Development and evaluation of a theory-informed mHealth intervention to promote viral suppression among women living with HIV who engage in sex work in Mombasa, Kenya: the role of text messaging, social support and stigma

Abstract

HIV is a global pandemic exacting a disproportionate burden on sub-Saharan Africa. A key population affected by HIV are women who engage in sex work. Effective antiretroviral therapy (ART) has revolutionized HIV treatment and prevention, yet strict adherence remains a barrier to achieving viral suppression. Mobile health (mHealth) interventions have been evidenced to improve ART adherence and viral suppression. HIV-related stigma is pervasive, especially in conjunction with the stigma of sex work. There is evidence that social support may buffer the effects of stigma on poor adherence and HIV treatment outcomes. However, current research on social support and stigma is limited by an individual focus. Social network analysis is an increasingly popular methodology utilized to overcome this shortcoming and more accurately describe the environment in which persons of interest interact. The aims of this dissertation are: 1) to develop a theory-informed, mHealth intervention to improve ART adherence and viral suppression among women who engage in sex work in Kenya, 2) to evaluate the efficacy of the intervention to improve ART adherence and viral suppression in a randomized controlled trial, and 3) to leverage social network analysis to examine the relative impact of HIV-related stigma and social support on viral suppression. Focus groups with women who engaged in sex work informed the content and structure of the mHealth intervention, entitled Motivation Matters!. When compared to an active standard of care condition, women receiving Motivation Matters! endorsed higher rates of ART adherence and viral suppression, especially among women who were viremic at baseline and reported engagement in sex work. Finally, although we did not find significant relationship between individual and network-level measures of stigma and social support on viral suppression, further examination of the women’s social networks suggested that the experience of stigma had a more significant impact on viral suppression. In conclusion, the improvements in ART adherence and viral suppression suggests that Motivation Matters! could be an effective tool to support the treatment of women living with HIV in sub-Saharan Africa. Moreover, utilizing social network analysis provides a more rich and in-depth depiction of the social topography of women living with HIV, which could open doors for researchers to develop more effective interventions to support the women’s health and wellbeing.