Remdesivir for Treatment of COVID-19 Requiring Oxygen Support: A Cross-Study Comparison from Two Large, Open-Label Studies.

BACKGROUND: Remdesivir, an RNA-polymerase prodrug inhibitor approved for treatment of COVID-19, shortens recovery time and improves clinical outcomes. This prespecified analysis compared remdesivir plus standard-of-care (SOC) with SOC alone in adults hospitalized with COVID-19 requiring oxygen support in the early stage of the pandemic. METHODS: Data for 10-day remdesivir treatment plus SOC from the extension phase of an open-label study (NCT04292899) were compared with real-world, retrospective data on SOC alone (EUPAS34303). Both studies included patients aged ≥18 years hospitalized with SARS-CoV-2 up to 30 May 2020, with oxygen saturation ≤94%, on room air or supplemental oxygen (all forms), and with pulmonary infiltrates. Propensity score weighting was used to balance patient demographics and clinical characteristics across treatment groups. The primary endpoint was time to all-cause mortality or end of study (day 28). Time-to-discharge, with a 10-day landmark to account for duration of remdesivir treatment, was a secondary endpoint. RESULTS: 1974 patients treated with remdesivir plus SOC, and 1426 with SOC alone, were included after weighting. Remdesivir significantly reduced mortality versus SOC (hazard ratio [HR]: 0.46, 95% confidence interval: 0.39-0.54). This association was observed at each oxygen support level, with the lowest HR for patients on low-flow oxygen. Remdesivir significantly increased the likelihood of discharge at day 28 versus SOC in the 10-day landmark analysis (HR: 1.64; 95% confidence interval: 1.43-1.87). CONCLUSIONS: Remdesivir plus early-2020 SOC was associated with a 54% lower mortality risk and shorter hospital stays compared with SOC alone in patients hospitalized with COVID-19 requiring oxygen support. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov NCT04292899 and EUPAS34303.

The Role of the Multidisciplinary HIV Care Center in Mitigating Social Isolation Among Patients with HIV During the Early COVID-19 Pandemic.

As the COVID-19 pandemic began in 2020, significant public health mitigation efforts were vital to combat an unprecedented health crisis. These efforts, which involved social distancing and self-quarantine, likely worsened a public health crisis of social isolation and loneliness in the U.S., particularly among people with HIV (PWH). Multidisciplinary HIV care centers, which served as the main source of clinical care for PWH and in some cases the only point of social contact, faced evolving dynamics of in-person visits during the COVID-19 pandemic, as well as a shift to telehealth services. Using in-depth interviews, we explored the role that multidisciplinary HIV care centers and providers played in the experience of social isolation among PWH in New York City. We recruited participants (n = 30) from a multidisciplinary HIV care center in NYC between October 2020 and June 2021. We conducted semi-structured interviews to understand the specific domains of social isolation that were mitigated. In this cohort, the major theme that drove both in-person and telehealth care continuity was the strength of the patient-provider relationship. We found that participants saw members of the HIV care center as part of their social network, and providers served both as a source of emotional support and provided important social resources and benefits. Thus, in times of heightened social isolation, HIV care centers can play a critical role in providing social support in addition to clinical care.

Rapid or Immediate ART, HIV Stigma, Medical Mistrust, and Retention in Care: An Exploratory Mixed Methods Pilot Study.

Rapid or immediate antiretroviral therapy (iART) after HIV diagnosis improves linkage to care and time to viral suppression. However, iART may affect or be affected by HIV-related stigma and medical mistrust. In this mixed-methods pilot study, we examined the bi-directional role of HIV stigma, medical mistrust, and visit adherence (VA) in the context of iART in a diverse, newly diagnosed patient population. Participants were recruited from an HIV clinic in New York City and we utilized a convergent parallel design integrating quantitative data from demographic surveys, the HIV Stigma Survey (HIVSS), the Medical Mistrust Index (MMI) and electronic medical records, and qualitative data from in-depth interviews. Among the sample (N = 30), 26% (N = 8) initiated ART same-day or within 3 days, while the majority (N = 17) initiated between 4 and 30 days, and 17% (N = 5) initiated ART > 30 days. The median (range) age was 35, and most were English-speaking, Black or Hispanic men and identified as gay. Time to ART initiation was associated with time to linkage to care and time to viral suppression. Day 0-3 group's major theme was iART as stigma prevention, and they had the highest mean HIVSS, lowest MMI score, and a visit adherence of 0.86. Day 4-30 group's major theme was alleviation of internalized stigma, and they had the lowest mean HIVSS score, and highest visit adherence of 0.91. Day > 30 group's major theme was exacerbation of perceived or anticipated stigma, had the highest MMI score and a visit adherence of 0.85. iART implementation requires equitable strategies that address HIV-stigma and mistrust.

Immediate ART and clinical outcomes in New York City among patients newly diagnosed with HIV.

Immediate antiretroviral therapy (iART) has been shown to decrease time to viral suppression. Our center underwent significant practice transformation to support iART, including a same-day Open Access (OA) model and enhanced care coordination. We examined whether same-day ART at linkage was associated with favorable proximate and long-term HIV care outcomes. From 2018 to 2019, patients newly diagnosed with HIV, linked to care at our institution, and iART eligible were included. We evaluated the association between iART and time to viral suppression, and between iART and initial/sustained viral suppression and retention in care. We also evaluated the association between use of OA and frequency of care coordination with the same outcomes. Of the 107 patients included, 72 initiated same-day ART at linkage and 35 did not. There was no statistically significant differences in whether patients were ever suppressed, had sustained viral suppression, or were retained in care between those who received same-day ART and those who did not. More care coordination was associated with retention in care (RR 1.21 [1.01-1.5]; p = 0.05). Organizing vital services and ensuring implementation strategies that facilitate iART, while tailoring the approach to the patient's comfort level, is likely optimal for longitudinal HIV care engagement.

A community health worker and mobile health app intervention to improve adherence to HIV medication among persons with HIV: the CHAMPS study protocol.

BACKGROUND: Persons with HIV (PWH) can now achieve a near-normal life expectancy due to antiretroviral therapy (ART). Despite widespread availability of ART in the United States (US), many of the country's approximate 1.1 million PWH are not achieving viral suppression due to poor ART adherence. Viral suppression rates are particularly low in Alabama (AL, 62%) and New York City (NYC, 67%). There is mixed evidence on the efficacy of community health workers (CHW) and mHealth interventions for improving ART adherence and viral suppression in PWH thus, we sought to combine these interventions and test the efficacy for improving health outcomes in PWH. METHODS: The CHAMPS study is a two-arm randomized controlled trial among 300 PWH with suboptimal primary care appointment adherence (n = 150 in AL and 150 in NYC) over the course of 12 months. Participants are randomly assigned to CHAMPS (intervention) or a standard-of-care (control) arm. Participants in the intervention arm are given a CleverCap pill bottle that syncs to the WiseApp to track medication adherence, reminds users to take their medication at a set time, and enables communication with CHW. All participants complete baseline, 6-month, and 12-month follow-up visits where surveys are administered and, CD4 and HIV-1 viral load are obtained through blood draw. DISCUSSION: Maintaining ART adherence has significant implications in HIV management and transmission. mHealth technologies have been shown to optimize the provision of health services, produce positive changes in health behavior, and significantly improve health outcomes. CHW interventions also provide personal support to PWH. The combination of these strategies may provide the necessary intensity to increase ART adherence and clinic attendance among PWH at highest risk for low engagement. Delivering care remotely enables CHW to contact, assess, and support numerous participants throughout the day, reducing burden on CHW and potentially improving intervention durability for PWH. The adoption of the WiseApp coupled with community health worker sessions in the CHAMPS study has the potential to improve HIV health outcomes, and will add to the growing knowledge of mHealth and CHW efforts to improve PWH medication adherence and viral suppression. TRIAL REGISTRATION: This trial was registered with Clinicaltrials.gov (NCT04562649) on 9/24/20.

Get2PrEP: An Electronic Medical Record Laboratory Comment Increased Safe Sex Counseling But Not Preexposure Prophylaxis Services at a Large Urban Academic Medical Center in Northern Manhattan.

BACKGROUND: HIV preexposure prophylaxis (PrEP) remains underutilized despite its efficacy and potential population impact. Achieving PrEP's full potential depends on providers who are knowledgeable and comfortable prescribing it to individuals at risk of acquiring HIV. Previous educational interventions targeting provider-related uptake barriers have had limited success. We designed and tested an electronic medical record (EMR) interpretative comment to improve the delivery of PrEP. METHODS: An EMR comment provided information on PrEP eligibility and referral resources to providers delivering positive chlamydia and gonorrhea results. Positive test results for bacterial sexually transmitted infections before intervention (January 1, 2019-August 23, 2019) and after intervention (August 24, 2019-December 31, 2019) were identified. A retrospective chart review was conducted to ascertain provider documentation of PrEP discussions or provision, HIV prevention discussions, and HIV screening. Pretest-posttest analysis was performed to compare the provision of PrEP and HIV prevention services. RESULTS: We reviewed 856 preintervention encounters spanning 8 months and 461 postencounters spanning 4 months. Patient demographics were comparable. We observed an increase in provider documentation of safe sex and condom counseling (odds ratios [ORs], 1.2 [95% confidence interval {CI}, 1.07-1.18] and 1.11 [95% CI, 1.05-1.17], respectively), and the absence of any HIV prevention discussion decreased (OR, 0.85; 95% CI, 0.80-0.90), but not HIV screening or PrEP documentation. CONCLUSIONS: We demonstrated that an EMR laboratory comment had a modest effect on increasing risk reduction counseling, although not HIV screening or PrEP prescriptions. Future strategies to encourage provider delivery of sexual health services may benefit from more targeted strategies that combine behavioral and information technology approaches.

Remdesivir for Severe Coronavirus Disease 2019 (COVID-19) Versus a Cohort Receiving Standard of Care.

BACKGROUND: We compared the efficacy of the antiviral agent, remdesivir, versus standard-of-care treatment in adults with severe coronavirus disease 2019 (COVID-19) using data from a phase 3 remdesivir trial and a retrospective cohort of patients with severe COVID-19 treated with standard of care. METHODS: GS-US-540-5773 is an ongoing phase 3, randomized, open-label trial comparing two courses of remdesivir (remdesivir-cohort). GS-US-540-5807 is an ongoing real-world, retrospective cohort study of clinical outcomes in patients receiving standard-of-care treatment (non-remdesivir-cohort). Inclusion criteria were similar between studies: patients had confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, were hospitalized, had oxygen saturation ≤94% on room air or required supplemental oxygen, and had pulmonary infiltrates. Stabilized inverse probability of treatment weighted multivariable logistic regression was used to estimate the treatment effect of remdesivir versus standard of care. The primary endpoint was the proportion of patients with recovery on day 14, dichotomized from a 7-point clinical status ordinal scale. A key secondary endpoint was mortality. RESULTS: After the inverse probability of treatment weighting procedure, 312 and 818 patients were counted in the remdesivir- and non-remdesivir-cohorts, respectively. At day 14, 74.4% of patients in the remdesivir-cohort had recovered versus 59.0% in the non-remdesivir-cohort (adjusted odds ratio [aOR] 2.03: 95% confidence interval [CI]: 1.34-3.08, P < .001). At day 14, 7.6% of patients in the remdesivir-cohort had died versus 12.5% in the non-remdesivir-cohort (aOR 0.38, 95% CI: .22-.68, P = .001). CONCLUSIONS: In this comparative analysis, by day 14, remdesivir was associated with significantly greater recovery and 62% reduced odds of death versus standard-of-care treatment in patients with severe COVID-19. CLINICAL TRIALS REGISTRATION: NCT04292899 and EUPAS34303.

Women Are Less Likely to Be Tested for HIV or Offered Preexposure Prophylaxis at the Time of Sexually Transmitted Infection Diagnosis.

BACKGROUND: Ending the HIV epidemic requires linkage of at-risk individuals from diverse health care settings to comprehensive HIV prevention services. Sexually transmitted infections (STIs) are significant biomarkers of HIV risk and should trigger preexposure prophylaxis (PrEP) discussion. We reviewed STI testing practices outside of sexual health clinics to identify opportunities for improvement in the provision of HIV prevention services. METHODS: An electronic sexual health dashboard was used to identify patient encounters with a positive gonorrhea, chlamydia, and/or rapid plasma reagin test result between January 1, 2019, and August 23, 2019, at a large urban academic medical center. A retrospective chart review was performed to assess HIV testing, completeness of STI screening, and HIV prevention discussion; inadequate screening was defined as no HIV test in 12 months before STI diagnosis. RESULTS: A total of 815 patients with 856 patient encounters were included. Patients were predominantly female (64.4%); median age was 24 years (range, 18-85 years). The most common test and most common positive test result was the genitourinary gonorrhea/chlamydia nucleic acid amplification test. Multisite testing was rare (7.5% of patient encounters) and performed more frequently in men than in women (20.3% vs. 0.36%). Women were also more likely to be inadequately screened for HIV (15.1% vs. 25.8%).Documentation of PrEP discussion was rare (4.7% of patient encounters) compared with safe sex (44.6%) and condoms (49.8%). Preexposure prophylaxis was discussed almost exclusively with men compared with women (17% vs. 1.1%). CONCLUSIONS: In patients diagnosed with bacterial STI outside of sexual health clinics, gaps in HIV prevention exist. HIV screening, multisite STI screening, and discussion of PrEP were particularly infrequent among women.

Attitudes and Perceived Barriers to Sexually Transmitted Infection Screening Among Graduate Medical Trainees.

ABSTRACT: Graduate medical training is an opportune time to improve provider delivery of sexually transmitted infection (STI) screening. A survey of trainees found that the majority feel STI screening is their job but identified barriers to successful screening. Training that intentionally address service-specific barriers will be valuable in ending the STI epidemic.

Single Room Occupancy Residence: Processes Linking Housing to Not Engaging in HIV Outpatient Care.

Homelessness and housing instability undermine engagement in medical care, adherence to treatment and health among persons with HIV/AIDS. However, the processes by which unstable and unsafe housing result in adverse health outcomes remain understudied and are the focus of this manuscript. From 2012 to 2014, we conducted qualitative interviews among inpatients with HIV disengaged from outpatient care (n = 120). We analyzed the content of the interviews with participants who reported a single room occupancy (SRO) residence (n = 44), guided by the Health Lifestyle Theory. Although SROs emerged as residences that were unhygienic and conducive to drug use and violence, participants remained in the SRO system for long periods of time. This generated experiences of living instability, insecurity and lack of control that reinforced a set of tendencies (habitus) and behaviors antithetical to adhering to medical care. We called for research and interventions to transform SROs into housing protective of its residents' health and wellbeing.

RESUMEN: La indigencia y la inestabilidad de vivienda reducen la participación en la atención médica, la adherencia al tratamiento y la salud de las personas viviendo con VIH/SIDA. Sin embargo, los procesos mediante los cuales la vivienda inestable e insegura conllevan a resultados adversos de salud permanecen poco estudiados y son el enfoque de este manuscrito. En el 2012­2014, llevamos a cabo entrevistas cualitativas con pacientes hospitalizados con VIH desconectados de servicios de atención ambulatoria (n = 120). Analizamos el contenido de las entrevistas (n = 44) con participantes que residían en un programa de ocupación de habitación individual (SRO, por sus siglas en inglés), guiados por la Teoría del Estilo de Vida Saludable. Aunque el programa de ocupación de habitación individual surgió en las entrevistas como residencias antihigiénicas y propicias para el uso de drogas y la violencia, los participantes se mantuvieron en el programa de ocupación de habitación individual por largo tiempo. Esto generó experiencias de inestabilidad en la vivienda, inseguridad y falta de control que reforzó tendencias (habitus) y comportamientos antitéticos a adherirse a la atención médica. Pedimos investigaciones e intervenciones para transformar los programas de ocupación de habitación individual en viviendas que protejan la salud y el bienestar de sus residentes.

Efficacy, Use, and Usability of the VIP-HANA App for Symptom Self-management in PLWH with HANA Conditions.

The purpose of this study was to evaluate the efficacy of the VIP-HANA application (app) for improving symptom burden in a randomized control trial of 100 people living with HIV (PLWH) who have non-AIDS conditions associated with HIV. The intervention group received the VIP-HANA app which allowed them to report their symptoms every week and receive self-management strategies tailored to their symptoms. The control arm received an app to report their symptoms every week but did not receive any strategies. The results of our study suggest that symptom burden improved in the participants of both study arms. Although these findings do not support the efficacy of VIP-HANA in improving symptom burden in PLWH who have HIV-associated non-AIDS (HANA) conditions, this could be a function of the study design. Findings suggest that PLWH are interested in monitoring their symptoms, which could have implications for the wider use of digital health for patient surveillance.

RESUMEN: El propósito de este estudio fue evaluar la eficacia de la aplicación VIP-HANA para mejorar la carga de síntomas en una prueba controlada aleatorizada de 100 personas que viven con VIH con condiciones no de SIDA asociadas al VIH. El grupo de intervención recibió la aplicación VIP-HANA que les permitió reportar sus síntomas cada semana y recibir estrategias de autogestión personalizadas. El brazo de control recibió una aplicación para reportar sus síntomas cada semana, pero no recibió ninguna estrategia. Los resultados de nuestro estudio sugieren que la carga general de los síntomas mejoro entre los participantes en ambos brazos del estudio. Aunque estos hallazgos no apoyan la eficacia de la aplicación VIP-HANA para mejorar la carga de síntomas en PVVS con condiciones de HANA, esto puede ser una función del diseño del estudio. Estos hallazgos sugieren que PVVS están interesados en monitorear sus síntomas, lo que puede tener implicaciones para el uso más amplio de salud digital para la vigilancia de pacientes.

Attitudes, practices and perceived barriers to hepatitis C screening among medical residents at a large urban academic medical center.

Infections with hepatitis C virus (HCV) are increasing among adolescents and adults born after 1965. Screening strategies may need to be adapted for this changing population. We surveyed trainees in different specialties about attitudes and practices related to HCV screening and identified specific barriers to screening across various healthcare settings. Constraints related to health system resources and the provider's role were among the most common barriers cited across specialties, but paediatrics residents also cited barriers specific to their population, which can likely be addressed with targeted education.

Self-Management Strategies for Coping with Adverse Symptoms in Persons Living with HIV with HIV Associated Non-AIDS Conditions.

People living with HIV (PLWH) are living longer, but many are now affected by HIV-associated non-AIDS (HANA) conditions and their associated adverse symptoms. An online survey was conducted with 769 PLWH with HANA conditions in the US. Information was elicited on symptoms experienced, self-management strategies employed, and the helpfulness of these strategies. Open ended responses were collected for self-management strategies. A qualitative data analytic approach was used to organize the 4036 self-management strategies into thematic categories, with eight main categories emerging, including: taking medication, modifying activity, altering diet, seeking help, waiting, substance use, managing thoughts and attitudes, and altering the physical environment. Of the self-management strategy subcategories, social support was the most helpful self-management strategy with waiting/doing nothing being the least helpful approach. Findings can be used to inform the development of self-management interventions and to support health care professionals in recommending symptom self-management strategies to their patients.

Racial and socioeconomic disparities in the symptom reporting of persons living with HIV.

Persons living with HIV (PLWH) today can survive decades with the disease, making the symptom experience much more relevant to their lifestyle and health outcomes. The goal of the research reported here was to assess the symptom reporting of PLWH in the Unites States (US) in the combined antiretroviral therapy (cART) age of the epidemic. We conducted an anonymous online survey of symptomatic PLWH in the US and asked participants to report the frequency and intensity of 28 frequently occurring symptoms in the past 30 days. The relationship between symptom reporting and demographic factors was investigated using the adaptive least absolute shrinkage and selection operator (LASSO) method. Fatigue was the most frequently reported symptom in our study population. Those with the lowest income were more likely to report more burdensome symptoms. In comparison to other racial and ethnic groups, Black non-Hispanic participants were significantly more likely to report a lower symptom burden score for fatigue, depression, muscle aches, anxiety, difficulties with memory and concentration. There were no racial/ ethnic differences in the burden of the symptoms related to sleep or neuropathy. Findings from this study present new evidence on the symptom reporting of PLWH in the US. Neuropathy continues to be a pervasive neurological symptom with no difference noted between racial/ ethnic groups.

Retained in HIV Care But Not on Antiretroviral Treatment: A Qualitative Patient-Provider Dyadic Study.

BACKGROUND: Patients retained in HIV care but not on antiretroviral therapy (ART) represent an important part of the HIV care cascade in the United States. Even in an era of more tolerable and efficacious ART, decision making in regards to ART offer and uptake remains complex and calls for exploration of both patient and provider perspectives. We sought to understand reasons for lack of ART usage in patients meeting the Health Resources Services Administration definition of retention as well as what motivated HIV primary care appointment attendance in the absence of ART. METHODS AND FINDINGS: We conducted a qualitative study consisting of 70 in-depth interviews with ART-naïve and ART-experienced patients off ART and their primary care providers in two urban safety-net HIV clinics in San Francisco and New York. Twenty patients and their providers were interviewed separately at baseline, and 15 dyads were interviewed again after at least 3 mo and another clinic visit in order to understand any ART use in the interim. We applied dyadic analysis to our data. Nearly all patients were willing to consider ART, and 40% of the sample went on ART, citing education on newer antiretroviral drugs, acceptance of HIV diagnosis, social support, and increased confidence in their ability to adhere as facilitators. However, the strength of the provider recommendation of ART played an important role. Many patients had internalized messages from providers that their health was too good to warrant ART. In addition, providers, while demonstrating patient-centered care through sensitivity to patients experiencing psychosocial instability, frequently muted the offer of ART, at times unintentionally. In the absence of ART, lab monitoring, provider relationships, access to social services, opiate pain medications, and acute symptoms motivated care. The main limitations of this study were that treatment as prevention was not explored in depth and that participants were recruited from academic HIV clinics in the US, making the findings most generalizable to this setting. CONCLUSIONS: Provider communication with regard to ART is a key focus for further exploration and intervention in order to increase ART uptake for those retained in HIV care.

Survey of HIV care providers on management of HIV serodiscordant couples - assessment of attitudes, knowledge, and practices.

Human immunodeficiency virus (HIV) serodiscordant couples are at risk of sexual transmission of HIV between the infected and uninfected partner. We assessed New York area care providers for people living with HIV regarding attitudes, knowledge, and practice patterns toward fertility and conception in serodiscordant couples. Data were collected via a survey distributed in October 2013. Seventeen percent of respondents reported prescribing antiretroviral preexposure prophylaxis (PrEP) for a woman in a serodiscordant couple, and 38% percent of respondents reported having counseled serodiscordant couples on timed, unprotected intercourse without PrEP. Respondents who reported being "very" familiar with the data on HIV transmission in serodiscordant couples were more likely to report counseling their patients in timed, unprotected intercourse compared with those who reported less familiarity with the data (41% vs. 8%, p = 0.001). Although only 20% reported being "very" or "somewhat" familiar with the data on the safety of sperm washing with intrauterine insemination, those who did were more likely to have reported referring a patient for assisted reproductive technology (61% vs. 32%, p = 0.006). Effective patient counseling and referral for appropriate reproductive options were associated with knowledge of the literature pertaining to these options. This emphasizes the need for further provider education on reproductive options and appropriate counseling for serodiscordant couples.

Comparison of evaluation methods for improving the usability of a Spanish mHealth tool.

OBJECTIVE: Mobile health (mHealth) technology is now widely used across health conditions and populations. The rigorous development of these tools has yielded improved health outcomes, yet the ideal approach for developing mHealth tools continues to evolve, indicating the need for rigorous usability evaluation methods. This study compares two usability evaluation methods - cognitive interviews and usability assessments employing a think-aloud approach - for adapting an evidence-based mHealth tool from English into Spanish. METHODS: We conducted cognitive interviews and usability assessments using a think-aloud protocol to evaluate the usability of an HIV mHealth application among 40 Spanish-speaking adults with HIV in New York City, NY, and La Romana, Dominican Republic. The Health IT Usability Evaluation Model (Health-ITUEM) was used to guide the analysis of qualitative data collected from each method. RESULTS: Participants (N = 40) averaged 43 years old (SD = 12.26; range 20-79), identified primarily Hispanic/Latino (92.5 %), and resided in La Romana (50 %) or New York City (50 %). Both usability evaluation methods yielded similar findings, highlighting learnability and information needs as crucial components of participant feedback for the mHealth application. Cognitive interviews captured participants' perspectives on the app's interface and design. On the other hand, results from usability assessments offered insights into participants' competency while interacting with the mHealth tool. CONCLUSION: Findings from this study highlight the contributions and limitations of including cognitive interviews and task-based usability assessments using a think-aloud approach in mHealth usability testing. Future research should employ a multi-method approach, incorporating complementary usability evaluation methods and engaging participants in multiple assessments. Using complementary usability evaluation methods may provide a more comprehensive understanding of the usability and participant experience aspects of a mHealth tool compared to using a single usability evaluation method.

Expert Feedback on the Adaptation and Translation of Spanish Version of WiseApp.

HIV-related disparities also exist in developing countries, such as the Dominican Republic, where minority groups and/or those with low socioeconomic status experience higher disease burdens and worse health outcomes than those with higher socioeconomic status. We used a community-based approach to ensure the WiseApp intervention is culturally relevant and addresses the needs of our target population. Expert panelists made recommendations on how to simplify the language and features of the WiseApp to accommodate Spanish-speaking users who may have lower levels of education, or color or vision deficiencies.