Effect of mobile text messages on antiretroviral medication adherence and patient retention in early HIV care: an open-label, randomized, single center study in south Florida

Digital Health in Enhancing Antiretroviral Therapy Adherence: A Systematic Review and Meta-Analysis

Adherence to antiretroviral therapy (ART) is essential in determining successful treatment of human immunodeficiency virus (HIV). The adoption of digital health is suggested to improve ART adherence among people living with HIV (PLHIV). This study aimed to systematically determine the effect of digital health in enhancing ART adherence among PLHIV from published studies. The systematic search was conducted on Scopus, Web of Science (WoS), PubMed, Ovid, EBSCOHost, and Google Scholar databases up to June 2022. Studies utilized any digital health as an intervention for ART adherence enhancement and ART adherence status as study's outcome was included. Digital health refers to the use of information and communication technologies to improve health. Quality assessment and data analysis were carried out using Review Manager (RevMan) version 5.4. A random-effects model computed the pooled odds ratio between intervention and control groups. The search produced a total of 1864 articles. Eleven articles were eligible for analysis. Digital health was used as follows: six studies used short message service or text message alone, three studies used mobile applications, and two studies used combination method. Four studies showed statistically significant impacts of digital health on ART adherence, while seven studies reported insignificant results. Results showed studies conducted using combination approach of digital health produced more promising outcome in ART adherence compared to single approach. New innovative in combination ways is required to address potential benefits of digital health in promoting ART adherence among PLHIV.

HIV drug resistance in the era of contemporary antiretroviral therapy: A clinical perspective

Contemporary antiretroviral therapy (ART) regimens have high barriers to the development of drug resistance. However, resistance to earlier antiretrovirals and uncommon cases of resistance to contemporary ART illustrate the continued need for good clinical management of HIV drug resistance. Here, we describe HIV drug-resistance mechanisms, the interaction of HIV drug-resistant mutations and the patterns of drug resistance to contemporary ART. We then provide guidance on the management of HIV drug resistance, including how to limit the development of resistance and manage virologic failure that is complicated by resistance. To complement this, links to resources and treatment guidelines are provided that can assist with the interpretation of HIV drug resistance test results and optimal ART selection in the clinic.

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 of mHealth on Adherence to Antiretroviral Therapy in Patients Living With HIV: Meta-analysis of Randomized Controlled Trials

BACKGROUND

The World Health Organization recommends that all adults with HIV adhere to antiretroviral therapy (ART). Good adherence to ART is beneficial to patients and the public. Furthermore, mHealth has shown promise in improving HIV medication adherence globally.

OBJECTIVE

The aim of this meta-analysis is to analyze the effectiveness of mHealth on adherence to antiretroviral therapy in patients living with HIV.

METHODS

Randomized controlled trials (RCTs) of the association between mHealth and adherence to ART published until December 2021 were searched in electronic databases. Odds ratios (ORs), weighted mean differences, and 95% CIs were calculated. This meta-analysis was performed using the Mantel-Haenszel method or the inverse variance test. We evaluated heterogeneity with the I2 statistic. If I2 was ≤50%, heterogeneity was absent, and a fixed effect model was used. If I2 was >50%, heterogeneity was present, and a random effects model was used.

RESULTS

A total of 2163 participants in 8 studies were included in this meta-analysis. All included studies were RCTs. The random effects model was used for a meta-analysis of the effects of various intervention measures compared to routine nursing; the outcome was not statistically significant (OR 1.54, 95% CI 0.99-2.38; P=.05). In the subgroups, only short messaging service (SMS)-based interventions significantly increased adherence to ART (OR 1.76, 95% CI 1.07-2.89; P=.03). Further analysis showed that only interactive or bidirectional SMS could significantly increase ART adherence (OR 1.69, 95% CI 1.22-2.34; P=.001). After combining the difference in CD4 cell count before and after the interventions, we concluded that there was no statistical heterogeneity among the studies (I2=0%; tau2=0.37; P=.95).

CONCLUSIONS

Interactive or bidirectional SMS can enhance intervention effects. However, whether mHealth can improve adherence to ART in patients with HIV needs further study. Owing to a lack of the required significant staff time, training, and ongoing supervision, there is still much more to do to apply mHealth to the clinical use of ART for patients living with HIV.

TRIAL REGISTRATION

PROSPERO CRD42022358774; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=358774.

Behavioral Theories and Motivational Features Underlying eHealth Interventions for Adolescent Antiretroviral Adherence: Systematic Review

Background

eHealth systems provide new opportunities for the delivery of antiretroviral therapy (ART) adherence interventions for adolescents. They may be more effective if grounded in health behavior theories and behavior change techniques (BCTs). Prior reviews have examined the effectiveness, feasibility, and acceptability of these eHealth systems. However, studies have not systematically explored the use of health behavior theories and BCTs in the design of these applications.

Objective

The purpose of this review was to explore whether health behavior theories and BCTs were considered to ground designs of eHealth systems supporting adolescents’ (10-24 years) ART adherence. More specifically, we examined which specific theories and BCTs were applied, and how these BCTs were implemented as design features. Additionally, we investigated the quality and effect of eHealth systems.

Methods

A systematic search was performed on IEEE Xplore, ACM, ScienceDirect, PubMed, Scopus, and Web of Science databases from 2000 to 2020. Theory use and BCTs were coded using the Theory Coding Scheme and the Behavior Change Technique Taxonomy version 1 (BCTTv1), respectively. Design features were identified using the lenses of motivational design for mobile health (mHealth). The number of BCTs and design features for each eHealth system and their prevalence across all systems were assessed.

Results

This review identified 16 eHealth systems aiming to support ART adherence among adolescents. System types include SMS text message reminders (n=6), phone call reminders (n=3), combined SMS text message and phone call reminders (n=1), electronic adherence monitoring devices (n=3), smartphone apps (n=1), smartphone serious games (n=1), gamified smartphone apps (n=1), leveraging existing social media (n=2), web-based applications (n=1), videoconferencing (n=1), and desktop applications (n=1). Nine were grounded in theory, of which 3 used theories extensively. The impact of adolescent developmental changes on ART adherence was not made explicit. A total of 42 different BCTs and 24 motivational design features were used across systems. Ten systems reported positive effects on 1 or more outcomes; however, of these ten systems, only 3 reported exclusively positive effects on all the outcomes they measured. As much as 6 out of 16 reported purely no effect in all the outcomes measured.

Conclusions

Basic applications (SMS text messaging and phone calls) were most frequent, although more advanced systems such as mobile apps and games are also emerging. This review indicated gaps in the use of theory and BCTs, and particularly the impact of developmental changes on ART adherence was not adequately considered. Together with adopting a developmental orientation, future eHealth systems should effectively leverage health theories and consider developing more advanced systems that open the door to using BCTs more comprehensively. Overall, the impact of eHealth systems on adolescent ART adherence and its mediators is promising, but conclusive evidence on effect still needs to be provided.

Toward improved adherence: a text message intervention in an human immunodeficiency virus pediatric clinic in Guatemala City

As access to human immunodeficiency virus treatment expands in Low to Middle Income Countries, it becomes critical to develop and test strategies to improve adherence and ensure efficacy. Text messaging improves adherence to antiretroviral treatment antiretroviral treatment in some patient populations, but data surrounding the use of these tools is sparse in pediatric and adolescent patients in low to middle income countries. We evaluated if a text message intervention can improve antiretroviral treatment adherence while accounting for cell phone access, patterns of use, and willingness to receive text messages.We carried out a cross sectional study to understand willingness of receiving text message reminders, followed by a randomized controlled trial to assess effectiveness of text message intervention.Enrolled participants were randomized to receive standard care with regular clinic visits, or standard care plus short message service reminders. Adherence was measured 3 times during the study period using a 4-day Recall Questionnaire. Outcome was measured based on differences in the average adherence between the intervention and control group at each time point (baseline, 3 months, 6 months).Most respondents were willing to receive text message adherence reminders (81.1%, n = 53). Respondent literacy, travel time to clinic, cell phone access, and patterns of use were significantly associated with willingness. In the randomized trial the intervention group (n = 50) experienced a small but significant mean improvement in adherence over the six-month period (4%, P < .01) whereas the control group (n = 50) did not (mean improvement: 0.8%, P = .64).Text message interventions effectively support antiretroviral adherence in pediatric patients living with human immunodeficiency virus. Studies designed to assess the impact of text messaging interventions must examine local context for cellular phone infrastructure and use and must account for potential loss to follow up when patients miss appointments and study assessments.

PrEP discontinuation among Latino/a and Black MSM and transgender women: A need for PrEP support services

Purpose

Disparities persist in HIV infection among Black and Latino men who have sex with men (BLMSM) and Black and Latina transgender women (BLTW). Increasing uptake and subsequent consistent use of pre-exposure prophylaxis (PrEP), an effective biomedical strategy for preventing HIV acquisition, can dramatically reduce HIV incidence in these populations. The purpose of this study was to explore reasons for PrEP discontinuation among BLMSM and BLTW living in Los Angeles County to inform the development of support services for these populations to remain persistent with their PrEP regimen.

Methods

In-depth, semi-structured interviews were conducted with 15 BLMSM and 7 BLTW who reported either temporary or indefinite PrEP discontinuation. A thematic analysis approach was used to analyze qualitative data.

Results

Four themes emerged related to reasons for PrEP discontinuation, including: (1) lower perceived HIV risk related to changes in sexual behavior; (2) structural or logistical barriers (e.g., lapse or loss of health insurance, cost, difficulty navigating complex medical systems); (3) anticipated and experienced medication side effects, with a sub-theme of interactions between PrEP and feminizing hormone medications; and (4) challenges with medication adherence.

Conclusions

PrEP is an important prevention tool for BLMSM and BLTW, particularly during periods of heightened HIV risk. However, both individual (e.g., inability to adhere to medication, changes in HIV sexual risk behaviors) and structural/logistical (e.g., loss of insurance, navigating complex medical systems) factors can cause temporary or indefinite PrEP discontinuation. Additional support services, beyond those offered by medical providers, are needed to help BLMSM and BLTW PrEP users overcome barriers to discontinuation and assist them to remain persistent with their PrEP regimen. We describe potential options for support services such as PrEP case management, expanded PrEP navigation services, or text messaging services.