The following report is proprietary information and constitutes trade secrets of The MetroHealth System and may not be disclosed in whole or part to

any external parties without the express consent of The MetroHealth System. This document is intended to be used internally for The MetroHealth

System discussion.

The Positive Peers App (PPA)

PI: Ann Avery, MD

PM: Jen McMillen Smith, LISW-S

PC: Josh Kratz, MA

Eval: Mary M. Step, PhD

Eval Assist: Theodore Russell, BA

Data: Steven Lewis, MPH

What is Positive Peers?

Positive Peers is a mobile application (app)

and companion website that aims to engage

young people in holistic HIV care within a

private, stigma-free, supportive online

community.

Positive Peers is made possible through a U.S. Department of Health and Human Services Health Resources and

Services Administration, HIV/AIDS Bureau Special Projects of National Significance (SPNS) Grant to The

MetroHealth System. For more information about the SPNS grant initiative, visit:

http://hab.hrsa.gov/abouthab/special/socialmedia.html#5

Set. Target. Deliver.

Setting:

• Positive Peers was implemented by the MetroHealth System in Cleveland, OH.

• The cross platform app is available from the Apple or Android app store.

• Participants can use the app anywhere they have data or Wifi service.

Target: • Young people living with HIV (YPLWH) between 13-34 years old at enrollment.

• Specific focus on recruiting newly diagnosed or those not fully retained in care.

• Recruited cohort of healthy, in care, YPLWH (Health Ambassadors) to form

nascent online community group.

Delivery:

• The mobile application is the intervention, which was integrated into overall wrap

around HIV services for young people.

• Intervention exposure was augmented by: in-person events, daily push

notifications, social media, and a companion website.

• Staff communications occurred by phone, text, email, the PPA, mail, social media,

and in-person.

Local Evaluation – Where are we at?

• Application Activity

• Few demographic differences in app activity

• Trend for more private chat activity among males (p = .07)

• Stigma

• Less overall, personal, disclosure, self image, & perceived public attitudes

(PA) stigma reported by African Americans at baseline and over time

• Overall and PA stigma lessened for all over time points

• >25 YO reported less disclosure stigma over time (p=.06; p=.03)

• 30+ reported less PA stigma over time (p=.01)

• Trending inverse relationship for broad use app activity and disclosure

stigma (p =.09)

• Reviewing next tier ACASI variable frequencies (see table)

• Drug use, incarceration, etc.

• Re-evaluate outcome model and pathways (see tables)

• Viral suppression

• Interpersonal connection

• Affordances analysis

• Create retrospective matched cohort w/survival analysis

Frequency of substance use greater than or equal to several times per month/week in the past 6 months.

Substance Baseline

(128) n(%)

6 M (n=97) 12 M (n=71) 18 M (n=50)

Alcohol 18 (8.4) 13 (6.1) 10 (4.7) 6 (2.8)

Marijuana ◆ 49 (44.6) 30 (16.9) 32 (12.4) 13 (7.34)

Tobacco 56 (36.8) 29 (19.0) 17 (11.1) 14 (9.2)

Ecstasy 2 1 2 0

Powder Cocaine 4 5 2 0

Poppers 1 3 1 0

Crack Cocaine 3 3 0 1

Methamphetamine 1 4 3 2

Amphetamines 2 0 1 1

◆ Not prescribed

Improving numbers

Preliminary Findings – Viral Suppression

Results: A small but significant effect (OR = 1.015; 95% CI: 1.00 to 1.03; P =

0.017) was found for increased application activity on viral suppression 6 months

post baseline.

• Adjusted for baseline viral load, time with HIV, patient demographics, and

socioeconomic status.

• Positive Peers participants who demonstrated broad app use (i.e., clicking and

spending time in My Health, Community and Resources tabs) were more likely to

be virally suppressed than those who used these functions less.

Hypothesis: Greater application activity will be associated with greater viral

suppression.

• Application activity defined as the sum total of automatically tracked activities

on each app function.

• Viral suppression was assessed via electronic medical record extraction and

compared across app users versus non-users.

Preliminary Findings - Continued

Retrospective Cohort (N = 508)

* Positive Peers

participants may have

higher percentage of

retention in care than

similar non-participants.

Extracted matched controls who did not participate in Positive Peers (PP)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

# linked (1 visit in year) # engaged (visit in 1stand 2nd half)

# engaged (CD4 or VL in1st and 2nd half

# undetectable

96%

61%

54%

63%

83%

45%

33%

59%58%

38%35%

53%

enrolled in PPA Not enrolled in PPA but eligible Eligible only by age

HIV Care Cascade 2017 Youth 13-34

Local Evaluation – Model Revision

Re-evaluate engagement construct

• More complex than application activity.

• Requires inter-mediated approach

• Contributions of tech design features/functions

(i.e., affordances)

• Interpersonal contact with intervention staff

• Interpersonal contact with other users

Affordances refer to features of user/tech

interaction that offer gratification of perceived

needs.

• Review associations between user characteristics,

self reported affordances administered at 12 months

and outcomes

• Accessibility, privacy, personalization, etc.

Perceived Community Outcome

• Does app create more than individual level

outcomes?

User

Characteristics

• Time since dx

• Age/Ethnicity

• ?

Intervention

Engagement

• Tech Affordances

• Interpersonal

Contacts

Application

Activity

Outcomes

• Perceived Community

• Viral Suppression

• Perceived Stigma

Sustainability Plans

Funding Options

• Local foundation

• 340B funds

• Exploring options within RW (all parts)

• NIH

• EtHE funds

Virtual Onboarding

• Finalizing virtual onboarding platform – using Wordpress

• Approval of and purchasing e-signature software/plug-in

• Test onboarding and baseline evaluation with CAB and solicit feedback

Evaluation Strategy

• Conduct online surveys at baseline, 3M, 6M, & 12M

• Baseline survey in final editing stage

• Anyone 13-34 living with HIV, willing to sign a medical information sharing release, and

has a smartphone/email address will be eligible to enroll

Sustainability Plans – Continued

IRB

• Update consent documents, study goals, surveys/instruments, etc.

Risk Assessment

• Overall, risk is very low but adverse events could impact app/website

functionality, brand credibility, & financial solvency

• Mechanisms to prevent and mitigate intrusions are in place

Future App Updates

• Wellness Tracker

• Calendar – Users can invite others to events

• In-app tutorials – How to use PPA

• Ability for users to change their own username

Lessons from the Field - Successes

• Recruited and retained a dynamic community advisory board to aid creation & implementation of Positive Peers,

• Built and grew an interdisciplinary team committed to ongoing success,

• Created a highly functional, aesthetically forward, complex mobile app capable of long term sustainability,

• Translated a holistic vision of community to virtual space,

• Retained > 100 participants for over 12 months,

• Reduced stigma for key targeted populations,

• Appear to have a positive effect on viral suppression of participants.

Lessons from the Field – Lessons Learned

• Don’t rush – ensure app is ready before roll-out,

• App retention requires diverse efforts (e.g., In-person events),

• Project coordinator should reflect participant characteristics,

• Community conversations focus less on HIV, more on life as a whole,

• Professional design and technology teams raise the level for all implementation activity,

Lessons from the Field – Lessons Learned

• Community requires effortful building,

• Size does matter…when it comes to apps,

• Privacy needs vary across individuals,

• Online recruiting sites are variably effective

(e.g., censor ads for the app),

• Google security – glitches happen,

• Most users don’t follow Positive Peers social

media, but lurk occasionally.

Questions?

Thank you!

“Undetectable = Untransmittable” isn’t something you keep to

yourself. It’s something to shout from the rooftops!

What does it mean? It means that scientists are certain that if your

viral load is undetectable and has been for six months or more (200

copies/ml or less), you cannot pass on the virus to anyone else.