Mobile apps for HIV prevention: how do they contribute to our epidemic response for adolescents and young adults?

Background

Mobile health (mHealth) and other digital health interventions (DHIs) have proliferated in recent years. A 2015 review of mobile applications (apps) related to HIV prevention revealed that most apps (71%) were developed by a nonacademic or public health institution, were free (83%), and reported information about one or more HIV prevention modalities (53%). However, only 7% of the apps focused specifically on men who have sex with men (MSM), and none dealt with post-exposure prophylaxis (PEP) (1). Since that time, updated inventories of mHealth interventions have been produced (2,3), mobile apps for HIV prevention have proliferated, and several apps have been tested in pilot studies or randomized trials that incorporate biomedical prevention options, including PrEP information and referrals, in their content (4-7). An updated inventory of mHealth tools for HIV prevention from the published scientific literature demonstrated that most HIV prevention mHealth tools for HIV-negative MSM focus on education and testing, rather than service delivery or linkage to care (3). Among 84 interventions included in this review, 31 (37%) focused specifically on adolescent and young adult MSM, highlighting the expansion of research using digital modalities in this group. What is lacking, however, is clarity regarding how DHIs fit into an overall strategy to address the HIV epidemic among adolescent and young adult MSM by increasing the uptake of prevention services, including HIV testing and PrEP.

In the paper, we consider several key questions that will situate mHealth tools in the epidemic response, focusing on relevance to HIV prevention for MSM and for adolescent and young adult MSM. We will illustrate the specialized functions for digital tools that have been developed and/or tested for efficacy within specific interventions, highlighting how these functions may be particularly relevant or impact for youth. Finally, we will consider how mHealth tools that are proven efficacious can be integrated into the broader public health response to the HIV epidemic among young MSM (YMSM) in the United States (US).

What opportunities for engaging YMSM in HIV prevention are offered by mHealth?

mHealth tools offer both reach and functions that are highly relevant to HIV prevention. In terms of reach, mHealth tools offer opportunities to provide specialized services [e.g., lesbian, gay, bisexual, transgender (LGBT)-friendly counseling or referrals (8), access to PrEP (9-11), prevention messages (5), and prevention commodities (1)] to MSM who cannot access them due to proximity (12), stigma, or concerns about confidentiality (13). This is especially true for MSM who live in rural areas, who are less likely to receive routinely recommended HIV prevention services, such as HIV testing, sexually transmitted infection (STI) testing, or PrEP services (14). It is important to note that, although DHIs offer opportunities to reach rural MSM, few DHIs have been developed that are specifically adapted to this important group (15). Reach also relates to the ability to provide services to men in disparate geographic areas: DHIs have been conducted that have enrolled MSM in the US nationally, demonstrating feasibility of providing interventions to a national service area from a single service location (16-19).

Specialized functions

Providing rich media

Because of increases in data speed in the US (20), it is feasible to deliver rich media, including videos or animations such as graphics interchange format (GIFs). Delivering information through videos and animations can help make for a more engaging user experience, and may increase comprehension of key information (21). MSM who tested pilot versions of a comprehensive HIV prevention app, MyChoices, originally developed for adult MSM, suggested decreasing text-heavy presentations of HIV prevention information in favor of GIFs or videos for presentation of content (6). Videos and images may also address literacy concerns that may limit youth’s comprehension of content. A study among MSM (median age 26 years) found that the use of video-delivered informed consent in health research increased comprehension of the elements of the informed consent process (22). Exploiting youth appetites for video content should be prioritized within future DHIs.

Tailoring interventions

Digital health tools are uniquely suited to tailoring intervention content and information based on user characteristics and preferences. Tailoring can be done based on specific prevention needs [e.g., providing information for antiretroviral (ART) treatment for users with HIV, and for PrEP or other prevention tools for users who are HIV-negative], location (e.g., using geolocation to recommend HIV testing or PrEP clinics that are nearby), or based on personal values or preferences [e.g., framing health recommendations in terms of the values of users (23,24)]. Further, mHealth tools can account for the fact that the needs and preferences of users change over time. This can be particularly relevant for YMSM who, in the course of development, experience cognitive, physical and emotional changes that may manifest in fluctuating periods of risk or rapid partner turnover. For example, an evaluation of the M-Cubed mobile app reassessed the levels of HIV risk after three months of use, and different prevention messages were provided to users based on their current levels of risk for HIV infection (5). Tailoring can also relate to the frequency of recommended services; for example, users of the HealthMindr app are offered a quiz to determine an optimal schedule for HIV testing based on their risks for HIV (25), and the Seattle/King County Public Health Department offered a similar digital tool (“Find your frequency”) to support MSM to make a plan for episodic HIV testing (26).

Providing reminders

mHealth apps can provide reminders for routine health services [e.g., HIV testing every 6 months; (6,25)] or to support pill taking [for example for PrEP or ART; (27)]. A meta-analysis of text-based reminders for medication adherence showed a significant benefit for chronic disease conditions (28) and some reminder systems improved ART adherence (29); two-way messaging proving more efficacious than one-way messages (30). Sustained efficacy of routine text message reminders for youth has proved limited and there is a need to make reminders more personalized and contextually relevant. Within P3, a PrEP adherence app for YMSM, reminders are tied to activities youth perform on a daily and consistent basis (e.g., brushing their teeth, plugging in their phone at night, opening Instagram), thereby facilitating habit building around PrEP medication taking. Consideration of exploiting the inherent capabilities of smartphones such as geolocation can also allow for reminders to be not only time but location dependent. Reminders that youth perceive as untimely (e.g., in presence of others who don’t know they use PrEP or due to a schedule change may not have access to their medications) can be adjusted to ensure that they are received when pills are present (e.g., they arrive home) rather than simply dismissing the reminder.

Locate services

Service locators can promote use of key HIV prevention services by helping users identify the right type of service that is in close proximity. The distance to a service location for HIV services matters: in Atlanta, MSM who had longer commute times to their regular care appointments were more likely to have missed care appointments than were men who received care closer to their homes (31). This may be particularly important for younger MSM who may lack personal vehicles and have to rely on others for rides or utilize public transportation. For HIV prevention and care, locators can provide geolocation-informed referrals to HIV testing, STI testing, HIV care, and PrEP services (32). If additional information about service facilities, such as forms of insurance accepted, services offered in multiple languages, times of operation, or whether the facility near a bus stop are available, faceted searches can be offered to help tailor service locations. Such faceted location searches can also incorporate data on service features collected specifically for the app users. For example, Get Connected (24), an mHealth intervention for MSM, utilizes a process of “secret shoppers” to curate lists of HIV testing locations known to be LGBT-affirming and to provide an adequate standard of care to LGBT youth (33). Intervention apps that utilize geofencing, a location-based service in which the app uses GPS, Wi-Fi or cellular data to trigger a pre-programmed action when a mobile device enters or exits a virtual boundary set up around a geographical location, to trigger HIV testing reminders when youth are near testing sites, are being explored within the LYNX and MyChoices apps. This strategy may be particularly impactful among youth who are less likely to engage in planning behaviors.

Screening (and rescreening) for appropriate services

In HIV prevention, some services have specific eligibility criteria. For example, PrEP is indicated if specific behavioral criteria or a history of STIs is present (34), and PEP is indicated after sex based on the time frame after exposure, which bodily fluids were contacted, and the perceived HIV serostatus of the sex partner (35). These decisions processes can be readily translated within DHIs into short “quizzes” or interactive activities that YMSM can take either periodically (to assess PrEP eligibility), or on-demand (after a sexual exposure if there is a concern that PEP might be indicated). Gamifying these assessments, by rewarding users with badges or rewards based on completion scores, may increase youth’s enjoyment and subsequent engagement with them. This is particularly important given that most prevention behaviors are meant to be enacted or assessed routinely [e.g., HIV testing is recommended at least annually and PrEP indications likely to change based on “seasons of risk” (36)]. Within the LYNX app, users are awarded badges such as the Golden Butt (an award for 100% condom use as a bottom for a month) for recording their sexual behaviors over time.

Delivery of multi-component interventions

Agent-based modeling suggests that reducing HIV incidence in MSM will require the uptake of multiple prevention services concurrently—for example, HIV testing, condom use, and PrEP and addressing co-morbid conditions (e.g., substance use, mental health issues) that disproportionately impact uptake and adherence to these services among YMSM. mHealth interventions are uniquely positioned to deliver multi-component interventions and are thus uniquely positioned to address the syndemic conditions placing YMSM, particularly those that identify as racial or ethnic minority at greater vulnerability. The HealthMindr PrEP app, which has been adapted for youth as MyChoices, is primarily focused on support PrEP uptake, but also screens for potentially problematic substance use [substance use has been associated with delayed PrEP start and lack of PrEP persistence (37)] and refers men to available substance use treatment resources if appropriate.

Will mHealth tools reach the people who need them for HIV prevention?

Early in the HIV epidemic, there was concern that some communities most impacted by the HIV epidemic—for example, racial/ethnic minorities and people with lower incomes—might not have ready access to mobile phones and adequate bandwidth to support engagement with rich media and prevention services; this concept was called the “digital divide” (38). However, recent data indicate that ownership of smartphones and access to high-speed data services is high among Americans overall, and is highest among young adults [96% of 18–29 years old have a smartphone (39)]. Ownership of smartphones is similarly high among white (82%), Black (80%) and Hispanic (79%) Americans (39). There are still some concerns about both levels of cell phone ownership in rural areas, and that the wireless data speed in rural areas is often slower than in urban areas (40). This may be especially problematic for mHealth tools that require higher data throughput speed to provide key services in rural areas, where specialized services are not available. For example, an mHealth approach to remote PrEP delivery for YMSM—ePrEP—utilizes videos and video-based counseling as part of remote PrEP provision (9). Rural areas are a major focus of this research, because of the limited availability of PrEP in many parts of the rural South and thus, rigorously assessing the technologic feasibility of this approach through both quantitative and qualitative evaluations is planned (12). Preliminary experience with the ePrEP intervention indicates that providing an option for phone calls instead of video calls may mitigate the need for high bandwidth, and that most younger users have internet access and are able to access video features (personal communication—Aaron Siegler).

Are public health systems and workforces ready for mHealth?

The primary responsibility for ensuring the public health lies with governmental agencies at the local, state and federal levels. Health departments are often service providers of last resort for key health services, especially communicable disease control services. When effective mHealth tools for HIV prevention and care are identified and ready for deployment, they might be delivered and managed either by health departments, by community-based organizations who receive direct or indirect funding from the Centers for Disease Control and Prevention (CDC), or by managed care organizations who wish to promote better outcomes for the people in their care. As reviewed elsewhere in this issue, many mHealth apps also include mailout services for HIV and/or STI testing, in which users collect their own specimens and return them to laboratories for analysis. In all phases of these operations—supporting clients to install and use apps, supporting communications with app users through participant management portals, conducting laboratory tests on self-collected samples and alternative specimen types—it is likely that additional training and, in some cases, equipment may be required to prepare and equip public health workforces to provide services through mHealth apps.

Strategies to mitigate these potential barriers to implementation are described in this issue by Paul et al. As part of formative processes in the development of mHealth tools, it is critical to consult with potential end-users to understand early on the training and skills of staff who will be implementing mHealth interventions with clients. A detailed example of a community-driven process for app development has been reported for the HealthMindr app, for which extensive pre-development consultations were held with potential users, potential funders, and potential implementers (41).

Conclusions

mHealth tools for HIV prevention have proliferated in the past several years, and there is a robust pipeline of new interventions along the HIV care and treatment continua that will yield efficacy results in the coming years. mHealth tools will not replace in-person clinical services and regular engagement with health care for people at risk for or living with HIV or regular engagement with prevention services in community settings But they will likely provide additional tools that can help support people with HIV prevention or care needs between clinical visits, enhance clinical care and support, and provide different modes of accessing information, services and prevention commodities. The value and possibilities for mHealth tools can only be fully realized by understanding the things that mHealth tools can do uniquely well, their limitations, and how they fit in the context of the delivery of HIV prevention services in communities.

Acknowledgments

Funding: This manuscript was completed with support from grant NICHD (U19HD089881) and was facilitated by the Emory University Center for AIDS Research (P30AI050409) and the UNC Center for AIDS Research (P30 AI050410).

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Lisa Hightow-Weidman) for the series “Technology-based Interventions in HIV Prevention and Care Continuum among American Youth”, published in mHealth. The article has undergone external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/mhealth-20-71). The series “Technology-based Interventions in HIV Prevention and Care Continuum among American Youth” was commissioned by the editorial office without any funding or sponsorship. LHW served as the unpaid Guest Editor of the series. PSS reports grants from NIH, during the conduct of the study; grants and personal fees from NIH, CDC and Gilead Sciences, personal fees from Merck and Ontario HIV Research Network, outside the submitted work; LHW reports grants from NICHD, during the conduct of the study. Both authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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