The proportion of older adults infected with HIV grows progressively [1], not only because of increased survival of cohorts but also because of an increase in the number of new diagnoses in this group of population [2,3]. With the increasing age of our patients, the possibility of AIDS diagnosis event, serious non-AIDS events (osteoporosis, renal failure, vascular events, non-AIDS cancers, and neurocognitive impairment), or metabolic conditions (diabetes, hypertension, and hyperlipidemia) that are associated with increased morbidity and mortality rises [4,5]. All these conditions are encompassed in the concept of comorbidities. These patients are a population group in which the accumulation of different types of medications and the potential for toxicity and interactions will also be greater [6]. The social stigma that accompanies HIV infection is not negligible, especially in patients of older age; so being able to share their experience with their peers could lead to reducing feelings of loneliness and stigmatization. The use of these technologies in smartphones (mobile health) has also been developed in the HIV-infected population, although a specific HIV-infected older adults’ experience has not been reported yet [7,8]. Probably, compared with the younger infected ones, older adults are a differentiated group, who are less accustomed to the use of new technologies and have a special interest in being informed not only about HIV infection but also about the comorbidities associated with age. In addition, the isolation is greater in older individuals, so an app specifically designed for this group could be useful [9].

New technologies allow the creation of virtual communities that help to maintain the anonymity of the individual while allowing interaction with other peers [10]. The creation of peer support groups formed with reference and access to tips for health promotion and commented on by medical personnel news may have beneficial effects in this population. Anonymity could favor those people who would not participate in face-to-face activities or with fear of losing their privacy and those who could benefit from being supported by peers. This can be especially important in older people belonging to generations in which HIV infection or sexual condition was associated with a certain stigma in Spain [11].

The GoSHAPE 2015 program was supported by Gilead to promote the use of new technologies and the empowerment of patients. In this context, we deliver the development of an app. Being a pilot study, our objective was to observe the acceptability and use of a mobile app on HIV infection in patients at least 60 years old as well as offer the possibility of establishing anonymous contact between peers.

The study was led by Costa del Sol Hospital Internal Medicine Unit (Marbella, Spain), in collaboration with the Pharmacy unit, the department of clinical investigation, and a local nongovernmental organization (Concordia). The approval of the local ethics committee was obtained, and all the patients signed informed consent before any study performance.

Baseline characteristics of the patients are shown in Table 1. All of them were receiving ART.

As for physical activity measured according to the IPAQ, 2/30 patients (7%) referred low activity, 11/30 (37%) moderate, and 17/30 (57%) high. They stated that they spent 5 hours sitting down (0-12). The quality of life perception was 4 (2-5). With that same scale, the perception of health was 3 (2-5).

The number of concomitant medications was 5 (0-12), and 17/30 (57%) patients were using at least four medications.

There were no significant differences found between the group that downloaded the app and the control group in any of the variables mentioned.

Over the 6 months of this project, there was no registry of any AIDS events, but there were 3 non-AIDS events: one sudden death in the group not assigned to use the app and 1 heart attack and colon cancer in 2 patients in the app use–assigned group.

There was no significant modification in body mass index parameters, blood pressure, lipid profile, or immuno-virology information data. There was no significant modification of the distance covered in the 6MWT. There was no significant modification in the perception of quality of life questionnaire scores, confessed physical activity, or ART or non-ART adherence. Table 2 shows the main analytical parameters, adherence to treatment, quality of life, and the 6MWT results at baseline and 6 months, without any significant differences being observed in any case.

The app was in use between April 30, 2017, and October 31, 2017. During these 6 months, 19 reports and 75 news were uploaded. There was a total of 2407 sessions and an average session time of 7 min and 56 seconds. The screen views ascended to 13,143, with an average of 5.46 screens per session.

The most visualized screens were the Chat (4046 views) and News (890) screens, at a considerable distance behind them were Contacts (96), Reports (90), and Useful addresses (66).

There were 75 news publications in different categories: HIV (34 published), healthy aging (27), project information (7), social and psychological (5), and Information and Communication Technologies (ICT) use and the elderly (2). A total of 135 likes were received, the most liked being “On going” (5 likes), “How walking a dog can help the elderly comply with physical exercise recommendations” (5), “How to get brown in a healthy way” (5), “Welcome!” (4), “A cure for HIV?” (4), “Food for people with HIV” (4), “Is the flu vaccine less effective in overweight people” (4), “A monthly injection can maintain AIDS virus confined” (4), and “Spain fails in recommended calcium intake” (4). There were 22 news comments, the most commented paper being “Around 5000 patients have HIV infection in Malaga province” (3 comments).

As an example, in the section corresponding to psychological, the key words were happiness, emotion, sadness, surprise, restlessness, and greetings. Within the key word sadness were included chat comments such as “you lose the desire of everything,” “today I’ve been very dejected and sad,” “we all have a bad day,” “I’m pulling, I have head like a pot of crickets,” “I never dream,” “I’m fed up,” “I do not know anything about anyone,” “I’m worried, without knowing anything,” “this heat kills me,” “hello guys you’re going to forgive me I’m not for nothing,” “it was a horrible time and without being able to talk to anyone, it passes very badly,” “I have the body as if I had been beaten,” “no one knows what it is,” “absolutely nobody in my family knows anything,” “I’m bored,” “my friends do not know after twelve years,” “that’s why it was so hard for me to admit it, it cost us much assimilate, fuck has cost me,” “I do not understand how people are so denied,” and “what a pity, we are the only survivors.”

As we already stated, terms were grouped by categories, where we can find the following:

The chat participants described the experience as purely positive; it allowed them to create “a space for freedom in which they could talk to other elderly patients infected,” they found “nice people with my same problems,” and all of them would repeat the experience. All the patients that downloaded the app referred that their knowledge about the infection had increased and their feelings of secret or taboo toward the disease had lessened.

In our experience, the use of a mobile app in older adults infected with HIV has translated into a frequent use of this app, with just over 2400 sessions and an average time of use of almost 8 min for each one of them. Far from being a collective that shies away from mobile app use, it is quite clear that if this population’s interest is stimulated toward these apps, they will make use of them and make the most of the information they have to offer. The fact that the navigation in each session implies an average of 5 screens in each one of them also shows user’s interest for the different sections of the app and that navigation is certainly dynamic. The most frequently viewed screens were Chat (over 4000 times) and News (over 800 times), which reveals that patients were clearly interested in the social relationship that the app implied and in commenting on latest medical news.

The population of our study responds to a pattern of comorbid and polymedicated patients (a median of 5 medications excluding antiretroviral), diagnosed at around 50 years of age and with a decade of ART use. Although the perception of their health was 3 over 5, the perception of quality of life was higher (4 out of 5), which definitely shows certain optimism about their own life in spite of the illness, verified again in the WHOQOL-BREF results, where the psychological quality of life results were higher than the physical quality of life ones. The high appreciation of health care and social services also stands out (75 over 100).

The use of the app was not associated with clinical or analytical parameter changes in patients. Changes in this type of parameters are probably not to be expected in this type of elderly population in such a short period as 6 months and also because of the low number of patients included in each group (n=15) of this pilot study.

Analysis of the chat reveals that the main area of concern for patients is disease in general, a lot more than HIV, referring to typically age-related pathologies rather than the chronic infection itself. The analysis of feeling-related terms reveals a positive attitude, with frequent mention of happiness.

Compared with other studies [18], our study population had physically active perception of itself (over 50% referred high physical activity), which could also be related to a better perception of their psychological welfare. Indirectly related information that supports this fact is that beach (94) and walking (87) stand out among the most quoted individual terms in the chat.

Experiences of the development of apps in HIV have been published with the purpose of improving adherence [19], but perhaps, elderly HIV-infected patients represent a group in which this type of apps can promote stigma reduction and sharing experience between peers. The use of mobile apps, where anonymity is preserved, can help reduce the social barriers that these patients have to confront [20]. The presence of this stigma can be associated with worse ART adherence rates and less viral suppression rates [21-23]. However, in our patients, adherence to ART was very high, although it could be improved in non-ART medication. Comorbidity presence related to age translates into a higher use of these medications, and making this treatment easier (lower amounts of pills, and precise indications) must be another step in the reinforcement of this adherence.

Similar to other mobile phone–based interventions [24], ours has not demonstrated a significant increase in ART adherence, although the truth is that the initial situation was very positive in that parameter (almost 90% referred over 95% adherence).

Ours constitutes a preliminary experience that seems to confirm that our older adults with HIV infection find the utilization of a mobile app to be able to receive information about the infection and connect with individuals with their same problems to be useful. Studies larger than ours, and probably more extended in time, should confirm if some kind of benefit is obtained in this group of patients (older adults with HIV infection) through new technologies.