Date Published: June 01, 2018
Publisher: Mary Ann Liebert, Inc.
Author(s): Rebecca Dillingham, Karen Ingersoll, Tabor E. Flickinger, Ava Lena Waldman, Marika Grabowski, Colleen Laurence, Erin Wispelwey, George Reynolds, Mark Conaway, Wendy F. Cohn.
Mobile health interventions may help People Living with HIV (PLWH) improve engagement in care. We designed and piloted PositiveLinks, a clinic-affiliated mobile intervention for PLWH, and assessed longitudinal impact on retention in care and viral suppression. The program was based at an academic Ryan White Clinic serving a nonurban population in Central Virginia. The PL intervention included a smartphone app that connected participants to clinic staff and provided educational resources, daily queries of stress, mood and medication adherence, weekly quizzes, appointment reminders, and a virtual support group. Outcomes were analyzed using McNemar’s tests for HRSA-1, visit constancy, and viral suppression and nonparametric Wilcoxon signed-rank tests for CD4 counts and viral loads. Of 77 participants, 63% were male, 49% black non-Hispanic, and 72% below the federal poverty level. Participants’ achievement of a retention in care benchmark (HRSA-1) increased from 51% at baseline to 88% at 6 months (p < 0.0001) and 81% at 12 months (p = 0.0003). Visit constancy improved from baseline to 6 months (p = 0.016) and 12 months (p = 0.0004). Participants' mean CD4 counts increased from baseline to 6 months (p = 0.0007) and 12 months (p = 0.0005). The percentage of participants with suppressed viral loads increased from 47% at baseline to 87% at 6 months (p < 0.0001) and 79% at 12 months (p = 0.0007). This study is one of the first to demonstrate that a mobile health intervention can have a positive impact on retention in care and clinical outcomes for vulnerable PLWH. Next steps include integration with clinical practice and dissemination.
HIV is a chronic, manageable disease, but only if patients engage with and stay in care. The 90-90-90 UNAIDS proposal sets global recommendations that by 2020, 90% of HIV-infected persons know their status, 90% of those who are HIV positive receive antiretroviral therapy (ART), and 90% of those receiving ART have viral suppression.1 Medication adherence is referred to as the “Plus” in the 90-90-90-Plus global challenge, emphasizing the importance of ART adherence in achieving viral suppression.2 Many gaps remain in meeting these goals. Twenty percent of People Living with HIV (PLWH) never establish primary HIV care after their initial visit and half of established patients have gaps in care.3 Missed appointments for HIV care are associated with lower likelihood of achieving viral suppression, transmission risk behaviors, and mortality.4,5 Many factors can contribute to poor engagement with care, including age, gender, socioeconomic status, comorbidities, and unmet psychosocial needs.6,7 Systemic issues, such as patient trust in physicians and healthcare institutions, can also influence retention in care.8 Racial and ethnic disparities remain an issue in HIV care in the United States, where black and Latino patients have lower rates of retention in care and viral suppression than white patients.9 Discontinuity of care is higher for male than female patients and higher for black than non-black patients.10 Nonwhite race is a risk factor for poor ART adherence, in addition to psychosocial factors of self-efficacy, depression, stigma, and stressful life events.2
This study showed that the PositiveLinks intervention, which includes a clinic-affiliated custom app that provided resources to patients and assisted in care coordination by clinic staff, resulted in improved retention in care at 6 and 12 months. CD4 counts and viral loads also improved at 6 and 12 months, perhaps due to improved retention in care for a population specifically targeted as high risk for poor retention. To our knowledge, this is the first published study of a clinic-affiliated smartphone app intervention for PLWH to demonstrate clear improvements in retention in care. These findings support the study hypotheses that the PL intervention would result in improved engagement in care and clinical outcomes at 6 and 12 months of follow-up. This is also the first study to demonstrate improvements in long-term HIV clinical outcomes for a custom smartphone app for PLWH.