Recommendations for the equitable integration of digital health interventions across the HIV care cascade

Digital health interventions (DHIs) are being increasingly adopted to improve care outcomes and experiences for people living with HIV (PLHIV). Here, we highlight the importance of DHIs in the context of HIV management and recommendations for their equitable integration in the HIV care cascade.

Gogishvili et al highlight the crucial role of digital health interventions (DHIs) in improving HIV care outcomes and experiences. They provide recommendations for the equitable integration of DHIs in the HIV care cascade, emphasizing the need to address the digital divide to ensure inclusive access to healthcare.

With significant advances in treatment, HIV has transitioned from an acute life-limiting illness to a manageable chronic condition, where PLHIV on antiretroviral therapy are able to live near-normal lives with no onward transmission of their HIV¹. However, to maintain the benefits conferred by treatment, life-long medication adherence is required¹. This can be challenging for many PLHIV for numerous reasons, including experience of adverse side-effects, fear or experience of stigma and discrimination, and the complexity of some treatment regimens². For vulnerable populations (e.g., men who have sex with men, transgender people, people who use drugs, sex workers, prisoners, and migrants), challenges around mental health, finances (e.g., lack of a secure job), home stability, and access to health insurance further complicate their ability to adhere to their HIV treatment^2–4.

To address some of these challenges and, ultimately, improve long-term treatment adherence, the World Health Organization (WHO) strongly recommends harnessing the potential of DHIs³. These recommendations for DHI integration were developed through a review of the literature and communication with knowledge experts via a Wilton Park consultation⁵. Wilton Park consultations are high-level meetings that bring together policymakers, health experts, and practitioners from around the world to discuss and develop strategies on pressing global issues. The topic of DHIs in HIV management was chosen due to the growing recognition of their potential to significantly improve health outcomes and the need to ensure their equitable integration into healthcare systems.

Importance of DHIs in HIV management

DHIs refer to technologies such as wearable devices (e.g., smartwatches, fitness trackers), mobile phones (e.g., that enable remote delivery of healthcare services), and artificial intelligence (e.g., chatbots, tools for medical screening and diagnosis). These can be used to manage health and well-being, implement health interventions, and conduct disease surveillance^6,7. Notably, the COVID-19 pandemic highlighted not only the potential utility and efficacy of incorporating DHIs into healthcare systems, but also demonstrated the capacity to integrate such innovations into care efficiently regardless of country income classification^8–10. This underscores the potential for DHIs to bridge gaps in healthcare access, thereby promoting equity within health systems.

As momentum towards adopting DHIs in HIV care accelerates around the world, early evidence demonstrates its potential and highlights its effectiveness^6,10–13. For example, DHIs have improved HIV awareness^6,10, healthy sexual behavior^6,11, HIV care and medication adherence^11,12, and overall access to HIV care and testing services for PLHIV¹³. DHIs can also be used to implement patient-reported outcome measures for the routine assessment of quality of life (QoL) among various cohorts of PLHIV, which is widely recognized as being important for further progress in HIV care and research^1,2,14,15. The use of DHIs in HIV care began well before the COVID-19 pandemic, for instance, mobile health applications and SMS-based reminders have been employed to improve medication adherence and appointment attendance among PLHIV, while telehealth services have facilitated remote consultations and follow-ups, particularly benefiting those in remote or underserved areas^10–13. Interest in the use of DHIs increased following the physical distancing and lockdown measures during the pandemic¹⁶. Early adoption of DHIs demonstrated their effectiveness in enhancing patient engagement, monitoring, and support, setting a foundation for their expanded use during and after the pandemic.

Towards equitable integration of DHIs in HIV care

Despite the benefits DHIs offer PLHIV and staff within healthcare systems, adopting such tools into routine clinical care is challenging and may exacerbate health access inequities¹⁷. Specifically, healthcare seekers who do not have easy and consistent access to technology (e.g., smartphones and WIFI/cellular data) in a safe and secure manner, may not be able to attain essential information or care if it is only available digitally^6,12. This is referred to as the digital divide¹⁸. Furthermore, research among PLHIV indicates that digital privacy, cyber security, and data ownership are important considerations for this population¹⁹. Since 2020, various studies have examined the efficacy of DHIs during the pandemic^20–22; however, few assessed the challenges faced and disparities created, while using DHIs, except during a pandemic when normal living conditions were disrupted^23,24. To support equitable integration of DHIs, evidence-informed guidelines and tools are necessary. The development of such strategies and guidelines requires detailed and nuanced understanding of DHIs and the inequities they create^{10,16,18,22–24}, which could ultimately enhance efficacy in HIV prevention, testing, treatment, and retention.

Now that we are moving to use digitalized healthcare more widely, it is of utmost importance that we build on the lessons learned and innovations developed during the COVID-19 pandemic to optimize healthcare provision for PLHIV through DHIs. However, as we continue to push for an equity-focused approach to ending the HIV/AIDS epidemic, we must strive to ensure that the digital divide is not furthered by DHI integration.

We provide 19 recommendations that we propose could further the equitable integration of DHIs into routine care and management, (Table 1). The recommendations start with proposals that could reduce costs. We also include recommendations for each part of the HIV care cascade, i.e., to improve prevention, diagnosis, linkage-to-care, treatment, and retention of PLHIV within care. The overall purpose of these recommendations is to drive global policy directives for the equitable integration of DHIs in the HIV field and to serve as a starting point for the responsible implementation of DHIs and development of international guidelines.

Table 1.

Recommendations for the equitable integration of DHIs across steps of the HIV Care Cascade

#	Recommendations	Ref
Cross-cutting considerations applicable at all stages of the HIV care cascade
1	Scale-up and support interoperable health information systems through networks of partners (e.g., public and private health system administrators, device manufacturers, pharmacies).	7,17
2	Meaningfully involve PLHIV in the design of DHIs to address privacy concerns (e.g., confidential communication channels that provide PLHIV with a space to talk openly and safely).	19
3	Prioritize research that assesses the quality of DHIs with PLHIV users.	17
4	Provide widespread and affordable internet access (e.g., WiFi and data plans).	17,18
5	Develop an international regulatory framework to ensure secure and equitable access to DHIs.	17
HIV prevention
6	Micro-target at-risk communities with outreach efforts on HIV education, prevention, and testing services through DHIs.	25–27
7	Use artificial intelligence (AI) to develop HIV prevention interventions (e.g., HIV risk prediction, social network mapping).	26,27
8	Use DHIs to promote uptake and to facilitate access to pre-exposure prophylaxis (PrEP) among key populations.	6
Diagnosis
9	Leverage real-time data collection and predictive machine learning to support a syndromic approach to early HIV detection.	26,27
10	Offer digital options to order self-testing kits free-of-charge.	25
Linkage to treatment and care
11	Invest in digital tools to aid personalised HIV treatment initiation and adherence support.	28
12	Invest in digital tools to aid HIV service awareness and access (e.g., maps with pinpoints for HIV services and organizations).	28
13	Enhance community-based linkage-to-care with digital and virtual support networks.	6,29
Routine care (e.g., retention, viral suppression, quality of life)
14	Invest in tools to enhance linkage to services beyond HIV-related needs, which are known to impact one’s HIV management and long-term well-being (e.g., resources for finding jobs, housing, and language-learning services).	4,30
15	Implement remote monitoring interventions that use patient-reported outcome and experience measures (PROMs/PREMs) to better identify and respond to clients’ challenges and concerns.	15,31
16	Invest in the development and integration of chatbots and other AI tools to support HIV self-management and to reduce burden on health personnel.	32
17	Offer optional telemedicine services to improve follow-up between clients and health professionals.	20,22
18	Offer digitalised access to mental health services, including virtual therapy or counselling services.	28
19	Use machine learning algorithms to predict poor viral load and CD4 outcomes to inform care management practices.	33

Conclusion

DHIs hold immense promise for enhancing the lives of PLHIV through improved treatment adherence, facilitated access to healthcare, and the use of patient-reported outcomes in modern HIV management. However, challenges may stymie health systems’ abilities to realize these benefits, including interoperable implementation with health information systems and equitable access, particularly for vulnerable populations who may face barriers such as lack of technology access, digital privacy concerns, and data security issues. To achieve the full benefits of DHIs, it is crucial to develop and implement evidence-informed guidelines that prioritize inclusivity and address the digital divide in HIV care and management.

Author contributions

J.V.L. contributed to the conceptualization and design of the study. A.K.A. and M.G. conducted the primary literature review and data analysis. T.M.W. conducted data interpretation. A.K.A., M.G., and T.M.W drafted the manuscript. J.V.L. provided critical revisions. All authors reviewed and approved the final manuscript.

Competing interests

J.V.L. has received speaker fees from Echosens, Gilead Sciences, Moderna, Novo Nordisk, Novovax, Pfizer and ViiV, and grants from Echosens, Boehringer Ingelheim, Gilead Sciences, GSK, Madrigal Pharmaceuticals, Novo Nordisk, and Roche Diagnostics, outside the submitted work. All other authors declare no competing interests.