Smartphone-Based Contingency Management Intervention to Improve Pre-Exposure Prophylaxis Adherence: Pilot Trial

Abstract

BackgroundPre-exposure prophylaxis (PrEP) provides a strong preventative benefit to individuals at risk for HIV. While PrEP adherence is highly correlated with its efficacy, adherence rates are variable both across and within persons.ObjectiveThe objective of this study was to develop and pilot-test a smartphone-based intervention, known as mSMART, that targets PrEP adherence. mSMART provides contingency management in the form of monetary incentives for daily PrEP adherence based on a real-time adherence assessment using a camera-based medication event-monitoring tool as well as medication reminders, PrEP education, individualized behavioral strategies to address PrEP adherence barriers, and medication adherence feedback.MethodsThis was a 4-week open-label, phase I trial in a community sample of young men who have sex with men already on PrEP (N=10).ResultsAlthough adherence composite scores corresponding to PrEP biomarkers indicated that 90% (9/10) of the sample already had an acceptable baseline adherence in the protective range, by the end of the 4-week period, the scores improved for 30% (3/10) of the sample—adherence did not worsen for any participants. Participants reported mean PrEP adherence rates of 91% via daily entries in mSMART. At the end of the 4-week period, participants indicated acceptable ratings of satisfaction, usability, and willingness to recommend mSMART to others. There were no technical difficulties associated with smartphone compatibility, user misunderstandings about mSMART features that interfered with daily use, or study attrition.ConclusionsThis study is the first to apply contingency management to PrEP adherence. Findings indicated that mSMART is feasible and acceptable. Such an adherence intervention administered via a user-friendly smartphone app can allow for widespread dissemination. Future efficacy trials are needed.Trial RegistrationClinicalTrials.gov NCT02895893; https://clinicaltrials.gov/ct2/show/NCT02895893 (Accessed by Webcite at http://www.webcitation.org/72JskjDJq)

Youth‐friendly services and a mobile phone application to promote adherence to pre‐exposure prophylaxis among adolescent men who have sex with men and transgender women at‐risk for HIV in Thailand: a randomized control trial

“…There are studies in adolescent HIV prevention research with preliminary data suggesting the feasibility and acceptability of apps in supporting PrEP adherence, however, trial results on efficacy are pending [51‐54]. The “Raincoat” app used in this trial did not show efficacy in PrEP adherence or service retention.…”

Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Men Who Have Sex with Men (MSM): A Scoping Review on PrEP Service Delivery and Programming

“…Technology-based interventions were reported in five studies and they can be viewed as uniting the micro- and mesosystem levels . These technologies were considered to be useful for service users and providers for setting reminders, [ 92 , 103 , 106 , 112 , 130 ] monitoring and surveillance (particularly those with a high risk of contracting HIV), [ 52 , 91 , 112 ] education and information, [ 82 , 102 , 106 , 130 ] tailoring care, [ 102 ] providing counselling, [ 52 , 66 , 77 , 107 , 131 ] adherence, [ 53 , 67 , 73 , 79 , 89 , 91 – 93 , 103 , 106 , 111 , 112 , 131 , 132 ] recording dosing regimen (event-based, intermittent or daily), [ 93 , 106 , 112 , 132 ] allowing individuals to feel connected and even providing maps that show where PrEP is offered in the local area [ 106 , 133 ]. In their studies, Refugio et al [ 130 ], Stekler et al [ 107 ] and Fuchs et al [ 89 ] implemented a text-based support strategy, which allowed participants to send messages, set reminders, download and receive information, abate stigma and enable staff to provide additional support throughout the PrEP user’s journey.…”

“…Tellalian et al [63] and Stekler et al [107] identified that service level support was needed in order to improve correct use of PrEP, adherence and retention. Other barriers to PrEP adherence at service user level included medication concerns, for example the pill being too big or tasting unpleasant, [108] missing clinics, [109] forgetting to take medication [54,75,103,110] and cost [111,112]. Disruption in routine was also reported [54,93,103,108] but Vaccher et al [103] stated that this could be reduced by carrying spare medication for emergencies.…”

PrEP discontinuation among Latino/a and Black MSM and transgender women: A need for PrEP support services

“…Intervention trials are underway to test simple mobile technology products (e.g., text messaging services, mobile applications) to support PrEP adherence [25][26][27]. In addition, there are ongoing investigations of alternative dosing strategies (e.g., intermittent dosing) that may be more acceptable and manageable for persons unable to adhere to daily dosing [28,29]. A long-acting injectable version of PrEP (Cabotegravir) is also awaiting approval by the US Food and Drug Administration and may prove useful for individuals who experience difficulty taking a daily medication [32].…”