HIVFactSheet: A mobile application designed and implemented by youth peer mentors to facilitate HIV and reproductive health care among adolescents and young adults

Background:Adolescents and HIV and sexual and reproductive health services. We describe and characterize the uptake of a unique mHealth intervention that was designed, led, and implemented by youth peer mentors (YPM) in the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods: YPM developed a mobile application to address the unmet needs that they identified in youth education around HIV testing, HIV care, and sexual and reproductive health. The application incorporates comprehensive educational materials and information about health services in Kenya. Users can set up reminders for clinic appointments and may call, text, or email a YPM for assistance accessing care or to ask care-related questions. The application has been promoted at AMPATH clinics and on social media. We describe its implementation in this setting. Results: Since launching the application in December 2017, as of April 2019 the application was downloaded 5,800 times, with 4,953 current users. Downloads primarily originated in Kenya (74%) and other African countries, but also globally. Texts to YPM through the application included questions about a broad range of topics on HIV testing, prevention, and care; reproductive and sexual health; substance abuse and addiction; and navigating health care. YPM contacted through the app provided individualized counseling and referred 183 users to health services. YPM utilize the application in large- and small-group and individual peer education sessions, and in trainings for healthcare workers, teachers and new YPM. Conclusions: Adolescents and young adults should be empowered to lead interventions to address the challenges that they face in navigating care. A unique mobile application intervention spearheaded by YPM providing access to comprehensive health education and individualized counseling and referral has great potential to facilitate HIV and sexual and reproductive health care for young people.


Background
The current generation of adolescents and young adults (AYA, ages 10 to 24), is the largest in history, at 1.8 billion, and is growing fastest in low-and middle-income countries, where 90% of AYA live. (1,2) 4 Fostering AYA health has great importance to the well-being of AYA, to the health of future generations, and to economic development, yet has been a neglected area. (3) HIV/AIDS and maternal disorders are leading causes of death among AYA, and unsafe sex and drug and alcohol use are major risk factors for reduced disability-adjusted life-years. (3,4) AYA have low rates of HIV testing, and those living with HIV infection have complex challenges related to their engagement and retention in care and adherence to antiretroviral therapy. (5)(6)(7)(8) Consequently, AYA face poor HIV outcomes and have been the only age group with increasing HIV-associated mortality in recent years. (9)(10)(11) AYA may also experience limited access to sexual and reproductive health (SRH) care and education, particularly access to and uptake of contraceptive methods. (12,13) Meanwhile, adolescent pregnancies and maternal disorders including complications of unsafe abortion are unacceptably prevalent. (14) Kenya has had extremely high uptake of mobile phones and a history of innovation in mobile technology. Leading the continent in smartphone penetration, over 90% of Kenyans have a mobile phone subscription, and mobile data subscriptions account for 99% of the 30.8 million internet subscriptions. (15,16) Mobile phones, particularly smart phones, offer an alternative media format for targeting AYA (both in and out of school) for high quality education and messaging about HIV and SRH. In addition, the interactive nature of this technology offers the opportunity for AYA to reach out for further information, and to feel supported. (17) AYA may be more likely to ask difficult questions through a mobile or tablet interface, rather than in-person to a health professional. (15) This may be particularly true for AYA in Kenya and other countries of sub-Saharan Africa, where AYA may be highly deferential to health professionals and hesitant to raise questions or concerns related to SRH. (18,19) Further, mHealth interventions potentially provide an avenue to maintain communication with AYA, who represent a highly mobile population who are at higher risk of loss to follow-up and disengagement from medical care, and to facilitate care and access for this group.
There has been considerable interest in mHealth interventions to improve adolescent engagement in HIV and SRH care. (20)(21)(22)(23)(24)  Mobile Application YPM identified a need to develop a mobile application (app) to provide educational resources on HIV and SRH, as well as access to AYA at AMPATH to assist in navigating care. They consulted with an HIV and SRH technical advisory team at AMPATH and MTRH, which included three pediatric physicians specializing in HIV care, a clinical officer, and five YPM. The advisory team reviewed and approved app content for both accuracy and appropriateness for AYA populations and also served as a consultation service to answer clinical and other questions that arose through texts, calls, and emails by clients using the app. YPM in AMPATH also reviewed the content and gave input on needed resources in the app through individual and group discussions. Educational content for the app was provided by Kenyan state bodies, including the Kenyan Ministry of Health, the National AIDS and STI Control Program, and National AIDS Control Council; as well as several NGOs including International Youth Alliance for Family Planning, LVCT Health, and Q Initiative. In addition, short films and narratives related to HIV disclosure and stigma (available at www.hiv-films.org) developed as part an NIH-funded study were also available through the app. (26) The HIVFactSheet app is available for free download on Android mobile devices through the Google 6 Play store (Fig. 1). Once downloaded, the app operates offline, which was important in this setting as many AYA cannot afford to use apps that require significant amounts of mobile data. The app is also now available on an online platform (available at https://hivfactsheet.org). Information in the app is categorized in several content sections (Table 1). With the app, users can set up reminders for clinic appointments. The app also provides a nationallevel referral directory with contact information for public and private health facilities, mental health centers, rehabilitation centers, and care centers providing HIV and SRH care throughout Kenya. A portal in the app allows users to call, text, or email a YPM directly for individualized counseling and referral. All communications through the app were fielded by the YPM app developers (SB and BK), who provided individualized counseling and answered specific health care questions. When YPM developers did not know or were not confident in an answer, they consulted with the technical advisory team through a regular WhatsApp chatroom where advisors were regularly available to respond to urgent questions and referral requests.
To increase awareness of the app among AYA at AMPATH, YPM began informing AYA about the HIVFactSheet app as part of individual peer support sessions as well as at social 'fun days' at Rafiki Center (Fig. 2). After an initial 3-month period of exclusively promoting the app at Rafiki Center, the potential user base was expanded through promotion of the app on multiple social media sites 7 including Facebook and Twitter. YPM then presented the app in fun days for AYA at several surrounding AMPATH sites (including MTRH, Kisumu, Chulaimbo, Busia, Kitale, among others).

Analysis
We describe the uptake and utilization of the HIVFactSheet app through summary routine data provided by Google to app developers. We quantified the number of app downloads and active users; communications through the app via calls, texts, and emails; the number of individual referrals made to health facilities; and activity on our social media pages. We also reviewed a deidentified set of texts that had been sent to YPM counselors through the app portal and categorized the types of   The content of messages sent to YPM included questions regarding a broad range of health topics (  Teaching around app educational content has been formalized in YPM-led peer group sessions with AYA, in which participants are assigned to lead a teaching session and discussion around dedicated topics, referencing materials provided in the app. In one-on-one counseling sessions with AYA, YPM inform AYA of the content provided by the app, as well as its utility for accessing YPM for further support.
The YPM developers and clinical consultants meet on a regular basis to discuss progress in implementing the app and areas where updates are desired, which are implemented by the developers on an iterative basis. Changes have been made to update content and to make the language more approachable to AYA. Further work may be needed to revise content to further resonate with AYA in African settings.

Discussion
The HIVFactSheet app represents a potentially powerful YPM-led intervention targeting AYA that There is a critical need to identify innovative strategies to expand HIV and SRH education and service uptake among AYA. (29) In Kenya, 15% of females and 22% of males have their sexual debut before age 15, and reported condom use is low. (30) AYA may have misconceptions about contraception, (13) and community support for AYA access to SRH may be lacking in some contexts. (12) Strategies are needed to provide direct, high-quality HIV and SRH education to AYA in a youth-friendly format that meets their needs in terms of the mode of communication, language appropriateness, cost, and privacy. We present a YPM-led mobile application designed to meet AYA needs and support both highquality SRH education and service uptake.
Mobile platforms can provide autonomy for the user to seek and access information as needed, as well as communication with peers and health providers. A mobile platform targeted at improving HIV and SRH knowledge among AYA in sub-Saharan Africa could provide much-needed education, even to those not currently accessing HIV services, particularly in countries like Kenya were mobile phone use is very high. This provides a means of reaching AYA who may be in or out of school, who are seeking