HIV Prevention: Digital Health Interventions to Improve Adherence to HIV Pre-Exposure Prophylaxis

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends digital health interventions to increase adherence to HIV pre-exposure prophylaxis (PrEP). Systematic review evidence shows interventions improve both daily-use pill taking and retention in PrEP care. This improves health for population groups who are not infected with HIV and engage in behaviors that may increase their chances of getting HIV.

The full CPSTF Finding and Rationale Statement and supporting documents for HIV Prevention: Digital Health Interventions to Improve Adherence to HIV Pre-Exposure Prophylaxis are available in The Community Guide Collection on CDC Stacks.

Intervention

Digital health interventions to improve adherence to HIV PrEP use text messages, mobile apps, phone calls, or websites to deliver reminders, guidance, and support that may be tailored to an individual’s needs.

Participants must be HIV-negative and have a prescription for PrEP consistent with CDC guidelines (CDC 2021 [PDF — 1.58 MB]). Interventions provide one or more of the following:

  • Information about HIV, PrEP, and strategies for medication adherence
  • Services intended to motivate participants such as automated or interactive feedback, online forum discussions, virtual support groups, or adherence self-tracking
  • Regular reminders for medications, virtual check-in appointments, and clinic visits

Interventions may be combined with in-person activities such as one-on-one counseling, peer-led group sessions, or patient navigation.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 7 studies (search period January 2000 to September 2021). Eligible studies were identified through a three-step process: CDC librarians identified eligible studies through a three-step process. First, they conducted searches and compiled a database of publications relevant to PrEP. Next, they performed queries within this database for publications relevant to digital health interventions to improve PrEP adherence. And finally, they conducted a PubMed search to identify more recent publications potentially relevant to PrEP.

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV prevention, treatment, and care.

Study Characteristics

  • Included studies were conducted in the United States (6 studies) and The Netherlands (1 study).
  • Studies evaluated a digital app only (2 studies), an app plus text messaging (1 study), text messaging only (1 study), or text messaging plus email, phone, or internet communication (3 studies).
  • Digital health services included medication reminders (5 studies), information and education (4 studies), adherence tracking (2 studies), support groups (2 studies), and counseling (1 study).
  • Interventions communicated with participants daily (2 studies), weekly (3 studies), or monthly (1 study).
  • Participants received feedback in one or more of the following ways: unidirectional communication (pre-set messages; 3 studies), automated bidirectional communication (questions were answered by pre-set messages; 3 studies), or personalized bidirectional communication (questions were answered by support person in real time; 2 studies).

Summary of Results

The systematic review included 7 studies.

Adherence:

  • Interventions increased “good adherence” to PrEP (defined as taking four or more doses of PrEP per week) by a median of 10.0 percentage points or a median of 11.1% when compared with standard care (5 studies).
  • Interventions increased “excellent adherence” to PrEP (defined as taking seven doses of PrEP per week) by a median of 13.6 percentage points or a median of 65.4% when compared with standard care (3 studies).
  • One study found adding visualized feedback to an app increased the number of participants achieving excellent adherence but did not reduce the number of participants with “poor adherence” (defined as less than four doses per week).
  • One study reported the intervention group missed fewer doses of PrEP when compared with the control group.

Retention:

  • One study found the intervention improved retention in PrEP care, measured as the proportion of participants who attended all of their clinic visits.

Summary of Economic Evidence

A systematic review of economic evidence has not been conducted.

Applicability

Based on results from the systematic review, the CPSTF finding should be applicable to younger gay and bisexual men and other men who have sex with men (collectively referred to as MSM) in urban U.S. settings independent of socioeconomic status, race, or ethnicity, or substance use.

Evidence Gaps

Setting:

  • How effective are digital health interventions for rural areas?

Population characteristics:

  • How effective are these interventions for the following populations?
    • Older adults
    • Females
    • People in racial or ethnic minority groups
    • People with mental health issues
    • People who engage in excessive alcohol use or drug use (including injection drug use)

Intervention characteristics:

  • Does intervention effectiveness change by offering participants the following?
    • All or part of the necessary equipment, such as mobile phones or data plans
    • Materials and communications in languages other than English
    • In-person services

Implementation Considerations and Resources

  • Digital interventions to improve adherence to daily-use HIV PrEP were highly accepted among study participants. Of the services offered, participants were most likely to use daily pill reminders and weekly check-ins.
  • Although three studies included participants over 40 years of age, included studies recruited relatively young participants who were more likely to be comfortable with digital communication, and few reported difficulties sending and receiving messages.
  • Interventions may need to be compliant with the Health Insurance Portability and Accountability Act (HIPAA). There are concerns around confidentiality when sending HIV-related text messages, and some interventions use innocuous language such as “time to take vitamin pills” to replace HIV-specific language. One study reported that their intervention was HIPAA compliant.
  • Digital health interventions have technology and equipment requirements. In 2021, 85% of U.S. adults used a smartphone (Statista), 77% had high-speed broadband service at home (Pew Research Center), and 93% used the Internet (Pew Research Center), suggesting digital interventions could be widely implemented. The digital divide for smartphone ownership has diminished by race or ethnicity, but still exists for Americans with lower incomes, older adults, and people living in rural areas. It is important to consider participants’ income, age, and geographic location when implementing these interventions.
  • Structural and financial barriers exist for PrEP access, including patients’ ability to get prescriptions and attend required clinic visits and testing appointments. These disparities in access lead to disparities in HIV care, morbidity, and mortality. Implementers may want to consider available ways to address some of these barriers. For example, most insurance plans and state Medicaid programs cover the cost of PrEP. The Ready, Set, PrEP program provides PrEP for free or at a reduced cost to those who qualify. Other programs include co-pay assistance programs that lower costs of PrEP medications and state PrEP assistance programs that cover costs for medication, clinical visits, and lab testing.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.