.

METHODS

This randomized controlled pilot study used stratified random sampling for the selection of seven intervention and seven control sites in Misungwi, Tanzania, a rural district in the northwestern region. Twenty-eight health workers at seven intervention health facilities used the Tanzania Health Information Technology (T-HIT) system during a 3-month period from February 23, 2015, through May 23, 2015, to capture antenatal, delivery, and postnatal patient visits.

RESULTS

T-HIT was designed for use on tablets with the goal to improve reporting, surveillance and monitoring of HIV rates and care delivery in the remote and rural settings. Health workers successfully recorded 2,453 visits. Of these, 1,594 were antenatal visits, 484 deliveries were recorded, and 375 were postnatal visits. Within the antenatal visits, 96% of women had a single visit (1474). Healthcare workers were unable to test 6.7% of women antenatally for HIV.

CONCLUSION

The T-HIT pilot demonstrated the feasibility for implementing an mHealth integrated solution in a rural, low-resource setting that links tablet-based surveillance, health worker capacity-building and patient reminders into a single robust and responsive system. Although the implementation phase was only three months, the pilot generated evidence that T-HIT has potential for improving patient outcomes by providing more comprehensive, linked, and timely PMTCT care data at the individual and clinic levels.