Utilizing mHealth for Advancing HIV Care and Prevention Initiatives

1. Kathryn Muessig, Institute on Digital Health and Innovation Florida State University, USA Bridging the digital divide mHealth to improve HIV prevention and treatment outcomes 23 – 26 July · Brisbane and virtual ias2023.org

2. Acknowledgements I acknowledge and am sincerely grateful for the contribution and partnerships of all study participants and the many individuals who have contributed to advancing research in HIV prevention and care. Institutions Funding organizations Technology partners 23 – 26 July · Brisbane and virtual ias2023.org

3. Conflict of Interest Disclosure I have no relevant financial relationships with ineligible companies to disclose. The information presented does not represent the official position of any institutional affiliations, funding organizations, or collaborating partners. 23 – 26 July · Brisbane and virtual ias2023.org

4. HOW IS MHEALTH BEING USED TO ADVANCE 95-95-95 GOALS? Health Treatment Factors Individual System/Societal Factors Personalize information & resources Navigate complex health systems Match people to services Increase convenience & accessibility Manage prevention & care regimens Optimize use of limited resources •Address stigma, promote inclusion & equity Foster self-efficacy & empowerment Increase engagement & continuity of care

5. WHAT MOBILE HEALTH TOOLS CAN WE USE IN SUPPORT OF HIV CARE AND PREVENTION INITIATIVES? Web-based tools, online order Rx & test kits Social networking/ media-based Text Messaging (SMS / MMS) Smartphone apps, smart devices Telehealth Video counseling & directly observed therapy Virtual reality Artificial Intelligence (AI) Sensors Wearable devices Digi-pills Electronic health and medical records

6. HOW WELL ARE THESE TOOLS WORKING?

7. EVIDENCE FOR MHEALTH APPROACHES Area eHealth for HIV care & prevention (2014 – 2018) Evidence 84 published interventions (more on education, behavior change, HIV testing, HIV care support), 62 interventions under development (more on managing HIV and PrEP care) Systematic review found improvements in physical health, mental health, care engagement, or behavior change Reference Maloney, 2020 PMC6945883 Kruse, 2023 PMC10106311 mHealth for treatment & management of HIV (2017 – 2022) mHealth for adolescent HIV prevention & care (2000 – 2021) Telehealth and ART (through Jan 2022) Goldstein, 2023 PMC9629200 Identified 27 studies among adolescents and young adults in LMICs but found few RCTs and inconclusive outcomes Esmaeili, 2023 PMC10022569 Meta-analysis found higher adherence with telehealth interventions Among 25 studies that promoted HIV testing or HIV self-testing trend found for increase in testing uptake and testing return Cao, 2017 PMC5722976 Social media HIV prevention & care (through Aug 2016)

8. EARLIER EVIDENCE STAGES Ingestible sensors, digital pills Review of studies (2000-2021) that deployed an ingestible sensor in human populations (n=18): Mean accuracy to detect a medication event 68 -100%. Better for acute disease state and new starts (Chai 2022 Digital Health) Video Observed Therapy (VOT) Primarily being used around TB, is acceptable and feasible, provided more autonomy, convenience, and ease of use for patients and providers compared with in-person DOT. Conditionally recommended by WHO as an alternative to DOT. (Stoner 2022 HIV Research & Clinical Practice; Holzman 2019 JMIR Formative Research) Embodied conversational agents (ECA) - avatars and chatbots Potential to increase user engagement in interventions and motivate behavioral change. Some evidence showing improvements in ART/PrEP adherence. (Provoost 2017 JMIR; Dworkin 2019 AIDS Ed and Prev; Kurth 2014 JAIDS; Balaji 2022 Sexual Health)

9. EVOLVING EVIDENCE ON DIGITAL GAMES AND GAMIFICATION The Second Kind of Life with HIV – China (1) Role playing for HIV disclosure and stigma reduction Viral Combat – USA (2) Immersive iPhone game with text messaging for PrEP adherence Tumaini – Kenya (3) Interactive narrative game for HIV education and prevention Epic Allies – USA (5) Gamified mobile app for ART adherence Game-based learning –Tanzania (4) Interactive narrative game for HIV education and prevention (1) Zhang 2022 JMIR Serious Games; (2) Whiteley 2021 AIDS Behav; (3) Winskell 2019 Health Education J; (4) Haruna 2018 Int J Environ Res Public Health; (5) Hightow-Weidman 2021 AIDS Behav

10. SMS FOR ADHERENCE TO ART/PREP  Multiple studies, including meta-analyses, integrative and systematic reviews provide confirmation of feasibility/acceptability and moderate short-term effects At what point can we consider SMS “mHealth Standard of Care”?  WHO recommends SMS adherence promotion interventions in their ART therapy guidelines  Sustained effects have been less robust, particularly among youth Studies were more likely to report larger effects when SMS:  were not sent daily  supported bidirectional communication  included personalized content Horvath 2012 Cochrane Library; Finitsis 2014 PLoS ONE; Linnemayr 2017 AJPH; Mayer 2017 AIDS Care; Daher 2017 BMJ Open

11. COMPREHENSIVE MHEALTH ADHERENCE INTERVENTIONS A FEW EXAMPLES P3 (Prepared, Protected, emPowered) PrEPmate Positive Links App supports medication adherence through gamification, social support and self-monitoring; in-app portal for delivery of adherence coaching mHealth intervention that promotes personalized communication between patients and providers through interactive weekly check-in messages App connects client to clinic staff & virtual support groups, queries daily medication adherence, and sends appointment reminders Improved viral suppression at 12 months Improved PrEP adherence at 3 months (TFV-DP in dried blood spot) Improved PrEP adherence at 9 months (TFV-DP in dried blood spot) LeGrand 2018 JMIR Res Protocols; Liu 2019 CID; Dillingham 2018 AIDS Patient Care and STDs

12. CHALLENGES, GAPS AND OPPORTUNITIES TO ADVANCE MHEALTH  Geographic imbalance in where mHealth strategies are being developed, tested, and scaled  Population imbalance in who mHealth tools are being developed for and with  Digital divide: older, fewer years of school completed, lower-income, rural and female individuals less likely to own a smartphone or have access to reliable internet  Wide variation in technology access, hardware, software, and payment models  Speed of mHealth research and implementation struggles to keep up with evolution of commercial technology advances Technology access as a human right Rising global recognition of the importance of mHealth and access to mobile tech Poushter 2018 Pew Research Center; Vogels 2021 Pew Research Center; West 2015 Brookings.edu; WHO 2019

13. WHAT FEATURES ARE CRITICAL TO MHEALTH ENGAGEMENT?  Most apps get deleted within a week of last use!  Comparable preferences for intervention components across multiple settings  Incorporating focused engagement strategies can support acceptability, usability, and adherence Tailoring interventions to users  Inclusion of “push factors” (reminders, notifications)  Provision of self-monitoring/feedback  Fostering support (through connection to peers, providers)  Inclusion of game-based elements and rewards Mulawa 2018 Curr HIV/AIDS Rep; Goldenberg 2014 JMIR mHealth and uHealth

14. APPLY DATA-INFORMED DESIGN & IMPLEMENTATION Paradata: metrics used to examine how users interact with the online intervention Extent of Use Amount Example Engagement is associated with stronger intervention effects in digital health interventions Count of modules completed, Count of activities completed, Amount of content consumed Log-ins per day, Total log-ins, Patterns of use Frequency Duration Total time spent, Usage rates over time, Time spent within each module Proportion and type of content/features consumed, content contributed, diversity of use Depth Bauermeister 2017 Curr Opin HIV/AIDS; Hightow-Weidman 2020 mHealth; Hightow-Weidman 2021 mHealth

15.  Streamline the process of developing, adapting, and disseminating evidence-informed interventions.  Deliver interventions that are more relevant and engaging to end-users.  Facilitate broader adoption of mHealth health interventions operating with the vision of narrowing the digital divide.  Utilize engagement to characterize optimal and efficient technology-based interventions and facilitate real-time adaptive intervention to provide the right type/amount of support IDEAS FOR SUPPORTING DIGITAL TRANSFORMATION AT SCALE

16. MHEALTH APP SCALE-UP  Can we create a platform that allows for user customization of their HIV prevention and care medication adherence needs through a menu of interventions delivered in real-time? HealthMpowerment (HMP) strives to be a state-of-the-art Digital Health Intervention platform  A dedicated group of technologists, researchers and end-users work together daily to improve the platform and keep content up-to-date, fresh, and relevant.  Vision is to leverage this common platform to deliver a broader scope of capabilities to intervention studies within a reasonable budget and faster turn- around than de novo development. https://healthmpowerment.org/ Hightow-Weidman et al. AIDS and Behavior, 2019

17. HMP 2.0 FEATURES Access to upcoming study-related activities (surveys, incentives, specimen collection) Multi-media tailored content including information and skills building activities Includes goal setting, milestones, tasks with goal progress and reminders Social component for user-generated content to include peer-to- peer sharing, exchange of health information and discussions Expert Q&As Includes calendar and provision of user feedback. Study timeline Resources Goals Forum Ask the Expert Med Tracker Self-monitoring of behaviors known to impact PrEP/ART adherence with reminders and provision of tailored feedback Allows for ordering and uploading testing results Two-way secure messaging between participants and staff; Calendar allows participants to request sessions (via in-app text, phone, video) and receive reminders to promote attendance Health Tracker Test Kit Portal Communication Portal

18. ADAPTATION FOR NEW GLOBAL SETTINGS Accelerated adaptation process o Local collaborators and organizations lead formative research and rebranding o Focus on tailoring content, look and feel, engagement tools o Appropriately optimize functions for local bandwidth settings, hardware, data and storage limitations o Consider using available tools and technologies (e.g. Whatsapp, Facebook, Wechat) o Balance online/offline content and features and links to external sources of information

19. HMP ACTIVE PROJECTS  Currently being used to support:  PrEP uptake and adherence  ART uptake and adherence  HIV testing  Engagement in care  Mental health  Stigma reduction  Virtual cohort engagement https://healthmpowerment.org/

20. THE RIGHT TOOLS TO ACHIEVE THE OUTCOMES YOU WANT WITH THE RESOURCES AND TECHNOLOGY ENVIRONMENT YOU (WILL) HAVE High-touch Video telehealth Live video DOT Digital pills, biosensors Chatbot, artificial intelligence Asynchronous video DOT Live virtual adherence support group Personalized resources – algorithm/AI Fully person-driven Fully automated Live chat with navigator Asynchronous chat with navigator Bi-directional SMS reminders Curated resources – end-user selects Online test kit ordering Medication self-tracking One-directional SMS reminders Low-touch

21. CLOSINGTHOUGHTS FROM END-USERS MHEALTHTOOLS ACROSS THE CONTINUUM Connected Equipped Empowered “It influenced my decisions because every time I take a look at the calendar, I would actually see that I was becoming more responsible. The app has a lot of influence because it helps you take your medication, track different habits because without the app who would have known?” (South Africa) “I truly feel it’s helpful, especially the people that felt the need to share their stories or seek help on the forum. And I could also relate and see how others thought of certain things in general, especially if you’re going through something similar.” (South Africa) “I don’t know how many times I screenshotted stuff, and would send it to people and just be like, hey, this is information I remember you were asking me, and fears and concerns they had. And I was able to take that knowledge and help someone else out.” (USA)