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

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 <i>stand-alone intervention</i> 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 <i>linkage gap</i> in the HIV treatment cascade.

Effect of a male-targeted digital decision support application aimed at increasing linkage to HIV care among men: Findings from the HITS cluster randomized clinical trial in rural South Africa

“…44 However, some participants did not use the earphones or needed assistance from the study staff to navigate the app. 45 Additionally, due to time constraints for both study staff and participants during household visits, some reported that they did not have sufficient time to explore the app or rushed through navigating the app. 45 Lastly, the number of new HIV diagnoses, and consequently those who were successfully reached and provided with EPIC-HIV 2 was low in this single round of intervention, which would have reduced the power to detect an intervention effect.…”

“…45 Additionally, due to time constraints for both study staff and participants during household visits, some reported that they did not have sufficient time to explore the app or rushed through navigating the app. 45 Lastly, the number of new HIV diagnoses, and consequently those who were successfully reached and provided with EPIC-HIV 2 was low in this single round of intervention, which would have reduced the power to detect an intervention effect. Building upon the high acceptability of the app, strategies to increase the reach and dose, such as offering the app through mobile phones or targeting a larger audience, could be considered in future.…”

“…The results of the process evaluation are published elsewhere. 45 Randomization was conducted to ensure balance across the arms using stratified sampling at the community-level based on the HIV incidence among young females aged 15-30 years.…”

The impact of a conditional financial incentive on linkage to HIV care: Findings from the HITS cluster randomized clinical trial in rural South Africa

“…Results of the process evaluation have been published elsewhere. 38 The trial was registered at the National Institute of Health (ClinicalTrials.gov # NCT03757104), and the complete trial protocol was published elsewhere. 36…”