The Promise and Peril of Mobile Phones for Youth in Rural Uganda: Multimethod Study of Implications for Health and HIV

Mobile Phone Technology for Preventing HIV and Related Youth Health Problems, Sexual Health, Mental Health, and Substance Use Problems in Southwest Uganda (Youth Health SMS): Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

East and Southern Africa have the highest HIV incidence and prevalence in the world, with adolescents and young adults being at the greatest risk. Despite effective combination prevention tools, including the recently available pre-exposure prophylaxis (PrEP), HIV incidence among adolescents and young adults in Uganda remains high, and PrEP use remains low. Mental health and substance use (behavioral health) play a role in sexual behavior and decision-making, contributing to an increase in the risk for acquiring HIV. Interventions that target multiple HIV risk factors, including sexual and mental health and problematic substance use, are crucial to ending the HIV epidemic. Yet few interventions addressing HIV related health disparities and comorbidities among adolescents and young adults in East and Southern Africa currently exist.

OBJECTIVE

This study aims to evaluate the acceptability and feasibility of Kirabo, an SMS text message intervention informed by the information, motivation, and behavior model and to be disseminated through secondary schools. The study will gather preliminary estimates of Kirabo's effectiveness in increasing HIV testing and linking users to mental health counselors.

METHODS

We identified Mobile 4 Reproductive Health for adaptation using the assessment, decision, administration, production, topical experts, integration, training, testing (ADAPT-ITT) framework. Mobile 4 Reproductive Health is an evidence-based automated 2-way SMS text messaging and interactive voice response platform that offers sexual and reproductive health information and links users to HIV clinics in East Africa. Through ADAPT-ITT we refined our approach and created Kirabo, an SMS text message-based intervention for linking adolescents and young adults to health services, including HIV testing and mental health counseling. We will conduct a 2-arm randomized controlled trial in Masaka, Uganda. Adolescents (N=200) will be recruited from local schools. Baseline sociodemographic characteristics, HIV test history, and behavioral health symptoms will be assessed. We will evaluate acceptability and feasibility using surveys, interviews, and mobile phone data. The preliminary efficacy of Kirabo in increasing HIV testing and linking users to mental health counselors will be evaluated immediately after the intervention and at the 3-month follow-up. We will also assess the intervention's impact on self-efficacy in testing for HIV, adopting PrEP, and contacting a mental health counselor.

RESULTS

Intervention adaptation began in 2019. A pretest was conducted in 2021. The randomized controlled trial, including usability and feasibility assessments and effectiveness measurements, commenced in August 2023.

CONCLUSIONS

Kirabo is a tool that assists in the efforts to end the HIV epidemic by targeting the health disparities and comorbidities among adolescents in Uganda. The intervention includes local HIV clinic information, PrEP information, and behavioral health screening, with referrals as needed. Increasing access to prevention strategies and mitigating factors that make adolescents and young adults susceptible to HIV acquisition can contribute to global efforts to end the HIV epidemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05130151; https://clinicaltrials.gov/study/NCT05130151.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49352.

Gendered access to digital capital and mobile phone ownership among young people in Rakai, Uganda

This article examines how gendered access to digital capital-in the form of the social and economic resources needed to own and use a mobile phone-is connected to key adult milestones, such as securing employment and engaging in romantic relationships. Descriptive statistical analysis of 11,030 young people aged 15-24 in Rakai, Uganda indicated that men were more likely to own mobile phones than women. Analysis of qualitative interviews with young people (N = 31) and ethnographic participant observations among young people (N = 24) add nuance and depth to the observed gender difference. We go beyond a 'categorical' approach to gender (i.e. comparing rates between men and women) to examine how access to digital capital is gendered both for men and for women. Mobile phone ownership both reproduces and destabilises gendered social organisation in ways that have implications for economic opportunities, social connections, HIV risk and overall health and well-being. Young men had greater access to the benefits of mobile phone ownership, whereas young women's access to those benefits was impeded by covert and overt gendered mechanisms of control that limited access to digital capital. Findings suggest that mhealth initiatives, increasingly deployed to reach under-resourced populations, must take into account gendered access to digital capital.

Cell Phone Availability and Usage for mHealth and Intervention Delivery to Persons Living With HIV in a Low-Resource Setting: Cross-sectional Study

BACKGROUND

HIV/AIDS is now a manageable chronic illness owing to effective antiretroviral therapy (ART), which involves routine follow-up care, including regular physical visits to the clinic. In the recent past, and in wake of the COVID-19 pandemic, there has been increased need for virtual care and intervention delivery, a modality known as mobile health (mHealth), which includes cell phone-delivered services for medical and public health practice.

OBJECTIVE

Here we describe cell phone use and its relationship with alcohol use in a cohort of persons living with HIV and latent tuberculosis (TB).

METHODS

We performed a cross-sectional analysis of baseline data from a cohort of persons living with HIV and latent TB in HIV care in southwestern Uganda. We estimated proportions of cell phone and text message use and evaluated their associations with alcohol use-a common modifiable behavior among persons living with HIV. Cell phone use (primary outcome) was defined as owning a cell phone that is turned on at least half of the day. Any alcohol use was defined as any self-reported alcohol use in the prior 3 months or a phosphatidylethanol (an alcohol biomarker) level of ≥8 ng/mL.

RESULTS

A total of 300 participants (median age 40 years; n=146, 48.7% male) were included in the analysis. Most (n=267, 89.0%) participants had access to a phone and of them, 26 (9.7%) shared the phone with someone else. In total, 262/300 (87.3%) of participants owned a cell phone that is turned on at least half of the time; the majority (n=269, 89.7%) rarely or never sent text messages, and over two-thirds (n=200, 66.9%) rarely or never received text messages. Most (n=214, 71.3%) had any alcohol use in the prior 3 months. In adjusted analyses, any alcohol use was not significantly associated with cell phone use (adjusted odds ratio [aOR] 0.48, 95% CI 0.18-1.25; P=.13) or sending (aOR 0.82, 95% CI 0.28-2.37; P=.71) or receiving (aOR 1.31, 95% CI 0.70-2.47; P=.40) text messages.

CONCLUSIONS

There is hope that mHealth interventions in this population can be carried out using cell phones owing to their popularity; however, the interventions may need to employ methods that do not rely on the sending and receiving of text messages only.

Brief Report: Mobile Phones, Sexual Behaviors, and HIV Incidence in Rakai, Uganda, From 2010 to 2018

BACKGROUND

Sub-Saharan Africa has the highest HIV incidence and prevalence in the world. In the past decade, mobile phone ownership has doubled, affecting social and sexual practices. Using longitudinal follow-up data, this study examined whether mobile phone ownership was associated with sexual behaviors and HIV incidence for youth and adults.

METHODS

The Rakai Community Cohort Study gathers demographic and sexual health information and conducts HIV testing among an open cohort in southcentral Uganda every 12-18 months.

RESULTS

Of the 10,618 participants, 58% owned a mobile phone, 69% lived in rural locations, and 77% were sexually active. Analyses were adjusted for time, location, religion, and socioeconomic status. Phone ownership was associated with increased odds of ever having had sex act for 15- to 19-year-olds [men adjusted odds ratio (AOR): 2.12, 95% confidence interval (CI): 1.78 to 2.52; women AOR: 3.20, 95% CI: 2.45 to 4.17]. Among sexually active participants, owning a phone was associated with increased odds of having 2 or more concurrent sex partners (15- to 24-year-old men AOR: 1.76, 95% CI: 1.34 to 2.32; 25 to 49-year-old men: AOR 1.81, 95% CI: 1.54 to 2.13; 25- to 49-year-old women AOR: 1.81, 95% CI: 1.32 to 2.49). For men, phone ownership was associated with increased odds of circumcision (15- to 24-year-old men AOR: 1.24, 95% CI: 1.08 to 1.41; 25- to 49-year-old men AOR: 1.12, 95% CI: 1.01 to 1.24). Phone ownership was not associated with HIV incidence.

CONCLUSION

Although mobile phone ownership was associated with sexual risk behaviors, it was not associated with increased risk of HIV acquisition. Research should continue exploring how phones can be used for reducing sexual health risk.

'This is what is going to help me': Developing a co-designed and theoretically informed harm reduction intervention for mobile youth in South Africa and Uganda

ABSTRACTYoung migrants in sub-Saharan Africa are particularly vulnerable to HIV-acquisition. Despite this, they are consistently under-served by services, with low uptake and engagement. We adopted a community-based participatory research approach to conduct longitudinal qualitative research among 78 young migrants in South Africa and Uganda. Using repeat in-depth interviews and participatory workshops we sought to identify their specific support needs, and to collaboratively design an intervention appropriate for delivery in their local contexts. Applying a protection-risk conceptual framework, we developed a harm reduction intervention which aims to foster protective factors, and thereby nurture resilience, for youth 'on the move' within high-risk settings. Specifically, by establishing peer supporter networks, offering a 'drop-in' resource centre, and by identifying local adult champions to enable a supportive local environment. Creating this supportive edifice, through an accessible and cohesive peer support network underpinned by effective training, supervision and remuneration, was considered pivotal to nurture solidarity and potentially resilience. This practical example offers insights into how researchers may facilitate the co-design of acceptable, sustainable interventions.

Interventions to address the mental health of adolescents and young adults living with or affected by HIV: state of the evidence

INTRODUCTION

Adolescents and young adults (AYA) remain vulnerable to HIV-infection and significant co-morbid mental health challenges that are barriers to treatment and prevention efforts. Globally millions of AYA are living with HIV (AYALH) and/or have been affected by HIV in their families (AYAAH), with studies highlighting the need for mental health programmes. With no current guidelines for delivering mental health interventions for AYALH or AYAAH, a scoping review was undertaken to explore current evidence-based mental health interventions for AYALH and AYAAH to inform future work.

METHODS

The review, targeting work between 2014 and 2020, initially included studies of evidence-based mental health interventions for AYALH and AYAAH, ages 10 to 24 years, that used traditional mental health treatments. Given the few studies identified, we expanded our search to include psychosocial interventions that had mental health study outcomes.

RESULTS AND DISCUSSION

We identified 13 studies, seven focused on AYALH, five on AYAAH, and one on both. Most studies took place in sub-Saharan Africa. Depression was targeted in eight studies with the remainder focused on a range of emotional and behavioural symptoms. Few studies used evidence-based approaches such as Cognitive Behaviour Therapy; psychosocial approaches included mental health treatments, group-based and family strengthening interventions, economic empowerment combined with family strengthening, group-based mindfulness and community interventions. Eleven studies were randomized control trials with four pilot studies. There was variation in sample size, treatment delivery mode (individual focus, group-based, family focus), and measures of effectiveness across studies. Most used trained lay counsellors as facilitators, with few using trained mental health professionals. Eleven studies reported positive intervention effects on mental health.

CONCLUSIONS

Despite the need for mental health interventions for AYALH and AYAAH, we know surprisingly little about mental health treatment for this vulnerable population. There are some promising approaches, but more work is needed to identify evidence-based approaches and corresponding mechanisms of change. Given limited resources, integrating mental health treatment into healthcare settings and using digital health approaches may support more standardized and scalable treatments. Greater emphasis on implementation science frameworks is needed to create sustainable mental health treatment for AYALH and AYAAH globally.