Adapting mHealth to improve HIV outcomes among older people with HIV in Ukraine

ABSTRACT Among the 5.5 million older people (>50 years) with HIV (OPWH), 80% live in low- and middle-income countries (LMIC). Ukraine, an emblematic LMIC in Eastern Europe and Central Asia (EECA), is the only world region with increasing HIV incidence and mortality. Among the 240,000 PWH in Ukraine, OPWH account for 15% of people with newly diagnosed HIV annually but OPWH are significantly less likely to initiate ART and be retained in care, compared to younger people with HIV. Consequently, mortality among OPWH is significantly higher than the age-matched general population. Key barriers to ART engagement for OPWH include stigma, social isolation and multimorbidity including depression. Our previous work demonstrates that OPWH in Ukraine crave giving and receiving peer support, are interested in mHealth options to increase social engagement and belonging within a community, and have capacity for smartphone use. PositiveLinks is an established mHealth platform demonstrated to effectively improve virologic outcomes in people living with HIV in the United States and in Russia, another higher-income country where it has been successfully piloted. This app delivers appointment reminders, daily queries (“check-ins”) of mood, stress and medication adherence, tailored educational resources, and the opportunity to interact with other users on a secure, anonymous community message board (CMB). We propose to adapt PositiveLinks for use in OPWH, for the Ukrainian LMIC context, and to incorporate into the mHealth platform a culturally appropriate depression screening with subsequent brief intervention and referral (SBIRT) to clinical evaluation. In the R21 phase, we will perform focus groups discussions with OPWH and key informant interviews with clinicians and clinic administrators to identify components to retain in the adaptation that are important for OPWH to meaningfully engage in HIV care. We will perform alpha and beta testing of PositiveLinks Ukraine to evaluate usability and functionality by OPWH to ensure that the R21 deliverable is a tailored, fully interactive app supported by local stakeholders. In the R33 phase, we will perform an individually randomized controlled trial among 240 OPWH, who are newly diagnosed or on ART without viral suppression, randomized 1:1 to the PositiveLinks Ukraine intervention versus treatment as usual, to evaluate a) feasibility using a validated framework, b) multilevel acceptability (OPWH, clinicians, clinic administrators, and policy makers), and c) efficacy examining viral load suppression at 12 months and secondarily ART initiation, retention at 12 months, VL suppression at 6 months, and time to ART initiation. These findings will provide key data necessary to design and conduct further mHealth implementation research within HIV care in Ukraine. Through this work, we will also stimulate capacity in mHealth through the development of a Consortium for mHealth Innovation and Intervention.