Introduction: Significant advances in combination anti-retroviral therapy have been instrumental in improving the quality of lives and life expectancy for people living with HIV. However, in the absence of a cure, sustained investment and innovation is required to improve adherence and quality of life for people living with HIV. We developed ARTAccess, a web-based application that links patient information on anti-retroviral therapy and viral load to an algorithm that guides a private community pharmacist on anti-retroviral therapy refills without the need for an additional nurse in the pharmacy. The aim of this paper is to describe the present the development process of the ARTAccess application and the exploration of the perceptions about its use by end users. Methods: Between October–December 2018, we conducted a qualitative observational study to document the processes of the ART-Access™ application development. Using theoretical frameworks of participatory action research and human-centred design, we undertook structured and unstructured observations of the application development review meetings. We observed and had interactions in 12 stakeholder meetings. Three observers attended each development meeting and independently drafted a reflective narration of the transcript and separately conducted their own analyses. ARTAccess was launched in January 2019 and in March 2019, three in-depth interviews were conducted with the nurse dispensers running the refill program at the three pharmacies where ARTAccess was piloted. Results: The ARTAccess application development meetings generated emerging themes. Introduction of a mHealth application for efficiency introduced job insecurity fears of health workers which needed to be addressed, to allow for increased engagement by health worker stakeholders. Stakeholder meetings provided important perceived gaps and needs for improvement at each stage of the ARTAccess application development. The user-centred design process led to five application versions; three more than the two originally planned; the feedback on the ARTAccess application became more positive as later versions were presented to stakeholders. Conclusions: The study provides evidence that participatory action research in a human-centred design approach enhanced the application development process of a new technology for health. In resource limited settings, where digital technologies may be used to support overstretched health systems, health workers need re-assurance that digital tools being developed will not threaten their employment.

Introduction Evidence shows benefit of digital technology for people living with human immunodeficiency virus on antiretroviral therapy adherence and retention in care, however, scalability and sustainability have scarcely been evaluated. We assessed participants’ willingness to pay a fee for mHealth “Call for life Uganda” support, a mobile-phone based tool with the objective to assess sustainability and scalability. Methods “Call for Life study”, approved by Makerere University, School of Public Health research & ethics committee, at 2 sites in Uganda, evaluated a MoTech based software “CONNECT FOR LIFE™” mHealth tool termed “Call for life Uganda”. It provides short messages service or Interactive Voice Response functionalities, with a web-based interface, allows a computer to interact with humans through use of voice and tones input via keypad. Participants were randomized at 1:1 ratio to Standard of Care or standard of care plus Call for life Uganda. This sends pill reminders, visit reminders, voice messages and self-reported symptom support. At study visits 18 and 24 months, through mixed method approach we assessed mHealth sustainability and scalability. Participants were interviewed on desire to have or continue adherence support and willingness to pay a nominal fee for tool. We computed proportions willing to pay (± 95% confidence interval), stratified by study arm and predictors of willingness to continue and to pay using multivariate logistic regression model backed up by themes from qualitative interviews. Results 95% of participants were willing to continue using C4LU with 77.8% willing to pay for the service. Persons receiving care at the peri-urban clinic (OR 3.12, 95% CI 1.43–9.11.86) and those with exposure to the C4LU intervention (OR 4.2, 95% CI 1.55–11.84) were more likely to continue and pay for the service. Qualitative interviews revealed mixed feelings regarding amounts to pay, those willing to pay, argued that since they have been paying for personal phone calls/messages, they should not fail to pay for Call for life. Conclusions Payment for the service offers opportunities to scale up and sustain mHealth interventions which may not be priorities for government funding. A co-pay model could be acceptable to PLHIV to access mHealth services in low resource settings. Clinical Trial Number NCT 02953080.