editorial using mobile health technology to improve hiv...

Hindawi Publishing CorporationAIDS Research and TreatmentVolume 2013, Article ID 194613, 3 pageshttp://dx.doi.org/10.1155/2013/194613

EditorialUsing Mobile Health Technology to Improve HIV Care forPersons Living with HIV and Substance Abuse

Gregory D. Kirk,1 Seth S. Himelhoch,2 Ryan P. Westergaard,3 and Curt G. Beckwith4

1 Departments of Epidemiology & Medicine, Johns Hopkins University, Baltimore, MD 21205, USA2Department of Psychiatry, University of Maryland, Baltimore, MD 21201, USA3Division of Infectious Diseases, University of Wisconsin-Madison, Madison, WI 53792, USA4Division of Infectious Diseases, The Miriam Hospital/Alpert Medical School of Brown University, Providence, RI 02912, USA

Correspondence should be addressed to Gregory D. Kirk; [email protected]

Received 10 November 2013; Accepted 10 November 2013

Copyright © 2013 Gregory D. Kirk et al.This is an open access article distributed under theCreative CommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Mobile phone technology has a growing and pervasiveinfluence on society, with >6 billion mobile phone sub-scribers worldwide. Round-the-clock connectedness increas-ingly represents the norm and smartphones are ubiquitousin many sectors of society. As costs for these technologiesdecrease, expansion into populations with more limitedresources is increasing. With many persons now routinelycarrying a portable computing and communication device,adaptation of these mobile technologies for monitoring orimproving health has been touted as a revolution in healthcare [1, 2]. Mobile health, or mHealth, has been broadlydefined as medical or public health practice supported bymobile devices.The purpose of this special issue is to providea research and implementation update on the incorporationof mHealth approaches to improve health outcomes amongpersons living with HIV/AIDS (PLWHA) and substance use.

PLWHAwho are drug and alcohol users facemany healthchallenges including delayed HIV diagnosis, delayed linkageto care, difficulty with adherence to antiretroviral treatment(ART), poorer virologic control, and difficulties with long-term retention in care, compared to nonsubstance users[3, 4]. Substance use may often be associated with otherbarriers to optimal care (e.g., mental illness, financial andlegal difficulties, and inadequate housing and transportation)[5]. Several strategies to improve HIV care among personswith substance abuse have been identified (e.g., multidisci-plinary case management, peer navigation) but often requiresubstantial resources. Novel, affordable, and evidence-basedstrategies that are feasible to implement are needed to identifysubstance-using persons at risk for poor outcomes, promote

engagement in HIV care, enhance adherence, and improvetreatment responses.

As with most chronic diseases that rely on adherence toprescribed medical regimens or lifestyle modifications, theunderpinnings of optimal HIV care include enhanced capac-ity for self-management by patients. mHealth strategies holdgreat promise to transform the approach to HIV care. Real-timemonitoring of PLWHAwithmHealth devices can gener-ate dynamic, individualized models of behavior and providea foundation to inform health behavior change strategies.Technology can empower patients, with direct delivery ofindividualized motivation, education, and support. mHealthstrategies will likely be significantly represented in evolvingmodels of care delivery. Wireless technologies remove thebarriers of time and distance between patients and providers;this is especially important for substance-using PLWHA andother populations that are hard to reach and difficult to keepengaged in care.Hopefully,mHealth approacheswill facilitateHIV care providers to work more effectively and be able tocollect higher quality data related to care delivery and healthoutcomes.

While mHealth holds great promise, this nascent fieldremains in early stages of development [6]. Current mHealthinterventions to support HIV care have been largely cen-tered in resource-limited countries. Strategies most widelyemployed have focused on supporting care providers inremote settings and providing text message support to HIVpatients. A growing evidence base indicates that weekly textmessages can improve ART adherence and viral suppression[7]. Text messaging appears to work best when the message

2 AIDS Research and Treatment

is individually tailored, context-sensitive, and associated withfollow-up intervention. In response to these accumulatingdata, UNAIDS has recommended that mHealth approachesbe incorporated into national HIV care programs. As thenext step, smartphone interventions will expand the abilityto collect intensive, real-time data from patients, providetailored education or counseling, and facilitate responsive,interactive communication.

To date, mHealth studies which focus on HIV-infectedpopulations with substance abuse have been limited. In thisspecial issue, eight manuscripts provide an assessment of thescope of mHealth strategies employed among marginalized,substance-using PLWHA.Consistent with the current state ofthe field, the studies largely represent early stage evaluationsof applying novel technology in diverse populations.

Conducting research studies among vulnerable popula-tions such as persons with HIV or substance abuse raises sev-eral ethical issues. Further, mHealth approaches that collectdata from and/or deliver interventions to participants duringtheir daily routine also pose unique ethical considerations.Dr. A. B. Labrique and colleagues apply a widely acceptedethical framework to describe a range of ethical issuessalient to protection of participants in mHealth research onHIV/AIDS and substance abuse.

Several manuscripts in this special issue report on theacceptability, feasibility, and implementation of mHealthapproaches. Dr. C. W. T. Miller and Dr. S. Himelhoch reporthigh levels of ownership and interest in using mobile phonesamong patients at an urban HIV clinic to help support andimprove adherence to ART. Dr. K. J. Horvath and colleaguesreport that while methamphetamine-using men who havesex with men (MSM) had poorer engagement in HIV care,their use of social media and mobile phone technologies wascomparable to nonstimulant using MSM, thus raising thepossibility of using mHealth in this population.

A major focus of mHealth interventions amongsubstance-using PLWHA is to facilitate ART adherence.Among methamphetamine users studied by Dr. D. J. Mooreand colleagues, daily texts were sent to assess drug use andART adherence. In the preliminary analysis, the proportionof texts responded to and both qualitative and quantitativeassessments of acceptability indicate favorable responses byparticipants. Among HIV-infected IDUs receiving ART inChina, Dr. M. B. DeSilva and colleagues evaluated real-time,wireless adherence monitoring using the Wisepill system.Overall, their findings were promising with only minortechnical issues and participant feedback highlighting theneed for unobtrusive technologies.

Novel intervention strategies which can capture andrespond to illicit drug use in realtime can provide a frame-work for improving engagement and adherence to HIV care.Dr. K. A. Phillips and colleagues report preliminary data froma study of video-based, risk reduction messaging deliveredthrough a smartphone to opioid-dependent patients in drugtreatment. Nested within a larger mHealth study in thispopulation, the authors demonstrated the feasibility andacceptability of delivering educational video content as wellas capturing feedback in drug users’ natural environments.Dr. G. D. Kirk and colleagues report on implementation of

ecological momentary analysis (EMA)methods usingmobiledevices among persons with a history of injecting drugs.During an intensive one-month study period, participantsreported drug craving and use in realtime and displayedhigh levels of response to multiple daily EMA questionnairesregarding their mood, activity, and social and physical envi-ronment. Finally, Dr. A. Kurth and colleagues describe anmHealth intervention focused on PLWHA involved in thecriminal justice system. In an ongoing randomized controlledtrial, computer-delivered counseling is combined with textmessaging to improve linkage, retention, and ART adherenceduring the critical transition following release from correc-tional settings.

The populations under study in this special issue arehighly diverse. Several studies focus on marginalized IDUpopulations from urban settings in the US. Two stud-ies evaluate mHealth approaches among MSM who abusemethamphetamine. Another study examines technology-enhanced ART adherence support among IDUs in China.Implementation into these disparate populations emphasizesthe broad reach of mHealth to cross socioeconomic, racial,or geographic boundaries. Further, successful demonstrationof mHealth strategies in these diverse groups bodes wellfor implementation into other HIV and substance-usingpopulations.

To summarize the findings reported in this specialissue, despite the field being in early stages of development,mHealth holds substantial promise for optimizing HIV careand improving adherence to treatment. These strategiesappear feasible and acceptable even among challenging,marginalized populations confronted by HIV and substanceuse. The next steps in development of mHealth interven-tion strategies will be challenging [8]. Substantial work isneeded to develop the theoretical frameworks underpinningmHealth interventions. Further efforts will be required torefine real-time data collection and analysis procedures,identify the best methods for delivering context-sensitiveinterventions, maintain patient confidentiality, and deter-mine themost appropriatemethods for defining effectivenessin mHealth. Challenges exist regarding data security, stayingcurrent with rapidly evolving technologies, and best prac-tices for interaction with market-driven industry partners.Despite these challenges, we remain strongly enthusiastic thatincreasingly available and affordable mHealth tools will con-tinue to evolve and provide successful strategies to improveHIV care outcomes among PLWHA and substance abuse.

Gregory D. KirkSeth S. Himelhoch

Ryan P. WestergaardCurt G. Beckwith

References

[1] F. Collins, “The real promise of mobile health apps,” ScientificAmerican, vol. 307, no. 1, p. 16, 2012.

[2] VitalWave Consulting,mHealth for Development:TheOpportu-nity ofMobile Technology forHealthcare in theDevelopingWorld,UN Foundation-Vodafone Foundation Partnership, Berkshire,UK, 2009.

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[3] R. P. Westergaard, T. Hess, J. Astemborski, S. H. Mehta, and G.D. Kirk, “Longitudinal changes in engagement in care and viralsuppression for HIV-infected injection drug users,” AIDS, vol.27, no. 16, pp. 2559–2566, 2013.

[4] G. M. Lucas, K. A. Gebo, R. E. Chaisson, and R. D. Moore,“Longitudinal assessment of the effects of drug and alcoholabuse on HIV-1 treatment outcomes in an urban clinic,” AIDS,vol. 16, no. 5, pp. 767–774, 2002.

[5] F. L. Altice, A. Kamarulzaman, V. V. Soriano, M. Schechter,and G. H. Friedland, “Treatment of medical, psychiatric, andsubstance-use comorbidities in people infected with HIV whouse drugs,”The Lancet, vol. 376, no. 9738, pp. 367–387, 2010.

[6] A. Labrique, L. Vasudevan, L. W. Chang, and G. Mehl, “H pefor mHealth: more, “y” or, “o” on the horizon?” InternationalJournal of Medical Informatics, vol. 82, no. 5, pp. 467–469, 2013.

[7] T. Horvath, H. Azman, G. E. Kennedy, and G. W. Rutherford,“Mobile phone text messaging for promoting adherence toantiretroviral therapy in patients with HIV infection,”CochraneDatabase of Systematic Reviews, vol. 3, Article ID CD009756,2012.

[8] S. Kumar, W. J. Nilsen, A. Abernethy et al., “Mobile healthtechnology evaluation: the mHealth evidence workshop,” TheAmerican Journal of Preventive Medicine, vol. 45, no. 2, pp. 228–236, 2013.

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