Do digital innovations for HIV and sexually transmitted infections work? Results from a systematic review (1996-2017)

Abstract

ObjectiveDigital innovations with internet/mobile phones offer a potential cost-saving solution for overburdened health systems with high service delivery costs to improve efficiency of HIV/STI (sexually transmitted infections) control initiatives. However, their overall evidence has not yet been appraised. We evaluated the feasibility and impact of all digital innovations for all HIV/STIs.DesignSystematic review.Setting/participantsAll settings/all participants.InterventionWe classified digital innovations into (1) mobile health-based (mHealth: SMS (short message service)/phone calls), (2) internet-based mobile and/or electronic health (mHealth/eHealth: social media, avatar-guided computer programs, websites, mobile applications, streamed soap opera videos) and (3) combined innovations (included both SMS/phone calls and internet-based mHealth/eHealth).Primary and secondary outcome measuresFeasibility, acceptability, impact.MethodsWe searched databases MEDLINE via PubMed, Embase, Cochrane CENTRAL and Web of Science, abstracted data, explored heterogeneity, performed a random effects subgroup analysis.ResultsWe reviewed 99 studies, 63 (64%) were from America/Europe, 36 (36%) from Africa/Asia; 79% (79/99) were clinical trials; 84% (83/99) evaluated impact. Of innovations, mHealth based: 70% (69/99); internet based: 21% (21/99); combined: 9% (9/99).All digital innovations were highly accepted (26/31; 84%), and feasible (20/31; 65%). Regarding impacted measures, mHealth-based innovations (SMS) significantly improved antiretroviral therapy (ART) adherence (pooled OR=2.15(95%CI: 1.18 to 3.91)) and clinic attendance rates (pooled OR=1.76(95%CI: 1.28, 2.42)); internet-based innovations improved clinic attendance (6/6), ART adherence (4/4), self-care (1/1), while reducing risk (5/5); combined innovations increased clinic attendance, ART adherence, partner notifications and self-care. Confounding (68%) and selection bias (66%) were observed in observational studies and attrition bias in 31% of clinical trials.ConclusionDigital innovations were acceptable, feasible and generated impact. A trend towards the use of internet-based and combined (internet and mobile) innovations was noted. Large scale-up studies of high quality, with new integrated impact metrics, and cost-effectiveness are needed. Findings will appeal to all stakeholders in the HIV/STI global initiatives space.

Strengthening Delivery of Health Services Using Digital Devices

“…All of these studies were conducted in high-income countries. Daher et al 50 conducted a systematic review and meta-analysis of 99 studies published from 1996 to 2017, and found that SMS interventions improved antiretroviral therapy adherence with pooled odds ratio (OR) of 2.15 (95% confidence interval [CI], 1.18 to 3.91) and clinic attendance rates with pooled OR of 1.76 (95% CI, 1.28 to 2.42). However, the authors did acknowledge that misclassification bias and recall bias were high (58% bias among randomized controlled trials and 64% among quasi-randomized trials) and raised concern regarding the quality of studies included in the meta-analysis.…”

Alone But Supported: A Qualitative Study of an HIV Self-testing App in an Observational Cohort Study in South Africa

“…mHealth strategies, which are described as mobile communications technology used to deliver health care [16], can help surmount issues related to logistics, culture and economics for groups that are either medically or socially marginalized [17]. In the context of HIV care, mHealth strategies have been effective in increasing clinic attendance, treatment adherence and turnaround time from testing to treatment [18]. Furthermore, strategies which utilize mobile technologies for HIV self-testing have been shown to support linkage to care [19,20].…”

Evaluation of smartphone APP-based case-management services among antiretroviral treatment-naïve HIV-positive men who have sex with men: a randomized controlled trial protocol

“…In this scenario, APP-based mHealth interventions have the potential to improve service delivery and positively affect patient outcomes [23]. Smartphones are more portable than computers, and together with their accessibility and intensive daily use by many people, they can enable point-to-point individualised interventions and help reduce some societal and structural barriers faced by stigmatised populations [28]. This study protocol provides a clear and thorough description of an APP-based mHealth intervention and will be used to investigate the effectiveness of mHealth intervention and underlying mechanisms.…”

“…Currently, smartphones are used by 68% of the population in China [24], with up to 97.5% of MSM having a smartphone [25]. Adherence-supporting interventions incorporating mHealth have shown good acceptability and feasibility in HIV-positive MSM [26], and demonstrated efficacy in improving PLWHA's linkage to care, retention in treatment and adherence to ART [27,28]. However, to the authors' knowledge, mHealth interventions to improve the adherence of HIV-positive MSM to ART and potential mechanisms of how an intervention works have not been fully explored in China, and many mHealth interventions have mainly relied on text messages [29].…”