A randomized controlled trial study of the acceptability, feasibility, and preliminary impact of SITA (SMS as an Incentive To Adhere): a mobile technology-based intervention informed by behavioral economics to improve ART adherence among youth in Uganda

Electronic monitoring device informed interventions for treatment adherence and clinical outcomes in children and adolescents: A systematic review

OBJECTIVE

To systematically review literature from randomised controlled trials (RCTs) investigating the effectiveness of electronic monitoring device informed interventions on adherence and clinical outcomes in children and adolescents with chronic conditions.

STUDY DESIGN

A systematic review was conducted. An electronic literature search covering studies, with no pre-specified starting date up to June 2024, was performed in Medline, EMBASE, Web of Science, Cochrane and Trials databases was conducted.

PARTICIPANTS

RCTs of electronic monitoring device informed interventions in individuals aged 0 to 18 years with chronic conditions, were identified, with no restriction on geography or publication date.

METHODS

Extracted data was synthesised. As a result of differences in definitions and analysis of adherence and clinical outcomes across the studies a pooled meta-analysis was not possible therefore, a descriptive analysis was conducted. Risk of bias across all studies was assessed using the Cochrane Collaboration risk of bias tool.

RESULTS

11 RCTs, with 1485 children and adolescents were included. Studies were all from high- and middle-income countries, conducted among children and adolescents with asthma, and one each among children and adolescents with kidney transplant, multiple sclerosis, and epilepsy. Eight of the 11 studies reported a positive effect on adherence. Only four studies reported a positive effect on clinical outcomes and seven studies found no effect on clinical outcomes.

CONCLUSIONS

Electronic monitoring device interventions show promise in improving adherence in children and adolescents with chronic conditions, in a limited number of chronic conditions, mostly asthma. Evidence for the efficacy of electronic monitoring device informed interventions on clinical outcomes and from low-income settings is lacking.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022312057, registered in March 2022.

TWEETABLE ABSTRACT

Electronic monitoring device informed interventions may improve treatment adherence in children and adolescents with chronic conditions but evidence from low-income settings is lacking @nyasha_dzavakwa @KatharinaKranz4 @dopapus @hilda_mujuru @rashida_abbferr @vickysimms_epi.

Behaviourally-informed two-way text messaging to improve return to HIV care in South Africa: evidence from a randomised controlled trial

Introduction

One-way text messaging to re-engage people in HIV care has shown promise, but little is known about two-way messaging where the recipient is asked to respond. We evaluated a two-way text messaging intervention, informed by behavioural science, to increase re-engagement in care following missed antiretroviral therapy (ART) visits.

Methods

We conducted an individual-level randomised controlled trial between February and March 2023 in Capricorn District, South Africa. Adults aged ≥18 years who had missed an ART visit by >28 days were randomised to (1) a standard one-way text message, or (2) behaviourally informed two-way text messages. Two-way messages asked recipients to reply by selecting from a list of reasons for their missed visit. Those who responded received another text message tailored to their response and designed using behavioural economics principles (affect heuristic, availability heuristic, loss aversion, social norms, providing slack, expanding choice). The primary outcome was return to care within 45 days, analysed as 1) intention to treat, and 2) restricted to successful message delivery.

Results

3,695 participants were randomised: 1,845 to the one-way message group and 1,850 to the two-way message group. 27.9% (515/1845) of participants sent a one-way message and 27.2% (503/1850) sent a two-way message returned for an ART visit within 45 days (proportion difference:-0.7%, p-value: 0.622). In an analysis restricted to participants whose text message was delivered, 28.3% (310/1094) in the one-way message group compared to 28.3% (304/1076) in the two-way message group returned to care (proportion difference:-0.09%, p-value: 0.966). 19.5% (210/1076) responded to the two-way message. The two most commonly reported reasons for missed appointments were being out of town (41.0%) and still having medication (31.0%.). Among those who responded, 27.1% (95%CI: 21.3-33.7) returned for an ART visit. Clients ≥50 years were less likely to respond to the two-way text message, (AOR 0.4; 95%CI: 0.2-0.9).

Conclusions

Behaviourally informed two-way text messages did not improve return to care over one-way messages. However, they elicited reasons for disengagement, which could inform future outreach for missed visits. Additional research is needed on the mode, content and timing of two-way messages intended to increase return to care.

Clinical Trial Number

PACTR202202748760768 & DOH-27-042022-6703.

Digital technology for HIV self-management in low- and middle-income countries: a scoping review of adolescents' preferences

Digital health technology interventions have shown promise in enhancing self-management practices among adolescents living with Human Immunodeficiency Virus (ALHIV). The objective of this scoping review was to identify the preferences of ALHIV in low- and middle-income countries (LMICs) concerning the use of digital health technology for the self-management of their chronic illness. Electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Plus with Full Text), Central (Cochrane Library), Epistemonikos, and Medline (EbscoHost), were searched. The review focused on English articles published before June 2023, that described a technology intervention for ALHIV specifically from LMIC. The screening and data extraction tool Covidence facilitated the scoping review process. Of the 413 studies identified, 10 were included in the review. Digital health technology interventions can offer enhanced support, education, and empowerment for ALHIV in LMICs. However, barriers like limited access, stigma, and privacy concerns must be addressed. Tailoring interventions to local contexts and integrating technology into healthcare systems can optimize their effectiveness.Review registration: OSF REGISTRIES (https://archive.org/details/osf-registrations-eh3jz-v1).

The association between adherence to antiretroviral therapy and viral suppression under dolutegravir-based regimens: an observational cohort study from Uganda

INTRODUCTION

Millions of people living with HIV (PLWH) take oral antiretroviral therapy (ART), which requires a lifetime of consistent medication adherence. The relationship between adherence and poor HIV outcomes is well documented. Newer ART regimens that include dolutegravir (DTG) could be more forgiving, but empirical evidence on the relationship between adherence and viral suppression under DTG is only emerging.

METHODS

In this observational cohort study (secondary analysis of data from a randomized trial), we used data from 313 ART clients from a large HIV clinic in Kampala, Uganda. Over the 4-year study period (January 2018-January 2022), 91% switched from non-DTG regimens to DTG regimens. We measured adherence using Medication Event Monitoring Systems-caps and extracted prescription information and viral load measures from electronic health records. We estimated unadjusted linear regressions and adjusted models that included individual and time fixed-effects.

RESULTS

Under non-DTG regimens, 96% of participants were virally suppressed (defined as viral load < 200 copies/ml) when adherence was 90% or higher in the 3 months before viral load measurement. Viral suppression was 32 percentage points lower when adherence was between 0% and 49% (95% CI -0.44, -0.20, p < 0.01), 12 percentage points lower when adherence was between 50% and 79% (95% CI -0.23, -0.02, p < 0.01), and not significantly different when adherence was between 80% and 89% (effect of 0.00, 95% CI -0.06, 0.07, p = 0.81). In contrast, for participants taking DTG, there was no statistically significant difference in viral suppression among any of the four adherence levels; more than 95% were virally suppressed at each adherence level. On average, switching to DTG increased viral suppression by 6 percentage points in our adjusted models (95% CI 0.00, 0.13, p = 0.03).

CONCLUSIONS

There was no significant association between adherence levels and viral suppression among PLWH taking DTG regimens, suggesting a high degree of forgiveness for missed doses. The use of DTG should be prioritized over older regimens, particularly for those with low adherence.

CLINICAL TRIAL NUMBER

NCT03494777.

Facilitated WhatsApp Support Groups for Youth Living With HIV in Nairobi, Kenya: Single-Arm Pilot Intervention Study

BACKGROUND

Mobile technology can support HIV care, but studies in youth are limited. In 2014, youth receiving HIV care at several health care facilities in Nairobi, Kenya spontaneously formed peer support groups using the social media platform WhatsApp.

OBJECTIVE

Inspired by youth-initiated groups, we aimed to evaluate the use of WhatsApp to deliver a social support intervention to improve HIV treatment and psychosocial outcomes in youth. We developed a facilitated WhatsApp group intervention (named Vijana-SMART), which was grounded in social support theory and guided by the design recommendations of youth living with HIV. This paper evaluates the intervention's acceptability and pre-post changes in health outcomes.

METHODS

The intervention involved interactive WhatsApp groups facilitated by study staff for 6 months, with each group having approximately 25 members. Study staff sent weekly structured messages, and the message content was based on social support theory and encouraged unstructured peer-to-peer messaging and support. We conducted a single-arm pilot among 55 youth living with HIV aged 14-24 years recruited from a government health care facility serving a mixed-income area of Nairobi. At enrollment and follow-up, self-report questionnaires assessed acceptability; antiretroviral therapy (ART) information, motivation, and behavioral skills (IMB); depression; social support; stigma; resilience; and ART adherence. All participants received the intervention. We used generalized estimating equations (GEEs) clustered by participant to evaluate changes in scores from baseline to follow-up, and correlates of participant WhatsApp messaging.

RESULTS

The median participant age was 18 years, and 67% (37/55) were female. Intervention acceptability was high. All participants reported that it was helpful, and 73% (38/52) sent ≥1 WhatsApp message. Messaging levels varied considerably between participants and were higher during school holidays, earlier in the intervention period, and among youth aged ≥18 years. IMB scores increased from enrollment to follow-up (66.9% to 71.3%; P<.001). Stigma scores also increased (8.3% to 16.7%; P=.001), and resilience scores decreased (75.0% to 70.0%; P<.001). We found no significant change in ART adherence, social support, or depression. We detected a positive association between the level of messaging during the study and the resilience score, but no significant association between messaging and other outcomes. Once enrolled, it was common for participants to change their phone numbers or leave the groups and request to be added back, which may present implementation challenges at a larger scale.

CONCLUSIONS

Increased IMB scores following WhatsApp group participation may improve HIV outcomes. Increased stigma and decreased resilience were unintended consequences and may reflect transient effects of group sharing of challenging experiences, which should be addressed in larger randomized evaluations. WhatsApp groups present a promising and acceptable modality to deliver supportive interventions to youth living with HIV beyond the clinic, and further evaluation is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05634265); https://clinicaltrials.gov/study/NCT05634265.

A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa

Despite widespread availability of life-saving antiretroviral therapy (ART) in sub-Saharan Africa, AIDS remains one of the leading causes of death among adolescents living with HIV (ALHIV) in sub-Saharan Africa. The purpose of this article was to review the state of the science regarding interventions to improve ART adherence and/or HIV care retention among ALHIV throughout sub-Saharan Africa. The primary aim of this review was to describe the impact of peer support interventions in improving treatment outcomes (i.e., ART adherence and retention in HIV care) among ALHIV in sub-Saharan Africa. The secondary aim of this review was to determine whether these interventions may be efficacious at improving mental health outcomes. We identified 27 articles that met the eligibility criteria for our review, and categorized each article based on the type of peer support provided to ALHIV-individualized peer support, group-based support, and individualized plus group-based support. Results regarding the efficacy of these interventions are mixed and most of the studies included were deemed moderate in methodological quality. Although studies evaluating group-based peer support interventions were the most common, most of these studies were not associated with retention, adherence, or mental health outcomes. More robust, fully powered studies are needed to strengthen our knowledge base regarding peer support for ALHIV.

Effectiveness of Behavioural Economics Informed Interventions for the Prevention, Screening, and Antiretroviral Treatment of HIV Infection: A Systematic Review of Randomized Controlled Trials

Failure to meet international targets set for the human immunodeficiency virus HIV pandemic suggests that more effective public health strategies are needed. New strategies informed by behavioural economics are now increasingly being tested, with promising results. However, the evidence base is diverse and challenging for policymakers to interpret. This paper aims to synthesise existing evidence by reporting results from a systematic review of behavioural economics-based interventions for addressing HIV prevention, testing and treatment. The reported study was a systematic review of randomized controlled trials. The search was conducted in four electronic medical literature databases, six trial registries, four grey literature sources and was not restricted to any country or region. Bias was assessed using criteria outlined in the Cochrane Handbook for Systematic Reviews; quality of evidence was assessed using GRADE methodology. Fifteen full text articles were included in the final analysis. The synthesis of these studies revealed that strategies involving opt-out defaults, active-choice defaults, and lottery incentives can potentially increase uptake of HIV testing. Lottery incentives also showed signs of effectiveness in improving HIV prevention, ART adherence and initiation. Despite the promising findings, the overall evidence was judged to be of moderate to very low quality. Behavioural economics-based interventions are promising behavioural change strategies, although more well-designed studies are needed to strengthen the evidence base.

m-Follow up for zinc adherence by caretakers of children with acute watery diarrhoea: A randomized controlled trial

The standard of care for children with acute watery diarrhea (AWD) with no dehydration comprises oral rehydration solution, zinc, and feeding advice. Adherence to zinc therapy may be an issue in the management of acute watery diarrhoea. Mobile phones are used by over 90% of the population in Tanzania, thus good means to improve adherence to prescribed medication and/or attendance to follow-up visits. The objective of this study was to see whether m-follow-up improves adherence rate to zinc therapy, possible reasons for non-adherence, in children with diarrhea.: A randomized controlled trial was carried out in a suburban municipality in Dar-es-Salaam. Block randomization of participants was carried out with a block size of 4 and a 1:1 ratio of intervention: control. The intervention group comprised participants who were to be followed up using text messages and voice calls; the control group was to be followed up in outpatient. The outcome of interest was adherence to the full course of 10 days' oral zinc, reasons for nonadherence and acceptability. Chi-square was used to compare the categorical variables. δ, the targeted difference in adherence between arms, was pre-set at 20%. The total number of participants were 196, of which 98 participants were enrolled in each arm. Full adherence to the 10-day course of zinc sulphate in children with AWD and no dehydration was 84.1% in the control arm and 89.7% in the m-follow up group (P = 0.33). m-follow up significantly improved physical attendance at 14-day clinic visit compared to control group (39.8% vs. 60.2%; P = 0.006). Commonest reasons for non-adherence in both groups were related to vomiting (67%). Vomiting at enrolment due to gastroenteritis was significantly associated with vomiting zinc sulphate with RR 2.17 (95% CI 1.24-3.79, P = 0.007). The acceptability of m-follow-up was high (99%). In conclusion the idea of m-follow-up was well received by participants who considered it acceptable. In this study, the adherence to Zinc dosing was not significantly different between the intervention and control group, and we consider that for zinc in AWD, counselling alone was good enough to achieve high adherence. The trial was registered with the Pan-African Clinical Trial Registry. Trial number: PACTR201711002737120.

Interventions to Improve Adolescent HIV Care Outcomes

PURPOSE OF REVIEW

This review of recent studies evaluating interventions to improve HIV care outcomes among adolescents with HIV (AHIV) was conducted to provide a comprehensive overview of the recent evidence, highlight promising approaches, and suggest directions for future research.

RECENT FINDINGS

Our scoping review revealed 65 studies evaluating a variety of interventions and using a range of study designs at various stages of research. Effective approaches included community-based, integrated service delivery models with case management, trained community adolescent treatment supporters, and consideration of social determinants of health. Recent evidence also supports the feasibility, acceptability, and preliminary efficacy of other innovative approaches, including mental health interventions as well as technology-delivered approaches; however, more research is needed to build the evidence base for these interventions. Our review's findings suggest that interventions providing comprehensive, individualized support are essential to improving HIV care outcomes among adolescents. More research is needed to build the evidence base for such interventions and ensure effective, equitable implementation to support the global target of ending the AIDS epidemic by 2030.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

Perceived norms about male circumcision and personal circumcision status: a cross-sectional, population-based study in rural Uganda

Introduction

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circucmsion for HIV and STI prevention. Despite male circumcision prevalence in Uganda nearly doubling from 26% in 2011 to 43% in 2016, it remained below the target level by 2020. Little is known about perceived norms of male circumcision and their association with circumcision uptake among men.

Methods

We conducted a cross-sectional study targeting all adult residents across eight villages in Rwampara District, southwestern Uganda in 2020-2022. We compared what men and women reported as the adult male circumcision prevalence within their village (perceived norm: >50% (most), 10% to <50% (some), <10%, (few), or do not know) to the aggregated prevalence of circumcision as reported by men aged <50 years. We used a modified multivariable Poisson regression model to estimate the association between perceived norms about male circumcision uptake and personal circumcision status among men.

Results

Overall, 167 (38%) men < 50 years old were circumcised (and 27% of all men were circumcised). Among all 1566 participants (91% response rate), 189 (27%) men and 177 (20%) women underestimated the male circumcision prevalence, thinking that few men in their own village had been circumcised. Additionally, 10% of men and 25% of women reported not knowing the prevalence. Men who underestimated the prevalence were less likely to be circumcised (aRR = 0.51, 95% CI 0.37 to 0.83) compared to those who thought that some village men were circumcised, adjusting for perceived personal risk of HIV, whether any same-household women thought most men were circumcised, and other sociodemographic factors.

Conclusions

Across eight villages, a quarter of the population underestimated the local prevalence of male circumcision. Men who underestimated circumcision uptake were less likely to be circumcised. Future research should evaluate norms-based approaches to promoting male circumcision uptake. Strategies may include disseminating messages about the increasing prevalence of adult male circumcision uptake in Uganda and providing personalized normative feedback to men who underestimated local rates about how uptake is greater than they thought.

A conceptual framework and exploratory model for health and social intervention acceptability among African adolescents and youth

Intervention acceptability has become an increasingly key consideration in the development, evaluation and implementation of health and social interventions. However, to date this area of investigation has been constrained by the absence of a consistent definition of acceptability, comprehensive conceptual frameworks disaggregating its components, and few reliable assessment measures. This paper aims to contribute to this gap, by proposing a conceptual framework and exploratory model for acceptability with a specific priority population for health and developmental interventions: adolescents and youth in Africa. We document our multi-staged approach to model development, comprising both inductive and deductive components, and both systematic and interpretative review methods. This included thematic analyses of respective acceptability definitions and findings, from 55 studies assessing acceptability of 60 interventions conducted with young people aged 10-24 in (mainly Southern and Eastern) Africa over a decade; a consideration of these findings in relation to Sekhon et al.'s Theoretical Framework of Acceptability (TFA); a cross-disciplinary review of acceptability definitions and models; a review of key health behavioural change models; and expert consultation with interdisciplinary researchers. Our proposed framework incorporates nine component constructs: affective attitude, intervention understanding, perceived positive effects, relevance, perceived social acceptability, burden, ethicality, perceived negative effects and self-efficacy. We discuss the rationale for the inclusion and definition of each component, highlighting key behavioural models that adopt similar constructs. We then extend this framework to develop an exploratory model for acceptability with young people, that links the framework components to each other and to intervention engagement. Acceptability is represented as an emergent property of a complex, adaptive system of interacting components, which can influence user engagement directly and indirectly, and in turn be influenced by user engagement. We discuss opportunities for applying and further refining or developing these models, and their value as a point of reference for the development of acceptability assessment tools.

The effect of group support psychotherapy on adherence to anti-retroviral therapy and viral suppression among HIV positive young people: Study protocol for a pilot randomized controlled trial

Background

Several studies have demonstrated an association between psychological risk factors and HIV disease progression. However, there is limited information on the use of psychological interventions to improve HIV treatment outcomes in young people living with HIV.

Objective

This pilot trial aims to evaluate the feasibility, acceptability and preliminary effectiveness of group support psychotherapy in improving adherence to anti-retroviral therapy and viral suppression in young people living with HIV in Uganda.

Methods

We recruited 120 young people with HIV, aged 10–18 years, who had non-viral suppression 6 months after initiating first-line anti-retroviral therapy (ART) from community based HIV clinics in Kitgum district, northern Uganda. Participants were randomly assigned to receive GSP plus IAC (N = 60) or IAC alone (N = 60). Primary outcomes will be indicators of feasibility and acceptability as well as preliminary effectiveness of GSP in improving ART adherence and viral suppression analysed by intention to treat using cluster-adjusted t tests and permutation tests. Secondary outcomes will be measures of depression, anxiety and cost-effectiveness.

Results

The trial has been approved by the Makerere College of Health Sciences School of Health Sciences Research Ethics Committee, and the Uganda National Council of Science and Technology. Recruitment began in June 2021 and 120 young people living with HIV with their adult caregivers have been recruited to the trial. An analysis of baseline and 6-month data is in progress. The results of this trial will not only be presented at national and international conferences but also submitted for publication in peer-reviewed journals and as a report to the funding agencies.

Conclusions

This pilot trial will provide critical evidence to support the ongoing mental health integration into routine HIV care in Uganda.

Trial Registration

Pan African Clinical Trials Registry (PACTR): 202006601935462

Does telehealth affect the adherence to ART among patients with HIV? A systematic review and meta-analysis

BACKGROUND

Several studies have shown different effects of telehealth interventions on adherence to Antiretroviral therapy (ART) among people living with HIV. This study conducted a meta-analysis of Randomized Controlled Trials (RCTs) to estimate the pooled effect of telehealth interventions on the treatment adherence of HIV patients.

METHODS

The researchers conducted literature searches in Scopus, PubMed, Web of Science, Google Scholar, and Cochrane Central Register of Controlled Trials databases. In addition, open grey was systematically searched until January 2022 for RCTs around the effects of telehealth on adherence to treatment ART among patients with HIV. Each study's methodological quality was assessed using the Cochrane Collaboration tool. Pooled Standard Mean Differences (SMD) and Risk Ratio (RR) with 95% CI were calculated using the random effects model.

RESULTS

In total, 12 eligible articles were considered in the present systematic review. A random-effects meta-analysis using 5 RCTs yielded the pooled RR estimate of 1.18 (95% CI: 1.03 to 1.35, p < 0.05); I2 = 0, suggesting the adherence to treatment among patients with HIV who received telehealth intervention was significantly 18% upper than control groups. Moreover, the random effects analysis of SMD showed a positive effect for telehealth with SMR = 0.36 (95% CI: 0.22 to 0.49, p < 0.05); I2 = 91.9%, indicating that telehealth intervention increased ART adherence to the treatment group compared to the control group.

CONCLUSION

Telehealth intervention as a new modality of health care service delivery could be a valuable strategy to improve ART adherence among patients with HIV. It can strengthen the capacity of HIV care services. On a large scale, telehealth can be utilized as a supplementary component for ART delivery and retention toward successful adherence to the therapy.

Effectiveness, Acceptability and Feasibility of Technology-Enabled Health Interventions for Adolescents Living with HIV in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Adolescents living with HIV (ALHIV) are challenged to remain adherent and engaged in HIV care. Technology-enabled interventions can be used to optimize healthcare delivery to adolescents. The largest proportion of ALHIV resides in sub-Saharan Africa. This review synthesized the evidence for the effectiveness, acceptability, and feasibility of technology-enabled health interventions for ALHIV in low and middle-income countries (LMIC).

METHODS

Eight electronic databases (Ebscohost, CINAHL, ERIC, MEDLINE, PubMed, SCOPUS, Science Direct, and Sabinet) and Google Scholar were searched to identify studies in LMIC published from 2010 to 2022. Quantitative and qualitative studies reporting on technology-enabled health interventions for predominantly adolescents (10-19 years) were included. The review was performed, and findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols. The review was registered with PROSPERO: CRD42022336330.

RESULTS

There is weak evidence that technology-enabled health interventions for ALHIV in LMIC improve treatment outcomes. However, most interventions appear to be acceptable and feasible.

CONCLUSION

There is a need to ensure that technology-enabled interventions have a strong theoretical base. Larger studies with rigorous evaluation designs are needed to determine the effects of these interventions on the health outcomes of ALHIV in LMIC.

Systematic Review of mHealth Interventions for Adolescent and Young Adult HIV Prevention and the Adolescent HIV Continuum of Care in Low to Middle Income Countries

Adolescents and young adults (AYA) in low to middle income countries (LMIC) have poorer outcomes along each step in the HIV continuum of prevention and care compared to younger children or older adults. The use of mHealth technology provides a potentially promising implementation strategy for interventions to remedy these disparities. We therefore conducted a systematic review of the English literature and conference proceedings from January 1, 2000 to April 1, 2021 evaluating mHealth interventions targeting AYA along each step of the HIV continuum of care in LMIC. We identified 27 mHealth interventions across the HIV continuum, with no interventions addressing transition from pediatric to adult care. The majority of studies were single arm, uncontrolled or underpowered, with few randomized trials resulting in mixed and inconclusive outcomes. mHealth interventions have potential to remedy disparities along the HIV continuum of care for AYA in LMIC but larger, powered randomized trials are needed.

Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review

PURPOSE OF REVIEW

This scoping review summarises the literature on HIV prevention and management interventions utilizing behavioural economic principles encapsulated in the MINDSPACE framework.

RECENT FINDINGS

MINDSPACE is an acronym developed by the UK's behavioural insights team to summarise nine key influences on human behaviour: Messenger, Incentives, Norms, Default, Salience, Priming, Affect, Commitment, and Ego. These effects have been used in various settings to design interventions that encourage positive behaviours. Currently, over 200 institutionalised behavioural insight teams exist internationally, which may draw upon the MINDSPACE framework to inform policy and improve public services. To date, it is not clear how behavioural insights have been applied to HIV prevention and management interventions. After screening 899 studies for eligibility, 124 were included in the final review. We identified examples of interventions that utilised all the MINDSPACE effects in a variety of settings and among various populations. Studies from high-income countries were most common (n = 54) and incentives were the most frequently applied effect (n = 100). The MINDSPACE framework is a useful tool to consider how behavioural science principles can be applied in future HIV prevention and management interventions. Creating nudges to enhance the design of HIV prevention and management interventions can help people make better choices as we strive to end the HIV/AIDS pandemic by 2030.

A Systematic Review of Digital Interventions to Improve ART Adherence among Youth Living with HIV in sub-Saharan Africa

An estimated 3.4 million youth aged 15-24 years live with human immunodeficiency virus (HIV), a majority of whom reside in sub-Saharan Africa (SSA). Youth living with HIV (YLHIV) generally maintain lower levels of antiretroviral therapy (ART) adherence compared to other age groups, which has negative impacts on long-term clinical outcomes. Given expanding mobile phone and Internet usage among youth in SSA, and a need for strategies to increase ART adherence, this review systematically assessed whether digital interventions could be used to improve YLHIV ART adherence in SSA. PRISMA 2020 guidelines were followed, and PubMed and Scopus databases were searched using terms to reflect the population of interest and different digital intervention strategies to improve ART adherence. Experimental or quasi-experimental studies in SSA evaluating the quantitative effect of digital interventions on YLHIV ART adherence were included. 3849 articles and abstracts, and 122 full texts were screened by two researchers (KG and RM). A third researcher (AC) resolved conflicts. Data were extracted from six eligible articles published between 2017 and 2021. Interventions from included studies lasted 13-96 weeks and took place in Kenya, Nigeria, Uganda, and Zimbabwe. Two of the six studies found significant intervention-related improvements in viral suppression. Of these two studies, one used short message service (SMS) for appointment and daily adherence reminders, and the other combined weekly SMS reminders with phone calls, support groups, home visits, and clinic-based counseling. The four remaining studies, using SMS and Internet-based interventions, did not find any significant adherence-related improvements. This review provides mixed evidence for using digital interventions to improve ART adherence among YLHIV in SSA. Given the relative novelty of using digital interventions in this context, further research is required to evaluate their effectiveness in improving youth ART adherence.

How mHealth Can Contribute to Improving the Continuum of Care: A Scoping Review Approach to the Case of Human Immunodeficiency Virus in Sub-Saharan Africa

Objectives: To determine mHealth’s contribution to improving the continuum of care in sub-Saharan Africa towards achieving treatment targets for human immunodeficiency virus (HIV) endorsed by the 2016 Political Declaration on ending acquired immunodeficiency syndrome (AIDS).

Methods: PubMed, Medline, Embase, Web of Science Core Collection and Cochrane databases; three observatories and four repositories were searched to identify and select relevant articles, projects and guidelines published from 1 January 2017, to 30 April 2021. Records focusing on the use of mHealth related to HIV treatment cascade or healthcare provider/patient relationship were considered.

Results: From 574 identified records, 381 (206 scientific manuscripts and 175 mHealth projects) were considered. After screening, 36 articles (nine randomized control trials, five cohort studies, 19 qualitative studies, and three economic studies) and 23 projects were included.

Conclusion: The cross-cutting benefits of mHealth that enhance patient empowerment have been identified. Important challenges such as gaps between research and implementation, lack of transdisciplinary collaboration, and lack of economic evidence were identified to support future mHealth research and accelerate the achievement of treatment targets for HIV.

Behavioral intervention grounded in motivational interviewing and behavioral economics shows promise with Black and English-speaking Latino persons living with HIV with unsuppressed HIV viral load in New York City: A mixed methods pilot study

Introduction

Sustained HIV viral suppression is the ultimate goal of HIV treatment. African American/Black and Latino persons with HIV (PWH) in the United States are less likely than their White peers to achieve and sustain viral suppression. To address these disparities, we developed a "low-touch" behavioral intervention drawing on motivational interviewing and behavioral economics. The intervention had three main components: (1) a motivational interviewing counseling session, (2) 16 weeks of automated text messages and quiz questions about HIV management, where participants earned points by answering quiz questions, and 3) a lottery prize, based on viral suppression status, number of points earned, and chance (max. $275).

Materials and methods

The intervention was tested in a pre-test/post-test design. The present pilot study used mixed methods to explore the intervention's feasibility, acceptability, impact, and ways it could be improved. Participants engaged in a baseline assessment, qualitative interview, and two structured follow-up assessments over an 8-month period, and provided laboratory reports to document HIV viral load. We carried out descriptive quantitative analyses. Qualitative data were analyzed using a directed content analysis approach. Data integration was carried out using the joint display method.

Findings

Participants (N = 40) were 50 years old, on average (SD = 11), and approximately half (58%) were male. Close to two-thirds (68%) were African American/Black and 32% were Latino. Participants were diagnosed with HIV 22 years ago on average (SD = 8). The intervention was feasible (e.g., mean number of quiz questions answered = 13/16) and highly acceptable. While not powered to assess efficacy, the proportion with suppressed HIV viral load increased from baseline to follow-up (46% participants at the first, 52% participants at the second follow-up evidenced HIV viral suppression). In qualitative analyses, perspectives included that overall, the intervention was acceptable and useful, it was distinct from other programs, lottery prizes were interesting and appreciated but not sufficient to motivate behavior change, and the structure of lottery prizes was not sufficiently clear. Regarding data integration, qualitative data shed light on and extended quantitative results, and added richness and context.

Conclusion

This low-touch intervention approach is sufficiently promising to warrant refinement and study in future research.

How Do Psychosocial Interventions for Adolescents and Young People Living With HIV Improve Adherence and Viral Load? A Realist Review

PURPOSE

Psychosocial interventions have the potential to support adolescents and young people living with HIV (AYPLHIV) to achieve better HIV outcomes. However, more evidence is needed to understand which interventions are most effective, and the mechanisms driving how they work in practice.

METHODS

We used realist methodologies to generate statements based on evidence from intervention studies and linked evidence included in a systematic review of psychosocial interventions for AYPLHIV. Key data were extracted from available sources to generate cases, including context-mechanism-outcome pathways. Higher level themes were refined iteratively to create a mid-range theory of how these interventions may work.

RESULTS

From 26 resulting cases, 8 statements were crafted, grouped into 3 overarching categories, to describe how these interventions worked. Interventions were overall found to set off mechanisms to improve adherence when (1) responding to individual-level factors to support AYPLHIV (via incorporating agency and empowerment, personalized and/or contextualized approaches, and self-care skills); (2) tailoring delivery strategies to address specific needs (via diverse strategies, longer duration, and digital delivery); and (3) providing supportive resources (via peer and broader support, and structural support and integration into existing services).

DISCUSSION

A collection of diverse mechanisms may individually or collectively drive improved outcomes for AYPLHIV engaged in psychosocial interventions. Recommendations for integrating our findings into practice are discussed.

Internet-based peer support interventions for people living with HIV: A scoping review

Peer support interventions for people living with HIV and AIDS (PLWHA) are effective, but their associated time and material costs for the recipient and the health system make them reachable for only a small proportion of PLWHA. Internet-based interventions are an effective alternative for delivering psychosocial interventions for PLWHA as they are more accessible. Currently, no reviews are focusing on internet-based interventions with peer support components. This scoping review aims to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We conducted a systematic scoping review of academic literature following methodological guidelines for scoping reviews, and 28 articles met our criteria. We summarized the main characteristics of the digital peer support interventions for PLWHA and how they implemented peer support in a virtual environment. Overall the reported outcomes appeared promising, but more robust evidence is needed.

Implementation Science for the Prevention and Treatment of HIV among Adolescents and Young Adults in Sub-Saharan Africa: A Scoping Review

Despite many evidence-based adolescent and young adult (AYA) HIV interventions, few are implemented at scale in sub-Saharan Africa (SSA). A growing implementation science literature provides important context for scaling up AYA HIV interventions in this high HIV-burden region. This scoping review examined the use of implementation research in AYA HIV studies conducted in SSA. We searched five databases and included articles which focused on AYA (10-24 years old), addressed HIV prevention or treatment, were conducted exclusively in SSA countries, and included an implementation science outcome. We included 44 articles in 13 SSA countries. Most were in East (52.3%) and South Africa (27.3%), and half focused exclusively on HIV prevention components of the care continuum. Acceptability and feasibility were the most cited implementation science outcomes. Only four articles used an established implementation science framework. The findings informed our recommendations to guide the design, implementation, and dissemination of further studies and health policymaking.

Preferences for a Game-Based SMS Adherence Intervention Among Young People Living with HIV in Ghana: A Qualitative Study

Young people living with HIV (YPLH) are at risk for poor treatment adherence. Short message service (SMS) interventions can improve adherence, yet few exist for YPLH. Our study investigated preferences for a game-based SMS intervention among YPLH in Ghana. Thirty-two YPLH, ages 18 to 24, were recruited from an HIV clinic to complete in-depth interviews. Content analysis of interview data revealed areas of technology use relevant to intervention implementation, including mobile communication preferences, internet access, and mobile game use. Participants reported high perceived utility towards intervention features: treatment reminders, gamification components, and involvement of supportive individuals (e.g., providers). Issues with privacy, literacy, and cultural/developmental appropriateness were among concerns raised. Suggestions were made for strengthening basic SMS features (e.g., using code words to protect privacy) and incorporating advanced features (e.g., simplifying game interactions). This novel approach may help engage YPLH in HIV care if carefully developed with attention towards its mechanisms and user preferences.

Perceptions About Local ART Adherence Norms and Personal Adherence Behavior Among Adults Living with HIV in Rural Uganda

Although misperceived norms often drive personal health behaviors, we do not know about this phenomenon in the context of antiretroviral therapy (ART) adherence. We conducted a cross-sectional study including all persons living with HIV (PLWH) on ART across eight villages in one parish in a rural region of southwestern Uganda. We used surveys to measure personal reports of ART adherence (not missing any doses of ART in the past 7 days was considered optimal adherence whereas missing doses was considered suboptimal adherence) and perceived norms about the local ART adherence norm (whether or not each individual thought 'most other PLWH on ART in this parish' missed any doses in the past 7 days). Multivariable Poisson regression models were used to estimate the association between perceived norms and personal adherence. Among 159 PLWH on ART (95% response rate), 142 (89%) reported no missed doses. However, 119 (75%) thought most individuals in this population of PLWH on ART were sub-optimally adherent. This misperception about the local ART adherence norm was prevalent in every subgroup of PLWH. Misperceiving the local ART adherence norm to be sub-optimal adherence was associated with a reduced likelihood of optimal adherence among married PLWH (adjusted relative risk [aRR] = 0.83; 95% confidence interval [CI] 0.71-0.97). The association was similar but imprecisely estimated for all PLWH (aRR = 0.91; 95% CI 0.82-1.01). Interventions to correct misperceived ART adherence norms as a stand-alone intervention or as a complement to other adherence promotion programs may influence ART adherence behavior and perhaps reduce HIV-related stigma.

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

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

The effectiveness and characteristics of mHealth interventions to increase adolescent's use of Sexual and Reproductive Health services in Sub-Saharan Africa: A systematic review

BACKGROUND

mHealth innovations have been proposed as an effective solution to improving adolescent access to and use of Sexual and Reproductive Health (SRH) services; particularly in regions with deeply entrenched traditional social norms. However, research demonstrating the effectiveness and theoretical basis of the interventions is lacking.

AIM

Our aim was to describe mHealth intervention components, assesses their effectiveness, acceptability, and cost in improving adolescent's uptake of SRH services in Sub-Saharan Africa (SSA).

METHODS

This paper is based on a systematic review. Twenty bibliographic databases and repositories including MEDLINE, EMBASE, and CINAHL, were searched using pre-defined search terms. Of the 10, 990 records screened, only 10 studies met the inclusion criteria. The mERA checklist was used to critically assess the transparency and completeness in reporting of mHealth intervention studies. The behaviour change components of mHealth interventions were coded using the taxonomy of Behaviour Change Techniques (BCTs). The protocol was registered in the 'International Prospective Register for Systematic Reviews' (PROSPERO-CRD42020179051).

RESULTS

The results showed that mHealth interventions were effective and improved adolescent's uptake of SRH services across a wide range of services. The evidence was strongest for contraceptive use. Interventions with two-way interactive functions and more behaviour change techniques embedded in the interventions improved adolescent uptake of SRH services to greater extent. Findings suggest that mHealth interventions promoting prevention or treatment adherence for HIV for individuals at risk of or living with HIV are acceptable to adolescents, and are feasible to deliver in SSA. Limited data from two studies reported interventions were inexpensive, however, none of the studies evaluated cost-effectiveness.

CONCLUSION

There is a need to develop mHealth interventions tailored for adolescents which are theoretically informed and incorporate effective behaviour change techniques. Such interventions, if low cost, have the potential to be a cost-effective means to improve the sexual and reproductive health outcomes in SSA.

Characteristics of psychosocial interventions to improve ART adherence in people living with HIV: A systematic review

The HIV/AIDS pandemic continues to be a significant global public health crisis. The main HIV/AIDS treatment is the antiretroviral therapy (ART), which is highly effective but depends on the patient's adherence to be successful. However, the adherence to antiretroviral therapy remains unsatisfactory across different populations, which raises considerable difficulties at both individual and collective levels. Suboptimal adherence to ART can be overcome through multidisciplinary management that includes evidence-based psychosocial interventions. Existing reviews on these interventions have focused mainly on studies with experimental designs, overlooking valuable interventions whose evidence comes from different study designs. Here, we aimed to carry out a comprehensive review of the current research on psychosocial interventions for ART adherence and their characteristics including studies with different designs. We conducted a systematic review following PRISMA guidelines. We searched five databases (Pubmed, EBSCO, LILACS, WoS and SCIELO) for articles reporting a psychosocial intervention to improve treatment adherence for people living with HIV (adults). The quality of each study was analyzed with standardized tools, and data were summarized using a narrative synthesis method. Twenty-three articles were identified for inclusion, and they demonstrated good to fair quality. Individual counseling was the most frequent intervention, followed by SMS reminders, education, and group support. Most interventions combined different strategies and self-efficacy was the most common underlying theoretical framework. This review provides insight into the main characteristics of current psychosocial interventions designed to improve ART treatment adherence. PROSPERO number: CRD42021252449.

Preliminary Effectiveness of Group Interpersonal Psychotherapy for Young Kenyan Mothers With HIV and Depression: A Pilot Trial

OBJECTIVE

The authors adopted a task-sharing strategy in which lay health workers delivered group interpersonal psychotherapy (IPT-G) in primary care clinics in Nairobi, Kenya, to young mothers with HIV and depression. The study examined the acceptability, feasibility, and effectiveness of IPT-G in improving depression and antiretroviral therapy adherence.

METHODS

Twenty-four mothers (ages 18-24 years and 6-12 weeks postpartum) participated. The women were randomly assigned to IPT-G or to a waitlist. Eight lay providers administered the IPT-G sessions across 8 weeks. The primary outcome was pre- to postintervention change in depression scores as measured on the Edinburgh Postnatal Depression Scale. The secondary outcome was antiretroviral therapy adherence. All waitlist participants subsequently received the intervention, and a secondary outcome, within-group analysis, was conducted and included those participants.

RESULTS

Participants' median age was 23.0 years, 17 (71%) lived with a partner, and 19 (79%) had fewer than two children. The intervention group had a mean±SD depression score of 15.9±4.3 at baseline and 6.8±7.0 postintervention. For the waitlist control group, the mean score was 17.3±5.9 at baseline and 13.2±6.6 at the first follow-up. Waitlist participants had significantly greater mean depression scores than did intervention group participants at the first follow-up (after the intervention group's 8-week IPT-G) (β=6.42, 95% confidence interval=1.17 to 11.66, p=0.017). No difference was observed between groups in antiretroviral therapy adherence.

CONCLUSIONS

This study provides preliminary evidence that IPT-G led by community health workers may have benefits for postpartum depression among young mothers with HIV.

Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis

INTRODUCTION

Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV).

METHODS

A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years.

RESULTS AND DISCUSSION

Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19.

CONCLUSIONS

This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.

Effect of SMS reminders on PrEP adherence in young Kenyan women (MPYA study): a randomised controlled trial

BACKGROUND

Pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV acquisition. However, adherence among young women (aged 18-24 years) has been challenging. SMS reminders have been shown to improve adherence to antiretroviral therapy in some contexts, including in combination with real-time adherence monitoring. We aimed to determine the effect of SMS reminders on PrEP adherence among young women in Kenya over a 2-year period.

METHODS

The monitoring PrEP among young adult women (MPYA) study was an open label randomised controlled trial involving young adult women at high risk of HIV in Thika and Kisumu, Kenya. Participants were recruited from colleges, vocational institutions, informal settlements, and community-based organisations supporting young women. Women had to be aged 18-24 years and at high risk of HIV acquisition (defined as a VOICE risk score of 5 or higher, or being in a serodiscordant relationship). Study staff randomly assigned participants (1:1) to receive either SMS reminders (SMS reminder group) or no reminders (no SMS reminder group). Study group assignment was known to trial staff but masked to investigators. Reminders were initially sent daily and participants could switch to as-needed reminders (ie, sent only if they missed opening the monitor as expected) after 1 month. Study visits occurred at 1 month, 3 months, and then quarterly (ie, every 3 months). The primary outcome was PrEP adherence over 24 months measured with a real-time electronic monitor and assessed by negative binomial models adjusted for the study site and quarter among participants who collected PrEP. This trial is registered with ClinicalTrials.gov, NCT02915367.

FINDINGS

Of 642 women initially approached, 348 eligible women were enrolled between Dec 21, 2016, and Feb 5, 2018. Participants were randomly assigned to either the SMS reminder group (n=173) or the no SMS reminder group (n=175). The median age was 21 years (IQR 19-22) and 228 (66%) of the 348 participants reported condomless sex in the month before baseline. 24 (14%) of the 173 participants assigned to receive daily SMS reminders later opted for as-needed reminders. 69 291 (97%) of 71 791 SMS reminders were sent as planned. Among participants collecting PrEP (thus potentially suggesting a desire for HIV protection), electronically monitored adherence averaged 26·8% over 24 months and was similar by study group (27·0% with SMS, 26·6% without SMS, adjusted incidence rate ratio 1·16 [95% CI 0·93-1·45], p=0·19). There were no serious adverse events related to trial participation; five social harms occurred in each study group, primarily related to PrEP use.

INTERPRETATION

SMS reminders were ineffective in promoting PrEP adherence among young Kenyan women. Given the overall low adherence in the trial, additional interventions are needed to support PrEP use in this population.

FUNDING

US National Institute of Mental Health.

The acceptability and feasibility of a pilot study examining the impact of a mobile technology-based intervention informed by behavioral economics to improve HIV knowledge and testing frequency among Latinx sexual minority men and transgender women

Background

We developed a novel intervention that uses behavioral economics incentives and mobile-health text messages to increase HIV knowledge and testing frequency among Latinx sexual minority men and Latinx transgender women. Here we provide a theoretically-grounded assessment regarding the intervention’s acceptability and feasibility.

Methods

We conducted 30-min exit interviews with a stratified sample of participants (n = 26 Latinx sexual minority men, 15 Latinx transgender women), supplemented with insights from study staff (n = 6). All interviews were recorded, transcribed, and translated for a content analysis using Dedoose. Cohen’s Kappa was 89.4% across coded excerpts. We evaluated acceptability based on how participants cognitively and emotionally reacted to the intervention and whether they considered it to be appropriate. We measured feasibility based on resource, scientific and process assessments (e.g., functionality of text messaging service, feedback on study recruitment procedures and surveys).

Results

Regarding acceptability, most participants clearly understood the intervention as a program to receive information about HIV prevention methods through text messages. Participants who did not complete the intervention shared they did not fully understand what it entailed at their initial enrollment, and thought it was a one-time engagement and not an ongoing program. Though some participants with a higher level of education felt the information was simplistic, most appreciated moving beyond a narrow focus on HIV to include general information on sexually transmitted infections; drug use and impaired sexual decision-making; and differential risks associated with sexual positions and practices. Latinx transgender women in particular appreciated receiving information about Pre-Exposure Prophylaxis. While participants didn’t fully understand the exact chances of winning a prize in the quiz component, most enjoyed the quizzes and chance of winning a prize. Participants appreciated that the intervention required a minimal time investment. Participants shared that the intervention was generally culturally appropriate. Regarding feasibility, most participants reported the text message platform worked well though inactive participants consistently said technical difficulties led to their disengagement. Staff shared that clients had varying reactions to being approached while being tested for HIV, with some unwilling to enroll and others being very open and curious about the program. Both staff and participants relayed concerns regarding the length of the recruitment process and study surveys.

Conclusions

Our theoretically-grounded assessment shows the intervention is both acceptable and feasible.

Trial registration

The trial was registered on May 5, 2017 with the ClinicalTrials.gov registry [NCT03144336].

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10335-5.

PEERNaija: A Gamified mHealth Behavioral Intervention to Improve Adherence to Antiretroviral Treatment Among Adolescents and Young Adults in Nigeria

Background: HIV is the leading cause of death for youth in Sub-Saharan Africa (SSA). The rapid proliferation of smart phones in SSA provides an opportunity to leverage novel approaches to promote adherence to life-saving antiretroviral therapy (ART) for adolescents and young adults living with HIV (AYA-HIV) that go beyond simple medication reminders.

Methods: Guided by the Integrate, Design, Assess and Share (IDEAS) framework, our multidisciplinary team developed a peer-based mHealth ART adherence intervention—PEERNaija. Grounded in Social Cognitive Theory, and principles of contingency management and supportive accountability, PEERNaija delivers a multi-faceted behavioral intervention within a smartphone application to address important obstacles to adherence.

Results:PEERNaija was developed as a gamified Android-based mHealth application to support the behavioral change goal of improving ART adherence among AYA-HIV within Nigeria, a low- and middle- income country (LMIC). Identified via foundational interviews with the target population and review of the literature, key individual (forgetfulness and poor executive functioning), environmental (poor social support) and structural (indirect cost of clinic-based interventions) barriers to ART adherence for AYA-HIV informed application features. Further informed by established behavioral theories and principles, the intervention aimed to improve self-efficacy and self-regulation of AYA-HIV, leverage peer relationships among AYA to incentivize medication adherence (via contingency management, social accountability), provide peer social support through an app-based chat group, and allow for outreach of the provider team through the incorporation of a provider application. Gamification mechanics incorporated within PEERNaija include: points, progress bar, leaderboard with levels, achievements, badges, avatars and targeted behavior change messages. PEERNaija was designed as a tethered mobile personal health record application, sharing data to the widely deployed OpenMRS electronic health record application. It also uses the secure opensource Nakama gamification platform, in line with Principles of Digital Development that emphasize use of opensource systems within LMICs.

Conclusions: Theory-based gamified mHealth applications that incorporate social incentives have the potential to improve adherence to AYA-HIV. Ongoing evaluations of PEERNaija will provide important data for the potential role for a gamified, smartphones application to deliver multifaceted adherence interventions for vulnerable AYA-HIV in SSA.