Information and communication technologies for adherence to antiretroviral treatment in adults with HIV/AIDS

Effectiveness, acceptability, and feasibility of technology-enabled health interventions for adolescents living with HIV in low- and middle-income countries: A systematic review protocol

Adolescents living with chronic conditions such as HIV (ALHIV) are challenged to remain adherent and engaged in HIV care. Technology offers a promising platform to deliver behaviour-change interventions to adolescents. The largest proportion of ALHIV resides in sub-Saharan Africa; yet little is known about the effectiveness, feasibility and acceptability of technology-enabled interventions to deliver and support health care to ALHIV in resource-constraint settings. This study aims to explore the literature and synthesise the evidence for the effectiveness, acceptability, and feasibility of technology-enabled health interventions for ALHIV in low and middle-income countries (LMIC). Eight electronic databases (Ebscohost, CINAHL, ERIC, MEDLINE, PubMed, SCOPUS, Science Direct, and Sabinet) and Google Scholar will be searched to identify technology-enabled health interventions for ALHIV in LMIC published from 2010-2022. Quantitative and qualitative studies reporting on technology-enabled health interventions for predominantly adolescents (10-19 years) will be included. The review will be performed, and findings reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols. A two-stage process of screening titles and abstracts, and then full-text, will be performed independently by two reviewers. The quality of the included studies will be assessed using the Critical Appraisal Skills Programme checklists, and the Risk of Bias in Non-randomised Studies of Interventions tool will be used to assess the risk of bias. The review will involve publications already in the public domain; therefore, ethics approval is not required. The results will be disseminated through a peer-reviewed journal publication and/or conference proceedings. PROSPERO registration number: CRD42022336330.

People Living with HIV and AIDS: Experiences towards Antiretroviral Therapy, Paradigm Changes, Coping, Stigma, and Discrimination-A Grounded Theory Study

BACKGROUND

The experiences in coping with HIV/AIDS from people living with HIV (PLWH) in Austria, Munich, and Berlin regarding adherence, antiretroviral therapy (ART), stigmatization, and discrimination were the main focus of this study. Therapy adherence is the cornerstone for PLWH to reduce disease progression and increase life expectancy combined with a high quality of life. The experience of stigmatization and discrimination in different life situations and settings is still experienced today.

AIMS

We aimed to examine the subjective perspective of PLWH concerning living with, coping with, and managing HIV/AIDS in daily life.

METHODS

Grounded Theory Methodology (GTM) was used. Data collection was conducted with semi-structured face-to-face interviews with 25 participants. Data analysis was performed in three steps, open, axial, and selective coding.

RESULTS

Five categories emerged, which included the following: (1) fast coping with diagnosis, (2) psychosocial burden due to HIV, (3) ART as a necessity, (4) building trust in HIV disclosure, (5) stigmatization and discrimination are still existing.

CONCLUSION

In conclusion, it can be said that it is not the disease itself that causes the greatest stress, but the process of coping with the diagnosis. Therapy, as well as lifelong adherence, is hardly worth mentioning today. Much more significant is currently still the burden of discrimination and stigmatization.

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.

Association between HIV clinic caseloads and viral load suppression in New York City

The relationship between HIV patient caseload and a clinic's ability to achieve viral load suppression (VLS) in their HIV patient population is not understood. The New York City Department of Health and Mental Hygiene (NYCDOHMH) administered a survey to clinics providing HIV care to people living with HIV (PLWH) in NYC in 2016. Clinics were stratified by quartiles of HIV patient caseload and dichotomized by whether ≥85% (n = 36) or <85% (n = 74) of their patients achieved VLS. Multivariable logistic regression adjusted for confounders of age, sex, ethnicity, and race. Provider to patient ratios (PPR) were calculated for each clinic as staffing full time equivalents per 100 HIV patients.

A novel extended approach under hesitant fuzzy sets to design a framework for assessing the key challenges of digital health interventions adoption during the COVID-19 outbreak

In recent years, Digital Technologies (DTs) are becoming an inseparable part of human lives. Thus, many scholars have conducted research to develop new tools and applications. Processing information, usually in the form of binary code, is the main task in DTs, which is happening through many devices, including computers, smartphones, robots, and applications. Surprisingly, the role of DTs has been highlighted in people's life due to the COVID-19 pandemic. There are several different challenges to implement and intervene in DTs during the COVID-19 outbreak; therefore, the present study extended a new fuzzy approach under Hesitant Fuzzy Set (HFS) approach using Stepwise Weight Assessment Ratio Analysis (SWARA) and Weighted Aggregated Sum Product Assessment (WASPAS) method to evaluate and rank the critical challenges of DTs intervention to control the COVID-19 outbreak. In this regard, a comprehensive survey using literature and in-depth interviews have been carried out to identify the challenges under the SWOT (Strengths, Weaknesses, Opportunities, Threats) framework. Moreover, the SWARA procedure is applied to analyze and assess the challenges to DTs intervention during the COVID-19 outbreak, and the WASPAS approach is utilized to rank the DTs under hesitant fuzzy sets. Further, to demonstrate the efficacy and practicability of the developed framework, an illustrative case study has been analyzed. The results of this study found that Health Information Systems (HIS) was ranked as the first factor among other factors followed by a lack of digital knowledge, digital stratification, economic interventions, lack of reliable data, and cost inefficiency In conclusion, to confirm the steadiness and strength of the proposed framework, the obtained outputs are compared with other methods.

Effectiveness of interventions for adherence to antiretroviral therapy in adults with HIV: a systematic review

OBJECTIVE

To identify the best available evidence of intervention effectiveness for adherence to antiretroviral therapy for HIV in adults.

METHOD

The methodology proposed by the Cochrane Collaboration was used, with search in the databases: PubMed, Embase, LILACS, CINAHL, Web of Science and SCOPUS. Randomized clinical trials of interventions to promote adherence to antiretroviral therapy for HIV, in the ≥ 18-year-old population, published from 2010 onward, were considered. The eligibility, inclusion and extraction of results were developed by two independent researchers.

RESULTS

The five studies included in the quantitative analysis were effective interventions that developed educational actions with the patient, especially mediated by software, the use of medication schedule reminders and the inclusion of treatment supporters that also received educational actions to develop such role.

CONCLUSION

The combination of interventions strengthens the promotion of adherence. There is a need for investment in the implementation of educational actions with patients, such as the inclusion of supporters, in addition to counseling and electronic devices for reminders, which must be offered in the services in an articulated and continuous manner.

Antiretroviral Therapy (ART)-related Knowledge Seeking among People Living with HIV (PLHIV) in China: Role of Information & Communication Technology (ICT)

This paper investigated the use of information communication technology (ICT) to seek antiretroviral therapy (ART)-related knowledge among people living with HIV (PLHIV) taking antiretroviral treatment in Guangxi, China. A total 1902 participants who undertook ART and had used ICT were recruited from 12 sites with the highest cumulative HIV incidence. A questionnaire survey was used to collect data on the participants’ sociodemographic characteristics, clinical outcomes, infections in the family and comorbidity, access to healthcare resources, ICT using behavior in HIV management, and ART-related knowledge. The results showed that 15% of the participants had searched HIV-related information online, fewer participants had contacted healthcare providers via computer (1.6%) or text messaging (11.9%), and only 7.7% of the participants had contacted other PLHIV using ICT. Education had a positive impact on the knowledge level of all three categories of ART-related knowledge. Participants with better medication and mechanisms knowledge were more likely to search HIV-related information online and less likely to contact healthcare providers using text messages. Findings of this study suggested that ICT was used as an effective approach to acquire some type of ART-related knowledge. ICT was underutilized in health communication among the PLHIV in this study due to low education level and insufficient eHealth literacy. Future intervention programs should address the customization of the communication tools and focus on improving the education level and eHealth literacy of the PLHIV to better promote ICT as an efficient platform for ART-related knowledge seeking.

Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1

OBJECTIVES

We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care.

METHODS

We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis.

RESULTS

We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care.

CONCLUSIONS

Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.

Economic and epidemiological evaluation of text message-based interventions in patients with the Human Immunodeficiency Virus

OBJECTIVE

to evaluate the cost-effectiveness ratio and the budget impact of sending text messages associated with medical consultations in order to reduce the viral load of patients infected with the Human Immunodeficiency Virus.

METHOD

a randomized clinical trial, basis for the development of a dynamic cohort model with Markov states in order to compare medical appointments for adults infected with the Human Immunodeficiency Virus versus the alternative strategy that associated medical consultations to sending text messages through telephone.

RESULTS

156 adults participated in the study. As for the viral load, it was verified that in the control group there was an increase, in the intervention group A (weekly messages) there was a reduction (p = 0.002) and in group B (biweekly messages) there was no statistically significant difference. Sending text messages would prevent 286,538 new infections by the Human Immunodeficiency Virus and 282 deaths in the 20-year period, compared to the standard treatment. The alternative strategy would result in saving R$ 14 billion in treatment costs.

CONCLUSION

weekly sending messages in association with the standard treatment can reduce the circulating viral load due to its effect in decreasing new infections, in addition to reducing health costs.

Bibliometric Study of Technology and Occupational Health in Healthcare Sector: A Worldwide Trend to the Future

Since the eighties, technological tools have modified how people interact in their environment. At the same time, occupational safety and health measures have been widely applied. The European Agency for Safety and Health at Work considers that information and communication technologies are the main methods to achieve the goals proposed to improve working life and the dissemination of good practices. The principal objective was to determine the trends of publications focused on these technologies and occupational safety in the healthcare sector during the last 30 years. A bibliometric study was carried out. The 1021 documents showed an increased trend per country, especially for the United States (p < 0.001) and year (p < 0.001). The citations per year showed significant differences between citations of articles published before 2007 (p < 0.001). The year was also linked to the increase or decrease of articles (72.2%) and reviews (14.9%) (p < 0.001). The analysis of journal co-citations also showed that the main journals (such as Infection Control and Hospital Epidemiology) were linked to other important journals and had a major part in the clusters formed. All these findings were discussed in the manuscript and conclusions were drawn.

Evidences on the effectiveness of text messages in the adherence to antiretroviral therapy in adults

ABSTRACT Objective: To analyze the evidence available in the literature on the effectiveness of text messages in the adherence to antiretroviral therapy in adults. Method: Integrative review. The search for primary studies was carried out in MEDLINE/PubMed, Web of Science, CINAHL, LILACS, and SCOPUS and the sample consisted of 18 studies, in April 2019, with no time delimitation. Results: The synthesis of the evidences indicated that, of the 18 analyzed articles, 11 showed an increase in the adherence rates to antiretroviral therapy and an increase in CD4, after using text messages. Conclusion: Text messages are an important tool for health education and the synthesis of knowledge can help nurses to obtain increasingly substantive adherence rates in relation to antiretroviral therapy.

GoPerio - impact of a personalized video and an automated two-way text-messaging system in oral hygiene motivation: study protocol for a randomized controlled trial

Background

Oral hygiene is of paramount importance for the preservation of oral health, and for patients affected by periodontal disease establishing an effective oral hygiene routine is the first step of therapy. Several clinical frameworks have been developed to foster behavior change, such as motivational interviewing. However, two obstacles can be identified. First, patients tend to forget the advice they were given during the consultation. Second, it is hard to maintain motivation in the long term, thus leading to relapse. An innovative eHealth solution was designed with the aim to tackle both obstacles and supplement the current clinical standard of care. The primary objective is to compare the full mouth plaque scores of study groups (eHealth plus standard of care versus standard of care only) at 8 weeks of follow up. The main secondary objective is to compare the full mouth bleeding score at 8 weeks of follow up.

Methods/design

The “GoPerio” study is a multicenter, randomized, controlled trial assessing the impact of a novel eHealth concept for oral hygiene motivation (personalized video of oral hygiene routine available for the patient via a cloud server plus interactive text messages) in addition to the current standard of care (motivational interviewing plus tooth scaling and polishing). The minimum sample size required is 86 patients. Participants will be randomized (allocation ratio 1:1): test group (eHealth plus standard of care) versus control group (standard of care only). The primary outcome is oral hygiene as measured by the full mouth (six sites per tooth) plaque control record (PCR) index. The main secondary outcome is gingival inflammation as measured by the full mouth (six sites per tooth) bleeding on probing (BOP) index. Both the primary and the main secondary outcomes are evaluated by blinded and calibrated examiners at 8 weeks of follow up. The other secondary outcomes are patient satisfaction and patient behavior change and motivation.

Discussion

The study will investigate the value of an innovative eHealth approach to strengthen patient motivation for oral hygiene. If proven effective, such an approach would supplement the current clinical standard of care, resulting in improved clinical outcomes with negligible impact on productivity in a dental practice.

Trial registration

ClinicalTrials.gov, NCT03109808. Registered on 12 April 2017.

Sponsor: Hospices Civils de Lyon. BP 2251, 3 quai des Célestins, 69,229 Lyon cedex 02.

Protocol version: 1.0 as of 21 September 2016.

Analysis of Systematic Reviews of Medication Adherence Interventions for Persons with HIV, 1996-2017

This overview of reviews summarizes the evidence from systematic reviews (SR) on the effectiveness of antiretroviral therapy (ART) adherence interventions for people with HIV (PWH) and descriptively compares adherence interventions among key populations. Relevant articles published during 1996-2017 were identified by comprehensive searches of CDC's HIV/acquired immunodeficiency syndrome (AIDS) Prevention Research Synthesis Database and manual searches. Included SRs examined primary interventions intended to improve ART adherence, focused on PWH, and assessed medication adherence or biologic outcomes (e.g., viral load). We synthesized the qualitative data and used the Assessment of Multiple Systematic Reviews (AMSTAR) for quality assessment. Forty-one SRs met inclusion criteria. Average quality was high. SRs that evaluated text-messaging interventions (n = 9) consistently reported statistically significant improvements in adherence and biologic outcomes. Other ART adherence strategies [e.g., behavioral, directly administered antiretroviral therapy (DAART)] reported improvements, but did not report significant effects for both outcomes, or intervention effects that did not persist postintervention. In the review focused on people who inject drugs (n = 1), DAART alone or in combination with medication-assisted therapy improved both outcomes. In SRs focused on children or adolescents aged <18 years (n = 5), regimen-related and hospital-based DAART improved biologic outcomes. ART adherence interventions (e.g., text-messaging) improved adherence and biologic outcomes; however, results differed for other intervention strategies, populations, and outcomes. Because few SRs reported evidence for populations at high risk (e.g., men who have sex with men), the results are not generalizable to all PWH. Future implementation studies are needed to examine medication adherence interventions in specific populations and address the identified gaps.

A Bibliometric Analysis of the Health Field Regarding Social Networks and Young People

Social networks have historically been used to share information and support regarding health-related topics, and this usage has increased with the rise of online social media. Young people are high users of social media, both as passive listeners and as active contributors. This study aimed to map the trends in publications focused on social networks, health, and young people over the last 40 years. Scopus and the program VOSviewer were used to map the frequency of the publications, keywords, and clusters of researchers active in the field internationally. A structured keyword search using the Scopus database yielded 11,966 publications. The results reveal a long history of research on social networks, health, and young people. Research articles were the most common type of publication (68%), most of which described quantitative studies (82%). The main discipline represented in this literature was medicine, with 6062 documents. North American researchers dominate the field, both as authors and partners in international research collaborations. The present article adds to the literature by elucidating the growing importance of social networks in health research as a topic of study. This may help to inform future investments in public health research and surveillance using these novel data sources.

Electronic Health Interventions to Improve Adherence to Antiretroviral Therapy in People Living With HIV: Systematic Review and Meta-Analysis

BACKGROUND

Electronic health (eHealth) is increasingly used for self-management and service delivery of HIV-related diseases. With the publication of studies increasingly focusing on antiretroviral therapy (ART) adherence, this makes it possible to quantitatively and systematically assess the effectiveness and feasibility of eHealth interventions.

OBJECTIVE

The purpose of this review was to explore the effectiveness of eHealth interventions on improving ART adherence in people living with HIV. The effects of different intervention characteristics, participant characteristics, and study characteristics were also assessed.

METHODS

We systematically searched MEDLINE (via PubMed), EMBASE, the Cochrane Central Register of Controlled Trials, and 3 conference abstract databases using search terms related to HIV, ART, adherence, and eHealth interventions. We independently screened the studies, extracted the data, and assessed the study quality and then compared the information in pairs. Articles published in English that used randomized controlled trials to assess eHealth interventions to improve ART adherence of people living with HIV were identified. We extracted the data including study characteristics, participant characteristics, intervention characteristics, and outcome measures. The Cochrane risk-of-bias tool was used to assess the risk of bias and study overall quality. Odds ratios, Cohen d, and their 95% CIs were estimated using random-effects models. We also performed multiple subgroup analyses and sensitivity analyses to define any sources of heterogeneity.

RESULTS

Among 3941 articles identified, a total of 19 studies (including 21 trials) met the inclusion criteria. We found 8 trials from high-income countries and 13 trials from low- and middle-income countries. Furthermore, at baseline, the health status of participants in 14 trials was healthy. Of the trials included, 7 of 21 used personality content, 12 of 21 used a 2-way communication strategy, and 7 of 21 used medical content. In the pooled analysis of 3937 participants (mean age: 35 years; 47.16%, 1857/3937 females), eHealth interventions significantly improved the ART adherence of people living with HIV (pooled Cohen d=0.25; 95% CI 0.05 to 0.46; P=.01). The interventions were also correlated with improved biochemical outcomes reported by 11 trials (pooled Cohen d=0.25; 95% CI 0.11 to 0.38; P<.001). The effect was sensitive to sample size (Q=5.56; P=.02) and study duration (Q=8.89; P=.003), but it could not be explained by other moderators. The primary meta-analysis result was stable in the 3 sensitivity analyses.

CONCLUSIONS

Some of the eHealth interventions may be used as an effective method to increase the ART adherence of people living with HIV. Considering that most of the trials included a small sample size and were conducted for a short duration, these results should be interpreted with caution. Future studies need to determine the features of eHealth interventions to better improve ART adherence along with long-term effectiveness of interventions, effectiveness of real-time adherence monitoring, enhancement of study design, and influences on biochemical outcomes.

Instant messaging application for the care of people living with HIV/aids

OBJECTIVE

To assess a specific instant messaging application as a tool of care for people living with HIV/aids, based on analysis of the interactions between nurse and patients.

METHOD

Descriptive, quantitative study with 102 patients from two outpatient infectious disease clinics of Fortaleza, Ceará. During four months, participants received a message every 15 days, totaling eight messages, regarding: adherence to antiretroviral therapy; physical activity; social support; self-esteem; anxiety/depression; eating habits; alcohol and drugs; and sexuality.

RESULTS

There were 816 interactions, especially for dialogs about performing physical activity (27.87%), sharing of signs and symptoms (18.03%), report of engagement with treatment (9.84%) and requests of information on the intake of medicine (9.84%). Most participants showed satisfaction with the follow-up, with willingness to continue receiving messages (90.58%).

CONCLUSION

The use of this application is a viable strategy to improve care for people with HIV by promoting instant communication.

Patient Perceptions of Text Messaging to Improve Antiretroviral Therapy Adherence: A Qualitative Study of Patients in a Ryan White Clinic

Evidence on the use of short message service (SMS) to improve medication adherence in people living with HIV (PLHIV) is mounting, yet qualitative research on patient perceptions regarding SMS content and utility for HIV/AIDS remains nascent. To explore the experience of receiving medication reminders via SMS among PLHIV, 45 uninsured and underinsured PLHIV nested within the intervention arm of a larger study received daily, 1-way SMS adherence reminders. Qualitative data were collected by face-to-face, structured interview and were analyzed using conventional content analysis methods. Three main themes emerged from the data: (1) reminders helping with adherence, (2) concerns about delivery modes, and (3) the need for confidentiality. Study findings offer enhanced focus on an emerging strategy in patient-centered HIV care: Equipped with greater context on the experiences of PLHIV using SMS adherence reminders, health-care providers can offer more targeted support and thereby maximize the benefits of this popular and powerful technology.

Design, validation and testing of short text messages for an HIV mobile-health intervention to improve antiretroviral treatment adherence in Mexico

Mobile Health (mHealth) interventions have become effective strategies to increase adherence to antiretroviral treatment (ART) in people living with HIV (PLWH). mHealth interventions use phone calls, e-mails, smartphone apps or short text messages (SMS) as reminders of medical appointments or ART adherence. SMS are a highly accepted mHealth strategy. Systematized processes to validate SMS tailored to end-user preferences are required to increase the effectiveness of mHealth interventions. We describe a structured approach to develop a set of SMS tailored to Mexican HIV+ individuals, focused on improving ART adherence and healthcare appointments. The process included three sequential phases: SMS design by HIV-healthcare professionals, validation by expert referees, and testing by PLWH. A set of 108 SMS in four categories (motivational self-healthcare messages, ART-collection, medical and laboratory-appointment reminders) was designed. Expert referees assessed 94.5% of messages as adequate, 65.7% as useful. Seventy-one SMS were further tested by PLWH, who considered 100% of SMS to be understandable and 57.7% useful. SMS had adequate intra-judge agreement scores for clarity and acceptability (ICC-2 = .08-.49). Qualitative feedback from expert referees and PLWH was incorporated into SMS. A final set of 41 highest-rated SMS was obtained. Careful validation of SMS could increase the effectiveness of mHealth interventions.

Effectiveness of a Viral Load Suppression Intervention for Highly Vulnerable People Living with HIV

We examine the effect of the Undetectables Intervention (UI) on viral loads among socially vulnerable HIV-positive clients. The UI utilized a toolkit that included financial incentives, graphic novels, and community-based case management services. A pre-post repeated measures analysis (n = 502) through 4 years examined longitudinal effects of the intervention. Logistic models regressed social determinants on viral loads. Finally, in-depth qualitative interviews (n = 30) examined how UI shaped adherence. The proportion of virally suppressed time-points increased 15% (from 67 to 82% pre to post-enrollment, p < 0.0001). The proportion of the sample virally suppressed at all time-points increased by 23% (from 39 to 62% pre to post-enrollment, p < 0.0001). African Americans and the homeless were the most likely to be unsuppressed at baseline, but, along with substance users, benefitted the most from UI. The intervention shaped adherence through two pathways, by: (1) establishing worth around adherence, and (2) increasing motivation to become suppressed, and maintain adherence.

Racial, Ethnic, and Socioeconomic Disparities in Web-Based Patient Portal Usage Among Kidney and Liver Transplant Recipients: Cross-Sectional Study

BACKGROUND

Kidney and liver transplant recipients must manage a complex care regimen after kidney transplant. Although the use of Web-based patient portals is known to improve patient-provider communication and health outcomes in chronic disease populations by helping patients manage posttransplant care, disparities in access to and use of portals have been reported. Little is known about portal usage and disparities among kidney and liver transplant recipients.

OBJECTIVE

The aim of this study was to examine patient racial/ethnic, socioeconomic, and clinical characteristics associated with portal usage among kidney and liver transplant recipients.

METHODS

The study included all adult kidney and liver transplant recipients (n=710) at a large academic transplant center in the Southeastern United States between March 2014 and November 2016. Electronic medical record data were linked with Cerner portal usage data. Patient portal use was defined as any portal activity (vs no activity) recorded in the Cerner Web-based portal, including viewing of health records, lab results, medication lists, and the use of secure messaging. Multivariable log-binomial regression was used to determine the patient demographic, clinical, and socioeconomic characteristics associated with portal usage, stratified by organ.

RESULTS

Among 710 transplant recipients (n=455 kidney, n=255 liver), 55.4% (252/455) of kidney recipients and 48.2% (123/255) of liver recipients used the patient portal. Black patients were less likely to use the portal versus white patients among both kidney (57% black vs 74% white) and liver (28% black vs 55% white) transplant recipients. In adjusted multivariable analyses, kidney transplant recipients were more likely to use the portal if they had higher education; among liver recipients, patients who were white versus black and had higher education were more likely to use the portal.

CONCLUSIONS

Despite studies showing that patient portals have the potential to benefit transplant recipients as a tool for health management, racial and socioeconomic disparities should be considered before widespread implementation. Transplant centers should include portal training and support to all patients to encourage use, given its potential to improve outcomes.

Improving the assessment of medication adherence: Challenges and considerations with a focus on low-resource settings

Improving patient survival and quality of life in chronic diseases requires prolonged and often lifelong medication intake. Less than half of patients with chronic diseases globally are adherent to their prescribed medications which preclude the full benefit of treatment, worsens therapeutic outcomes, accelerates disease progression, and causes enormous economic losses. The accurate assessment of medication adherence is pivotal for both researchers and clinicians. Medication adherence can be assessed through both direct and indirect measures. Indirect measures include both subjective (self-report measures such as questionnaire and interview) and objective (pill count and secondary database analysis) measures and constitute the mainstay of assessing medication adherence. However, the lack of an inexpensive, ubiquitous, universal gold standard for assessment of medication adherence emphasizes the need to utilize a combination of measures to differentiate adherent and nonadherent patients. The global heterogeneity in health systems precludes the development of a universal guideline for evaluating medication adherence. Methods based on the secondary database analysis are mostly ineffectual in low-resource settings lacking electronic pharmacy and insurance databases and allowing refills without updated, valid prescriptions from private pharmacies. This significantly restricts the choices for assessing adherence until digitization of medical data takes root in much of the developing world. Nevertheless, there is ample scope for improving self-report measures of adherence. Effective interview techniques, especially accounting for suboptimal patient health literacy, validation of adherence questionnaires, and avoiding conceptual fallacies in reporting adherence can improve the assessment of medication adherence and promote understanding of its causal factors.

Adherence Connection for Counseling, Education, and Support: Research Protocol for a Proof-of-Concept Study

Background

The highest rates of new HIV infections are observed in African Americans and Hispanics/Latinos (ethnic minority) adolescents and young adults (youth). HIV-infected ethnic minority youth are less likely to initiate and maintain adherence to antiretroviral treatment (ART) and medical care, as compared with their adult counterparts.

Objective

The objective of this research protocol was to describe our proposed methods for testing a peer-led mobile health cognitive behavioral intervention, delivered via remote videoconferencing and smartphones with HIV-infected ethnic minority youth, Adherence Connection for Counseling, Education, and Support (ACCESS). Our secondary aim was to obtain initial estimates of the biobehavioral impact of ACCESS on HIV virologic outcomes and self-reported ART adherence, beliefs and knowledge about ART treatment, adherence self-efficacy, and health care utilization (retention in care).

Methods

An exploratory, sequential mixed-methods study design will be used with conceptual determinants of adherence behavior informed by the information-motivation-behavioral skills model. HIV-infected ethnic minority youth aged 16 to 29 years with a detectable HIV serum viral load of more than 200 copies/ml (N=25) will be recruited. Qualitative pretesting will be conducted, including semistructured, in-depth, individual interviews with a convenience sample meeting the study inclusion criteria. Preliminary analysis of qualitative data will be used to inform and tailor the ACCESS intervention. Testing and implementation will include a one-group pre-posttest pilot, delivered by a trained successful peer health coach who lives with HIV and is well-engaged in HIV care and taking ART. A total of 5 peer-led remote videoconferencing sessions will be delivered using study-funded smartphones and targeting adherence information (HIV knowledge), motivation (beliefs and perceptions), and behavioral skills (self-efficacy). Participant satisfaction will be assessed with poststudy focus groups and quantitative survey methodology. Bivariate analyses will be computed to compare pre- and postintervention changes in HIV biomarkers, self-reported ART adherence, beliefs and knowledge about ART, adherence self-efficacy, and retention in care.

Results

As of December 2018, we are in the data analysis phase of this pilot and anticipate completion with dissemination of final study findings by spring/summer 2019. The major outcomes will include intervention feasibility, acceptability, and preliminary evidence of impact on serum HIV RNA quantitative viral load (primary adherence outcome variable). Self-reported ART adherence and retention in care will be assessed as secondary outcomes. Findings from the qualitative pretesting will contribute to an improved understanding of adherence behavior.

Conclusions

Should the ACCESS intervention prove feasible and acceptable, this research protocol will contribute to a shift in existent HIV research paradigms by offering a blueprint for technology-enabled peer-led interventions and models.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12543

Understanding Women's Willingness to Use e-Health for HIV-Related Services: A Novel Application of the Technology Readiness and Acceptance Model to a Highly Stigmatized Medical Condition

Background: E-health may expand access to effective behavioral interventions for women living with HIV (WLH), and others living with a highly stigmatized medical condition. Introduction: Theory may help us to understand e-health program uptake. This mixed methods study examined theoretical applications of the Technology Readiness and Acceptance Model (TRAM) to predict willingness to take part in an e-health videoconferencing group program (i.e., participants interacting with each other in real time via videoconferencing) among a group of WLH. Materials and Methods: Women were recruited from HIV/AIDS clinics in an urban area of the southeastern United States. Each participant completed a structured interview. Data were analyzed using a parallel convergent mixed methods design. Results: Participants (N = 91) had a mean age of 43 years and were primarily African American (66%). Despite limited experience with videoconferencing (14.3%), many (71%) reported willingness to attend an intervention via video group for WLH. Qualitative analysis revealed that the constructs of the TRAM (Innovativeness, Optimism, Discomfort, Insecurity, Perceived Usefulness, or Perceived Ease-of-Use) were evident; however, additional mediating factors specific to WLH emerged, including group readiness and HIV-related privacy concerns. Discussion: Group readiness and privacy concerns may be important considerations when applying the TRAM to technology-based group programs for highly stigmatized populations, including WLH. Conclusions: Existing theoretical frameworks may be useful in understanding the willingness of people to take part in group-based e-health interventions, but may need to be modified to account for the role of stigma in e-health program uptake.

Resilience after withdrawing a technology-based medication adherence support intervention from people living with HIV in rural Uganda

Technology-based interventions for behavior change, such as adherence monitors and SMS text messages, can improve adherence to HIV antiretroviral therapy. It is unclear, however, how the effects of such interventions are maintained when interventions are withdrawn. We explored resiliency of people living with HIV in coping with adherence to antiretroviral therapy (ART) after withdrawing an adherence support intervention of real-time adherence monitors linked to SMS text messages at study closure. This is a qualitative study conducted with former participants of a pilot randomized controlled trial after study closure. Between April 2016 and November 2016, we used convenient sampling to interview 28 of the 62 participants from the pilot trial, which was conducted in rural Uganda. Interviews elicited information on experiences of taking ART in the absence of the intervention, coping strategies, and changes in social support interactions. Data were analyzed inductively using content analysis. Most participants demonstrated resilience through learning adherence from the intervention; and internalizing the habit of medication adherence. They seemed to have a sense of self-esteem, positive thinking, and access to supportive relationships. Other participants employed adaptive coping strategies, such as using alternative cues (e.g., alarms), accessing spiritual support, and adjusting their medication time to their routine. A few participants lacked resiliency, lost the habit and struggled with adherence. They were dependent on the intervention, appeared isolated and psychologically stressed, and were unable to overcome challenges associated with poor social support systems. Intervention-related benefits may or may not persist after the intervention is withdrawn. Contingent on individuals" underlying characteristics and relationships, participants manifested resiliency through learning and internalization, as well as using alternative coping strategies. Such resiliency could facilitate the use of short-term interventions, which are particularly important for resource-limited settings. Participants should be referred to available additional support at study closure when needed.

Web-Based Tailored Intervention to Support Optimal Medication Adherence Among Kidney Transplant Recipients: Pilot Parallel-Group Randomized Controlled Trial

Background

Optimal immunosuppressive medication adherence is essential to graft survival. Transplant-TAVIE is a Web-based tailored intervention developed to promote this adherence.

Objective

The objective of our study was to evaluate the Transplant-TAVIE intervention’s acceptability, feasibility, and preliminary efficacy.

Methods

In a pilot, parallel-group, randomized controlled trial, we randomly assigned a convenience sample of 70 kidney transplant patients on immunosuppressive medication either to an experimental group (Transplant-TAVIE) or to a control group (existing websites). Kidney transplant recipients had to be older than 18 years, be taking immunosuppressant medication, and have access to the internet to participate in this study. Transplant-TAVIE was composed of three interactive Web-based sessions hosted by a virtual nurse. We documented user appreciation of and exposure to the intervention. Furthermore, we assessed medication adherence, medication self-efficacy, intake-related skills, and medication side effects at baseline and 3 and 6 months later. Analyses of variance were used to assess intergroup differences over time.

Results

After baseline questionnaire completion, participants were randomly assigned either to Transplant-TAVIE (n=35) or to the websites (n=35) group. All participants had received their kidney graft <1 year to 32 years earlier (mean 6.8 years). Of the experimental group, 54% (19/35) completed the sessions of Transplant-TAVIE. Users found the intervention to be acceptable—33% were extremely satisfied (6/18), 39% were very satisfied (7/18), and 28% were satisfied (5/18). At baseline and over time, both experimental and control groups reported high medication adherence, high medication self-efficacy, and frequent use of skills related to medication intake. No intergroup differences emerged over time.

Conclusions

The results of this study support the feasibility and acceptability of Transplant-TAVIE. It could constitute an accessible adjunct in support of existing specialized services.

Use of the Whatsapp application in health follow-up of people with HIV: a thematic analysis

Abstract Objective: To investigate the statements of people living with HIV during a health follow-up through the WhatsApp® application. Methods: A descriptive study, using a qualitative approach, was conducted with 26 people accompanied by two specialized care services for HIV/AIDS in Fortaleza, Ceará. Data were collected from September 2016 to February 2017, with participants' statements given during the online follow-up and submitted to thematic content analysis. Results: The following categories emerged: difficulties with treatment, antiretroviral dose delayed or missed, side effects, association between antiretroviral drugs and alcohol, use of dietary supplements and medicines, emotional changes, life habits, social rights, physical symptoms, and coping with and committing to with treatment. Conclusion: Follow-up over WhatsApp® improved access to health professionals, by providing an open and immediate communication channel.

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

OBJECTIVE

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

DESIGN

Systematic review.

SETTING/PARTICIPANTS

All settings/all participants.

INTERVENTION

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

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility, acceptability, impact.

METHODS

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

RESULTS

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

CONCLUSION

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

The effectiveness of daily SMS reminders in pharmaceutical care of older adults on improving patients' adherence to antihypertensive medication (SPPA): study protocol for a randomized controlled trial

BACKGROUND

Despite a variety of efficient and cost-effective antihypertensive medication, hypertension remains a serious health and economic burden. High consumption of cardiovascular drugs in the Slovak Republic does result neither in better hypertension control nor in significant decrease in cardiovascular mortality. At the same time, Slovakia has alarmingly low patients' adherence to medication intake. Studies have shown the efficiency of short messaging service (SMS) reminders to improve patients' adherence and health outcomes at low costs. Since SMS is popular among Slovaks, this approach may be feasible also in Slovakia. The primary objective is to assess if daily SMS reminders of antihypertensive medication intake provided by pharmacists in addition to the standard pharmaceutical care increase the proportion of adherent older hypertensive ambulatory patients.

METHODS

The SPPA trial is a pragmatic randomized parallel group (1:1) trial in 300 older hypertensive patients carried out in community pharmacies in Slovakia. Trial pharmacies will be selected from all main regions of Slovakia. Trial intervention comprises daily personalized SMS reminders of medication intake embedded into usual pharmaceutical practice. The primary outcome is a combined adherence endpoint consisting of subjective self-reported medication adherence via the eight-item Morisky Medication Adherence Scale (MMAS-8) and objective pill count rate. Secondary outcomes include: change in the MMAS-8; comparison of adherence rates using pill count; change in systolic blood pressure; and patient satisfaction. Also, direct treatment costs will be evaluated and a cost-effectiveness analysis will be carried out.

DISCUSSION

The SPPA trial engages community pharmacists and mobile health (mHealth) technologies via evidence-based pharmaceutical care to efficiently and cost-effectively addresses current main healthcare challenges: high prevalence of hypertension; overconsumption of cardiovascular medicines; low adherence to medication treatment; and resulting uncontrolled blood pressure. The results may identify new possibilities and capacities in healthcare with low additional costs and high value to patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03105687 . Registered on 07 March 2017.

Validação de mensagens telefônicas para promoção da saúde de pessoas com HIV

Resumo Objetivo Avaliar a opinião de experts sobre o conteúdo de mensagens telefônicas para a promoção da saúde de pessoas vivendo com HIV. Métodos Estudo de desenvolvimento metodológico direcionado à validação de dez mensagens telefônicas, com participação de 11 experts que avaliaram sua clareza e grau de relevância. O índice de validade de conteúdo relativo a cada mensagem foi calculado e estabeleceu-se uma concordância mínima de 75%. Resultados Foram consideradas mensagens claras (79,1%) e muito relevantes (98,2%). O índice de validade de conteúdo geral foi 0,98. Principais alterações sugeridas: inclusão de um questionamento sobre o tema no início de cada mensagem; adequação para uma linguagem mais simples e interativa; substituição de termos específicos e exclusão de palavras ou expressões relacionadas ao HIV. Conclusão Os experts consideraram as mensagens claras e relevantes para a promoção da saúde das pessoas vivendo com HIV.

Impact of Information and Communication Technologies on Nursing Care: Results of an Overview of Systematic Reviews

Background

Information and communication technologies (ICTs) are becoming an impetus for quality health care delivery by nurses. The use of ICTs by nurses can impact their practice, modifying the ways in which they plan, provide, document, and review clinical care.

Objective

An overview of systematic reviews was conducted to develop a broad picture of the dimensions and indicators of nursing care that have the potential to be influenced by the use of ICTs.

Methods

Quantitative, mixed-method, and qualitative reviews that aimed to evaluate the influence of four eHealth domains (eg, management, computerized decision support systems [CDSSs], communication, and information systems) on nursing care were included. We used the nursing care performance framework (NCPF) as an extraction grid and analytical tool. This model illustrates how the interplay between nursing resources and the nursing services can produce changes in patient conditions. The primary outcomes included nurses’ practice environment, nursing processes, professional satisfaction, and nursing-sensitive outcomes. The secondary outcomes included satisfaction or dissatisfaction with ICTs according to nurses’ and patients’ perspectives. Reviews published in English, French, or Spanish from January 1, 1995 to January 15, 2015, were considered.

Results

A total of 5515 titles or abstracts were assessed for eligibility and full-text papers of 72 articles were retrieved for detailed evaluation. It was found that 22 reviews published between 2002 and 2015 met the eligibility criteria. Many nursing care themes (ie, indicators) were influenced by the use of ICTs, including time management; time spent on patient care; documentation time; information quality and access; quality of documentation; knowledge updating and utilization; nurse autonomy; intra and interprofessional collaboration; nurses’ competencies and skills; nurse-patient relationship; assessment, care planning, and evaluation; teaching of patients and families; communication and care coordination; perspectives of the quality of care provided; nurses and patients satisfaction or dissatisfaction with ICTs; patient comfort and quality of life related to care; empowerment; and functional status.

Conclusions

The findings led to the identification of 19 indicators related to nursing care that are impacted by the use of ICTs. To the best of our knowledge, this was the first attempt to apply NCPF in the ICTs’ context. This broad representation could be kept in mind when it will be the time to plan and to implement emerging ICTs in health care settings.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews: CRD42014014762; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014014762 (Archived by WebCite at http://www.webcitation.org/6pIhMLBZh)