Development and Acceptability of a Tablet-Based App to Support Men to Link to HIV Care: Mixed Methods Approach

Abstract

Background The poor engagement of men with HIV care is attributed to a number of factors: fear of stigma, masculine representations, concerns related to confidentiality, and the time commitment needed to visit public health clinics. Digital technologies are emerging as an approach to support the engagement of men with care. Objective This study aims to deliver a usable and engaging tablet-based app, called EPIC-HIV 2 (Empowering People through Informed Choices for HIV 2), to support men in making informed decisions about engaging with HIV care in rural KwaZulu Natal, South Africa. Methods We employed a mixed methods, iterative, and three-phased design that was guided by self-determination theory (SDT), a person-based approach, and human-computer interaction techniques. We reviewed related literature and conducted secondary analyses of existing data to identify barriers and facilitators to linkage to care and inform content development and design principles and used focus group discussions with members of the community advisory board and general community to evaluate a PowerPoint prototype of the app; used observations and guided questions with a convenience sample of potential users from the intervention community to iteratively test and refine a functioning interactive app; and conducted qualitative interviews and satisfaction surveys with actual users to evaluate acceptability. Results Phase 1 identified supply- and demand-side barriers to linkage to care. Specifically, clinics were feminized spaces unattractive to men with high social costs of attendance. Men did not feel vulnerable to HIV, preferred traditional medicine, and were afraid of the consequences of being HIV positive. Thus, the app needed to allow men to identify the long-term health benefits to themselves and their families of starting antiretroviral therapy early and remaining on it, and these benefits typically outweigh the social costs of attending and being seen at a clinic. SDT led to content design that emphasized long-term benefits but at the same time supported the need for autonomy, competence, and relatedness and informed decision making. Phase 2 indicated that we needed to use simpler text and more images to help users understand and navigate the app. Phase 3 indicated that the app was acceptable and likely to encourage men to link to care. Conclusions We found that iteratively developing the app with potential users using local narratives ensured that EPIC-HIV 2 is usable, engaging, and acceptable. Although the app encouraged men to link to HIV care, it was insufficient as a stand-alone intervention for men in our sample to exercise their full autonomy to link to HIV care without other factors such as it being convenient to initiate treatment, individual experiences of HIV, and support. Combining tailored digital interventions with other interventions to address a range of barriers to HIV care, especially supply-side barriers, should be considered in the future to close the present linkage gap in the HIV treatment cascade.

Engaging the ‘Missing Men’ in the HIV Treatment Cascade: Creating a Tailored Intervention to Improve Men’s Uptake of HIV Care Services in Rural South Africa: A Study Protocol

“…Several studies have shown that men are less likely to test for HIV and link to HIV treatment if found to be positive, resulting in poor health outcomes such as unsuppressed viral load and higher AIDS-related death among men [ 5 , 6 , 12 , 17 ]. The recent Test-as-Prevention (TasP) trial conducted in rural South Africa had no significant effect [ 17 ].…”

“…Men (especially young men) have been consistently missing from the cascade of HIV care, leading to poor health outcomes in men and ongoing transmission of HIV in young women. Although these men may not be missing for the same reasons across the cascade and may need different interventions, early work has shown similar trends in men’s low uptake of HIV care services and suggested that the social costs of testing and accessing care are extremely high for men, particularly in South Africa [ 3 , 5 , 6 , 12 , 17 , 18 ]. Interventions and data collection have hitherto, by and large, focused on men in relation to HIV prevention in women and have not approached the problem through the male lens.…”

“…Once access has been granted, individuals need to navigate some pathways to access care, which requires an active response from the users [ 1 , 10 ]. We adopted the candidacy framework to elucidate some of the barriers identified in previous studies in our locality [ 1 , 5 , 6 , 11 , 12 ] and guide the development of a male-tailored intervention that will ease the pathway to accessing and engaging with HIV testing, treatment, and prevention services.…”

Measuring and evaluating sexual health in the era of digital health: challenges and opportunities

“…3), including for those who would otherwise not engage in testing. [13][14][15][16] Service level Digital health enables remote service delivery, including the provision of health and service information online, the ability for a service user to book appointments and access test kits, and to provide appointment reminders, test results and other information using SMS, email and web applications. Many DHIs, for example, online postal self-sampling services in England, have been developed to provide access to care to those with the least needs remotely in order to free up capacity to see more complex cases in clinic-based service.…”

Thetha Nami: participatory development of a peer-navigator intervention to deliver biosocial HIV prevention for adolescents and youth in rural South Africa

“…Drivers of risk and barriers to effective uptake of multi-level HIV prevention for adolescents and young adults in rural KZN drawn from survey data (n = 4918) and studies conducted 2016-2018[1,6,8,37,40,[43][44][45][46][47][48][49][51][52][53][54][55][56] …”