The use of digital health (eHealth) has a promising potential in delivering healthcare services to patients living with chronic conditions, especially with the opportunity to apply mobile phones technology (mHealth)1. The irruption of the novel coronavirus (COVID-19) outbreak in 2020 has increased the adoption of eHealth, mHealth, or other Telemedicine technologies as a practical solution to continue with chronic patients’ healthcare while restricting presential appointments to healthcare facilities. Besides, previous experiences with eHealth and mHealth in chronic patients resulted in a better quality of care, enhanced clinical outcomes, and patient experience, in addition to a reduction in medical costs2–6.

People living with human immunodeficiency virus (PLWH) could significantly benefit from mHealth tools since they necessitate close clinical monitoring and effective interdisciplinary care: they require lifelong antiretroviral therapy (ART), regular follow-up visits, and laboratory tests, and often accumulate multiple clinical comorbidities7. In addition, some of them have a high prevalence of comorbidities and polypharmacy8. Thus, implementing a mHealth tool to assist the PLWH management might help improve disease monitoring and treatment adherence, optimizing the current health care delivery.

The implementation of mHealth tools targeting complex populations such as PLWH is challenging. The mHeart application (app), recently implemented in our heart transplant outpatient clinic, is already a consolidated eHealth tool designed to help enhance chronic-stage heart transplant recipients’ clinical care. The mHeart implementation has increased medication adherence in heart transplant recipients and has enhanced patients’ experience and satisfaction with care9–11.

Based on this previous experience, we are currently developing a new standard of care for PLWH and the mHealth app needed to support it, the EMMASalud (eHealth Medical Multiplatform Aid) MyPlan version. EMMASalud MyPlan is grounded on the theoretical framework of mHeart; therefore, it has been designed to promote targeted disease management.

The study was set out as part of a global project to implement a strategy for improving the current PLWH’ journey using an interdisciplinary technology-based behavioral app. The study described in this article has two specific objectives: 1) to explore the view of patients and healthcare professionals (HCPs) on the possibilities of mHealth tools on HIV care, 2) and to implement their feedback into the new EMMASalud MyPlan and into the new standard of care for PLWH.

The present study is part of an implementation strategy of a clinical practice improvement model. It was conducted by the pharmacy service together with the infectious disease unit at a tertiary university hospital between 2020 and 2022. The coordinator team comprised two clinical pharmacists with extensive experience in implementing digital health strategies and in the guidance of focus groups. The study was approved by the referent Ethics Committee (IIBSP-ARV-2020-78).

The study had two different phases: phase one was to apprise PLWH’ and HCPs’ perspectives on mHealth using the qualitative methodology of the focus groups, whereas phase two aimed to implement their feedback into the app and the new standard of care for PLWH.

The project's ideation was carried out between 2019 and 2021 (before starting phase 1: focus groups). This preliminary step of the project aimed to define the study objectives, design, and phases, set up the research team, conduct the administrative procedures (approval of the ethics committee) and search for funding. A summary of the phases of the study is described in figure 1.

Figure 1.

Summary of the phases of the study within the development of the EMMASalud MyPlan approach.

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The use of mHealth systems —and, more specifically, mobile apps— to support chronic patients’ management improves quality of care, health outcomes and patient experience and also reduces medical costs in some settings2–6. Our study has contributed to develop an interdisciplinary technology-based behavioral app for PLWH patients.

In general, patients and HCPs shared common viewpoints on the possibilities of mHealth tools on HIV care. For example, both agreed that a mHealth tool could promote patients’ education, improve patients-HCPs communication, or integrate medical appointments and drug prescription and dispensation. In line with our results, in a previous focus group conducted in the United States15, young PLWH thought that a mHealth app might ease access and communication to HCPs and provide them with updated health education. In addition, it could help them schedule medical appointments or track personal data. Similarly, a group of physicians considered that mobile medical apps would be useful for informing and educating their patients and assisting their clinical decision-making or patient monitoring16.

Patients and HCPs in the study agreed on important aspects. However, they focused on diferent aspects of mHealth tools for PLWH. HCPs placed special focus on the use of mHealth technology to improve health outcomes, including patient quality of life, disease control, and patient adherence. Conversely, patients were centered on the fact that mHealth technology may help them be treated more discretely and change the dispensation medication model out of the hospital environment. Previous experiences demonstrated that digital health interventions might allow for greater PLWH anonymity and more flexibility in scheduling appointments17. They might also improve the efficiency of pharmacy follow-up visits or facilitate medication home delivery18,19.

Results of the focus groups enabled us to gain an in-depth understanding of the app end-users’ needs and incorporate them into the app as functionalities. Among these functionalities is the information about the disease, health promotion, and prevention, the possibility of direct patient-HCPs communication, or synchronization with other devices.

A key aspect of the development of any healthcare technology is its validation under real-life conditions and its implementation into the patients’ care pathway. Accordingly, this new tool is currently being implemented in our institution. The app is being tested in a group of PLWH in real-world conditions and compared with routine care. With the implementation in clinical practice, we expected an improvement in the PLWH’ journey in terms of patients’ and HCPs’ communication, medication adherence, patient empowerment, and healthy lifestyles. This has been corroborated in other technology-based interventions and settings20–23. Adherence to ART is crucial in HIV management to avoid drug resistance, disease progression, and complications24. In line with this, different interventions show that digital health help PLWH comply with ART25–27. Additionally, our experience with digital health intervention (mHeart) with chronic-stage heart transplant recipients resulted in higher adherence rates9–11.

Another challenge is to improve patients’ monitoring through mHealth. PLWH require lifelong and close follow-up as they might accumulate age-related comorbidities and polypharmacy7,8. In that respect, we believe that the use of mHealth might facilitate close and long-term monitoring of clinical parameters (i.e., blood pressure, heart rate, weight, glycemia, etc.), symptoms, and adverse effects. Clinicians may take clinical actions in response to these patients’ reports. Furthermore, we expect that our intervention might facilitate the monitoring of Patient-Reported Outcomes (PROs) and Patient-Reported Experiences (PREs) such as patients’ quality of life and satisfaction with their care, which might help to improve patients’ experience and ultimately strengthen their engagement and retention in their care as previously shown28,29.

Our study has some limitations. First, the PLWH's- sample was small. However, due to the qualitative nature of the study, the small sample did not limit the obtention of rich and detailed information about patient's view. Secondly, all patients were men. Nevertheless, most PLWH treated in Spain are men, what makes this sample a good representation of the end-users of the mHealth in our center30.

In conclusion, improving patients’ quality of life, therapeutic adherence, or disease control are key objectives for the optimization of PLWH’ journey. We are currently implementing our technology-based behavioral app EMMASalud MyPlan into our clinical protocols to establish a new PLWH’ journey. In addition, the app is being tested in real-world conditions. With the fully implementation of the app and the new healthcare model we expected to overcome these important challenges in HIV management through better patients-HCPs communication, patients’ monitoring and satisfaction, and engagement with their care.

This study was supported by Gilead. This contribution aimed to reinforce the study resources and implementation of the new patient journey and the study procedures.

The current sponsor Amgen has supported the Hospital to fund the technical development of the app EMMASalud MyPlan (EMMA, eHealth Medical Multiplatform Aid).

The funders mentioned above and the firm in charge of the technological development of the software (Trilema Salud Group S.L.) played no role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript.

This work would not have been possible without the patients’ contributions and willingness to achieve a patient-centered design. Furthermore, we would like to express our gratitude to the Pharmacy Service and the rest of the clinical team involved in the focal groups and particularly to Sílvia Cermeño Reyes, Jessica Muñoz, Gemma Ballarín Laliena, Helena Ruppmann, Pilar Lozano and Fiorella Pérez, Jessica Muñoz Rodríguez.

The authors declare no conflicts of interest. The technological development of the EMMASalud MyPlan application was carried out by a private Spanish firm specializing in health care system apps (Trilema Salud Group S.L.). Most of the authors of this study participated as consultants of the application design. Neither the funding entities mentioned above nor the technical developers played any role in study design, data collection and analysis, publication decision, or manuscript preparation.