With significant advances in treatment, HIV has transitioned from an acute life-limiting illness to a manageable chronic condition, where PLHIV on antiretroviral therapy are able to live near-normal lives with no onward transmission of their HIV1. However, to maintain the benefits conferred by treatment, life-long medication adherence is required1. This can be challenging for many PLHIV for numerous reasons, including experience of adverse side-effects, fear or experience of stigma and discrimination, and the complexity of some treatment regimens2. For vulnerable populations (e.g., men who have sex with men, transgender people, people who use drugs, sex workers, prisoners, and migrants), challenges around mental health, finances (e.g., lack of a secure job), home stability, and access to health insurance further complicate their ability to adhere to their HIV treatment2,3,4.

To address some of these challenges and, ultimately, improve long-term treatment adherence, the World Health Organization (WHO) strongly recommends harnessing the potential of DHIs3. These recommendations for DHI integration were developed through a review of the literature and communication with knowledge experts via a Wilton Park consultation5. Wilton Park consultations are high-level meetings that bring together policymakers, health experts, and practitioners from around the world to discuss and develop strategies on pressing global issues. The topic of DHIs in HIV management was chosen due to the growing recognition of their potential to significantly improve health outcomes and the need to ensure their equitable integration into healthcare systems.

Importance of DHIs in HIV management

DHIs refer to technologies such as wearable devices (e.g., smartwatches, fitness trackers), mobile phones (e.g., that enable remote delivery of healthcare services), and artificial intelligence (e.g., chatbots, tools for medical screening and diagnosis). These can be used to manage health and well-being, implement health interventions, and conduct disease surveillance6,7. Notably, the COVID-19 pandemic highlighted not only the potential utility and efficacy of incorporating DHIs into healthcare systems, but also demonstrated the capacity to integrate such innovations into care efficiently regardless of country income classification8,9,10. This underscores the potential for DHIs to bridge gaps in healthcare access, thereby promoting equity within health systems.

As momentum towards adopting DHIs in HIV care accelerates around the world, early evidence demonstrates its potential and highlights its effectiveness6,10,11,12,13. For example, DHIs have improved HIV awareness6,10, healthy sexual behavior6,11, HIV care and medication adherence11,12, and overall access to HIV care and testing services for PLHIV13. DHIs can also be used to implement patient-reported outcome measures for the routine assessment of quality of life (QoL) among various cohorts of PLHIV, which is widely recognized as being important for further progress in HIV care and research1,2,14,15. The use of DHIs in HIV care began well before the COVID-19 pandemic, for instance, mobile health applications and SMS-based reminders have been employed to improve medication adherence and appointment attendance among PLHIV, while telehealth services have facilitated remote consultations and follow-ups, particularly benefiting those in remote or underserved areas10,11,12,13. Interest in the use of DHIs increased following the physical distancing and lockdown measures during the pandemic16. Early adoption of DHIs demonstrated their effectiveness in enhancing patient engagement, monitoring, and support, setting a foundation for their expanded use during and after the pandemic.

Towards equitable integration of DHIs in HIV care

Despite the benefits DHIs offer PLHIV and staff within healthcare systems, adopting such tools into routine clinical care is challenging and may exacerbate health access inequities17. Specifically, healthcare seekers who do not have easy and consistent access to technology (e.g., smartphones and WIFI/cellular data) in a safe and secure manner, may not be able to attain essential information or care if it is only available digitally6,12. This is referred to as the digital divide18. Furthermore, research among PLHIV indicates that digital privacy, cyber security, and data ownership are important considerations for this population19. Since 2020, various studies have examined the efficacy of DHIs during the pandemic20,21,22; however, few assessed the challenges faced and disparities created, while using DHIs, except during a pandemic when normal living conditions were disrupted23,24. To support equitable integration of DHIs, evidence-informed guidelines and tools are necessary. The development of such strategies and guidelines requires detailed and nuanced understanding of DHIs and the inequities they create10,16,18,22,23,24, which could ultimately enhance efficacy in HIV prevention, testing, treatment, and retention.

Now that we are moving to use digitalized healthcare more widely, it is of utmost importance that we build on the lessons learned and innovations developed during the COVID-19 pandemic to optimize healthcare provision for PLHIV through DHIs. However, as we continue to push for an equity-focused approach to ending the HIV/AIDS epidemic, we must strive to ensure that the digital divide is not furthered by DHI integration.

We provide 19 recommendations that we propose could further the equitable integration of DHIs into routine care and management, (Table 1). The recommendations start with proposals that could reduce costs. We also include recommendations for each part of the HIV care cascade, i.e., to improve prevention, diagnosis, linkage-to-care, treatment, and retention of PLHIV within care. The overall purpose of these recommendations is to drive global policy directives for the equitable integration of DHIs in the HIV field and to serve as a starting point for the responsible implementation of DHIs and development of international guidelines.

Table 1 Recommendations for the equitable integration of DHIs across steps of the HIV Care Cascade
Full size table

Conclusion

DHIs hold immense promise for enhancing the lives of PLHIV through improved treatment adherence, facilitated access to healthcare, and the use of patient-reported outcomes in modern HIV management. However, challenges may stymie health systems’ abilities to realize these benefits, including interoperable implementation with health information systems and equitable access, particularly for vulnerable populations who may face barriers such as lack of technology access, digital privacy concerns, and data security issues. To achieve the full benefits of DHIs, it is crucial to develop and implement evidence-informed guidelines that prioritize inclusivity and address the digital divide in HIV care and management.