Information and communication technologies for adherence to treatment in adults with HIVAIDS

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InternationalJournalofMedicalInformatics92(2016)54–61

ContentslistsavailableatScienceDirect

International

Journal

of

Medical

Informatics

jo u r n al h om e p a g e :w w w . i j m i j o u r n a l . c o m

Review

article

Information

and

communication

technologies

for

adherence

to

antiretroviral

treatment

in

adults

with

HIV/AIDS

Ivana

Cristina

Vieira

de

Lima

a,∗

_,

_Marli

_Teresinha

_Gimeniz

_Galvão

b

_,

Herta

de

Oliveira

Alexandre

a

_,

_Francisca

_Elisângela

_Teixeira

_Lima

b

_,

Thelma

Leite

de

Araújo

b

a_Federal_University_of_Ceará_(UFC),_Fortaleza,_CE,_Brazil

b_Federal_University_of_Ceará_(UFC),_Nursing_Department,_Fortaleza,_CE,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received9September2015

Receivedinrevisedform22April2016

Accepted26April2016

Keywords: Technology Communication HIV

Medicationadherence

Efficacy

a

b

s

t

r

a

c

t

Introduction:Informationandcommunicationtechnologiessupportinterventionsdirectedatthe pre-ventionofHIVtransmissionandpatientmonitoringbypromotingimprovedaccessibilityandqualityof care.

Objective:Toevaluatetheefficacyofinformationandcommunicationtechnologiesintheadherenceto antiretroviraltreatmentinadultswithHIV/AIDS.

Methodology:SystematicreviewconductedfromMarchtoMayof2015inthreedatabases—the Cumula-tiveIndextoNursingandAlliedHealthLiterature(CINAHL);theLatin-AmericanandCaribbeanLiterature inHealthSciences(LILACS/BIREME)andSCOPUS;andtheCochranelibraryandtheMedicalLiterature AnalysisandRetrievalSystemOnlineportal(MEDLINE/PubMed).Thesampleconsistedofnine random-izedclinicaltrialsbasedontheuseofinformationandcommunicationtechnologiesforadherenceto antiretroviraltreatmentinadultswithHIV/AIDS.

Results:Threestudiesanalysedtheuseofashortmessageservice–SMS–twophonecalls,twoalarm devices,oneweb-enabledHand-helddeviceandonewebelectronicintervention.Improvementsinthe levelsofadherenceinthegroupsubjectedtotheinterventionwereidentifiedinsevenstudies.The phonewasthetypeofinformationandcommunicationtechnologywithprovenefficacywithrespect toadherence.Itwasusedtomakecalls,aswellastosendalertmessagesandremindersabouttaking medications.Pagerswerenotconsideredtobeeffectiveregardingadherencetoantiretroviraltherapy. Conclusion:Theintegrateduseofinformationandcommunicationtechnologieswithstandardcare pro-motesincreasedaccesstocare,strengtheningtherelationshipbetweenpatientsandhealthservices,with thepossibilityofmitigatingthedifficultiesexperiencedbypeoplewithHIVinachievingoptimallevels ofadherencetodrugtherapy.

1. Introduction

Informationand communication technologies (ICTs) include any communication devices, including radio, television, cell phones, computers, network equipment (hardware), programs (software)andsatellitesystems,aswellasthevariousservicesand

∗Correspondenceto:TipógrafoSalesSt.,992,AmadeuFurtado,60455-500

Fort-aleza,CE,Brazil.

E-mailaddresses:doutorandaivana@gmail.com(I.C.V.d.Lima), marligalvao@gmail.com(M.T.G.Galvão),oliveiraherta@gmail.com

(H.d.O.Alexandre),felisangela@yahoo.com.br(F.E.T.Lima),

thelmaaraujo2003@yahoo.com.br(T.L.d.Araújo).

applicationsforwhichtheyareused,suchasvideoconferencing, onlinechattinganddistancelearning[1].

Inhealthcare,theuseofICTgoesbeyondthetransmissionof information asitsupports self-care,behaviouralchanges, infor-mationexchangesamongpeersandemotionalsupport,aswellas providingbenefitsintrackingpeoplewithchronicdiseases[2,3].In thecontextofHIV/AIDS,ICTshavemediatedinterventionsdirected atpreventingthetransmissionofthevirusormonitoringpatients bypromotingimprovedaccessibilityandqualityofcare[4].

TheinfluenceoftheadvancementsinthetreatmentofHIV/AIDS in the transition from acute to chronic disease is highlighted. Antiretroviraltherapy(ART)hasimprovedhealth,reduced oppor-tunisticinfections,andincreasedsurvivalandimprovedqualityof lifeinapproximately9.7millionpeopleworldwide[5,6].

http://dx.doi.org/10.1016/j.ijmedinf.2016.04.013

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Despitethesebenefits,thelong-termuseofARTimplies chal-lenges.The main difficultyfaced by persons livingwith HIV is adherence(representedbyingestingatleast95%oftablets)dueto thelargenumbersofpillsandsideeffectsandthehighfrequency ofdosesand/ortabletstakenperday[7,8].

Failureoftreatmentadherenceelicitsindividual(decreasedCD4 Tcells,viralresistance, riskbehaviour,progressiontoAIDSand death)and collectivelosses(increased transmissionof HIV and othersexuallytransmittedinfections,highertreatmentcostsand hospitalizations)[6,9].Forthesereasons,caretoolsaimedat contin-uousmonitoringandcounselling,aswellasstrategiesforpatient orientation/training,withafocusonachievingoptimallevelsof adherencetoART,areneeded[5].

Atheoreticalreviewpresentedconsiderationsregardingtheuse ofinformationtechnologyinthecontextofHIV,highlightingthe possibilityofa positive impactonthelevelsofsatisfaction and patientsafety,inadditiontoimprovementsinadherencetoART andcarequalityindicators.Moreover,theuseoftheInternet, digi-talmedia,informationsystems/monitoringandtelephoneprovides information for thediagnosis and treatmentof HIV, as wellas opportunitiesfortheelectronicregistrationofdataandincreased accesstoinformationforboththepatientandthemultidisciplinary team[4].

Asystematicreviewanalysed23publicationsand32ongoing projectsontheuseofthetelephone,Internetandsocialmediain healthcarein thecontextofHIV treatment.Therewas empha-sisontheuseoftechnologyinthefollowingsituations:primary preventionofHIVtransmission,promotionofHIVtesting, estab-lishmentofbondsandconservationcare,supportforstartingART, andpromotingadherencetoART,aswellasachievingincreased viralsuppressionandpreventingsecondaryinfections.Although increasingattentionhasbeendevotedtotheuseoftechnology,it isnecessarythatotherstudiesalsoanalysetheefficacyofthesecare tools[10].Thetermefficacyentailsthataninterventionproduces theexpectedresultunderidealcircumstances[11].

Furthermore,reviewshaveconsideredthepossibilitiesofthe useofICTsinthecontextofHIV/AIDS,butnosystematicreviews abouttheefficacyofthesetechnologiesintreatmentadherencein adultswithHIVhavebeenfound.Therefore,thefollowingresearch question was asked: “What is the efficacy of information and communicationtechnologiesinsupportingHIV/AIDS antiretrovi-raltreatmentadherenceinadults?”Inthisreview,weconsidered thetypesofICTthataremainlyusedtomonitorpeoplewithHIV: computers,phones,softwareandpagers.

Analysis of the efficacy of ICT as a health care instrument can identify alternatives to supportive care for people living withHIV/AIDS, aswell asthebenefits and limitations ofthese alternatives. Analysis also highlights the possibility of sharing withpractitioners and researchersthetheoretical and practical assumptionsforthereplicationofinformationandcommunication technologieswithprovenefficacywithrespecttotheadherenceto antiretroviraltreatmentinadultswithHIV/AIDS.

This study aimed to evaluate the efficacy of information and communication technologies withrespect to adherenceto antiretroviraltreatmentinadultswithHIV/AIDS.

2. Methods

Asystematicreview wasconductedaccordingtothe recom-mendationsoftheCochraneHandbookforSystematicReviewsof Interventions[12].Asystematicreviewisatypeofsecondarystudy thatenablesthedevelopmentofclinicalguidelinesfor decision-makingandfacilitatestheplanningofclinicalresearchinhealth care[13].

TheresearchquestionwasdesignedbasedonthePICO strat-egy,whichstandsforPatient(adultslivingwithHIV),Intervention (usingICT)Comparison(standardcare)andOutcomes(treatment) [14].

Weperformedintentionalsamplingfromclinicaltrialsbasedon theuseofICTforadherencetoantiretroviraltreatmentbyadults withHIV/AIDS,regardlessofthepublicationyearand language. Weexcludedrepeatpublications;thosethatdidnotanswerthe researchquestion;casereports,experiencereportsandtheoretical, qualitativeorcross-sectionalstudies;reviewpapers andclinical trialprotocols,aswellasclinicaltrialsthathaveaddressedtheuse ofinformationandcommunicationtechnologiesinHIVprevention andrapidtesting.

Theelectronicsearchwascarriedoutbytworeviewers simul-taneouslyinthreedatabases−theCumulativeIndextoNursing and Allied Health Literature (CINAHL); theLatin-American and CaribbeanLiteratureinHealthSciences(LILACS/BIREME)and SCO-PUS;andtheCochranelibraryandtheMedicalLiteratureAnalysis andRetrievalSystemOnlineportal(MEDLINE/PubMed),accessed throughthePortalCAPES(HigherEducationPersonnel Improve-mentCoordination).

ThefollowingcontrolleddescriptorsavailableinMeSH(Medical SubjectHeadings):Technology;HIV;Internet;CellPhones; Soft-ware;Telemedicine;eHealth;RemoteSensingTechnology;Clinical Trialwereused.Thecrossesperformedwere[HIVand Technol-ogy],[InternetandHIVandTechnology],[HIVandTechnologyand CellPhone],[HIVandTechnologyandSoftware],[HIVandNursing andTechnology],[HIVandTelemedicine],[HIVandeHealth],and [RemoteSensingTechnologyandHIV].Thecontrolleddescriptor ClinicalTrialwasincludedinallcrosses.

AfterthesearchwascompletedonMay22,2015,thearticles wereanalysedbytwoauthors,whoreadthetitlesandabstracts. Eli-giblestudiesweretranslatedintothenativelanguageoftheauthors (Portuguese)andreadinfull.

Tworeviewersassessedthequalityoftheclinicaltrialsandthe dataindependently.Incaseofdoubt,thereweremeetingsbetween thereviewerstoreachconsensus.Toanalysethescopeofthe stud-ies,thereviewersusedareferencelist.

Fromthecrossesthatwerecarriedout,a totalof2517 stud-ieswerefoundintheinvestigateddatabases.Fromthesestudies, 91replicateswereremoved.Analysesofthetitlesandabstracts yielded65pre-selectedstudies;however,59studieswereexcluded becausetheywerenotclinicaltrials,asdescribedbelow:fourcase reports,fiveexperiencereports,13theoreticalstudies,nine qualita-tivestudies,ninecross-sectionalstudies,fourquasi-experimental studies,12reviewpapersandthreeclinicaltrialprotocols.Among thesixselectedarticles,threewerefoundinMEDLINE/PubMed, threewerefoundinSCOPUS,andthreewerefoundusingreverse search.Ultimately,thesampleconsistedofninestudies(Fig.1).

Analysisofthequalityofthestudieswasbasedonaqualityscale describedbyJadadetal.[15],inwhichthescorerangesfrom0to5 andiscalculatedfromthefollowingparameters:(1a)Thestudywas random(usingwordssuchas‘random’,“randomization”)?;(1b) Themethodwasappropriate?;(2a)Thestudywasdoubleblinded? (2b)Themethodwasappropriate?;and(3)Thereweredescriptions oflossesandexclusions?

Thestudieswerealsoanalysedforallocationconfidentialityand wereclassifiedasCategoryA—theallocationconfidentiality pro-cesswasadequate;CategoryB—theallocationconfidentialitywas notdescribed,butitwasstatedinthetextthatthestudywas ran-dom;CategoryC—theallocationconfidentiality wasinadequate; andCategoryD—thestudywasnotrandom[12].

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56 I.C.V.d.Limaetal./InternationalJournalofMedicalInformatics92(2016)54–61

Studies excluded for not addressing the research question -

2361

Selected studies - 6 Pre-selected studies - 65

Replicates studies excluded - 91

Additional records (reverse search) -

3 Total of studies found – 2517

Cinahl (669) Cochrane (103) Lilacs (96)

Medline/Pubmed (648) SCOPUS (1001)

59 excluded studies

Case Report (4) Experience Report (5) Theoretical Study (13) Qualitative Study (9) Cross-sectional Study (9) Quase-experimental Study (4) Review papers (12)

Clinical Trial Protocol (3)

Total studies analysed analysed – 9

Fig.1.Flowchartoftheidentification,selectionandinclusionofstudies.

Fortheethicalquestions,theintegrityofthearticlesandthe copyrightwererespected,withnomodificationofthecontentin favourofthisresearch.

3. Results

Table1 characterizesthestudiesbasedontheauthor, coun-try,proposedtechnology,sample,clinicaltrial,improvementsin adherence,Jadadscalescoreandallocationconfidentiality.

Theyearsofthestudies’publicationwerefrom2008to2015.All studieswererandomizedandincludedatotalof1866adultswith HIVusingARTwhowererecruitedfromoutpatientclinics[16–21] andhospitals[22–24].Regardinglocation,mostofthestudieswere developedintheUnitedStatesofAmerica(USA)[16,19,20–23]and inAfricancountriessuchasKenya[15,16,18]andCameroon[22] (Table1).

Theproposedtechnologieswereshortmessageservices—SMSs [18,22,23,24], phone calls [16,19], pagers [17,23], web-enabled hand-helddevicepluspersonalhealthrecord[20]andweb elec-tronicintervention[21].Thesubjects’timesoffollow-upranged from4(1month)to72weeks(18months).Improvementsin adher-encelevelsinthegroupsubjectedtotheinterventionbasedon theuseoftechnologywereidentifiedinsevenstudies[16,18–23] (Table1).

Regardingthetypeofcommunication,intwostudies,telephone callsweresynchronouslyused[16,19];infivestudies,thefeedback wasasynchronousfromthesubjectafterreceivinganSMS[22–24], web-enabledHand-helddevice[20]andwebelectronic interven-tion[21].Intwostudies,thesubjectsreceivedasynchronouspager messages,webelectronicinterventionandSMSwithout provid-ingfeedback[17,18].Thequalityoftheevaluationofthestudies showedgoodmethodologicalquality,withapredominantscoreof 3[17,18,23,24].Regardingallocationconfidentiality,therewasan emphasisplacedonCategoryA—theallocationconfidentialitywas

adequate,exceptfortwostudies,whoseallocationconfidentiality hasbeenpreviouslydescribed[16,18](Table1).

Table2providesinformationontheuseoftechnologyandthe measurementofadherence.

Regardingtheuseofinformationandcommunication technolo-gies,therewasapredominanceofthecombinationoftheabove technologieswithstandard care,whichincludedpatient educa-tion[16,20],counsellingsessionsforARTuse[17,21]andfollow-up visits[18–20,22,23].Inonestudy,technologywasalsousedin iso-lation[30].Inanotherstudy,technologywasusedbothinisolation andincombinationwithothertherapies[17](Table2).

Regardingthefrequencyofofferinginformationtechnology,the dailyratewaspredominant[17,19].Onestudyusedamonthly fre-quency[16],onestudyusedaweeklyfrequency[24],andanother study compared the daily and weekly use of technology [18]. Regarding the professionals who implemented the technology, differenthealthprofessionalswerenoted,includingnurses, phar-macistsanddoctors[16–23]orqualifiedprofessionalsfromother areas[18,19,24](Table2).

Regardingthemethods of ARTadherencemeasurement and self-reportedadherence [16,22–24],the useof other measures, suchasadherenceself-efficacy[20,21],pillcounts[17,21],drug monitoringsystems [17,19], visual analogue scales[19,24] and pharmacy records on replenishment [24] was also noted. The combination ofdifferentforms of adherencemeasurement was observedintwoclinicaltrials[23,24].Additionally,multiple adher-encemeasuresduringthestudyperiodwerehighlighted,fromthe beginningofthefollow-upperiodtothe72ndweek(Table2).

4. Discussion

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measure-I.C.V.d.

Lima

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International

Journal

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Medical

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54–61

57

Studycharacterizations.

Authors,Year,Country Technologiesproposed Sample Typeofclinicaltrial Timeoffollow-up Results Jadad scale/Allocation confidentiality

Reynoldsetal.(2008), USA

Phonecall 109 Classic 64weeks/16months AdherencerateintheIG99.7%

(p=0.023)andintheCG97.3% (p=0.019)

2/B IGa_:₅₄

CGb_:₅₅

Lesteretal.(2010),

Kenya

SMSc ₅₃₈ _Classic ₄₈_weeks/12_months _{Self-reported}_adherence_by₁₆₈_of_the₂₇₃

IG,comparedwith132ofthe265inthe

CG(RRd_to_nonadherence₌_0.81;_95%;

CIe₌_0.69-0.94;_p₌_0.006)

2/A a_IG:₂₇₃

b_CG:₂₆₅

Chungetal.(2011),

Kenya

Alarmdevice×Counselling 400 Factorial 72weeks/18months Nosignificantimpactofthealarm

deviceusageinadherence

(HRf₌_0.93;_95%;_CI₌_0.65–1.32;

p=0.7)

3/A a_IG:₃₀₀

b_CG:₁₀₀

Pop-Elechesetal.

(2011),Kenya

SMSdaily×SMSmonthly 431 Classic 48weeks/12months 90%ofIGadherencecompared

with40%ofCGadherence(p=0.03)

3/B a_IG:₃₀₂

b_CG:₁₃₉

Hardyetal.(2011),USA SMS×Alarmdevice 22 Classic 6weeks/1.5months Self-reportedadherenceinIG

92.6%(CI=77.5–107.7)andinCG

72.4%(CI=56.5–88.3)

3/A a_IG:₁₂

b_CG:₁₁

Mbuagbawetal.

(2012),Cameroon

SMS 200 Classic 24weeks/6months Nosignificanteffectofthe

interventiononadherence

measuredbythevisualanalogue

scale(RR=1.06;95%;CI=0.89,

1.29;p=0.542)

3/A a_IG:₁₀₁

b_CG:₉₉

Belzeretal.(2014),USA PhoneCall 37 Behavioural 48weeks/12months Self-reportedadherence

significantlyhigherinIGcompared

toCG(p=0.007)

2/A a_IG:₁₉

b_CG:₁₈

Fiscellaetal.(2015),

USA

Web-enabledHand-helddevice

plusPersonalHealthRecord

32 Classic 52weeks/13months Largerimprovementsin

self-efficacyandself-reported

adherenceinIG

4/A

a_IG:_Not_mentioned

b_CG:_Not_mentioned

Clabornetal.(2014),

USA

WebElectronicintervention 97 Classic 4weeks/onemonth Self-efficacyandself-reported

adherencesignificantlyhigherinIG

(Mg₌_8.79;_SDh₌_{1.34/M:80.53;}

SD=26.29)comparedtoCG

(M=7.96;SD=1.67/M=81.40;

SD=25.21).

4/A a_IG:₄₇

b_CG:₅₀

a_IG:_Intervention_group.

b _CG:_Control_group.

c _SMS:_Short_Message_Service.

d _RR:_Risk_ratio.

e_CI:_Confidence_interval.

f _HR:_Hazard_ratio.

g_M:_Mean.

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Table2

Informationontheuseoftechnologyandthemeasurementofadherence.

Author/year Useoftechnology Technologyproviding frequency

Professionalwhomeasuredthe technology

Adherence

measurementmethod

Measurement frequency

Reynoldsetal.(2008) Combinedwithpatient education

Monthly Nurse Self-reported

adherence

Weeks4,16,48and64

Lesteretal.(2010) Combinedwith appointments

Notmentioned Nurseordoctor Self-reported adherence

Weeks24and48

Chungetal.(2011) Isolatedandcombined withcounselling sessionsforHAART

Daily Pharmacist Tabletscount Weeks4,8,12,16,20, 24,28,32,36,40,44, 48,52,56,60,64,68,72 Pop-Elechesetal.(2011) Combinedwith

appointments

Dailyandweekly Commercialservicesprovider Monitoringdrug eventssystem

Weeks4,8,12,16,20, 24,28,32,36,40,44,48 Hardyetal.(2011) Combinedwith

appointments

Daily Nurse,doctor, pharmacistand counsellor

—Self-reported adherence;

Weeks0,3and6.

—Tabletscount; —Monitoringdrug eventssystem Mbuagbawetal.(2012) Combinedwith

appointments

Weekly Secretary —Visualanalogue

scale;

Weeks12and24

—Self-reported adherence;

—Pharmacyrecordson replenishment Belzeretal.(2014) Combinedwith

appointments

Daily Adherencefacilitator Visualanaloguescale Weeks6,12,24,36and 48

Fiscellaetal.(2015) Combinedwithgroup sessionsandvisits

Notmentioned Doctor Self-efficacyand

Self-reported adherence

Weeks8–10,14–24

Clabornetal.(2014) Combinedwith counselling

Notmentioned Pharmacistand Pharmacy’sstudent

—Self-efficacyand Self-reported adherence

Weeks0and4

—Tabletscount

mentmeasuresof theoutcome variable,multipleinterventions withvariousformsofapproachandinsufficientstatisticaldata.

Theuseofinformationandcommunicationtechnologiesto pro-videhealthcarebeganinthe1990s,withanexpansioninrecent yearsviathemobileweb,smartphonesandsocialmedia.These technologieshaveproveneffectiveasmediationtoolsofinteraction andhealtheducation,withsatisfactorycost-benefits.Inaddition, thesetechnologiesconstituteinnovativemeansofhealth promo-tionanddiseaseprevention[11].

InthecontextoftheHIVepidemic,informationtechnologies havebeensuggestedastoolsforexpandingaccesstohealthcare byreducing thegeographicbarriersandcostsinvolvedin infec-tionpreventionand treatment.If theyare usedin combination withstandard care,itwillbepossibletostrengthenhealth ser-vicesandimprovementsincarequality[4,25].TheUnitedNations ProgrammeonHIV(UNAIDS)andtheWorldHealthOrganization supportinitiativesfocusedonmobilecommunicationasastrategic action[6].

AfricancountriessufferfromtheeffectsoftheAIDSepidemic becausetheyhavelimitedhumanandmaterialresourcestocare forpeoplelivingwithHIV,withrepercussionsrelatedtodecreased adherencetoARTbeingobservedover time[22,26].Clinical tri-alspublishedinthisregionshowconsistencywiththescientific literature[27,28]anddemonstratethebenefitsofusing informa-tionandcommunicationtechnologies,especiallymobilephonesto sendSMSs[18,22],toimproveadherencetoARTinplaceswith lim-itedresources.Ithasbeensuggestedthattheapplicationofmobile telephonesasamethodofcaringforpeoplelivingwiththevirusin otherunderdevelopedcountriesisefficacious.

Mobiletelephoneshavebeenidentifiedas acaretool inthe contextofHIVduetheirfeasibility,acceptance,potentialfor large-scaleuse,potentialforinteractivefeedbackandefficacy[29,30]. Thefindingsofthisreviewsupportthisevidence.Onlyone clin-icaltrialusingmobilephonesdidnotnoteimprovedadherence toART[24].However,thisstudyutilizedmonitoringforonlysix months,whereasinotherreviews,monitoringwaspredominantly

performedfora periodequal toorgreaterthantwelvemonths [16,18,19].Inaddition,inthisstudy,themessageshada motiva-tionalnatureandwerenotdirectlyassociatedwithART.

Asystematic reviewontheuseofmobiletelephonesin HIV preventionandtreatmentanalysed64publicationsinitsmajority descriptive.Inaddition,similarresultstothisstudywere identi-fiedinrelationtotheprevalenceofsendingtextmessagesaspart oftheprovisionofcarecomparedwithothertechnologies. Approxi-mately60%ofthestudiesanalysedinthereviewprovidedwarnings andreminders,usingmobilemessagestoencouragedisease treat-ment[25].

SMScanbeusedasamethodofasynchronouscommunication withandwithoutfeedbackfromsubjectsaftertheyreceive mes-sages.Thefeedbackfromthesubjectsaftertheyreceivemessages, withinaspecifiedperiod,provestobemoreeffectiveand strength-enstherelationshipsamongstakeholdersandenablesprofessional supportforproblem-solving[22].However,thepotentialforthe lossofprivacy,confidentialityandsecrecyshouldbeconsidered withrespecttotheuseofthistechnology[24].

Shortmessagessentbycellphoneareassociatedwithhigh sat-isfactionindicatorsinadultswithHIV.Inaddition,theyassistin thereductionoferrorsandforgetfulnessandstrengthenthelink betweenthepatientandtheprofessionalfrominteractive commu-nicationamongpeers[31].

Inturn,mobiletelephonyisasubtypeoftelephonecallwhose useallows the provisionof information, patienteducation and development of effective skills that can influence behavioural changes[32].InmonitoringchronicconditionssuchasHIV infec-tion,itenablesreal-timeproblem-solving,withapositiveimpact ontreatmentself-efficacy[16].

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evaluationoftheuseoftechnologyandhealthservicesinrealtime [16,19].

Thetwoclinicaltrialsthatusedphonecallshadpositiveresults regardingadherenceinadultsaffectedbyHIV[16,19],butinone ofthetrials,thesamplewasreduced [19].Theauthorsofthese studiesissuedawarningregardingthegeneralizabilityofsamples withdifferentcharacteristicsandsuggestedconducting compara-tivestudiesontheefficacyofphonecallsandtextmessaging.

Anothertype ofinformation and communication technology usedtosupportthetreatmentof peoplewithHIV iselectronic devicereminders(pagers),alow-costtechnologywitheasy han-dling and distribution [17]. Despite these positive points, the literatureshowssimilarresultstothisreviewwithrespecttothe limitedefficacyofthisdeviceintheadherencetoART[27,33,34]. Ontheotherhand,theuseofaweb-enabledhand-helddevice(a mobiletelephonyfeaturewithusability,interactionand versatil-itysuperiortopager)combinedwithinteractivePersonalHealth Recordshowntobeeffectivein improvingtheself-efficacyand self-reportedadherence[20].

This result may be correlated with the lack of interper-sonal interactions with the user, which differs from mobile telephony,wherethereiscontinuousfeedbackbetween patient-to-professionalorpatient-to-patient[31].Thealarmdevicedoesnot capturebarrierstogoodadhesion,suchasdepressionandstigma, whichcanbebetterdetectedinperson[17].Anotherfactorthat contributestotheineffectivenessof thistechnologyisthe abil-itytogeneratecuriositybythosewholivewithpeoplewithHIV, indirectlyviolatingconfidentiality[23].

These review results agree with studies that demonstrate the success of eHealth interventions in Promoting changes in behaviour,self-efficacy, knowledge, and clinicaloutcomes [35]. Therewasemphasisontheuseoftoolssuchasvideos,quizand web-hand-helddevice[20,21]tomotivateadherencetoARTand adherenceself-efficacy.Inaddition,mostpublishedstudiesaddress theuseofeHealthinprimarypreventionofHIV[10],so,itwasnot possibletoestablishmorespecificcomparison.

Therelationshipbetweeninterventionsandbehaviouralchange modelsisan importantfactor.Thereis consensusinthe litera-tureabouttheimportanceofsupportandprofessionalmonitoring guidedbyemotionalprocesses,suchaschangesinbehaviourof peoplewithHIV[16,17,19].Whenmotivated,subjectscandevelop skillstoimproveadherence[17].

However,theuseofonlythemotivationalapproachasan inter-ventionframeworkinICTisnotsufficient[24].Otherbehavioural cognitivestrategies,suchasmotivationalinterviewing,mustbe usedto furtherimprovetheefficacyof technologiesfor adher-encetoART.Theaimistopromoteself-efficacy,socialsupportand copingstrategiesfocusedproblem-solvinganddecreasingstress [19].

Despitetheavailableinformationanddiversityof communica-tiontechnologies,themajorityoftheabovementionedclinicaltrials wererestrictedtomobilephonesandpagers.Withthepopularity ofsocialmediaandsmartphoneapplications,itisexpectedthat futureresearchwillbedevelopedtodemonstratetheuseofthese toolsandtheirefficacyinstimulatingadherencetoantiretroviral treatment.Theexistenceofstudiesintheliteratureontheuseof thesetoolstomediateprimaryandsecondarypreventioninthe contextofHIVhasbeenemphasized[10].

Regardingthequality of theanalysed clinicaltrials, noneof thestudiesreachedthemaximumscoreintheJadadScale[15]. Thecauseofthisfindingwasthelackofblinding.Althoughitwas notpossibletoperformadouble-blinded(investigatorsand peo-plewhoreceivetheintervention)study,itissuggestedthatfuture clinicaltrialsusesimpleblindingtominimizebias.Additionally, therandomizationtechniquedecreasesselectionbias[36].

Anotherimportantfactortonoteistheaccuracyofthe mea-surements of adherencetoARTasan outcome variablefor the useof informationand communication technologiestosupport treatment.Therearetwotypesofadherencemeasurement meth-ods:directandindirect.Thedirecttypemeasuresthepresenceof antiretroviraldrugsin theblood,urineorotherbodilyfluidsby theanalysisofmetabolitesandmarkers.Theindirecttypeassesses otherantiretroviraluseindicatorsbyself-reporting,clinical evalu-ations,reviewsofmedicalrecords,outpatientcareorbehavioural observation(pill counts,pharmacy refillrecords,and electronic drugmonitoring)[37].Inthisreview,wehighlightedtheindirect methodsofadherencemeasurement.

Interviews and questionnaires based on self-reporting have advantages,suchaslowcost,easeandapplicationspeed,aswell asthepotentialtocapturespecificinformationaboutdosagesand adherencetodietaryrequirements[38].Despiteitshigh reliabil-ityandspecificity,self-reportingissusceptibletorecallbiasand canprovideinaccurateinformation;therefore,itmustbecombined withothermethods[37].

The visual analogue scale (VAS) is an indirect method of adherencemeasurementthatconsistsofcharacteristicorattitude measurementinstrumentsthatarenoteasilymeasuredandare subjective.Thepatientmarksahorizontallinelength,which rep-resentstheirperceptionoftheircurrentstate[39].

Anotherindirectmethodofmeasuringadherenceisthe quan-tificationofremainingpillsthatmaybeheldbythepharmacist formedicationrefill.Itisameasuresubjecttobiasbecauseofthe possibilityofpillomissionbythepatient[17].Amoreaccurate mea-surementisbasedonadrugeventmonitoringsystemheldbythe pharmacistthatusesmicrosensorsthatarelocatedinthemedicine bottle,allowingtheanalysisofthenumberofopenings[17].

5. Conclusion

Theuseofinformationandcommunicationtechnologiesin sup-portingthecareofadultswithHIVisconsideredtobeeffectivein improvingadherencetoART.Theadvantagesofthesetechnologies includetheirpotentialforinteraction,collaboration,lowcostand useinareaswithlimitedhumanandmaterialresourcesforthe pro-visionofcare.However,accesstoelectronicdevicesandtheneed forusertrainingareimportantconsiderations.

The most effective type of information and communication technologywasthephone,whichwasusedtodelivercallsandsend alertmessages,aswellasremindersabouttakingmedications.The electronicdevicealarm(pager)wasnotconsideredtobeeffective forARTadherence.

Apreference fortechnologiesenabling synchronous commu-nication(telephonecalls)asynchronouslyfeedbackfromsubjects (SMS)fortheformationofclosertiesandthepromotionof profes-sionalsupportinrealtimewasnoted.Thisreviewwasunableto comparetheuseofICTsincombinationwithstandardcarewith classroomtechnologies.

TheeHealthinterventionssuchasvideos,quizand web-hand-held device were effective to motivate adherence to ART and adherence self-efficacy. It is recommended that clinical trials involvingspecificallytheuseofthesetechnologiestosupportthe treatmentofHIVareconducted.

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Summarytable

Whatwasalreadyknownonthistopic?

• Information and communication technologies subsidize

interventionsaimedatpatientmonitoringorpreventingthe transmission of HIV bypromoting improved accessibility andqualityofcare.

• Theliteraturehighlightsthepossibilityofapositiveeffect

onthelevelsofsatisfactionandpatientsafety,inadditionto improvingadherencetoantiretroviraltherapywiththeuse ofinformationandcommunicationtechnologiestosupport care.

Whatthisstudyaddedtoourknowledge?

• Theuseofinformationandcommunicationtechnologiesto

supportcareinadultswithHIVwasconsideredtobeeffective inimprovingadherencetoART.

• Themostprominenttypeofinformationandcommunication

technologywasthephone,whichwasusedtodeliver tele-phonecallsandsendalertmessages,aswellasreminders abouttakingmedications.

• Theelectronicdevicealarmwasnotconsideredtobe

effec-tiveforadherencetoART.

• Nostudiesmeetingthe inclusioncriteria focusing onthe

useofinteractive technologies,suchassmartphoneapps andsocialmediamonitoringinadultswithHIV,havebeen found.Therefore,conductingclinicaltrialsregardingtheuse ofthesetechnologiesto supportthetreatmentof HIVare recommended.

Forfutureexperimentalstudiesontheuseofinformationand communicationtechnologies,wesuggesttheanalysisof interven-tionsmediatedbysmartphonesandsocialmediaapplicationsand theirassociationwithadherencemeasurementmethods,aswell astheconductionofclinicaltrialsofthefactorialtype(multiple interventions),detaileddescriptionsofrandomizationandtheuse ofsimpleblinding.

Finally,informationtechnologiesareaninstrumentofproven efficacyandgreatcost-benefitswithrespecttotheexpansionof accesstocare.Moreover,thisreviewalsohighlightedthe narrow-ingoftherelationshipbetweenpatientsandhealthservices,with thepossibilityofmitigatingthedifficultiesexperiencedbypeople withHIVinachievingoptimallevelsofadherencetoART.

Authors’contributions

TheauthorICVLparticipatedinthemanagementofthe system-aticreviewwordingprocess.TheauthorsICVLandHOAcontributed duringthedifferentstagesofthereview,includingtheselection ofarticlesandthecriticalreading andanalysisofabstractsand selectedarticles.Theresearchers MTGG,FETLand TLAcritically analysedtheconstructionofthearticleandprovidedcomments. Finally, all authors read and approved the final version of the manuscript.

Acknowledgements

TheauthorsaregratefultotheNationalCouncilforScientificand TechnologicalDevelopment(CNPq)forprovidingfinancialsupport. WewouldalsoliketothankthemembersoftheStudyGroupon HIV/AIDSandAssociatedDiseasesoftheFederalUniversityofCeará fortheirencouragementandcontributions.

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