Implementation of an electronic fingerprint-linked data collection system: a feasibility and acceptability study among Zambian female sex workers

Piloting the Inclusion of the Key Populations Unique Identifier Code in the South African Routine Health Information Management System: Protocol for a Multiphased Study

BACKGROUND

The global community has set an ambitious goal to end HIV/AIDS as a public health threat by 2030. Significant progress has been achieved in pursuing these objectives; however, concerns remain regarding the lack of disaggregated routine data for key populations (KPs) for a targeted HIV response. KPs include female sex workers, transgender populations, gay men and other men who have sex with men, people who are incarcerated, and people who use drugs. From an epidemiological perspective, KPs play a fundamental role in shaping the dynamics of HIV transmission due to specific behaviors. In South Africa, routine health information management systems (RHIMS) do not include a unique identifier code (UIC) for KPs. The purpose of this protocol is to develop the framework for improved HIV monitoring and programming through piloting the inclusion of KPs UIC in the South African RHIMS.

OBJECTIVE

This paper aims to describe the protocol for a multiphased study to pilot the inclusion of KPs UIC in RHIMS.

METHODS

We will conduct a multiphased study to pilot the framework for the inclusion of KPs UIC in the RHIMS. The study has attained the University of Johannesburg Research Ethics Committee approval (REC-2518-2023). This study has four objectives, including a systematic review, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (objective 1). Second, policy document review and in-depth stakeholder interviews using semistructured questionnaires (objective 2). Third, exploratory data analysis of deidentified HIV data sets (objective 3), and finally, piloting the framework to assess the feasibility of incorporating KPs UIC in RHIMS using findings from objectives 1, 2, and 3 (objective 4). Qualitative and quantitative data will be analyzed using ATLAS.ti (version 6; ATLAS.ti Scientific Software Development GmbH) and Python (version 3.8; Python Software Foundation) programming language, respectively.

RESULTS

The results will encompass a systematic review of literature, qualitative interviews, and document reviews, along with exploratory analysis of deidentified routine program data and findings from the pilot study. The systematic review has been registered in PROSPERO (International Prospective Register of Systematic Reviews; CRD42023440656). Data collection is planned to commence in September 2024 and expected results for all objectives will be published by December 2025.

CONCLUSIONS

The study will produce a framework to be recommended for the inclusion of the KP UIC national rollout. The study results will contribute to the knowledge base around the inclusion of KPs UIC in RHIMS data.

TRIAL REGISTRATION

PROSPERO CRD42023440656; https://tinyurl.com/msnppany.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55092.

Progress towards unique patient identification and case-based surveillance within the Southern African development community

Population mobility makes patient-tracking and care linkage in the South African Development Community (SADC) challenging. Case-based surveillance (CBS) through individual-level clinical data linked with a unique patient-identifier (UPI) is recommended. We conducted a mixed-methods landscape analysis of UPI and CBS implementation within selected SADC countries, this included: (1) SADC UPI implementation literature review; (2) assessment of UPI and CBS implementation for high HIV-prevalence SADC countries; (3) UPI implementation case-study in selected South African primary healthcare (PHC) facilities. Research into CBS and UPI implementation for the SADC region is lacking. Existing patient-identification methods often fail and limit patient-tracking. Paper-based records and poor integration between health-information systems further restrict patient-tracking. Most countries were in the early-middle stages of CBS and faced UPI challenges. Our South African case-study found that the UPI often goes uncaptured. Difficulties tracking patients across prevention and care cascades will continue until a functional and reliable UPI is available.

Risks and Opportunities to Ensure Equity in the Application of Big Data Research in Public Health

The big data revolution presents an exciting frontier to expand public health research, broadening the scope of research and increasing the precision of answers. Despite these advances, scientists must be vigilant against also advancing potential harms toward marginalized communities. In this review, we provide examples in which big data applications have (unintentionally) perpetuated discriminatory practices, while also highlighting opportunities for big data applications to advance equity in public health. Here, big data is framed in the context of the five Vs (volume, velocity, veracity, variety, and value), and we propose a sixth V, virtuosity, which incorporates equity and justice frameworks. Analytic approaches to improving equity are presented using social computational big data, fairness in machine learning algorithms, medical claims data, and data augmentation as illustrations. Throughout, we emphasize the biasing influence of data absenteeism and positionality and conclude with recommendations for incorporating an equity lens into big data research.

Exploring Factors Associated with Women's Willingness to Provide Digital Fingerprints in Accessing Healthcare Services: A Cross-Sectional Study in Urban Slums of Bangladesh

Digital fingerprints are increasingly used for patient care and treatment delivery, health system monitoring and evaluation, and maintaining data integrity during health research. Yet, no evidence exists about the use of fingerprinting technologies in maternal healthcare services in urban slum contexts, globally. The present study aimed to explore the recently delivered women's willingness to give digital fingerprints to community health workers to access healthcare services in the urban slums of Bangladesh and identify the associated factors. Employing a two-stage cluster random sampling procedure, we chose 458 recently delivered women from eight randomly selected urban slums of Dhaka city, Bangladesh. Chi-square tests were performed for descriptive analyses, and binary logistic regression analyses were performed to explore the factors associated with willingness to provide fingerprints. Overall, 78% of the participants reported that they were willing to provide digital fingerprints if that eased access to healthcare services. After adjusting for potential confounders, the sex of the household head, family type, and household wealth status were significantly associated with the willingness to provide fingerprints to access healthcare services. The study highlighted the potentials of using fingerprints for making healthcare services accessible. Focus is needed for female-headed households, women from poor families, and engaging husbands and in-laws in mobile health programs.

Acceptability and perceived facilitators and barriers to the usability of biometric registration among infants and children in Manhiça district, Mozambique: A qualitative study

In low-and middle-income countries, many infants and children remain unregistered in both civil registration and healthcare records, limiting their access to essential rights-based services, including healthcare. A novel biometric registration prototype, applying a non-touch platform using smart phones and tablets to capture physical characteristics of infants and children for electronic registration, was tested in rural Mozambique. This study assessed acceptability and perceived barriers and facilitators to the usability of this biometric registration prototype in Manhiça district, southern Mozambique. The study followed a qualitative design consisting of 5 semi-structured interviews with healthcare providers, 7 focus group discussions with caregivers of infants aged between 0 and 5 years old, and 2 focus group discussions with data collectors involved in the implementation of the biometric registration pilot project. Data were thematically analysed. The results of this study show that there is wide acceptability of the biometric registration prototype among healthcare providers and caregivers. Participants were aware of the benefits of the biometric registration prototype. The perceived benefits included that the biometric registration prototype would solve the inefficiency of paper-based registration, and the perception of biometric registration as “healthcare norm”. Perceived potential barriers to the implementation of the biometric registration prototype included: myths and taboos, lack of information, lack of time, lack of father’s consent, and potential workload among healthcare providers. In conclusion, the biometric prototype was widely accepted due to its perceived usefulness. However, there is a need to address the perceived barriers, and involvement of children’s fathers and/or other relevant family members in the process of biometric registration.

A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data

BACKGROUND

Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia.

METHODS/DESIGN

Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics.

RESULTS

The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline.

DISCUSSION

In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC.

Biometric Registration to an HIV Research Study may Deter Participation

Biometric registration may improve services associated with HIV research. A cross-sectional, observational survey was used to evaluate biometric fingerprint scanning for identification (ID) verification in the setting of an HIV prevention study. Survey outcomes were dichotomized (discouraged or not discouraged) by biometric scanning and statistical analyses were used to determine if participation decreased by greater than 10% overall and after stratifying by demographic variables and risk behaviors. 206 participants were recruited from a community-based HIV and sexual health research screening program. Participants completed a quantitative survey to assess their perceptions of biometric scanning for ID verification. The majority of participants (n = 160; 77.7%) indicated no deterrence from testing due to biometric scanning, yet a significant number (n = 45; 23.3%, P < .001) reported at least partial deterrence. Research using biometric scanning for ID verification may significantly limit access to HIV prevention services and may risk reducing meaningful participation among marginalized populations.

Loss to follow-up among female sex workers in Zambia: findings from a five-year HIV-incidence cohort

HIV-incidence studies are used to identify at-risk populations for HIV-prevention trials and interventions, but loss to follow-up (LTFU) can bias results if participants who remain differ from those who drop out. We investigated the incidence of and factors associated with LTFU among Zambian female sex workers (FSWs) in an HIV-incidence cohort from 2012 to 2017. Enrolled participants returned at month one, month three and quarterly thereafter. FSWs were considered LTFU if they missed six consecutive months, or if their last visit was six months before the study end date. Of 420 FSWs, 139 (33%) were LTFU at a rate of 15.7 per 100 person years. In multivariable analysis, LTFU was greater for FSWs who never used alcohol, began sex work above the age of consent, and had a lower volume of new clients. Our study appeared to retain FSWs in most need of HIV-prevention services offered at follow-up.

Sustainable support solutions for community-based rehabilitation workers in refugee camps: piloting telehealth acceptability and implementation

Background

The lack of training and education of Community-Based Rehabilitation (CBR) workers poses one of the most significant barriers to receiving effective occupational, physical and speech therapy for individuals with disabilities in Low-to-Middle Income Countries (LMIC), especially in countries with significant refugee populations. The aim of this study was to successfully implement a telehealth support system for CBR workers, evaluate the feasibility and acceptability of this intervention’s implementation among CBR workers in the CBR setting, and further identify strategies to address the deficit of skilled rehabilitation workers in LMIC through technological intervention.

Methods

This pilot study included CBR workers and CBR managers to inform feasibility, acceptability, and sustainable implementation. The RE-AIM and Dynamic Sustainability Framework were incorporated to guide procedural design, survey development, data collection, data evaluation, and increase success of telehealth implementation. CBR workers participate in trainings, telehealth sessions, surveys and focus groups to inform feasibility and acceptability. CBR Managers participated in focus groups to inform feasibility and sustainable implementation. NVIVO 12 Software was utilized to develop themes from CBR worker and CBR manager responses.

Results

Findings from this study demonstrate the need for additional training support for CBR workers in CBR settings throughout the entire treatment process. The telehealth system demonstrated successful short-term implementation across several domains of feasibility. Telehealth utilization was also proven acceptable, appropriate and necessary. Cultural beliefs, CBR worker training, and CBR Center infrastructure pose the most significant barriers to implementation of telehealth technologies in CBR Centers. CBR workers and managers confirmed the demand for future telehealth-based support systems, strengthening effort towards sustainability and scale-up.

Conclusions

Telehealth can be utilized to support CBR workers that serve vulnerable and marginalized populations, and in turn improve the global health status among refugee populations by reducing inequitable access to quality health care. The results support the need for further research to rigorously evaluate effectiveness of telehealth interventions to support CBR workers.

A Population-Specific Optimized GeneXpert Pooling Algorithm for Chlamydia trachomatis and Neisseria gonorrhoeae To Reduce Cost of Molecular Sexually Transmitted Infection Screening in Resource-Limited Settings

The sexually transmitted infections (STIs) chlamydia (CT) and gonorrhea (NG) are often asymptomatic in women and undetected by syndromic management, leading to complications such as pelvic inflammatory disease, infertility, and ectopic pregnancy. Molecular testing, such as the GeneXpert CT/NG assay, is highly sensitive, but cost restraints preclude implementation of these technologies in resource-limited settings. Pooled testing is one strategy to reduce the cost per sample, but the extent of savings depends on disease prevalence. The current study describes a pooling strategy based on identification of sociodemographic and laboratory factors associated with CT/NG prevalence in a high-risk cohort of Zambian female sex workers and single mothers conducted from 2016 to 2019. Factors associated with testing positive for CT/NG via logistic regression modeling included city, younger age, lower education, long-acting reversible contraception usage, Trichomonas vaginalis infection, bacterial vaginosis, and incident syphilis infection. Based on these factors, the study population was stratified into high-, intermediate-, and low-prevalence subgroups and tested accordingly-individually, pools of 3, or pools of 4, respectively. The cost per sample was reduced from $18 to as low as $9.43 in the low-prevalence subgroup. The checklist tool and pooling approach described can be used in a variety of treatment algorithms to lower the cost per sample and increase access to molecular STI screening. This is particularly valuable in resource-limited settings to detect and treat asymptomatic CT/NG infections missed by traditional syndromic management.

Sociodemographic factors and STIs associated with Chlamydia trachomatis and Neisseria gonorrhoeae infections in Zambian female sex workers and single mothers

Sexually transmitted infections (STIs) in women caused by Chlamydia trachomatis (CT) and/or Neisseria gonorrhoeae (NG) are epidemiologically distinct. In this study, associations with sociodemographic and clinical risk factors are explored separately for CT and NG. Multivariate logistic regression (MLR) models quantify associations between potential CT and/or NG risk factors within a cross-sectional study of high-risk women in two Zambian cities, Lusaka and Ndola. CT was associated with living in Lusaka, younger age, and literacy. Long-acting reversible contraception (LARC) was predictive of CT in Ndola, but protective in Lusaka. In Lusaka only, CT was associated with lower education and reported unprotected sex. NG was associated with younger age, lower education, concurrent Trichomonas vaginalis, bacterial vaginosis, and incident syphilis infection. Signs and symptoms were rare and not associated with either infection. CT was more prevalent, nearly 11%, compared to NG, 6.8%. The higher prevalence of CT could explain the lack of association with other STIs. The associations observed with NG could be the result of high-risk sexual networks or lack of protective immunity. Risk factors for CT and NG are distinct and may differ geographically, which should be considered when developing diagnostic tools or guiding presumptive treatment in specific populations.

Real-Time Person Identification in a Hospital Setting: A Systematic Review

In the critical setting of a trauma team activation, team composition is crucial information that should be accessible at a glance. This calls for a technological solution, which are widely available, that allows access to the whereabouts of personnel. This diversity presents decision makers and users with many choices and considerations. The aim of this review is to give a comprehensive overview of available real-time person identification techniques and their respective characteristics. A systematic literature review was performed to create an overview of identification techniques that have been tested in medical settings or already have been implemented in clinical practice. These techniques have been investigated on a total of seven characteristics: costs, usability, accuracy, response time, hygiene, privacy, and user safety. The search was performed on 11 May 2020 in PubMed and the Web of Science Core Collection. PubMed and Web of Science yielded a total n = 265 and n = 228 records, respectively. The review process resulted in n = 23 included records. A total of seven techniques were identified: (a) active and (b) passive Radio-Frequency Identification (RFID) based systems, (c) fingerprint, (d) iris, and (e) facial identification systems and infrared (IR) (f) and ultrasound (US) (g) based systems. Active RFID was largely documented in the included literature. Only a few could be found about the passive systems. Biometric (c, d, and e) technologies were described in a variety of applications. IR and US techniques appeared to be a niche, as they were only spoken of in few (n = 3) studies.

Beyond mobile phones: exploring using technology to support sustained engagement in care for HIV-infected women on antiretroviral therapy

Disengagement from HIV care has emerged as a challenge to the success of universal test and treat strategies for HIV-infected women. Technology may enhance efforts to monitor and support engagement in HIV care, but implementation barriers and facilitators need to be evaluated. We conducted a mixed-method study among HIV-infected, pregnant women and healthcare workers (HCWs) in Malawi to evaluate barriers and facilitators to three technologies to support monitoring HIV care: (1) text messaging, (2) SIM card scanning and (3) biometric fingerprint scanning. We included 123 HIV-infected, pregnant women and 85 HCWs in a survey, 8 focus group discussions and 5 in-depth interviews. Biometric fingerprint scanning emerged as the preferred strategy to monitor engagement in HIV care. Among HCWs, 70% felt biometrics were very feasible, while 48% thought text messaging and SIM card scanning were feasible. Nearly three quarters (72%) of surveyed women reported they would be very comfortable using biometrics to monitor HIV appointments. Barriers to using text messaging and SIM card scanning included low phone ownership (35%), illiteracy concerns, and frequent selling or changing of mobile phones. Future work is needed to explore the feasibly of implementing biometric fingerprint scanning or other technologies to monitor engagement in HIV care.

Improving Monitoring of Engagement in HIV Care for Women in Option B+: A Pilot Test of Biometric Fingerprint Scanning in Lilongwe, Malawi

Sustained engagement in HIV care is critical to the success of Option B+ for HIV-infected pregnant women. However, monitoring women's engagement in care across clinics and over time is challenging due to migration and clinic transfers. Improved strategies to identify and monitor women's engagement in HIV care across a network of clinics are needed, but have not been pilot tested. We evaluated the feasibility and acceptability of biometric fingerprint scanning to identify women and monitor HIV visit attendance among women in Option B+. Over a 3-month period, we enrolled HIV-infected pregnant women receiving care at two antenatal clinics in Lilongwe, Malawi and monitored their engagement in care using biometric fingerprint scanning and the standard-of-care electronic medical record (EMR) monitoring system. Biometric data was collected by trained research assistants, who uploaded and synced data across study sites daily using wireless internet. We collected data weekly on the biometric scanner performance, reliability, and usability. We assessed the feasibility and acceptability of using biometric fingerprint scanning to record HIV visits during exit interviews with a sample of participants and healthcare workers and by comparing visit concordance between the biometric fingerprint scanning and EMR systems. We enrolled 314 HIV-infected pregnant women and 51 HCWs (n = 365 total participants). The majority of participants felt the biometric fingerprint scanning system was easy to use (64%), required no additional assistance (69%) and met their expectations (76%). No major issues with data security, privacy, or scanner functionality were reported by HIV-infected women or healthcare workers. Of the 542 HIV visits captured during the study period among women in Option B+, 80% were recorded in the biometric fingerprint system versus 51% in the EMR system (PR 1.57, 95% CI 1.43, 1.72, p-value < 0.05). Among HIV-infected pregnant women engaged in HIV care, biometric fingerprint scanning is a feasible and acceptable way to monitor HIV visits and may improve the ability to monitor women's engagement in HIV care over time and across clinics. Biometric fingerprint scanning should be scaled-up and evaluated as an implementation strategy to support sustained engagement in HIV care for women during the perinatal period.

Acceptability of Interventions to Improve Engagement in HIV Care Among Pregnant and Postpartum Women at Two Urban Clinics in South Africa

INTRODUCTION

Pregnant women initiating antiretroviral therapy (ART) in sub-Saharan Africa have been shown to have sub-optimal engagement in care, particularly after delivery, and interventions to improve engagement in care for this unique population are urgently needed.

METHODS

We enrolled 25 pregnant women living with HIV at each of two large antenatal clinics in Johannesburg and Cape Town, South Africa (n = 50), and conducted in-depth interviews. We assessed participants' reported acceptability of the following proposed interventions to improve engagement in care and retention monitoring data systems: financial incentives, educational toys, health education, combined maternal/infant visits, cell phone text reminders, mobility tracking, fingerprint/biometric devices, and smartcards.

RESULTS

Acceptability overall for interventions was high, with mixed responses for some interventions. Overall themes identified included (i) the intersection of individual and facility responsibility for a patient's health, (ii) a call for more health education, (iii) issues of disclosure and concerns about privacy, and (iv) openness to interventions that could improve health systems.

DISCUSSION

These findings provide insight into the preferences and concerns of potential users of interventions to improve engagement in HIV care for pregnant women, and support the development of tools that specifically target this high-risk group.

Feasibility and acceptability of an iris biometric system for unique patient identification in routine HIV services in Kenya

BACKGROUND

Use of routine HIV programme data for surveillance is often limited due to inaccuracies associated with patient misclassification which can be addressed by unique patient identification.We assessed the feasibility and acceptability of integrating an iris recognition biometric identification system into routine HIV care services at 4 sites in Kenya.

METHODS

Patients who had recently tested HIV-positive or were engaged in care were enrolled. Images of the iris were captured using a dual-iris camera connected to a laptop. A prototype iris biometric identification system networked across the sites, analysed the iris patterns; created a template from those patterns; and generated a 12-digit ID number based on the template. During subsequent visits, the patients' irises were re-scanned, and the pattern was matched to stored templates to retrieve the ID number.

RESULTS

Over 55 weeks 8,614 (98%) of 8,794 new patients were assigned a unique ID on their first visit. Among 6,078 return visits, the system correctly re-identified patients' IDs 5,234 times (86%). The false match rate (a new patient given the ID of another patient) was 0·5% while the generalized false reject rate (re-scans assigned a new ID) was 4·7%. Overall, 9 (0·1%) agreed to enrol but declined to have an iris scan. The most common reasons cited for declining an iris scan were concerns about privacy and confidentiality.

CONCLUSION

Implementation of an iris recognition system in routine health information systems is feasible and highly acceptable as part of routine care in Kenya. Scale-up could improve unique patient identification and tracking, enhancing disease surveillance activities.

Single Mothers and Female Sex Workers in Zambia Have Similar Risk Profiles

The aim of the study was to compare reproductive health and high-risk behaviors in female sex workers (FSWs) and single mothers (SMs) in Zambia's two largest cities, Lusaka and Ndola. FSWs were invited from known community hot spots, and sexually active HIV- SMs were referred from infant vaccination services for free and anonymous screening and treatment for HIV and other sexually transmitted infections (STIs) and long acting reversible contraception. A subset completed an interviewer-administered survey. From 2012 to 2016, 1,893 women (1,377 FSWs and 516 HIV- SMs) responded to referrals. HIV prevalence was 50% in Lusaka and 33% in Ndola FSWs. Positive syphilis serology (rapid plasmin reagin) was found in 29%-31% of HIV+ FSWs and 9%-12% of HIV- FSWs and SMs. Trichomonas was more common in Ndola (11%-12%), compared with Lusaka (3%-7%). Antiretroviral therapy (ART) use among HIV+ FSWs was 9%-15%. In all groups, consistent condom use (8%-11%) and modern contraceptive use (35%-65%) were low. Low literacy and reported coercion at first sexual intercourse were common in both FSWs and SMs, as was alcohol use during sex among FSWs. Zambian FSWs and SMs have low condom use and high HIV/STI and unplanned pregnancy risk. Many FSWs and half of SMs are ≥25 years of age, and thus too old for HIV prevention services targeting "adolescent girls and young women" (aged 15-24). Tailored and targeted reproductive health services are needed to reduce HIV, STI, and unplanned pregnancy in these vulnerable women.

Feasibility, Acceptability, and Adoption of Digital Fingerprinting During Contact Investigation for Tuberculosis in Kampala, Uganda: A Parallel-Convergent Mixed-Methods Analysis

Background

In resource-constrained settings, challenges with unique patient identification may limit continuity of care, monitoring and evaluation, and data integrity. Biometrics offers an appealing but understudied potential solution.

Objective

The objective of this mixed-methods study was to understand the feasibility, acceptability, and adoption of digital fingerprinting for patient identification in a study of household tuberculosis contact investigation in Kampala, Uganda.

Methods

Digital fingerprinting was performed using multispectral fingerprint scanners. We tested associations between demographic, clinical, and temporal characteristics and failure to capture a digital fingerprint. We used generalized estimating equations and a robust covariance estimator to account for clustering. In addition, we evaluated the clustering of outcomes by household and community health workers (CHWs) by calculating intraclass correlation coefficients (ICCs). To understand the determinants of intended and actual use of fingerprinting technology, we conducted 15 in-depth interviews with CHWs and applied a widely used conceptual framework, the Technology Acceptance Model 2 (TAM2).

Results

Digital fingerprints were captured for 75.5% (694/919) of participants, with extensive clustering by household (ICC=.99) arising from software (108/179, 60.3%) and hardware (65/179, 36.3%) failures. Clinical and demographic characteristics were not markedly associated with fingerprint capture. CHWs successfully fingerprinted all contacts in 70.1% (213/304) of households, with modest clustering of outcomes by CHWs (ICC=.18). The proportion of households in which all members were successfully fingerprinted declined over time (ρ=.30, P<.001). In interviews, CHWs reported that fingerprinting failures lowered their perceptions of the quality of the technology, threatened their social image as competent health workers, and made the technology more difficult to use.

Conclusions

We found that digital fingerprinting was feasible and acceptable for individual identification, but problems implementing the hardware and software lead to a high failure rate. Although CHWs found fingerprinting to be acceptable in principle, their intention to use the technology was tempered by perceptions that it was inconsistent and of questionable value. TAM2 provided a valuable framework for understanding the motivations behind CHWs’ intentions to use the technology. We emphasize the need for routine process evaluation of biometrics and other digital technologies in resource-constrained settings to assess implementation effectiveness and guide improvement of delivery.

Biometrics and public health surveillance in criminalised and key populations: policy, ethics, and human rights considerations

Widespread public health surveillance efforts focused on key populations (men who have sex with men, sex workers, people who inject drugs, and others) gather data on population sizes, HIV prevalence, and other information for planning and resource allocation. Biometric identification might improve this data gathering. However, in the context of extensive criminalisation of these populations, the use of biometrics such as fingerprints raises concerns that are insufficiently addressed in current policies. These concerns include infringing privacy, exposing participants to risks of legal action or violence, biasing surveillance results, and undermining trust in the health system. We set out key ethics and human rights considerations regarding the use of biometrics in HIV surveillance among these populations, and outline a typology of jurisdictions wherein such methods might be considered, based on data about legal, political, and social environments. In this Review, we suggest that the biometrics approach is not currently likely to be appropriate in many jurisdictions.

Using Digital Technologies in Clinical HIV Research: Real-World Applications and Considerations for Future Work

BACKGROUND

Digital technologies, especially if used in novel ways, provide a number of potential advantages to clinical research in trials related to human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) and may greatly facilitate operations as well as data collection and analysis. These technologies may even allow answering questions that are not answerable with older technologies. However, they come with a variety of potential concerns for both the participants and the trial sponsors. The exact challenges and means for alleviation depend on the technology and on the population in which it is deployed, and the rapidly changing landscape of digital technologies presents a challenge for creating future-proof guidelines for technology application.

OBJECTIVE

The aim of this study was to identify and summarize some common themes that are frequently encountered by researchers in this context and highlight those that should be carefully considered before making a decision to include these technologies in their research.

METHODS

In April 2016, the Global HIV Vaccine Enterprise surveyed the field for research groups with recent experience in novel applications of digital technologies in HIV clinical research and convened these groups for a 1-day meeting. Real-world uses of various technologies were presented and discussed by 46 attendees, most of whom were researchers involved in the design and conduct of clinical trials of biomedical HIV prevention and treatment approaches. After the meeting, a small group of organizers reviewed the presentations and feedback obtained during the meeting and categorized various lessons-learned to identify common themes. A group of 9 experts developed a draft summary of the findings that was circulated via email to all 46 attendees for review. Taking into account the feedback received, the group finalized the considerations that are presented here.

RESULTS

Meeting presenters and attendees discussed the many successful applications of digital technologies to improve research outcomes, such as those for recruitment and enrollment, participant identification, informed consent, data collection, data quality, and protocol or treatment adherence. These discussions also revealed unintended consequence of technology usage, including risks to study participants and risks to study integrity.

CONCLUSIONS

Key lessons learned from these discussions included the need to thoroughly evaluate systems to be used, the idea that early success may not be sustained throughout the study, that some failures will occur, and considerations for study-provided devices. Additionally, taking these key lessons into account, the group generated recommendations on how to move forward with the use of technology in HIV vaccine and biomedical prevention trials.