A scoping review of mobile health for ART adherence in pregnant and breastfeeding women with HIV in sub-Saharan Africa: preferences, acceptability, and privacy concerns

Abstract

Background

Interventions involving Mobile Health (mHealth) have shown promise to improve retention in care and adherence to antiretroviral therapy (ART) among pregnant or breastfeeding women living with HIV (PBWLH). However, there are concerns surrounding the message preferences, acceptability, and confidentiality. This study aims to map and summarize the available evidence on the use of mHealth interventions in HIV care, especially ART adherence and retention in care, among PBWLH in sub-Saharan Africa, as well as their preferences, acceptability, and privacy concerns about these mHealth interventions.

Methodology

This scoping review was conducted through a comprehensive search using PubMed, Google Scholar, Scopus, and AJOL following PRISMA-ScR guidelines. Search terms included combinations of “mHealth,” “telehealth,” “SMS,” “pregnant,” “HIV,” “Breastfeeding,” and “sub-Saharan Africa” using Boolean operators (AND, OR). Studies were assessed for eligibility, ensuring that only primary studies focusing on mHealth in PBWLH in sub-Saharan Africa were included.

Results

A total of 10 eligible studies were included, including randomized controlled trials (RCTs), qualitative studies, and mixed-methods research. The sample sizes ranged from 20 to 825 participants, focusing on PBWLH in sub-Saharan Africa. The mHealth tools included SMS-based texts and phone calls. Most participants preferred covert messages when compared with overt messages due to privacy concerns such as unintentional disclosure of status and phone sharing. Also, there was a high acceptability of mHealth interventions. For the studies on retention in care (n = 5), three studies showed positive impact of mHealth intervention compared to control whereas two studies were not statistically significant. The two studies had a long intervention length compared to the three which showed positive impact.

Conclusion

The acceptability of mHealth interventions among PBLWH in sub-Saharan Africa is high, with a higher preference for covert messages. mHealth shows promise in improving retention in care and ART adherence, however, there are mixed results and insufficient evidence. More randomized controlled trials are needed in other sub-Saharan regions to provide more evidence.

Clinical trial number

Not applicable.

Introduction

Globally, as of 2023, over 1.2 million pregnant women are living with Human immunodeficiency virus (HIV) [1], and Sub-Saharan Africa accounts for more than two-thirds of the affected population worldwide [2]. Also, of the over 6000 new infections that occur daily globally, more than 70% occur in SSA [2]. Since the wake of the 21st century, even though the region has witnessed a significant decline in the incidence of new HIV infections [3], the results are not representative of the entire population. The burden of HIV among pregnant women in sub-Saharan Africa is high, as it is estimated to be 7.22%, only in Nigeria [4]. More concerning is the exposure of infants through vertical transmission. Vertical transmission can occur in the uterus, during childbirth, and after childbirth as a result of breastfeeding [5]. The major risk factor for vertical transmission is poor adherence to antiretroviral therapy (ART) by the mothers [6]. Hence, consistent ART adherence is essential to reduce this risk and provide prophylaxis against HIV exposure [7].

However, gaps exist in adherence to ART therapy among pregnant and breastfeeding women with HIV (PBWLH). In a study conducted to examine the factors contributing to non-adherence to ART therapy in the Eastern Cape, South Africa, unwillingness to disclose status to friends and families, forgetfulness, and fear of stigmatization were the major contributory factors to non-adherence to ART [8]. Similar results occurred in other parts of SSA [8, 9]. Knowledge gaps still exist among pregnant and lactating women on the importance of ART adherence and its role in the prevention of vertical transmission, as well as the reduction of the burden of HIV/AIDS in sub-Saharan Africa.

Digital tools and mobile health (mHealth) have shown promise in improving ART adherence among various populations [10, 11]. Various mHealth platforms, such as SMS, mobile apps, and interactive voice response systems, have been studied in improving adherence to ART in low-resource settings [12, 13]; however, there is a paucity of evidence on its use among PBWLH in sub-Saharan Africa.

Using mHealth is expected to significantly reduce or eliminate factors militating against adherence, such as forgetfulness and clinic attendance fatigue. In a rural community in Uganda, short message services (SMS) were noted to have significantly impacted ART adherence [14]. The same was the case among Men Who Have Sex with Men (MSM), where there was significant acceptability of mHealth, as well as improvement in ART adherence [15].

Despite the promising impact of mHealth in ART adherence, it still presents challenges. In some settings where mHealth interventions were found to impact ART adherence significantly, some of the participants accepted such interventions, while some raised concerns, including unintentional disclosure of status and infringement of privacy. Inasmuch as mHealth is targeted at improving adherence, the tone, message content, messaging style, and frequency of the reminders may impact the success of the intervention [16]. As PBWLH are an important population whose improvement in HIV care and ART adherence is essential to reduce vertical transmission, this is a timely and essential study. Our study considers the users’ preferences, which are important as the success of mHealth interventions depends not only on technological access but also on how well these interventions align with users’ preferences.

In sub-Saharan Africa, where the dual burden of HIV and limited access to health services persists [17], understanding the preferences of end-users is critical to ensure that mHealth interventions are both acceptable and effective. Therefore, it is important to design mHealth interventions that are user-centered, culturally sensitive, and tailored to the preferences and needs of the target population. This study aims to map and summarize the available evidence on the use of mHealth interventions in HIV care, particularly ART adherence and retention in care, among PBWLH in sub-Saharan Africa, as well as their preferences, acceptability, and privacy concerns about these interventions. Given the emerging nature and heterogeneity of studies in this area, a scoping review approach was appropriate to map the existing evidence and inform future research directions. This study provides foundation for future systematic reviews as well as the design of culturally-appropriate and user-centered mHealth interventions for PBWLH to be implemented in Africa.

Methods

Search strategy

Following PRISMA-ScR guidelines [18], we conducted an extensive search on 12th December, 2024 across PubMed, Google Scholar and Scopus and on 7th May, 2025 for African Journal Online (AJOL) using the following Medical Subject Headings (MeSH) terms and keyword combinations including “mobile health,” “telehealth,” “SMS,” “pregnant,” “breastfeeding,” “HIV,” and “sub-Saharan Africa” using Boolean operators (AND, OR). PubMed, Google Scholar, and Scopus were selected for their comprehensive indexing of biomedical, public health, and global health research relevant to HIV interventions, while AJOL was included to capture African-led research that reflects local implementation and user experiences often underrepresented in international indexing platforms.

We also restricted our papers to those published within the last 10 years to capture the most current evidence on the integration of mHealth in ART adherence among PBLWH in sub-Saharan Africa. mHealth interventions received much attention in HIV care across sub-Saharan Africa within the last 10 years. Older studies may not adequately represent current digital health tools or mobile phone usage patterns relevant to PBLWH. After the removal of duplicates, title and abstract screening were conducted independently by two reviewers (C.E.A and C.S.A) using Rayyan.

Studies that met the inclusion criteria were retrieved for full-text review. Also, full-text screening was conducted independently by the same reviewers. Discrepancies at any stage of screening were resolved through consensus or consultation with a third reviewer (I.J.O) to ensure accuracy and reduce potential bias. See Fig. 1.

Fig. 1.

PRISMA flowchart of included studies

Inclusion and exclusion criteria

Inclusion and exclusion criteria were defined to ensure the rigorous selection of research studies for this study, specifically focusing on the mHealth interventions to improve ART adherence among PBWLH in sub-Saharan Africa.

Inclusion criteria

Studies were included if:

• The participants involved pregnant and/or breastfeeding mothers living with HIV in sub-Saharan Africa

• mHealth interventions to improve ART adherence among PBWLH in sub-Saharan Africa were evaluated

• Outcomes included one of the following: ART adherence rates, clinic retention, infant health outcomes, user preferences, acceptability, and privacy concerns

• They were primary studies such as Randomized Controlled Trials, Qualitative Studies, Mixed-Methods study, etc

• They are published within the last 10 years

• They are published in peer-reviewed journals

Exclusion criteria

• Studies not focusing on PBWLH.

• Studies conducted outside sub-Saharan Africa.

• Reviews, conference abstracts, and proceedings were excluded. They were excluded because they often provide insufficient methodological detail or incomplete data on intervention design and outcomes, making them unsuitable for charting within a scoping review framework.

• Studies published ten years after 2024 were excluded to ensure the most recent evidence was evaluated.

• Studies published in any language other than English were excluded.

Data extraction process

After the full-text screening using the pre-defined eligibility criteria, data extraction was conducted. The data extraction process for this study was conducted to ensure the collection of relevant and essential data from the selected research studies. Data was extracted using a form containing columns grouped into: Author and Year, Study Design, Study Objectives, Sample Size, Sample Characteristics, Intervention means, Intervention frequency, Intervention length, Intervention mode of delivery, Outcomes, Key findings and Conclusion. Two independent reviewers (C.E.A and C.S.A) carried out this process to minimize bias and enhance the reliability of the extracted data, and conflicts were resolved by a third reviewer (I.J.O).

Data synthesis and analysis

A narrative synthesis was performed to provide a holistic overview of the data from the selected research studies. This method was chosen due to the heterogeneity of study designs (including qualitative, RCTs, and mixed-methods studies), variations in intervention types (e.g., SMS, phone calls), and differing outcome measures across studies. These differences made statistical pooling inappropriate. This synthesis aimed to identify patterns, trends, and variations in the results of different research studies regarding evaluating the preferences, acceptability, and privacy concerns of using mHealth interventions to improve ART adherence among PBWLH in sub–Saharan Africa. Data were grouped under outcome categories: ART adherence, retention in care, maternal/infant outcomes, message preferences, and privacy concerns. Themes from qualitative studies were identified using thematic analysis and compared across studies. Preferences entailed participant-reported choices regarding message tone, content, timing, and format (e.g., overt vs. covert), while acceptability entailed willingness to engage with or use the intervention, as reported through qualitative feedback. Acceptability levels were interpreted based on authors’ descriptions and participant feedback reported in each study, as no uniform quantitative benchmarks were applicable across studies. Privacy concerns were expressions of worry related to unintentional HIV status disclosure, phone sharing, or unwanted exposure of health information.

The mHealth interventions considered included SMS-based messaging, mobile phone calls, and app-based or web-supported systems, provided they were designed to enhance ART adherence or retention in care among pregnant or breastfeeding women living with HIV.

Quality assessment

The quality assessment was carried out using the Critical Appraisal Skill Program (CASP) Tool (for the randomized controlled trials and qualitative studies), while the Mixed-Methods Appraisal Tool (MMAT) 2018 was used for the mixed-methods study. Two authors (C.E.A and C.S.A) independently assessed each article for risk of bias, and disagreements were resolved by I.J.O.

Results

Summary of included studies

This review included 11 studies, and six of them were randomized controlled trials [19–24]. Other study types included qualitative studies, which used focus group discussions and in-depth interviews (n = 3, 30%) [25–27], and mixed-method approaches (n = 2, 10%) [28, 29].

The sample size range in these studies ranged from 20 to 825 participants. Three of the selected studies included women in the postpartum period and also included their male partners [20, 25, 26]. Kebaya et al. [23] studied the mothers and the infants. Other studies (n = 7, 63.6%) included PBLWH. Most of the studies (n = 9, 81.8%) were done in Kenya. The mobile health interventions utilized were SMS-based (9 studies), with only two studies involving mobile calls [21, 23]. Also majority of the studies used an asynchronous mode of contact (9 studies), while the synchronous mode was used in two studies [21, 23].

Preferences, acceptability, and privacy concerns of mHealth intervention

Participants described mHealth as a supportive tool that helped with appointment reminders, ART adherence and psychosocial support. Five studies assessed acceptability and found a high acceptability of the intervention among the participants [25–29]. In Musoke et al., participants also viewed text messaging as a means of improving the use of antenatal care services [25]. In Mabachi et al. and Fairbanks et al. participants viewed the messages as helpful in improving motivation and retention to care [26, 27]. Participants also revealed the role of partner support in influencing acceptability, as their male partners need to be adequately informed about the intervention [25].

Preferences were mainly influenced by how comfortable the participant was in receiving the messages due to status disclosure, privacy concerns, and phone-sharing dynamics. Covert messaging was preferred by participants in Musoke et al., Mabachi et al., Fairbanks et al., and Nachega et al. [25–28]. Although the evaluation of preference between overt vs. covert messaging was not a primary outcome in Ngowi et al., [29], some participants still hinted that they preferred covert messaging. In these studies, covert messaging style utilized neutral or euphemistic language that avoided explicit mention of HIV or ART. This preference was more pronounced among women who had not disclosed their status to family and partners, or shared phones with others [25–29]. In Ronen et al., however, 31.3% preferred covert-only SMS messaging while 66.1% still opted for overt HIV-related messages, especially when they had disclosed their status [19].

Impact on ART adherence and retention outcomes

The impact of mHealth on adherence rates demonstrated by Musoke et al., Mabachi et al., Fairbanks et al., Finocchario-Kessler et al., and Nachega et al. [24–28] show that the participants recognized that mHealth interventions will positively influence their adherence rates. Ngowi et al.’s study also demonstrated that SMS intervention improved self-reported ART adherence after 6 months using participants’ replies of “YES” as a metric (99%) [29].

Kebaya et al. 2021 [23] demonstrated the improvement in adherence rates, with the rates at 6 weeks of follow-up in the intervention arm and the control arm being 90.7% and 72%, respectively (p = 0.005). Sarna et al., showed that retention at 6 weeks postpartum increased from 72.9% to 93.9% in intervention vs. control (p < 0.001) [21], while Nordberg et al.’s study did not show improvement in PMTCT care retention postpartum (RR: 1.02; CI: 0.92–1.14; p = 0.697) [22]. However, Finocchario-Kessler et al. showed that only one-third of the participants maintained >95% ART adherence across all appointments [24], while Kinuthia et al. showed no significant difference in viral suppression between the control and SMS arms (p = 0.94 for 1-way versus control; p = 0.31 for 2-way versus control) [20].

Furthermore, Kebaya et al., 2021 [23] also demonstrated an increased retention level, with 78.7% of mother-infant pairs in the intervention group remaining in care, compared to 58.7% in the control group (OR = 2.6, p = 0.009). Finocchario-Kessler et al., 2021 [24] also showed higher complete retention (56.6% vs. 17.1%).

Maternal and infant health outcomes

mHealth showed promising PMTCT outcomes demonstrated by Finocchario-Kessler et al., 2021 [24] with better attendance at antenatal clinics (73.6% vs. 37.8%), more hospital deliveries (96.2% vs. 63.4%), and timely infant HIV testing (77.4% vs. 43.9%) compared to standard care. Early diagnosis rates were higher in infants with mHealth interventions, although not statistically significant [23]. Also, the increased adherence rates among the mothers correlated to reduced risk of HIV transmission to the infants (adjusted odds ratio = 0.20; 95% CI = 0.04, 0.99) [21]. See Tables 1 and 2 for a detailed information.

Table 1.

Study and sample characteristics

Author & Year	Study Design	Study Objectives	Sample Size	Participant Characteristics
Ronen et al., 2018 [19]	Randomized Controlled Trial	To evaluate the preferences of PBWLH regarding overt and covert HIV-related messages to support ART adherence and PMTCT in Kenya	825	Pregnant women living with HIV (≥ 14 years) randomized into overt or covert SMS groups
Musoke et al., 2018 [25]	Qualitative Study	To assess the acceptability and feasibility of a text messaging intervention to support ART adherence and retention in care among PBWLH (and their male partners) under Option B + in rural western Kenya.	20	PBLWH with their partners (20 males) undergoing in-depth interviews
Mabachi et al., 2021 [26]	Qualitative study with focus group discussion	To understand SMS message content, tone, timing, and delivery preferences for supporting ART adherence, antenatal care appointment attendance, and facility-based delivery among PBWLH and their male partners in Kenya	40	PBWLH with their male partners (N = 33)
Kinuthia et al., 2021 [20]	Randomized, non-blinded, 3-arm trial (2-way, 1-way, No SMS)	To evaluate the effectiveness of 1-way or 2-way SMS messaging integrated into a maternal-child health (MCH) SMS platform in improving retention, ART adherence, and viral suppression among women in PMTCT programs	824	Pregnant women living with HIV (≥ 14 years) who had access to their phones. They were randomized into three groups in a 1:1:1 ratio: 1-way SMS. 2-way SMS and control (No SMS)
Fairbanks et al., 2018 [27]	Qualitative Study	To explore SMS content preferences among PBLWH, male partners, and healthcare workers to inform message design for a PMTCT-ART adherence intervention	87	PBWLH with 15 male partners and 30 healthcare workers in group discussions and semi-structured interviews
Finocchario-Kessler et al., 2021 [24]	Matched cluster randomized design	To assess the preliminary impact of the adapted HITSystem 2.0 intervention on PMTCT outcomes in Kenya.	157	Pregnant women living with HIV assigned to either the HIV Infant Tracking System (HITSystem 2.0) or the standard of care.
Nachega et al., 2016 [28]	Exploratory study using a mixed-methods approach	To examine the acceptability and feasibility of two SMS and community-based directly observed therapy among pregnant women with HIV receiving PMTCT services under Option B + in South Africa	129	Pregnant women living with HIV (≥ 18 years)
Sarna et al., 2019 [21]	Randomized Controlled Study	To evaluate the effectiveness of a cell phone counseling intervention on maternal retention in HIV care and uptake of early infant HIV diagnosis (EID) in Kenya	404	Pregnant women (≥ 16 years) between 14 and 36 weeks. They were randomized into a counsellor-delivered phone call or a control arm (standard care)
Nordberg et al., 2023 [22]	Randomized Controlled Trial	To determine the effectiveness of a weekly, interactive text-messaging intervention in improving postpartum retention in PMTCT care among pregnant women living with HIV in Kenya	600	Pregnant women with HIV (≥ 18 years). They were randomized into the interactive text-messaging intervention arm in addition to standard care, or, to control arm (standard care only)
Kebaya et al., 2021 [23]	Open-label Randomized Controlled Trial	To evaluate the impact of 2-weekly mobile calls received by mothers on the adherence to infant nevirapine prophylaxis and retention in care, for HIV-exposed infants	150	Women living with HIV (≥ 18 years) who had a live birth and own a mobile phone through which calls can be received. They were randomized to two arms (Intervention and control), with their infants
Ngowi et al., 2020 [29]	Mixed-Methods Study	To investigate the acceptability and technical feasibility of SMS reminders to support ART adherence among PBWLH in Tanzania.	25	PBWLH on ≥ 6 months of ART therapy and own a phone through which they can receive and read an SMS

Table 2.

Intervention details, outcomes, and findings

Author & Year	Intervention					Outcome	Findings	Conclusion
	Means	Frequency	Mode of Delivery (Synchronous or Asynchronous)		Length
Ronen et al., 2018 [19]	SMS-based intervention called Mobile WAChX RCT, which used either one-way or two-way educational SMS messages. The messages were developed based on the Health Belief Model and included reminders, educational content, and social support	Weekly	Asynchronous		Exact time not explicitly mentioned	ART adherence among participants. Preferences for overt or covert HIV-related content in SMS and their impact on confidentiality concerns and ART adherence.	66.1% opted for system-initiated overt HIV-related SMS. 9.6% chose participant-initiated overt SMS. 31.3% preferred covert SMS only. Privacy concerns highlighted by participants included non-disclosure of HIV status, and sharing of phones in overt messaging	The study supports the acceptability of overt HIV-related messaging when confidentiality risks are low. Allowing participants to choose the type of SMS they receive based on their disclosure status and phone access can balance educational content delivery with privacy concerns, potentially improving ART adherence.
Musoke et al., 2018 [25]	Proposed SMS content developed using the Health Belief Model framework. Messages gave reminders and information on ART adherence, safe pregnancy and delivery practices as well as general well-being	N/A	Asynchronous		N/A	Perceptions of the text messaging intervention for ART adherence and clinic visit retention. Participant preferences for message content, timing, format, and confidentiality concerns	Most participants supported the idea of text messages to remind them of clinic visits and ART adherence. Participants favored messages on ART adherence, clinic visits, and general health, with some recommending inclusion of information on HIV prevention in discordant couples. Some participants worried that messages might inadvertently disclose their HIV status, especially in shared phone situations. The analysis showed that the acceptability of the text messaging intervention could depend on male partners’ support, especially in situations where mobile phones are shared within the household. Participants suggested avoiding direct references to HIV in the messages and preferred covert messages.	Text messaging interventions are generally acceptable for supporting ART adherence and clinic retention in rural Kenya, but message content and timing must be carefully tailored to protect confidentiality.
Mabachi et al., 2021 [26]	Proposed SMS-based reminders containing messages on ART adherence, Ante-Natal Care attendance, and hospital delivery	N/A	Asynchronous		N/A	Preferences for messages for ART adherence, antenatal attendance, and facility-based delivery. Privacy and confidentiality concerns	Women preferred messages with low verbal immediacy (indirect, neutral content) to protect confidentiality. High acceptability of SMS messaging for all components of PMTCT care. There were privacy concerns, especially related to the risk of unintentional HIV status disclosure.	SMS messaging was widely accepted as a tool for improving engagement in the PMTCT cascade. However, privacy concerns must be addressed through low-verbal immediacy messages for ART adherence. Direct, emotionally appealing messages were preferred for antenatal attendance and delivery reminders.
Kinuthia et al., 2021 [20]	An SMS platform called Mobile WACh-X, which delivered messages on ART adherence, infant health, pregnancy education, clinic appointments, and postpartum contraception. The 2-way arm allowed messaging with nurses.	Weekly messages and follow-ups for missed visits	Asynchronous		From point of enrolment during pregnancy to 2 years after childbirth	Primary outcomes include: Viral non-suppression (viral load ≥ 1,000 copies/mL); On-time clinic attendance; Infant HIV-free survival, while the Secondary outcomes were ART adherence; ART resistance	There was no significant difference in viral suppression, clinic attendance, or infant HIV-free survival between the control and SMS arms. Virologic nonsuppression at any point: Control (9.6%), 1-way (11.2%), 2-way (8.5%). None significantly different (2-way vs. control aRR: 0.80 [95% CI 0.52–1.23], p = 0.31) There was a preference for covert messages and a high acceptability	Integrated HIV/Maternal Child Health messaging did not improve HIV outcomes such as viral suppression or clinic retention
Fairbanks et al., 2018 [27]	Proposed SMS intervention involving reminder messages, educational messages, and encouraging/supportive messages.	N/A	Asynchronous	N/A		The acceptability of SMS text messaging as a tool to improve ART adherence, clinic attendance, and health outcomes for pregnant and postpartum women living with HIV.	Pregnant women and other groups supported using SMS, especially covert messages, for HIV-related care, citing benefits like maintaining anonymity and enabling open communication. There are some concerns about SMS privacy and the risk of HIV status disclosure. Healthcare workers (HCWs) noted difficulties in ensuring SMS delivery due to literacy, phone access, and electricity constraints. Many women expressed that SMS could help with emotional support and motivation for ART adherence, combating stigma, and enhancing their connection with healthcare providers	SMS text messaging was widely accepted by women, male partners, and HCWs to improve ART adherence, clinic attendance, and PMTCT care. Women preferred educational and encouraging messages, emphasizing the need for anonymity to prevent unintentional HIV status disclosure
Finocchario-Kessler et al., 2021 [24]	HITSystem 2.0, a web-based mHealth intervention, operates through algorithm-driven alerts and SMS reminders for patients. Messages support attendance to appointments, adherence to ART, and preparation for child delivery	2–4 days prior to appointments; 2–4 weeks prior to the child delivery due date	Asynchronous	From the point of enrolment to 12 weeks after childbirth		Primary Outcome: Complete PMTCT retention (attendance at all scheduled antenatal appointments, hospital-based delivery, and infant HIV-testing before 7 weeks postpartum). Secondary Outcomes: Hospital-based delivery; Infant HIV testing within 7 weeks; ART adherence	There was a high acceptability of the intervention, as 92.5% of participants opted to receive SMS for ART adherence. The HITSystem 2.0 intervention significantly improved PMTCT outcomes, with higher complete retention (56.6% vs. 17.1%), better antenatal attendance (73.6% vs. 37.8%), more hospital deliveries (96.2% vs. 63.4%), and timely infant HIV testing (77.4% vs. 43.9%) compared to standard care. The intervention was the strongest predictor of retention (aOR 5.7), while the standard care group had twice the risk of disengagement (aHR 6.8). These results highlight HITSystem 2.0’s effectiveness in enhancing PMTCT retention and reducing HIV transmission risk.	The HITSystem 2.0 intervention significantly increased complete PMTCT retention, with better outcomes for mother-infant pairs compared to standard care
Nachega et al., 2016 [28]	Proposed SMS text messages for updates, motivation, and as reminders.	N/A	Asynchronous	N/A		Primary outcomes include: Acceptability of mHealth and cDOT, while the secondary outcome was preferences for SMS	Preference for neutral or euphemistic SMS texts, as well as a high acceptability (88.1%). There were concerns about the unintentional disclosure of status, especially for covert messages.	The mHealth and cDOT interventions were well-received and are promising tools for enhancing ART adherence in pregnant women under PMTCT programs. However, careful attention is required to ensure SMS confidentiality and to support the training and reliability of cDOT supporters to avoid unintended HIV status disclosure
Sarna et al., 2019 [21]	Intervention entailed one-on-one counseling delivered by trained counsellors via cell phone. Counseling was based on Self-Regulation Theory	Antenatal period: Week 1: 2 calls Weeks 2–delivery: 1 call/week Postnatal period: Week 1: 2 calls Weeks 2–14: 1 call/week	Synchronous	From enrollment to 14 weeks postpartum		Primary Outcome: Retention in care until 14 weeks postpartum, defined by attendance at antenatal care (ANC) and postnatal care (PNC) visits as well as infant HIV testing. Secondary Outcomes: Maternal attendance at ANC and PNC services; HIV transmission rate to infants; Adherence to ART	Retention rates were significantly higher in the intervention group at delivery (95.2% vs. 77.7%), 6 weeks postpartum (93.9% vs. 72.9%), and 14 weeks postpartum (83.3% vs. 66.5%; p < 0.001) compared to the control group.	The cell phone counseling intervention was effective in retaining mothers with HIV in care and improving ANC and PNC visit attendance.
Nordberg et al., 2023 [22]	SMS where participants were expected to respond, while non-respondents or those reporting problems were followed up by healthcare workers via phone	Weekly	Asynchronous	From enrolment to 24 months postpartum		The primary outcome was retention in PMTCT care at 18 months postpartum, while the secondary outcomes include Retention in care between 6 and 12 months postpartum. Linkage to chronic HIV care up to 30 months postpartum; Facility delivery rates and Infant HIV infection rates.	There was numerically higher retention in the intervention group compared to the control at 18 months postpartum (70.2% vs. 68.8%), but it was not statistically significant (p = 0.697). No significant difference was found between the intervention and control arms for both the primary and secondary outcomes.	The weekly, interactive SMS intervention did not significantly improve retention in PMTCT care at 18 months postpartum. This study also highlighted the need for additional support mechanisms to improve retention in long-term PMTCT and chronic HIV care.
Kebaya et al., 2021 [23]	Mobile phone calls delivering PMTCT-related reminders	Fortnightly	Synchronous	From birth to 10 weeks postpartum		Primary Outcomes: Adherence to infant Nevirapine prophylaxis and Retention in care Secondary Outcomes: Early Infant Diagnosis (EID) rates (measured by HIV PCR tests).	At 6 weeks, 90.7% of infants in the intervention group received NVP as prescribed, compared to 72% in the control group (OR = 3.8, p = 0.005). At 6 weeks, 78.7% of mother-infant pairs in the intervention group remained in care, compared to 58.7% in the control group (OR = 2.6, p = 0.009). At 6 weeks, 70.7% of infants in the intervention group received HIV PCR testing, compared to 58.7% in the control group. However, the difference was not statistically significant (OR = 1.7, p = 0.126).	Fortnightly mobile phone calls significantly improved adherence to Nevirapine prophylaxis and retention in care for HIV-exposed infants.
Ngowi et al., 2020 [29]	SMS reminder messages sent 30 min before medication time; a follow-up question was sent 1 h later, asking if the medication was taken	3 times per week on randomly selected days per participant	Asynchronous	6 months		The primary outcomes were the acceptability of receiving SMS reminders, ART adherence; and the technical feasibility of the SMS	89% of the participants reported satisfaction with the intervention; only 2 participants rated it as “not good”. Some participants reported privacy concerns about the overt nature of the messages. The intervention supported improvement in the self-reported ART adherence, as 1003 participants (99%) replied “YES” out of all the sent messages.	SMS was acceptable to the majority of PBWLH in Tanzania to remind them to take their medication. However, privacy concerns have to be considered.

Quality assessment

The 6 included randomized controlled trials [19–24] were assessed using the Critical Appraisal Skill Programme Tool for RCTs. The studies were not blinded [19–21, 23, 24] except for Nordberg et al., 2023 [22]. However, the method of randomization was not elucidated. The Confidence interval was not stated in the analysis of 2 studies [19, 24]. See Table 3.

Table 3.

Quality assessment for the randomized controlled trials using the CASP tool

Authors and year of Publications	Q1	Q2	Q3	Q4a	Q4b	Q4c	Q5	Q6	Q7	Q8	Q9	Q10	Q11
Ronen et al. 2018 [19]	Y	CT	CT	N	N	N	Y	CT	N	CT	Y	Y	CT
Kinuthia et al. 2021 [20]	Y	N	Y	N	N	N	Y	Y	Y	Y	Y	Y	Y
Finoccharo-Kessler et al. 2021 [24]	Y	CT	CT	N	N	CT	Y	Y	Y	N	Y	Y	Y
Sarna et al. 2019 [21]	Y	CT	Y	N	N	N	Y	Y	Y	Y	CT	Y	Y
Nordberg et al. 2023 [22]	Y	CT	Y	Y	Y	CT	Y	Y	Y	Y	CT	Y	Y
Kebaya et al. 2021 [23]	Y	Y	Y	N	N	N	Y	CT	Y	Y	Y	Y	CT

Y = YES, N = NO, CT = Cannot Tell

The included qualitative studies [25–27] all had a clear research statement, and the method of choice was appropriate for the studies. However, justification for the utilization of the research design was not well stated in the study by Mabachi et al. 2021 [26]. Also, the study by Musoke et al. 2018 [25] did not provide sufficient data analysis for the results, and the researchers also did not examine their role, potential biases, and their possible effect on the study outcomes. This was also observed in the study by Fairbanks et al., 2018 [27]. See Table 4.

Table 4.

Quality assessment for the qualitative studies using the CASP tool

	Authors and Year of Publications
	Musoke et al. 2018 [25]	Mabachi et al. 2021 [26]	Fairbanks et al. 2018 [27]
(Q1) Was there a clear statement of the aims of the research?	Y	Y	Y
(Q2) Is a qualitative methodology appropriate?	Y	Y	Y
(Q3) Was the research design appropriate to address the aims of the research?	CT	CT	CT
(Q4) Was the recruitment strategy appropriate to the aims of the research?	Y	Y	Y
(Q5) Was the data collected in a way that addressed the research issue?	Y	Y	Y
(Q6) Has the relationship between researcher and participants been adequately considered?	N	Y	CT
(Q7) Have ethical issues been taken into consideration?	Y	Y	Y
(Q8) Was the data analysis sufficiently rigorous?	CT	Y	Y
(Q9) Is there a clear statement of findings?	Y	Y	Y
(Q10) How valuable is the research?	Y	Y	Y

Y = YES, N = NO, CT = Cannot tell

In the included mixed-methods studies [28, 29], the preliminary quality criteria were met, as the study presented a clear research objective and collected data that were appropriate to address that objective.

However, no specific qualitative analysis method was described in Ngowi et al., making it difficult to judge adherence to qualitative quality criteria. See Table 5.

Table 5.

Quality assessment of the mixed-methods study using the 2018 mixed-methods appraisal tool

	Nachega et al., 2016 [28]	Ngowi et al., 2020 [29]
(Q1) Is there an adequate rationale for using a mixed methods design to address the research question?	Y	Y
(Q2) Are the different components of the study effectively integrated to answer the research question?	Y	Y
(Q3) Are the outputs of the integration of qualitative and quantitative components adequately interpreted?	Y	Y
(Q4) Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?	CT	N
(Q5) Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?	Y	CT

Y = YES, N = NO, CT = Cannot tell

Discussion

Retention in care and adherence to ART have been identified as essential factors in reducing vertical transmission of HIV among PBWLH. This study aims to map and summarize the available evidence on the use of mHealth interventions in HIV care, particularly ART adherence and retention in care, among PBWLH in sub-Saharan Africa. We also evaluate their preferences, acceptability, and privacy concerns about these mHealth interventions.

This scoping review found that mHealth interventions, especially SMS reminders and phone-based counselling, show promise in improving ART adherence and retention in care among pregnant and breastfeeding women living with HIV in sub-Saharan Africa, although results were mixed across studies. Overall, acceptability of mHealth interventions was high and most women preferred covert or neutral messages to protect their privacy and avoid unintended HIV status disclosure.

There was a consistent preference for covert messages in the studies. However, Ronen et al. [19] showed that more than half of the participants opted for overt messages due to their desire for more detail in the message. Covert messages use neutral language or euphemistic terms, giving participants their privacy. Most studies report unintentional disclosure of status and phone sharing as major concerns for overt messages [19, 25–28]. It was also common that most of those keen on privacy issues either shared phones with others and had not made their status known to those around them, or due to a fear of stigma [25, 27]. Privacy and confidentiality are essential, especially in stigmatized diseases such as HIV, hence the higher preference for covert messages. Most of the study population opted for flexibility and customization of messages, which is valid given that each individual, although having the same condition and/or treatment, is on a different journey and adapting to this new life in different ways and paces. Introducing more flexible and customized messages (especially the frequency, timing, language, and choice of words) would help deal with each patient individually and pass more accurate/helpful information depending on the patient’s issue or state of mind [19, 25]. This also helps the women feel that their care is personalized and improves their psychological health. Customizing the messages would also solve the discrepancies between those wanting overt messages and those wanting covert messages, making it a win-win solution.

There was a high acceptability for the use of mHealth. In general, most women had a similar take that these messages provided them with psychosocial support and strengthened the healthcare worker-patient relationship. Also, they opined that the mHealth intervention is a promising tool to solve their forgetfulness in taking their ART and meeting up with clinic appointments. These findings show the need for the integration of mHealth into HIV care for PBLWH in sub-Saharan Africa.

The impact of mHealth in improving retention in care and adherence showed mixed results in the randomized controlled trials, and Ngowi et al. [29]. The study by Ngowi and his colleagues showed improvement in ART adherence; however, this was self-reported and was not assessed using viral suppression, pill counts, or real-time retention in care. Finocchario-Kessler et al., Sarna et al., and Kebaya et al. showed improvement in retention in care for those receiving the mHealth intervention compared to the control arm [21, 23, 24]. However, Kinuthia et al. and Nordberg et al. showed non-significant findings compared to the control [20, 22]. Kinuthia et al. and Nordberg et al. had a larger number of participants and a longer intervention length of 2 years, showing higher statistical power and robust methodology. However, their negative results may be attributed to the intervention length (2 years) without adaptation and re-engagement strategies. Over 2 years, participants may experience diminished engagement over time due to repetitive messaging, fatigue, or loss of interest. Also, in resource-constrained settings, frequent changes in phone access or network instability can further compromise intervention fidelity, making it difficult to isolate the true impact of the intervention. To address reducing engagement in long-term mHealth interventions, future programs should incorporate adaptive strategies that evolve with participants’ needs over time.

A systematic review also showed the promising effect of mobile-phone-based interventions in PMTCT care [30]. However, most of the studies involving the mHealth intervention had a short follow-up. There remains a need for future research to explore sustained, adaptive mHealth models that can maintain user engagement and improve long-term retention outcomes among PBLWH.

Limitations of the study

This study presents evidence on the use of mHealth among PBLWH in sub-Saharan Africa, however, some limitations must be acknowledged. Most of the studies were conducted in Kenya, making generalizability to other sub-Saharan countries difficult. While this gives an idea of the use of mHealth in sub-Saharan Africa, the underrepresentation of other regions limits the applicability of findings. This situation calls for more research in other regions of Africa to fully understand the landscape of mHealth among PBLWH. Additionally, the study designs varied widely across studies, making it difficult to quantitatively compare effect sizes across studies. Also, this review included only peer-reviewed studies, which may have excluded relevant evidence from gray literature such as NGO reports, implementation briefs, or governmental publications. Future reviews that incorporate gray literature sources could provide a more comprehensive view of ongoing or unpublished mHealth initiatives in sub-Saharan Africa. Five potentially relevant studies published in Chinese and French were excluded due to lack of translation support, which may have led to omission of evidence from non–English-speaking regions of sub-Saharan Africa.

Some studies whose method of data collection was through a qualitative approach or focused group discussion are prone to social-desirability bias. Thus, their true opinion on the use and acceptability of mHealth may have been overestimated. Some of the included studies had small sample sizes, especially Musoke et al. and Mabachi et al. [25, 26]. While their findings provide insights into the preferences, acceptability, and use of mHealth among PBWLH, the small sample size may limit the statistical power and generalizability of findings.

Practical considerations for mHealth implementation

In designing mHealth interventions for pregnant women living with HIV, a one-size-fits-all approach should not be used; interventions newly diagnosed should be different from those who have been on ART before pregnancy [31]. Transition is necessary from the traditional calls and SMS on clinic and medication reminders to more interactive mobile apps that give education, current trends, and even social networking among people living with HIV [32].

mHealth interventions have been useful in other aspects of patient care to encourage weight monitoring, medication adherence, and other health behaviours. Mobile technology impacts behavior in real-time, especially during high-opportunity moments or regularly in people’s daily lives, increasing the possibility of behavior change. As such, it can be used to target behavioral changes in HIV treatments and prevention [33, 34].

More work is still needed in channelling mHealth interventions and future studies to address the root of non-adherence, which is stigmatisation and non-disclosure of status to partners.

Conclusion

mHealth is widely accepted among PBWLH in sub-Saharan Africa, with the majority having a preference for covert messages over overt messages in SMS-based interventions due to privacy concerns such as unintentional disclosure. The impact of mHealth on retention and ART adherence is promising; however, there are mixed results and insufficient evidence to make a conclusive recommendation on its effectiveness in sub-Saharan Africa. More randomized controlled trials in other regions of sub-Saharan Africa are needed to provide more evidence.

Future research should involve investigating factors that can influence user engagement with mHealth devices, including usability, accessibility, psychosocial status, and cultural relevance among both healthcare providers and patients and how mHealth can be tailored to address them. Also, there is a need to assess sustainable and adaptive mHealth models that can maintain user engagement for a long time.

Abbreviations

mHealth

Mobile Health

ART

Antiretroviral Therapy

PBWLH

Pregnant or Breastfeeding Women Living with HIV

PLWHA

People Living With HIV/AIDS

PMTCT

Prevention of Mother–To–Child Transmission (of HIV)

LMICs

Low–and Middle–Income Countries

Author contributions

C.E.A conceptualized the study; All authors were involved in the literature review; I.J.O & C.S.A extracted the data from the reviewed studies; C.E.A prepared Figure 1; Table 1; O.A prepared tables 3, 4 and 5. All authors wrote the final and first drafts. All authors (C.S.A, I.J.O, V.O.A, C.S.A, K.K.M, T.F.O, O.A, J.O.A, A.K.O, A.A.O, I.S.B, A.I and C.S.N) read and approved the final manuscript.

Funding

No funding was received for this study.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Code availability

Not applicable.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.