Mobile-Health Interventions for Youth with HIV—The Time to Scale Up is Now

Lisa Hightow-Weidman, MD, MPH

A review of the research on computer-based "eHealth" and mobile platform "mHealth" interventions to enhance treatment adherence among youth infected with HIV found proven feasibility and benefits of many of these interventions and concluded that these should now be scaled up and their proven components widely adopted.

Traditional approaches to improve treatment adherence and outcomes in youth with HIV have been inadequate, according to Lisa Hightow-Weidman, MD, MPH, Behavior and Technology Lab, Institute for Global Health and Infectious Diseases, the University of North Carolina at Chapel Hill, Chapel Hill, NC, and colleagues.

"Targeted interventions are urgently needed to improve the knowledge of undiagnosed HIV infection, access to and retention in prevention and care, medication adherence, and long-term viral load outcomes among youth at risk for or infected with HIV," Hightow-Weidman and colleagues declared, in a separate report from their Innovative Technology (ITECH) program at the University of North Carolina.

In the ITECH report, the investigators cite stark statistics demarking this population: over one-fifth (22%) of all new HIV infections in the US occur among persons in the youth age category, 13 to 24 years, and at the end of 2013, an estimated 60,900 youth in the US were living with HIV. Of these individuals, 51% (31,300) were living with undiagnosed HIV, the highest rate of undiagnosed HIV in any age group, according to the investigators. Furthermore, data from the 2015 Youth Risk Behavior Surveillance System indicated that only 21% of high-school-aged males having sex with males had ever been tested for HIV.

Youth at high-risk for HIV report several barriers to accessing diagnostic and treatment services that are particularly prevalent in, if not unique to their age group, Hightow-Weidman and colleagues found in their recent review of the research on innovative interventions. Among these are structural barriers such as limited access to transportation, conflicts with school scheduling, and requirements for permission; misperceptions of individual risk, fear of testing positive, and intimidation in health care settings. In addition, there was a commonly reported conflict between wanting to communicate with other HIV-positive youth and wanting to maintain their privacy.

After overcoming barriers to testing and gaining access to the PrEP regimen or treatment for active infection, there is a similarly disproportionate number of youth who fail to attain and maintain successful outcomes. The investigators found that only 48.1% of youth who commence treatment for HIV infection will achieve viral suppression (VS, indicated as <200 copies/mL) at the most recent viral load test. Furthermore, they estimate that less than 6% of the HIV-infected youth in the United States will remain virally suppressed.

A key contributor to the poor outcomes in youth at-risk or infected with HIV is their particularly low rates of treatment adherence. Reasons for treatment nonadherence provided by youth in the research reports reviewed by Hightow-Weidman and colleagues include medical reasons, such as adverse effects or dissatisfaction with the medical team; logistical reasons, such as forgetting to take their medication or finding it inconvenient; and psychological reasons, such as being depressed, lacking emotional support, and facing perceived stigma.

Although they may have barriers to receiving traditional health care outreach, many youth at-risk or infected with HIV are also particularly skilled at accessing, appreciating, and utilizing e-communication platforms. It is in this domain, that Hightow-Weidman and colleagues find the most likely means to enhancing treatment access and adherence, and to improving outcomes.

Recommended components of successful programs should include the following:

• Interventions that are more "holistic" rather than just focusing on "pill-taking." The youth included in the review reported communications about general health and wellness to be more relevant and more successful in fostering engagement.
• Social media support groups that maintain privacy through password-protected logins and/or pseudonyms/avatars.
• Telehealth communications that decrease the requirement for in-person consultations. Many youths reported feeling more comfortable disclosing their problems to the health care provider through that medium than in-person.
• "Gamification" and dynamic tailoring in these interventions that is based on frequent assessments, including use of points, rewards, contests, and other game-based elements.

The dissemination of successful programs and program elements will be facilitated when more collaborative relationships obviate the need to keep "recreating the wheel", Hightow-Weidman and colleagues indicated. They advocate for a "more collaborative future", in which both the content within eHealth interventions and the platforms upon which the interventions are built are shared.

"Consideration should be given to the creation of a content repository for researchers that could be updated and adapted for the unique needs, developmental stage, and cultural features of the population of interest," the investigators suggest. "Additionally, building interventions for youth living with HIV on existing platforms or using open source options would allow for more rapid development and result in substantial cost savings."

The review of eHealth and mHealth interventions to enhance treatment adherence among youth living with HIV was published in the August issue of Current HIV/AIDS Reports.