Evaluating implementation and participants’ engagement with digital adherence tools (DAT) to improve antiretroviral adherence among children and adolescents living with HIV in Tanzania. A mixed method study

<ns3:p>Digital adherence tools (DAT) have shown promise in assisting children and adolescents living with HIV (CALHIV) and their caregivers in dealing with non-adherence barriers. However, the effectiveness of the DAT depends on how well participants use/engage with the intervention. We evaluated the implementation of a DAT intervention among CALHIV using the RE-AIM theoretical framework. We assessed four constructs: reach, effectiveness, implementation fidelity, and maintenance. We conducted a mixed-method study among CALHIV who used the DAT intervention for 12 months. The intervention included the use of a Wisepill box, receiving daily reminder Short Message Service (SMS) texts, and tailored feedback on adherence patterns. Quantitative data were derived from the device opening/intake reports generated by the pillbox. We calculated monthly device usage and conducted a linear mixed-effects analysis to determine whether DAT use changed over time. Furthermore, we conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with participants. We conducted a thematic content analysis of the qualitative data using the RE-AIM theoretical framework. We included 78 children (aged 0-14) with their caregivers and 88 adolescents (aged 14-18). We conducted eight IDIs with caregivers of children and eight IDIs and three focus group discussions with adolescents. We observed a decreasing trend in the monthly median device use over the 12 months for both groups. However, adolescents experienced a steeper decline in device use compared to children. Reasons for decreased device use over time included fear of HIV status disclosure due to the inability to hide the device and its purpose, as well as challenges related to device charging. DAT engagement was initially high but declined over time. Improving the device to omit the beep alert produced upon opening and assessing participants' lifestyle and living conditions before providing them with the device could enhance its implementation among people living with HIV (PLHIV)</ns3:p>