United States
2018

PositiveLinks is a mobile intervention for people with HIV, which includes use of a custom smartphone app that can be tailored to the needs and preferences of participants. The intervention was created to improve linkage and retention in care, as well as improve clinical outcomes, in a rural population of people with HIV living in the southern United States.

Pilot study participants were newly diagnosed with HIV (within 90 days of study enrolment), returning to care after a lapse, or at risk for falling out of care, and study results indicate significantly improved treatment retention and consistency of visits within a year, as well as significantly improved CD4 and viral load counts.

PositiveLinks program description^1,2

The pilot of the PositiveLinks intervention was affiliated with the Ryan White HIV Clinic at the University of Virginia and was informed by research suggesting that people with HIV prefer mobile health interventions and appreciate tailored bidirectional communication. The smartphone intervention provides the opportunity for participants to connect with peers for support through an app and accommodates for low literacy levels. New content was added to components of the app over the 12-month study period, and app content included:

• tailored educational resources (e.g., orientation to the clinic, HIV-related health information, stress reduction techniques);
• daily queries related to stress, mood, and medication adherence;
• weekly quizzes;
• contact information for the clinic-affiliated study team, which participants could use for individualized counselling and assistance;
• appointment reminders; and
• a community message board (CMB) where participants could leave or respond to messages. CMB content was monitored by the study team for misinformation and participants were advised not to use identifying information when participating.

Participants were provided with a smartphone when they enrolled in PositiveLinks with the app installed and an unlimited voice and data plan for 12 months. Participants received smartphone and app training, if required. Both the phone and app were password secured and consent addressed potential privacy risks.

Study results¹

Participants were mostly male (64%) (34% female; 3% transgender male to female); 49% were black non-Hispanic, 34% were white non-Hispanic, and 8% were Hispanic. Approximately 25% of participants had unstable housing and more than half of participants reported an income between 0 and 49% of the federal poverty level. Study results indicate that 40% of participants showed sustained use of the app.

The study looked at retention in HIV care, visit constancy, and clinical outcomes in 77 enrolled participants at baseline and at six and 12 months.

• The average response rates to the daily queries that assessed medication adherence, mood, and stress levels were 50%, 47%, and 47%, respectively, at six months and 41%, 39%, and 39%, respectively, at 12 months. The average response rates to weekly quizzes assessing general and HIV-specific knowledge were 43% at six months and 37% at 12 months.
• There were significant improvements in retention (i.e., keeping two appointments with an HIV provider separated by 90 days within a year) at six months (88%) and 12 months (81%) compared with baseline (51%).
• There were significant improvements in visit constancy (i.e., the proportion of four-month time internals in which one visit with an HIV provider was completed in one year) at six months (36%) and 12 months (51%) compared with baseline (22%).
• Mean CD4 counts significantly increased to 581 cells/mm³ at six months and 614 cells/mm³ at 12 months compared with baseline (522 cells/mm³).
• Mean viral load significantly decreased to 14,912 copies/mL at six months and 13,890 copies/mL at 12 months compared with 23,682 copies/mL at baseline. Additionally, the percentage of participants who were virally supressed (<200 copies/mL) significantly increased at six months (87%) and 12 months (79%) compared with baseline (47%).

What does this mean for service providers?

PositiveLinks provides an example of a mobile app that was effective at increasing engagement and improving treatment outcomes in participants in rural communities. A similar intervention could be adopted in other locations with similar population characteristics. This intervention used “warm technology,” which facilitates human contact and may have been an important component of its success and sustained usage.

Related resources

Text Message Reminder Tool – The Sex You Want

Adherence Apps – The Positive Side

References

1. Dillingham R, Ingersoll K, Flickinger TE, et al. PositiveLinks: a mobile health intervention for retention in HIV care and clinical outcomes with 12-month follow-up. AIDS Patient Care and STDs. 2018;32(6).
2. Flickinger TE, DeBolt C, Xie A, et al. Addressing stigma through a virtual community for people living with HIV: a mixed methods study of the PositiveLinks mobile healthiIntervention. AIDS and Behavior. 2018 Jun 7.

2018

Overview

On World AIDS Day 2017, the Gay Men’s Sexual Health Alliance (GMSH) launched a free text message reminder initiative as part of their The Sex You Want campaign for sexually active cisgender and transgender gay, bisexual, queer and other men who have sex with men. The text message reminder tool provides free text reminders to help individuals adhere to HIV treatment, as well as pre-exposure prophylaxis (PrEP) and testing. Text-based reminders can help people to stay on top of their medication and testing routines.

Why was the tool developed?

Research shows that the success of HIV treatment and PrEP are largely dependent on an individual’s adherence to their medications. However, there can be many barriers to medication adherence, such as substance use, mental health, age, and medication side effects. Text messages have been shown to be effective in promoting adherence to HIV treatment.

Testing and diagnosis for HIV and sexually transmitted infections (STIs) are important, to detect new infections and bring people into care and treatment. Diagnoses of infections can not only improve the health of people living with HIV or STIs through care and treatment but also help to prevent new infections, thus controlling infection in communities. Text messages may help to ensure that people are getting tested often, making it easier to detect HIV and STIs early.

How does it work?

Interested individuals can sign up by visiting this website: http://thesexyouwant.ca/reminder/ Users enter their Canadian cell phone number and select the type of reminder that they would like to receive – daily reminders for PrEP or HIV treatment, or 3-, 6-, or 12-month reminders for sexual health testing – as well as the time of day that they would like the reminder. Users can sign up for more than one type of reminder. Users must agree to the terms and conditions of the site. The information shared with the service remains private and the service can be stopped at any time.

How can I incorporate this tool into programming?

Agencies can integrate this tool into their programming to provide additional support for clients. For example, the use of this service has been taken up by some HIV care clinics; however, it could be used by any organization providing HIV and STI services.

For more information on the Sex You Want text-message reminder service please contact:

Dane Griffiths, Manager of Health Promotion
Gay Men’s Sexual Health Alliance
296 Jarvis Street, Unit 5
Toronto, ON  M5B 2C5
Phone: 416-364-4555
Email: Dgriffiths@gmsh.ca

United States
2017

The Mpowerment (MP) program is a community-level intervention designed to help prevent HIV among young men who have sex with men (MSM). The program works to address psychosocial factors (e.g., one’s sense of agency) that can affect sexual risk behaviours.^1,2 The MP program is one of the Effective Interventions – High Impact Prevention programs of the Centers for Disease Control and Prevention (CDC)³ and has been previously evaluated and found to have positive outcomes.²

A recent study that focused on outcomes of MP delivery in racial/ethnic minority communities found positive psychosocial changes, a reduction in sexual risk taking and an increase in HIV testing among participants when MP was delivered to a group of young MSM of colour.¹

Mpowerment (MP) program description

The MP program is tailored to the needs of the local community. A logic model provided by the CDC helps to guide program implementation.

MP targets a variety of factors (e.g., beliefs, social support, peer influence and community empowerment) that can reduce sexual risk behaviours and increase HIV testing in participants. The program includes six core elements that are intended to work together, although there is no requirement that participants attend activities; participants are free to attend as many elements of the MP program as they wish.¹ The core elements of MP are as follows: ^1,2

• A core group of 12 to 15 young men serve as the project's decision-making body; the group’s work can include designing project materials and outreach methods.
• Formal outreach includes young MSM going to places frequented by young MSM to deliver safer sex messages/education.
• M-groups (small peer-led group meetings) last 3 hours and focus on factors contributing to unsafe sex among young MSM (e.g., misperceptions about safer sex, having poor sexual communication skills).
• Informal outreach includes young MSM having casual conversations with their friends about the need for safer sex.
• Publicity is targeted at young MSM to provide messaging related to safer sex and to recruit participants.
• A project space is established where young MSM can meet and socialize.

The CDC recommends that volunteers and a project coordinator deliver and oversee MP and that a Community Advisory Board be convened³ to provide advice to the core group.²

Using a repeated measures design, participants of the study completed baseline and follow-up surveys at 3 and 6 months. An individual’s participation in M-group was considered to be the start of their involvement in MP because M-groups provided the most significant dose of the intervention.¹

Results¹

• Significant improvements in participants’ belief that they have the capacity to participate in safer sex were found at the 3 and 6 month follow ups (i.e., follow ups 1 and 2) compared with the baseline survey, and participants’ self-acceptance as an MSM improved by follow-up 2, as compared to baseline.
• More exposure to MP (measured by a score that considered participation in and weight of the core elements noted above) was associated with significant improvements in perceived social norms about safer sex and HIV testing among gay/bisexual/transgender friends, as well as increased discussions about safer sex among gay/bisexual/transgender friends.
• Participants reported significantly higher levels of HIV testing (in the past 6 months) at both follow-up points (54% at baseline to 65% at follow-up 1 to 70% at follow-up 2).
• Participants reported a significant reduction in condomless sex with any partner at follow-up 1, but this change was not sustained at follow-up 2 (40% at baseline to 34% at follow-up 1 to 41% at follow-up 2).
• No significant changes in participants’ reports of engaging in condomless sex with non-primary partners, while intoxicated or high (injection drugs), with a partner of unknown HIV status or in the context of transactional sex were found.

What does this mean for service providers?

The MP program has been adapted in Canada and may provide service providers with a way to promote new biomedical prevention strategies (e.g., pre-exposure prophylaxis) and empower individuals to take control of and manage their sexual health. The adaptable nature of MP allows for elements of the program such as outreach locations, the project space and program publicity to be tailored to individual target communities. The MP program has been shown to be successful in increasing testing within racially/ethnically diverse communities of young MSM¹ and could be further explored and used to promote testing among young MSM.

Related resources:

Sexual Health Information Project – Case Study

YouthCo Mpowerment Program (BC)

Mpowerment Effective Interventions (CDC)

Mpowerment Implementation Planning Tool and M&E Activities (CDC)

Mpowerment Project page – mpowerment.org

References:

1. a. b. c. d. e. f. g. Shelley G, Williams W, Uhl G et al. An evaluation of Mpowerment on individual-level HIV risk behavior, testing, and psychosocial factors among young MSM of color: The monitoring and evaluation of MP (MEM) Project. AIDS Education and Prevention. 2017;29(1):24–37.
2. a. b. c. d. Kegeles SM, Hays RB, Coates TJ. The MP Project: A community-level HIV prevention intervention for young gay men. American Journal of Public Health. 1996;86:1129–36. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380625/pdf/amjph00519-0075.pdf
3. a. b. Centers for Disease Control and Prevention. Effective interventions: HIV prevention that works. High impact prevention: Mpowerment. 2017. Available from: https://effectiveinterventions.cdc.gov/en/HighImpactPrevention/Interventions/Mpowerment.aspx

USA
2017

A recent study evaluated the effectiveness of a nurse navigator program in supporting engagement in care and improving clinical outcomes among veterans with HIV. For those who used the nurse navigator program, the number of clinic visits doubled, medication renewal increased from 41% to 81%, and attainment of an undetectable viral load (<200 copies/mL) increased from 48% to 69% after approximately one year.

Nurse-led navigation program

The program employed a nurse who provided HIV education, appointment reminders to support clinic attendance, and adherence support interventions to veterans. Patients were referred for navigation if they were identified as being poorly engaged (e.g., multiple no shows for appointments, inconsistent medication renewals, and elevated viral loads) by a member of the clinical team. An intensive follow-up process for missed appointments was used, which included the nurse navigator calling both the veteran and emergency contacts.

A variety of strategies to increase adherence to medication and clinic engagement were used, including:

• reminder calls (appointments and medication renewal)
• text reminders
• same-day walk-in appointments
• collaboration with family members and medical staff
• pillbox renewals

This study took place within the Veterans Affairs (VA) Infectious Disease (ID) primary care clinic in Washington DC, which strives to create an inclusive and accepting “medical home” for veterans.

Results

Patients referred to the nurse-led navigation program were compared with the overall cohort of veterans with HIV who were receiving care from the ID primary care clinic. At the start of the program, those who enrolled in the nurse navigator program were less likely to have a viral load <200 copies/mL, less likely to live in permanent housing, more likely to have substance use, and more likely to have comorbid depression or a disability than the overall ID primary care clinic study cohort.

When participants in the nurse navigation program were followed up approximately one year after they enrolled in the program, the percentage of participants with a viral load of <200 cells/mL increased from 48% to 69%. Additionally, the study found a significant increase in the average number of clinic visits (from one to two clinic visits) and in the rate of medication renewal (from 41% to 81%).

What does this mean for Canadian service providers?

This study demonstrates the importance of individualized care in a vulnerable population with a variety of comorbid conditions, as well as the potential benefits to having a nurse navigator as part of a primary care team treating people with HIV.

This program worked with a group of poorly engaged veterans; however, there is potential that this approach could also be used in other populations that show signs of poor engagement.

Examples of patient navigation services exist in the Canadian context, for example, Peer Navigation Services and Chronic Health Navigation Program. This study provides an additional example of the roles that a patient navigator could play, as well as the potential benefits to having a nurse provide a navigation role as a member of the treatment team.

Related resources

Health Navigation – Evidence Review

Patient Navigation – Evidence Brief

ARTAS – Evidence Brief

Effective Interventions: Patient Navigation Resources and Tools – Center for Disease Control and Prevention

References

Hemmy Asamsama O, Squires L, Tessema A, et al. HIV Nurse Navigation: Charting the course to improve engagement in care and HIV virologic suppression. Journal of the International Association of Providers of AIDS Care. 2017; 1-5.