Evaluation of a Smart Phone App-based Case Management Model Among ART-naive HIV-infected MSM

Experimental: Intervention group

participants in this arm receive the APP-based case management service and standard-of-care followup service.

Conductual: APP-based case management service

The intervention consists of 4 parts, educational articles, online communication with case managers, supportive service information and visit reminder. Educational articles are both delivered automatically and retrieved by participants. Online communication can also be initiated by participants and case managers. Case managers are request to respond to questions from participants as well as care about medication taking behaviors of each patients during the first month. Supportive service information, which include time, location and charges of service providers will be retrieved by participants, with reminders of available service information scheduled at the beginning of every month. Visit reminders are scheduled at one week before due date.

Conductual: Standard-of-care followup service

When participants initiate HIV antiretroviral treatment (ART), they receive 20-minute ART-related education from the case managers, and have physical examination including blood test, CD4 count, hepatic and renal function tests. Subsequent visits are scheduled at month 1, 2, 3, 6 and 12. During each visit, pills enough to cover days until the next visit will be distributed. And patients will be asked about their medication adherence, high risk behavior and side effects experienced. Any relevant questions from patients will be answered. Physical tests are also included in the routine of each visits.

Comparador activo: control group

participants in the control arm receive standard-of-care followup service

Conductual: Standard-of-care followup service

When participants initiate HIV antiretroviral treatment (ART), they receive 20-minute ART-related education from the case managers, and have physical examination including blood test, CD4 count, hepatic and renal function tests. Subsequent visits are scheduled at month 1, 2, 3, 6 and 12. During each visit, pills enough to cover days until the next visit will be distributed. And patients will be asked about their medication adherence, high risk behavior and side effects experienced. Any relevant questions from patients will be answered. Physical tests are also included in the routine of each visits.

self-reported ART medication adherence

Measured by visual analogue scale (VAS) ranging from 0 to 100%. The ART medication visual analogue scale is a instrument for patients to rate their dose taken percentages. 100% of doses taken will be regarded as good adherence.

CD4 count

measured by flow cytometer during visits to hospitals

Anxiety

Reference： Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of internal medicine 2006; 166(10):1092-1097.

Anxiety will be measured by Generalized Anxiety Disorder (GAD)-7, including 7 Likert-style items. Response options include "not at all", "several days", "more than half the days", "nearly every day". Scores of 0, 1, 2, and 3 will be assigned to the response categories, respectively. Cronbach's alpha was 0.92. Total score for the scale ranges from 0 to 21. Score will be categorized into 4 level to indicate anxiety level: minimal anxiety (0-4 points), mild anxiety (5-9 points), moderate anxiety (10-14), severe anxiety (15-21)

Depression

Reference: Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals 2002; 32(9):509-515.

The Patient Health Questionnaire (PHQ) -9 is a 9-question instrument given to patients in a primary care setting to screen for the presence and severity of depression. The total of all 9 responses from the PHQ-9 aims to predict the presence and severity of depression. Questions are about the level of interest in doing things, feeling down or depressed, difficulty with sleeping, energy levels, eating habits, self-perception, ability to concentrate, speed of functioning and thoughts of suicide. Responses range from "0" (Not at all) to "3" (nearly every day). A total sum of the responses suggests varying levels of depression. Scores range from 0 to 27. Scores of 10 or higher is suggestive of the presence of depression, with higher score indicating more severe level of depression.

Quality of Life

Reference: Pedroso B, Gutierrez GL, Duarte E, Pilatti LA, Picinin CT. Quality of life assessment in people living with HIV/AIDS: clarifying the WHOQOL-HIV and WHOQOL-HIV-Bref instruments. In: Global view of HIV infection: InTech; 2011.

The WHOQOL-HIV BREF is an abbreviated version instrument for evaluation of quality of life specifically designed for people with HIV or AIDS. It contains five extra items specific to PLWHA, and in total contains 31 items. Its items are rated on a 5-points Likert scale, and the available responses are 1 (not at all), 2 (a little) 3 (a moderate amount), 4 (very much) and 5 (an extreme amount). The WHOQOL-HIV BREF contains six domains (physical, psychological, independence, social relations, environment, spiritual/religion/person beliefs) and overall quality of life and general health perceptions. After reverse negatively phrased items, domains and facet scores are scaled in a positive direction where higher scores denote higher quality of life.

ART-related perception

Reference: The Life Windows Project Team. The Life Windows Information Motivation Behavioral Skills ART Adherence Questionnaire (LW-IMB-AAQ). 2006. Center for Health, Intervention, and Prevention. University of Connecticut.

The LW-IMB-AAQ was developed as a measure of barriers to antiretroviral therapy (ART)adherence among HIV+ patients in clinical care, following the constructs identified in the Information--Motivation--Behavioral Skills (IMB) model of adherence

The Information and Motivation subscale includes 19 and 10 Likert-style items, respectively. Response options include "Strongly Disagree", "Somewhat Disagree", "Neither Agree nor Disagree", "Somewhat Agree", and "Strongly Agree". Cronbach's alpha was 0.59 and 0.75 in a sample of youth living with HIV, respectively. Higher scores indicate greater knowledge and motivation of ART treatment.

This subscale includes 14 items. Cronbach's alpha was 0.90. Higher scores indicate greater motivation towards adherence.

High risk sexual behavior

measured by self-selected items including "how many male/female regular/casual partners did you engage in sexual intercourse with during the last month?" And "How frequent did you use condoms during sexual intercourses in the last month with your regular/casual partners?"

Retention in ART

kept and missed primary care visits record retrieved from hospital document

HIV RNA viral load

measured by polymerase chain reaction(PCR) during visits to hospitals

utilization of the case-management service in the intervention group

Utilization of the APP will be measured using data retrieved from the APP, including numbers of online communicational messages sent, numbers of each articles being read.

uptake of supportive service

will be measured by data from collaborative organization to see if participants use supportive service.

intervention adherence of participants in the intervention group

will be measured by a single item asking how frequent they read the educational articles.

sexually transmitted infection

number of self-reported sexually transmitted infection (STI) in the past 30 days,

sexual orientation disclosure

Status of coming out was coded as involuntarily coming out (outing) (3), voluntarily coming out (2), no coming out with thinking (1), and no coming out and no thinking (0).

HIV infection status disclosure

Disclosure of HIV testing was assessed by asking, "Does your main sex partner know that you have been HIV tested?" and "Have you told your main sex partner your HIV test results?"