PositiveLinks is a mobile intervention for people with HIV, which includes use of a custom smartphone app that can be tailored to the needs and preferences of participants. The intervention was created to improve linkage and retention in care, as well as improve clinical outcomes, in a rural population of people with HIV living in the southern United States.
Pilot study participants were newly diagnosed with HIV (within 90 days of study enrolment), returning to care after a lapse, or at risk for falling out of care, and study results indicate significantly improved treatment retention and consistency of visits within a year, as well as significantly improved CD4 and viral load counts.
PositiveLinks Program Description1,2
The pilot of the PositiveLinks intervention was affiliated with the Ryan White HIV Clinic at the University of Virginia and was informed by research suggesting that people with HIV prefer mobile health interventions and appreciate tailored bidirectional communication. The smartphone intervention provides the opportunity for participants to connect with peers for support through an app and accommodates for low literacy levels. New content was added to components of the app over the 12-month study period, and app content included:
- tailored educational resources (e.g., orientation to the clinic, HIV-related health information, stress reduction techniques);
- daily queries related to stress, mood, and medication adherence;
- weekly quizzes;
- contact information for the clinic-affiliated study team, which participants could use for individualized counselling and assistance;
- appointment reminders; and
- a community message board (CMB) where participants could leave or respond to messages. CMB content was monitored by the study team for misinformation and participants were advised not to use identifying information when participating.
Participants were provided with a smartphone when they enrolled in PositiveLinks with the app installed and an unlimited voice and data plan for 12 months. Participants received smartphone and app training, if required. Both the phone and app were password secured and consent addressed potential privacy risks.
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Participants were mostly male (64%) (34% female; 3% transgender male to female); 49% were black non-Hispanic, 34% were white non-Hispanic, and 8% were Hispanic. Approximately 25% of participants had unstable housing and more than half of participants reported an income between 0 and 49% of the federal poverty level. Study results indicate that 40% of participants showed sustained use of the app.
The study looked at retention in HIV care, visit constancy, and clinical outcomes in 77 enrolled participants at baseline and at six and 12 months.
- The average response rates to the daily queries that assessed medication adherence, mood, and stress levels were 50%, 47%, and 47%, respectively, at six months and 41%, 39%, and 39%, respectively, at 12 months. The average response rates to weekly quizzes assessing general and HIV-specific knowledge were 43% at six months and 37% at 12 months.
- There were significant improvements in retention (i.e., keeping two appointments with an HIV provider separated by 90 days within a year) at six months (88%) and 12 months (81%) compared with baseline (51%).
- There were significant improvements in visit constancy (i.e., the proportion of four-month time internals in which one visit with an HIV provider was completed in one year) at six months (36%) and 12 months (51%) compared with baseline (22%).
- Mean CD4 counts significantly increased to 581 cells/mm3 at six months and 614 cells/mm3 at 12 months compared with baseline (522 cells/mm3).
- Mean viral load significantly decreased to 14,912 copies/mL at six months and 13,890 copies/mL at 12 months compared with 23,682 copies/mL at baseline. Additionally, the percentage of participants who were virally supressed (<200 copies/mL) significantly increased at six months (87%) and 12 months (79%) compared with baseline (47%).
What Does This Mean for Service Providers?
PositiveLinks provides an example of a mobile app that was effective at increasing engagement and improving treatment outcomes in participants in rural communities. A similar intervention could be adopted in other locations with similar population characteristics. This intervention used "warm technology," which facilitates human contact and may have been an important component of its success and sustained usage.
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- Dillingham R, Ingersoll K, Flickinger TE, et al. PositiveLinks: a mobile health intervention for retention in HIV care and clinical outcomes with 12-month follow-up. AIDS Patient Care and STDs. 2018;32(6).
- Flickinger TE, DeBolt C, Xie A, et al. Addressing stigma through a virtual community for people living with HIV: a mixed methods study of the PositiveLinks mobile healthiIntervention. AIDS and Behavior. 2018 Jun 7.
[Note from TheBodyPRO: This article was originally published by CATIE in Sept. 2018. We have cross-posted it with their permission.]