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Previously incarcerated individuals have suboptimal linkage and engagement in community HIV care. Mobile health (mHealth) interventions have been shown to be effective in addressing these gaps. In Washington, District of Columbia (DC), we conducted a randomized trial of an SMS text messaging–based mHealth intervention (CARE+ Corrections) to increase linkage to community HIV care and antiretroviral treatment adherence among HIV-infected persons involved in the criminal justice system.
This study aimed to describe the SMS text messaging–based intervention, participant use of the intervention, and barriers and facilitators of implementation.
From August 2013 to April 2015, HIV-positive incarcerated individuals were recruited within the DC Department of Corrections, and persons released in the past 6 months were recruited within the community via street-based recruitment, community partnerships, and referrals. Participants were followed for 6 months and received weekly or daily SMS text messages. Formative research resulted in the development of the content of the messages in 4 categories: HIV Appointment Reminders, Medication Adherence, Prevention Reminders, and Barriers to Care following release from jail. Participants could customize the timing, frequency, and message content throughout the study period.
Of the 112 participants enrolled, 57 (50.9%) were randomized to the intervention group and 55 (49.1%) to the control group; 2 control participants did not complete the baseline visit, and were dropped from the study, leaving a total of 110 participants who contributed to the analyses. Study retention was similar across both study arms. Median age was 42 years (IQR 30-50), 86% (49/57) were black or African American, 58% (33/57) were male, 25% (14/57) were female, and 18% (10/57) were transgender. Median length of last incarceration was 4 months (IQR 1.7-9.0), and median lifetime number of times incarcerated was 6.5 (IQR 3.5-14.0). Most participants (32/54, 59%) had a baseline viral load of <200 copies/mL. Nearly all participants (52/57, 91%) chose to use a cell phone provided by the study. The most preferred Appointment Reminder message was
Participants’ ability to customize their SMS text message plan proved helpful. Further large-scale research on mHealth platforms is needed to assess its efficacy among HIV-infected persons with a history of incarceration.
ClinicalTrials.gov NCT01721226; https://clinicaltrials.gov/ct2/show/NCT01721226
In 2016, more than 6.6 million adults—or 1 in 38 in the United States—were involved in the criminal justice (CJ) system [
Ownership of smartphones in the United States has greatly increased from 35% in 2011 to 81% in 2019 [
A variety of mHealth interventions have been implemented to address HIV/AIDS outcomes among PLWH [
The National Institute on Drug Abuse funded the Seek, Test, Treat, and Retain (STTR) research initiative to improve the identification, linkage, and engagement in care of HIV-infected vulnerable persons [
The CARE+ Corrections study was a randomized, controlled, and longitudinal pilot study in Washington, District of Columbia (DC), and it has been described in detail elsewhere [
The CARE+ intervention was delivered to study participants randomized to the intervention arm and included 2 components: (1) a one-time computerized counseling session called CARE+ Corrections, which was adapted for CJ populations from the CARE+ tool [
Participants were offered the choice of using a basic Android smartphone provided by the study with SMS capability or a monthly US $25 reimbursement to cover texting expenses if they preferred to use their own SMS texting–capable phone. Study phones were provided at no cost to participants (further information about the cell phone plans are detailed elsewhere) [
Study staff set up the SMS intervention on participant’s cell phones using an SMS platform website and completed a registration form that included the participant’s new phone number (or existing one if using their own phone), a participant-chosen nickname (real names were not used to protect privacy of participants), and SMS text message preferences on content and frequency. If participants wanted to make changes to their SMS plan during follow-up visits, a follow-up form was completed by study staff on the SMS platform website.
Formative work conducted in Washington, DC, and Providence, Rhode Island, informed the content of the CARE+ Corrections SMS text messages [
Messages focused on reminding participants to attend their prescheduled HIV care appointment or reminded participants to schedule a new appointment.
This comprised message reminders to take their HIV medications. Messages varied from highlighting the importance of medications to,
Participants chose to receive a message on safe sex practices or tips and mantras to avoid substance use.
Messages focused on areas participants may need help with when leaving the correctional system, such as finding housing, employment, etc. This category was adapted from the formative work to include specific resources found in Washington, DC, eg, providing the actual phone number of the office that helps returning citizens find employment within the message.
CARE+ Corrections study staff worked with an SMS vendor (Dimagi, Cambridge, MA) to create an SMS platform for automated text messaging. The initial SMS platform delivered messages from all 4 content areas in a single message thread at a preset frequency and in a single communication. Before study initiation, study staff members conducted pilot testing of the platform and concluded that greater flexibility in the frequency of messaging was required. Staff members indicated that receiving all messages in a single thread led to message fatigue and content was often overlooked, given multiple messages needed to be read at the same time. In response to this feedback, the SMS vendor was able to adapt the platform to allow participants to choose the frequency of messaging (daily versus weekly), timing of messaging (eg, am or pm), and ability to change messaging content in each category (
Frequency for the HIV appointment reminder message depended on the date of the participant’s appointment and the Barriers to Care message was only available once per week to participants during the first month of the intervention or, if reincarcerated during the study period, 1 month following reentry into the community.
SMS message content details, customization, time options, and frequency.
Message category | Able to write own custom text message | Time options | Able to customize text message frequency options | Able to change options during follow-up |
HIV appointment reminder | ✓a |
8:00 am 10:00 am 12:00 pm 2:00 pm 5:00 pm 8:00 pm |
Xb |
✓ |
Medication adherence | ✓ |
8:00 am 10:00 am 12:00 pm 2:00 pm 5:00 pm 8:00 pm |
✓ |
✓ |
Prevention reminder | ✓ |
8:00 am 10:00 am 12:00 pm 2:00 pm 5:00 pm 8:00 pm |
✓ |
✓ |
Barriers to care | ✓ | X | X |
X |
a✓: Yes, participants were able to customize this area
bX: No, participants were unable to customize this area.
We generated descriptive statistics (eg, frequency, mean, and/or median) of characteristics of study participants in the intervention arm and their message preferences (content, time, and frequency) throughout the study using SAS version 9.4 (SAS Institute Inc, Cary, NC, USA).
The George Washington University and The Miriam Hospital Institutional Review Boards approved the CARE+ Corrections Study and the US Office of Human Research Protections reviewed it.
Of 219 persons assessed for eligibility, 112 (51.1%) were enrolled and randomized. Of those enrolled, 57 (50.9%) were randomized to the CARE + Corrections intervention group and 55 (49.1%) to the control group; two control participants did not complete the baseline visit, and were therefore dropped from the study, leaving a total of 110 participants who contributed to the analyses. Study retention was similar across both study arms. Although 41 of 110 (37.3%) experienced reincarceration during the 6-month follow-up period, 96 of 110 (87.3%) completed all three study visits. This paper will focus on the experience of the 57 individuals randomized to the intervention group (
Most participants (37/57, 65%) were enrolled in the community after recent release from a correctional facility. The median age was 42 years (IQR 30-50). Most (49/57, 86%) were black or African American and male (33/57, 58%), with 25% (14/57) being female and 18% (10/57) being male-to-female transgender. The participants’ median length of last incarceration was 4 months (IQR 1.7-9.0), and the median number of times of being incarcerated throughout their lifetime was 6.5 times (IQR 3.5-14.0).
Characteristics of intervention arm (n=57) at baseline.
Characteristic | Values | |
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Community | 37 (65) |
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District of Columbia Department of Corrections | 20 (35) |
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Male | 33 (58) |
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Female | 14 (25) |
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Transgender (male to female) | 10 (18) |
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Non-Hispanic black/African American | 49 (86) |
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Non-Hispanic white | 2 (3) |
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Other | 6 (11) |
Age (years), median (IQR) | 42 (30-50) | |
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Heterosexual or straight | 45 (78) |
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Homosexual, gay, or lesbian | 6 (11) |
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Bisexual | 6 (11) |
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≤High school | 49 (86) |
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>High school | 8 (14) |
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Stable | 45 (79) |
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Unstable | 12 (21) |
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No (9-11) | 25 (44) |
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Yes (12-18) | 32 (56) |
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No | 47 (82) |
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Yes | 10 (18) |
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No | 6 (60) |
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Yes | 4 (40) |
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No | 9 (16) |
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Yes | 48 (84) |
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No | 15 (31) |
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Yes | 33 (69) |
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No | 29 (51) |
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Yes | 28 (49) |
Length of last incarceration (months), median (IQR) | 4 (1.7-9.0) | |
Number of times in jail/prison, lifetimec, median (IQR) | 6.5 (3.5-14.0) | |
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<200 copies/mL | 32 (59) |
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≥200 copies/mL | 22 (41) |
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CARE+ phone | 52 (91) |
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Personal phone | 5 (9) |
a12 months before last incarceration.
bAmong 10 participants reporting ever injection drug use.
cAmong 48 participants reporting ever noninjection drug use.
dAmong 54 participants.
Most participants (52/57, 91%) chose to use a cell phone provided by the study (
As nearly two-third of the phones provided by the study had to be replaced because of loss or theft, many were left without service while waiting for a replacement phone. In addition, reincarceration led to service disruptions. To avoid intervention interruptions because of phone issues, study staff had regular clinic hours in a known location throughout the duration of the study and participants knew to drop-in regarding any issues with phones. Furthermore, participants knew which community partners were affiliated with the CARE+ study, and study staff would receive calls from participants at these community partner locations to schedule appointments for phone replacements.
We used a pooled minutes cell phone plan, in which all phone lines shared available minutes, to account for some participants using more minutes and others less. Using this model, the study never went over its total allotted monthly minutes. Several participants exceeded their monthly minute allotments, and if the amount was significant, study staff would call the participant and review the participant’s cell phone plan. In 2 instances, participants used smartphone services that incurred additional fees (eg, downloading apps and calling 411 for information). In both cases, study staff worked with participants to call one of the community partners instead for information and inform participants that downloading apps on the study phone was not allowed. In addition, study staff worked with the phone carrier to limit the downloading of apps on study phones.
As the median age of CARE+ Corrections participants was 42 years, study staff recognized that cell phone training for smartphones would be required for some study participants. During the initial session, study staff assessed participants’ knowledge and ability in using the smartphones provided by the study and found that the majority of participants required 1-on-1 training before the initiation of the intervention. Study staff developed a 5- to 10-min cell phone training module that was delivered during the baseline visit (see
Participants had the option of customizing the content, timing, and frequency of the SMS text messages by the 4 topic areas.
The most popular message chosen at baseline for the HIV appointment reminder message (see
A total of 3 participants created custom message content at baseline, such as,
HIV appointment reminder messaging.
Messaging options, HIV appointment reminder | Values, n (%) | |
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Your doctor wants you to come to your appointment | 5 (9) |
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Your health comes first – go to your appointment | 4 (7) |
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Your doctors are here to help you –go to your appointment | 4 (7) |
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Custom message content | 3 (5) |
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Call your case manager – he/she can help you get to clinic | 2 (4) |
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Going to the clinic helps you stay healthy | 1 (2) |
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Can’t remember when your next appointment is? Call the clinic to find out | 0 (0) |
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Total | 57 (100) |
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10:00 am | 11 (19) |
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5:00 pm | 6 (11) |
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2:00 pm | 4 (7) |
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8:00 pm | 4 (7) |
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Total | 57 (100) |
aItalics indicate the 3 most popular messages and 2 most popular message time options at baseline.
The most popular message chosen at baseline was
A participant created a custom message at baseline and wanted us to include a smiley face within the message,
Medication adherence messaging.
Messaging options, medication adherence | Values, n (%) | |
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You got to play to win. So don’t forget your meds | 3 (5) |
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The best way to stay healthy is to take your meds on time and the right way | 2 (4) |
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Give meaning to your life … Now! | 2 (4) |
|
Custom message content | 1 (2) |
|
Your meds may not work anymore if you forget to take them | 1 (2) |
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Adherence to meds means taking the right dose at the right time | 0 (0) |
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Call your case manager—he/she can help you find ways to remember to take your meds | 0 (0) |
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Total | 57 (100) |
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8:00 pm | 14 (25) |
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5:00 pm | 4 (7) |
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2:00 pm | 4 (7) |
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12:00 pm | 3 (5) |
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Total | 57 (100) |
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Weekly | 21 (37) |
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Total | 57 (100) |
aItalics indicate the 3 most popular messages, 2 most popular message time options, and most popular message frequency option at baseline.
The most popular message chosen at baseline was,
A total of 2 participants created custom content at baseline (see
When the messages were categorized as substance use prevention, safe sex, or custom content, most participants (31/57, 54%) chose substance use content. The most popular message times chosen at baseline were 8:00 am (13/57, 23%) and 8:00 pm (12/57, 21%). At baseline, most participants chose weekly message frequency (31/57, 54%). During follow-up, 26% (15/57), 28% (16/57), and 18% (10/57) of participants made changes to message content, time, and frequency, respectively. The most popular message time change during follow-up was to 10:00 am (7/18, 39%). The most popular message frequency change during follow-up was from weekly to daily (9/13, 69%).
Prevention reminder messaging.
Messaging options, prevention reminders | Values, n (%) | |
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One day at a time. Just for today, don’t useb | 6 (10) |
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Did you read “Get your Freak on for Dummies”—it says you must wear a rubber!c | 5 (9) |
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Staying clean is most important. Call your case manager for helpb | 4 (7) |
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If you are using, you may forget your medsb | 3 (5) |
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Don’t forget to wrap it or don’t give it up!c | 3 (5) |
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Custom message content | 2 (4) |
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Protect yourself and your partner. Use a condomc | 1 (2) |
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Total | 57 (100) |
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2:00 pm | 11 (19) |
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10:00 am | 10 (18) |
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5:00 pm | 7 (12) |
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12:00 pm | 4 (7) |
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Total | 57 (100) |
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Daily | 26 (46) |
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Total | 57 (100) |
aItalics indicate the 3 most popular messages, 2 most popular message time options, and most popular message frequency option at baseline.
bSubstance use prevention content.
cSafe sex content.
The most popular messages chosen at baseline for the Barriers to Care messaging (
More participants chose to create custom content for this message category compared with the other categories (see
Barriers to care messaging.
Messaging options, barriers to care | Values, n (%) | |
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Remember to get a case manager: call xxx-xxx-xxxx | 7 (12) |
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Custom message content | 5 (9) |
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Get help getting your entitlement/insurance programs: call xxx-xxx-xxxx | 3 (5) |
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Can’t get your prescriptions? Call your clinic or case manager | 2 (3) |
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Need a ride to your appointment? Call your case manager at xxx-xxx-xxxx | 1 (2) |
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Call transportation services so you can get to your clinic visits: call xxx-xxx-xxxx | 0 (0) |
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Total | 57 (100) |
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2:00 PM | 10 (18) |
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8:00 PM | 7 (12) |
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5:00 PM | 4 (7) |
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12:00 PM | 3 (5) |
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Total | 57 (100) |
aItalics indicate the 3 most popular messages and 2 most popular message time options at baseline.
bThe 3 most popular message content options among those enrolled in the community.
cThe 3 most popular message content options among those enrolled in the District of Columbia Department of Corrections.
There were minor differences in message preferences between those enrolled in the community (released from a correctional facility within the last 6 months) versus those enrolled in the DC DOC. For the prevention reminder messaging, the most popular messages chosen at baseline among those enrolled in the community were
HIV-infected individuals with a history of incarceration represent a vulnerable community in need of innovative interventions to address many barriers to HIV care and adherence to ART. We were able to implement an SMS-based intervention and report lessons learned for implementation and message preferences. This knowledge will be invaluable to others delivering SMS interventions in this vulnerable population.
As reported elsewhere [
The study team saw huge improvements to the CARE+ Corrections intervention after pilot testing the intervention. Recognizing the significance of customization (ie, timing and frequency) of messaging to avoid message fatigue, the study team was able to make changes to the SMS platform before intervention implementation to provide study participants more flexibility.
Adapting the SMS text message library to accurately reflect the common experiences for the population was essential. For example, study participants were more likely to choose a substance use message versus the safe sex message under the Prevention Reminder category. This reflected what has been previously observed among incarcerated persons facing a 3- to 8-fold increased risk of drug-related death, 1 to 2 weeks following release compared with 3 to 12 weeks following release [
In addition, as our study population was older, adapting the implementation strategy to meet the needs of older participants was essential to effective implementation of the SMS text message plan. On the basis of previous literature [
The Android smartphones provided by the study were highly desirable; however, participants’ chaotic personal environments impacted smartphone retention. Most CARE+ participants opted to receive the phone provided by the study; however, most required a replacement phone and almost all kept their phone at the end of the study. In contrast, another STTR study reported 100% of users discarded the inexpensive, older model flip phone [
Leveraging community partnerships proved very useful to avoid cell phone service interruptions because of lost or faulty phones. In addition to having regular office/study hours at the CARE+ community site, CARE+ staff identified contacts at multiple popular CBOs to provide participants with options for study engagement. Participants knew which community partners were affiliated with CARE+ and study staff would receive calls from participants at these community partner locations to set up appointments for phone replacements. This also proved useful for study retention purposes
Identifying economic solutions with the cell phone carrier reduced economic burden on study budget. Using the pooled minutes approach provided the much-needed flexibility for CARE+ study participants, as some used very little of the suggested minutes allotted per month whereas others went over consistently. Future interventions should consider the pooled minutes approach to avoid overage issues and work with carriers to turn off specific apps and phone options that could incur monthly charges. Furthermore, incorporating cost-effectiveness analyses using templates [
Previous research has indicated that SMS interventions with 1 or more daily messages demonstrated
Few chose to create their own message. We believe this could reflect the success and importance of the formative work, adequately reflecting the messages they wanted to receive. However, even with few selecting to create their own message, providing this as an option is important, as interventions that allow for message customization are more effective at promoting adherence to ART than those that send uniform messages to all participants [
For those who did create custom messages (see
Participants who were enrolled in the jail chose different Barriers to Care messaging compared with those participants enrolled in the community—highlighting the differences in barriers encountered at 2 different time points (immediate release versus up to 6 months before release from jail). The popularity of messages about seeking housing and job training programs among jail enrollees versus community-enrolled participants could be because of the fact that the latter may have had more time in the community to address these needs. This is supported by the literature, with persons immediately released from correctional facilities reporting transitional challenges, such as not knowing how to find shelter and feeling dumped into the city, unsure where to spend their first night [
Although this study provides important details for future mHealth interventions among this vulnerable population, this study had several limitations. First, this study reported on the intervention arm of a pilot feasibility study. Given the small sample size, we lacked that statistical power to make between-group comparisons (eg, gender, race, and enrollment site), limiting our ability to inform mHealth interventions among specific populations. In addition, our SMS platform website (Dimagi) was a 1-way text service; thus, we could not evaluate engagement in the SMS intervention or confirm receipt of the SMS text messages. Furthermore, this study was limited to programming data (from Dimagi) and the experiences of study staff. Future mHealth intervention studies would benefit from larger sample sizes to evaluate messaging preference among various sociodemographic variables and qualitative research to better understand the specifics of SMS interventions that work well for the target population.
In this paper, we report the implementation of an SMS intervention for HIV-infected persons with a history of incarceration. Highlighting the implementation of a real-world application of an mHealth platform, subsequent programs working with the same or other vulnerable populations can use the findings, methodology, and trainings to implement and benefit from our lessons learned.
CARE+ Corrections SMS Messaging Library.
How to Use Your Droid 4.
CARE+ Customized Messages at Baseline.
CONSORT-EHEALTH checklist (V 1.6.1).
antiretroviral therapy
community-based organization
criminal justice
District of Columbia
Department of Corrections
mobile health
people living with HIV
Seek, Test, Treat, and Retain
University of North Carolina
The authors would like to acknowledge funding from the National Institutes of Health and National Institute on Drug Abuse (R01DA030747 and T32DA023356) and institutional support from the University of North Carolina (UNC)—Chapel Hill Center for AIDS Research (P30AI50410), Providence/Boston Center for AIDS Research (P30AI042853), and the DC Center for AIDS Research (P30AI117970). The authors would also like to acknowledge CARE+ team members Anthony Rawls and Avery Barber, DC DOC partners (Drs Beth Mynett and Reena Chakraborty), and community-based partners for their support and assistance in conducting this work. In addition, the authors would like to acknowledge Lorin Bruckner with the UNC Davis Library, who assisted with the data visualization (
None declared.