Mobile technology shows great promise in resource-limited settings due to its low cost and pervasive nature. Early evidence-based studies have shown robust support for mHealth interventions implemented among people living with HIV (PLWH); however, this type of inquiry is lacking amongst the most vulnerable groups of PLWH such as men who have sex with men (MSM), prisoners, and those facing substance use disorders (SUDS) and structural instabilities. These populations face barriers more profound than the general PLWH population including social stigma and discrimination. In response to the lack of rigorous evaluation of mHealth implementation and the tremendous potential for mHealth tools in underserved PLWH, we propose a 3-pronged approach in rooting mHealth tools using evidence-based methodology—(a) assessing mHealth feasibility and accessibility through descriptive studies, (b) conducting pilot projects testing mHealth tools, and (c) integrating mHealth tools into existing large-scale studies. The set of research steps proffered here aims to build a solid body of evidence on mHealth interventions among underserved populations and the health conditions that disproportionately affect them.

Background Mobile health (mHealth) can be beneficial in monitoring the complex healthcare regimen for people with HIV that includes adhering to medication and refraining from risky practices such as unsafe sex and injection drug use. Not only is mHealth often implemented without appropriate feasibility and acceptability research, but there is limited mHealth research among key HIV-positive populations such as men who have sex with men (MSM) and transgender women (TGW). Methods This study assessed access to and use of mobile technology and acceptability of mHealth among 150 HIV-positive MSM and TGW who were prescribed antiretroviral therapy (ART) in Malaysia–an emerging economy with rapid telecommunications growth and societal stigma against these groups. Results Findings among the 114 MSM and 36 TGW reveal high levels of depression (42%), stigma (2.53/4.00) and risky sexual behavior (30%), and suboptimal ART adherence (22%). On the other hand, the sample had excellent access to smartphones (75.3%) and the internet (78%), and had high acceptance of mHealth especially for those with suboptimal ART adherence. Conclusion In settings like Malaysia where homosexuality and cross-dressing are socially and legally stigmatized, HIV prevention and treatment strategies delivered using an mHealth platform have the potential to overcome in-person barriers.

Background Antiretroviral therapy is effective in reducing HIV-related morbidity, mortality, and transmission among people with HIV. However, adherence and persistence to antiretroviral therapy are crucial for successful HIV treatment outcomes. People with HIV who use cocaine have poor access to HIV services and lower retention in care. Objective The primary goal of this paper is to provide a detailed description of a mobile health intervention. This study is designed to improve medication adherence among people with HIV who use cocaine. A secondary goal is to list the important challenges and adaptations incorporated in the study design. Methods This study, titled Project SMART, used a wireless technology–based intervention, including cellular-enabled electronic pillboxes called TowerView Health and smartphones, to provide reminders and feedback on adherence behavior. The intervention design was based on the theoretical frameworks provided by the self-determination theory and the Motivation Technology Model. The 12-week pilot randomized controlled trial with four arms provided three types of feedback: automated feedback, automated+clinician feedback, and automated feedback+social network feedback. Results The study was funded by the National Institute of Drug Abuse (R21DA039842) on August 1, 2016. The institutional review board for the study was approved by Yale University on March 21, 2017. Data collection lasted from June 2017 to January 2020. The final enrollment was 71 participants, of whom 57 (80%) completed the study. The data are currently undergoing analysis, and the manuscript is being developed for publication in early 2022. Conclusions Implementing complex mobile health interventions for high-risk and marginalized populations with multicomponent interventions poses certain challenges, such as finding companies with adequate technology for clients and financial stability and minimizing the research-related burden for the study population. Conducting feasibility studies is important to recognize these challenges and the opportunity to address these challenges with solutions while keeping the design of a randomized controlled trial as true as possible. Trial Registration Clinicaltrials.gov NCT04418076; https://clinicaltrials.gov/ct2/show/NCT04418076 International Registered Report Identifier (IRRID) DERR1-10.2196/28332

Mobile health (mHealth) holds considerable promise as a way to give people greater control of their health information, privacy, and sharing in the context of HIV research and clinical services. The purpose of this study was to determine the feasibility of an mHealth research application from the perspective of three stakeholder groups involved in an HIV clinical trial in Jakarta, Indonesia: (a) incarcerated people living with HIV (PLWH), (b) research assistants (RAs), and (c) research investigators. Incarcerated PLWH (n = 150) recruited from two large all-male prisons completed questionnaires, including questions about mHealth acceptability, on an mHealth survey application using a proprietary data collection software development platform. RAs who administered questionnaires (n = 8) rated the usability of the software application using the system usability scale (SUS) and open-ended questions. Research investigators (n = 2) completed in-depth interviews, that were coded and analyzed using the technology acceptance model (TAM) as a conceptual framework. Over 90% of incarcerated PLWH felt the mHealth application offered adequate comfort, privacy, and accuracy in recording their responses. RAs' SUS scores ranged from 60% to 90% (M = 76.25) and they found the mHealth survey application challenging to learn, but highly satisfying. Compared with paper-based data collection, researchers felt that electronic data collection led to improved accuracy and efficiency of data collection and the ability to monitor data collection remotely and in real time. The researchers perceived the learnability of the application as acceptable but required self-instruction.

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BACKGROUND Antiretroviral therapy (ART) is effective in reducing HIV-related morbidity and mortality, and transmission among people with HIV (PWH). Adherence and persistence to ART, however, is crucial for successful HIV treatment outcomes. PWH who are cocaine users have poor access to HIV services and lower retention in care. OBJECTIVE The goal of this study was to examine the feasibility and acceptability of an mHealth intervention on ART adherence among cocaine using PWH. METHODS This project, titled Project SMART, used a wireless technology-based intervention, including cellular-enabled electronic pillboxes called TowerView Health® and smartphones to provide reminders and feedback on adherence behavior. This 12-week pilot (randomized control trial) with four arms provided three types of feedback: automated feedback, automated + clinician feedback, and automated feedback + social network feedback. RESULTS Between June 2017 to January 2020, this study screened 182 participants, out of which 80 successfully completed baseline, 71 enrolled to the intervention, and 57 completed the study. Study challenges included data loss due to untimely closure of the pillbox company, high drop-out rate (19.7%) likely due to the complexity of this study and burden of research components on the study population. CONCLUSIONS Implementing mHealth interventions for high-risk and marginalized populations is important in order to provide easy access to adherence services and scaling back the cost of personnel. Managing multi-component interventions come with certain challenges such as finding stable companies with adequate technology and financial support, and minimizing research-related burden for study population. The ability to adapt to these challenges posed by evolving technologies is important in conducting feasibility studies.