The Florida Mobile Health Adherence Project for People Living With HIV (FL-mAPP): Longitudinal Assessment of Feasibility, Acceptability, and Clinical Outcomes

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Abstract

Background

For people living with HIV (PLWH), antiretroviral therapy (ART) adherence is crucial to attain better health outcomes. Although research has leveraged consumer health information technologies to enhance ART adherence, no study has evaluated feasibility and clinical outcomes associated with the usage of a commercially available, regularly updated mobile health (mHealth) app for improving ART adherence among PLWH.

Objective

This study aimed to assess the feasibility, acceptability, and clinical outcomes of Care4Today, an existing, free, biprogrammatic mHealth app for improving ART adherence among PLWH.

Methods

The Florida mHealth Application Adherence Project (FL-mAPP) was a 90-day longitudinal pilot study conducted in 3 public HIV clinics in Florida, United States. After obtaining informed consent, 132 participants completed a survey and then were given the option to try an existing mHealth app to help with ART adherence. Of these, 33.3% (44/132) declined, 31.1% (41/132) agreed but never used the app, and 35.6% (47/132) used the app. All were asked to complete follow-up surveys at 30 days and 90 days after enrollment. Usage data were used to assess feasibility. Clinical outcomes of self-reported ART adherence and chart-obtained HIV viral load and CD4+ T-cell counts were compared among those who used the platform (users) versus those who did not (nonusers). Participants and HIV care providers also provided responses to open-ended questions about what they liked and did not like about the app; comments were analyzed using thematic analysis.

Results

Of 132 participants, 47 (35.6%) and 85 (64.4%) were categorized as users and nonusers, respectively. Among users, a Kaplan-Meier plot showed that 25 persons (53%) continued using the app after the 90-day follow-up. At 30-day follow-up, 13 (81.3%) of those who used the mHealth app reported ≥95% ART adherence, compared with 17 (58.6%) nonusers ( P=.12). Overall, 39 (82%) users liked or somewhat liked using the platform. Participants’ favorite features were medication reminders, ability to create custom reminders, and adherence reports.

Conclusions

This longitudinal study found that a commercially available medication adherence mHealth app was a feasible and acceptable intervention to improve ART adherence among PLWH and engaged in clinical care across 3 public HIV clinics in the state of Florida. Overall, participants liked the Care4Today app and thought the medication reminders were their favorite feature. Generally, self-reports of ART adherence were better among users than nonusers, both at 30- and 90-day follow-ups. Further clinical research needs to address user fatigue for improving app usage.

Related collections

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To compare electronically monitored (MEMS) with self-reported adherence in drug users, including the impact of adherence on HIV load, we conducted a 6-month observational study of 67 antiretroviral-experienced current and former drug users. Adherence (percentage of doses taken as prescribed) was calculated for both the day and the week preceding each of 6 research visits. Mean self-reported 1-day adherence was 79% (median, 86%), and mean self-reported 1-week adherence was 78% (median, 85%). Mean MEMS 1-day adherence was 57% (median, 52%), and mean MEMS 1-week adherence was 53% (median, 49%). One-day and 1-week estimates were highly correlated (r>.8 for both measures). Both self-reported and MEMS adherence were correlated with concurrent HIV load (r=.43-.60), but the likelihood of achieving virologic suppression was greater if MEMS adherence was high than if self-reported adherence was high. We conclude that self-reported adherence is higher than MEMS adherence, but a strong relationship exists between both measures and virus load. However, electronic monitoring is more sensitive than self-report for the detection of nonadherence and should be used in adherence intervention studies.

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To characterize the impact of longitudinal adherence on survival in drug-naive individuals starting currently recommended highly active antiretroviral therapy (HAART) regimens. Eligible study participants initiated HAART between January 2000 and November 2004 and were followed until November 2005 (N = 903). HAART regimens contained efavirenz, nevirapine, or ritonavir-boosted atazanavir or lopinavir. Marginal structural modeling was used to address our objective. The all-cause mortality was 11%. Individual adherence decreased significantly over time, with the mean adherence shifting from 79% within the first 6 months of starting HAART to 72% within the 24- to 30-month period (P value <0.01). Nonadherence over time (<95%) was strongly associated with higher risk of mortality (hazard ratio: 3.13; 95% confidence interval (CI): 1.95 to 5.05). Nonadherent (<95%) patients on nonnucleoside reverse transcriptase inhibitor (NNRTI)-based and boosted protease inhibitor-based regimens were, respectively, 3.61 times (95% CI: 2.15 to 6.06) and 3.25 times (95% CI: 1.63 to 6.49) more likely to die than adherent patients. Within the NNRTI-based regimens, nonadherent individuals on efavirenz were at a higher risk of mortality. Incomplete adherence to modern HAART over time was strongly associated with increased mortality, and patients on efavirenz-based NNRTI therapies were particularly at a higher risk if nonadherent. These results highlight the need to develop further strategies to help sustain high levels of adherence on a long-term basis.

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Is Open Access

mHealth for HIV Treatment & Prevention: A Systematic Review of the Literature

Caricia Catalani, William Philbrick, Hamish Fraser … (2013)

This systematic review assesses the published literature to describe the landscape of mobile health technology (mHealth) for HIV/AIDS and the evidence supporting the use of these tools to address the HIV prevention, care, and treatment cascade. The speed of innovation, broad range of initiatives and tools, and heterogeneity in reporting have made it difficult to uncover and synthesize knowledge on how mHealth tools might be effective in addressing the HIV pandemic. To do address this gap, a team of reviewers collected literature on the use of mobile technology for HIV/AIDS among health, engineering, and social science literature databases and analyzed a final set of 62 articles. Articles were systematically coded, assessed for scientific rigor, and sorted for HIV programmatic relevance. The review revealed evidence that mHealth tools support HIV programmatic priorities, including: linkage to care, retention in care, and adherence to antiretroviral treatment. In terms of technical features, mHealth tools facilitate alerts and reminders, data collection, direct voice communication, educational messaging, information on demand, and more. Studies were mostly descriptive with a growing number of quasi-experimental and experimental designs. There was a lack of evidence around the use of mHealth tools to address the needs of key populations, including pregnant mothers, sex workers, users of injection drugs, and men who have sex with men. The science and practice of mHealth for HIV are evolving rapidly, but still in their early stages. Small-scale efforts, pilot projects, and preliminary descriptive studies are advancing and there is a promising trend toward implementing mHealth innovation that is feasible and acceptable within low-resource settings, positive program outcomes, operational improvements, and rigorous study design

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Author and article information

Contributors

César Escobar-Viera:

ORCID: https://orcid.org/0000-0002-1031-499X

Center for Research on Media, Technology, and HealthUniversity of Pittsburgh230 McKee PlaceSuite 600Pittsburgh, PA, 15213United States1 412 692 4297escobar-viera@pitt.edu

Journal

Journal ID (nlm-ta): JMIR Mhealth Uhealth

Journal ID (iso-abbrev): JMIR Mhealth Uhealth

Journal ID (publisher-id): JMU

Title: JMIR mHealth and uHealth

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Electronic): 2291-5222

Publication date Collection: January 2020

Publication date (Electronic): 8 January 2020

Volume: 8

Issue: 1

Electronic Location Identifier: e14557

Affiliations

[1 ] Center for Research on Media, Technology, and Health University of Pittsburgh Pittsburgh, PA United States

[2 ] College of Public Health and Health Professions University of Florida Gainesville, FL United States

[3 ] Division of Infectious Disease and International Medicine Morsani College of Medicine University of South Florida Tampa, FL United States

[4 ] College of Nursing University of Florida Gainesville, FL United States

[5 ] The AIDS Institute Tampa, FL United States

[6 ] College of Pharmacy & Health Sciences Lipscomb University Nashville, TN United States

[7 ] Southern HIV and Alcohol Research Consortium Center for Translational HIV Research University of Florida Gainesville, FL United States

Author notes

Corresponding Author: César G Escobar-Viera escobar-viera@ 123456pitt.edu

Author information

César Escobar-Viera https://orcid.org/0000-0002-1031-499X

Zhi Zhou https://orcid.org/0000-0002-3861-5911

Jamie P Morano https://orcid.org/0000-0002-4254-5127

Robert Lucero https://orcid.org/0000-0002-8089-466X

Spencer Lieb https://orcid.org/0000-0002-5536-4384

Sean McIntosh https://orcid.org/0000-0001-5834-2925

Kevin A Clauson https://orcid.org/0000-0003-2774-8169

Robert L Cook https://orcid.org/0000-0002-7770-3754

Article

Publisher ID: v8i1e14557

DOI: 10.2196/14557

PMC ID: 6996722

PubMed ID: 31913127

SO-VID: d1a02668-f924-4d1c-8dd5-47519d3d7d1e

Copyright © ©César G Escobar-Viera, Zhi Zhou, Jamie P Morano, Robert Lucero, Spencer Lieb, Sean McIntosh, Kevin A Clauson, Robert L Cook. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 08.01.2020.

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.

History

Date received : 2 May 2019

Date revision requested : 15 June 2019

Date revision received : 11 August 2019

Date accepted : 28 September 2019

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