Improving Linkage to and Retention in Care in Newly Diagnosed HIV-Positive Patients Using Smartphones in South Africa: Randomized Controlled Trial

Abstract

Background South Africa provides free antiretroviral therapy for almost 5 million people living with HIV, but only 71% of the eligible people are on treatment, representing a shortfall in the care cascade, especially among men and youth. Many developing countries have expanded access to smartphones; success in health apps raises the possibility of improving this cascade. Objective SmartLink is a health app for Android smartphones providing HIV-related laboratory results, information, support, and appointment reminders to engage and link patients to care. This study aimed to evaluate the ability of SmartLink to improve linkage to care for HIV-positive smartphone owners. Methods This study was a multisite randomized controlled trial in Johannesburg. The intervention arm received the app (along with referral to a treatment site) and the control arm received the standard of care (referral alone). Linkage to care was confirmed by an HIV-related blood test reported on the National Health Laboratory Service database between 2 weeks and 8 months after initiation. Results A total of 345 participants were recruited into the study; 64.9% (224/345) of the participants were female and 44.1% (152/345) were aged less than 30 years. In addition, 46.7% (161/345) were employed full time, 95.9% (331/345) had at least secondary school education, and 35.9% (124/345) were from Zimbabwe. Linkage to care between 2 weeks and 8 months was 48.6% (88/181) in the intervention arm versus 45.1% (74/164) in the control ( P =.52) and increased to 64.1% (116/181) and 61.0% (100/164) ( P =.55), respectively, after the initial 8-month period. Moreover, youth aged 18 to 30-years showed a statistically significant 20% increase in linkage to care for the intervention group. Conclusions Youth aged less than 30 years have been historically difficult to reach with traditional interventions, and the SmartLink app provides a proof of concept that this population reacts to mobile health interventions that engage patients in HIV care. Trial Registration ClinicalTrials.gov NCT02756949; https://clinicaltrials.gov/ct2/show/NCT02756949 (Archived by WebCite at http://www.webcitation.org/6z1GTJCNW)

Digitized HIV/AIDS Treatment Adherence Interventions: A Review of Recent SMS/Texting Mobile Health Applications and Implications for Theory and Practice

“…Despite the lack of documentation regarding behavioral frameworks, we did find that (100%) of the four studies with quantitative results demonstrated significant HIV-related outcomes, i.e., improved visit attendance (Dillingham et al, 2018;Yè et al, 2018;Venter et al, 2019), improved HIV biological markers (Dillingham et al, 2018) and lessening of personal level barriers (Flickinger et al, 2018). Many used other approaches to design their interventions, namely Iterative processes that built on prior success, or contracting a commercial app development company.…”

“…Authors reported that 90% of community workers were illiterate, and, when surveyed, the majority reported having used a mobile phone for the first time during the training. SmartLink is an mHealth app that was tested with 345 PLWH across 5 sites in South Africa (Venter et al, 2019). The app was designed to improve linkage to HIV care for young newly diagnosed PLWH.…”

“…Worldwide, South Africa has the highest number of persons living with HIV (Avert, 2018). Venter et al (2019) reported the following: ∼65% women, 66% over 30 years old, 96% completed secondary school and 47% were employed full time. Thirty six percentage were originally from neighboring Zimbabwe, tended to have achieved higher levels of education and qualified for employment in Johannesburg.…”

“…The SmartLinks intervention (Venter et al, 2019) was designed for young adults under the age of 30 living with HIV-a population of high HIV transmission risk in South Africa. The app accommodated for both the English or Zulu language and communicated to participants in "simple" language.…”

“…Personal privacy was addressed in four (4) of the 7 studies we reviewed- Marent et al's (2018a) Commonalities across the studies included the fact that personal privacy was incorporated into the mHealth system design (i.e., Dillingham et al, 2018;Flickinger et al, 2018;Venter et al, 2019), or addressed qualitatively, when participants expressed their concerns about personal privacy guarantees of digital technologies (e.g., Dillingham et al, 2018;Marent et al, 2018a;Sabin et al, 2018). Table 4 details specific examples.…”