Acceptability of a mobile health intervention to enhance HIV care coordination for patients with substance use disorders

Experiences of people living with HIV/AIDS in selected hospitals in Imo state, Nigeria, regarding the usability and satisfaction of reminders using M-health features: a qualitative study

HIV presents an ongoing, serious issue within the global public health domain, with prevalence across all nations. Mobile health (m-Health) is the use of mobile and wireless devices to improve health outcomes, health care services, and health research has been shown to have the capacity to improve medication adherence. Good adherence to ART is beneficial to patients and the public. This study aimed to assess the reported usability and satisfaction of m-Health among people living with HIV/AIDS (PLWHA). The study included PLWHA under care at the Federal University Teaching Hospital (FUTH) Owerri who were previously enrolled in m-Health intervention programme. A total of 50 participants were purposefully selected for this study. This descriptive-qualitative study lasted for 3 months. In-depth interviews were conducted with 50 participants who had completed at least 7 weeks since enrolling in the trial. Data results were grouped into five main themes: varying usefulness of the intervention, the need for confidentiality, concerns about delivery modes, reasons for non-compliance, and barriers to attending appointments. Majority of the participants expressed satisfaction with the intervention they received, while some discontinued before the end due to reasons such as faith healing, use of herbal drugs, and fear of disclosure. The study emphasizes the need to integrate m-Health into standard care for PLWHA to enhance adherence to antiretroviral therapy (ART) refill schedules, medication dosage, and timing of intake. Due to the ongoing demand for more diverse and advanced technology, using mobile health to assist PLWHA in adhering to their medication is very feasible. Text messaging, phone calls, and WhatsApp audio notes have been recognized as valuable tools for promoting medication adherence and facilitating timely drug refills. The findings underscored the factors affecting patients' readiness, acceptance, and the barriers to effectively utilizing mobile health solutions for managing adherence challenges. The majority of study participants expressed satisfaction with the ease of use of this m-Health intervention. They reported that it helped them with the timely intake of their medication at the correct dosage, prompt refills, and keeping appointments with healthcare personnel. It is important to integrate m-Health into standard hospital procedures. Future studies should focus on developing an app that automatically tracks medication intake for PLWHA.

How Mobile Health Can Change the Contexts of Living With HIV and Engaging With Treatment and Care in Iran: A Realist-Informed Qualitative Study

Mobile health (mHealth) interventions are increasingly used to address the challenges of living with HIV and engaging with antiretroviral therapy. A wealth of evidence supports the efficacy of mHealth in supporting living with HIV. Yet, there is a dearth of evidence on how mHealth improves outcomes, which features are effective, and why these work in a particular setting. This study uses stakeholder views, including patients, providers, peer supporters, counsellors, and program directors, to conceptualize how specific mHealth features could interact with contexts of living with HIV and mechanisms that shape engagement with treatment. The study is part of an ongoing research project on engagement with HIV care in Iran. We draw on the perspectives of recently diagnosed and more treatment-experienced patients and their providers, using purposive sampling, conducting 9 focus group discussions with a total of 66 participants, in addition to 17 interviews. Our findings suggest that mHealth designs that feature provider connection, proactive care, and privacy and personalization are expected to dilute the harsh contexts of living with HIV. We build on previously identified socioecological pathways that disrupt antiretroviral therapy in Iran and find that mHealth can enhance the relation between the health system and patients. Our findings suggest that personalized mHealth features and provisions can partially mitigate the compounded impacts of harsh socioecological pathways that impede treatment success in Iran. Our social constructivist study was augmented with realist-informed analysis and could have transferability to similar contexts that trigger similar mechanisms of treatment disruption.

mHealth Engagement for Antiretroviral Medication Adherence Among People With HIV and Substance Use Disorders: Observational Study

BACKGROUND

Despite the increasing popularity of mobile health (mHealth) technologies, little is known about which types of mHealth system engagement might affect the maintenance of antiretroviral therapy among people with HIV and substance use disorders.

OBJECTIVE

This study aimed to use longitudinal and detailed system logs and weekly survey data to test a mediation model, where mHealth engagement indicators were treated as predictors, substance use and confidence in HIV management were treated as joint mediators, and antiretroviral therapy adherence was treated as the outcome. We further distinguished the initiation and intensity of system engagement by mode (expression vs reception) and by communication levels (intraindividual vs dyadic vs network).

METHODS

Tailored for people with HIV living with substance use disorders, the mHealth app was distributed among 208 participants aged >18 years from 2 US health clinics. Supervised by medical professionals, participants received weekly surveys through the app to report their health status and medication adherence data. System use was passively collected through the app, operationalized as transformed click-level data, aggregated weekly, and connected to survey responses with a 7-day lagged window. Using the weekly check-in record provided by participants as the unit of analysis (N=681), linear regression and structure equation models with cluster-robust SEs were used for analyses, controlling within-person autocorrelation and group-level error correlations. Racial groups were examined as moderators in the structure equation models.

RESULTS

We found that (1) intensity, not initiation, of system use; (2) dyadic message expression and reception; and (3) network expression positively predicted medication adherence through joint mediators (substance use and confidence in HIV management). However, intraindividual reception (ie, rereading saved entries for personal motivation) negatively predicts medication adherence through joint mediators. We also found Black participants have distinct usage patterns, suggesting the need to tailor mHealth interventions for this subgroup.

CONCLUSIONS

These findings highlight the importance of considering the intensity of system engagement, rather than initiation alone, when designing mHealth interventions for people with HIV and tailoring these systems to Black communities.

Supporting treatment adherence for resilience and thriving (START): protocol for a mHealth randomized controlled trial

BACKGROUND

Although behavioral interventions show some promise for reducing stimulant use and achieving durable viral suppression in sexual minority men (SMM) with HIV, scalable mHealth applications are needed to optimize their reach and cost-effectiveness.

METHODS

Supporting Treatment Adherence for Resilience and Thriving (START) is a randomized controlled trial (RCT) testing the efficacy and cost-effectiveness of a mHealth application that integrates evidence-based positive affect regulation skills with self-monitoring of adherence and mood. The primary outcome is detectable HIV viral load (i.e., > 300 copies/mL) from self-collected dried blood spot (DBS) specimens at 6 months. Secondary outcomes include detectable DBS viral load at 12 months, self-reported stimulant use severity, anti-retroviral therapy (ART) adherence, and positive affect over 12 months. A national sample of up to 250 SMM with HIV who screen positive for stimulant use disorder and reporting suboptimal ART adherence is being recruited via social networking applications through April of 2024. After providing informed consent, participants complete a run-in period (i.e., waiting period) including two baseline assessments with self-report measures and a self-collected DBS sample. Those who complete the run-in period are randomized to either the START mHealth application or access to a website with referrals to HIV care and substance use disorder treatment resources. Participants provide DBS samples at baseline, 6, and 12 months to measure HIV viral load as well as complete self-report measures for secondary outcomes at quarterly follow-up assessments over 12 months.

DISCUSSION

To date, we have paid $117,500 to advertise START on social networking applications and reached 1,970 eligible participants ($59.77 per eligible participant). Although we identified this large national sample of potentially eligible SMM with HIV who screen positive for a stimulant use disorder and report suboptimal ART adherence, only one-in-four have enrolled in the RCT. The run-in period has proven to be crucial for maintaining scientific rigor and reproducibility of this RCT, such that only half of consented participants complete the required study enrollment activities and attended a randomization visit. Taken together, findings will guide adequate resource allocation to achieve randomization targets in future mHealth research SMM with HIV who use stimulants.

TRIAL REGISTRATION

This protocol was registered on clinicaltrials.gov (NCT05140876) on December 2, 2021.

Characteristics of Existing Online Patient Navigation Interventions: Scoping Review

BACKGROUND

Patient navigation interventions (PNIs) can provide personalized support and promote appropriate coordination or continuation of health and social care services. Online PNIs have demonstrated excellent potential for improving patient knowledge, transition readiness, self-efficacy, and use of services. However, the characteristics (ie, intervention type, mode of delivery, duration, frequency, outcomes and outcome measures, underlying theories or mechanisms of change of the intervention, and impact) of existing online PNIs to support the health and social needs of individuals with illness remain unclear.

OBJECTIVE

This scoping review of the existing literature aims to identify the characteristics of existing online PNIs reported in the literature.

METHODS

A scoping review based on the guidelines outlined in the Joanna Briggs Institute framework was conducted. A search for peer-reviewed literature published between 1989 and 2022 on online PNIs was conducted using MEDLINE, CINAHL, Embase, PsycInfo, and Cochrane Library databases. Two independent reviewers conducted 2 levels of screening. Data abstraction was conducted to outline key study characteristics (eg, study design, population, and intervention characteristics). The data were analyzed using descriptive statistics and qualitative content analysis.

RESULTS

A total of 100 studies met the inclusion criteria. Our findings indicate that a variety of study designs are used to describe and evaluate online PNIs, with literature being published between 2003 and 2022 in Western countries. Of these studies, 39 (39%) studies were randomized controlled trials. In addition, we noticed an increase in reported online PNIs since 2019. The majority of studies involved White females with a diagnosis of cancer and a lack of participants aged 70 years or older was observed. Most online PNIs provide support through navigation, self-management and lifestyle changes, counseling, coaching, education, or a combination of support. Variation was noted in terms of mode of delivery, duration, and frequency. Only a small number of studies described theoretical frameworks or change mechanisms to guide intervention.

CONCLUSIONS

To our knowledge, this is the first review to comprehensively synthesize the existing literature on online PNIs, by focusing on the characteristics of interventions and studies in this area. Inconsistency in reporting the country of publication, population characteristics, duration and frequency of interventions, and a lack of the use of underlying theories and working mechanisms to inform intervention development, provide guidance for the reporting of future online PNIs.

"Your Package Could Not Be Delivered": The State of Digital HIV Intervention Implementation in the US

PURPOSE OF REVIEW

Despite continuous innovations and federal investment to create digital interventions addressing the HIV prevention and care continua, these interventions have not reached people in the U.S. at scale. This article reviews what is known about U.S. implementation of digital HIV interventions and presents a strategy to cross the research-to-practice chasm for these types of interventions.

RECENT FINDINGS

We conducted a narrative review of U.S.-based original research on implementation of digital HIV interventions and identified few studies reporting on implementation determinants, strategies, processes, or outcomes, particularly outside the context of effectiveness trials. To supplement the literature, in 2023, we surveyed 47 investigators representing 64 unique interventions about their experiences with implementation after their research trials. Respondents placed high importance on intervention implementation, but major barriers included lack of funding and clear implementation models, technology costs, and difficulty identifying partners equipped to deliver digital interventions. They felt that responsibility for implementation should be shared between intervention developers, deliverers (e.g., clinics), and a government entity. If an implementation center were to exist, most respondents wanted to be available for guidance or technical assistance but largely wanted less involvement. Numerous evidence-based, effective digital interventions exist to address HIV prevention and care. However, they remain "on the shelf" absent a concrete and sustainable model for real-world dissemination and implementation. Based on our findings, we call for the creation of national implementation centers, analogous to those in other health systems, to facilitate digital HIV intervention delivery and accelerate progress toward ending the U.S. epidemic.

Understanding mHealth Adoption and Lifestyle Improvement: An Empirical Test of the Antecedents and Mediating Mechanisms

The potential of using mobile phones for health care service delivery has been well acknowledged. Despite that mobile health (mHealth) related research has proliferated in the past decade, mHealth is still in the fledgling stage with a low adoption rate. There is a research gap in understanding factors influencing mHealth adoption and examining the effects of mHealth use on health outcomes. The purpose of this study was thus to explore influential factors of mHealth use, and test mediation pathways through which mHealth use impacts healthy lifestyle behaviors (e.g. sleep, exercise, and social participation). Survey results from 432 online participants illustrate that performance expectancy, social influence, support conditions, and perceived reliability were significantly associated with mHealth use. However, the impact of effort expectancy on mHealth use was statistically nonsignificant. Moreover, the results indicate that mHealth use can not only contribute to the improvement of healthy lifestyle behaviors directly but also exert an impact through the mediating effect of health competence. Knowing what factors motivate people's mHealth use and how mHealth use contributes to lifestyle improvement can help trigger interventions to boost mHealth adoption and improve public health. Implications and limitations are discussed.

'She showed me a new path, a way forward': exploring how navigation influences mental health among Guatemalan gay and bisexual men living with HIV

Mental health problems, including anxiety and depression, are a common comorbidity among gay, bisexual and other men who have sex with men (GBMSM) living with HIV. Informed by social support theory, health navigation is a strengths-based intervention that has been demonstrated to improve HIV care outcomes. The purpose of this study was to explore how health navigation influences the mental health of GBMSM living with HIV. We analyzed longitudinal qualitative in-depth interviews conducted with GBMSM (n = 29) in a 12-month multi-component intervention to improve HIV care outcomes, including health navigation. We used narrative and thematic analytic approaches to identify salient themes, including if and how themes changed over time. Participants described that navigator support helped them maintain good mental health, prevent crises and respond to crises. Navigator support included providing motivational messaging, facilitating participants' control over their health and improving access to care, which aided with supporting mental health. Navigators also responded to acute crises by providing guidance for those newly diagnosed with HIV and support for those experiencing critical life events. Participants emphasized the importance of feeling heard and valued by their navigators and gaining hope for the future as key to their wellbeing. In conclusion, health navigation may be an effective intervention for promoting mental health among GBMSM living with HIV. Additional research is needed to examine mediating pathways between navigation and mental health, including informational support, or if navigator support moderates the relationship between stressors and mental health outcomes for GBMSM.

Leveraging mHealth and Patient Supporters for African Americans' and Latinxs' Engagement in HIV Care (LEAN): Protocol for a Randomized, Controlled, Effectiveness-Implementation Trial

BACKGROUND

Despite substantial investments in ending the HIV epidemic, disparities in HIV care persist, and there is an urgent need to evaluate novel and scalable approaches to improving HIV care engagement and viral suppression in real-world settings.

OBJECTIVE

This paper aims to describe a study protocol for a pragmatic type II hybrid effectiveness-implementation randomized controlled trial comparing existing standard of care clinic HIV linkage, adherence, and retention (LAR) protocols to a mobile health (mHealth)-enhanced linkage, adherence, and retention (mLAR) intervention.

METHODS

The study will enroll 450 participants from clinics in Baltimore City. Eligibility criteria include being ≥18 years of age, having a new HIV diagnosis or being HIV-positive and out of care, or being HIV-positive and deemed by clinic staff as someone who could benefit from linkage and retention services. Participants randomized to the intervention receive mHealth-supported patient navigation for 12 months. Participants in the control group receive the referring clinic's standard of care patient support. The primary outcome is HIV virologic suppression at 12 months. A subset of participants will be interviewed at 12 months to learn about their HIV care experiences and, for those in the intervention arm, their experiences with the mLAR intervention. This protocol was developed in collaboration with the Baltimore City Health Department (BCHD) and the Maryland Department of Health (MDH) and with input from a community advisory board.

RESULTS

Enrollment began on February 25, 2020. As of August 11, 2022, 411 of the 450 target participants had been enrolled.

CONCLUSIONS

Pragmatic implementation science trials designed with input from key stakeholders, including health departments and community members, can help evaluate the evidence for mHealth interventions to reduce HIV health disparities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03934437; https://clinicaltrials.gov/ct2/show/NCT03934437.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42691.

Examining the Role of Autonomy Support, Goal Setting, and Care Coordination Quality on HIV PrEP Adherence in Black Men Who Have Sex with Men: HPTN 073

Autonomy support is a concept that is derived from self-determination theory. Autonomy refers to the freedom to act as one chooses. The current study aimed to examine if autonomy support was associated with dried blood spot validated pre-exposure prophylaxis (PrEP) adherence, and whether the association was mediated by PrEP adherence goal setting and progress toward PrEP adherence goals. Our sample was drawn from Black men who have sex with men (MSM) from across three cities (Chapel Hill, NC; Los Angeles, CA; and Washington, DC) in the United States between February 2013 and September 2014. We used logistic regression to evaluate associations between study variables and path analysis to test mediation effects. Participants were, on average, 28 [standard deviation (SD) = 1.12] years old and 25% were unemployed. We found that MSM who experienced high autonomy support were more likely to adhere to PrEP [odds ratio (OR) = 1.17; 95% confidence interval: 1.00-1.38]. MSM who set PrEP adherence goals were more likely to adhere to PrEP. Moreover, MSM who reported making progress toward their goals were also more likely to adhere to PrEP. Finally, client perception of coordination quality enhanced the magnitude of the association between goal setting and goal progress and the effect size of goal progress on PrEP adherence. Autonomy support, goal setting, goal monitoring/evaluation, and care coordination quality influenced PrEP adherence among Black MSM. Our findings indicate that while it is important to set goals for PrEP adherence, goal setting may need to be accompanied by progress monitoring to achieve the maximal effect.

Addressing Health Inequities in Digital Clinical Trials: A Review of Challenges and Solutions From the Field of HIV Research

Clinical trials are considered the gold standard for establishing efficacy of health interventions, thus determining which interventions are brought to scale in health care and public health programs. Digital clinical trials, broadly defined as trials that have partial to full integration of technology across implementation, interventions, and/or data collection, are valued for increased efficiencies as well as testing of digitally delivered interventions. Although recent reviews have described the advantages and disadvantages of and provided recommendations for improving scientific rigor in the conduct of digital clinical trials, few to none have investigated how digital clinical trials address the digital divide, whether they are equitably accessible, and if trial outcomes are potentially beneficial only to those with optimal and consistent access to technology. Human immunodeficiency virus (HIV), among other health conditions, disproportionately affects socially and economically marginalized populations, raising questions of whether interventions found to be efficacious in digital clinical trials and subsequently brought to scale will sufficiently and consistently reach and provide benefit to these populations. We reviewed examples from HIV research from across geographic settings to describe how digital clinical trials can either reproduce or mitigate health inequities via the design and implementation of the digital clinical trials and, ultimately, the programs that result. We discuss how digital clinical trials can be intentionally designed to prevent inequities, monitor ongoing access and utilization, and assess for differential impacts among subgroups with diverse technology access and use. These findings can be generalized to many other health fields and are practical considerations for donors, investigators, reviewers, and ethics committees engaged in digital clinical trials.

Internet-based peer support interventions for people living with HIV: A scoping review

Peer support interventions for people living with HIV and AIDS (PLWHA) are effective, but their associated time and material costs for the recipient and the health system make them reachable for only a small proportion of PLWHA. Internet-based interventions are an effective alternative for delivering psychosocial interventions for PLWHA as they are more accessible. Currently, no reviews are focusing on internet-based interventions with peer support components. This scoping review aims to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We conducted a systematic scoping review of academic literature following methodological guidelines for scoping reviews, and 28 articles met our criteria. We summarized the main characteristics of the digital peer support interventions for PLWHA and how they implemented peer support in a virtual environment. Overall the reported outcomes appeared promising, but more robust evidence is needed.

Integrating HIV and substance misuse services: a person-centred approach grounded in human rights

Integrating HIV-related care with treatment for substance use disorder provides an opportunity to better meet the needs of people living with these conditions. People with substance use disorder are rendered especially vulnerable by prevailing policies, structural inequalities, and stigmatisation. In this Series paper we analyse existing literature and empirical evidence from scoping reviews on integration designs for the treatment of HIV and substance use disorder, to understand barriers to and facilitators of care integration and to map ways forward. We discuss how approaches to integration address two core gaps in current models: a failure to consider human rights when incorporating the perspectives of people living with HIV and people who use drugs, and a failure to reflect critically on structural factors that determine risk, vulnerability, health-care seeking, and health equity. We argue that successful integration requires a person-centred approach, which is grounded in human rights, treats both concerns holistically, and reconnects with underlying social, economic, and political inequalities.

Peer Approaches to Improve HIV Care Cascade Outcomes: a Scoping Review Focused on Peer Behavioral Mechanisms

PURPOSE OF REVIEW

There are three main components of peer-based approaches regardless of type: education, social support, and social norms. The purpose of this scoping review was to examine evidence in the literature among peer-based interventions and programs of components and behavioral mechanisms utilized to improve HIV care cascade outcomes.

RECENT FINDINGS

Of 522 articles found, 40 studies were included for data abstraction. The study outcomes represented the entire HIV care cascade from HIV testing to viral suppression. Most were patient navigator models and 8 of the studies included all three components. Social support was the most prevalent component. Role modeling of behaviors was less commonly described. This review highlighted the peer behavioral mechanisms that operate in various types of peer approaches to improve HIV care and outcomes in numerous settings and among diverse populations. The peer-based approach is flexible and commonly used, particularly in resource-poor settings.

What Works Best to Engage Participants in Mobile App Interventions and e-Health: A Scoping Review

Background: Despite the growing popularity of mobile app interventions, specific engagement components of mobile apps have not been well studied. Methods: The objectives of this scoping review are to determine which components of mobile health intervention apps encouraged or hindered engagement, and examine how studies measured engagement. Results: A PubMed search on March 5, 2020 yielded 239 articles that featured the terms engagement, mobile app/mobile health, and adult. After applying exclusion criteria, only 54 studies were included in the final analysis. Discussion: Common app components associated with increased engagement included: personalized content/feedback, data visualization, reminders/push notifications, educational information/material, logging/self-monitoring functions, and goal-setting features. On the other hand, social media integration, social forums, poor app navigation, and technical difficulties appeared to contribute to lower engagement rates or decreased usage. Notably, the review revealed a great variability in how engagement with mobile health apps is measured due to lack of established processes. Conclusion: There is a critical need for controlled studies to provide guidelines and standards to help facilitate engagement and its measurement in research and clinical trial work using mobile health intervention apps.

Informing the future of PrEP navigation: Findings from a five-site cluster evaluation

The PrEP (pre-exposure prophylaxis) Implementation, Data to Care and Evaluation (PrIDE) demonstration project funded 12 health departments (HD) (2016-2019) to scale up PrEP among sexual minorities at risk for HIV. Each health department (HD) conducted an evaluation of at least one local strategy, and, to maximize crossvalidation, an adapted cluster evaluation approach was employed. As a result, five HDs with similar evaluation questions regarding PrEP navigation were identified. Overall, PrEP navigation fit in well with HD clinics and community-based organizations. A hybrid model of patient, peer, and systems navigation linking clients to PrEP and social services was commonly used. Although there were no differences by setting regarding linking clients to PrEP providers, one HD demonstrated that having all PrEP services in the same location contributed the most to PrEP uptake. Navigator skill for case management and rapport building facilitated navigation, whereas staff turnover and lack of client health insurance were challenges. While one HD in a non-Medicaid expansion state was affected by health insurance issues the most, another HD demonstrated that providing payment assistance increased client PrEP use. The findings pinpoint PrEP navigation hybrid modality and having health insurance as promising strategies to increase PrEP uptake among priority groups.

HIV Patient Navigation in the United States: A Qualitative Meta-Synthesis of Navigators' Experiences

Patient navigation is increasingly used to link and (re)engage persons with human immunodeficiency virus (HIV) to care. A more holistic understanding of patient navigation can be achieved by exploring the experiences of navigators, the persons who comprise half of the navigation process. We conducted a meta-synthesis of navigator experiences with HIV patient navigation using a phenomenological approach. We identified nine relevant studies. Data were analyzed using thematic synthesis. Analysis identified two overarching themes relating to (1) the breadth and depth of bidirectional relationships and functional activities that navigators undertake to connect their clients to care and (2) the inherently personal experience of delivering navigation services. From these thematic findings, we recommend that HIV patient navigators exhibit capacity and expertise in developing and maintaining interpersonal relationships with clients and health care systems/providers and develop self-care practices and emotional boundaries with clients. Our review seeks to advance public health research and practice by articulating key experiences and perspectives of HIV patient navigators, drawing findings and recommendations applicable to the development, implementation, and evaluation of HIV patient navigation.

Perspectives among women receiving medications for opioid use disorder: Implications for development of a peer navigation intervention to improve access to family planning services

Background Studies have consistently found high rates of unintended pregnancy among women with opioid use disorder (OUD). Few interventions have been developed to specifically engage and address the family planning (FP) needs of women in substance use disorder treatment. Objectives: Our goal was to collect formative qualitative data to identify the FP experiences, needs and service preferences of women receiving medications for OUD and to use these data to develop a FP education and navigation intervention that could be tested in diverse, resource-limited treatment settings. Methods: From August 2016 to April 2017, we conducted 21 guided qualitative interviews with women from two outpatient treatment clinics in Denver, Colorado. We recorded, transcribed, and coded all interviews. We then facilitated three focus groups (n = 16) from May to July 2017 to verify or challenge interview themes and to further inform the development of the FP intervention. Results: Most participants expressed ambivalence or low perceived risk regarding unintended pregnancy and desired more information about contraceptive methods. Many participants described mistrust or lack of engagement in the medical system and histories of trauma were a common barrier to seeking services. Focus group participants endorsed a peer-led FP navigation intervention and provided feedback to tailor existing FP educational materials to fit the specific needs of women in recovery. Conclusions/Importance: Results from this qualitative study suggest that women in recovery from OUD have unique, unmet FP education and service needs. These findings provide important information for the development of feasible and acceptable FP service delivery within diverse, resource-limited treatment settings and informed the development of a trauma-informed, peer-led FP education and navigation intervention that would be implemented in a subsequent phase of the study.

"He Gave Me Spirit and Hope": Client Experiences with the Implementation of Community Health Worker Programs in HIV Care

Community health workers (CHWs) are members of the frontline health workforce who serve as intermediaries between health services and communities. In the United States, the role of CHWs has begun to expand as they have been shown to improve outcomes and reduce inequities in care for chronic conditions. This study used qualitative methods to explore the experiences of clients in CHW programs to inform their implementation in HIV care. Thirty clients from 6 Ryan White HIV/AIDS Program care settings across the United States participated in individual semistructured interviews to learn more about their experiences working with a CHW. Four key themes arose from the client perspective. First, CHWs embodied key qualities. Some of the qualities clients attributed to CHWs included being caring and supportive, along with capable of fostering personal connections. Second, CHWs met clients where they were. Clients described the CHW approach as more holistic compared with other care team members; they emphasized CHWs were able to focus on whatever was needed in that moment. Third, CHWs occupied a unique role in the HIV care team. Clients noted CHWs had more time to dedicate to their interactions; they also saw CHWs as representing a different level of authority. Finally, CHWs influenced how clients engaged with care and accessed resources. This included empowering clients to access resources independently in the future. Overall, clients' perceptions of CHWs in terms of their qualities, approach, role, and influence on the HIV care experience suggest they are a valuable resource on the care team.

Factors Influencing the Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review of the Literature

Patient navigation is a model of care that aims to improve access to care by reducing the complexity of navigating health, education, and social services across the continuum of care and care settings. Little is known about the processes that facilitate or impede the implementation of patient navigation programs (PNPs). We conducted a scoping review to identify and summarize the current state of knowledge regarding the implementation and outcomes of existing implemented PNPs. We employed a 6-stage scoping review framework to identify and review eligible articles. Sixty-articles met the inclusion criteria (58 peer-reviewed and 2 grey literature). The Consolidated Framework for Implementation Research served as the theoretical framework during analysis to help extract factors relevant to implementation of navigator programs. Results of the scoping review are reported thematically. Influences on implementation were identified: (a) planning to ensure alignment with organizational need (b) funding (c) multidisciplinary engagement (d) establishing workflow (e) mechanisms for communication (f) stakeholders to encourage buy-in (g) appropriate caseload (h) in kind resources. PNPs improve the experiences of patients and families. The findings of this scoping review provides implementation considerations of PNPs across global care settings. Strategies for overcoming pragmatic and logistical issues must be developed for optimal implementation.

Acceptability of an mHealth App That Provides Harm Reduction Services Among People Who Inject Drugs: Survey Study

Background

Harm reduction services reduce the negative consequences of drug injection and are often embedded within syringe service programs (SSPs). However, people who inject drugs (PWID) suboptimally engage with such services because of stigma, fear, transportation restrictions, and limited hours of operation. Mobile health (mHealth) apps may provide an opportunity to overcome these barriers and extend the reach of SSPs beyond that of the traditional brick-and-mortar models.

Objective

This study aims to assess the prevalence of smartphone ownership, the level of comfort in providing the personal information required to use mHealth apps, and interest in using an mHealth app to access harm reduction services among PWID to guide the development of an app.

Methods

We administered a survey to 115 PWID who were enrolled via respondent-driven sampling from July 2018 to July 2019. We examined the extent to which PWID had access to smartphones; were comfortable in providing personal information such as name, email, and address; and expressed interest in various app-based services. We measured participant characteristics (demographics, health status, and behaviors) and used binary logistic and Poisson regressions to identify independent correlates of mHealth-related variables. The primary regression outcomes included summary scores for access, comfort, and interest. The secondary outcomes included binary survey responses for individual comfort or interest components.

Results

Most participants were White (74/105, 70.5%), male (78/115, 67.8%), and middle-aged (mean=41.7 years), and 67.9% (74/109) owned a smartphone. Participants reported high levels of comfort in providing personal information to use an mHealth app, including name (96/109, 88.1%), phone number (92/109, 84.4%), email (85/109, 77.9%), physical address (85/109, 77.9%), and linkage to medical records (72/109, 66.1%). Participants also reported strong interest in app-based services, including medication or sterile syringe delivery (100/110, 90.9%), lab or appointment scheduling (90/110, 81.8%), medication reminders (77/110, 70%), educational material (65/110, 59.1%), and group communication forums (64/110, 58.2%). Most participants were comfortable with the idea of home delivery of syringes (93/109, 85.3%). Homeless participants had lower access to smartphones (adjusted odds ratio [AOR] 0.15, 95% CI 0.05-0.46; P=.001), but no other participant characteristics were associated with primary outcomes. Among secondary outcomes, recent SSP use was positively associated with comfort with the home delivery of syringes (AOR 3.29, 95% CI 1.04-10.3 P=.04), and being older than 50 years was associated with an increased interest in educational materials (AOR 4.64, 95% CI 1.31-16.5; P=.02) and group communication forums (AOR 3.69, 95% CI 1.10-12.4; P=.04).

Conclusions

Our findings suggest that aside from those experiencing homelessness or unstable housing, PWID broadly have access to smartphones, are comfortable with sharing personal information, and express interest in a wide array of services within an app. Given the suboptimal access to and use of SSPs among PWID, an mHealth app has a high potential to address the harm reduction needs of this vulnerable population.

Evaluation of HIV/AIDS-related mobile health applications content using an evidence-based content rating tool

Background

Despite the increasing number of mobile health applications, the validity of their content is understudied. The objective of this study was to rate the content of HIV/AIDS-related mobile applications and to determine the extent to which evidence-based medicine is being incorporated into their content using a new tool called the Evidence-based content rating tool of mobile health applications (EBCRT-mHealth).

Methods

All available HIV/AIDS-related applications in Iran from Cafe Bazaar and Google Play Store were evaluated. This study was first conducted in 2018, then after almost two years in 2021 was done again. In this study, researchers developed the EBCRT-mHealth tool to rate the content of applications based on the evidence-based medicine pyramid. Its reliability was calculated (α = 0.78), and five specialists confirmed its validity. Two reviewers independently reviewed all HIV/AIDS applications directly downloaded and installed from the Google Play Store and Cafe Bazaar.

Results

Out of 980 retrieved applications, in 2018, 85, and in 2021, 78 applications were included in the study. Only in 17 (28%) out of the 60 in 2018, and 25 (51%) in 2021 Google Play store applications the source of content information was mentioned. All Cafe Bazaar mobile applications mentioned the source of information. The mean rating of all application content in 2018 was 2.38 (SD = 0.74), and in 2021 was 2.90 (SD = 1.35) out of 5. The mean rating of the content of Cafe Bazaar applications in 2018 was 2.10 (SD = 0.49), and in 2021 was 1.94 (SD = 0.29). The mean content rating of Google Play store applications in 2018 was 2.50 (SD = 0.80) and in 2021 was 3.86 (SD = 1.18).

Conclusion

After two years, the rating of the content of HIV/AIDS-related applications available in Iran that existed in Cafe Bazaar decreased from "poor" to "inappropriate". Also, the content score of the Google Play Store applications increased from "poor" to "good". It is critical to ensure the credibility of the sources used in developing their content and removing applications with inappropriate and unreliable content from the App Stores. Also, mobile health application developers should use the highest quality information in their applications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01498-7.

Event-Level Association Between Daily Alcohol Use and Same-Day Nonadherence to Antiretroviral Therapy Among Young Men Who Have Sex With Men and Trans Women Living With HIV: Intensive Longitudinal Study

BACKGROUND

Young trans women (TW) and men who have sex with men (MSM) are disproportionately impacted by HIV. Optimizing adherence to antiretroviral therapy (ART) is one mechanism by which public health experts aim to achieve favorable HIV health outcomes while reducing disease transmission. However, alcohol use is prevalent among young TW and MSM and threatens optimal adherence. In addition, the daily variations in alcohol use and ART adherence and their association with each other are poorly understood, warranting more appropriate methodological approaches, such as analysis of ecological momentary assessment (EMA) data.

OBJECTIVE

The aim of this analysis is to characterize the association between daily alcohol use and same-day ART nonadherence captured by an EMA study of young MSM and TW living with HIV in San Francisco.

METHODS

Young MSM and TW enrolled in the Health eNav digital HIV care navigation intervention were included in the analytic sample (N=113). Data on alcohol and ART use were collected by daily EMA surveys administered via text messaging and were analyzed over 30 days of follow-up. A multivariable mixed-effects logistic regression model adjusting for baseline sociodemographic characteristics was specified to investigate whether daily alcohol use was associated with same-day ART nonuse.

RESULTS

Daily alcohol use was associated with higher same-day ART nonuse. On average, participants drank alcohol on 15.20 (SD 8.93) days and used ART on 15.19 (SD 10.16) days out of 30 days. Daily alcohol use was associated with 1.89 (95% CI 1.14-3.15) times the adjusted odds of same-day ART nonuse for each participant.

CONCLUSIONS

Results are consistent with other analyses of daily alcohol and ART use and underscore the importance of individually targeted interventions that are sensitive to each participant's dynamic risk environment.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16406.

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.

Technology Acceptance in Mobile Health: Scoping Review of Definitions, Models, and Measurement

BACKGROUND

Designing technologies that users will be interested in, start using, and keep using has long been a challenge. In the health domain, the question of technology acceptance is even more important, as the possible intrusiveness of technologies could lead to patients refusing to even try them. Developers and researchers must address this question not only in the design and evaluation of new health care technologies but also across the different stages of the user's journey. Although a range of definitions for these stages exists, many researchers conflate related terms, and the field would benefit from a coherent set of definitions and associated measurement approaches.

OBJECTIVE

This review aims to explore how technology acceptance is interpreted and measured in mobile health (mHealth) literature. We seek to compare the treatment of acceptance in mHealth research with existing definitions and models, identify potential gaps, and contribute to the clarification of the process of technology acceptance.

METHODS

We searched the PubMed database for publications indexed under the Medical Subject Headings terms "Patient Acceptance of Health Care" and "Mobile Applications." We included publications that (1) contained at least one of the terms "acceptability," "acceptance," "adoption," "accept," or "adopt"; and (2) defined the term. The final corpus included 68 relevant studies.

RESULTS

Several interpretations are associated with technology acceptance, few consistent with existing definitions. Although the literature has influenced the interpretation of the concept, usage is not homogeneous, and models are not adapted to populations with particular needs. The prevalence of measurement by custom surveys suggests a lack of standardized measurement tools.

CONCLUSIONS

Definitions from the literature were published separately, which may contribute to inconsistent usage. A definition framework would bring coherence to the reporting of results, facilitating the replication and comparison of studies. We propose the Technology Acceptance Lifecycle, consolidating existing definitions, articulating the different stages of technology acceptance, and providing an explicit terminology. Our findings illustrate the need for a common definition and measurement framework and the importance of viewing technology acceptance as a staged process, with adapted measurement methods for each stage.

Efficacy and Acceptability of My Care Hub Mobile App to Support Self-Management in Australians with Type 1 or Type 2 Diabetes

The aim of this study was to evaluate the preliminary efficacy and user acceptance of My Care Hub (MCH) mobile app-developed to provide evidenced-based support and education on diabetes self-management (DSM). Using a mixed-methods design, the efficacy and acceptability of MCH were measured among people with type 1 or type 2 diabetes after three weeks of intervention. The primary outcome measure was level of involvement with DSM, while the mediating factors were skills and self-efficacy for DSM. Telephone interviews were conducted to elucidate information on perceptions of the app's impact on participants' DSM and interest in future use. Statistically significant improvements were observed between pre- and post-intervention measures: DSM activities (4.55 ± 1.14 vs. 5.35 ± 0.84; p = 0.001); skills (7.10 ± 1.99 vs. 7.90 ± 1.67; p = 0.04); and self-efficacy (7.33 ±1.83 vs. 8.07 ± 1.54; p = 0.03). Multivariate analysis showed that self-efficacy had the strongest, though not significant influence on DSM. Interview findings revealed that the app reinforced knowledge and provided motivation to participate in DSM activities. The study suggested a positive impact of MCH on DSM and acceptability by patients. To confirm these promising results, further large scale and long-term studies are required.

Preliminary Effects of a Mobile Interactive Supervised Therapy Intervention on People Living With HIV: Pilot Randomized Controlled Trial

BACKGROUND

As people living with HIV infection require lifelong treatment, nonadherence to medication will reduce their chance of maintaining viral suppression and increase the risk of developing drug resistance and HIV transmission.

OBJECTIVE

This study aimed to evaluate the efficacy of a mobile app, Mobile Interactive Supervised Therapy (MIST), for improving adherence to oral HIV medications among HIV-infected adults in Singapore.

METHODS

We conducted a two-group pilot randomized controlled trial (RCT) with a process evaluation, in which 40 HIV-infected participants with once-daily medication regimes were recruited from a public tertiary hospital in Singapore and randomly assigned equally to either the intervention (receiving MIST and routine care) or control (receiving routine care only) groups. The intervention lasted for 2 months. The outcome of antiretroviral therapy (ART) adherence was measured by a 7-day recall self-report (SR), pill count (PC), an electronic medical device-Medication Event Monitoring System (MEMS)-and a mobile app-MIST (for the intervention group only). In total, 20 participants from the intervention group were interviewed at the end of the intervention to assess the acceptability of MIST. Data were collected at baseline and at 1-month and 2-month postintervention.

RESULTS

All participants had excellent medication adherence at baseline (median 100, IQR 100-100). The use of MIST did not result in a significant improvement in ART adherence when measured by the SR, PC, and MEMS, as compared with the control group at 1-month (P values >.99, .86, and .74, respectively) and 2-month (P values=.80, .84, and .82, respectively) postintervention. ART adherence also did not improve in each group over the same period. MIST was perceived to be a beneficial tool based on the process evaluation results.

CONCLUSIONS

Although MIST did not enhance medication adherence to HIV treatments, mainly owing to the ceiling effect, it was perceived to be beneficial among the participants of this study. Our process evaluation provided useful data to further develop MIST for bigger and long-term mobile phone app-assisted intervention RCTs in the future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03794648; https://clinicaltrials.gov/ct2/show/NCT03794648.

Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis

BACKGROUND

Mobile health (mHealth), refers to healthcare practices supported by mobile devices, such as mobile phones and tablets. Within primary care, health workers often use mobile devices to register clients, track their health, and make decisions about care, as well as to communicate with clients and other health workers. An understanding of how health workers relate to, and experience mHealth, can help in its implementation.

OBJECTIVES

To synthesise qualitative research evidence on health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services, and to develop hypotheses about why some technologies are more effective than others.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, Science Citation Index and Social Sciences Citation Index in January 2018. We searched Global Health in December 2015. We screened the reference lists of included studies and key references and searched seven sources for grey literature (16 February to 5 March 2018). We re-ran the search strategies in February 2020. We screened these records and any studies that we identified as potentially relevant are awaiting classification.

SELECTION CRITERIA

We included studies that used qualitative data collection and analysis methods. We included studies of mHealth programmes that were part of primary healthcare services. These services could be implemented in public or private primary healthcare facilities, community and workplace, or the homes of clients. We included all categories of health workers, as well as those persons who supported the delivery and management of the mHealth programmes. We excluded participants identified as technical staff who developed and maintained the mHealth technology, without otherwise being involved in the programme delivery. We included studies conducted in any country.

DATA COLLECTION AND ANALYSIS

We assessed abstracts, titles and full-text papers according to the inclusion criteria. We found 53 studies that met the inclusion criteria and sampled 43 of these for our analysis. For the 43 sampled studies, we extracted information, such as country, health worker category, and the mHealth technology. We used a thematic analysis process. We used GRADE-CERQual to assess our confidence in the findings.

MAIN RESULTS

Most of the 43 included sample studies were from low- or middle-income countries. In many of the studies, the mobile devices had decision support software loaded onto them, which showed the steps the health workers had to follow when they provided health care. Other uses included in-person and/or text message communication, and recording clients' health information. Almost half of the studies looked at health workers' use of mobile devices for mother, child, and newborn health. We have moderate or high confidence in the following findings. mHealth changed how health workers worked with each other: health workers appreciated being more connected to colleagues, and thought that this improved co-ordination and quality of care. However, some described problems when senior colleagues did not respond or responded in anger. Some preferred face-to-face connection with colleagues. Some believed that mHealth improved their reporting, while others compared it to "big brother watching". mHealth changed how health workers delivered care: health workers appreciated how mHealth let them take on new tasks, work flexibly, and reach clients in difficult-to-reach areas. They appreciated mHealth when it improved feedback, speed and workflow, but not when it was slow or time consuming. Some health workers found decision support software useful; others thought it threatened their clinical skills. Most health workers saw mHealth as better than paper, but some preferred paper. Some health workers saw mHealth as creating more work. mHealth led to new forms of engagement and relationships with clients and communities: health workers felt that communicating with clients by mobile phone improved care and their relationships with clients, but felt that some clients needed face-to-face contact. Health workers were aware of the importance of protecting confidential client information when using mobile devices. Some health workers did not mind being contacted by clients outside working hours, while others wanted boundaries. Health workers described how some community members trusted health workers that used mHealth while others were sceptical. Health workers pointed to problems when clients needed to own their own phones. Health workers' use and perceptions of mHealth could be influenced by factors tied to costs, the health worker, the technology, the health system and society, poor network access, and poor access to electricity: some health workers did not mind covering extra costs. Others complained that phone credit was not delivered on time. Health workers who were accustomed to using mobile phones were sometimes more positive towards mHealth. Others with less experience, were sometimes embarrassed about making mistakes in front of clients or worried about job security. Health workers wanted training, technical support, user-friendly devices, and systems that were integrated into existing electronic health systems. The main challenges health workers experienced were poor network connections, access to electricity, and the cost of recharging phones. Other problems included damaged phones. Factors outside the health system also influenced how health workers experienced mHealth, including language, gender, and poverty issues. Health workers felt that their commitment to clients helped them cope with these challenges.

AUTHORS' CONCLUSIONS

Our findings propose a nuanced view about mHealth programmes. The complexities of healthcare delivery and human interactions defy simplistic conclusions on how health workers will perceive and experience their use of mHealth. Perceptions reflect the interplay between the technology, contexts, and human attributes. Detailed descriptions of the programme, implementation processes and contexts, alongside effectiveness studies, will help to unravel this interplay to formulate hypotheses regarding the effectiveness of mHealth.

Digital HIV Care Navigation for Young People Living With HIV in San Francisco, California: Feasibility and Acceptability Study

BACKGROUND

HIV continues to be a public health challenge adversely affecting youth and young adults, as they are the fastest-growing group of new HIV infections in the United States and the group with the poorest health outcomes among those living with HIV. HIV prevention science has turned to mobile health as a novel approach to reach and engage young people living with HIV (YPLWH) experiencing barriers to HIV care.

OBJECTIVE

This study aimed to assess the feasibility and acceptability of a text message-based HIV care navigation intervention for YPLWH in San Francisco. Health eNavigation is a 6-month text message-based HIV care navigation where YPLWH are connected to their own HIV care navigator through text messaging to improve engagement in HIV primary care. Digital HIV care navigation included delivery of the following through SMS text messaging: (1) HIV care navigation, (2) health promotion and education, (3) motivational interviewing, and (4) social support.

METHODS

We evaluated the feasibility and acceptability of a text message-based HIV care navigation intervention among YPLWH. We assessed feasibility using quantitative data for the overall sample (N=120) to describe participant text messaging activity during the intervention. Acceptability was assessed through semistructured, in-depth interviews with a subsample of 16 participants 12 months after enrollment. Interviews were audio-recorded, transcribed, and analyzed using grounded theory.

RESULTS

Overall, the text message-based HIV care navigation intervention was feasible and acceptable. The majority of participants exhibited medium or high levels of engagement (50/120 [41.7%] and 26/120 [21.7%], respectively). Of the majority of participants who were newly diagnosed with HIV, 63% (24/38) had medium to high engagement. Similarly, among those who were not newly diagnosed, 63% (52/82) had medium to high engagement. The majority of participants found that the intervention added value to their lives and improved their engagement in HIV care, medication adherence, and viral suppression.

CONCLUSIONS

Text message-based HIV care navigation is a potentially powerful tool that may help bridge the gaps for linkage and retention and improve overall engagement in HIV care for many YPLWH. Our results indicate that participation in text message-based HIV care navigation is both feasible and acceptable across pervasive structural barriers that would otherwise hinder intervention engagement.

Acceptability of electronic healthcare predictive analytics for HIV prevention: a qualitative study with men who have sex with men in New York City

BACKGROUND

Large data sets, also known as "big data", shared in health information exchanges (HIEs), can be used in novel ways to advance health, including among communities at risk for HIV infection. We examined values and opinions about the acceptability of using electronic healthcare predictive analytics (eHPA) to promote HIV prevention in men who have sex with men (MSM). Our aims were twofold: (I) to evaluate the perspectives of MSM with diverse race/ethnicity and age on the acceptability of predictive analytics to determine individual HIV risk and (II) to determine acceptability of having targeted prevention messaging based upon those risk estimates sent directly to the consumer.Method: Two of the authors facilitated 12 focus groups (n=57) with adult MSM without HIV, living in NYC. Groups were divided by ethnicity (Black, Latino, and White) and age (under 35 and 35 and over). Participants were recruited through HIV prevention sites, community-based organizations, social media, and Internet sites that serve these communities. Grounded theory methods were used to analyze the data with Dedoose.

RESULTS

We identified six main themes related to acceptability: (I) reach, relevance, and potential uptake of using predictive analytics to establish HIV risk and deliver targeted prevention messaging; (II) patient-provider communication; (III) public health and individual rights; (IV) perceptions of intervention effectiveness; (V) electronic health data security; and (VI) stigma. Within each thematic domain, MSM discussed concerns, benefits, and provided recommendations for implementation.

CONCLUSIONS

MSM in this study were supportive of the use of "big data" and technology to reach marginalized populations and improve public health, yet expressed concerns about the relevance, effectiveness, and security eHPA. Efforts to advance eHPA for HIV prevention should address these concerns, especially among the most-at-risk communities of color. Development of eHPA for HIV prevention should involve targeted messaging that addresses specific concerns regarding eHPA security, accuracy, and relevance.

Electronic and other new media technology interventions for HIV care and prevention: a systematic review

INTRODUCTION

Electronic and other new media technologies (eHealth) can facilitate large-scale dissemination of information and effective delivery of interventions for HIV care and prevention. There is a need to both monitor a rapidly changing pipeline of technology-based care and prevention methods and to assess whether the interventions are appropriately diversified. We systematically review and critically appraise the research pipeline of eHealth interventions for HIV care and prevention, including published studies and other funded projects.

METHODS

Two peer-reviewed literature databases were searched for studies describing the development, trial testing or implementation of new technology interventions, published from September 2014 to September 2018. The National Institutes of Health database of grants was searched for interventions still in development. Interventions were included if eHealth was utilized and an outcome directly related to HIV treatment or prevention was targeted. We summarized each intervention including the stage of development, eHealth mode of delivery, target population and stage of the HIV care and prevention continua targeted.

RESULTS AND DISCUSSION

Of 2178 articles in the published literature, 113 were included with 84 unique interventions described. The interventions utilize a variety of eHealth technologies and target various points on the prevention and care continua, with greater emphasis on education, behaviour change and testing than linkage to medical care. There were a variety of interventions for HIV care support but none for PrEP care. Most interventions were developed for populations in high income countries. An additional 62 interventions with funding were found in the development pipeline, with greater emphasis on managing HIV and PrEP care.

CONCLUSIONS

Our systematic review found a robust collection of eHealth interventions in the published literature as well as unpublished interventions still in development. In the published literature, there is an imbalance of interventions favouring education and behaviour change over linkage to care, retention in care, and adherence, especially for PrEP. The next generation of interventions already in the pipeline might address these neglected areas of care and prevention, but the development process is slow. Researchers need new methods for more efficient and expedited intervention development so that current and future needs are addressed.

Adding quality to quantity in randomized controlled trials of addiction prevention and treatment: a new framework to facilitate the integration of qualitative research

BACKGROUND AND AIMS

Randomized controlled trials (RCTs) are important for evaluating interventions, and qualitative research is increasingly recognized as being crucial to the success of this enterprise. We aimed to describe and demonstrate a temporal parallel purpose framework to help researchers understand how to make optimum use of qualitative research before, during and after RCTs. This framework sets out specific rationales for conducting qualitative research at each stage of a trial, where the rationales presented relate to both the intervention and evaluation methodology.

METHOD AND RESULTS

We conducted a scoping review of published qualitative studies undertaken alongside RCTs focusing on illicit drug use. We then used the temporal parallel purpose framework to present key findings to demonstrate how qualitative studies can add value to addiction RCTs by enhancing understanding of the intervention being trialled and/or the RCT itself. In so doing, we highlight the missed opportunities for addiction science when qualitative research is overlooked. We also explain why barriers to combining qualitative research and RCTs are neither inevitable nor insurmountable.

CONCLUSIONS

The temporal parallel purpose framework provides a tool for assessing when and why to combine qualitative research with addiction treatment and prevention RCTs. Our paper and framework can help researchers formulate key questions that qualitative research can address. This can potentially save resources by reducing the number of poorly designed interventions and trials and prevent morbidity, mortality, and other addiction-related harms by facilitating the identification and implementation of interventions that are most likely to be effective.

Review and Implementation of Self-Help and Automated Tools in Mental Health Care

Self-help and automated technologies can be useful for behavioral and mental health education and interventions. These technologies include interactive media, online courses, artificial intelligence-powered chatbots, voice assistants, and video games. Self-help media can include books, videos, audible media like podcasts, blog and print articles, and self-contained Internet sites. Social media, online courses, and mass-market mobile apps also can include such media. These technologies serve to decrease geospatial, temporal, and financial barriers. This article describes different self-help and automated technologies, how to implement such technologies in existing clinical services, and how to implement according to patient needs.

An Acceptability Study Of A Personal Portable Device Storing Critical Health Information To Ensure Treatment Continuity Of Home-Dwelling Older Adults In Case Of A Disaster

AIMS

DEPPAS ("Dispositivo Electrónico Personal y Portable en Salud" or Personal, Portable Electronic Health Device in English) is a portable device in form of a bracelet that allows storing electronic health records of older adults experiencing chronic illnesses. The device seeks to support the vital sustainability of older adults by storing critical health information when electronic or paper records have been lost as a consequence of a disaster. Older adults are particularly vulnerable to experience negative consequences in this context. The present study explores the end-user acceptability of DEPPAS in order to inform the next design stages of the device.

METHODS

Twenty home-dwelling urban male and female older adults enrolled in a chronic health management program were invited to participate in two focus groups. A prototype of DEPPAS was presented and reactions to health service disruption scenarios were explored. Focus groups were transcribed. Content analysis based on the Technology Acceptance Model was conducted.

RESULTS

Older adults are acutely aware of their vulnerable health status. Participants report overall positive reactions to DEPPAS. The device was associated with feelings of relief and an increased sense of control over their health management. DEPPAS is perceived as useful, usable, and safe. Even though concerns regarding confidentiality were raised, benefits are perceived as more relevant than potential risks. Participants agree that its usefulness could be extended beyond disaster situations to everyday health care management. Implications for future development and limitations are discussed.

CONCLUSION

The conceptual design DEPPAS shows a high level of acceptability by this end user and a high potential to be integrated with other complementary technologies (e.g. GPS, medication reminders) that could significantly contribute to improving health management in disaster situations.

A Pilot Study of a Mobile App to Support HIV Antiretroviral Therapy Adherence Among Men Who Have Sex with Men Who Use Stimulants

APP+ is a theoretically-grounded mobile app intervention to improve antiretroviral (ART) adherence among men who have sex with men (MSM) who use stimulants. We assessed the feasibility and acceptability of APP+ in a six-month randomized controlled trial among a national sample of 90 MSM recruited online; secondarily, we examined changes in self-reported ART adherence by study arm. Retention at the final assessment was 82%, and acceptability ratings were comparable to other technology-based interventions. MSM in the APP+ group reported higher self-reported percentage ART adherence in the past 30 days at the four-month timepoint compared to a no-treatment control group (89.0% vs. 77.2%). However, once access to the app was removed after month four, group differences in ART adherence diminished by month six. APP+ may be a potentially promising intervention approach for MSM living with HIV who use stimulants but would require enhancements to optimize acceptability and demonstrate more sustained effects.

Client Perspectives and Experiences With HIV Patient Navigation in the United States: A Qualitative Meta-Synthesis

Patient navigation is increasingly utilized to link and (re)engage persons with HIV to care. Understanding client experiences with HIV patient navigation can facilitate intervention design and translation of evidence to practice. We conducted a qualitative meta-synthesis of client experiences with HIV patient navigation. Data were analyzed using thematic synthesis. We identified seven relevant studies; all collected data via in-depth interviews with persons with HIV who participated in HIV patient navigation. Four interrelated themes emerged from analysis that pertain to (1) the complexity of the health and social service environment and the holistic approaches taken by the navigator, (2) the profound significance of the client-navigator relationship, (3) client reluctance to end the navigation program, and (4) client self-efficacy and feelings of hope and psychological change as a result of their navigation experience. The unifying theme across all studies was the value and impact of the client-navigator relationship on client experience and quality of life. Programs should consider hiring navigators who possess strong relational skills and are peers of the clients, and clearly delineating the role of the navigator. Research should examine the impact of the client-navigator relationship on client outcomes and further investigate how participating in patient navigation affects client self-efficacy, client resiliency, and the role of posttraumatic growth to achieve improved HIV outcomes. This review underscores the significance of the relationship within intensive, multilevel interventions for individuals and communities marginalized and isolated from health and social service systems.

What are the important design features of personal health records to improve medication adherence for patients with long-term conditions? A systematic literature review

OBJECTIVES

This systematic literature review aims to identify important design features of the electronic personal health record (PHR) that may improve medication adherence in the adult population with long-term conditions.

DATA SOURCES

PubMed (including MEDLINE), CINAHL, Science Direct (including EMBASE), BioMed Central, ACM digital, Emerald Insight, Google Scholar and Research Gate.

METHODS

Studies that were published between 1 January 2002 and 31 May 2018 in English were included if the participants were adults, with at least one long-term condition, were able to self-administer their medication and were treated in primary care settings. The quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and the risk of bias was appraised using the Cochrane risk of bias tool.

RESULTS

From a total of 27 studies that matched the inclusion criteria, 12 were excluded due to low quality of evidence, 10 were rated moderate and 5 were rated high quality. All the included studies had low sample size and limited follow-up duration. Thirteen of the included studies found that the use of a PHR has increased medication adherence. The identified design features are reminders, education, personalisation and tailoring, feedback and alerts, gamification, medication management, medical appointment management, diary and self-monitoring, health condition management, set goals, patient's blog and tethered. It was impossible to draw conclusions as to which feature is important to what group of patients and why. The most frequently identified conditions were HIV and diabetes. This review did not identify any papers with negative results. It was not possible to numerically aggregate the PHR effect due to high heterogeneity of the medication adherence measurement, study type, participants and PHRs used.

CONCLUSION

Although we found recurrent evidence that PHRs can improve medication adherence, there is little evidence to date to indicate which design features facilitate this process.

PROSPERO REGISTRATION NUMBER

CRD42017060542.

A need for implementation science to optimise the use of evidence-based interventions in HIV care: A systematic literature review

To improve health outcomes in people living with HIV, adoption of evidence-based interventions (EBIs) using effective and transferable implementation strategies to optimise the delivery of healthcare is needed. ViiV Healthcare's Positive Pathways initiative was established to support the UNAIDS 90-90-90 goals. A compendium of EBIs was developed to address gaps within the HIV care continuum, yet it was unknown whether efforts existed to adapt and implement these EBIs across diverse clinical contexts. Therefore, this review sought to report on the use of implementation science in adapting HIV continuum of care EBIs. A systematic literature review was undertaken to summarise the evaluation of implementation and effectiveness outcomes, and report on the use of implementation science in HIV care. Ten databases were reviewed to identify studies (time-period: 2013-2018; geographic scope: United States, United Kingdom, France, Germany, Italy, Spain, Canada, Australia and Europe; English only publications). Studies were included if they reported on people living with HIV or those at risk of acquiring HIV and used interventions consistent with the EBIs. A broad range of study designs and methods were searched, including hybrid designs. Overall, 118 publications covering 225 interventions consistent with the EBIs were identified. These interventions were evaluated on implementation (N = 183), effectiveness (N = 81), or both outcomes (N = 39). High variability in the methodological approaches was observed. Implementation outcomes were frequently evaluated but use of theoretical frameworks was limited (N = 13). Evaluations undertaken to assess effectiveness were inconsistent, resulting in a range of measures. This review revealed extensive reporting on implementation science as defined using evaluation outcomes. However, high variability was observed in how implementation outcomes and effectiveness were defined, quantified, and reported. A more specific and consistent approach to conducting and reporting on implementation science in HIV could facilitate achievement of UNAIDS 90-90-90 targets.

Patients' Perceptions of mHealth Apps: Meta-Ethnographic Review of Qualitative Studies

BACKGROUND

Mobile phones and tablets are being increasingly integrated into the daily lives of many people worldwide. Mobile health (mHealth) apps have promising possibilities for optimizing health systems, improving care and health, and reducing health disparities. However, health care apps often seem to be underused after being downloaded.

OBJECTIVE

The aim of this paper is to reach a better understanding of people's perceptions, beliefs, and experience of mHealth apps as well as to determine how highly they appreciate these tools.

METHODS

A systematic review was carried out on qualitative studies published in English, on patients' perception of mHealth apps between January 2013 and June 2018. Data extracted from these articles were synthesized using a meta-ethnographic approach and an interpretative method.

RESULTS

A total of 356 articles were selected for screening, and 43 of them met the inclusion criteria. Most of the articles included populations inhabiting developed countries and were published during the last 2 years, and most of the apps on which they focused were designed to help patients with chronic diseases. In this review, we present the strengths and weaknesses of using mHealth apps from the patients' point of view. The strengths can be categorized into two main aspects: engaging patients in their own health care and increasing patient empowerment. The weaknesses pointed out by the participants focus on four main topics: trustworthiness, appropriateness, personalization, and accessibility of these tools.

CONCLUSIONS

Although many of the patients included in the studies reviewed considered mHealth apps as a useful complementary tool, some major problems arise in their optimal use, including the need for more closely tailored designs, the cost of these apps, the validity of the information delivered, and security and privacy issues. Many of these issues could be resolved with more support from health providers. In addition, it would be worth developing standards to ensure that these apps provide patients accurate evidence-based information.

Social Inequity and Structural Barriers to Completion of Ecological Momentary Assessments for Young Men Who Have Sex With Men and Trans Women Living With HIV in San Francisco

BACKGROUND

Ecological momentary assessments (EMAs) administered via text messaging facilitate real-time data collection. With widespread cell phone access, EMAs are becoming more available to even the most disenfranchised communities, such as those living with HIV. However, structural barriers disproportionately burden young men who have sex with men (MSM) and trans women (TW) living with HIV and threaten participation in HIV research.

OBJECTIVE

We aim to identify structural barriers to completing EMA text surveys nested within a digital HIV care intervention for young MSM and TW living with HIV in San Francisco.

METHODS

A total of 10,800 EMA text messages were delivered daily over 90 days to 120 participants enrolled in the Health eNav intervention (2017-2018) at the San Francisco Department of Public Health. EMA surveys inquired about participants' daily affect, sexual behaviors, substance use, and treatment adherence. Survey completion was calculated after 30, 60, and 90 days of follow-up. We described characteristics of nonstarters (those who provided less than four complete responses to the first seven EMA surveys) and analyzed structural correlates of days to first weeklong or more EMA survey noncompletion using multivariable Cox proportional hazards regression. Qualitative interviews were used to evaluate the acceptability of EMA surveys.

RESULTS

Participants completed 4384 of 10,800 (40.59%) EMA surveys. Completion of 70% or more of EMA surveys was attained by 56 of 120 participants (46.7%) at 30 days of follow-up, 40/120 (33.3%) at 60 days of follow-up, and 30/120 (25.0%) by the end of the 90-day study period. Twenty-eight participants (23.3%) were identified as nonstarters, and were more likely to be recently incarcerated (prevalence ratio [PR] 2.3, 95% CI 1.3-4.4), forego basic needs for HIV medications (PR 2.4, 95% CI 1.3-4.5), and be diagnosed with HIV in the last year (PR 2.2, 95% CI 1.1-4.1). Adjusting for nonstarters, young MSM and TW living in temporary/transitional housing (adjusted hazard ratio [aHR] 1.8, 95% CI 1.1-3.0), foregoing HIV medications to afford basic needs (aHR 1.7, 95% CI 1.1-2.7), and having less than a college education (aHR 3.5, 95% CI 1.4-9.0) had greater hazard of weeklong or more EMA survey noncompletion. Overall, there was high acceptability of the EMA surveys.

CONCLUSIONS

Although access to and use of technology is increasingly ubiquitous, this analysis demonstrates persisting gaps in EMA completion by socioeconomic factors such as incarceration, education level, housing, and competing needs for young MSM and TW living with HIV in San Francisco. Moreover, those recently diagnosed with HIV were more likely to experience an immediate drop-off in completing EMA surveys. EMAs are feasible for individuals not experiencing social inequity and structural barriers. HIV prevention technologies addressing these barriers and leveraging similar methodology may prove effective for young MSM and TW living with HIV.

Exploring and Prioritization of Mobile-Based Self-Management Strategies for HIV Care

OBJECTIVE

Appropriate mobile-based self-management strategies can be as new approaches to decelerate the HIV infection progression and improve the quality of life. This study aims at (i) identifying in the literature mobile-based self-management strategies for HIV care and (ii) prioritizing those from the point of view of infectious diseases specialists. This study provides some clues to design useful mobile-based self-management tools for HIV patients, from the point of view of practitioners.

METHODS

This mixed methods study was done in two main phases. In the first phase, a review was conducted in: PubMed, Web of Science, Science Direct, Scopus, and Ovid. In this manner, related studies published between 2010 and 2017 and in the English language were reviewed. In the second phase, identified mobile-based self-management strategies were scored and prioritized by 23 participants. Frequency distribution and mean reports were calculated using SPSS statistical software.

RESULTS

By detailed reviewing of 24 related articles, the HIV mobile-based self-management strategies were identified in 47 categories and subcategories. According to the findings, "enhance the quality of life" was the main self-management strategy addressed by reviewed studies. However, "antiretroviral therapy and medication adherence" was reported at a higher rate to be a more helpful strategy than "enhance the quality of life".

CONCLUSION

In this study, helpful HIV mobile-based self-management strategies were identified that can be used to guide self-management interventions which have the potential to improve the healthcare services for people living with HIV.

A novel mHealth application for improving HIV and Hepatitis C knowledge in individuals with opioid use disorder: A pilot study

AIMS

There is a critical need to reduce infectious disease transmission among individuals with opioid use disorder (OUD). Here we examine the ability of a novel, automated educational intervention, delivered via iPad in a single visit, to improve human immunodeficiency virus (HIV) and Hepatitis C (HCV) knowledge among adults with OUD.

METHODS

Participants were 25 adults enrolled in a 12-week trial evaluating the efficacy of an Interim Buprenorphine Treatment for reducing illicit opioid use and other risk behaviors during delays to opioid treatment. Participants completed baseline HIV and HCV knowledge assessments with corrective feedback. They then completed an interactive HIV flipbook and HCV video followed by a second administration of the knowledge assessments. The knowledge assessments were repeated at post-intake Weeks 4 and 12.

RESULTS

At baseline, participants answered 69% and 65% of items correctly on the HIV and HCV assessments, respectively. The educational intervention was associated with significant increases in knowledge (86% and 86% correct on the HIV and HCV assessments, respectively; p's<.001). These improvements persisted throughout the study, with scores at Week 4 and 12 significantly greater than baseline (p's<.001).

CONCLUSION

This HIV+Hepatitis Education intervention was associated with significant and sustained improvements in knowledge of HIV + HCV transmission and risk behaviors in this vulnerable group of individuals with OUD. Given the continuing opioid epidemic, efforts are urgently needed to reduce HIV and HCV contraction and transmission among individuals with OUD. Mobile health educational interventions may offer a time- and cost-effective approach for addressing these risks.

Barriers to and Facilitators of Engagement With Remote Measurement Technology for Managing Health: Systematic Review and Content Analysis of Findings

BACKGROUND

Remote measurement technology refers to the use of mobile health technology to track and measure change in health status in real time as part of a person's everyday life. With accurate measurement, remote measurement technology offers the opportunity to augment health care by providing personalized, precise, and preemptive interventions that support insight into patterns of health-related behavior and self-management. However, for successful implementation, users need to be engaged in its use.

OBJECTIVE

Our objective was to systematically review the literature to update and extend the understanding of the key barriers to and facilitators of engagement with and use of remote measurement technology, to guide the development of future remote measurement technology resources.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving original studies dating back to the last systematic review published in 2014. We included studies if they met the following entry criteria: population (people using remote measurement technology approaches to aid management of health), intervention (remote measurement technology system), comparison group (no comparison group specified), outcomes (qualitative or quantitative evaluation of the barriers to and facilitators of engagement with this system), and study design (randomized controlled trials, feasibility studies, and observational studies). We searched 5 databases (MEDLINE, IEEE Xplore, EMBASE, Web of Science, and the Cochrane Library) for articles published from January 2014 to May 2017. Articles were independently screened by 2 researchers. We extracted study characteristics and conducted a content analysis to define emerging themes to synthesize findings. Formal quality assessments were performed to address risk of bias.

RESULTS

A total of 33 studies met inclusion criteria, employing quantitative, qualitative, or mixed-methods designs. Studies were conducted in 10 countries, included male and female participants, with ages ranging from 8 to 95 years, and included both active and passive remote monitoring systems for a diverse range of physical and mental health conditions. However, they were relatively short and had small sample sizes, and reporting of usage statistics was inconsistent. Acceptability of remote measurement technology according to the average percentage of time used (64%-86.5%) and dropout rates (0%-44%) was variable. The barriers and facilitators from the content analysis related to health status, perceived utility and value, motivation, convenience and accessibility, and usability.

CONCLUSIONS

The results of this review highlight gaps in the design of studies trialing remote measurement technology, including the use of quantitative assessment of usage and acceptability. Several processes that could facilitate engagement with this technology have been identified and may drive the development of more person-focused remote measurement technology. However, these factors need further testing through carefully designed experimental studies.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42017060644; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=60644 (Archived by WebCite at http://www.webcitation.org/70K4mThTr).

Avoidance, meaning and grief: psychosocial factors influencing engagement in HIV care

Although the introduction of antiretroviral therapy has rendered HIV a chronic illness, inconsistent engagement in HIV care by key populations limits its public health impact. Poor engagement in care is especially prevalent among vulnerable populations with mental health and substance use disorders. Beyond structural and health system considerations, psychosocial factors may present challenges to sustained engagement. We conducted a qualitative study using in-depth interviews with 31 primarily African American, urban-based individuals, many with past or current drug use and mental disorders, living with HIV. Participants identified several psychosocial barriers that detract from their motivation to attend appointments and take medication. These included mental distress or detachment over a lack of purpose in life; denial about the need to be engaged in care; insufficient trust in the efficacy of care or the health system; deaths of loved ones leading to bereavement or loss of social support; and engagement in specific avoidance behaviors like drugs and alcohol. The study findings suggest that more comprehensive HIV care, which integrates mental health and substance abuse services in order to enhance meaning and address coping and grief, may be important. Considering these services in addition to improving the logistical components of care such as cues/reminders, accessibility, and patient-provider communication may improve intervention packages.

Using technology to assess and intervene with illicit drug-using persons at risk for HIV

PURPOSE OF REVIEW

This review describes recent literature on novel ways technology is used for assessment of illicit drug use and HIV risk behaviours, suggestions for optimizing intervention acceptability, and recently completed and ongoing technology-based interventions for drug-using persons at risk for HIV and others with high rates of drug use and HIV risk behaviour.

RECENT FINDINGS

Among studies (n = 5) comparing technology-based to traditional assessment methods, those using Ecological Momentary Assessment (EMA) had high rates of reported drug use and high concordance with traditional assessment methods. The two recent studies assessing the acceptability of mHealth approaches overall demonstrate high interest in these approaches. Current or in-progress technology-based interventions (n = 8) are delivered using mobile apps (n = 5), text messaging (n = 2) and computers (n = 1). Most intervention studies are in progress or do not report intervention outcomes; the results from one efficacy trial showed significantly higher HIV testing rates among persons in need of drug treatment.

SUMMARY

Studies are needed to continually assess technology adoption and intervention preferences among drug-using populations to ensure that interventions are appropriately matched to users. Large-scale technology-based intervention trials to assess the efficacy of these approaches, as well as the impact of individual intervention components, on drug use and other high-risk behaviours are recommended.

Review of Use and Integration of Mobile Apps Into Psychiatric Treatments

PURPOSE OF REVIEW

Mental health practitioners should understand the features of current, publicly available apps; the features of novel, research apps; and issues behind the integration of mobile apps and digital health services into clinical workflows.

RECENT FINDINGS

The review is based on a research literature and the authors' clinical and healthcare administration experiences. Articles searched-on telepsychiatry, telemental health, mobile mental health, informatics, cellular phone, ambulatory monitoring, telemetry, and algorithms-were restricted to 2016 and 2017. Technologies are used in a variety of clinical settings, including patients with varying mental illness severity, social supports, and technological literacy. Good practices for evaluating apps, understanding user needs, and training and educating users can increase success rates. Ethics and risk management should be considered. Mobile apps are versatile. Integrating apps into psychiatric treatment requires addressing both patient and clinical workflows, design and usability principles, accessibility, social concerns, and digital health literacy.