Systematic review of mobile health behavioural interventions to improve uptake of HIV testing for vulnerable and key populations

Mobile Phone-Based Confidential Social Network Referrals for HIV Testing (CONSORT): Protocol for a Randomized Controlled Trial

BACKGROUND

Critical to efforts to end the HIV epidemic is the identification of persons living with HIV who have yet to be diagnosed and engaged in care. Expanded HIV testing outreach efforts need to be both efficient and ambitious, targeting the social networks of persons living with HIV and those at above-average risk of undiagnosed HIV infection. The ubiquity of mobile phones across many high HIV prevalence settings has created opportunities to leverage mobile health (mHealth) technologies to engage social networks for HIV testing outreach, prevention, and treatment.

OBJECTIVE

The purpose of this study is to evaluate the acceptability and efficacy of a novel mHealth intervention, "Confidential Social Network Referrals for HIV Testing (CONSORT)," to nudge at-risk individuals to test for HIV using SMS text messages.

METHODS

We will conduct the CONSORT study in Moshi, Tanzania, the commercial center and administrative capital of the Kilimanjaro Region in northern Tanzania. After qualitative formative work and pilot testing, we will enroll 400 clients presenting for HIV counseling and testing and 200 persons living with HIV and receiving care at HIV care and treatment centers as "inviters" into a randomized controlled trial. Eligible participants will be aged 18 years or older and live, work, or regularly receive care in Moshi. We will randomize inviters into 1 of 2 study arms. All inviters will be asked to complete a survey of their HIV testing and risk behaviors and to think of social network contacts who would benefit from HIV testing. They will then be asked to whom they would prefer to extend an HIV testing invitation in the form of a physical invitation card. Arm 1 participants will also be given the opportunity to extend CONSORT invitations in the form of automated confidential SMS text messages to any of their social network contacts or "invitees." Arm 2 participants will be offered physical invitation cards alone. The primary outcome will be counselor-documented uptake of HIV testing by invitees within 30 days of inviter enrollment. Secondary outcomes will include the acceptability of CONSORT among inviters, the number of new HIV diagnoses, and the HIV risk of invitees who present for testing.

RESULTS

Enrollment in the randomized controlled trial is expected to start in September 2024. The findings will be disseminated to stakeholders and published in peer-reviewed journals.

CONCLUSIONS

If CONSORT is acceptable and effective for increasing the uptake of HIV testing, given the minimal costs of SMS text reminders and the potential for exponential but targeted growth using chain referrals, it may shift current practices for HIV testing programs in the area.

TRIAL REGISTRATION

ClincalTrials.gov NCT05967208; https://clinicaltrials.gov/study/NCT05967208.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55068.

Effectiveness of eHealth interventions for HIV prevention, testing and management: An umbrella review

BACKGROUND

Human immunodeficiency virus (HIV) infection has become a major contributor to the global burden of disease. Globally, the number of cases of HIV continues to increase. Electronic health (eHealth) interventions have emerged as promising tools to support disease self-management among people living with HIV. The purpose of this umbrella review is to systematically evaluate and summarize the evidence and results of published systematic reviews and meta-analyses on the effectiveness of eHealth interventions for HIV prevention, testing and management.

METHODS

PubMed, Embase and the Cochrane Library were searched for reviews. The methodological quality of the included studies was assessed using AMSTAR-2.

RESULTS

A total of 22 systematic reviews were included. The methodological quality of the reviews was low or critically low. EHealth interventions range from Internet, computer, or mobile interventions to websites, programs, applications, email, video, games, telemedicine, texting, and social media, or a combination of them. The majority of the reviews showed evidence of effectiveness (including increased participation in HIV management behaviours, successfully changed HIV testing behaviours, and reduced risk behaviours). EHealth interventions were effective in the short term.

CONCLUSIONS

Ehealth interventions have the potential to improve HIV prevention, HIV testing and disease management. Due to the limitations of the low methodological quality of the currently available systematic reviews, more high-quality evidence is needed to develop clear and robust recommendations.

High Interest in the Use of mHealth Platform for HIV Prevention among Men Who Have Sex with Men in Nepal

Mobile technology growth in Nepal offers promising opportunities for using mobile health (mHealth) interventions to facilitate HIV prevention efforts. However, little is known about access and utilization of communication technology and their willingness to use mHealth for HIV prevention services in Nepal. We conducted a cross-sectional respondent-driven sampling survey of 250 MSM in Kathmandu Valley of Nepal from October to December 2022. We collected information on participant characteristics, HIV risk-related behaviors, ownership, or access to and frequency of use of communication technology (phones, tablets, laptops, and computers), and willingness to use mHealth to access HIV prevention services. Descriptive, bivariate, and multivariate linear regression analyses were performed. Almost all participants had smartphones with the internet (231/250, 92.4%) and accessed the internet daily (219/250, 87.6%) on the smartphone (236/250, 94.4%). The median score for willingness to use mHealth for HIV prevention was 10 (IQR: 3 to 17). Willingness to use mHealth was higher among those participants with a high school or above education (β = 0.223, p = < 0.001), had experienced violence (β = 0.231, p = 0.006), and had moderate to severe depressive symptoms (β = 0.223, p = < 0.001). However, monthly income above NPR 20,000 (USD 150) (β= -0.153, p = 0.008), disclosure of their sexual orientation to anyone (β= -0.159, p = < 0.007), and worry about being negatively judged by health care workers (β= -0.136, p = 0.023) were less willing to use mHealth strategies. The findings from this study suggest that there is a high willingness for utilizing mHealth interventions for HIV prevention in MSM population who are at higher risk of HIV acquisition.

Exploring Barriers and Facilitators That Influence Uptake of Oral Pre-Exposure Prophylaxis Among Men Who Have Sex With Men in Bulawayo, Zimbabwe: Key Stakeholder's Perspectives

The world has been on the path to ending HIV and AIDS as a global threat by 2030; despite these efforts, the rate of new HIV infections among men who have sex with men remains very high. This study sought to explore the perceptions of key stakeholders on the potential barriers and facilitators of pre-exposure prophylaxis use among this key population. An exploratory, descriptive (through interviews) qualitative study was conducted on 10 key informants who were purposively selected and snowballed based on their knowledge and experience toward pre-exposure prophylaxis programming among men who have sex with men. The interviews were recorded, transcribed verbatim, coded, and thematically analyzed on MAXQDA. Stated barriers were stigma, lack of information, wrong messaging around pre-exposure prophylaxis, hearing negative things about the pills, the burden of taking pills daily, negative attitudes from health care providers, non-friendly health care facilities, pre-exposure prophylaxis not being affordable, and lack of flexibility and privacy from public hospitals. Identified facilitators were correct messaging on pre-exposure prophylaxis, long-lasting injectable pre-exposure prophylaxis, improved packaging, de-stigmatization, more friendly facilities, differentiated service approach, community groups, engagement, and partnership. To address these barriers and leverage the facilitators, it is imperative to have accessible, affordable services, non-judgmental health care providers, and peer support networks to empower men who have sex with men to make informed decisions regarding their sexual and reproductive health. Continued efforts to remove barriers and promote facilitators are crucial for maximizing the potential of pre-exposure prophylaxis as an effective HIV prevention tool among this population.

Interventions to increase the uptake and continuation of pre-exposure prophylaxis (PrEP) by adolescent girls and young women at high risk of HIV in low-income and middle-income countries: a scoping review

INTRODUCTION

Effective strategies to increase pre-exposure prophylaxis (PrEP) uptake and continuation among adolescent girls and young women (AGYW) who engage in sex work or transactional sex are sparsely reported. We aimed to describe the available evidence on strategies for improving the uptake and continuation of PrEP among AGYW who engage in sex work or transactional sex, or otherwise are at high risk of acquiring HIV, and report their implementation outcomes.

METHOD

PubMed, Embase, CINAHL and Global Health were searched for studies describing strategies to increase uptake and continuation of PrEP for HIV prevention among AGYW at high risk of acquiring HIV in low-income and middle-income countries. Two independent reviewers screened citations for inclusion and performed data abstraction. Proctor's framework was used to report the implementation outcomes of the interventions.

RESULT

We identified 1046 citations, and reviewed 69 full-text documents, of which we included 11 in the scoping review. A social marketing campaign was used in one study to create demand for PrEP. A decision support tool was used in one study to improve PrEP initiation. SMS reminders (two studies), drug-level feedback (two studies), peer group support (one study) and conditional economic incentives (one study) were used to improve PrEP continuation. Five studies reported adoption outcomes, two of which were high. Four studies reported sustainability outcomes; these were low or moderate. One study found private youth-friendly clinics a better fit for AGYW PrEP delivery compared with public hospitals, and prescription of PrEP by non-study staff in the hospital facility was low.

CONCLUSION

Multiple promising interventions have been used to deliver PrEP to AGYW at high risk of acquiring HIV; however, more information is needed to understand how these interventions would likely perform at scale outside of a research context.

Acceptance of Index Case HIV Testing and Its Associated Factors Among HIV/AIDS Clients on ART Follow-Up in West Ethiopia: A Multi-Centered Facility-Based Cross-Sectional Study

Background

Index case HIV/AIDS testing (ICHT) is a good approach for addressing and improving the efficiency and yield of testing among high-risk populations. Partners and families of people living with HIV/AIDS are among the high-risk populations for contracting HIV/AIDS. However, there is limited study on index case HIV testing among HIV patients attending Anti-Retroviral Therapy (ART). Hence, this study was aimed at assessing the magnitude and factors associated with ICHT among HIV patients attending ART in Nekemte town public health facilities.

Methods

An institution-based cross-sectional study was conducted at Nekemte town public health facilities from May 20 to July 21, 2020. A systematic random sampling method was used to select the study participants. Multivariable logistic regression analysis was used to determine the predictors of acceptance of ICHT among HIV patients.

Results

The ICHT acceptance was 85.2% (95% CI=84.9–91.1%). Disclosure of their HIV status (AOR=9.74, 95% CI=4.11–23.06), having good knowledge of ICHT (AOR=4.70, 95% CI=1.92–11.61), believing HIV index case testing has benefits (AOR=3.43, 95% CI=1.27–9.29), and being on ART for more than 1 year (AOR=4.78, 95% CI=2.13–10.76) were significantly associated with index case HIV test acceptance.

Conclusion and Recommendation

This study revealed a significant proportion of index case HIV testing acceptance. HIV status disclosure of index cases, knowledge of ICHT, the perceived benefit of ICHT, and long duration on ART were found to be significantly associated with acceptance of ICHT. Hence, it is essential to give attention to counseling on the importance of ICHT, enhance people living with HIV (PLWHIV) to have positive belief on the advantage of ICHT, strengthen disclosure counseling, and assist HIV status disclosure in health facilities.

Mobile Health Technology Use and the Acceptability of an mHealth Platform for HIV Prevention Among Men Who Have Sex With Men in Malaysia: Cross-sectional Respondent-Driven Sampling Survey

BACKGROUND

The growth in mobile technology access, utilization, and services holds great promise in facilitating HIV prevention efforts through mobile health (mHealth) interventions in Malaysia. Despite these promising trends, there is a dearth of evidence on the use of mHealth platforms that addresses HIV prevention among Malaysian men who have sex with men.

OBJECTIVE

The goal of this study was to gain insight into (1) access and utilization of communication technology (eg, landline phone, internet, mobile phone), (2) acceptability of mHealth-based interventions for HIV prevention services, and (3) preferences regarding the format and frequency of mHealth interventions among Malaysian men who have sex with men.

METHODS

We conducted a cross-sectional survey with Malaysian men who have sex with men between July 2018 and March 2020. Participants were recruited using respondent-driven sampling in the Greater Kuala Lumpur region of Malaysia. We collected information on demographic characteristics, HIV risk-related behaviors, access to and the frequency of use of communication technology, and acceptability of using mHealth for HIV prevention using a self-administered questionnaire with a 5-point scale (1, never; 2, rarely; 3, sometimes; 4, often; 5, all the time).

RESULTS

A total of 376 men participated in the survey. Almost all respondents owned or had access to a smartphone with internet access (368/376, 97.9%) and accessed the internet daily (373/376, 99.2%), mainly on a smartphone (334/376, 88.8%). Participants on average used smartphones primarily for social networking (mean 4.5, SD 0.8), followed by sending or receiving emails (mean 4.0, SD 1.0), and searching for health-related information (mean 3.5, SD 0.9). There was high acceptance of the use of mHealth for HIV prevention (mean 4.1, SD 1.5), including for receiving HIV prevention information (345/376, 91.8%), receiving medication reminders (336/376, 89.4%), screening and monitoring sexual activity (306/376, 81.4%) or illicit drug use (281/376, 74.7%), and monitoring drug cravings (280/376, 74.5%). Participants overwhelmingly preferred a smartphone app over other modalities (eg, text, phone call, email) for engaging in mHealth HIV prevention tools. Preference for app notifications ranged from 186/336 (53.9%), for receiving HIV prevention information, to 212/336 (69.3%), for screening and monitoring sexual activity. Acceptance of mHealth was higher for those who were university graduates (P=.003), living in a relationship with a partner (P=.04), engaged in sexualized drug use (P=.01), and engaged in receptive anal sex (P=.006).

CONCLUSIONS

Findings from this study provide support for developing and deploying mHealth strategies for HIV prevention using a smartphone app in men who have sex with men-a key population with suboptimal engagement in HIV prevention and treatment.

Client Experiences in a Mobile-Phone Counseling Intervention for Enhancing Access to Prevention of Mother To-Child Transmission (PMTCT) Services in Kenya

Background

The prevention of mother-to-child transmission (PMTCT) is considered one of the most successful HIV prevention strategies in detecting and reducing HIV acquisition in utero or at birth. It is anticipated that with the increasing growth of digital technologies mobile phones can be utilized to enhance PMTCT services by improving provider-client interactions, expanding access to counseling services, and assisting in counteracting social and structural barriers to uptake of PMTCT services. Understanding the subjective experiences of women accessing PMTCT services in different settings has the potential to inform the development and promotion of such methods. This paper explores the perspectives of HIV-positive pregnant women attending maternal and neonatal clinic services in Kisumu, Kenya.

Methods

Data are reported from in-depth interviews with women, following a longitudinal study investigating the impact of a structured, counselor-delivered, mobile phone counseling intervention to promote retention in care and adherence to ARV prophylaxis/treatment, for HIV-positive pregnant women. Thematic content analysis was conducted.

Results

Discussions indicated that mobile-phone counseling provided useful health-related information, enhanced agency, and assisted mothers access critical PMTCT services across the cascade of care. Similarly, mobile-phone counseling offered personalized one-to-one contact with trained health providers including facilitating discussion of personal issues that likely affect access to services. Findings also identified barriers to the uptake of services, including a lack of partner support, poor health, poverty, facility-related factors, and provider attitudes.

Discussion

Overall, findings show that mobile-phone counseling is feasible, acceptable, and can enhance access to PMTCT services by overcoming some of the individual and facility-level barriers. Although mobile-phone counseling has not been routinized in most health facilities, future work is needed to assess whether mobile-phone counseling can be scaled-up to aid in the effective use of HIV and PMTCT services, as well as improving other related outcomes for mother and child dyad.

Lessons from management of syphilis in Nunavut, Canada, 2012-2020

BACKGROUND

Nunavut, part of Inuit Nunangat, is a geographically vast territory in northern Canada, with a population of over 38,000 people. Most (85%) of the population identify as Inuit. Nunavut has experienced a significant rise in heterosexual infectious syphilis cases since 2012. Management of communicable diseases, including syphilis, is challenging due to high staff turnover and long delays in specimen transport times. Social determinants of health are also an important contributor. The aim of this study is to describe the epidemiology and program elements for infectious syphilis from 2012-2020 and to highlight beneficial interventions.

METHODS

Syphilis is a notifiable disease in Nunavut with all cases reported to the Territorial Department of Health. Cases were staged by a medical consultant. Data were analyzed and released in public reports as part of the public health program.

RESULTS

From 2012 to 2020, 655 infectious syphilis cases were reported, with 53% of reported cases among females. Infection rates were highest in 20 to 39-year-olds. There was significant variability in reported cases over this time period by geographic region, with the majority of infectious cases reported from the Kivalliq region. Despite 48 reported cases in pregnancy, no confirmed congenital syphilis cases were identified. Program staff identified strengths of the response as well as ongoing needs, such as plain language resources available in multiple languages.

CONCLUSION

Despite the logistical challenges with syphilis management in the territory, the overall outcomes have been positive, with no confirmed congenital cases identified. We attribute this to a coordinated effort by multiple partners including key actions by public health nurses and community health representatives.

An Integrated Conceptual Framework of Behavioral Intervention Technologies to Promote Healthcare Utilization Among Socially-Marginalized Populations in the United States

In the U.S., socially marginalized groups disproportionately shoulder the burden of health outcomes. The evolving development of behavioral intervention technologies provides opportunities to support users in changing behaviors and improving health. No conceptual model is available to guide technology-based behavioral interventions among vulnerable groups in the new era of digitalization. Our conceptual framework combines the Behavioral Model of Healthcare Utilization (HCU) for Vulnerable Populations and the Integrated Model of Behavioral Prediction (IMBP). With the Socioecological Model leading the vertical direction, the overarching HCU-IBMP model is incorporated by the Behavioral Intervention Technology-Technological Instantiation Framework (BIT-Tech). The HCU model explains how vulnerable populations influence healthcare access and utilization behaviors by personal and contextual factors. Through the lens of the IMBP, healthcare utilization intention is highly predictable and maybe even causally correlated with the corresponding behavior. To assist the healthcare utilization intention translates into the corresponding behaviors, we employ a medium using the technological implementation in a system that can assist the end-users in adopting the desired behavior. With the integrated model that combines a technological framework with the behavioral components, the BIT-Tech guides the procedure intervention development. Our integrated conceptual framework indicated that theoretical and technical components should be considered during a technological tool development to support the research community. A real-world intervention design has been demonstrated using the framework to guide behavioral intervention technologies to promote PrEP care and utilization among racial/ethnic minority women in the U.S.

Privacy and Confidentiality Concerns Related to the Use of mHealth Apps for HIV Prevention Efforts Among Malaysian Men Who Have Sex With Men: Cross-sectional Survey Study

BACKGROUND

The use of mobile health (mHealth), including smartphone apps, can improve the HIV prevention cascade for key populations such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, the mHealth platform has the potential to open new frontiers for HIV prevention efforts. However, little guidance is available to inform researchers about privacy and confidentiality concerns unique to the development and implementation of app-based HIV prevention programs.

OBJECTIVE

Given the lack of empirical data in this area, we aim to understand the privacy and confidentiality concerns associated with participation in a hypothetical app-based research study for HIV prevention efforts.

METHODS

A cross-sectional, web-based survey was conducted between June and July 2020 among 355 Malaysian MSM. The survey included demographic and sexual health questions and a series of short videos describing a hypothetical app-based HIV prevention program, followed by questions related to privacy and confidentiality concerns in each step of the app-based program (ie, recruitment, clinical interaction, risk assessment, and weekly reminder). Multivariable logistic regression models were used to identify the correlates of willingness to use such an app-based program.

RESULTS

Most of the participants (266/355, 74.9%) indicated their willingness to participate in a hypothetical mHealth app-based HIV prevention program. Participants expressed concerns about privacy, confidentiality, data security, and risks and benefits of participating in all stages of the app-based HIV research process. Multivariate analyses indicated that participants who had a higher degree of perceived participation benefits (adjusted odds ratio [aOR] 1.873; 95% CI 1.274-2.755; P=.001) were more willing to participate. In contrast, participants who had increased concerns about app-based clinical interaction and e-prescription (aOR 0.610; 95% CI 0.445-0.838; P=.002) and those who had a higher degree of perceived risks of participating (aOR 0.731; 95% CI 0.594-0.899; P=.003) were less willing to participate.

CONCLUSIONS

Overall, our results indicate that mHealth app-based HIV prevention programs are acceptable for future research on Malaysian MSM. The findings further highlighted the role of privacy and confidentiality, as well as the associated risks and benefits associated with participation in such a program. Given the ever-evolving nature of such technological platforms and the complex ethical-legal landscape, such platforms must be safe and secure to ensure widespread public trust and uptake.

Factors Associated With HIV Testing Among High-School Girls in the U.S., 2015‒2017

INTRODUCTION

Few studies have examined the factors associated with HIV testing, specifically among U.S. high-school girls.

METHODS

Investigators analyzed 2015 and 2017 Youth Risk Behavior Survey data to calculate the prevalence ratios and the corresponding 95% CIs for the association of HIV-related risk behaviors and other factors with HIV testing. Analyses were completed in March 2020.

RESULTS

Approximately 1 in 10 high-school girls reported ever having had an HIV test. Ever having had an HIV test was most common among girls who had ≥4 lifetime sexual partners and those who had ever injected illegal drugs.

CONCLUSIONS

High-school girls who engage in behaviors or experience other factors that put them at higher risk for HIV are more likely to have ever gotten tested. However, the prevalence of having ever had an HIV test remains relatively low, indicating that continued efforts may be warranted to reduce risk behaviors and increase testing among high-school girls.

Text message reminders and peer education increase HIV and Syphilis testing among female sex workers: a pilot quasi-experimental study in Uganda

BACKGROUND

Globally, female sex workers (FSW) are disproportionately affected by HIV and other sexually transmitted infections (STIs). However, uptake of STI and HIV testing services among FSW in sub-Saharan Africa remains low. We aimed to assess the effect of FSW-led peer education and text message reminders on 3-monthly syphilis and HIV testing among FSW in Uganda.

METHODS

Between September 2019 and February 2020, we implemented weekly peer education sessions and bi-monthly SMS reminders for FSW in Mbarara (intervention city). Peer education sessions were implemented by 20 FSW, who received five days of basic training as peer educators. We held monthly meetings with peer educators throughout the six-month implementation period. FSW in Mbale (control city) continued to receive standard of care consisting of HIV testing outreach campaigns, and facility-based testing. Using a quasi-experimental design in one intervention city, and one control city, we conducted pre- and post- questionnaire-based surveys on recent syphilis and HIV testing behavior among FSW in July-October 2018, and March 2020. We compared proportions and prevalence ratios at baseline and follow-up using chi-square tests and negative binomial regression.

RESULTS

We conducted 436 interviews (200 before/236 after) with FSW. At baseline similar proportions reported taking an HIV test (57 % vs. 54 %; p = 0.72), and a syphilis serology test (35 % vs. 39 %; p = 0.67) in the intervention and control cities, respectively, in the prior three months. After the intervention, this proportion increased to 82 % (95 % confidence interval [CI] 74.0-88.2) for HIV, and 81 % (95 % CI: 73.0-87.0) for syphilis in the intervention city. Relative to baseline in the control city, the proportion testing for HIV was unchanged (52 %) but decreased for syphilis (26 %).

CONCLUSIONS

Bi-monthly text message reminders with weekly peer education sessions increased uptake of 3-monthly syphilis and HIV testing in a Ugandan female sex work population and could help increase sex worker engagement in HIV/STI services in line with World Health Organization recommendations.

The role of telemedicine in gynecologic healthcare: A narrative review

ABSTRACT

This article offers a comprehensive narrative literature review on telemedicine use in gynecologic healthcare analyzing current telemedicine integration in the field and outlining innovative and best practices. Telemedicine use in contraceptive care, sexually transmitted infections, acute and chronic gynecologic conditions, and education are discussed. NPs are in a unique position to offer these services to patients in need of women's healthcare services. Barriers, facilitators, clinical implications, and future research are addressed.

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

ABSTRACT

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

Peer Group Focused eHealth Strategies to Promote HIV Prevention, Testing, and Care Engagement

PURPOSE OF REVIEW

Electronic communication platforms are increasingly used to support all steps of the HIV care cascade (an approach defined as eHealth). Most studies have employed individual-level approaches in which participants are connected with information, reminders, or a healthcare worker. Recent growth in use of social media platforms, which create digital communities, has created an opportunity to leverage virtual peer-to-peer connection to improve HIV prevention and care. In this article, we describe the current landscape of peer group eHealth interventions in the HIV field, based on a review of published literature, an online survey of unpublished ongoing work, and discussions with practitioners in the field in an in-person workshop.

RECENT FINDINGS

We identified 45 published articles and 12 ongoing projects meeting our inclusion criteria. Most reports were formative or observational; only three randomized evaluations of two interventions were reported. Studies indicated that use of peer group eHealth interventions is acceptable and has unique potential to influence health behaviors, but participants reported privacy concerns. Evaluations of health outcomes of peer group eHealth interventions show promising data, but more rigorous evaluations are needed. Development of group eHealth interventions presents unique technological, practical, and ethical challenges. Intervention design must consider privacy and data sovereignty concerns, and respond to rapid changes in platform use. Innovative development of open-source tools with high privacy standards is needed.

Shifting Coronavirus Disease 2019 Testing Policy and Research to Include the Full Translation Pipeline

The current severe acute respiratory syndrome coronavirus 2 testing policy and practice limits testing as a prevention tool. Radical shifts are required to increase the scale of rapid testing strategies and improve dissemination and implementation of venue-based and self-testing approaches. Attention to the full translation pipeline is required to reach high-risk segments of the population.

Use of Smartphone to Seek Sexual Health Information Online Among Malaysian Men Who Have Sex with Men (MSM): Implications for mHealth Intervention to Increase HIV Testing and Reduce HIV Risks

In settings where stigma and discrimination toward men who have sex with men (MSM) are high or illegal, like in Malaysia, innovative methods to anonymously reach them are urgently needed. The near ubiquitous availability of mobile technology, including smartphones, has the potential to open new frontiers (such as mHealth) to prevent HIV and other sexually transmitted infections (STIs). The extent to which MSM use mHealth tools for HIV and STI prevention in the Malaysia context, however, is unknown. A cross-sectional online survey in 622 Malaysian MSM was conducted between July and November 2017. Participants were recruited via advertisements on mobile apps frequently used by MSM. In addition to demographic, smartphone access and utilization, and other information were assessed using logistic regression to determine factors associated with the use of a smartphone to search for online sexual health information. Nearly all (99.2%) participants owned a smartphone, with 63% reported having used one to seek sexual health information, including HIV/STIs. Overall, 96% used smartphones to find sexual partners, with high levels of HIV risk behavior reported. Independent correlates of smartphone use to seek online sexual health information included older age (aOR 0.943, p = 0.005), higher education (aOR 2.14, p = 027), recent (past year) HIV testing (aOR 3.91, p = 0.026), and seeking sexual partners using geosocial networking apps (aOR 5.58, p = 0.006). These findings suggest high smartphone use by high-risk MSM to seek sexual health information and suggests that mHealth strategies may be an effective strategy to engage MSM in HIV prevention activities.

Mass media and communication interventions to increase HIV testing among gay and other men who have sex with men: Social marketing and visual design component analysis

Mass media and communication interventions can play a role in increasing HIV testing among gay, bisexual and other men who have sex with men (GBMSM). Despite the key role of social marketing principles and visual design within intervention development of this type, evidence is limited regarding interventions’ social marketing mix or visual design. As part of a systematic review, intervention content was assessed using social marketing theory and social semiotics. Data were extracted on the nature of the intervention, mode of delivery, use of imagery, content and tone and the eight key characteristics of social marketing. Data were synthesised narratively. Across the 19 included studies, reference to social marketing principles was often superficial. Common design features were identified across the interventions, regardless of effectiveness, including: the use of actors inferred to be GBMSM; use of ‘naked’ and sexually explicit imagery; and the use of text framed as statements or instructions. Our results suggest that effective interventions tended to use multiple modes of delivery, indicating high social marketing complexity. However, this is only part of intervention development, and social marketing principles are key to driving the development process. We identified consistent aspects of intervention design, but were unable to determine whether this is based on evidence of effectiveness or a lack of originality in intervention design. An openness to novel ideas in design and delivery is key to ensuring that evidence-informed interventions are effective for target populations.

Exploring the equity impact of mobile health-based human immunodeficiency virus interventions: A systematic review of reviews and evidence synthesis

Objective

While mobile health-based human immunodeficiency virus (HIV) interventions are often designed to promote health equity, systematic differences in the use of and access to mobile technologies may counteract that and widen treatment gaps. This systematic review applies an equity lens to investigate whether existing research provides adequate evidence on the ethical implications of mHealth technologies in HIV treatment and prevention.

Methods

This study included a two-stage methodology, consisting of (a) a systematic review of systematic reviews and (b) an evidence synthesis of primary studies. For the review of reviews we searched eight electronic databases, eight electronic journals and Google Scholar. We also screened reference lists and consulted authors of included studies. Primary studies were extracted from eligible reviews. We based our data extraction and analysis on the Place of residence, Race, Occupation, Gender/Sex, Religion, Education, Socioeconomic status, Social capital and other disadvantage related characteristics (PROGRESS-Plus) framework and the use of harvest plots, focusing on the socio-demographic distribution of mHealth effects.

Results

A total of 8786 citations resulted in 19 eligible reviews and 39 eligible primary studies. Existing reviews did not provide any analyses of the equity impacts of mobile health-based HIV initiatives. Information availability was higher in primary studies, predominantly suggesting no social gradient of mobile health-based HIV interventions. Overall, evidence remains weak and not sufficient to allow for confident equity statements.

Conclusions

Despite the negative force of socio-demographic inequities and the emerging nature of mobile health technologies, evidence on the equity implications of mobile health interventions for HIV care remains scarce. Not knowing how the effects of mobile health technologies differ across population subgroups inevitably limits our capacities to equitably adopt, adjust and integrate mobile health interventions towards reaching those disproportionally affected by the epidemic.

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.

Uptake and Impact of Short Message Service Reminders via Sexually Transmitted Infection Partner Services on Human Immunodeficiency Virus/Sexually Transmitted Infection Testing Frequency Among Men Who Have Sex With Men

BACKGROUND

Sexually transmitted infection (STI) partner services (PS) allow provision of human immunodeficiency virus (HIV)/STI prevention interventions to high-risk individuals, including testing reminders via short message service (SMS).

METHODS

In King County, Washington, PS attempt to reach all men who have sex with men (MSM) with early syphilis and those with gonorrhea or chlamydia as resources allow. Since 2013, PS offered quarterly SMS testing reminders. We evaluated correlates of reminder uptake and the association between reminder uptake and postinterview asymptomatic STI diagnosis using Poisson regression, and the association between preinterview SMS reminder use and intertest interval among HIV-negative MSM using median regression.

RESULTS

During July 1, 2013 to January 17, 2018, 8236 MSM were reported with 1 or more STI diagnoses and 5237 received PS interviews. Of these, 4087 (78%) were offered SMS reminders; 545 (13%) accepted, 265 (7%) were already receiving SMS, 3277 (80%) refused. Of 2602 patients who refused and were asked about other reminders, 37% used none, 16% received reminders from medical providers, 20% tested at routine physicals, and 26% used other reminders. SMS reminder use before and after PS interview was associated with negative HIV status, younger age, and diagnosis with gonorrhea or chlamydia (vs. syphilis) (P < 0.05 for all). Preinterview intertest interval was longer among MSM testing at physicals (9.6 months) than those using no reminder (5.6), SMS reminders (4.7, P < 0.05 vs. physicals), and non-SMS reminders (3.6, P < 0.001 vs. SMS). Reminder uptake was not associated with postinterview STI diagnosis.

CONCLUSIONS

Offering SMS reminders through STI PS is feasible. Uptake was low, but higher among young MSM not on preexposure prophylaxis. The SMS reminders may increase testing frequency.

A Sexual Health Promotion App for Transgender Women (Trans Women Connected): Development and Usability Study

BACKGROUND

HIV severely impacts the transgender communities in the United States, and transgender women have the highest HIV incidence rates among any identified risk group. Guided by formative research with transgender women and by an expert advisory panel of transgender women, we designed a prototype mobile app to promote HIV prevention among transgender women.

OBJECTIVE

This study aimed to develop and test the usability and acceptability of the prototype Trans Women Connected mobile app.

METHODS

We engaged in a 3-phase prototype development process. After conducting formative research about the health needs of this population, we outlined a theory-based app framework and developed three prototype activities (ie, a vision board, a pre-exposure prophylaxis [PrEP] education activity, and an interactive map). We then tested the usability and acceptability of the mobile app and activities with 16 transgender women using pre- and posttests, think-aloud protocols, and open-ended questions.

RESULTS

Participants reported high acceptability for the mobile app; the mean rating across all usability and likability questions was 5.9 out of 7. Service utilization intention, goal setting, and social support increased at posttest compared with pretest. Increases in self-efficacy in finding lesbian, gay, bisexual, transgender, and queer-friendly services; intention to seek online social support; and PrEP knowledge were statistically significant. Participants described the app as attractive and useful and perceived all three activities positively.

CONCLUSIONS

This study describes the development and usability and acceptability evaluation of a prototype mobile app designed for and with transgender women for HIV prevention. The usability testing findings provided important insights toward refining and the further development of the Trans Women Connected mobile app. The results suggest that a mobile health intervention can support positive changes. The remaining development and efficacy randomized trial of the Trans Women Connected mobile app is currently underway.

Pilot Study of a Multilevel Mobile Health App for Substance Use, Sexual Risk Behaviors, and Testing for Sexually Transmitted Infections and HIV Among Youth: Randomized Controlled Trial

BACKGROUND

Preventing and reducing substance use disorders, sexually transmitted infections (STIs)/HIV, and teen pregnancy, and the associated risk behaviors (ie, substance use and sexual risk behaviors) among youth remain public health priorities in the United States. Equally important is improving the uptake of STI/HIV testing among the youth. Mobile health (mHealth) apps may be a solution to ameliorate these public health concerns; however, few mHealth preventive interventions have demonstrated efficacy in reducing substance use or sexual risk behaviors or improving the uptake of STI/HIV testing among the youth, particularly in clinic settings.

OBJECTIVE

This small-scale study aimed to examine the feasibility of conducting a pilot randomized controlled trial (RCT). We evaluated the effects of Storytelling 4 Empowerment (S4E), relative to enhanced usual practice, on the potential mechanisms by which behavior change occurs, namely clinician-youth risk communication, prevention knowledge, and substance use and sexual risk refusal self-efficacy. We also assessed the ability to measure targeted outcomes of past 30-day substance use (ie, alcohol, tobacco, and other drug use), condomless sex, and alcohol or drug use before sex, as well as the uptake of STI/HIV testing.

METHODS

Employing community-based participatory research principles, 50 youths aged 13 to 21 years were recruited from a youth-centered community health clinic in Southeast Michigan, randomized sequentially to either S4E or enhanced usual practice, and assessed at baseline, immediately postintervention, and 30 days postintervention. S4E consists of 3 modules, including alcohol and drug use, tobacco, and STI/HIV.

RESULTS

Relative to youth in the enhanced usual practice group, S4E participants demonstrated higher youth-clinician risk communication (mean 3.22, SD 1.67) and increases in prevention knowledge (∆ score mean 0.36, SD 0.51) and self-efficacy (∆ score mean 0.16, SD 0.47). In addition, youth in the S4E group showed reductions in the proportions of past 30-day overall substance use (Cohen h=0.71, 95% CI 0.15 to 1.27), as well as past 30-day alcohol (Cohen h=0.71, 95% CI 0.15 to 1.27), tobacco (Cohen h=0.17, 95% CI -0.39 to 0.73), and drug use (Cohen h=1.28, 95% CI 0.72 to 1.84). The results also suggest a reduction in the proportion of youths who reported past 30-day condomless sex (Cohen h=0.18, 95% CI -0.38 to 0.74) and alcohol use before sex (Cohen h=0.44, 95% CI -0.12 to 1.00). Finally, the findings also demonstrated an increase in the proportion of youths who reported STI/HIV testing over time (Cohen h=0.16, 95% CI -0.39 to 0.72).

CONCLUSIONS

The findings suggest the feasibility of a small-scale pilot RCT. S4E demonstrated shifts in the hypothesized direction, reducing substance use, sexual risk behaviors, and improving the uptake of STI/HIV testing among youth in a clinic setting. The findings suggest that a larger RCT may be warranted.

TRIAL REGISTRATION

ClinicalTrails.gov NCT03855410, https://clinicaltrials.gov/ct2/show/NCT03855410.

Do combination HIV prevention programmes result in increased empowerment, inclusion and agency to demand equal rights for marginalised populations in low-income and middle-income countries? A systematic review

Introduction

This systematic review aims to determine if combination HIV prevention programmes include outcome measures for empowerment, inclusion and agency to demand equal rights and measure the relationship between empowerment and HIV prevention outcomes.

Methods

An electronic literature search of PubMed, POPLINE, Index Medicus and Google Scholar was conducted between August and October 2018. We included studies that evaluated combination prevention programmes that had all three types of intervention components and that specifically serve members of populations disproportionately affected by HIV published from 2008 to 2018. The selected studies were screened for inclusion, and relevant data abstracted, assessed for bias and synthesised.

Results

This review included a total of 15 studies. Findings indicate that combination HIV prevention programmes for marginalised populations have delivered a variety of theory-based behavioural and structural interventions that support improvements in empowerment, inclusion and agency. However, empowerment, inclusion and least of all agency are not measured consistently or in a standardised way. In addition, analysis of their relationships with HIV prevention outcomes is rare. Out of our 15 included studies, only two measured a relationship between an empowerment, inclusion or agency outcome and an HIV prevention outcome.

Conclusion

These findings suggest that policy-makers, programme planners and researchers might need to consider the intermediate steps on the pathway to increased condom use and HIV testing so as to explain the ‘how’ of their achievements and inform future investments in HIV prevention. This will support replication and expansion of programmes and ensure sustainability of the programmes.

PROSPERO registration number

CRD42018106909

What are mass media interventions made of? Exploring the active content of interventions designed to increase HIV testing in gay men within a systematic review

PURPOSE

Mass media HIV testing interventions are effective in increasing testing, but there has been no examination of their theory or behaviour change technique (BCT) content. Within a heterogeneous body of studies with weak evaluative designs and differing outcomes, we attempted to gain useful knowledge to shape future interventions.

METHODS

Within a systematic review, following repeated requests to the authors of included studies for intervention materials, the Theory Coding Scheme, the Theoretical Domains Framework (TDF), and Behaviour Change Technique Taxonomy (BCTT) were used to extract data relating to active intervention content.

RESULTS

Of 19 studies, five reported an explicit theoretical basis to their intervention. TDF analysis highlighted the key domains employed within the majority of interventions: 'knowledge', 'social roles and identities', and 'beliefs about consequences'. BCT analysis showed three BCT groupings commonly reported within interventions: 'Comparison of outcomes', 'Natural consequences', and 'Shaping knowledge'. Three individual BCTs formed the backbone of most interventions and can be considered 'standard' content: 'Instructions on how to perform behaviour'; 'Credible source'; and 'Information about health consequences'.

CONCLUSIONS

This is the first study to examine and detail active intervention content in this field. It suggests future interventions should improve knowledge about testing, and use well-branded and trusted sources that endorse testing. Future interventions should also provide clear information about the health benefits of testing. Our analysis also suggests that to improve levels of effectiveness characterizing the current field, it may be useful to elicit commitment, and action plans, relating to how to implement testing intentions.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Interventions are urgently needed to increase HIV testing among men who have sex with men (MSM) and enable increased access to effective treatment for HIV infection. There is some evidence of the effectiveness of mass media interventions in increasing HIV testing among MSM. Nothing is known about the active components of existing mass media interventions targeting HIV testing. What does this study add? It describes the available literature concerning evaluated mass media interventions to increase HIV testing. It shows few interventions report any explicit theoretical basis although many interventions share common components, including coherently connected causal mechanisms and behaviour change techniques to moderate them. As a minimum, future interventions should improve knowledge about testing; use well-branded and trusted sources that endorse testing; and provide clear information about the health benefits of testing. Our analysis also tentatively suggests it may be useful to elicit commitment and planning of how to implement testing intentions.

A Systematic Review of Interventions that Promote Frequent HIV Testing

As of 2017, the Centers for Disease Control and Prevention (CDC) HIV testing guidelines recommend that those at increased risk for HIV are tested two to four times per year. Evidence-based interventions that promote frequent and repeated testing remain sparse. We conducted a systematic review to: (1) identify frequent testing interventions; and (2) determine which were successful in increasing frequent testing rates. We searched PubMed, PsycINFO, Web of Science, Embase, and CINAHL for peer-reviewed articles published between January 1, 2010 and September 30, 2017. Ten studies met inclusion criteria. Operationalization of frequent HIV testing varied widely across studies. Four interventions involved text message reminders for HIV testing, three involved community-based testing, two self-testing, and one rapid testing. Text message reminder interventions were most successful in increasing rates of frequent HIV testing. Future research should standardize frequent testing measurement to allow for more robust comparisons of intervention efficacy.

Reaching key adolescent populations

PURPOSE OF REVIEW

Adolescents and young people who fit within key populations face some of the greatest barriers to HIV care, but are frequently overlooked. We review the recent literature on these young, vulnerable populations including HIV risk factors, barriers to care, and strategies for engagement.

RECENT FINDINGS

Common risk factors include age, risky sexual practices, poor education, and high levels of alcohol and drug abuse. Barriers to care include limited data, criminalization, and high levels of stigma. Strategies to increase engagement include incorporating adolescents into biological and behavioral surveys and the use of social media. Digital innovations for HIV prevention and testing show promise, and pre-exposure prophylaxis may be acceptable. At a policy level, decriminalizing same-sex activity and commercial sex work are priorities. Differentiated models of care including HIV self-testing, after-hour services, community-based delivery, and multimonth dispensing of antiretroviral therapy, should be combined into holistic care.

SUMMARY

There has been limited success in reaching these key adolescent populations largely because of criminalization and stigma. Accurate, generalizable data are needed to inform the development of innovative strategies for holistic care.

Barriers to HIV care and adherence for young people living with HIV in Zambia and mHealth

BACKGROUND

The control of HIV/AIDS has been a contemporary public health success story however, whilst infection rates are falling and people are living longer due to antiretroviral therapy, adolescents and young people remain disproportionally affected. Infection rates and AIDS-related deaths continue to increase in these age groups in some areas globally. This has been primarily attributed to structural barriers including HIV-services not being youth friendly with opening hours conflicting with school time, fears around unintended disclosure and confidentiality, and the attitudes of healthcare professionals-but research targeting these specific age groups remains limited. Early mHealth (i.e., the use of mobile and wireless devices to assist in achieving health objectives) projects have been shown to improve health outcomes in other disease areas and health settings however, amongst people living with HIV, current research is limited. The aim of this study was to explore barriers to HIV care and the acceptability and feasibility of using mHealth to improve retention into care and ART adherence for young people living with HIV (16-24 years old) in Lusaka, Zambia.

METHODS

Qualitative in-depth interviews and focus group discussions were carried out in four CIDRZ-supported health facilities in Lusaka, Zambia. Six interviews were carried out with nurses and peer-support workers working with young people living with HIV and three focus groups with a total of 24 young people. Recruitment was via purposive sampling. Interviews and focus groups were recorded, translated and transcribed and entered into NVivo for thematic analysis.

RESULTS

Twenty-four of the young persons interviewed had access to mobile phones and reported using them for social networking, information gathering and regular communication. Barriers to HIV care and adherence were largely underpinned by stigma. Participants described healthcare facilities as not being conducive for confidentiality and therefore were reluctant to be seen attending or collecting medication from the pharmacy due to possible unintended disclosure and consequential HIV-related stigma. Clinic opening and waiting times and experiences with healthcare professionals also served as barriers. It was felt unanimously by participants that mHealth would be beneficial in improving retention into care and ART adherence in young people living with HIV.

CONCLUSIONS

HIV-related stigma remains a barrier to care. With growing access to mobile phones and internet, and a growing population of adolescents who are already using their phones to support each other and seek information, mHealth appears to be both a feasible and acceptable tool to support retention, provide young people with information, and potentially reduce time spent at health facilities via appointment reminders and electronic drug refill requests.

The UCL-Lancet Commission on Migration and Health: the health of a world on the move

With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency.

In response to these issues, the UCL-Lancet Commission on Migration and Health was convened to articulate evidence-based approaches to inform public discourse and policy. The Commission undertook analyses and consulted widely, with diverse international evidence and expertise spanning sociology, politics, public health science, law, humanitarianism, and anthropology. The result of this work is a report that aims to be a call to action for civil society, health leaders, academics, and policy makers to maximise the benefits and reduce the costs of migration on health locally and globally. The outputs of our work relate to five overarching goals that we thread throughout the report.

First, we provide the latest evidence on migration and health outcomes. This evidence challenges common myths and highlights the diversity, dynamics, and benefits of modern migration and how it relates to population and individual health. Migrants generally contribute more to the wealth of host societies than they cost. Our Article shows that international migrants in HICs have, on average, lower mortality than the host country population. However, increased morbidity was found for some conditions and among certain subgroups of migrants, (eg, increased rates of mental illness in victims of trafficking and people fleeing conflict) and in populations left behind in the location of origin. Currently, in 2018, the full range of migrants’ health needs are difficult to assess because of poor quality data. We know very little, for example, about the health of undocumented migrants, people with disabilities, or lesbian, gay, bisexual, transsexual, or intersex (LGBTI) individuals who migrate or who are unable to move.

Second, we examine multisector determinants of health and consider the implication of the current sector-siloed approaches. The health of people who migrate depends greatly on structural and political factors that determine the impetus for migration, the conditions of their journey, and their destination. Discrimination, gender inequalities, and exclusion from health and social services repeatedly emerge as negative health influences for migrants that require cross-sector responses.

Third, we critically review key challenges to healthy migration. Population mobility provides economic, social, and cultural dividends for those who migrate and their host communities. Furthermore, the right to the highest attainable standard of health, regardless of location or migration status, is enshrined in numerous human rights instruments. However, national sovereignty concerns overshadow these benefits and legal norms. Attention to migration focuses largely on security concerns. When there is conjoining of the words health and migration, it is either focused on small subsets of society and policy, or negatively construed. International agreements, such as the UN Global Compact for Migration and the UN Global Compact on Refugees, represent an opportunity to ensure that international solidarity, unity of intent, and our shared humanity triumphs over nationalist and exclusionary policies, leading to concrete actions to protect the health of migrants.

Fourth, we examine equity in access to health and health services and offer evidence-based solutions to improve the health of migrants. Migrants should be explicitly included in universal health coverage commitments. Ultimately, the cost of failing to be health-inclusive could be more expensive to national economies, health security, and global health than the modest investments required.

Finally, we look ahead to outline how our evidence can contribute to synergistic and equitable health, social, and economic policies, and feasible strategies to inform and inspire action by migrants, policy makers, and civil society. We conclude that migration should be treated as a central feature of 21st century health and development. Commitments to the health of migrating populations should be considered across all Sustainable Development Goals (SDGs) and in the implementation of the Global Compact for Migration and Global Compact on Refugees. This Commission offers recommendations that view population mobility as an asset to global health by showing the meaning and reality of good health for all. We present four key messages that provide a focus for future action.

Health Behavior Theory to Enhance eHealth Intervention Research in HIV: Rationale and Review

PURPOSE OF REVIEW

Optimal design and evaluation of eHealth interventions requires the specification of behavioral targets and hypothesized mechanisms of action-both of which can be enhanced with the use of established health behavior theories (HBTs). In this paper, we describe the major HBTs and examine their use in studies of eHealth interventions for HIV prevention and treatment and assess the contribution of HBT in developing and evaluating eHealth interventions.

RECENT FINDINGS

Based on our review of the literature, we argue the field can benefit from more systematic selection, application, and reporting of HBT. We highlight theories specifically designed for eHealth and describe ways that HBT can be used by researchers and practitioners to improve the rigor and impact of eHealth interventions for individuals living with or at risk for HIV. This brief overview of HBTs and their application to eHealth intervention in HIV research has underscored the importance of a theoretically intentional approach. The theory should be used to inform the design of the eHealth intervention; the intervention should not determine the theory. A theory-driven iterative model of eHealth intervention development may not only improve our repertoire of effective strategies but also has the potential to expand our theoretical and empirical knowledge of health behavior change.

Forming a Kanyakla: A qualitative study to develop a novel social support intervention for adolescents living with HIV

INTRODUCTION

HIV is a leading cause of morbidity and mortality among youth in sub Saharan Africa. This study explores the adaptation of an adult social network intervention for adolescents, entitled Kanyakla.

METHODS

The study was conducted in Kisumu, Kenya from July to November 2016. Data was collected from: (1) semi-structured interviews (n = 32) with adolescents living with HIV aged 15-19; and (2) two focus group discussions (n = 21). Transcripts were coded using thematic analysis through the lens of an Adolescent Development Model.

RESULTS

Participants were interested in joining a Kanyakla to build social support, learn new skills, and partake in recreational activities. Many participants feared inadvertent disclosure related to stigma. Certain dichotomous themes emerged including the need for privacy versus the need for social support; and the desire for inclusion of elders versus preference for same-aged peers in the Kanyaklas.

CONCLUSIONS

With this study, we have key information that can be applied to developing the Kanyakla intervention for adolescents. Further study is needed to reconcile the dichotomies that emerged.

Using behavioural insights to increase HIV self-sampling kit returns: a randomized controlled text message trial to improve England's HIV self-sampling service

OBJECTIVES

The aim of the study was to determine whether behaviourally informed short message service (SMS) primer and reminder messages could increase the return rate of HIV self-sampling kits ordered online.

METHODS

The study was a 2 × 2 factorial design randomized control trial. A total of 9585 individuals who ordered a self-sampling kit from www.freetesting.hiv different SMS combinations: 1) standard reminders sent days 3 and 7 after dispatch (control); 2) primer sent 1 day after dispatch plus standard reminders; 3) behavioural insights (BI) reminders (no primer); or 4) primer plus BI reminders. The analysis was restricted to individuals who received all messages (n = 8999). We used logistic regression to investigate independent effects of the primer and BI reminders and their interaction. We explored the impact of sociodemographic characteristics on kit return as a secondary analysis.

RESULTS

Those who received the primer and BI reminders had a return rate 4% higher than that of those who received the standard messages. We found strong evidence of a positive effect of the BI reminders (odds ratio 1.13; 95% confidence interval 1.04-1.23; P = 0.003) but no evidence for an effect of the primer, or for an interaction between the two interventions. Odds of kit return increased with age, with those aged ≥ 65 years being almost 2.5 times more likely to return the kit than those aged 25-34 years. Men who have sex with men were 1.5-4.5 times more likely to return the kit compared with other sexual behaviour and gender identity groups. Non-African black clients were 25% less likely to return the kit compared with other ethnicities.

CONCLUSIONS

Adding BI to reminder messages was successful in improving return rates at no additional cost.

Mate Yako Afya Yako: Formative research to develop the Tanzania HIV self-testing education and promotion (Tanzania STEP) project for men

The purpose of this formative research, guided by the Integrated Behavioral Model, was to assess men's attitudes and personal agency towards HIV self-testing (HIVST) and confirmatory HIV testing in order to inform the development of the Tanzania STEP (Self-Testing Education and Promotion) Project, a peer-based HIV self-testing intervention for young men in Tanzania. Qualitative in-depth interviews were conducted with 23 men in Dar es Salaam, Tanzania who socialize in networks locally referred to as "camps". Men reported privacy, confidentiality, and saving time as the primary reasons for their self-testing interest. Most participants had high perceived control and self-efficacy to self-test and seek confirmatory HIV testing. Nevertheless, men reported concerns related to their ability to perform the test and the potential lack of post-test counseling. Specific recommendations for the intervention included providing HIVST education and pre-test counseling, and using mobile health (mHealth) strategies for participants to reach a healthcare professional for further assistance. The findings suggest that while HIVST is highly acceptable among men in Tanzania, future interventions will need to address the challenges that men may face with HIVST before promoting it as an alternative or supplement to facility-based HIV testing.

Costing analysis of an SMS-based intervention to promote HIV self-testing amongst truckers and sex workers in Kenya

Objective

HIV testing rates in many sub-Saharan African countries have remained suboptimal, and there is an urgent need to explore strategic yet cost-effective approaches to increase the uptake of HIV testing, especially among high-risk populations.

Methods

A costing analysis was conducted for a randomized controlled trial (RCT) with male truckers and female sex workers (FSWs) registered in the electronic health record system (EHRS) of the North Star Alliance, which offers healthcare services at major transit hubs in Southern and East Africa. The RCT selected a sample of truckers and FSWs who were irregular HIV testers, according to the EHRS, and evaluated the effect of SMSs promoting the availability of HIV self-testing (HIVST) kits in Kenyan clinics (intervention program) versus a general SMS reminding clients to test for HIV (enhanced and standard program) on HIV testing rates. In this paper, we calculated costs from a provider perspective using a mixed-methods approach to identify, measure, and value the resources utilized within the intervention and standard programs. The results of the analysis reflect the cost per client tested.

Results

The cost of offering HIVST was calculated to be double that of routine facility-based testing (USD 10.13 versus USD 5.01 per client tested), primarily due to the high price of the self-test kit. In the two study arms that only offered provider-administered HIV testing in the clinic, only 1% of truckers and 6% of FSWs tested during the study period, while in the intervention arm, which also offered HST, approximately 4% of truckers and 11% of FSWs tested. These lower than expected outcomes resulted in relatively high cost per client estimates for all three study arms. Within the intervention arm, 65% of truckers and 72% of FSWs who tested chose the HIVST option. However, within the intervention arm, the cost per additional client tested was lower for FSWs than for truckers, at USD 0.15 per additional client tested versus USD 0.58 per additional client tested, driven primarily by the higher response rates.

Conclusion

Whilst the availability of HIVST increased HIV testing among both truckers and FSWs, the cost of providing HIVST is higher than that of a routine health facility-based test, driven primarily by the price of the HIV self-test kit. Future research needs to identify strategies which increase demand for HIVST, and determine whether these strategies and the subsequent increased demand for HIVST are cost-effective in relation to the conventional facility based testing currently available.

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.

The MomConnect helpdesk: how an interactive mobile messaging programme is used by mothers in South Africa

South Africa’s MomConnect mobile messaging programme, which aims to promote safe motherhood and improve pregnancy outcomes for South African women, includes a helpdesk feature which allows women registered on the system to ask maternal and child health (MCH)-related questions and to provide feedback on health services received at public health clinics. Messages sent to the helpdesk are answered by staff located at the National Department of Health. We examined event data from the MomConnect helpdesk database to identify any patterns in messages received, such as correlation of frequency or types of messages with location. We also explored what these data could tell us about the helpdesk’s effectiveness in improving health service delivery at public health clinics. We found that approximately 8% of registered MomConnect users used the helpdesk, and that usage was generally proportional to the use of antenatal care (ANC) services in provinces (as indicated by number of ANC first visits and number of MomConnect registrations), except in two provinces. Language, category and key topics of helpdesk messages were correlated with provinces. Most users accessed the helpdesk to seek maternal information, and where feedback about health services was provided, there were significantly more compliments than complaints. The MomConnect helpdesk is an important resource providing expectant mothers and mothers of infants with an interactive option for accessing MCH-related information—above that included in the standard MomConnect messages—and advances achievement of the health goals of the MomConnect programme.

Facilitators and barriers for HIV-testing in Zambia: A systematic review of multi-level factors

It was estimated that 1.2 million people live with HIV/AIDS in Zambia by 2015. Zambia has developed and implemented diverse programs to reduce the prevalence in the country. HIV-testing is a critical step in HIV treatment and prevention, especially among all the key populations. However, there is no systematic review so far to demonstrate the trend of HIV-testing studies in Zambia since 1990s or synthesis the key factors that associated with HIV-testing practices in the country. Therefore, this study conducted a systematic review to search all English literature published prior to November 2016 in six electronic databases and retrieved 32 articles that meet our inclusion criteria. The results indicated that higher education was a common facilitator of HIV testing, while misconception of HIV testing and the fear of negative consequences were the major barriers for using the testing services. Other factors, such as demographic characteristics, marital dynamics, partner relationship, and relationship with the health care services, also greatly affects the participants' decision making. The findings indicated that 1) individualized strategies and comprehensive services are needed for diverse key population; 2) capacity building for healthcare providers is critical for effectively implementing the task-shifting strategy; 3) HIV testing services need to adapt to the social context of Zambia where HIV-related stigma and discrimination is still persistent and overwhelming; and 4) family-based education and intervention should involving improving gender equity.

Do digital innovations for HIV and sexually transmitted infections work? Results from a systematic review (1996-2017)

OBJECTIVE

Digital innovations with internet/mobile phones offer a potential cost-saving solution for overburdened health systems with high service delivery costs to improve efficiency of HIV/STI (sexually transmitted infections) control initiatives. However, their overall evidence has not yet been appraised. We evaluated the feasibility and impact of all digital innovations for all HIV/STIs.

DESIGN

Systematic review.

SETTING/PARTICIPANTS

All settings/all participants.

INTERVENTION

We classified digital innovations into (1) mobile health-based (mHealth: SMS (short message service)/phone calls), (2) internet-based mobile and/or electronic health (mHealth/eHealth: social media, avatar-guided computer programs, websites, mobile applications, streamed soap opera videos) and (3) combined innovations (included both SMS/phone calls and internet-based mHealth/eHealth).

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility, acceptability, impact.

METHODS

We searched databases MEDLINE via PubMed, Embase, Cochrane CENTRAL and Web of Science, abstracted data, explored heterogeneity, performed a random effects subgroup analysis.

RESULTS

We reviewed 99 studies, 63 (64%) were from America/Europe, 36 (36%) from Africa/Asia; 79% (79/99) were clinical trials; 84% (83/99) evaluated impact. Of innovations, mHealth based: 70% (69/99); internet based: 21% (21/99); combined: 9% (9/99).All digital innovations were highly accepted (26/31; 84%), and feasible (20/31; 65%). Regarding impacted measures, mHealth-based innovations (SMS) significantly improved antiretroviral therapy (ART) adherence (pooled OR=2.15(95%CI: 1.18 to 3.91)) and clinic attendance rates (pooled OR=1.76(95%CI: 1.28, 2.42)); internet-based innovations improved clinic attendance (6/6), ART adherence (4/4), self-care (1/1), while reducing risk (5/5); combined innovations increased clinic attendance, ART adherence, partner notifications and self-care. Confounding (68%) and selection bias (66%) were observed in observational studies and attrition bias in 31% of clinical trials.

CONCLUSION

Digital innovations were acceptable, feasible and generated impact. A trend towards the use of internet-based and combined (internet and mobile) innovations was noted. Large scale-up studies of high quality, with new integrated impact metrics, and cost-effectiveness are needed. Findings will appeal to all stakeholders in the HIV/STI global initiatives space.

Addressing engagement in technology-based behavioural HIV interventions through paradata metrics

PURPOSE OF REVIEW

The goal of this review was to examine how often researchers report participants' online engagement using paradata (i.e. intervention usage metrics) when describing the outcomes of online behavioural HIV prevention and care interventions. We also highlight the utility of paradata collection and analysis in future technology-based trials.

RECENT FINDINGS

We focused on studies indexed on PubMed and published between 1 January 2016 and 31 March 2017 that reported the development and testing of online behavioural interventions for HIV prevention and/or care. Of the 705 extracted citations, six met study criteria.

SUMMARY

Only one study reported paradata reflecting participants' engagement with a technology-based intervention. Researchers should systematically collect and analyse paradata to strengthen the evidence base for technology-based interventions (do they work?), advance the use of behaviour change theory across modalities and platforms (how/why do they work?) and inform reach and scale-up efforts (for whom do they work?). Researchers may also rely on paradata to examine dose-response relationships due to user engagement, to identify replicable core components linked to behaviour change outcomes, to allocate resources judiciously and drive down development costs, and to pool these metrics for use in future meta-analyses.

Text Messaging in the Patient-Centered Medical Home to Improve Glucose Control and Retinopathy Screening

Purpose: To evaluate the effectiveness of a text messaging program (TMP) to improve glucose control, retinopathy screening (RS) rates, and self-care behaviors in patients with uncontrolled type 2 diabetes. Methods: A single-group design with a quasi-systematic random sample (n=20) received educational/exhortational text messages on their cellular phones for 3 months. Subjects, 12 of whom identified as a minority ethnicity, were mostly male, aged 27-73 years. Results: Glucose control and RS rates improved significantly. Subjects (>70%) reported changes in self-care behaviors. Conclusion: Leveraging ubiquitous technology, a TMP for patients with limited access to healthcare education, holds promise.