Pilot RCT of bidirectional text messaging for ART adherence among nonurban substance users with HIV

Personalized interventions for behaviour change: A scoping review of just-in-time adaptive interventions

PURPOSE

Examine the development, implementation and evaluation of just-in-time adaptive interventions (JITAIs) in behaviour change and evaluate the quality of intervention reporting.

METHODS

A scoping review of JITAIs incorporating mobile health (mHealth) technologies to improve health-related behaviours in adults. We searched MEDLINE, Embase and PsycINFO using terms related to JITAIs, mHealth, behaviour change and intervention methodology. Narrative analysis assessed theoretical foundations, real-time data capturing and processing methods, outcome evaluation and summarized JITAI efficacy. Quality of intervention reporting was assessed using the template for intervention description and replication (TIDieR) checklist.

RESULTS

Sixty-two JITAIs across physical activity, sedentary behaviour, dietary behaviour, substance use, sexual behaviour, fluid intake, treatment adherence, social skills, gambling behaviour and self-management skills were included. The majority (71%) aimed to evaluate feasibility, acceptability and/or usability. Supporting evidence for JITAI development was identified in 46 studies, with 67% applying this to develop tailored intervention content. Over half (55%) relied solely on self-reported data for tailoring, and 13 studies used only passive monitoring data. While data processing methods were commonly reported, 44% did not specify their techniques. 89% of JITAI designs achieved full marks on the TIDieR checklist and provided sufficient details on JITAI components. Overall, JITAIs proved to be feasible, acceptable and user-friendly across behaviours and settings. Randomized trials showed tailored interventions were efficacious, though outcomes varied by behaviour.

CONCLUSIONS

JITAIs offer a promising approach to developing personalized interventions, with their potential effects continuously growing. The recommended checklist emphasizes the importance of reporting transparency in establishing robust intervention designs.

Technology-Based Interventions for Substance Use Treatment Among People Who Identify as African American or Black, Hispanic or Latino, and American Indian or Alaska Native: Scoping Review

BACKGROUND

In the United States, racial and ethnic disparities in substance use treatment outcomes are persistent, especially among underrepresented minority (URM) populations. Technology-based interventions (TBIs) for substance use treatment show promise in reducing barriers to evidence-based treatment, yet no studies have described how TBIs may impact racial or ethnic health equity.

OBJECTIVE

This study explored whether TBIs in substance use treatment research promote health equity among people who identify as African American or Black, Hispanic or Latino, and American Indian or Alaska Native through their inclusion in research. We explored whether research that includes the aforementioned groups consciously considers race and/or ethnicity beyond including these populations as participants.

METHODS

We conducted a scoping review of 5 electronic databases to identify TBIs in substance use treatment studies published in English between January 2000 and March 2021. Studies were included if ≥50% of participants identified as African American or Black, Hispanic or Latino, or American Indian or Alaska Native when combined. Included studies were evaluated for conscious consideration of race and ethnicity in at least one manuscript section. Finally, we conducted a critical appraisal of each study's potential to facilitate insights into the impact of a TBI for members of specific URM groups.

RESULTS

Of 6897 titles and abstracts screened and 1158 full-text articles assessed for eligibility, nearly half (532/1158, 45.9%) of the full-text articles were excluded due to the absence of data on race, ethnicity, or not meeting the aforementioned demographic eligibility criteria. Overall, 110 studies met the inclusion criteria. Study designs included 39.1% (43/110) randomized trials, and 35.5% (39/110) feasibility studies. In total, 47.3% (52/110) of studies used computer-based interventions, including electronic screening, brief interventions, and referrals to treatment, whereas 33.6% (37/110) used interactive voice response, ecological momentary assessment or interventions, or SMS text messaging via mobile phones. Studies focused on the following substances: alcohol or drugs (45/110, 40.9%), alcohol alone (26/110, 23.6%), opioids (8/110, 7.3%), cannabis (6/110, 5.5%), cocaine (4/110, 3.6%), and methamphetamines (3/110, 2.7%). Of the studies that consciously considered race or ethnicity (29/110, 26.4%), 6.4% (7/110) explicitly considered race or ethnicity in all manuscript sections. Overall, 28.2% (31/110) of the studies were critically appraised as having a high confidence in the interpretability of the findings for specific URM groups.

CONCLUSIONS

While the prevalence of TBIs in substance use treatment has increased recently, studies that include and consciously consider URM groups are rare, especially for American Indian or Alaska Native and Hispanic or Latino groups. This review highlights the limited research on TBIs in substance use treatment that promotes racial and ethnic health equity and provides context, insights, and direction for researchers working to develop and evaluate digital technology substance use interventions while promoting health equity.

Feasibility of Lantern Using WhatsApp to Improve Antiretroviral Therapy Adherence

This pilot study tested the feasibility of Lantern program, an adherence program to HIV medications using WhatsApp, a secure social media messaging application from Meta, for a smartphone-based platform to enhance medication-taking adherence of antiretroviral therapy among people living with HIV in Indonesia. Thirty participants were recruited for this 8-week study. We recruited persons if they had taken antiretroviral therapy for at least 3 months prior to the study, had a smartphone, Internet access, and could use Lantern with WhatsApp. Here, we report the results from the focus group discussions, with the participants evaluating the qualitative aspects of the experiences. The WhatsApp platform was found to be safe, practical, and relatively inexpensive and provided confidentiality for the participants. Three themes emerged from the focus groups: the study motivated participants to take their antiretroviral therapy medications on time, they still set medication reminder alarms, and being in the study made them feel supported. The Lantern program indicated good feasibility and acceptability for adherence to antiretroviral therapies among people living with HIV. Future research should examine on how community organizations and healthcare providers can take advantage of the WhatsApp program to improve adherence to antiretroviral therapies.

An mHealth Platform for People With HIV Receiving Care in Washington, District of Columbia: Qualitative Analysis of Stakeholder Feedback

BACKGROUND

HIV viral suppression and retention in care continue to be challenging goals for people with HIV in Washington, District of Columbia (DC). The PositiveLinks mobile app is associated with increased retention in care and viral load suppression in nonurban settings. The app includes features such as daily medication reminders, mood and stress check-ins, an anonymized community board for peer-to-peer social support, secure messaging to care teams, and resources for general and clinic-specific information, among other features. PositiveLinks has not been tailored or tested for this distinct urban population of people with HIV.

OBJECTIVE

This study aimed to inform the tailoring of a mobile health app to the needs of people with HIV and their providers in Washington, DC.

METHODS

We conducted a 3-part formative study to guide the tailoring of PositiveLinks for patients in the DC Cohort, a longitudinal cohort of >12,000 people with HIV receiving care in Washington, DC. The study included in-depth interviews with providers (n=28) at study clinics, focus groups with people with HIV enrolled in the DC Cohort (n=32), and a focus group with members of the DC Regional Planning Commission on Health and HIV (COHAH; n=35). Qualitative analysis used a constant comparison iterative approach; thematic saturation and intercoder agreement were achieved. Emerging themes were identified and grouped to inform an adaptation of PositiveLinks tailored for patients and providers.

RESULTS

Emerging themes for patients, clinic providers, and COHAH providers included population needs and concerns, facilitators and barriers to engagement in care and viral suppression, technology use, anticipated benefits, questions and concerns, and suggestions. DC Cohort clinic and COHAH provider interviews generated an additional theme: clinic processes. For patients, the most commonly discussed potential benefits included improved health knowledge and literacy (mentioned n=10 times), self-monitoring (n=7 times), and connection to peers (n=6 times). For providers, the most common anticipated benefits were improved communication with the clinic team (n=21), connection to peers (n=14), and facilitation of self-monitoring (n=11). Following data review, site principal investigators selected core PositiveLinks features, including daily medication adherence, mood and stress check-ins, resources, frequently asked questions, and the community board. Principal investigators wanted English and Spanish versions depending on the site. Two additional app features (messaging and documents) were selected as optional for each clinic site. Overall, 3 features were not deployed as not all participating clinics supported them.

CONCLUSIONS

Patient and provider perspectives of PositiveLinks had some overlap, but some themes were unique to each group. Beta testing of the tailored app was conducted (August 2022). This formative work prepared the team for a cluster randomized controlled trial of PositiveLinks' efficacy. Randomization of clinics to PositiveLinks or usual care occurred in August 2022, and the randomized controlled trial launched in November 2022.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/37748.

Description of patient questions received by clinical pharmacists in the Nudge Study

PURPOSE

The Nudge Study is a patient level-randomized trial testing different text message medication refill reminders sent to patients assigned to 4 arms: (1) usual care, (2) generic text, (3) optimized text, and (4) optimized text plus chatbot. This report describes the frequency and types of patient questions sent to clinical pharmacists (CPs) following text reminders.

METHODS

Patients were enrolled from Denver Health and Hospital Authority (DHHA) and Veterans Affairs Eastern Colorado Health Care System (VA ECHCS) from October 1, 2019, through May 30, 2021. Included patients responded to at least 1 text or interactive voice response (IVR) message. Patients were dichotomized as those who posed at least 1 question to a CP and those who posed no questions.

RESULTS

Of the 6,325 patients enrolled in an intervention arm, 3,323 (52.5%) responded to at least 1 text or IVR message, and among those responding, 305 (9.2%) responded with a pharmacist question. Patient factors associated with submitting a CP question included age (45-74 years), enrollment from DHHA, and receipt of the optimized text or optimized text plus chatbot message versus the generic text. Questions to CP were in the following categories: medication related (48.2%), refill logistics (38.4%), cost (9.2%), and other (17.7%).

CONCLUSION

In a text messaging intervention focused on medication refills, there were few questions directed to the CP. Patients assigned to receive optimized texts were more likely to have questions. We hypothesize that this may suggest greater patient engagement regarding their condition, resulting in more questions.

Telephone messages regarding preventive measures against COVID-19

OBJECTIVE

To analyze the evidence of content validity of telephone messages regarding preventive measures against COVID-19.

METHOD

Methodological study, in which messages containing text and image were developed through a narrative literature review and whose content was evaluated by eight judges in terms of clarity, practical relevance, theoretical relevance and vocabulary. The content validity index (CVI) was calculated, and messages that reached levels above 90% were considered to have adequate evidence of validity.

RESULTS

Eighteen text messages/images were developed containing information about COVID-19, hand hygiene, use and handling of masks and the importance of social distancing. After second round of evaluation, a content validity index above 90% was obtained in all evaluated indicators.

CONCLUSION

The telephone messages were developed and showedadequate evidence of content validity.

Efficacy of an mHealth self-management intervention for persons living with HIV: the WiseApp randomized clinical trial

IMPORTANCE

Progression of HIV disease, the transmission of the disease, and premature deaths among persons living with HIV (PLWH) have been attributed foremost to poor adherence to HIV medications. mHealth tools can be used to improve antiretroviral therapy (ART) adherence in PLWH and have the potential to improve therapeutic success.

OBJECTIVE

To determine the efficacy of WiseApp, a user-centered design mHealth intervention to improve ART adherence and viral suppression in PLWH.

DESIGN, SETTING, AND PARTICIPANTS

A randomized (1:1) controlled efficacy trial of the WiseApp intervention arm (n = 99) versus an attention control intervention arm (n = 101) among persons living with HIV who reported poor adherence to their treatment regimen and living in New York City.

INTERVENTIONS

The WiseApp intervention includes the following components: testimonials of lived experiences, push-notification reminders, medication trackers, health surveys, chat rooms, and a "To-Do" list outlining tasks for the day. Both study arms also received the CleverCap pill bottle, with only the intervention group linking the pill bottle to WiseApp.

RESULTS

We found a significant improvement in ART adherence in the intervention arm compared to the attention control arm from day 1 (69.7% vs 48.3%, OR = 2.5, 95% CI 1.4-3.5, P = .002) to day 59 (51.2% vs 37.2%, OR = 1.77, 95% CI 1.0-1.6, P = .05) of the study period. From day 60 to 120, the intervention arm had higher adherence rates, but the difference was not significant. In the secondary analyses, no difference in change from baseline to 3 or 6 months between the 2 arms was observed for all secondary outcomes.

CONCLUSIONS

The WiseApp intervention initially improved ART adherence but did not have a sustained effect on outcomes.

Study Protocol for a Pilot Randomized Trial of a Virtual Occupational Therapy Fall Prevention Intervention for People With HIV and Alcohol Use

Background

People living with HIV (PLWH) are at risk for falls due to polypharmacy, unhealthy substance (risky alcohol and/or illicit drug) use, low physical activity, and frailty combined with typical age-related physical changes. Fall prevention is needed to reduce the morbidity related to falls and fractures, however, there is a paucity of data on the design of a fall prevention intervention and whether it can be delivered virtually. We describe the protocol of a pilot randomized trial of a virtual occupational therapy fall prevention intervention for people with HIV at high risk for falls and recent alcohol and/or drug use.

Method

PLWH will be recruited from the Boston ARCH 4F Cohort study, an observational study of PLWH to examine the impact of alcohol on falls. Trial participants will be randomized to either an occupational therapy-led fall prevention intervention or provided with written education about fall prevention and alcohol use (control). The 10-week fall prevention intervention was based upon results from qualitative interviews with PLWH about falls and will consist of weekly virtual group sessions, home exercises and phone-check-ins, delivered by occupational therapists. The primary outcome measures will be number of groups attended and a participant-completed satisfaction survey. Change in number of falls, alcohol and other drug use, and physical functioning will be examined.

Discussion

A virtual occupational therapy fall prevention intervention addresses the emerging concern of fall risk in PLWH and alcohol use. This pilot study will provide preliminary estimates of fall-related outcomes as well as feasibility of study procedures for a larger trial.

ClinicalTrialsgov Identifier

NCT04804579. Boston University Protocol Record H-41041.

Applications of Behavioral Economics to Pharmaceutical Policymaking: A Scoping Review with Implications for Best-Value Biological Medicines

BACKGROUND AND OBJECTIVE

Pharmaceutical policies are generally based on the assumption that involved stakeholders make rational decisions. However, behavioral economics has taught us that this is not always the case as people deviate from rational behavior in rather predictable patterns. This scoping review examined to what extent behavioral concepts have already been applied in the pharmaceutical domain and what evidence exists about their effectiveness, with the aim of formulating future applications and research hypotheses on policymaking for best-value biologicals.

METHODS

A scoping literature review was conducted on the evidence of behavioral applications to pharmaceuticals. Scientific databases (Embase, MEDLINE, APA PsycArticles, and Scopus) were searched up to 20 October, 2021.

RESULTS

Forty-four full-text scientific articles were identified and narratively described in this article. Pharmaceutical domains where behavioral concepts have been investigated relate to influencing prescribing behavior, improving medication adherence, and increasing vaccination uptake. Multiple behavioral concepts were examined in the identified studies, such as social norms, defaults, framing, loss aversion, availability, and present bias. The effectiveness of the applied interventions was generally positive, but depended on the context. Some of the examined interventions can easily be translated into effective policy interventions for best-value biological medicines. However, some applications require further investigation in a research context.

CONCLUSIONS

Applications of behavioral economics to pharmaceutical policymaking are promising. However, further research is required to investigate the effect of behavioral applications on policy interventions for a more sustainable market environment for best-value biological medicines.

Accountability in reminder-based adherence interventions: A review

OBJECTIVE

Interventions to elicit accountability capitalize on social behaviors to improve adherence but are distinct from reminders. However, little is known about the impact of accountability in reminder-based adherence interventions. Through a literature review, we aim to identify the frequency and effectiveness of accountability in reminder-based intervention studies.

METHODS

PubMed and PsycArticles were searched for reminder-based adherence studies. Articles were categorized as reminder-only or reminder with accountability studies. Studies were characterized by outcome measures, and differences between control and intervention groups were compared for studies that used electronic monitoring devices.

RESULTS

165 studies met the inclusion criteria; 154 used reminders without accountability (93%). 79 of the 154 reminder-only studies (51%) improved adherence in intervention groups compared to controls. Eleven of the 165 studies (6.6%) included an accountability aspect. The intervention group had better adherence than controls in 10 out of the 11 reminder with accountability studies (91%).

CONCLUSIONS

Although distinct from reminders, accountability can be incorporated in reminder-based interventions. However, it is not commonly included in reminder-based interventions.

PRACTICE IMPLICATIONS

It is important to consider accountability's effects on encouraging patient medication adherence. The addition of accountability interventions may further boost adherence, but few studies currently incorporate these types of interventions.

Technology-mediated just-in-time adaptive interventions (JITAIs) to reduce harmful substance use: a systematic review

BACKGROUND AND AIMS

Lapse risk when trying to stop or reduce harmful substance use is idiosyncratic, dynamic and multi-factorial. Just-in-time adaptive interventions (JITAIs) aim to deliver tailored support at moments of need or opportunity. We aimed to synthesize evidence on decision points, tailoring variables, intervention options, decision rules, study designs, user engagement and effectiveness of technology-mediated JITAIs for reducing harmful substance use.

METHODS

Systematic review of empirical studies of any design with a narrative synthesis. We searched Ovid MEDLINE, Embase, PsycINFO, Web of Science, the ACM Digital Library, the IEEE Digital Library, ClinicalTrials.gov, the ISRCTN register and dblp using terms related to substance use/mHealth/JITAIs. Outcomes were user engagement and intervention effectiveness. Study quality was assessed with the mHealth Evidence Reporting and Assessment checklist.

FINDINGS

We included 17 reports of 14 unique studies, including two randomized controlled trials. JITAIs targeted alcohol (S = 7, n = 120 520), tobacco (S = 4, n = 187), cannabis (S = 2, n = 97) and a combination of alcohol and illicit substance use (S = 1, n = 63), and primarily relied on active measurement and static (i.e. time-invariant) decision rules to deliver support tailored to micro-scale changes in mood or urges. Two studies used data from prior participants and four drew upon theory to devise decision rules. Engagement with available JITAIs was moderate-to-high and evidence of effectiveness was mixed. Due to substantial heterogeneity in study designs and outcome variables assessed, no meta-analysis was performed. Many studies reported insufficient detail on JITAI infrastructure, content, development costs and data security.

CONCLUSIONS

Current implementations of just-in-time adaptive interventions (JITAIs) for reducing harmful substance use rely on active measurement and static decision rules to deliver support tailored to micro-scale changes in mood or urges. Studies on JITAI effectiveness are lacking.

Evaluation of the Implementation and Effectiveness of a Mobile Health Intervention to Improve Outcomes for People With HIV in the Washington, DC Cohort: Study Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Gaps remain in achieving retention in care and durable HIV viral load suppression for people with HIV in Washington, DC (hereafter DC). Although people with HIV seeking care in DC have access to a range of supportive services, innovative strategies are needed to enhance patient engagement in this setting. Mobile health (mHealth) interventions have shown promise in reaching previously underengaged groups and improving HIV-related outcomes in various settings.

OBJECTIVE

This study will evaluate the implementation and effectiveness of a clinic-deployed, multifeature mHealth intervention called PositiveLinks (PL) among people with HIV enrolled in the DC Cohort, a longitudinal cohort of people with HIV receiving care in DC. A cluster randomized controlled trial will be conducted using a hybrid effectiveness-implementation design and will compare HIV-related outcomes between clinics randomized to PL versus usual care.

METHODS

The study aims are threefold: (1) We will perform a formative evaluation of PL in the context of DC Cohort clinics to test the feasibility, acceptability, and usability of PL and tailor the platform for use in this context. (2) We will conduct a cluster randomized controlled trial with 12 DC Cohort clinics randomized to PL or usual care (n=6 [50%] per arm) and measure the effectiveness of PL by the primary outcomes of patient visit constancy, retention in care, and HIV viral load suppression. We aim to enroll a total of 482 participants from DC Cohort clinic sites, specifically including people with HIV who show evidence of inconsistent retention in care or lack of viral suppression. (3) We will use the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to measure implementation success and identify site, patient, provider, and system factors associated with successful implementation. Evaluation activities will occur pre-, mid-, and postimplementation.

RESULTS

Formative data collection was completed between April 2021 and January 2022. Preliminary mHealth platform modifications have been performed, and the first round of user testing has been completed. A preimplementation evaluation was performed to identify relevant implementation outcomes and design a suite of instruments to guide data collection for evaluation of PL implementation throughout the trial period. Instruments include those already developed to support DC Cohort Study activities and PL implementation in other cohorts, which required modification for use in the study, as well as novel instruments designed to complete data collection, as guided by the CFIR and RE-AIM frameworks.

CONCLUSIONS

Formative and preimplementation evaluations will be completed in spring 2022 when the trial is planned to launch. Specifically, comprehensive formative data analysis will be completed following data collection, coding, preliminary review, and synthesis. Corresponding platform modifications are ready for beta testing within the DC Cohort. Finalization of the platform for use in the trial will follow beta testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04998019; https://clinicaltrials.gov/ct2/show/NCT04998019.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37748.

mHealth Intervention to Improve Treatment Outcomes Among People With HIV Who Use Cocaine: Protocol for a Pilot Randomized Controlled Trial

Background

Antiretroviral therapy is effective in reducing HIV-related morbidity, mortality, and transmission among people with HIV. However, adherence and persistence to antiretroviral therapy are crucial for successful HIV treatment outcomes. People with HIV who use cocaine have poor access to HIV services and lower retention in care.

Objective

The primary goal of this paper is to provide a detailed description of a mobile health intervention. This study is designed to improve medication adherence among people with HIV who use cocaine. A secondary goal is to list the important challenges and adaptations incorporated in the study design.

Methods

This study, titled Project SMART, used a wireless technology–based intervention, including cellular-enabled electronic pillboxes called TowerView Health and smartphones, to provide reminders and feedback on adherence behavior. The intervention design was based on the theoretical frameworks provided by the self-determination theory and the Motivation Technology Model. The 12-week pilot randomized controlled trial with four arms provided three types of feedback: automated feedback, automated+clinician feedback, and automated feedback+social network feedback.

Results

The study was funded by the National Institute of Drug Abuse (R21DA039842) on August 1, 2016. The institutional review board for the study was approved by Yale University on March 21, 2017. Data collection lasted from June 2017 to January 2020. The final enrollment was 71 participants, of whom 57 (80%) completed the study. The data are currently undergoing analysis, and the manuscript is being developed for publication in early 2022.

Conclusions

Implementing complex mobile health interventions for high-risk and marginalized populations with multicomponent interventions poses certain challenges, such as finding companies with adequate technology for clients and financial stability and minimizing the research-related burden for the study population. Conducting feasibility studies is important to recognize these challenges and the opportunity to address these challenges with solutions while keeping the design of a randomized controlled trial as true as possible.

Trial Registration

Clinicaltrials.gov NCT04418076; https://clinicaltrials.gov/ct2/show/NCT04418076

International Registered Report Identifier (IRRID)

DERR1-10.2196/28332

The Role of Alcohol-Related Behavioral Risk in the Design of HIV Prevention Interventions in the Era of Antiretrovirals: Alcohol Challenge Studies and Research Agenda

HIV/AIDS remains a significant health threat and alcohol is a robust contributing factor. After 25 years of alcohol challenge studies investigating alcohol-related behavioral risk (ARBR), much has been learned delineating how drinking influences sexual transmission. We examine this research and consider its relevance for interventions in the era of antiretrovirals. We consider prototypic alcohol challenge methods, illustrative findings, and prevention/intervention implications, noting three perspectives: (a) scale up/extend existing interventions, including identifying under-targeted risk groups and intersecting with PrEP/PEP interventions; (b) modify existing interventions by cultivating psychoeducational content related to alcohol expectancies, alcohol myopia, sexual arousal, risk perception, sexual abdication, and condom use resistance; and (c) innovate new interventions through Science of Behavior Change approaches and repurposing ARBR paradigms. Finally, we suggest research directions concluding that until HIV incidence diminishes significantly, psychosocial interventions addressing the nexus of alcohol use, sexual transmission, and adherence to biomedical protocols will be an important priority.

Digitized HIV/AIDS Treatment Adherence Interventions: A Review of Recent SMS/Texting Mobile Health Applications and Implications for Theory and Practice

BACKGROUND

Mobile health technologies (mHealth) are efficacious along the continuum of HIV/AIDS-from prevention of HIV transmission to those at the highest risk of acquiring infection, to adherence to HIV medical care, for those living with the disease-decreasing the public health burden of the disease. HIV/AIDS is a complex condition, as certain population subgroups are disproportionately affected. Furthermore, barriers experienced at the individual level (e.g., HIV stigma) and at the systems level (i.e., access to care) contribute to these disparities. Low cost, high penetration rates and ease of use mean mHealth SMS/texting solutions hold the biggest promise for curbing the global HIV/AIDS epidemic; yet these technologies have their own challenges. Our primary objective was to assess interventions that promote adherence, which are delivered via SMS/texting, and important design and ethical considerations of these technologies. Specifically, we evaluated the underlying frameworks underpinning intervention design, strategies to safeguard privacy and confidentiality, and measures taken to ensure equity and equitable access across different subgroups of persons living with HIV (PLWH). We also synthesized study outcomes, barriers/facilitators to adherence, and barriers/facilitators of technology to support HIV adherence.

METHODS

A scoping review methodology was utilized, searching the Medline database for recently published articles (January 2017 to June 2019). Two reviewers independently screened titles and abstracts for relevancy using the following eligibility criteria: (a) original research or protocol; (b) inclusion of persons living with HIV; (c) intervention delivery via SMS/text messaging; and, (d) intervention included HIV care adherence.

RESULTS

Seven (7) of the 134 articles met full criteria. The great majority (n = 6) did not report whether the interventions were developed under established behavioral change models or frameworks. Strategies to address privacy, confidentiality and equity/equitable access were taken in four (n = 4) studies.

CONCLUSION

Our mixed methods review determined that privacy and confidentiality remain a concern for PLWH. Provisions to accommodate literacy, infrastructure, technology and other challenges (e.g., access to smartphones and Wifi) are important ethical considerations that guarantee equity and equitable access. Further investigation will determine the contexts within which theoretical models and frameworks remain relevant in the rapidly evolving field of digitized interventions that support adherence.

Improving Care Outcomes for PLWH Experiencing Homelessness and Unstable Housing: a Synthetic Review of Clinic-Based Strategies

PURPOSE OF REVIEW

Singular interventions targeting vulnerable populations of people living with HIV (PLWH) are necessary for reducing new infections and optimizing individual-level outcomes, but extant literature for PLWH who experience homelessness and unstable housing (HUH) has not been compiled. To inform implementation of clinic-based programs that improve care outcomes in this population, we present a synthetic review of key studies examining clinic-based interventions, specifically case management, patient navigation, financial incentives, and the use of mobile technology.

RECENT FINDINGS

Results from unimodal interventions are mixed or descriptive, are limited by inability to address related multi-modal barriers to care, and do not address major challenges to implementation. Multi-component interventions are needed, but gaps in our knowledge base may limit widespread uptake of such interventions before further data are compiled. Future research evaluating interventions for PLWH experiencing HUH should include implementation outcomes in order to facilitate adaptation across diverse clinical settings.

mHealth Interventions to Promote Anti-Retroviral Adherence in HIV: Narrative Review

Background

Antiretrovirals (ARVs) are key in the management of HIV. Although no cure exists, ARVs help patients live healthy lives and prevent transmission to others. Adherence to complex regimens is paramount to outcomes and in avoiding the emergence of drug-resistant viruses. The goal of therapy is to reach an undetectable viral load. However, adherence is a common problem, stemming from issues such as mental health, chaotic home situations, and busy work schedules. Mobile health (mHealth) represents a new approach in improving medication adherence, and multiple studies have been performed in this area.

Objective

This study aims to review the current implementation of mHealth in the management of HIV among different groups of patients.

Methods

We used PubMed, Academic Search Elite, and 1 journal database with various search terms to review the current implementation of mHealth in HIV care.

Results

Titles and abstracts were screened, and 61 papers were identified and fully reviewed. The literature was divided into lower- and higher-income nations, as defined by the United Nations. A total of 20 studies with quantitative results were identified, with 10 being text- and SMS-based interventions (the majority of these being in lower-income countries) and 8 being smartphone-based apps (primarily in higher-income countries). The majority of these studies determined whether there was an effect on adherence or biochemical parameters (viral load and CD4 count). Various qualitative studies have also been conducted, and many have focused on determining the specific design of interventions that were successful (frequency of messaging, types of messages, etc) as well as priorities for patients with regard to mHealth interventions.

Conclusions

There seems to be a role of mHealth in the management of HIV in lower-income nations; however, the optimal design of an intervention needs to be delineated. In higher-income countries, where the 2 significant risk factors were injection drugs and men who have sex with men, the benefit was less clear, and more research is needed.

Do interventions to improve adherence to antiretroviral therapy recognise diversity? A systematic review

People living with HIV (PLWH) are often culturally and linguistically diverse populations; these differences are associated with differing barriers to antiretroviral therapy (ART) adherence. Cultural competence measures the extent to which trial design recognises this diversity. This systematic review aimed to determine whether adherence trial participants represent the diversity of PLWH. Randomised Controlled Trials in Organisation for Economic Co-operation and Development countries to improve ART adherence were eligible. We searched MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews. For all included trials, we searched for their development, testing and evaluation studies. We compared trial participant characteristics with nationally reported PLWH data. We appraised trial cultural competence against ten criteria; scoring each criterion as 0, 1 or 2 indicating cultural blindness, pre-competence or competence respectively. For 80 included trials, a further 13 studies presenting development/testing/evaluation data for the included trials were identified. Only one of the 80 included studies reported trial participants representative of the country's population of PLWH. The median (IQ) cultural competence score was 2.5 (1.0, 4.0) out of 20. HIV adherence trial participants are not reflective of the population with HIV, which may be due to limited adoption of culturally competent research methods.

Applying the Electronic Health Literacy Lens: Systematic Review of Electronic Health Interventions Targeted at Socially Disadvantaged Groups

BACKGROUND

Electronic health (eHealth) has the potential to improve health outcomes. However, eHealth systems need to match the eHealth literacy needs of users to be equitably adopted. Socially disadvantaged groups have lower access and skills to use technologies and are at risk of being digitally marginalized, leading to the potential widening of health disparities.

OBJECTIVE

This systematic review aims to explore the role of eHealth literacy and user involvement in developing eHealth interventions targeted at socially disadvantaged groups.

METHODS

A systematic search was conducted across 10 databases for eHealth interventions targeted at older adults, ethnic minority groups, low-income groups, low-literacy groups, and rural communities. The eHealth Literacy Framework was used to examine the eHealth literacy components of reviewed interventions. The results were analyzed using narrative synthesis.

RESULTS

A total of 51 studies reporting on the results of 48 interventions were evaluated. Most studies were targeted at older adults and ethnic minorities, with only 2 studies focusing on low-literacy groups. eHealth literacy was not considered in the development of any of the studies, and no eHealth literacy assessment was conducted. User involvement in designing interventions was limited, and eHealth intervention developmental frameworks were rarely used. Strategies to assist users in engaging with technical systems were seldom included in the interventions, and accessibility features were limited. The results of the included studies also provided inconclusive evidence on the effectiveness of eHealth interventions.

CONCLUSIONS

The findings highlight that eHealth literacy is generally overlooked in developing eHealth interventions targeted at socially disadvantaged groups, whereas evidence about the effectiveness of such interventions is limited. To ensure equal access and inclusiveness in the age of eHealth, eHealth literacy of disadvantaged groups needs to be addressed to help avoid a digital divide. This will assist the realization of recent technological advancements and, importantly, improve health equity.

Targeted client communication via mobile devices for improving sexual and reproductive health

BACKGROUND

The burden of poor sexual and reproductive health (SRH) worldwide is substantial, disproportionately affecting those living in low- and middle-income countries. Targeted client communication (TCC) delivered via mobile devices (MD) (TCCMD) may improve the health behaviours and service use important for sexual and reproductive health.

OBJECTIVES

To assess the effects of TCC via MD on adolescents' knowledge, and on adolescents' and adults' sexual and reproductive health behaviour, health service use, and health and well-being.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials of TCC via MD to improve sexual and reproductive health behaviour, health service use, and health and well-being. Eligible comparators were standard care or no intervention, non-digital TCC, and digital non-targeted communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second. We have presented results separately for adult and adolescent populations, and for each comparison.

MAIN RESULTS

We included 40 trials (27 among adult populations and 13 among adolescent populations) with a total of 26,854 participants. All but one of the trials among adolescent populations were conducted in high-income countries. Trials among adult populations were conducted in a range of high- to low-income countries. Among adolescents, nine interventions were delivered solely through text messages; four interventions tested text messages in combination with another communication channel, such as emails, multimedia messaging, or voice calls; and one intervention used voice calls alone. Among adults, 20 interventions were delivered through text messages; two through a combination of text messages and voice calls; and the rest were delivered through other channels such as voice calls, multimedia messaging, interactive voice response, and instant messaging services. Adolescent populations TCCMD versus standard care TCCMD may increase sexual health knowledge (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.23 to 1.71; low-certainty evidence). TCCMD may modestly increase contraception use (RR 1.19, 95% CI 1.05 to 1.35; low-certainty evidence). The effects on condom use, antiretroviral therapy (ART) adherence, and health service use are uncertain due to very low-certainty evidence. The effects on abortion and STI rates are unknown due to lack of studies. TCCMD versus non-digital TCC (e.g. pamphlets) The effects of TCCMD on behaviour (contraception use, condom use, ART adherence), service use, health and wellbeing (abortion and STI rates) are unknown due to lack of studies for this comparison. TCCMD versus digital non-targeted communication The effects on sexual health knowledge, condom and contraceptive use are uncertain due to very low-certainty evidence. Interventions may increase health service use (attendance for STI/HIV testing, RR 1.61, 95% CI 1.08 to 2.40; low-certainty evidence). The intervention may be beneficial for reducing STI rates (RR 0.61, 95% CI 0.28 to 1.33; low-certainty evidence), but the confidence interval encompasses both benefit and harm. The effects on abortion rates and on ART adherence are unknown due to lack of studies. We are uncertain whether TCCMD results in unintended consequences due to lack of evidence. Adult populations TCCMD versus standard care For health behaviours, TCCMD may modestly increase contraception use at 12 months (RR 1.17, 95% CI 0.92 to 1.48) and may reduce repeat abortion (RR 0.68 95% CI 0.28 to 1.66), though the confidence interval encompasses benefit and harm (low-certainty evidence). The effect on condom use is uncertain. No study measured the impact of this intervention on STI rates. TCCMD may modestly increase ART adherence (RR 1.13, 95% CI 0.97 to 1.32, low-certainty evidence, and standardised mean difference 0.44, 95% CI -0.14 to 1.02, low-certainty evidence). TCCMD may modestly increase health service utilisation (RR 1.17, 95% CI 1.04 to 1.31; low-certainty evidence), but there was substantial heterogeneity (I2 = 85%), with mixed results according to type of service utilisation (i.e. attendance for STI testing; HIV treatment; voluntary male medical circumcision (VMMC); VMMC post-operative visit; post-abortion care). For health and well-being outcomes, there may be little or no effect on CD4 count (mean difference 13.99, 95% CI -8.65 to 36.63; low-certainty evidence) and a slight reduction in virological failure (RR 0.86, 95% CI 0.73 to 1.01; low-certainty evidence). TCCMD versus non-digital TCC No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may modestly increase in service attendance overall (RR: 1.12, 95% CI 0.92-1.35, low certainty evidence), however the confidence interval encompasses benefit and harm. TCCMD versus digital non-targeted communication No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may increase service utilisation overall (RR: 1.71, 95% CI 0.67-4.38, low certainty evidence), however the confidence interval encompasses benefit and harm and there was considerable heterogeneity (I2 = 72%), with mixed results according to type of service utilisation (STI/HIV testing, and VMMC). Few studies reported on unintended consequences. One study reported that a participant withdrew from the intervention as they felt it compromised their undisclosed HIV status.

AUTHORS' CONCLUSIONS

TCCMD may improve some outcomes but the evidence is of low certainty. The effect on most outcomes is uncertain/unknown due to very low certainty evidence or lack of evidence. High quality, adequately powered trials and cost effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCC delivered by mobile devices. Given the sensitivity and stigma associated with sexual and reproductive health future studies should measure unintended consequences, such as partner violence or breaches of confidentiality.

Mobile Health Intervention for Outpatient Treatment of Tuberculosis and HIV Infection

Aim of the study. To describe the results of using mobile health intervention for improving the compliance of patients with tuberculosis and HIV (TB/HIV). Materials and methods. Piloted clinic-affiliated mobile intervention was carried out in 54 patients with TB/HIV and with a history of psychoactive substances abuse in Irkutsk Regional Clinical Tuberculosis Hospital. The mobile intervention included a smartphone application that connected the participants to the staff of Irkutsk Regional TB Hospital and provided daily queries on stress, mood and medication adherence; appointment reminders; virtual support group and consultation resources; weekly quizzes. We assessed longitudinal impact on retention in medical care, visit constancy, viral loads and CD4 counts, TB outcomes. Results. In 6 months, we registered the increase (in comparison with baseline) in mean CD4 counts (F = 6.61; р = 0.04) and in the number of cases of suppressed viral loads – from 20.5 % (9/44) to 55.3 % (21/38) (p < 0.01) in TB/HIV users of e-health app. We found a lower level of TB treatment interruption in patients who used the application in comparison with the patients who refused to use it (4/44 vs 5/10; χ2 = 7.09; р = 0.008). App users completed the course of TB treatment in 63.6 % of cases (28/44), and 61.4 % of patients (27/44) were cured which was higher than the level in the control group (20 % (2/10)) (χ2 = 7.54; p = 0.03). Conclusion. This study has demonstrated that a mobile health intervention can have a positive impact on improving the medical and social care and clinical outcomes for TB/HIV patients with history of psychoactive substances abuse.

The Implementation of a Text Messaging Intervention to Improve HIV Continuum of Care Outcomes Among Persons Recently Released From Correctional Facilities: Randomized Controlled Trial

Background

Previously incarcerated individuals have suboptimal linkage and engagement in community HIV care. Mobile health (mHealth) interventions have been shown to be effective in addressing these gaps. In Washington, District of Columbia (DC), we conducted a randomized trial of an SMS text messaging–based mHealth intervention (CARE+ Corrections) to increase linkage to community HIV care and antiretroviral treatment adherence among HIV-infected persons involved in the criminal justice system.

Objective

This study aimed to describe the SMS text messaging–based intervention, participant use of the intervention, and barriers and facilitators of implementation.

Methods

From August 2013 to April 2015, HIV-positive incarcerated individuals were recruited within the DC Department of Corrections, and persons released in the past 6 months were recruited within the community via street-based recruitment, community partnerships, and referrals. Participants were followed for 6 months and received weekly or daily SMS text messages. Formative research resulted in the development of the content of the messages in 4 categories: HIV Appointment Reminders, Medication Adherence, Prevention Reminders, and Barriers to Care following release from jail. Participants could customize the timing, frequency, and message content throughout the study period.

Results

Of the 112 participants enrolled, 57 (50.9%) were randomized to the intervention group and 55 (49.1%) to the control group; 2 control participants did not complete the baseline visit, and were dropped from the study, leaving a total of 110 participants who contributed to the analyses. Study retention was similar across both study arms. Median age was 42 years (IQR 30-50), 86% (49/57) were black or African American, 58% (33/57) were male, 25% (14/57) were female, and 18% (10/57) were transgender. Median length of last incarceration was 4 months (IQR 1.7-9.0), and median lifetime number of times incarcerated was 6.5 (IQR 3.5-14.0). Most participants (32/54, 59%) had a baseline viral load of <200 copies/mL. Nearly all participants (52/57, 91%) chose to use a cell phone provided by the study. The most preferred Appointment Reminder message was Hey how you feeling? Don’t forget to give a call and make your appointment (19/57, 33%). The most preferred Medication Adherence message was Don’t forget your skittles! (31/57, 54%), and 63% (36/57) of participants chose to receive daily (vs weekly) messages from this category at baseline. The most preferred Prevention Reminder message was Stay strong. Stay clean (18/57, 32%). The most preferred Barriers to Care message was Holla at your case manager, they’re here to help (12/57, 22%). Minor message preference differences were observed among participants enrolled in the jail versus those from the community.

Conclusions

Participants’ ability to customize their SMS text message plan proved helpful. Further large-scale research on mHealth platforms is needed to assess its efficacy among HIV-infected persons with a history of incarceration.

Trial Registration

ClinicalTrials.gov NCT01721226; https://clinicaltrials.gov/ct2/show/NCT01721226

A novel technology-enhanced internalized stigma and shame intervention for HIV-positive persons with substance use disorders

Internalized stigma, shame, and other negative self-conscious emotions are inadequately addressed barriers to HIV-related self-care, particularly among people actively using substances. Innovative approaches are needed to optimize antiretroviral treatment (ART) adherence as well as engagement in HIV care among people living with HIV and substance use disorders. Based on qualitative feedback from providers and patients, we iteratively developed and conducted a proof-of-concept study of a relatively brief transdiagnostic emotion regulation intervention designed to improve ART adherence care by addressing behavioral and psychological barriers, including internalized stigma and shame, among people living with HIV and active substance use disorders. The final intervention included 5 individual sessions focused on metacognitive awareness of emotions and thoughts, cognitive reframing of dysfunctional thoughts about the self using concepts such as self-compassion, and identifying and reaching the participants' personalized HIV-self-care goal(s). All participants received daily texts querying current emotion and weekly texts querying ART adherence and substance use. To extend the effects of the intervention, we developed a personalized bi-directional text component through which participants received their personalized compassionate self-statements, informed by the intervention content, in response to their answers to emotion queries for 8 weeks after the 5 sessions. The texts modeled using compassionate self-statements as a form of cognitive reframing, consistent with cognitive restructuring of distorted core beliefs. We consented 10 participants living with HIV and problematic substance use in the proof-of-concept pilot. Of the 8 participants who completed all intervention sessions, participants replied to 70% of all text messages sent. All 8 reported strong acceptability of the intervention content. This emotion-focused, technology-enhanced intervention demonstrated proof-of-concept, in that this patient population would participate in this intervention. A larger randomized controlled pilot is needed to determine feasibility and acceptability among people living with HIV and substance use disorders, a hard-to-reach and underserved population.

The Florida Mobile Health Adherence Project for People Living With HIV (FL-mAPP): Longitudinal Assessment of Feasibility, Acceptability, and Clinical Outcomes

Background

For people living with HIV (PLWH), antiretroviral therapy (ART) adherence is crucial to attain better health outcomes. Although research has leveraged consumer health information technologies to enhance ART adherence, no study has evaluated feasibility and clinical outcomes associated with the usage of a commercially available, regularly updated mobile health (mHealth) app for improving ART adherence among PLWH.

Objective

This study aimed to assess the feasibility, acceptability, and clinical outcomes of Care4Today, an existing, free, biprogrammatic mHealth app for improving ART adherence among PLWH.

Methods

The Florida mHealth Application Adherence Project (FL-mAPP) was a 90-day longitudinal pilot study conducted in 3 public HIV clinics in Florida, United States. After obtaining informed consent, 132 participants completed a survey and then were given the option to try an existing mHealth app to help with ART adherence. Of these, 33.3% (44/132) declined, 31.1% (41/132) agreed but never used the app, and 35.6% (47/132) used the app. All were asked to complete follow-up surveys at 30 days and 90 days after enrollment. Usage data were used to assess feasibility. Clinical outcomes of self-reported ART adherence and chart-obtained HIV viral load and CD4+ T-cell counts were compared among those who used the platform (users) versus those who did not (nonusers). Participants and HIV care providers also provided responses to open-ended questions about what they liked and did not like about the app; comments were analyzed using thematic analysis.

Results

Of 132 participants, 47 (35.6%) and 85 (64.4%) were categorized as users and nonusers, respectively. Among users, a Kaplan-Meier plot showed that 25 persons (53%) continued using the app after the 90-day follow-up. At 30-day follow-up, 13 (81.3%) of those who used the mHealth app reported ≥95% ART adherence, compared with 17 (58.6%) nonusers (P=.12). Overall, 39 (82%) users liked or somewhat liked using the platform. Participants’ favorite features were medication reminders, ability to create custom reminders, and adherence reports.

Conclusions

This longitudinal study found that a commercially available medication adherence mHealth app was a feasible and acceptable intervention to improve ART adherence among PLWH and engaged in clinical care across 3 public HIV clinics in the state of Florida. Overall, participants liked the Care4Today app and thought the medication reminders were their favorite feature. Generally, self-reports of ART adherence were better among users than nonusers, both at 30- and 90-day follow-ups. Further clinical research needs to address user fatigue for improving app usage.

Long term impact of PositiveLinks: Clinic-deployed mobile technology to improve engagement with HIV care

Background

PositiveLinks (PL) is a smartphone-based platform designed in partnership with people living with HIV (PLWH) to improve engagement in care. PL provides daily medication reminders, check-ins about mood and stress, educational resources, a community message board, and an ability to message providers. The objective of this study was to evaluate the impact of up to 24 months of PL use on HIV viral suppression and engagement in care and to examine whether greater PL use was associated with improved outcomes.

Setting

This study occurred between September 2013 and March 2017 at a university-based Ryan White HIV clinic.

Methods

We assessed engagement in care and viral suppression from study baseline to the 6-, 12-, 18- and 24-month follow-up time periods and compared trends among high vs. low PL users. We compared time to viral suppression, proportion of days virally suppressed, and time to engagement in care in patients with high vs. low PL use.

Results

127 patients enrolled in PL. Engagement in care and viral suppression improved significantly after 6 months of PL use and remained significantly improved after 24 months. Patients with high PL use were 2.09 (95% CI 0.64–6.88) times more likely to achieve viral suppression and 1.52 (95% CI 0.89–2.57) times more likely to become engaged in care compared to those with low PL use.

Conclusion

Mobile technology, such as PL, can improve engagement in care and clinical outcomes for PLWH. This study demonstrates long-term acceptability of PL over two years and provides evidence for long-term improvement in engagement in care and viral suppression associated with PL use.

A Randomized Controlled Trial of a Text Messaging Intervention to Promote Virologic Suppression and Retention in Care in an Urban Safety-Net Human Immunodeficiency Virus Clinic: The Connect4Care Trial

Background

Text messaging is a promising strategy to support human immunodeficiency virus (HIV) care engagement, but little is known about its efficacy in urban safety-net HIV clinics.

Methods

We conducted a randomized controlled trial of a supportive and motivational text messaging intervention, Connect4Care (C4C), among viremic patients who had a history of poor retention or were new to the clinic. Participants were randomized (stratified by new or established HIV diagnosis status) to receive either of the following for 12 months: (1) thrice-weekly intervention messages, plus texted primary care appointment reminders and a monthly text message requesting confirmation of study participation or (2) texted reminders and monthly messages alone. Viral load was assessed at 6 and 12 months. The primary outcome was virologic suppression (<200 copies/mL) at 12 months, estimated via repeated-measures log-binomial regression, adjusted for new-diagnosis status. The secondary outcome was retention in clinic care.

Results

Between August 2013 and November 2015, a total of 230 participants were randomized. Virologic suppression at 12 months was similar in intervention and control participants (48.8% vs 45.8%, respectively), yielding a rate ratio of 1.07 (95% confidence interval, .82-1.39). Suppression was higher in those with newly diagnosed infection (78.3% vs 45.3%). There were no intervention effects on the secondary outcome. Exploratory analyses suggested that patients with more responses to study text messages had better outcomes, regardless of arm.

Conclusions

The C4C text messaging intervention did not significantly increase virologic suppression or retention in care. Response to text messages may be a useful way for providers to gauge risk for poor HIV outcomes.

Clinical Trials Registration

NCT01917994.

Electronic Health Interventions to Improve Adherence to Antiretroviral Therapy in People Living With HIV: Systematic Review and Meta-Analysis

BACKGROUND

Electronic health (eHealth) is increasingly used for self-management and service delivery of HIV-related diseases. With the publication of studies increasingly focusing on antiretroviral therapy (ART) adherence, this makes it possible to quantitatively and systematically assess the effectiveness and feasibility of eHealth interventions.

OBJECTIVE

The purpose of this review was to explore the effectiveness of eHealth interventions on improving ART adherence in people living with HIV. The effects of different intervention characteristics, participant characteristics, and study characteristics were also assessed.

METHODS

We systematically searched MEDLINE (via PubMed), EMBASE, the Cochrane Central Register of Controlled Trials, and 3 conference abstract databases using search terms related to HIV, ART, adherence, and eHealth interventions. We independently screened the studies, extracted the data, and assessed the study quality and then compared the information in pairs. Articles published in English that used randomized controlled trials to assess eHealth interventions to improve ART adherence of people living with HIV were identified. We extracted the data including study characteristics, participant characteristics, intervention characteristics, and outcome measures. The Cochrane risk-of-bias tool was used to assess the risk of bias and study overall quality. Odds ratios, Cohen d, and their 95% CIs were estimated using random-effects models. We also performed multiple subgroup analyses and sensitivity analyses to define any sources of heterogeneity.

RESULTS

Among 3941 articles identified, a total of 19 studies (including 21 trials) met the inclusion criteria. We found 8 trials from high-income countries and 13 trials from low- and middle-income countries. Furthermore, at baseline, the health status of participants in 14 trials was healthy. Of the trials included, 7 of 21 used personality content, 12 of 21 used a 2-way communication strategy, and 7 of 21 used medical content. In the pooled analysis of 3937 participants (mean age: 35 years; 47.16%, 1857/3937 females), eHealth interventions significantly improved the ART adherence of people living with HIV (pooled Cohen d=0.25; 95% CI 0.05 to 0.46; P=.01). The interventions were also correlated with improved biochemical outcomes reported by 11 trials (pooled Cohen d=0.25; 95% CI 0.11 to 0.38; P<.001). The effect was sensitive to sample size (Q=5.56; P=.02) and study duration (Q=8.89; P=.003), but it could not be explained by other moderators. The primary meta-analysis result was stable in the 3 sensitivity analyses.

CONCLUSIONS

Some of the eHealth interventions may be used as an effective method to increase the ART adherence of people living with HIV. Considering that most of the trials included a small sample size and were conducted for a short duration, these results should be interpreted with caution. Future studies need to determine the features of eHealth interventions to better improve ART adherence along with long-term effectiveness of interventions, effectiveness of real-time adherence monitoring, enhancement of study design, and influences on biochemical outcomes.

Clients' perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis

BACKGROUND

Governments and health systems are increasingly using mobile devices to communicate with patients and the public. Targeted digital client communication is when the health system transmits information to particular individuals or groups of people, based on their health or demographic status. Common types of targeted client communication are text messages that remind people to go to appointments or take their medicines. Other types include phone calls, interactive voice response, or multimedia messages that offer healthcare information, advice, monitoring, and support.

OBJECTIVES

To explore clients' perceptions and experiences of targeted digital communication via mobile devices on topics related to reproductive, maternal, newborn, child, or adolescent health (RMNCAH).

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-Process & Other Non-Indexed Citations (OvidSP), Embase (Ovid), World Health Organization Global Health Library, and POPLINE databases for eligible studies from inception to 3-6 July 2017 dependant on the database (See appendix 2).

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; that explored clinets' perceptions and experiences of targeted digital communication via mobile device in the areas of RMNCAH; and were from any setting globally.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, employing a three-step sampling frame. We conducted a framework thematic analysis using the Supporting the Use of Research Evidence (SURE) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether potential implementation barriers identified in our synthesis had been addressed in the trials included in the related Cochrane Reviews of effectiveness.

MAIN RESULTS

We included 35 studies, from a wide range of countries on six continents. Nineteen studies were conducted in low- and middle-income settings and sixteen in high-income settings. Some of the studies explored the views of people who had experienced the interventions, whereas others were hypothetical in nature, asking what people felt they would like from a digital health intervention. The studies covered a range of digital targeted client communication, for example medication or appointment reminders, prenatal health information, support for smoking cessation while pregnant, or general sexual health information.Our synthesis showed that clients' experiences of these types of programmes were mixed. Some felt that these programmes provided them with feelings of support and connectedness, as they felt that someone was taking the time to send them messages (moderate confidence in the evidence). They also described sharing the messages with their friends and family (moderate confidence).However, clients also pointed to problems when using these programmes. Some clients had poor access to cell networks and to the internet (high confidence). Others had no phone, had lost or broken their phone, could not afford airtime, or had changed their phone number (moderate confidence). Some clients, particularly women and teenagers, had their access to phones controlled by others (moderate confidence). The cost of messages could also be a problem, and many thought that messages should be free of charge (high confidence). Language issues as well as skills in reading, writing, and using mobile phones could also be a problem (moderate confidence).Clients dealing with stigmatised or personal health conditions such as HIV, family planning, or abortion care were also concerned about privacy and confidentiality (high confidence). Some clients suggested strategies to deal with these issues, such as using neutral language and tailoring the content, timing, and frequency of messages (high confidence).Clients wanted messages at a time and frequency that was convenient for them (moderate confidence). They had preferences for different delivery channels (e.g. short message service (SMS) or interactive voice response) (moderate confidence). They also had preferences about message content, including new knowledge, reminders, solutions, and suggestions about health issues (moderate confidence). Clients' views about who sent the digital health communication could influence their views of the programme (moderate confidence).For an overview of the findings and our confidence in the evidence, please see the 'Summary of qualitative findings' tables.Our matrix shows that many of the trials assessing these types of programmes did not try to address the problems we identified, although this may have been a reporting issue.

AUTHORS' CONCLUSIONS

Our synthesis identified several factors that can influence the successful implementation of targeted client communication programmes using mobile devices. These include barriers to use that have equity implications. Programme planners should take these factors into account when designing and implementing programmes. Future trial authors also need to actively address these factors and to report their efforts in their trial publications.

Randomized Controlled Trial of Daily Text Messages to Support Adherence to Preexposure Prophylaxis in Individuals at Risk for Human Immunodeficiency Virus: The TAPIR Study

Background

Adherence is critical for efficacy of tenofovir disoproxil fumarate/emtricitabine (FTC) as preexposure prophylaxis (PrEP).

Methods

Between February 2013 and February 2016, 398 men who have sex with men and transgender women were randomized 1:1 to receive individualized texting for adherence building (iTAB) or standard care (SoC) for 48 weeks. The primary endpoint was dried blood spot (DBS) tenofovir diphosphate (TFV-DP) concentrations at both week 12 and the last on-drug visit of >719 fmol/punch (ie, adequate adherence). Secondary outcomes included DBS TFV-DP concentrations of >1246 fmol/punch (ie, near-perfect adherence) and plasma FTC >350 ng/mL (consistent with dosing within the past 24 hours).

Results

Concentrations >719 fmol/punch of TFV-DP were found in 88.6% of participants at week 12 and 82.5% at week 48. For the primary endpoint, the study arms did not differ (72.0% in iTAB and 69.2% in SoC; P > .05). For the secondary composite endpoint of >1246 fmol/punch the iTAB arm was superior to SoC (33.5% vs 24.8%; P = .06), reaching statistical significance when adjusting for age (odds ratio, 1.56 [95% confidence interval, 1.00-2.42]; P < .05). At week 48, iTAB was superior to SoC for near-perfect adherence (51.0% vs 37.4%; P = .02). At week 12, iTAB was superior to SoC for dosing in past 24 hours by plasma FTC (47.5% vs 33.3%; P = .007), but not at weeks 24, 36, and 48 (all P > .05).

Conclusions

Automated text messaging is a low-burden tool that improves durability of near-perfect PrEP adherence.

Clinical Trials Registration

NCT01761643.

A Mobile Health Intervention to Improve Hepatitis C Outcomes Among People With Opioid Use Disorder: Protocol for a Randomized Controlled Trial

Background

People who inject drugs are at a disproportionate risk for contracting hepatitis C virus (HCV). However, use of HCV prevention and treatment services remains suboptimal among people with substance use disorders due to various health system, societal, and individual barriers. Mobile health applications offer promising strategies to support people in recovery from substance use disorders. We sought to determine whether the Addiction-Comprehensive Health Enhancement Support System (A-CHESS), an existing mobile health application for opioid use disorder, could be adapted to improve HCV screening and treatment.

Objective

The goals of this paper are to describe: (1) the components and functionality of an HCV intervention incorporated into the existing A-CHESS system; and (2) how data are collected and will be used to evaluate HCV testing, linkage to care, and treatment.

Methods

People with recent opioid use were enrolled in a randomized controlled trial to test whether A-CHESS reduced relapse. We developed and implemented HCV intervention content within the A-CHESS platform to simultaneously evaluate whether A-CHESS improved secondary outcomes related to HCV care. All A-CHESS users received the HCV intervention content, which includes educational information, private messages tailored to an individual’s stage of HCV care, and a public discussion forum. Data on patients’ HCV risk behaviors and stage of care were collected through quarterly telephone interviews and weekly surveys delivered through A-CHESS. The proportion of people with opioid use disorder who are HCV untested, HCV-negative, HCV antibody-positive, or HCV RNA–positive, as well as linked to care, treated and cured at baseline is described here. The 24-month follow-up is ongoing and will be completed in April 2020. Survey data will then be used to assess whether individuals who received the HCV-enhanced A-CHESS intervention were more likely to reduce risky injection behaviors, receive HCV testing, link to medical care, initiate treatment, and be cured of HCV compared to the control group.

Results

Between April 2016 and April 2018, 416 individuals were enrolled and completed the baseline interview. Of these individuals, 207 were then randomly assigned to the control arm and 209 were assigned to the intervention arm. At baseline, 202 individuals (49%) self-reported ever testing HCV antibody-positive. Of those, 179 (89%) reported receiving HCV RNA confirmatory testing, 134 (66%) tested HCV RNA–positive, 125 (62%) were linked to medical care and 27 (13%) were treated and cured of HCV. Of the remaining 214 individuals who had never tested HCV antibody–positive, 129 (31%) had tested HCV antibody–negative within the past year and 85 (20%) had not been tested within the past year.

Conclusions

The A-CHESS mobile health system allows for the implementation of a bundle of services as well as the collection of longitudinal data related to drug use and HCV care among people with opioid use disorders. This study will provide preliminary evidence to determine whether HCV-specific services embedded into the A-CHESS program can improve HCV outcomes for people engaged in addiction treatment.

Trial Registration

ClinicalTrials.gov NCT02712034; https://clinicaltrials.gov/ct2/show/NCT02712034

International Registered Report Identifier (IRRID)

DERR1-10.2196/12620

A systematic review and meta-analysis in the effectiveness of mobile phone interventions used to improve adherence to antiretroviral therapy in HIV infection

BACKGROUND

Antiretroviral therapy is effective in preventing the progression of HIV to AIDS, but adherence to HIV medication is lower than ideal. A previous Cochrane review concluded that SMS interventions increased adherence to HIV medication, but more recent trials have reported mixed results. Our review aims to provide an up-to-date synthesis of the effects of interventions delivered by mobile phone on adherence.

METHODS

We searched Cochrane, Medline, CINAHL, EMBASE and Global Health for randomised control trials (RCTs) of interventions delivered by mobile phones, designed to increase adherence to antiretroviral medication. Risk of bias was assessed using the Cochrane risk of bias tool. We calculated relative risk ratios (RR) or standardised mean difference (SMD) with 95% confidence interval (CI). Trials were analysed depending on delivery mechanism and intervention characteristics. We conducted meta-analysis for primary objective outcome measures.

RESULTS

We identified 19 trials. No trials were at low risk of bias. Interventions were delivered as follows; nine via text message, five via mobile phone call, one via mobile phone imagery and four via mixed interventions. There was no effect when interventions delivered by text message were pooled in the RR1.25 (CI 0.97 to 1.61) P = 0.08. The SMD 0.42 (0.03 to 0.81) p = 0.04 showed a moderate effect to improve adherence. There was mixed evidence of the effect of text messages delivered daily, weekly, at scheduled or triggered times, however, messages with link to support, interactivity and three or more behavior change techniques (BCTs) all improved adherence. Of the five trials delivered by mobile phone call, one reported a reduction in HIV viral load. One trial using mobile phone imagery reported a reduction in HIV viral load. Three trials that delivered interventions by text message and mobile phone counselling reported improved biological outcomes.

CONCLUSION

Specific interventions, of proven effectiveness should be considered for implementation, rather than mobile phone-based interventions in general. Interventions targeting a wider range of barriers to adherence may be more effective than existing interventions. The effects and cost-effectiveness of such interventions should be evaluated in a randomised controlled trial alongside long term objective and clinically important outcomes.

Development of PositiveLinks: A Mobile Phone App to Promote Linkage and Retention in Care for People With HIV

Background

Linkage to and retention in HIV care are challenging, especially in the Southeastern United States. The rise in mobile phone app use and the potential for an app to deliver just in time messaging provides a new opportunity to improve linkage and retention among people living with HIV (PLWH).

Objective

This study aimed to develop an app to engage, link, and retain people in care. We evaluated the acceptability, feasibility, and impact of the app among users.

Methods

App development was informed by principles of chronic disease self-management and formative interviews with PLWH. Once developed, the app was distributed among participants, and usability feedback was incorporated in subsequent iterations. We interviewed app users after 3 weeks to identify usability issues, need for training on the phone or app, and to assess acceptability. We tracked and analyzed usage of app features for the cohort over 2 years.

Results

A total of 77 participants used the app during the pilot study. The query response rate for the first 2 years was 47.7%. Query response declined at a rate of 0.67% per month. The community message board was the most popular feature, and 77.9% (60/77) of users posted on the board at least once during the 2 years.

Conclusions

The PositiveLinks app was feasible and acceptable among nonurban PLWH. High participation on the community message board suggests that social support from peers is important for people recently diagnosed with or returning to care for HIV.

Focus groups inform a mobile health intervention to promote adherence to a Mediterranean diet and engagement in physical activity among people living with HIV

Background

A personalized mobile health intervention (iSTEP) aims to promote a Mediterranean diet and increase physical activity, thereby improving neurocognitive functioning among persons living with HIV (PLWH). This article describes a qualitative study conducted to develop iSTEP for PLWH, including assessment of diet habits and preferences for tracking physical activity.

Method

Two focus groups, with seven and 13 PLWH respectively, discussed barriers and facilitators of a healthy diet and provided feedback to refine iSTEP components, including the feasibility of using a Fitbit and the content of text messages designed to encourage improved diet and physical activity.

Results

Focus group discussions revealed several healthy diet barriers, including housing instability, time required for food preparation, cost of healthy food, depression, gastrointestinal issues, physical disability, and changes in appetite since HIV diagnosis. Participant-identified healthy diet facilitators included affordable price options for healthy food, a structured food plan, desire to modify appearance or weight, access to medical professionals, motivation for disease prevention, and social support. Participants endorsed wearing a Fitbit on the wrist and receiving text messages as useful methods to monitor and encourage a better diet and greater physical activity.

Conclusions

These findings assisted the expansion of a mobile health intervention that promotes health behaviors in order to improve neurocognitive outcomes among PLWH.

Trial registration

NCT03123731, prospectively registered on ClinicalTrials.gov, April 21, 2017.

Effectiveness of text messaging interventions on prevention, detection, treatment, and knowledge outcomes for sexually transmitted infections (STIs)/HIV: a systematic review and meta-analysis

BACKGROUND

Rates of STIs continue to rise worldwide, and novel evidence-based interventions such as text messaging aimed at improving client services are needed. We conducted a meta-analysis to evaluate text messaging to support STI/HIV prevention and treatment interventions.

METHODS

We included articles that reported findings from randomized controlled trials (RTCs) involving adults and youth who were at risk of acquiring (or who currently had) a STI and/or HIV, a text message and comparator intervention, and reported provided outcome data on adherence to STI/HIV treatments. Articles were excluded if they were not published in English. We only included studies that have full-text publications so certainty and risk of bias assessments could be performed. Eight databases were searched to retrieve articles published between 1996 and March 2017. The Cochrane risk of bias tool was used and certainty of the evidence was assessed using GRADE. Effect estimates were pooled using a random effects model.

RESULTS

A total of 35 RCTs were found, 6 of which were considered at low risk of bias. Eight studies found an increased association using text messaging in appointments attended compared to standard care (OR 1.64, 95% CI 1.28 to 2.10). Participants receiving text messages had an increase in HIV testing compared to standard care (n = 6; OR 1.73, 95% CI 1.39 to 2.15). Ten text messaging RCTs measuring adherence using micro-electro-mechanical systems (MEMS) pill counts has a non-significant association (OR 1.17, 95% CI 0.95-1.45) while five studies measuring adherence by self-report was found to be significant (OR 1.64, 95% CI 1.28-2.11).

CONCLUSIONS

The effectiveness of text message interventions is equivocal. While text messaging has the potential to enhance the delivery of STI/HIV interventions, program planners are encouraged to evaluate any SMS intervention to ensure it is achieving the desired result.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013006503.

Feasibility of a Texting Intervention to Improve Medication Adherence Among Older HIV+ African Americans: A Mixed-Method Pilot Study

Antiretroviral therapy (ART) is the primary treatment for HIV, and adherence to it is crucial to addressing health disparities. Approximately half of individuals in the United States living with HIV are African Americans, and those over 45 years of age are more likely to die early from HIV/AIDS than their White counterparts. This mixed-method pilot study evaluated the feasibility of a text-based mobile phone intervention designed to improve ART adherence among older African Americans with HIV. Feasibility was assessed via implementation, participant adherence, acceptability, and satisfaction, as well as short-term impact on medication adherence, adherence-related self-efficacy, and positive affect. The intervention utilized pill reminder, motivational, and health educational texts. Participants (N = 21) ranged in age from 50 to 68 years. Outcomes were evaluated via quantitative results from self-report measures and qualitative data from four focus groups. Attrition to the study was 100%. After 8 weeks, participants reported statistically significant improvements in medication adherence, but not in self-efficacy or affect scores. Qualitative findings highlight the psychologically supportive potential of the intervention, challenges to adherence, as well as suggestions for improvement. The study demonstrates that a text messaging intervention may be feasible for older African Americans with HIV, and helpful in supporting ART adherence.

Addressing Stigma Through a Virtual Community for People Living with HIV: A Mixed Methods Study of the PositiveLinks Mobile Health Intervention

Stigma has negative consequences for quality of life and HIV care outcomes. PositiveLinks is a mobile health intervention that includes a secure anonymous community message board (CMB). We investigated discussion of stigma and changes in stigma scores. Of 77 participants in our pilot, 63% were male, 49% Black, and 72% had incomes below the federal poverty level. Twenty-one percent of CMB posts (394/1834) contained stigma-related content including negative (experiencing stigma) and positive (overcoming stigma) posts addressing intrapersonal and interpersonal stigma. Higher baseline stigma was positively correlated with stress and negatively correlated with HIV care self-efficacy. 12-month data showed a trend toward more improved stigma scores for posters on the CMB versus non-posters (- 4.5 vs - 0.63) and for posters of stigma-related content versus other content (- 5.1 vs - 3.3). Preliminary evidence suggests that a supportive virtual community, accessed through a clinic-affiliated smartphone app, can help people living with HIV to address stigma.

A New Era of HIV Risk: It's Not What You Know, It's Who You Know (and How Infectious)

HIV is transmitted in social and sexual relationships, and HIV transmission risks, as well as protective actions, are evolving as HIV epidemics unfold. The current focus of HIV prevention is centered on antiretroviral medications used to reduce HIV infectiousness in persons already infected with HIV [treatment as prevention (TasP)]. The same medications used to treat infected persons can also be used by uninfected persons as pre-exposure prophylaxis (PrEP) to reduce the infectivity of HIV. Both PrEP and TasP are effective when adherence is high and individuals do not have co-occurring sexually transmitted infections. HIV prevention is most effective and efficient when delivered within sexual networks with high HIV prevalence. Specific network characteristics are recognized as important facilitators of HIV transmission; these characteristics include the degree of similarity among network members (homophily), gender role norms, and belief systems. Since 2011, HIV risk has been redefined based on infectiousness and infectivity, ushering in a new era of HIV prevention with the potential to end HIV epidemics.

Efficacy and Safety of Oral TDF-Based Pre-exposure Prophylaxis for Men Who Have Sex With Men: A Systematic Review and Meta-Analysis

Background: Pre-exposure prophylaxis (PrEP) is used as an HIV prevention method by people at substantial risk of HIV infection. This systematic review and meta-analysis evaluates current clinical evidence for use of oral TDF-based PrEP among men who have sex with men.

Methods: A comprehensive literature search in PubMed, web of science, Google Scholar and ClinicalTrials.gov was performed. A random-effects meta-analysis was conducted using the event rate (ER) for estimation of the incidence of HIV and grade 3 or 4 adverse events (AE) among PrEP arm and using risk ratio (RR) for comparison of incidence of HIV and grade 3 or 4 AE between PrEP recipients and PrEP non-users. Blood-based adherence levels were also divided into three categories with reference to previous meta-analysis. Subgroup meta-analysis was also performed to evaluate whether blood-based adherence levels moderated the effect of TDF-based PrEP on HIV incidence. Narrative review was used due to inconsistent measurements of risk behavior and drug resistance. This review is registered on the PROSPERO database (CRD42017077965).

Results: Fourteen studies were included in the review. Oral TDF-based PrEP significantly reduced HIV incidence with minimum drug resistance and tolerable safety risks (HIV incidence, ER = 1.1%, 95% CI 0.6–2.0%, p < 0.001, RR = 0.244, 95% CI 0.111–0.537, p < 0.001 and grade 3 or 4 AEs, ER = 13.0%, 95% CI 9.9–16.9%, p < 0.001, RR = 1.059, 95% CI 0.824–1.362, p = 0.653). Oral TDF-based PrEP was more effective in reducing HIV incidence with high levels of blood-based PrEP adherence (ER, 0.4%) compared to moderate adherence (2.9%; p < 0.001). Most studies found no association between PrEP use and self-reported sexual behavior.

Conclusion: Oral TDF-based PrEP is an effective intervention to prevent against HIV infection among MSM. Well-designed implementation science studies that integrate sociobehavioral and biomedical interventions are needed to identify optimal PrEP delivery models in different populations to translate biomedical efficacy into real-world efficacy.

Feasibility and Effects of Digital Interventions to Support People in Recovery From Substance Use Disorders: Systematic Review

Background

The development and evaluation of digital interventions aimed at preventing or treating substance use–related problems and disorders is a rapidly growing field. Previous reviews of such interventions reveal a large and complex picture with regard to targeted users, use, and efficacy.

Objective

The objective of this review was to investigate the feasibility and effects of interventions developed specifically for digital platforms. These interventions are focused on supporting people in recovery from substance use disorders by helping them achieve their substance use goals and develop a more satisfying life situation.

Methods

The review is based on a systematic search in MEDLINE, Embase, PsycInfo, and Cochrane Library databases. Of the 1149 identified articles, 722 were excluded as obviously not relevant. Of the remaining articles, 21 were found to be previous reviews, 269 were on interventions aimed at reducing hazardous alcohol or cannabis use, and 94 were on digitized versions of standard treatment methods. The remaining 43 articles were all read in full and systematically scored by both authors.

Results

The 43 articles cover 28 unique interventions, of which 33 have been published after 2013. The interventions are aimed at different target groups (defined by age, substance, or comorbidity). Based on the number of features or modules, the interventions can be categorized as simple or complex. Fourteen of the 18 simple interventions and 9 of the 10 complex interventions have been studied with quantitative controlled methodologies. Thirteen of the 18 simple interventions are integrated in other treatment or support systems, mainly delivered as mobile phone apps, while 6 of the 10 complex interventions are designed as stand-alone interventions, most often delivered on a platform combining desktop/Web and mobile phone technologies. The interventions were generally easy to implement, but in most cases the implementation of the complex interventions was found to be dependent on sustained organizational support. Between 70% and 90% of the participants found the interventions to be useful and easy to use. The rates of sustained use were also generally high, except for simple interventions with an open internet-based recruitment and some information and education modules of the complex interventions. Across all interventions, slightly more than half (55%) of the studies with control groups generated positive findings on 1 or more substance use outcomes, with 57% of the interventions also found to be efficacious in 1 or more studies. In the positive studies, effects were typically in the small to moderate range, with a few studies yielding larger effects. Largely due to the inclusion of stronger control conditions, studies of simple interventions were less likely to produce positive effects.

Conclusions

The digital interventions included in this review are in general feasible but are not consistently effective in helping people in recovery from substance use disorder reduce their substance use or achieving other recovery goals.

Individualized texting for adherence building (iTAB) for methamphetamine users living with HIV: A pilot randomized clinical trial

BACKGROUND

Methamphetamine (METH) use poses a barrier to antiretroviral therapy (ART) adherence. We evaluated the efficacy of the individualized texting for adherence building (iTAB) intervention among persons living with HIV (PLWH) who meet criteria for METH use disorder. We examined daily associations between ART adherence and text-reported METH use and depressed mood.

METHODS

We conducted a single site, 2-arm, 6-week, pilot randomized clinical trial comparing a personalized, bidirectional, text messaging system (iTAB; n = 50) to an active control condition (n = 25). All participants received adherence psychoeducation and daily texts assessing METH use and depressed mood. The iTAB group received personalized daily ART reminder texts. ART adherence was monitored using Medication Event Monitoring System (MEMS) caps.

RESULTS

Response rates to daily ART reminder texts were high (79%), with good concordance between MEMS-derived and text-reported ART adherence (p < .001). Intervention groups did not differ in MEMS-derived ART adherence (68% iTAB, 70% active control; p = .68); however, participants in the iTAB group had fewer METH use days (median 14.4 iTAB, 22.0 active control; p = .05). Text-reported METH use, but not depressed mood, was associated with poorer MEMS-derived ART adherence.

CONCLUSIONS

High text response rates and good concordance between MEMS-derived and text-reported adherence suggests text messaging is a feasible intervention delivery approach that provides a valid indication of ART adherence. Reductions in METH use among iTAB participants suggest daily health reminders may help attenuate substance use. Further research is needed to substantiate daily text messaging as a harm reduction approach.

Health Care Provider Utilization and Cost of an mHealth Intervention in Vulnerable People Living With HIV in Vancouver, Canada: Prospective Study

BACKGROUND

Improving adherence to combined antiretroviral therapy (cART) can be challenging, especially among vulnerable populations living with HIV. Even where cART is available free of charge, social determinants of health act as barriers to optimal adherence rates. Patient-centered approaches exploiting mobile phone communications (mHealth) have been shown to improve adherence to cART and promote achievement of suppressed HIV plasma viral loads. However, data are scarce on the health care provider (HCP) time commitments and health care costs associated with such interventions. This knowledge is needed to inform policy and programmatic implementation.

OBJECTIVE

The purpose of this study was to approximate the resources required and to provide an estimate of the costs associated with running an mHealth intervention program to improve medication adherence in people living with HIV (PLWH).

METHODS

This prospective study of HCP utilization and costs was embedded within a repeated measures effectiveness study of the WelTel short-message service (SMS) mHealth program. The study included 85 vulnerable, nonadherent PLWH in Vancouver, Canada, and resulted in improved medication adherence and HIV plasma viral load among participants. Study participants were provided mobile phones with unlimited texting (where required) and received weekly bidirectional text messages to inquire on their status for one year. A clinic nurse triaged and managed participants' responses, immediately logging all patient interactions by topic, HCP involvement, and time dedicated to addressing issues raised by participants. Interaction costs were determined in Canadian dollars based on HCP type, median salary within our health authority, and their time utilized as part of the intervention.

RESULTS

Participant-identified problems within text responses included health-related, social, and logistical issues. Taken together, management of problems required a median of 43 minutes (interquartile range, IQR 17-99) of HCP time per participant per year, for a median yearly cost of Can $36.72 (IQR 15.50-81.60) per participant who responded with at least one problem. The clinic nurse who monitored the texts solved or managed 65% of these issues, and the remaining were referred to a variety of other HCPs. The total intervention costs, including mobile phones, plans, and staffing were a median Can $347.74/highly vulnerable participant per year for all participants or Can $383.18/highly vulnerable participant per year for those who responded with at least one problem.

CONCLUSIONS

Bidirectional mHealth programs improve HIV care and treatment outcomes for PLWH. Knowledge about the HCP cost associated, here less than Can $50/year, provides stakeholders and decision makers with information relevant to determining the feasibility and sustainability of mHealth programs in a real-world setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/70IYqKUjV).

A systematic review of community-based interventions to improve oral chronic disease medication regimen adherence among individuals with substance use disorder

BACKGROUND

Poor medication adherence has been shown to cause medical complications, death, and increased healthcare costs and may be of particular importance in patients with substance use disorder (SUD). Concerns regarding adherence in this population may influence a healthcare provider's decision to prescribe a medication requiring high adherence. Guidance defining best practices that promote adherence among individuals with SUD is lacking.

METHODS

A review of English articles in Medline and PsycINFO databases, published between October 1, 1994 and October 31, 2017, was conducted in order to identify studies of interventions intended to improve adherence to oral chronic disease medication regimens among patients with SUD. Randomized controlled trials, quasi-experimental study designs, and case series were included. Article quality was assessed.

RESULTS

A total of 854 abstracts were retrieved, of which 24 met inclusion criteria. Adherence interventions were categorized as those: 1) addressing the chronic disease state; 2) addressing SUD; or 3) both. Studies varied greatly with respect to intervention length, method of measuring adherence, and quality. Statistically significant improvement in adherence was observed in 12 of 24 studies (50%). Specific interventions that improved adherence included incentive-based interventions, directly observed therapy, and telephonic/home visits. Counseling-based interventions such motivational interviewing and cognitive behavioral therapy presented mixed results.

CONCLUSIONS

While effective interventions were identified, heterogeneity of study designs and study quality preclude determination of optimal interventions to promote adherence in this population. Further evaluation with sound study design may inform the development of best practices for treating chronic disease in patients with SUD.

Psychiatric Disorders, Antiretroviral Medication Adherence and Viremia in a Cohort of Perinatally HIV-Infected Adolescents and Young Adults

BACKGROUND

Perinatally HIV-infected (PHIV+) adolescents and young adults (AYA) are at risk for suboptimal antiretroviral therapy (ART) adherence and mental health and substance use problems that, in HIV-infected adults, predict nonadherence. Studies on the relationship between psychiatric and substance use disorders (SUD) and adherence among PHIV+ AYA are limited, but may be important for informing evidence-based interventions to promote adherence.

METHODS

Data were analyzed from 3 annual follow-up interviews (FU2-FU4, N = 179) in a longitudinal study of PHIV+ AYA. Psychiatric disorders (anxiety, disruptive behavior, mood and SUD) were assessed with the Diagnostic Interview Schedule for Children. Adherence was self-reported missed ART doses within the past week. Viral load (VL) results were abstracted from medical charts. Multiple logistic regression analyzed cross-sectional associations between psychiatric disorders and (1) missed ART dose and (2) VL > 1000 copies/mL. Multiple linear regression assessed associations between psychiatric disorders and proportion of VL values >1000 copies/mL over time.

RESULTS

At FU2, 53% of PHIV+ AYA had any psychiatric disorder, 35% missed an ART dose in the past week and 47% had a VL > 1000 copies/mL. At FU2, behavioral disorders were associated with missed dose (P = 0.009) and VL > 1000 (P = 0.019), and mood disorders were associated with missed dose (P = 0.041). At FU4, behavioral disorders were associated with missed dose (P = 0.009). Behavioral disorders (P = 0.041), SUD (P = 0.016) and any disorder (P = 0.008) at FU2 were associated with higher proportion of VLs >1000 across FU2-FU4.

CONCLUSIONS

Addressing psychiatric disorder and SUD among PHIV+ AYA may improve ART adherence outcomes in this population. Targeted interventions should be developed and tested.

A Systematic Review on Promoting Adherence to Antiretroviral Therapy in HIV-infected Patients Using Mobile Phone Technology

OBJECTIVE

Adherence to antiretroviral therapy (ART) is paramount to successful long-term suppression of human immunodeficiency virus (HIV). For poorly adherent patients with HIV, barriers to remaining adherent may be overcome by the implementation of targeted interventions delivered via mobile devices. This systematic review is focused specifically on mobile phone technologies to deliver adherence interventions in HIV/acquired immunodeficiency syndrome (AIDS) populations.

METHODS

This review (PROSPERO #CRD42017065131) systematically extracted data from published literature from five databases on mobile phone interventions to improve adherence to ART for HIV. The reported studies had been conducted between 2007 and 2017. Risk of bias was assessed using the Cochrane method ranking each criterion as low, high, or unclear risk of bias.

RESULTS

Of the 835 articles returned, we identified 26 randomized controlled trials (RCTs), retrospective and prospective cohort trials, or mixed method studies with a comparison group that fit criteria for inclusion. No standard measure of adherence was consistent throughout the examined studies, and assessments by self-report, pill counting, and medication event monitoring system (MEMS) were utilized. The studies reported mixed results, with 17 reporting significant improvements to adherence, 3 reporting improvements without supplying p-values, and 6 reporting no significant change or a reduction in adherence.

CONCLUSION

The mixed nature of the results exemplifies the need for more comprehensive approaches and larger scale trials to confirm results observed in limited cohort sizes. To better retain satisfactory adherence within the HIV population, and especially in low-resource settings, we recommend that future interventions incorporate multiple strategies: mobile-based reminders, social support structures, and personalized content.

PositiveLinks: A Mobile Health Intervention for Retention in HIV Care and Clinical Outcomes with 12-Month Follow-Up

Mobile health interventions may help People Living with HIV (PLWH) improve engagement in care. We designed and piloted PositiveLinks, a clinic-affiliated mobile intervention for PLWH, and assessed longitudinal impact on retention in care and viral suppression. The program was based at an academic Ryan White Clinic serving a nonurban population in Central Virginia. The PL intervention included a smartphone app that connected participants to clinic staff and provided educational resources, daily queries of stress, mood and medication adherence, weekly quizzes, appointment reminders, and a virtual support group. Outcomes were analyzed using McNemar's tests for HRSA-1, visit constancy, and viral suppression and nonparametric Wilcoxon signed-rank tests for CD4 counts and viral loads. Of 77 participants, 63% were male, 49% black non-Hispanic, and 72% below the federal poverty level. Participants' achievement of a retention in care benchmark (HRSA-1) increased from 51% at baseline to 88% at 6 months (p < 0.0001) and 81% at 12 months (p = 0.0003). Visit constancy improved from baseline to 6 months (p = 0.016) and 12 months (p = 0.0004). Participants' mean CD4 counts increased from baseline to 6 months (p = 0.0007) and 12 months (p = 0.0005). The percentage of participants with suppressed viral loads increased from 47% at baseline to 87% at 6 months (p < 0.0001) and 79% at 12 months (p = 0.0007). This study is one of the first to demonstrate that a mobile health intervention can have a positive impact on retention in care and clinical outcomes for vulnerable PLWH. Next steps include integration with clinical practice and dissemination.

A Mobile Health Strategy to Support Adherence to Antiretroviral Preexposure Prophylaxis

Preexposure prophylaxis is a highly protective HIV prevention strategy, yet nonadherence can significantly reduce its effectiveness. We conducted a mixed methods evaluation of a mobile health intervention (iText) that utilized weekly bidirectional text or e-mail support messages to encourage preexposure prophylaxis (PrEP) adherence among participants in the multi-site iPrEx open-label extension study. A convenience sample of PrEP users from the San Francisco and Chicago sites participated in a 12-week pilot study. Fifty-six men who have sex with men were enrolled; a quarter of them were less than 30 years of age, 13% were black/African American, 11% were Latino, and most (88%) completed some college. Two-thirds opted for text message delivery. Of the 667 messages sent, only 1 individual requested support; initial nonresponse was observed in 22% and was higher among e-mail compared to text message recipients. Poststudy, a majority of participants would recommend the intervention to others, especially during PrEP initiation. Moreover, younger participants and men of color were more likely to report that they would use the iText strategy if it were available to them. Several participants commented that while they were aware that the messages were automated, they felt supported and encouraged that “someone was always there.” Study staff reported that the intervention is feasible to administer and can be incorporated readily into clinic flow. A pre–post intervention regression discontinuity analysis using clinic-based pill counts showed a 50% reduction in missed doses [95% confidence interval (CI) 16–71; p = 0.008] and 77% (95% CI 33–92; p = 0.007) when comparing pill counts at quarterly visits just before and after iText enrollment. A mobile health intervention using weekly bidirectional messaging was highly acceptable and demonstrated promising effects on PrEP adherence warranting further evaluation for efficacy in a randomized controlled trial.

Correlates of missed clinic visits among youth living with HIV

Youth living with HIV (YLH) have significant problems with attending their medical appointments. Poor attendance, consequently, predicts viral non-suppression and other negative health outcomes. To identity targets of intervention, this cross-sectional study examined correlates of past-year missed clinic visits among YLH (N = 2125) attending HIV clinics in the United States and Puerto Rico. Thirty-six percent of YLH missed two or more visits in the past year. Several factors were associated with missed visits in our regression model. Among sociodemographic characteristics and HIV disclosure status, females (adjusted odds ratio [OR] = 1.63, compared to males), Black YLH or YLH of mixed racial heritage (AORs = 1.76, 1.71, respectively, compared to White YLH), YLH with an unknown route of infection (AOR = 1.86, compared to YLH with perinatal infection), and YLH endorsing HIV disclosure (AOR = 1.37, compared to YLH not endorsing disclosure) were at greater risk for missed visits. Among behavioral health risks, YLH who endorsed marijuana use (AOR = 1.42), frequent other drug use (AOR = 1.60), or a history of incarceration (AOR = 1.27) had greater odds of missed visits than youth not endorsing these risks. Finally, two social-cognitive resources emerged as protective factors: adherence self-efficacy (AOR = .28) and social support (AOR = .88). We discuss how providers working with YLH can improve this population's retention outcomes.

A Rapid Review of eHealth Interventions Addressing the Continuum of HIV Care (2007-2017)

National HIV prevention goals call for interventions that address Continuum of HIV Care (CoC) for persons living with HIV. Electronic health (eHealth) can leverage technology to rapidly develop and disseminate such interventions. We conducted a qualitative review to synthesize (a) technology types, (b) CoC outcomes, (c) theoretical frameworks, and (d) behavior change mechanisms. This rapid review of eHealth, HIV-related articles (2007-2017) focused on technology-based interventions that reported CoC-related outcomes. Forty-five studies met inclusion criteria. Mobile texting was the most commonly reported technology (44.4%, k = 20). About 75% (k = 34) of studies showed proven or preliminary efficacy for improving CoC-related outcomes. Most studies (60%, k = 27) focused on medication adherence; 20% (k = 9) measured virologic suppression. Many eHealth interventions with preliminary or proven efficacy relied on mobile technology and integrated knowledge/cognition as behavior change mechanisms. This review identified gaps in development and application of eHealth interventions regarding CoC.

Lessons Learned From the Implementation of Seek, Test, Treat, Retain Interventions Using Mobile Phones and Text Messaging to Improve Engagement in HIV Care for Vulnerable Populations in the United States

In the United States, little is known about interventions that rely on mobile phones and/or text messaging to improve engagement in HIV care for vulnerable populations. Domestic studies using these technologies as part of the National Institute on Drug Abuse "Seek, Test, Treat, Retain" research initiative were queried regarding intervention components, implementation issues, participant characteristics, and descriptive statistics of mobile phone service delivery. Across five studies with 1,135 predominantly male, minority participants, implementation challenges occurred in three categories: (1) service interruptions; (2) billing/overage issues, and; (3) the participant user experience. Response rules for automated text messages frequently frustrated participants. The inability to reload minutes/texting capacity remotely was a significant barrier to intervention delivery. No study encountered confidentiality breaches. Service interruption was common, even if studies provided mobile phones and plans. Future studies should attend to the type of mobile phone and service, the participant user experience, and human subjects concerns.

Mobile Text Messaging to Improve Medication Adherence and Viral Load in a Vulnerable Canadian Population Living With Human Immunodeficiency Virus: A Repeated Measures Study

Background

Combination antiretroviral therapy (cART) as treatment for human immunodeficiency virus (HIV) infection is effective and available, but poor medication adherence limits benefits, particularly in vulnerable populations. In a Kenyan randomized controlled trial, a weekly text-messaging intervention (WelTel) improved cART adherence and HIV viral load (VL). Despite growing evidence for short message service (SMS) text-message interventions in HIV care, there is a paucity of data utilizing these interventions in marginalized or female cohorts.

Objective

This study was undertaken to assess whether the standardized WelTel SMS text-message intervention applied to a vulnerable, predominantly female, population improved cART adherence and VL.

Methods

We conducted a repeated measures study of the WelTel intervention in high-risk HIV-positive persons by measuring change in VL, CD4 count, and self-reported adherence 12 months before and 12 months after the WelTel intervention was introduced. Inclusion criteria included VL ≥200 copies/mL, indication for treatment, and meeting vulnerability criteria. Participants were given a mobile phone with unlimited texting (where required), and weekly check-in text messages were sent for one year from the WelTel computer platform. Clinical data were collected for control and intervention years. Participants were followed by a multidisciplinary team in a clinical setting. Outcomes were assessed using Wilcoxon signed ranks tests for change in CD4 and VL from control year to study end and mixed-effects logistic regressions for change in cART adherence and appointment attendance. A secondary analysis was conducted to assess the effect of response rate on the outcome by modeling final log₁₀ VL by number of responses while controlling for mean log₁₀ VL in the control year.

Results

Eighty-five participants enrolled in the study, but 5 withdrew (final N=80). Participants were predominantly female (90%, 72/80) with a variety of vulnerabilities. Mean VL decreased from 1098 copies/mL in the control year to 439 copies/mL at study end (P=.004). Adherence to cART significantly improved (OR 1.14, IQR 1.10-1.18; P<.001), whereas appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). A response was received for 46.57% (1753/3764) of messages sent and 9.62% (362/3764) of text messages sent were replied to with a problem. An outcome analysis examining relationship between reply rate and VL did not meet statistical significance (P=.07), but may be worthy of investigating further in a larger study.

Conclusions

WelTel may be an effective tool for improving cART adherence and reducing VLs among high-risk, vulnerable HIV-positive persons.

Trial Registration

Clinicaltrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/6qK57zCwv)