A Systematic Review on Promoting Adherence to Antiretroviral Therapy in HIV-infected Patients Using Mobile Phone Technology

Digital health to promote adherence to antiretroviral treatment in patients with HIV/AIDS: Meta review

INTRODUCTION

Digital health or "e-Health" is a set of applications based on Information and Communication Technologies that can be used to promote self-care and medication adherence in patients with chronic diseases. The aim of this study was to carry out a review of systematic reviews (meta-review) on efficacy studies of e-Health interventions to promote adherence to antiretroviral therapy in people living with HIV/AIDS.

METHOD

A review of systematic reviews ("meta-review") was performed using the Medline-PubMed database on efficacy studies of e-Health components to promote adherence to antirretroviral therapy, in patients with HIV/AIDS, proposing a structured search strategy (PICO question). A selection process for systematic reviews was conducted based on inclusion and exclusion criteria. Subsequently, the corresponding data were extracted, and the analysis was accomplished in descriptive tables.

RESULTS

A total of 29 systematic reviews were identified, from which 11 were selected. These reviews comprised 55 randomized controlled therapies with different e-Health interventions and enrolled a total of 15,311 HIV/AIDS patients. Studies included a total of 66 comparisons (experimental group vs. control group) in indirect adherence measurements based on different measurement techniques (36 statistically significant); 21 comparisons of viral load measurements (10 statistically significant); and 8 comparisons of CD4+ cell count measurements (3 statistically significant). m-Health was the most studied component followed by the telephone call and e-Learning.

CONCLUSIONS

Evidence was found that supports that some e-Health interventions are effective in promoting adherence to antirretroviral therapy and improving health outcomes in patients with HIV/AIDS, although it is identified that more studies are needed for more robust evidence.

[Translated article] Digital health for promoting adherence to antiretroviral treatment in patients with HIV/AIDS: A meta-review

INTRODUCTION

Digital health or "e-health" is a set of applications based on information and communication technologies (ICTs) that can be used to promote self-care and medication adherence in patients with chronic diseases. The aim of this study was to carry out a review of systematic reviews (meta-review) on efficacy studies of e-health interventions to promote adherence to antiretroviral therapy (ART) in people living with HIV/AIDS.

METHODOLOGY

A review of systematic reviews ("meta-review") was performed using the Medline-PubMed database on efficacy studies of e-health components to promote adherence to ART, in patients with HIV/AIDS, proposing a structured search strategy (PICO question). A selection process for systematic reviews was conducted based on inclusion and exclusion criteria. Subsequently, the corresponding data were extracted, and the analysis was accomplished in descriptive tables.

RESULTS

A total of 29 systematic reviews were identified, from which 11 were selected. These reviews comprised 55 RCTs with different e-health interventions and enrolled a total of 15,311 HIV/AIDS patients. Studies included a total of 66 comparisons (experimental group vs. control group) in indirect adherence measurements based on different measurement techniques (36 statistically significant); 21 comparisons of viral load (VL) measurements (10 statistically significant); and 8 comparisons of CD4+ cell count measurements (3 statistically significant). m-Health was the most studied component followed by the telephone call and e-learning.

CONCLUSION

Evidence was found that supports that some e-health interventions are effective in promoting adherence to ART and improving health outcomes in patients with HIV/AIDS, although it is identified that more studies are needed for more robust evidence.

Changes in Quality of life Outcomes of Patients with HIV/AIDS Under a Theory-based Mobile Health Intervention

This study examined the effectiveness of a theory-based mHealth intervention on the quality of life (QOL) of people living with HIV. A randomized controlled trial was performed at two outpatient clinics in Hanoi, Vietnam. There were 428 patients with HIV/AIDs in selected clinics and were divided into the intervention arm (receiving HIV-assisted smartphone application and usual care) and the control arm (receiving only usual care). The WHOQOLHIV-BREF instrument was utilized to measure QOL. An intention-to-treat approach using Generalized Linear Mixed Model analysis was performed. The trial showed significant improvements in Physical health, Psychological health, and Level of Dependence among patients in the intervention arm compared to the control arm. However, the Environment and Spirituality/Personal beliefs improvements would require additional interventions, both individual, organizational, or governmental. This study explored the utility of a smartphone mobile application for individuals with HIV, and how the resultant application could improve the overall QOL.

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

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

Feasibility and Acceptability of the Adherence Connection Counseling, Education, and Support (ACCESS) Proof of Concept: A Peer-Led, Mobile Health (mHealth) Cognitive Behavioral Antiretroviral Therapy (ART) Adherence Intervention for HIV-Infected (HIV+) Adolescents and Young Adults (AYA)

Effective antiretroviral therapy (ART) adherence strategies for HIV+ adolescents and young adults (AYA) are needed to prevent HIV-related morbidity, mortality, and onward transmission. In the Adherence Connection for Counseling, Education, and Support (ACCESS) pilot, an exploratory sequential mixed-methods design was used to develop and test a peer-led, mobile health (mHealth) cognitive behavioral ART adherence intervention. HIV+ AYA (ages 16-29 years) with unsuppressed plasma HIV RNA (HIV viral load) were eligible for this five-session intervention directed to improving ART adherence and HIV viral load. A total of 78 peer-led remote videoconferencing sessions (via WebEx) were delivered to 16 participants. High completion rates (97.5%) and client satisfaction scores (mean = 29.13 of 32; SD = 2.45) were observed. Self-reported ART adherence improved (32% increase in doses taken; 95th CI 11.2-53.3) with an annualized average rate of 47.5% (0.28 log10) reduction in HIV viral load. We established proof of concept for the ACCESS peer-led, mHealth cognitive behavioral ART adherence intervention, with promising adherence and virologic outcome data.

[Use of Multiple Methods to Measure Adherence to Antiretroviral Treatment in La Romana, Dominican RepublicMedição da adesão a antirretrovirais com múltiplos métodos em La Romana, República Dominicana]

Objective

To develop a tool that measures levels of adherence to antiretroviral treatment (ART) in resource-poor settings, based on a combination of four methods for measuring adherence.

Methods

Retrospective review of 500 medical records of people living with HIV, randomly selected from October 2017 to January 2020. Adherence to ART was measured by combining four measurement methods (coverage of prescribed ART, ART picked up at pharmacies, viral load, and self-reported adherence). Chi-squared tests were performed with p<0.05 for statistically significant differences and logistic binary regression to identify the probability of optimal and suboptimal adherence. Spearman tests were performed for correlation of categories, and Cronbach's alpha was used to measure the internal consistency of the tool.

Results

We obtained 497 adherence scores. Of these, 307 (61.8%) users qualified as adherent, 141 (28.4%) as semi-adherent, and 49 (9.8%) as non-adherent. A higher probability of optimal adherence was found in groups aged 60 years and older (odds ratio [OR]: 1.6; CI95%: 0.8-3.5), with no difference between men and women (OR: 0.9; CI95%: 0.7-1.4). Spearman's test reported a relationship (r = 0.8) between viral load levels and final score, and Cronbach's alpha yielded modest internal consistency (α = 0.7).

Conclusions

A tool was developed to measure adherence to ART in a resource-poor environment. The tool shows modest levels of internal consistency and a strong correlation between viral load and adherence.

A Scoping Review of Methods Used to Assess Medication Adherence in Patients with Chronic Conditions

BACKGROUND

Medication nonadherence of patients with chronic conditions is a complex phenomenon contributing to increased economic burden and decreased quality of life. Intervention development relies on accurately assessing adherence but no "gold standard" method currently exists.

PURPOSE

The present scoping review aimed to: (a) review and describe current methods of assessing medication adherence (MA) in patients with chronic conditions with the highest nonadherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, hypertension), (b) outline and compare the evidence on the quality indicators between assessment methods (e.g., sensitivity), and (c) provide evidence-based recommendations.

METHODS

PubMed, PsycINFO and Scopus databases were screened, resulting in 62,592 studies of which 71 met criteria and were included.

RESULTS

Twenty-seven self-report and 10 nonself-report measures were identified. The Medication Adherence Report Scale (MARS-5) was found to be the most accurate self-report, whereas electronic monitoring devices such as Medication Event Monitoring System (MEMS) corresponded to the most accurate nonself-report. Higher MA rates were reported when assessed using self-reports compared to nonself-reports, except from pill counts.

CONCLUSIONS

Professionals are advised to use a combination of self-report (like MARS-5) and nonself-report measures (like MEMS) as these were found to be the most accurate and reliable measures. This is the first review examining self and nonself-report methods for MA, across chronic conditions with the highest nonadherence rates and provides evidence-based recommendations. It highlights that MA assessment methods are understudied in certain conditions, like epilepsy. Before selecting a MA measure, professionals are advised to inspect its quality indicators. Feasibility of measures should be explored in future studies as there is presently a lack of evidence.

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

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

Randomized Pilot Study of an Advanced Smart-Pill Bottle as an Adherence Intervention in Patients With HIV on Antiretroviral Treatment

BACKGROUND

Adherence is critical to achieve the benefits of antiretroviral therapy. A smart-pill bottle service that transmits real-time adherence data via cellular networks to a central service and prompts nonadherent patients with phone or text messages may improve adherence.

METHODS

Adults with HIV taking a tenofovir-containing regimen with suboptimal adherence were randomized to adherence counseling ± a smart-pill bottle service for 12 weeks. Tenofovir diphosphate (TFV-DP) levels by dried blood spot, HIV RNA levels, CD4 cell counts, and self-reported adherence were collected.

RESULTS

Sixty-three participants (22% women; 48% black, 25% Latino) were randomized: 30 to the smart-pill bottle (2 of whom were lost to follow-up before the baseline visit), and 33 to control arms. At baseline, 49% of participants had HIV RNA ≤20 copies/mL and 61% reported 100% adherence with ART over 4 days. From baseline to week 12, median TFV-DP levels were +252 and -41 fmol/punch in the bottle and control arms, respectively (P = 0.10). Exploratory exclusion of 3 participants with known or suspected drug-drug interactions found median TFV-DP levels of +278 and -38 fmol/punch, respectively (P = 0.04). There were no differences in study discontinuations, HIV RNA suppression, CD4 cell counts, or self-reported adherence at week 12.

CONCLUSIONS

In a diverse group of participants with suboptimal adherence to ART, the smart-pill bottle service was associated with higher TFV-DP levels.

A mobile health intervention in HIV primary care: supporting patients at risk for ART non-adherence

Mobile health (mHealth) interventions that are integrated in HIV clinical settings to facilitate ongoing patient-provider communication between primary care visits are garnering evidence for their potential in improving HIV outcomes. Rango is an mHealth intervention to support engagement in HIV care and treatment adherence. This study used a single-arm prospective design with baseline and 6-month assessments for pre-post comparisons, as well as a matched patient sample for between-group comparisons to test Rango's preliminary efficacy in increasing viral suppression. The Rango sample (n = 406) was predominantly 50 years of age or older (63%; M = 50.67; SD = 10.97, 23-82), Black/African-American (44%) or Hispanic/Latinx (38%), and male (59%). At baseline, 18% reported missing at least one dose of ART in the prior three days and chart reviews of recent VL showed that nearly 82% of participants were virally suppressed. Overall 95% of the patients enrolled in Rango returned for a medical follow-up visit. Of the 65 unsuppressed patients at baseline who returned for a medical visit, 38 (59%) achieved viral suppression and only 5% of the suppressed group at baseline had an increase in viral load at 6 months despite being at risk for ART non-adherence. While viral suppression was similar between Rango participants and patients receiving treatment as usual over the same time period, it is unknown whether those patients were similarly at risk for non-adherence. Our findings support efforts to formally test this innovative approach in addressing ART non-adherence and viral suppression particularly to reach HIV treatment goals.

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.

mHealth Interventions to Promote Anti-Retroviral Adherence in HIV: Narrative Review

Background

Antiretrovirals (ARVs) are key in the management of HIV. Although no cure exists, ARVs help patients live healthy lives and prevent transmission to others. Adherence to complex regimens is paramount to outcomes and in avoiding the emergence of drug-resistant viruses. The goal of therapy is to reach an undetectable viral load. However, adherence is a common problem, stemming from issues such as mental health, chaotic home situations, and busy work schedules. Mobile health (mHealth) represents a new approach in improving medication adherence, and multiple studies have been performed in this area.

Objective

This study aims to review the current implementation of mHealth in the management of HIV among different groups of patients.

Methods

We used PubMed, Academic Search Elite, and 1 journal database with various search terms to review the current implementation of mHealth in HIV care.

Results

Titles and abstracts were screened, and 61 papers were identified and fully reviewed. The literature was divided into lower- and higher-income nations, as defined by the United Nations. A total of 20 studies with quantitative results were identified, with 10 being text- and SMS-based interventions (the majority of these being in lower-income countries) and 8 being smartphone-based apps (primarily in higher-income countries). The majority of these studies determined whether there was an effect on adherence or biochemical parameters (viral load and CD4 count). Various qualitative studies have also been conducted, and many have focused on determining the specific design of interventions that were successful (frequency of messaging, types of messages, etc) as well as priorities for patients with regard to mHealth interventions.

Conclusions

There seems to be a role of mHealth in the management of HIV in lower-income nations; however, the optimal design of an intervention needs to be delineated. In higher-income countries, where the 2 significant risk factors were injection drugs and men who have sex with men, the benefit was less clear, and more research is needed.

Targeted client communication via mobile devices for improving maternal, neonatal, and child health

BACKGROUND

The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH.

OBJECTIVES

To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second.

MAIN RESULTS

We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences.

AUTHORS' CONCLUSIONS

The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

Targeted client communication via mobile devices for improving sexual and reproductive health

BACKGROUND

The burden of poor sexual and reproductive health (SRH) worldwide is substantial, disproportionately affecting those living in low- and middle-income countries. Targeted client communication (TCC) delivered via mobile devices (MD) (TCCMD) may improve the health behaviours and service use important for sexual and reproductive health.

OBJECTIVES

To assess the effects of TCC via MD on adolescents' knowledge, and on adolescents' and adults' sexual and reproductive health behaviour, health service use, and health and well-being.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials of TCC via MD to improve sexual and reproductive health behaviour, health service use, and health and well-being. Eligible comparators were standard care or no intervention, non-digital TCC, and digital non-targeted communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second. We have presented results separately for adult and adolescent populations, and for each comparison.

MAIN RESULTS

We included 40 trials (27 among adult populations and 13 among adolescent populations) with a total of 26,854 participants. All but one of the trials among adolescent populations were conducted in high-income countries. Trials among adult populations were conducted in a range of high- to low-income countries. Among adolescents, nine interventions were delivered solely through text messages; four interventions tested text messages in combination with another communication channel, such as emails, multimedia messaging, or voice calls; and one intervention used voice calls alone. Among adults, 20 interventions were delivered through text messages; two through a combination of text messages and voice calls; and the rest were delivered through other channels such as voice calls, multimedia messaging, interactive voice response, and instant messaging services. Adolescent populations TCCMD versus standard care TCCMD may increase sexual health knowledge (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.23 to 1.71; low-certainty evidence). TCCMD may modestly increase contraception use (RR 1.19, 95% CI 1.05 to 1.35; low-certainty evidence). The effects on condom use, antiretroviral therapy (ART) adherence, and health service use are uncertain due to very low-certainty evidence. The effects on abortion and STI rates are unknown due to lack of studies. TCCMD versus non-digital TCC (e.g. pamphlets) The effects of TCCMD on behaviour (contraception use, condom use, ART adherence), service use, health and wellbeing (abortion and STI rates) are unknown due to lack of studies for this comparison. TCCMD versus digital non-targeted communication The effects on sexual health knowledge, condom and contraceptive use are uncertain due to very low-certainty evidence. Interventions may increase health service use (attendance for STI/HIV testing, RR 1.61, 95% CI 1.08 to 2.40; low-certainty evidence). The intervention may be beneficial for reducing STI rates (RR 0.61, 95% CI 0.28 to 1.33; low-certainty evidence), but the confidence interval encompasses both benefit and harm. The effects on abortion rates and on ART adherence are unknown due to lack of studies. We are uncertain whether TCCMD results in unintended consequences due to lack of evidence. Adult populations TCCMD versus standard care For health behaviours, TCCMD may modestly increase contraception use at 12 months (RR 1.17, 95% CI 0.92 to 1.48) and may reduce repeat abortion (RR 0.68 95% CI 0.28 to 1.66), though the confidence interval encompasses benefit and harm (low-certainty evidence). The effect on condom use is uncertain. No study measured the impact of this intervention on STI rates. TCCMD may modestly increase ART adherence (RR 1.13, 95% CI 0.97 to 1.32, low-certainty evidence, and standardised mean difference 0.44, 95% CI -0.14 to 1.02, low-certainty evidence). TCCMD may modestly increase health service utilisation (RR 1.17, 95% CI 1.04 to 1.31; low-certainty evidence), but there was substantial heterogeneity (I2 = 85%), with mixed results according to type of service utilisation (i.e. attendance for STI testing; HIV treatment; voluntary male medical circumcision (VMMC); VMMC post-operative visit; post-abortion care). For health and well-being outcomes, there may be little or no effect on CD4 count (mean difference 13.99, 95% CI -8.65 to 36.63; low-certainty evidence) and a slight reduction in virological failure (RR 0.86, 95% CI 0.73 to 1.01; low-certainty evidence). TCCMD versus non-digital TCC No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may modestly increase in service attendance overall (RR: 1.12, 95% CI 0.92-1.35, low certainty evidence), however the confidence interval encompasses benefit and harm. TCCMD versus digital non-targeted communication No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may increase service utilisation overall (RR: 1.71, 95% CI 0.67-4.38, low certainty evidence), however the confidence interval encompasses benefit and harm and there was considerable heterogeneity (I2 = 72%), with mixed results according to type of service utilisation (STI/HIV testing, and VMMC). Few studies reported on unintended consequences. One study reported that a participant withdrew from the intervention as they felt it compromised their undisclosed HIV status.

AUTHORS' CONCLUSIONS

TCCMD may improve some outcomes but the evidence is of low certainty. The effect on most outcomes is uncertain/unknown due to very low certainty evidence or lack of evidence. High quality, adequately powered trials and cost effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCC delivered by mobile devices. Given the sensitivity and stigma associated with sexual and reproductive health future studies should measure unintended consequences, such as partner violence or breaches of confidentiality.

Clinicians' Values and Preferences for Medication Adherence and Cost Clinical Decision Support in Primary Care: A Qualitative Study

BACKGROUND

Medication nonadherence and unaffordability are prevalent, burdensome issues in primary care. In response, technology companies are capitalizing on clinical decision support (CDS) to deliver patient-specific information regarding medication adherence and costs to clinicians using electronic health records (EHRs). To maximize adoption and usability, these CDS tools should be designed with consideration of end users' values and preferences.

OBJECTIVE

This article evaluates primary care clinicians' values and preferences for a medication adherence and cost CDS.

METHODS

We conducted semistructured interviews with primary care clinicians with prescribing privileges and EHR access to identify clinicians' perceptions of and approaches to assessing medication adherence and costs, and to determine perceived values and preferences for medication adherence and cost CDS. Interviews were conducted until saturation of responses was reached. ATLAS.ti was used for thematic analysis.

RESULTS

Among 26 clinicians interviewed, themes identified included a high value, but moderate need for a medication adherence CDS and high value and need for cost CDS. Clinicians expressed the cost CDS would provide actionable solutions and greatly impact patient care. Another theme identified was a desire for medication adherence and cost CDS to be separate tools yet integrated into workflow. The majority of clinicians preferred a medication adherence CDS that integrated claims data and actively displayed data using color-coded adherence categories within patients' medication lists in the EHR. For the cost CDS, clinicians preferred medication out-of-pocket costs and a list of cheaper or payor-preferred alternatives to display within the order queue of the EHR.

CONCLUSION

We identified valuable insights regarding clinician values and preferences for medication adherence and cost CDS. Overall, primary care clinicians feel CDS for medication adherence and cost are valuable and prefer them to be separate. These insights should be used to inform the design, implementation, and EHR integration of future medication and cost CDS tools.

Effectiveness of a Web-Based Intervention to Support Medication Adherence Among People Living With HIV: Web-Based Randomized Controlled Trial

Background

Taking antiretroviral therapy (ART) is part of the daily life of people living with HIV. Different electronic health (eHealth) initiatives adjunctive to usual care have been proposed to support optimal medication adherence. A web-based intervention called HIV Treatment, Virtual Nursing Assistance, and Education or VIH-TAVIE (from its French version Virus de l’immunodéficience humaine-Traitement assistance virtuelle infirmière et enseignement) was developed to empower people living with HIV to manage their ART and symptoms optimally.

Objective

We aimed to evaluate the effectiveness of VIH-TAVIE in a web-based randomized controlled trial (RCT).

Methods

This RCT was entirely web-based, including recruitment, consent granting, questionnaire completion, and intervention exposure (consultation with VIH-TAVIE [experimental group] or websites [control group]). To be eligible for the study, people living with HIV had to be 18 years or older, be on ART for at least 6 months, have internet access, and have internet literacy. Participants were randomly assigned to either the experimental group (n=45) or control group (n=43). The primary outcome was ART adherence. The secondary outcomes included self-efficacy regarding medication intake, symptom-related discomfort, skills and strategies, and social support. All outcomes were measured with a self-administered web-based questionnaire at the following three time points: baseline and 3 and 6 months later. A generalized linear mixed model was built to assess the evolution of ART adherence over time in both groups.

Results

The sample included 88 participants, and of these, 73 (83%) were men. The median age of the participants was 42 years. Participants had been diagnosed with HIV a median of 7 years earlier (IQR 3-17) and had been on ART for a median of 5 years (IQR 2-12). The proportion of treatment-adherent participants at baseline was high in both groups (34/41, 83% in the experimental group and 30/39, 77% in the control group). Participants also reported high treatment adherence, high self-efficacy, and high skills; perceived good social support; and experienced low discomfort from symptoms. Analyses revealed no intergroup difference regarding ART adherence (OR 1.9, 95% CI 0.6-6.4).

Conclusions

This study highlights the challenges and lessons learned from conducting an entirely web-based RCT among people living with HIV. The challenges were related to the engagement of people living with HIV on the following three levels: starting the web-based study (recruitment), completing the web-based intervention (engagement), and continuing the study (retention). The results contribute to the existing body of knowledge regarding how to conduct web-based evaluation studies of eHealth interventions aimed at developing and strengthening personal skills and abilities.

Trial Registration

ClinicalTrials.gov NCT01510340; https://clinicaltrials.gov/ct2/show/NCT01510340

Factors Affecting Patients' Acceptance of and Satisfaction with Cloud-Based Telehealth for Chronic Disease Management: A Case Study in the Workplace

OBJECTIVE

Understanding patients' acceptance of and satisfaction with telehealth use is important for workplace health promotion. In this study, we used a questionnaire to measure patients' usage behavior and satisfaction with cloud-based telehealth services in the workplace. We empirically investigated the factors that influence patients' usage and satisfaction based on data collected from 101 participants.

METHODS

As its main research framework, this study utilized a revised version of the technology acceptance model 2 that was based on the telehealth services provided for chronic disease management. Through integrating a cross-sectional research design with an author-developed structured questionnaire that was assessed using reliability and validity tests, an anonymous survey was conducted on selected participants. The proposed research model and hypotheses were validated through path analysis using SPSS.

RESULTS

We found that users believe telehealth services can promote their workplace health management; that job relevance, result demonstrability, and perceived ease of use (PEOU) positively affect the perceived usefulness (PU), which implies that cognitive instrumental processes have the most significant impact on the PU of cloud-based telehealth; and that both PEOU and PU positively affect the intention to use (IU), but PU has a bigger influence than PEOU on users' intentions to continue using telehealth. In particular, the IU and actual usage behavior were critical to the patients' satisfaction with telehealth services.

CONCLUSION

This research contributes to the rapid developing field of technology acceptance research by examining workplace telemedicine engagement. Our results will provide researchers with useful advice and a user-centered strategy for promoting workplace health management, which benefits both health care providers and corporate managers.

Preliminary Efficacy of a Cognitive Behavioral Therapy Text Messaging Intervention Targeting Alcohol Use and Antiretroviral Therapy Adherence: A Randomized Clinical Trial

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov, NCT02603471.