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By Bradley Allf, Features Writer for UNC Institute for Global Health & Infectious Diseases

Engaging with technology has become a ubiquitous part of everyday life, in our country and around the world. For example, a 2013 study found that 79 percent of U.S. households had some form of Internet connection. In fact, Cary, North Carolina, is the second-most connected city in the country with more than 95 percent of households connected to the web.

Worldwide, the rates are lower but increasing every year. Forty percent of all the people on the planet have an Internet connection, and about 85 percent have access to a cell phone, as of 2013. To put that in perspective, that same year just 64 percent of people had access to working toilets.

With this increased connectivity comes new opportunities to engage people with the healthcare they need. Lisa Hightow-Weidman, MD, MPH, Associate Professor of Medicine in the UNC School of Medicine and UNC Institute for Global Health & Infectious Diseases, wants to tap into that opportunity by designing new ways of engaging people with healthcare using technology. Her research aims to connect people, especially young people, with essential health services through technology like apps, online interventions and even virtual reality.

Lisa Hightow-Weidman, MD, MPH

Hightow-Weidman says she has been interested in technology-driven healthcare, or eHealth, since coming to UNC back in 2001. She is the principal investigator of the Behavior and Technology Lab at UNC or BAT Lab. And she recently received an $18 million award from the U.S. National Institutes of Health (NIH) to fund a “Center for Innovative Technology,” also known as iTech, to develop technology-based interventions for youth that are at-risk for or infected with HIV.

“I was driven by the fact that we had been seeing increases in HIV in young black men, particularly in young black men who had sex with men,” she says. “And at the time, again this was in the early 2000s, the Internet was certainly different than what it is today, but young people were still using the Internet to find sex partners. And there was a rise in meeting people online and then meeting them to have sex.”

Hightow-Weidman thought that if she could engage with at-risk groups at the place where they were meeting potential sex partners that she could have a better chance of improving health outcomes. So, after receiving an NIH K23 award to create a technology-driven HIV intervention, she started work on a project called “HealthMpowerment.”

HealthMpowerment works to engage at-risk groups, particularly young black men who have sex with men (YBMSM) and transgender women (TW), with information and support that promotes safer sex practices and general wellness. The intervention allows participants to talk with physicians online, to access relevant information and to support other HealthMpowerment participants through built-in social media. A pilot trial last year found statistically significant improvements in social support, social isolation and depressive symptoms among participants in the program. These results are important since, due to HIV’s status as a highly stigmatized disease, a lack of good mental health and social support has been shown to be an important barrier to individuals accessing the care they need.

In 2014, Hightow-Weidman received an NIH R01 grant to complete a fully randomized control trial of HealthMpowerment. This trial, which will be completed later this year, will parse out whether the online intervention also affects other outcomes, such as a decrease in risky sexual behavior.

“The hope is, if the full trial demonstrates efficacy at risk reduction then we will look to scale up the project and disseminate it,” Hightow-Weidman says.


Another technology-driven intervention Hightow-Weidman has been developing is aimed specifically at newly diagnosed HIV-positive young men. The project, for which Hightow-Weidman received a National Institutes of Health R21 grant, aims to improve health outcomes for HIV-positive individuals by engaging them with a mobile app called AllyQuest.

AllyQuest uses social networking and a narrative structure to connect participants with support and promote healthy behavior. The app itself functions much like a game, which Hightow-Weidman says is important.

“The idea is that the more you do, the more rewards you get—high fives, medals, badges, and virtual points that unlock things throughout the game. And those rewards motivate you to come back,” she says.

AllyQuest also allows participants to explore a whole virtual world. “We ask them to choose their own adventure and they get to make choices. By the end of their choice, they are presented with a bad outcome, an OK outcome and a good outcome. They can then go back and rehearse,” says Hightow-Weidman. There are also different characters whose lives participants get to explore through the app.

Hightow-Weidman says that nesting an HIV intervention within an interactive, gamified world like AllyQuest allows participants to engage with their healthcare in a deeper and more personal way than just reading about their prognosis. “Our hope is that they get something else from [AllyQuest] that they would not from informational articles,” she says.

Tough Talks
Hightow-Weidman’s research in eHealth is even delving into the world of virtual reality through her involvement in a project called “Tough Talks.” For HIV-positive individuals, disclosing one’s status to potential partners is always difficult, but not disclosing has been shown to increase risky sexual behaviors like engaging in unprotected sex. Thus, figuring out a way to increase status disclosure rates is a critical public health concern.

Tough Talks, a virtual character-driven disclosure intervention, aims to do just that. The project works by allowing people living with HIV to practice disclosing their status in realistic scenarios. Using virtual avatars that respond intelligently to messages from project participants, Tough Talks is able to normalize disclosure conversations and has the potential to make HIV-positive individuals more comfortable disclosing their status to potential partners.

Hightow-Weidman says the design of realistic virtual partners was a particularly important step in developing the project. “We had actual focus groups with youth to design the avatar,” she says. “We literally showed them probably hundreds of pictures of men and had them rate them on who they would date, who they found attractive and who they would rate as too attractive.”

At this stage, the avatars can only respond to written text, but eventually the project will be expanded so that they can respond to verbal text. If the project is successful, Hightow-Weidman hopes to package it such that “if you were newly diagnosed, you’d come to the clinic and talk to your doctor; and your doctor could onboard you to this intervention— you could do it at home where you could practice disclosing to a sex partner.”


Technology and Healthcare
Advances in medical research have brought previously untreatable diseases like HIV to the cusp of being manageable in the same way as other chronic conditions like diabetes. With proper adherence to antiretroviral medication, people living with HIV can expect near-normal life expectancy.

“It’s pretty amazing. I mean it’s really sort of magical, I think, that you can treat HIV with one pill,” says Hightow-Weidman. “But it doesn’t take away the stigma that a lot of people still face, and the shame and the guilt and the homophobia or transphobia that people feel, which then impacts whether or not they come to clinic and take their medicines.”

Hightow-Weidman believes that bringing healthcare to at-risk groups through technology may be a big part of successfully addressing the health disparities they face. She says that many of the projects she’s developing could eventually be scaled up in a way that traditional face-to-face interventions, which require small groups and human instructors, never could. eHealth also meets people where they are, particularly young people, by engaging with the technological world of apps and games that is oftentimes more familiar and less intimidating than in-person interventions.

Moving Forward
The innovative work Hightow-Weidman and her team have been doing in the field of eHealth has been getting a lot of attention. Just this summer she was awarded the John Bartlett Innovation in Research Award from the NC Community AIDS Fund for her “commitment to HIV/AIDS medical, behavioral, or social research.” And in September, the iTech funding was announced.

Hightow-Weidman says the main purpose of the iTech Center is to create “sustainable eHealth platforms that can be adapted rather than starting from scratch.” Rather than having researchers all over the country designing different health apps to do similar things, the Center will allow researchers to develop platforms cooperatively that can be adapted for different purposes.

These interventions will target adolescents, the age group with the majority of new HIV infections in the United States and the biggest consumers of mobile technology. The goal is to reduce the number of new HIV infections in youth and connect those who test positive for the virus with care and treatment.

“iTech will be home to six studies with each study using technology to address a barrier to the HIV care continuum,” said Hightow-Weidman. “For youth at risk of becoming infected with HIV, we will develop apps that list HIV testing sites and medical providers who prescribe pre-exposure prophylaxis or PrEP to prevent HIV. For youth who test positive for the virus, we will develop electronic health interventions to engage them in care and improve adherence to antiretroviral therapy.”

Coming out of medical school, Hightow-Weidman knew she wanted to work in HIV research, particularly with the gay, lesbian and transgender populations that continue to face health disparities. Delving into the world of mobile apps and technology interventions, however, came as something of a surprise.

But, the evidence for the need for new ways of engaging people with eHealth is all around. “Technology isn’t going anywhere,” says Hightow-Weidman. “My 70-year-old dad loves his MyChart you know, he can get his own labs and he wants me to log in and check it.”

This need for more technology-driven healthcare will only increase as technology continues to expand the breadth of its impact on how humans live their lives all over the world.

This article was originally featured on on UNC Institute for Global Health & Infectious Diseases. Read the article on their website here.

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