Acceptability of a Mobile Phone Support Tool (Call for Life Uganda) for Promoting Adherence to Antiretroviral Therapy Among Young Adults in a Randomized Controlled Trial: Exploratory Qualitative Study

Background: Adherence to treatment is critical for successful treatment outcomes. Although factors influencing antiretroviral therapy (ART) adherence vary, young adults are less likely to adhere owing to psychosocial issues such as stigma, ART-related side effects, and a lack of access to treatment. The Call for Life Uganda (CFLU) mobile health (mHealth) tool is a mobile phone–based technology that provides text messages or interactive voice response functionalities through a web interface and offers 4 modules of support. Objective: This study aims to describe the acceptability and feasibility of a mobile phone support tool to promote adherence to ART among young adults in a randomized controlled trial. Methods: An exploratory qualitative design with a phenomenological approach at 2 study sites was used. A total of 17 purposively selected young adults with HIV infection who had used the mHealth tool CFLU from 2 clinics were included. In total, 11 in-depth interviews and 1 focus group discussion were conducted to examine the following topics: experience with the CFLU tool (benefits and challenges), components of the tool, the efficiency of the system (level of comfort, ease, or difficulty in using the system), how CFLU resolved adherence challenges, and suggestions to improve CFLU. Participants belonged to 4 categories of interest: young adults on ART for the prevention of mother-to-child transmission, young adults switching to or on the second-line ART, positive partners in an HIV-discordant relationship, and young adults initiating the first-line ART. All young adults had 12 months of daily experience using the tool. Data were analyzed using NVivo version 11 software (QSR International Limited) based on a thematic approach. Results: The CFLU mHealth tool was perceived as an acceptable intervention; young adults reported improvement in medication adherence, strengthened clinician-patient relationships, and increased health knowledge from health tips. Appointment reminders and symptom reporting were singled out as beneficial and helped to address the problems of forgetfulness and stigma-related issues. HIV-related stigma was reported by a few young people. Participants requested extra support for scaling up CFLU to JMIR Mhealth Uhealth 2021 | vol. 9 | iss. 6 | e17418 | p. 1 https://mhealth.jmir.org/2021/6/e17418 (page number not for citation purposes) Twimukye et al JMIR MHEALTH AND UHEALTH


Introduction Background
In 2018, of the 3.9 million young people living with HIV globally, 80% were in Sub-Saharan Africa [1]. The 2017 Uganda Bureau of Statistics report indicated that more than half of Uganda's population (55%) is aged under 18 years [2]. The burden of HIV among youth in Uganda is high. In Uganda, HIV prevalence triples from those aged 15-19 years (1.1%) to those aged 20-24 years (3.3%), suggesting that new infections remain an issue in this age group [3]. Among young adults (aged 15-24 years), there is a disparity in HIV prevalence by sex. HIV prevalence is almost 4 times higher among women than men aged 15-19 years and 20-24 years [4].
HIV care and treatment services in the region should adapt to adequately meet the antiretroviral therapy (ART) demand to suppress the viral load to undetectable levels and improve health outcomes. Suboptimal ART adherence over time predicts virological failure, development of drug resistance, and death [5][6][7][8]. Adolescents and young adults have poorer rates of adherence to ART and retention in care than older adults [9]. Young adults are less likely to adhere to ART medication if they have psychosocial issues such as stigma, previously experienced side effects with the treatment, and lack of access to treatment [10][11][12].
In 2018, 50% of the population (24.7 million) were phone subscribers (fixed or cellular) [13]. Compared with adults (40%), young adults (66%) are more likely to use mobile phone SMS text messaging [13]. Mobile phones have become a common accessory for most young people in Uganda. Self-reported quantitative survey data collected in 2008-2009 from 1503 secondary school students in Mbarara, Uganda, suggest that 27% currently had mobile phones and about half (51%) of all students and 61% of those who owned a mobile phone believed that they would access an SMS text messaging-based HIV prevention program [14]. One study assessed the patterns and dynamics of mobile phone use among an ART cohort in rural Uganda, ascertained its feasibility for improving clinic attendance, and found that mobile phones have the potential for use in resource-constrained settings to improve the clinical management of people living with HIV [15]. Texting-based and other mobile health (mHealth) interventions could be particularly suitable for young adults who, irrespective of their socioeconomic status, are typically competent users of mobile phones and text messages. Globally, mHealth interventions have resulted in improvements in treatment adherence for patients with asthma, diabetes, and tuberculosis [16].

Objectives
Various mHealth studies have shown improved virological outcomes [17,18], lower risk of nonadherence [19][20][21], and good retention in care before ART initiation [15]. However, there is little specific evidence on the effect of mHealth on young adults living with HIV. We used qualitative methods to describe the acceptability of using Call for Life Uganda (CFLU, an adherence support tool offering interactive voice response [IVR] or SMS) to promote adherence to ART for young adults in a randomized controlled trial (RCT).

Study Design
We implemented an exploratory qualitative design using a phenomenological approach to describe the acceptability and feasibility of a mobile phone support tool to promote adherence to ART among young adults. The study was nested within an open-label RCT titled Improving Outcomes in HIV Patients Using Mobile Phone-Based Interactive Software Support. The technology evaluated in this study is connect for life (CfL), a MOTECH-based, open-source platform developed by the Grameen Foundation and the University of Southern Maine. It was supported by Janssen, the Pharmaceutical Companies of Johnson and Johnson, and was released under the terms of MOTECH's open-source license agreement. We adapted CfL for use among people living with HIV and named the system CFLU. CFLU allows a computer to interact with patients using voice and tone input via keypad (IVR) or by SMS, with the choice made by the patient. All content was developed in English and 2 additional local languages, following the Uganda HIV treatment guidelines. People living with HIV in the control arm received standard of care comprising face-to-face facility appointments, no remote adherence or appointment reminders, and no remote symptom reporting. In the intervention arm, the people living with HIV received standard of care and daily adherence IVR call or SMS text messaging at the preplanned times of taking ART. In the intervention arm, the people living with HIV also received a dedicated call offering a health education message (a health tip) weekly. Patients received IVR calls or SMS text message appointment reminders on or before the scheduled appointment date. The CFLU platform allows patients to report symptoms at the end of the scheduled call, or at any time, through a toll-free line. Multimedia Appendix 1 illustrates the call flow from the CFLU tool to the end user. Participants chose the preferred languages, time, and frequency of receiving calls.
In this qualitative study, we used in-depth interviews (IDIs) and 1 focus group discussion (FGD) to gain insights into individual and community perspectives about the CFLU tool. The purpose of the FGD in this study was to stimulate group conversations on specific themes, to assess the differences and similarities in perceptions, values, norms, and preferences among young adults. We explored only the normative and topics that were not considered sensitive in the FGD [22].

Study Participants and Selection
Participants were enrolled from 2 HIV clinics acting as study sites for the CFLU RCT (the Infectious Diseases Institute clinic at Mulago National Referral Hospital, Kampala, and Kasangati Health Centre facility level IV, a periurban government health facility). Purposive sampling of young adults with HIV infection aged 18-25 years was carried out from these 2 clinics.
The total number of young adults was 161. We undertook purposive sampling within this group to recruit them for this study. Inclusion criteria were registration in the CfL RCT, had access to a mobile phone, had the ability to use basic mobile phone functions such as making and receiving calls, and willingness to comply with scheduled visits. Patients who understood 1 of the 2 local languages or English were eligible for the study. Young adults who were critically ill; those aged under 18 years; and those whose clinical condition interfered with the appropriate use of their mobile phone, such as deafness or severe cognitive impairment, were excluded from the study. The young adults could also belong to other groups of interest enrolled in the study, including pregnant women receiving ART for the prevention of mother-to-child transmission, those switching to or on second-line ART, those initiating first-line ART, and positive partners in a discordant relationship.

Data Collection
We made telephone calls to potential young adults to brief them about the study and invite them for the study. We negotiated an appropriate time, place, and day for the interview with the IDI and FGD participants and booked secure private locations to conduct interviews at the Infectious Diseases Institute clinic and Kasangati, as appropriate. Clinic study staff, a counselor with social science expertise and Good Clinical Practice, and a postdoctoral scholar trained in FGD note taking collected the data. The FGD had a range of 6-12 participants. The clinic study staff contacted potential participants by phone, described the study, and extended an invitation to participate. We conducted 2 interviews in English and 10 in the local language (Luganda) at the Infectious Diseases Institute and Kasangati in private locations (IDIs) and community centers (FGDs). Before data collection, we translated the topic guides from English into Luganda, the main language spoken in the catchment area of the study clinics. Each IDI and FGD lasted for approximately 1 hour and were audio recorded and complemented by written notes. We examined the following topics in IDIs and FGD: (1) experience with the CFLU tool (likes and dislikes), (2) components of the tool (health tips, pill and appointment reminders, and symptom reporting), (3) efficiency and willingness to pay for the system (level of comfort, ease, or difficulty in using the system), (4) how CFLU resolved adherence challenges, and (5) suggestions to improve CFLU. All young adults had 12 months of daily experience using the tool. Young adults were recruited and interviewed until no new themes emerged, and saturation was reached when there was repetition of the previously mentioned themes.

Data Analysis and Interpretation
All audio recordings from IDIs and FGDs were transcribed verbatim after translation by independent professionals. The research team read the typed transcripts several times and filled in the gaps by listening to the audio recordings. Data were managed and analyzed using NVivo version 11 (QSR International Limited). Each independent transcript was read and reread by a senior social scientist for emergent themes and recurrent ideas and then aggregated into themes. Codes were assigned to relevant segments of the text; similar codes were aggregated to form themes, which were then used to address the research questions and develop coherent narratives. The team developed an explicit codebook describing each category and theme. In the next step, the team sorted the quotes based on themes. The team then examined the degree to which these themes were distributed across gender, age group, and social target group. After team members read the interview transcripts, data were coded into meaning units and major themes were developed. Quotations and key phrases are highlighted in the findings.

Ethical and Regulatory Approval
The CFLU RCT was approved by the Makerere University School of Public Health Higher Degrees Research and Ethics and Committee (Number 378) and the Uganda National Council of Science and Technology (Number Health Sciences 3005) and was registered with ClinicalTrials.gov (NCT02953080). All the study procedures, compensation, benefits, potential risk of participation, and voluntary and confidential nature of participation were discussed. Written informed consent was obtained from all respondents before enrollment in the qualitative study. For young adults with low literacy, we used a thumbprint in the presence of a witness.

Overview
A total of 82 young adults who used the CFLU tool were given a telephone call, inviting them for FGD or IDIs (Multimedia Appendix 2). Of the 82 young adults, 37 were found ineligible as their age limit was slightly more than that required for young adults (26-28 years) and 28 could not make it for the discussion because of various reasons such as busy schedules and phones not available owing to poor network. A total of 21 young adults agreed to participate, 17 on the intervention arm and 4 on the control arm (analyzed separately and not included here (Multimedia Appendix 2).
A total of 11 IDIs and 1 FGD with those on the intervention arm were conducted. A total of 6 young adults were from the Infectious Diseases Clinic, whereas 11 were from Kasangati Health Center IV. The age range of young adults was 18-25 years; the majority were females, and more than 81% (17/21) of them were in a steady sexual relationship. Most young adults had a formal education, with only 14% (3/21) having reached the tertiary level ( Table 1).
The results covered 4 major themes related to CFLU. These were attitudes toward CFLU, components of CFLU, barriers to and challenges of CFLU, and suggestions or recommendations from youth to improve CFLU. The following sections organize the results into 3 levels: personal and household factors, facility or service delivery factors, and community factors (Table 2).

CFLU System Perceived as an Adherence Supporter
Most young adults from both sites, but mainly from Kasangati, perceived the CFLU system as an aid to adherence through its pill reminders, especially for youth who had trouble taking their medication and who forgot to take their medication because of busy work and school schedules. CFLU comes in as a treatment supporter to remind one to take medication; it is like a parent asking, "Hey, did you swallow your medication?" It is a voice message but sounds like a person who is aware of one's HIV status.

Resolving Forgetfulness
Both male and female youth across different groups admitted to poor adherence to ART in the past and believed that CFLU would resolve most of the barriers to adherence, such as forgetfulness. The reminder call was deemed critical when a young adult slept off or during a busy school or work schedule: There was a perception among most young adults from both sites that the tool improved their health through viral load suppression. Most youth on CFLU said that pill reminders helped them take drugs properly, daily, and on time, which led to viral suppression compared with when they were not on the system:

Management of HIV Stigma-Related Challenges
Most young adults, mainly from Infectious Diseases Institute clinic, stated that CFLU resolved the fear of stigma through its health tips that continuously educated them about how to overcome stigma and emphasized the importance of disclosure to avoid stigma and the importance of adherence to ART. Adherence to ART was easier in the context of young adults on CFLU who had not disclosed their HIV status:

Increased Psychosocial Support
Most young adults, mainly from Kasangati, expressed that they received psychosocial support from the tool, especially in those starting ART. Emotionally, the youth on CFLU felt that they were not alone. Through interaction with the loving voice that instructed them on how to take treatment, they were able to obtain coping support and gain hope for the future. The counseling provided during CFLU reduced high-risk behavior and promoted their own psychological well-being:

Strengthened the Clinician-Patient Relationship
The young adults, mainly from IDI, expressed that the tool improved the relationship between health care workers and patients, making the patients feel cared for. The youth said that there was a good relationship and interaction between patients and CFLU doctors. Paying attention to detail, politeness, care, and treatment, as well as offering transport refund by doctors enhanced proper treatment adherence that would lead to health improvement for youth: There is that element of a good relationship. You see the moment you get used to someone, you try to open up about your challenges; there is that bridging of the gap, that closeness that is created between the two parties. [IDI, male, 24 years, intervention arm, Mulago]

The Kind Tone of Voice of the System
Most participants from both sites perceived that the tone of voice and the wording used through the system was kind and conveyed friendliness, trust, and care by the health providers. They looked forward to the call that reminded them to take their drugs properly on time:

Confidentiality and Privacy
Most participants from both sites, but mainly from Kasangati, liked confidentiality and privacy through the use of the individualized secret pin code. Young adults were taught how to use the system, especially how to enter their secret pin number, and they found it easy to use:

Ease of Use for the System
The majority of young adults from both sites found the system easy to use and attributed this to the training or orientation they had received. The system also allows convenient settings for young adults, including individualized pill reminders and time to receive health tips:

Beneficial Clinic Visit Call Reminders
All young adults described CFLU as a call system that emphasized mainly pill reminders, health information tips, clinic appointment reminders, and symptom self-reporting, and they were all useful as far as adherence support was concerned.
Most young adults, but mainly from IDI, said that CFLU enhanced keeping routine clinic appointments that promoted ART adherence. Clinic appointment reminders were considered beneficial for those who misplaced cards or forgot appointments. Clinic visit remainders enabled young adults to plan for payment for transport: When in a faraway place, so when you get a reminder 2 days before the appointment, you plan for transport. [

Value of Symptom Reporting
Through symptom reporting, young adults from both sites, but mainly from IDI, were able to seek treatment and medical advice for themselves or their child. Young adults reported symptoms such as headache, diarrhea, fever, chest pain, abdominal pain, cough, and constipation:

Use of Health Tips Call
Access to information through health tips increased patient knowledge in young adults from both sites, but mainly IDI. The most frequent health tips selected were positive living, HIV, nutrition, avoidance of risky sexual behaviors such as having multiple partners, alcohol and drug abuse, breastfeeding options, and prevention of mother-to-child transmission. Few young adults reported the fear of stigma and discrimination that was addressed in the health tips messaging: Majority of young adults requested more diverse and additional health information. Positive female partners in discordant relationships requested for more health information about healthy relationships, disclosure in sero-discordancy, and conception in sero-discordant relationships. Textbox 1 summarizes the different requests. Textbox 1. Health tips requested by young adults to be added to the Call for Life Uganda system.

Health tips and illustrative quotes
• HIV discordancy and relationship advice • Overcoming the stigma and discrimination (how to disclose the HIV status) • "Teach us how to manage stigma. I have seen some people...who insult the positive ones. They keep saying so and so is sick and many more words...teach us how to respond to other people in case they stigmatize us." (IDI, female, 19 years, intervention arm, Mulago) • Sexual maturation (how to manage body odor) • "Young people these days have bad odours, so call for life can come in and sensitize on how to ensure good body hygiene. Teach us how to manage and prevent that foul smell." (IDI, male, 24 years, intervention, Mulago) •

Explanation on viral load
• "Personally, I take a while to know about my viral load. They can tell us whether it is high or low and its implications." (IDI, male, 24 years, intervention arm, Mulago) •

Dangers of alcohol use and drug abuse
• "Advise youth not to take alcohol and drugs. There are some who use cigarettes and marijuana, there is need to teach them avoidance of harmful habits like alcohol especially when one is on drugs" (IDI, female, 24 years, intervention arm, Mulago) • Drug side effects • "Teach us when and how to swallow the drugs. If there is any side effect, explain how to manage them. I think that education can be helpful." (IDI, male, 24 years, intervention arm, Mulago) • Basic antiretroviral therapy (ART) education and emphasis on ART adherence • "Re-emphasize ART adherence...if you don't swallow your pills you will get such and such problems or if you don't swallow your drugs on time, you will get such and such problem." (IDI, female, 23 years, intervention arm, Mulago) • How to overcome low self-esteem, self-pity, and stress management

Daily Pill Reminder Call
Youth, mainly from Kasangati, found that the twice daily remainder call that came through at an agreed specific time was found to be useful in promoting adherence:

Technical Issues With the System
IDIs and FGD elicited challenges related to the tool. According to most young adults, these were mainly the temporary technical problems that they faced during an upgrade to a newer version. This led to interruptions in calls and the system calling beyond the time scheduled.
Youth from both sites, mainly those from Infectious Diseases Institute Clinic, reported blocked pin codes, the failure of the system to complete outbound health tips, and poor pin recognition (nonresponse after entering a pin code). Most youth reported that the irregularities or inconsistencies of the system were frustrating: .

Fear of the HIV-Related Stigma
There was a shared perspective from IDIs and FGD young adults from both sites about the fear of stigma and discrimination associated with HIV. The perception that HIV is a fatal disease associated with promiscuity led to low self-esteem and poor adherence among youth:

Promote Peer Support Meeting
Although there was a positive response to the tool, most young people provided suggestions to improve CFLU. They requested extra support to scale up the CFLU system, such as promotion of peer support meetings among youth with HIV infection on CFLU. This would help them break stigma trends by sharing experiences and attaining peer mentorship. Majority of youth said that peer support meetings would promote youth's economic capacity to become financially independent. This could be led by empowering them to start an income generation activity as a way of addressing some of the adherence challenges:

Establish Youth-Friendly HIV Services and Scale Up CFLU
Youth requested for additional health tips, setting up of a designated space and staff for CFLU youth, resolving technical issues, and supporting youth to overcome stigma and discrimination, as summarized in Textbox 2 and Table 3. JMIR Mhealth Uhealth 2021 | vol. 9 | iss. 6 | e17418 | p. 11 https://mhealth.jmir.org/2021/6/e17418 (page number not for citation purposes) Textbox 2. Suggestions by young adults to improve the use of the Call for Life Uganda (CFLU) system.

Suggestions and illustrative quotes
• Encourage young people to maintain the same phone line • "Many young adults change their phone lines and fail to inform the health providers about it. Tell them stick to one line or in case they change, they should inform the health providers about the new phone lines so that they don't miss the call. • Establish a designated staff to handle young adults enrolled on CFLU at Kasangati Health facility.
• "The call for life staff people should let us know the focal person to talk to when we come here...It's by luck to find the right doctor and room to go to...we should get a permanent call for life space, so that we know that once we come we go right away to that place or room, Instead of wasting time looking around." (FGD, female, 18-24 years, intervention arm, Kasangati) • Sensitize all patients about the CFLU system and do it as a team-doctors, nurses, and patients. Make announcements on television and radio • "You have to work as a team, doctors, nurses, counselors, tell the patients about the benefits of the system. If you sensitise more people on TV or radio, very many people will come up and join the system. It's just about creating awareness regarding how the system works and its related benefits." (IDI, 24 years, intervention arm, Mulago) • Support young people to overcome the stigma • "Teach us (young people) how to overcome stigma and respond to people who point fingers at us." (FGD, female, 18-24 years, intervention arm, Kasangati) • Combine research study appointments with routine general HIV clinic so that patients do not come twice • "Suggest that doctors Combine study appointments with general clinic so that patients do not come twice. The return appointment for call for life system should be recorded in the system and in the general file...When one comes for call for life clinic visit...prior to return appointment, they should supply drugs once for all to avoid confusion." (FGD, female, 18-24 years, intervention arm, Kasangati)

Principal Findings
In this study, we sought to describe the acceptability of a mobile phone support tool to promote adherence to ART in young adults in an RCT. Understanding the acceptability of a mobile phone support tool to promote adherence to ART in young adults was important to enhance adherence intervention strategies. Four themes emerged from interviews with young adults, including the positive attitude toward CFLU, which included improvement of medication adherence, management of problems of forgetfulness, management of stigma-related issues, and psychosocial support. Negative attitudes toward CFLU were reported under barriers to and challenges of the CFLU theme, including technical issues, poor access to mobile phones, fear of stigma, and financial constraints. One theme was about the components of CFLU and suggestions and recommendations from youth to improve CFLU. This study reveals that the CFLU system supports adherence, which is a critical challenge for youth on ART. The most common barriers to ART adherence mentioned by the young adults in this study included forgetfulness, nondisclosure of serostatus, ART-related side effects, stigma, and pill burden. Forgetfulness is a major factor previously pointed out in other mHealth studies as a barrier to ART adherence [23]. Majority of young adults in this study said that CFLU resolved most of the adherence challenges such as forgetfulness, missed pills and clinic visits, and fear of stigma.
Fear of stigma and discrimination associated with HIV was reported as a challenge to CFLU, which is similar to previous mHealth studies [24]. Health tips emphasized the importance of disclosure to avoid stigma that would affect drug adherence. Patients suggested the desire for CFLU to continue educating youth about HIV and how to overcome stigma through continuous health tips.
Results revealed that CFLU resolved most of the barriers to adherence, such as forgetfulness. A major barrier to ART adherence was also tied closely with daily routine, as reported in some other study [25]. There is a need to make CFLU appealing to the youth so that it can be scaled up to eradicate barriers to ART initiation and adherence, such as fear of disclosing HIV status to partners, drug-related factors (side effects and the big size of the tablet), and HIV stigma [26]. This is in agreement with mHealth interventions that were first deployed in noncommunicable diseases and later used in infectious diseases [27]. Evidence reviews suggest that mHealth interventions delivered in low-income and middle-income countries can be effective in improving health outcomes for people living with chronic diseases [28]. A systematic review of mHealth interventions for monitoring chronic disease by Watkins et al [29] found articles on the monitoring of hypertension, stroke, and people living with HIV from Kenya, Pakistan, Honduras, Mexico, and South Africa. The 6 components of mHealth found in all 4 interventions included reminders, patient observation of health state, motivational education or advice, provision of support communication, targeted actions, and praise and encouragement [29].
Communicating with young adults about health issues and adherence and explaining the possible side effects are important in enhancing their informed decision making.
Concerns about CFLU reported ranged from technical issues, poor access to mobile phones, fear of stigma, and financial constraints. The disadvantages of CFLU reported by young adults were similar to those reported in other studies that reported the cost and convenience of SMS text message, given that its low cost is well suited for supporting the treatment of conditions managed over extended periods compared with interactive voice calls [23]. In the WelTel Kenya 1 trial, SMS intervention was considered inexpensive, and each SMS costed approximately US $0.05, equivalent to US $20 per 100 patients per month, and follow-up voice calls averaged US $3.75 per nurse per month [19]; however, SMS can only be applicable in a population with some literacy [30]. One study in Zanzibar showed that behavioral change was significantly higher with pushed SMS enrollees than with voice messaging enrollees [31]; this was not assessed in our study. However, of the 300 young adults enrolled in the CFLU mHealth intervention arm, only 2 opted for SMS text messaging and were not among the young adults.
Lost phone problems and battery issues made it difficult for some young people to access CFLU, and few young adults preferred messages that they could retrieve after restoring the phone battery. Similar studies report that message delivery rates are far more successful among SMSs than among voice enrollees. Pushing voice messages to clients with personal phones is a complex process that requires the client to answer the phone at the time of delivery, whereas SMS messages can be delivered at any time, including when the phone is turned off. This is the major reason that SMS messages pushed to personal phones have a higher delivery success rate than voice messages [32]. The disadvantage of SMS text messaging reported by other studies includes breaches of confidentiality, and the majority of the patients have a fear of revealing their HIV serostatus, which makes voice calls superior to SMSs unless messages are coded.
The use of the individualized secret pin code enhanced the confidentiality and privacy of most young adults on CFLU. However, blocked pin codes and poor pin recognition of the system hindered the use of the system for most young adults. In a similar study in western Uganda, pin-protected messages reduced the odds of clinic return, as the use of pins was a challenge; hence, they often missed the message alerting them for clinic appointments [30]. Our adolescents advised empowering youth to overcome stigma and setting up a customer help desk at the health facility to resolve technical issues related to CFLU. Other studies suggest the involvement of end users during the development of mHealth apps.

Limitations
At the time of these interviews (September 2017), the CFLU system was experiencing technical issues following a newer software release; therefore, the calls kept dropping for both outbound and inbound calls. This was resolved first by contacting the software developer and consultant, halting calls, and temporarily turning off the system until the causes for technical issues were investigated and resolved. Automated alerts were developed to notify the principal investigator, the study coordinator, and the information system team on system errors.
During the same period, there was a national deadline by the Uganda Communication Commission to register all phone SIM cards, and some phones were cut off during this period. Young adults bought newly registered phone lines for CFLU.

Conclusions
The CFLU system can support adherence, despite some of the temporary technical issues. Enhancing adherence to ART using the CFLU system addresses the challenges reported by young people. The CFLU system is user friendly, acceptable, and a feasible strategy to monitor and improve adherence of patients in resource-limited settings.