Youth Power Action Feasibility Study of Online Support Group Intervention Among Adolescents Living With HIV in Nigeria
Phase: NA
Conditions: HIV/AIDS, Adolescent Behavior, Medication Adherence, Health Behavior
Sponsor: FHI 360

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 1 of 28 
 
 
YouthPower Action- Feasibility study of an 
online support group intervention among 
adolescents living with HIV in Nigeria  
 
Protocol Version 3.0  
PHSC Study #930307 
 
Date:  
August 2017 
 
 
Funded by:  
 
USAID 
Study Sponsor:  
FHI 360 
FHI 360 Project Leader:  
Lisa Dulli, FHI 360 
Study Sites:  
Ikot Ekpene and Uyo Local Government Areas, Akwa Ibom, Nigeria 
 
 
 
 
 
 
Principal Investigator 
Dr. Lisa Dulli, FHI 360 
Co-Investigators: 
Dr. Donna McCarraher, FHI 360 
Dr. Mario Chen, FHI 360 
Ms. Kate Plourde, FHI 360 
Ms. Kathleen Ridgeway, FHI 360 
 
Site Study Coordinator 
Dr. Ogha Okpokam, SIDHAS Project, FHI 360 
 
Nigeria Lead Investigator 
Professor Oladosu Akanbi Ojengbede, Center for Population and Reproductive Health (CPRH) 
Dr. Adesola O. Olumide, CPRH 
Ms. Tolulope Mumuni, CPRH 
 
 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 2 of 28 
Contents 
Study Summary ....................................................................................................................................................... 4 
Acronyms and Abbreviations .................................................................................................................................. 5 
Background ............................................................................................................................................................. 6 
Nigeria ................................................................................................................................................................. 7 
Study Aim and Objectives ....................................................................................................................................... 8 
Methods .................................................................................................................................................................. 8 
Design .................................................................................................................................................................. 8 
Intervention Description ..................................................................................................................................... 9 
Study Setting ..................................................................................................................................................... 11 
Study Population ............................................................................................................................................... 11 
Sample Size and Sampling Design ..................................................................................................................... 12 
Data collection .................................................................................................................................................. 12 
Structured questionnaires............................................................................................................................. 13 
Clinical data ................................................................................................................................................... 13 
Participation data .......................................................................................................................................... 13 
In-depth interviews ....................................................................................................................................... 13 
Measures ........................................................................................................................................................... 14 
Data Management and Analysis ........................................................................................................................... 18 
Data management ............................................................................................................................................. 18 
Structured questionnaires............................................................................................................................. 18 
Clinical data ................................................................................................................................................... 18 
Participation data .......................................................................................................................................... 18 
In-depth interviews ....................................................................................................................................... 18 
Analyses............................................................................................................................................................. 18 
Structured questionnaires and clinical data ................................................................................................. 18 
Participation data .......................................................................................................................................... 18 
In-depth interviews ....................................................................................................................................... 19 
Project Management and Study Team Roles ........................................................................................................ 19 
Ethical Issues ......................................................................................................................................................... 19 
Considerations for inclusion of minors ............................................................................................................. 20 
Informed consent .............................................................................................................................................. 20 
Risks to Participation ......................................................................................................................................... 20 
Anticipated benefits to participation ................................................................................................................ 21 
Compensation ................................................................................................................................................... 21 
Participant privacy and confidentiality ............................................................................................................. 22 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 3 of 28 
Anticipated Outputs and Results Dissemination................................................................................................... 22 
Timeline: ................................................................................................................................................................ 23 
Appendix 1: Facebook data policy ........................................................................................................................ 24 
Appendix 2: Safety at Facebook ............................................................................................................................ 24 
Appendix 3: What are the privacy settings for groups? ........................................................................................ 24 
Appendix 4: How do I remove or block someone from a group? ......................................................................... 24 
References ............................................................................................................................................................. 25 
 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 4 of 28 
Study Summary 
 
Title:  
YouthPower Action - Feasibility study of an online support group intervention among 
adolescents living with HIV in Nigeria 
IRBNet #:  
930307 
Purpose:  
Study aim is to examine the feasibility and acceptability of an intervention designed to 
improve retention in HIV care services and improve anti-retroviral therapy (ART) 
adherence among adolescents ages 15-19 years living with HIV enrolled in ART services. 
Design:  
A single group, pre/posttest design including structured questionnaires with 
adolescents living with HIV. Additionally, we will abstract clinical data from the medical 
record system. We will also conduct in-depth interviews with a subset of participants, 
as well as health care staff who are engaged in the intervention, at endline.  
Study Population:  
Adolescents living with HIV (ALHIV), ages 15-19 years, who initiated ART at least 6 
months prior to enrollment. 
Study Site(s): 
Ikot Ekpene General Hospital, Uyo University Teaching Hospital, and Uyo Primary 
Health Center in Akwa Ibom State, Nigeria 
Study Duration:  
Study duration is approximately 9 months from IRB approval to data analysis. 
Objectives: 
 
1. To examine the feasibility of implementing a mobile/electronic health (m/eHealth) intervention 
designed to improve retention in HIV care services and ART adherence among ALHIV ages 15-19 years 
through an online support group (using Facebook). 
2. To assess acceptability of and engagement in the intervention by the target audience to inform 
improvements to the intervention. 
3. To gather preliminary data on the psycho-social and health-related outcomes that the intervention is 
designed to affect to inform an outcome evaluation study that will be conducted following the 
conclusion of the feasibility study. 
4. To collect information on recruitment, informed consent and data collection processes to inform the 
outcome evaluation study of the current intervention that will be conducted once findings from this 
feasibility study are incorporated into the intervention design. 
Primary Endpoints/Outcomes:  
The primary outcome of this study is to assess feasibility, as measured through participant acceptability and 
engagement in the intervention, and provider ability to implement. This information will be used to adjust the 
intervention prior to a subsequent outcome evaluation. 
 
 
 
 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 5 of 28 
Acronyms and Abbreviations 
AACTG 
Adult AIDS Clinical Trials Group 
ALHIV 
Adolescents living with HIV 
ART 
Anti-retroviral Treatment 
AUDIT/AUDIT-C 
Alcohol Use Disorders Identification Test 
CBO 
Community-based organization 
EC 
Ethics Committee 
FHI 360 
Family Health International 
GoN 
Government of Nigeria 
IRB 
Institutional review board 
IDI 
In-depth interview 
IT 
Information Technology 
LGA 
Local Government Area 
LMIC 
Low and middle income countries 
LTF 
Loss to follow-up 
m/eHealth 
Mobile/electronic health 
MOS-SSS 
Medical Outcomes Study – Social Support Survey 
ODK 
Open Data Kit 
OIRE 
FHI 360’s Office of International Research and Ethics 
PHQ-8 
Patient Health Questionnaire Depression Scale - 8 
PHSC 
FHI 360’s Protection of Human Subjects Committee 
PI 
Principal Investigator 
PLHIV 
People living with HIV 
RMNCH 
Reproductive, Mother, Newborn and Child Health 
SHERO 
Supporting Health and Redemption Organization  
SIDHAS 
Strengthening Integrated Delivery of HIV/AIDS Services 
SMS 
Short messaging service 
USAID 
United States Agency for International Development 
YP Action 
YouthPower Action project 
 
 
 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 6 of 28 
Background 
Globally, young people 15 to 24 years old account for 42% of all new non-pediatric HIV infections, the majority 
of whom live in sub-Saharan Africa.1 The epidemic among adolescents living with HIV (ALHIV) differs 
substantially from that among adults, as mortality among ALHIV is increasing rather than decreasing over time. 
Between 2005 to 2012, the numbers of HIV-related deaths among ALHIV increased by 50%, while the number 
of deaths among all ages decreased by 30%.2-4  
Adolescents face many challenges with adherence to antiretroviral therapy (ART) and retention in HIV care, 
including fear of stigma or disclosure to others, lack of social support, and limited knowledge about the disease 
itself.5-8 There is a lack of age-disaggregated data on ART coverage for adolescents, largely due to reporting of 
program data for ages less than 15 and 15 years and older; however, available data show that even when 
adolescents are enrolled in care, they experience higher loss to follow up (LTF) and suboptimal adherence 
compared to younger children or adults.7,9 
YouthPower Action (YPA) conducted a review of the peer-reviewed and grey literatures to identify 
interventions implemented in low and middle -income countries (LMIC) that have been shown to improve 
retention and adherence among adolescents (ages 10-19), as well as interventions that were successful among 
youth and adults (≥ 20 years of age) and had potential to be adapted for adolescents. Most interventions were 
conducted among adults and aimed to improve ART adherence, while fewer interventions targeted long-term 
retention in care. We identified that group counseling interventions show some evidence for effectiveness 
both on adherence and retention in care among adults, and have been implemented to a lesser degree with 
adolescents in LMIC.10-14 
Our review also showed that mobile phones are an acceptable platform for delivering interventions to adult 
PLHIV in LMIC settings. mHealth interventions such as mobile reminders and interactive voice or SMS response 
also have some evidence of effectiveness in improving adherence in people living with HIV (PLHIV) in LMIC 
settings.15-20 Although there is no published evidence for these interventions’ effectiveness on ALHIV in LMIC, 
there is preliminary evidence for the feasibility and potential impact on ART adherence on adolescents in high 
income countries.21-24 Furthermore, two recent studies (in South Africa and the US) have integrated social 
networking into interventions for adolescents and youth living with HIV in order to improve social support and 
found them to be acceptable and feasible.25,26 Increasing availability of internet, feature and smart phones in 
LMIC makes these interventions possible. Therefore, mHealth interventions present an innovative opportunity 
to apply successful adherence and retention strategies from adults in LMIC and adolescents in HIC to 
adolescents in LMIC.  
There is a small body of evidence supporting the effectiveness of support groups to improve health outcomes 
among PLHIV. In a quasi-experimental study in Kenya conducted among adult PLHIV, researchers found 
statistically significant decrease in LTF among intervention participants who participated in support groups 
compared to the comparison group.11 Munoz and colleagues conducted a quasi-experimental study of a multi-
faceted intervention that included support groups and found that, at 2 years, a significantly higher proportion 
of intervention group participants had >95% ART adherence compared to the comparison group (79.3% versus 
44.1%), and a greater odds of viral load suppression (OR=2.46, 95%CI(1.03, 6.09)).27 In a second study 
conducted in Kenya, Achieng and colleagues found that adherence was statistically significantly higher among 
those who participated in > 3 support group meetings (90% vs. 83%, p < 0.05), and who had pill counts 
performed by their clinician (90% vs. 76%, p = 0.001).28 The role of social support has been extensively studied 
for a number of health outcomes and is correlated with many beneficial health effects. For PLHIV, social 
support can be limited because of the stigmatized nature of the disease. Support groups hold potential for 
increasing retention and adherence. (ADD GENERAL REF ABOUT SUPPORT GROUPS.) They 
Support groups provide PLHIV an opportunity to extend their social network and to increase the social support 
available to them from others who are experiencing many of the same health and social issues that they are 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 7 of 28 
experiencing. Peer influences play a substantial role during the adolescent period. Older adolescents (age 15-
19), in particular have increased autonomy and independence compared to younger adolescents, and 
frequently look towards peers during this time for experiences and relationships that often shape and define 
their early young adult perspectives and identities. However, despite the potential benefits of support groups, 
in-person support groups also present specific challenges to long-term sustainability such as costs associated 
with travel to meeting groups which are often beyond the means of participants and must be supported by the 
group organizers. Support groups can also encounter difficulties organizing meetings at times and places 
convenient to all members. Additionally, not all people are interested in or comfortable in group settings. 
Nigeria 
Nigeria is experiencing a generalized HIV epidemic. Although the overall prevalence of HIV in Nigeria is small 
compared to many countries in Eastern and Southern Africa, because of the size of its population, the country 
has the second largest burden of the disease in the world with an estimated 3,438,442 people currently living 
with HIV.29 
Consistent with other countries in the region, adolescents (15-19) living with HIV in Nigeria experience high LTF 
from HIV treatment services, with the greatest losses occurring early in treatment. The USAID-funded 
Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) project supports health facilities in PEPFAR 
designated priority, local government areas (LGA) throughout Nigeria. An analysis of data from SIDHAS in 
Rivers, Cross River, Lagos and Akwa Ibom States found that LTF is greatest in the first year after ART initiation 
and drops off considerably after 1 year (Figure 1). The largest loss occurs at initiation with 17.7% of all patients 
never returning after initiating ART. Monthly LTF remains substantial through the first 3 to 6 months then 
reduces to 3.8% from 6 to 12 months and continues to drop from there. 
 
Similar to young people in other LMIC in the region, ALHIV in Nigeria have not been specifically targeted with 
interventions to improve health outcomes, beyond the broader orphans and vulnerable children activities 
which are not specific to ALHIV. The Government of Nigeria (GoN) has prioritized this sub-population and is 
now focusing activities to better meet its needs. The USAID-funded SIDHAS project is supporting the GoN 
priorities by implementing or planning to implement activities to support better retention in health services 
and adherence to ART among ALHIV. In the SIDHAS FY2017 work plan, ALHIV will be targeted with adolescent-
17.7%
8.1%
3.2%
3.8%
3.9%
1.3%
2.0%
39.9%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
Never
return
1 to 3
4 to 6
6 to 12
>12 to 24 >24 to 36
> 36
Total LTF
Figure 1. Number of months between ART initation and last clinic visit for those 
lost to follow-up among all youth (15-19 years) ever initiated on ART (n=5,197), 
SIDHAS data, Scale-up LGAs in 4 States.
Number of months 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 8 of 28 
specific support groups, in addition to broader activities designed to reach all ART clients, including intensive 
case management for new ART patients, reduced frequency of ART follow-up visits for stable patients (from 
monthly to quarterly), and permitting the distribution of ART in community pharmacies as opposed to only in 
ART clinics. As part of its plans for the adolescent support groups, SIDHAS has voiced interest in working with 
YP ACTION to structure the support groups using the USAID-funded Positive Connections curriculum for 
adolescent support groups.30  
Anecdotal evidence collected during an information gathering trip for this study revealed that in-school 
adolescents in particular have a difficult time traveling to health facilities. Many SIDHAS staff and health facility 
personnel stated that many students in Nigeria attend boarding schools, and they often find it difficult to leave 
school to attend health care appointments, support groups, or other reasons related to their HIV infection. 
Students may not disclose their HIV status to teachers or other students, so leaving school for anything to do 
with their HIV infection can be challenging. Even among those ALHIV who live at home, going to health 
facilities and to meetings can raise questions for those to whom the ALHIV have not disclosed their HIV status. 
Therefore, SIDHAS is keen to work with YP ACTION to develop and test alternatives to existing strategies to 
identify additional tools to support better health outcomes among ALHIV. 
Given the increasing access to and use of mobile phone technology in Nigeria, m/eHealth strategies have 
potential to meet the informational and social support needs of ALHIV who might not be able to participate or 
interested in in-person support groups. According to a survey conducted in 2014 by the Pew Research Center, 
89 percent of Nigerians ages 18 and older own a cell phone, and phone ownership has been increasing at a 
dramatic rate over the past decade.31 A 2012 study conducted in Nigeria found that, at the time, more than 
half of females ages 12-30 years owned a phone and almost all of the girls and women who did not own a 
phone had access to one supporting the feasibility of using mobile phones as a medium for health 
interventions.32  
Study Aim and Objectives 
The principle aim of this research is to examine the feasibility and acceptability of an intervention designed to 
improve retention in HIV care services and improve anti-retroviral therapy (ART) adherence among 
adolescents ages 15-19 years living with HIV enrolled in ART services. 
Specific feasibility study objectives include: 
1. To examine the feasibility of implementing an online, mobile/electronic health (m/eHealth) intervention 
designed to improve retention in HIV care services and ART adherence among ALHIV ages 15-19 years 
using an online support group (using Facebook). 
2. To assess acceptability of, demand for and engagement in the intervention by the target audience to 
inform improvements to the intervention. 
3. To gather preliminary data on the social and health-related outcomes that the intervention is designed 
to affect to inform a follow-on outcome evaluation study. 
4. To collect information on recruitment, informed consent and data collection processes to inform the 
design of the intervention for the follow-on outcome evaluation study. 
Methods 
Design 
This feasibility study will be a single-arm, pre-test/posttest study in which ALHIV ages 15 to 19 will be enrolled 
to receive six of the fourteen sessions from the Positive Connections curriculum through the m/eHealth 
intervention that will use Facebook to conduct online structured support groups. Up to 50 participants will be 
enrolled to form five groups of 8 to 10 participants. Baseline data will be collected from all participants, then 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 9 of 28 
participants will participate in the 6 sessions of the 14-session structured educational and group counseling 
curriculum through the online platform. Upon completion of the six sessions, endline data will be collected, 
approximately three to four months after baseline. Data will also be collected on an ongoing basis throughout 
the delivery of the intervention session to examine implementation processes. 
Structured questionnaires will be completed through face-to-face interviews with ALHIV participants at both 
baseline and endline. Clinical data on ART diagnosis, visits and biological tests (CD4 and viral load) will be 
abstracted from electronic patient medical records. At endline, we will repeat the structured questionnaires 
from baseline, adding questions on participation and perspectives on the intervention. Additionally, in-depth 
interviews with a subset of participants will be conducted, stratified by participation in group counseling (high 
participation and low/no participation). We will also conduct IDIs with health facility and CBO staff who take 
part in the intervention. 
We will use a software specifically designed to collect and analyze Facebook group use data. We will collect 
data on a weekly basis per group on the number of active members, the number of posts, the number of 
comments, the number of reactions to posts by type (“wow,” “love,” “like,” “angry,” “haha,” and “sad”). We 
will also document the number and reason for personal messages to the group facilitator, such as question 
about side effects, question about appointment, etc. Monitoring the push messages from the group facilitator 
will also permit analysis of the degree of fidelity to the messages and delivery schedule that is implemented. 
Intervention Description 
The intervention to be tested is based on our current understanding of existing evidence gathered through a 
systematic literature review identifying intervention strategies that have been shown to increase ART 
adherence or retention in HIV care among adults or adolescents in LMIC settings. The systematic review was 
supplemented with a review of effective interventions among adolescents in high-income countries that had 
the potential to be adapted to a LMIC setting. From these reviews, two intervention strategies stood out: 
structured group counseling and using mobile technologies to improve reach and uptake of health information 
and services. Experiences from the SIDHAS staff in Nigeria indicate that face-to-face group counseling or 
support groups have proven a challenge to implement in this setting. Difficulties finding times when 
adolescents are available to meet, coupled with the expenses associated with travel and meeting venues, limit 
the sustainability of this approach at this time. Therefore, the focus of this experimental intervention will be to 
deliver components of the structured group counseling through a mobile/electronic technology platform 
(m/eHealth). A limitation of this intervention is that, although it addresses psycho-social barriers to adherence 
and retention, it does not directly address other types of barriers such as difficulties accessing to HIV care 
facilities.  
The overall aim of the intervention is to promote adherence and retention through leveraging social networks 
and psycho-social support, with an emphasis on informational, emotional and network dimensions of social 
support. The platform selected for this intervention is Facebook. To inform this decision, workshops were 
conducted with ALHIV in Akwa Ibom State to gather input into intervention design. Text messaging through 
SMS platform and Facebook were the top two platforms suggested by participants. Facebook has been used in 
a similar manner for other health promotion interventions.25,33-39 The advantages to using a Facebook platform 
are as follows: 
• 
Facebook was well-known among adolescents who participated in the workshops. Nigeria has the 
largest number of Facebook users on the African continent and among the highest cell phone 
penetration rate (89% in 2015) in Africa31 
• 
Facebook groups can be constructed with a limited number of people, and the membership can be 
controlled through an administrator40 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 10 of 28 
• 
Facebook groups’ privacy can be set to “secret” mode, which makes it impossible for non-members to 
find the groups through searching either within Facebook or through other search engines such as 
Google40 
• 
The Facebook platform requires users to log-in from their device, so participants can also log-out, 
preventing other users of their phone to view anything on the Facebook application 
• 
Using an online social media platform permits the users to create user names that can disguise their 
real identities, if they choose, which can even further reduce their exposure to unintentional 
disclosure 
• 
The use of social media platforms to deliver health information is more cost effective than SMS 
programs and are as a result more likely to be sustainable beyond the project period 
More information on Facebook groups and Facebook’s data use policy are attached to this protocol in 
appendices. 
The m/eHealth intervention components include: 
• 
Informational messages that reflect the content of the structured group counseling curriculum, 
Positive Connections, and are posted to the group wall on a regular basis for approximately 6 months 
[data collection for the feasibility study will last 3 months, though the intervention will continue for the 
full 6 months for participants] 
• 
Moderated, closed group chats in a “secret” Facebook group where ALHIV can interact with their peers 
and with a trained health counselor on a biweekly basis 
• 
Access to a trained counselor via Facebook Messenger (during normal business hours) for the duration 
of the intervention who will be able to provide information or basic counseling on ART/HIV care 
related issues, with referral to health care services as needed  
FHI 360 will work with the SIDHAS local implementing partner, SHERO (Supporting Health and Redemption 
Organization), responsible for community-based interventions to carry out the m/eHealth interventions. FHI 
360 YP ACTION study staff will work with SHERO and the Akwa Ibom State FHI 360 SIDHAS staff to train and 
support the m/eHealth support group facilitator. Facilitators, who are community volunteers with SHERO, have 
been extensively trained to facilitate support groups for other HIV-related support groups, will receive 
intervention training and an implementation guide that outlines the key informational messages that will be 
shared, group discussion prompts, and a delivery schedule. The informational messages will be developed 
from key messages identified in each of the Positive Connections curriculum sessions. Positive Connections is a 
14-session curriculum, developed by members of the Interagency Youth Working Group with funding through 
the USAID Prevention Technologies Agreement.30 The Positive Connections curriculum provides guidance to 
professionals trained in HIV counseling to create support groups for ALHIV between 15 and 19 years of age. It 
also provides 14 sessions to be covered during support group meetings, covering the following topics:1) 
Understanding HIV; 2) Disclosure and Developing Trust in Relationships; 3) Treatment and Adherence; 4) 
Nutrition and Health; 5) Growing and Changing; 6) Sex and Relationships; 7) Pregnancy: Planning and 
Prevention; 8) Sexual Health and Positive Prevention; 9) Violence and HIV; 10) Communication and Problem-
Solving Skills; 11) Exploring Your Feelings; 12) Knowing Your Rights: Handling Stigma and Discrimination; 13) 
Making Decisions and Planning for the Future; and 14) Your Support Network and Next Steps.  
Each virtual support groups will consist of 8 to 10 ALHIV between the ages of 15 to 19 years. Once a sufficient 
number of ALHIV have been recruited to form a group, the group will begin with an initial, in-person group 
meeting with the group facilitator and co-facilitator. During this meeting, the participants will have an 
opportunity to meet one another, possibly for the first time, and the facilitators face-to-face. The intent and 
design of the intervention will be described and ground rules for participation will be set. Ground rules will be 
discussed and accepted by the group members, but at a minimum, group members will be advised not to talk 
about what is discussed in the online group with people outside of the group. A brief activity that highlights 
confidentiality and the consequences of breaking confidentiality will be implemented. During this meeting the 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 11 of 28 
participants will also receive their study phones and the facilitator will record their contact information 
(telephone numbers, email addresses and Facebook ID). Those who prefer can use their existing sim card (in 
the study phone), phone or Facebook ID to participate in the project, as long as they are willing to provide the 
information to the facilitator to enable them to be enrolled in the group. The facilitator will enroll each 
participant into the virtual group, and then a demonstration of how to open, log-in, post comments and log-
out of the group will be made. Each participant should demonstrate the ability to log in and out to the 
facilitator. The facilitator will also set conditions and expectations for responding to posts and messages by the 
facilitator, such as limiting his/her responses to group members to business hours and perhaps certain times of 
the day. Also, the facilitator will instruct the participants if they need to contact the facilitator individually, to 
send a generic SMS to call back when it is safe to do so without risk of breaking confidentiality and the 
facilitator will call the person. 
Study Setting 
This feasibility study will take place in Ikot Ekpene and Uyo, a local government areas (LGA) with a population 
of approximately 428,000 (as of 2006) that lies in the State of Akwa Ibom.41 Ikot Ekpene is a commerce center 
in the region for palm oil and other agricultural products. The USAID-funded SIDHAS project currently supports 
four ART treatment centers in the LGA, one of which, the Ikot Ekpene General Hospital, will serve as a study 
site for the feasibility study. In Ikot Ekpene General Hospital there are currently 3 physicians, 18 nurses, 3 
laboratory staff and 2 pharmacists who support HIV services. As of March 2016, the four SIDHAS-supported 
health facilities in the LGA were serving a total of 4,773 PLHIV actively on treatment, including 69 ALHIV ages 
15-19. From March 2015 to April 2016, 52 new ALHIV enrolled in ART services in these two facilities. 
Uyo is the State Capital and the University of Uyo Teaching Hospital is the leading academic health facility in 
the state.  
Study Population 
The primary population of interest for this feasibility study is ALHIV, ages 15-19 years in Akwa Ibom State in 
Nigeria. Eligibility criteria to participate in the study include: 
• 
HIV positive and currently on ART for at least 6 months 
• 
Age 15 to 19 years 
• 
Can demonstrate basic literacy necessary to participate in online chats1 
Exclusion criteria include: 
• 
Not planning to remain in the study area (within Akwa Ibom State) for the duration of the study 
(approximately 6 months) 
• 
Currently enrolled in an in-person support group 
• 
Currently enrolled in another research study related to HIV service retention or ART adherence 
• 
Critically or severely ill requiring hospitalization or such that the individual is unable to provide 
informed consent at the time of study recruitment 
The primary target population for this intervention is ALHIV who initiate ART in the first 12 months following 
initiation. An outcome evaluation study is planned for this intervention after the feasibility study. Because the 
number of ALHIV newly enrolling in ART in the study sites is relatively small, to avoid depleting our potential 
                                                          
1 The design of the intervention will require basic (e.g. at least some primary school) literacy to read and respond to text messages and 
online chats. We want to ensure those who are enrolled in the study have the potential to benefit from the intervention. Therefore, 
during recruitment, the data collector will screen potential participants by providing 3 short messages that will be part of the 
intervention and ask the participant to read them aloud. Only those who can read the messages will be eligible to enroll in the study. 
Data collectors will record the number of potential participants who are deemed ineligible and the reason for ineligibility, including 
inability to read the screening messages. This information will also inform feasibility. 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 12 of 28 
participant pool for the outcome study, we will restrict eligibility for this feasibility phase to ALHIV who have 
been enrolled in ART for 6 months or longer. This eligibility restriction may result in a biased sample for the 
feasibility study because these adolescents have already been retained in care for 6 months and may be 
different than those who are enrolled 0-6 months after enrollment in ART. However, this will permit overlap 
with the target population for the feasibility and outcome studies, but also preserve adequate numbers of 
ALHIV to be enrolled in the outcome study, which should begin approximately 6 months after the feasibility 
study is initiated.  
Sample Size and Sampling Design 
The intent of this feasibility study is to ascertain if each of the intervention components can be implemented in 
a way that could lead to the intended outcome. Given that the target group size for group counseling is 
between 8-10 individuals, we will enroll enough participants to form 5 m/eHealth support groups (40-50 
individuals). This sample size was determined based on logistical considerations and to provide sufficient data 
for addressing the objectives in a descriptive manner. Eligible participants will be sequentially recruited from 
patients who attend clinic visits at the study facility until the total sample size has been achieved. Patients 
currently attend ART clinic visits monthly. If recruitment extends beyond 4 weeks, alternately, we will ask the 
health ART clinic point person to identify potentially eligible patients based on eligibility criteria from their 
facility records and to contact the person by telephone to tell them about the study and, if interested, to come 
to the facility if they may be interested in participating in a research study. 
At endline, in-depth interviews, using a semi-structured interview guide, will be conducted with 6 to 8 
participants who have moderate to high participation in the intervention (the cut-off to be determined once 
participation data are available) and 6 to 8 interviews with participants who have low to no participation in the 
intervention.  
Revised endline structured questionnaires with added questions on intervention acceptability, participation 
and challenges, and the in-depth interview guides will be submitted separately for ethics review near the end 
of the study. We will do this to ensure we include questions on any important issues that arise during 
implementation. 
Data collection 
The health care providers who provide ART services to patients within the two study facilities will be oriented 
on the study and asked to refer ALHIV ages 15-19 as they present to services to the study staff member who 
will be stationed in the facility during the recruitment period. ART services are set within the general 
outpatient clinic where the reason for the patient’s visit cannot be known by others waiting with them. Study 
staff will be stationed in a separate location within the facility so that they do not know with whom the health 
staff have discussed the study. ALHIV who approach the study staff will be informed about the research study.  
Potential participants will be assessed for eligibility and written informed consent will be obtained from each 
participant prior to enrollment in the study. The study staff will communicate verbally that the study is for 
adolescents living with HIV and the groups will be made up of adolescents living with HIV. The study staff will 
verbally confirm that the potential participant believes he/she meets the study eligibility criteria. Parental 
consent will also be obtained for non-emancipated potential participants who are ages 15-17 years. Responses 
to structured questionnaires will be recorded in electronic files on computer tablets. Contact information, 
including name, phone number, address, date of birth, sex, medical record number, and name and relationship 
for a second contact person, if available, will be recorded. All identifying information/contact information will 
be recorded in a separate, password-protected file and only a unique study identification numbers will be 
recorded with all data collection instruments (structured questionnaire, clinical data abstraction form, in-depth 
interview responses). All interviews will be conducted in a private setting either onsite at the facility or offsite 
at a nearby location, per the participant’s preference. 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 13 of 28 
At endline, the participant will be contacted during his/her regularly scheduled clinic appointment to complete 
the endline questionnaire. If the participant misses the scheduled appointment by more than one week, the 
study staff may attempt to contact the participant and/or his/her parent using the contact information 
provided by the participant/participant’s parent up to three times over two weeks to reschedule the final 
interview and ask if the participant wishes to continue to take part in the research. The person who calls or 
visits the participant will not identify himself/herself as part of the study to avoid inadvertent breach of 
confidentiality. 
Structured questionnaires 
Participants will be asked to respond to structured questionnaires through face-to-face interviews conducted 
by trained interviewers prior to the launch of the intervention and at the end of the project period. Data to be 
collected include: basic demographic information (e.g. sex, age, education level, relationship status (e.g. 
married, partnered, single), living arrangements (whether they live with a parent or guardian, how many 
people are in their household, and relationship to those people), as well as contact information (phone 
number, place of residence); HIV-related information including how long since diagnosis, current ART regimen, 
last CD4 and viral load test date and results, disclosure status, self-reported adherence; social support 
measures covering emotional, instrumental, informational and network social support dimensions; factors 
associated with poor retention and adherence, including depression/anxiety, alcohol and other substance use, 
and perceived and experienced stigma; and access to and use of mobile telephones and social media 
applications. Forms will be administered at baseline and again at endline, which will be 3 months after the 
intervention is initiated. Endline questionnaires will include additional, closed- and open-ended questions 
pertaining to intervention participation, perspectives on utility and acceptability of the intervention, any 
barriers to participation encountered and suggestions for improvement in the intervention. 
Clinical data 
A data abstraction sheet will be developed to abstract relevant clinical data for each study participant. As 
noted, the form will only record the participant’s unique study ID for identification purposes. Data to be 
abstracted will include: date and results of most recent CD4 cell count and viral load test; date of HIV 
diagnosis; date of ART initiation; WHO clinical stage at ART initiation; date of last ART prescription; date of last 
ART clinic visit. 
Participation data 
Data from the group participation will be abstracted and analyzed using a social media analytics tool called 
Grytics (https://grytics.com/). We will collect data on a weekly basis per group on the number of active 
members, the number of posts, the number of comments, the number of reactions to posts by type (“wow,” 
“love,” “like,” “angry,” “haha,” and “sad”). We will also document the number and reason for personal 
messages to the group facilitator, such as question about side effects, question about appointment, etc. For 
messages, we will ask the facilitator to keep a log of message indicating the date, time and main reason for 
contact. 
In-depth interviews 
IDIs will be conducted with a sub-set of ALHIV participants from the original sample. Participants in group on-
line group counseling will be categorized as having moderate/high participation or low/no participation, the 
cut-off for which will be determined after participation data have been collected and examined. Those who are 
categorized as moderate/high participation will be asked questions to explore their perspective (likes, dislikes 
and suggestions for improvement) on the intervention platform, the content of the intervention, and the 
implementation of the three components (push informational messages, moderated group chats and 
unstructured access to peers and their counselor through the Facebook site). For those with low/no 
participation, we will explore reasons for non-participation and suggestions for changes, if any that could serve 
to enhance participation. 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 14 of 28 
IDIs will also be carried out with all health facility and community-based organization (CBO) staff involved in 
intervention coordination or implementation. The aim of these interviews will be to explore experiences 
related to intervention implementation, challenges, if any, encountered and suggestions for improving the 
intervention to achieve greater participation. 
Note: IDI guides will be developed after the baseline data collection is conducted; these and their 
corresponding informed consent forms will be submitted for approval in a protocol amendment prior to the 
start of endline data collection. 
Measures 
We will collect basic demographic information on participants (sex, age, marital/relationship status, education, 
occupation, religion) as well as background information on the participant’s HIV infection: when diagnosed, 
when started ART, disclosure of HIV status to others, viral load and CD4 testing. Additionally, we will collect 
data on psycho-social factors associated with poor retention and adherence, including depression/anxiety, 
alcohol and other substance use, and perceived and experienced stigma. 
The measures for which data will be collected are outlined below, by study objective. A summary of the 
measures and source of data, by objective, is found below in Table 1. 
Objective 1: To examine the feasibility of implementing a mobile/electronic health (m/eHealth) intervention 
designed to improve retention in HIV care services and ART adherence among ALHIV ages 15-19 years,  
Questions to be answered for this objective include: 1) Can the intervention be implemented as designed 
(factoring in constraints with human resources, IT, and/or infrastructure, policy and cultural context); 2) Which 
components pose the greatest challenges in terms of implementation and why; 3) What can be done to 
overcome those challenges; and 4) Do facilitators send out the correct informational messages at the correct 
frequency and engage with participants both during the structured moderated chat and at other times?  
To meet this objective, we will document facilitator knowledge regarding the Positive Connections support 
group curriculum topics using a pretest and posttest during the weeklong training on the curriculum. We will 
document fidelity to implementation by monitoring the frequency and content of push messages sent to group 
members, as well as if the regularly scheduled structured group chat occurs following each session’s messages. 
We will provide a log to facilitators to document additional correspondence between the facilitator and group 
members that will record date, time, reason for contact, action taken by the facilitator and medium of 
communication (Facebook post, SMS message, phone call or in-person meeting). We will also document any 
challenges encountered by the group members or facilitators in terms of enrolling members into the Facebook 
group, logging into or out of the group, telephone related challenges such as gaps in airtime credit or 
electricity charging problems. This information will be recorded in notes during monthly meetings with the 
facilitators. We will also explore such problems during the endline interviews. 
During the baseline interviews with participants, we will include questions on cell phone ownership, use as 
well as barriers to use such as access to electricity, running out of credit, and experience using the internet and 
social media, including Facebook. 
Objective 2: To assess acceptability of, demand for and engagement in the intervention by the target audience 
to inform improvements to the intervention. 
The following will be measured to get at the concepts of accessibility, demand and participation. 
Acceptability – To understand acceptability, at endline we will include a series of close-ended and open-ended 
questions on the structured questionnaire to explore the following: how do adolescents like or dislike the 
different components of the intervention? Are they acceptable – if so, what do they like best/least; if not, why 
not and how might they be changed to be better received? We will also explore whether adolescents are 
comfortable in mixed sex groups or if they prefer single sex groups. We will further explore these issues and 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 15 of 28 
other, yet to be determined issues that may arise during implementation using a semi-structured in-depth 
interview approach. 
Participation/engagement – For this we will explore if adolescents participate in the components of the 
intervention; which components have the greatest uptake, which the least. We will record how frequently a 
participant posted comments or questions. As noted above, we will collect data on a weekly basis per group on 
the number of active members, the number of posts, the number of comments, the number of reactions to 
posts by type (“wow,” “love,” “like,” “angry,” “haha,” and “sad”). We will also document the number and 
reason for personal messages to the group facilitator, such as question about side effects, question about 
appointment, etc. For messages, we will ask the facilitator to keep a log of message indicating the date, time 
and main reason for contact. 
At endline, we will explore both through questions added to the structured questionnaire for ALHIV and 
through IDIs conducted with a subset of participants, why people participated or did not and how the 
intervention components might be changed to increase uptake. 
Objective 3: To gather preliminary data on the social and health-related outcomes that the intervention is 
designed to affect to inform an outcome evaluation study that will be conducted following the conclusion of 
the feasibility study. 
For the third objective, we will record measures of our intended health-related and psycho-social outcomes as 
specified below. Although the time period is too short and the sample size too small to attempt to assess the 
effect of the intervention on the measures of retention, adherence and social support, this feasibility study 
provides an opportunity to gather baseline information on all three measures to inform the outcome study, as 
well as to ensure our measures work with this group. 
Retention: This main outcome is defined as retention in clinical HIV services and on treatment. In the feasibility 
study, retention will be assessed at 3 months after enrollment. We will abstract data from the clinic electronic 
medical record system on date of visits between enrollment and the endline of this study. To be considered 
retained in HIV services, an individual must, at 3 months after enrollment, have attended his/her most recently 
scheduled clinical follow-up visit within 1 month of the date when it was scheduled to take place. We will 
record, from the medical record, if a participant has knowingly enrolled in services elsewhere (transferred), in 
which case attempts to contact the participant will be made, if feasible; we will also record if the participant 
has died or recorded as lost to follow-up. Personal contact information, including phone number and home 
address, gathered during study enrollment will be used to trace participants who do not return for endline 
interviews.  
Adherence to anti-retroviral treatment: Adherence to ART will be measured through self-reported measures in 
the structured questionnaire of treatment adherence and challenges with taking medication as prescribed. In 
the feasibility study, we will measure self-reported adherence using the AIDS Clinical Trials Group adherence 
measure (AACTG baseline: http://caps.ucsf.edu/uploads/tools/surveys/pdf/2098.4186.pdf).42 This validated 
measure has been widely used to measure adherence for research purposes. We will also collect viral load and 
CD4 cell count data from patient medical records.  
Social support: To measure social support, we will use the Medical Outcomes Study – Social Support Survey 
(MOS-SSS).43 This scale, developed in the early 1990’s, has been used extensively in a number of different 
countries and with a variety of health outcomes, including HIV in China, Ireland, the US and in Ghana.44-52 The 
MOS-SSS is a 19-item scale that covers the dimensions of emotional, information, affectionate and tangible 
social support in addition to positive social interaction. 
We will also gather data on key psycho-social factors that have been demonstrated to be associated with 
adherence and retention in services elsewhere: alcohol and other drug use; depression and stigma.53 For 
alcohol use, we will use the AUDIT-C abbreviated, 3-item scale.54 The AUDIT-C is an abbreviated version of the 
10-item Alcohol Use Disorders Identification Test (AUDIT) tool developed by the World Health Organization to 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 16 of 28 
measure harmful and hazardous alcohol drinking behaviors.55 For the AUDIT-C, each of the three items is 
scored on a 5-point scale (0-4), and the scores are totals across items for a final score that ranges from 0 to 12. 
A score of 3 or greater for women or a score of 4 or greater for men is indicative of harmful alcohol use.54 We 
will measure other drug use through an item adapted from the AACTG adherence questionnaire.42  
Depression will be measured using the 8 items from the Stanford Patient Education Research Center’s Patient 
Health Questionnaire Depression Scale (PHQ-8).56 The PHQ-8 asks respondents on how many days over the 
prior two weeks they experienced 8 possible symptoms, with response options of “not at all”=0, “a few days”= 
1, “more than half the days”=2, and “most all of the days”=3. The score for each item is summed and a total 
score that ranges from 0 to 24 is assigned. Respondents who score 10-19 points are considered to have major 
depression and those who score 20 or more have severe depression.56 Finally, for HIV-related stigma, we will 
use an adapted measure from the ongoing NIH-funded Pilot of family-based self-management for HIV-infected 
adolescents in two clinics in Ndola, Zambia. 
Objective 4: To collect information on recruitment, informed consent and data collection processes to inform 
the outcome evaluation study of the current intervention that will be conducted once findings from this 
feasibility study are incorporated into the intervention design. 
Reports from the local research partner, the Center for Population and Reproductive Health (CPRH), Ibadan, 
Nigeria, on recruitment, enrollment and the informed consent process will be used to understand challenges 
to study implementation and devise strategies to improve these processes for the outcome study to follow. 
After the baseline wave of data have been collected, we will hold a meeting with data collectors, study staff in 
Nigeria and health facility staff to document successes, keys for success as well as any challenges that they 
encountered and suggestions for improvement. The same meeting will be conducted after the endline wave of 
data collection. Meeting notes will be taken by a designated recorder and reviewed by study investigators. 
 
Table 1. Summary of study measures by objective. 
Study objective 
Concept/variable 
Measures 
Source of data 
Objective 1: To examine 
the feasibility of 
implementing a 
mobile/electronic health 
(m/eHealth) intervention 
designed to improve 
retention in HIV care 
services and ART 
adherence among ALHIV 
ages 15-19 years. 
Feasibility of 
implementation 
 
 
 
 
 
 
Provider topical knowledge 
on topics covered through 
Positive Connections 
 
Logistic challenges 
(internet connection, 
electricity, airtime) 
 
 
 
Perspectives on feasibility, 
challenges and strategies to 
improve the delivery and 
uptake of the intervention 
Training pre/posttest. 
 
 
 
Monthly facilitator/study 
staff meeting notes 
 
Baseline/endline structured 
participant questionnaires 
 
Endline IDI with health 
facility staff and facilitators 
engaged in intervention 
implementation 
 
Fidelity of implementation 
Ability to push out correct 
messages, hold regularly 
scheduled group chats as 
directed in intervention 
guide 
Grytics software linked to 
Facebook groups 
 
Objective 2: To assess 
acceptability of, demand 
for and engagement in the 
intervention by the target 
Acceptability 
Open-ended questions on 
perspectives regarding 
intervention components 
Endline Structured 
participant questionnaire 
Endline IDIs with subset of 
participants 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 17 of 28 
audience to inform 
improvements to the 
intervention. 
and how to improve the 
intervention 
 
Closed-ended questions on 
perspective regarding 
intervention components. 
 
 
Endline Structured 
participant questionnaire 
 
Participation/engagement 
Frequency of participation 
(number of active 
members, the number of 
posts, the number of 
comments, the number of 
reactions to posts by type) 
 
Number, type, reason for 
and outcome of personal 
communications between 
facilitator and members 
Grytics software linked to 
Facebook groups 
 
 
 
 
 
Facilitator log of individual 
communications with 
group members 
Objective 3: To gather 
preliminary data on the 
social and health-related 
outcomes that the 
intervention is designed to 
affect to inform an 
outcome evaluation study. 
Social support 
MOS-SSS items 
Structured baseline and 
endline participant 
questionnaires 
Adherence to ART 
AACTG Adherence 
Assessment items 
 
 
Viral load 
Structured baseline and 
endline participant 
questionnaires 
 
Medical record data 
Retention in HIV services 
Questions adapted from 
AACTG Adherence 
Assessment items 
 
Dates of clinic visits during 
study 
Structured baseline and 
endline participant 
questionnaires 
 
Medical record data 
HIV-related Stigma 
12-item stigma scale 
Structured baseline and 
endline participant 
questionnaires 
Substance use 
AACTG Adherence 
Assessment items 
Structured baseline and 
endline participant 
questionnaires 
Depression/anxiety 
 
PHQ-8 
Structured baseline and 
endline participant 
questionnaires 
Objective 4: To collect 
information on 
recruitment, informed 
consent and data collection 
processes to inform the 
outcome evaluation study 
of the current intervention 
that will be conducted once 
findings from this feasibility 
study are incorporated into 
the intervention design. 
Challenges to recruitment, 
informed consent and data 
collection processes 
Structured meetings with 
health facility and CBO staff 
engaged in intervention, as 
well as data collectors. 
Meeting notes 
 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 18 of 28 
Data Management and Analysis 
Data management 
Structured questionnaires 
Structured questionnaires will be programmed into electronic format using Open Data Kit (ODK) software and 
data will be collected on computer tablets, then uploaded to a secure FHI 360 server daily. The data will be 
stored in a password protected file on a secure server which is accessible only to study investigators. Data will 
be reviewed periodically during data collection for completeness and errors. Once data collection is complete, 
the final raw data set will be downloaded to study staff computers, which are also password protected, for 
final cleaning and analysis. Once the project is closed out, all data will be downloaded and stored at FHI 360, 
and the server database will be deleted. 
Clinical data 
A data abstraction form will be developed and programmed into computer tablets using ODK. These data will 
be entered into the tablets and uploaded to the secure server in the same manner as the structured 
questionnaires. 
Participation data 
Grytics permits users to collect use data from the Facebook groups for which they serve as administrators. For 
the purposes of this study, the group facilitator will be the primary administrator for the Facebook group. A 
study Facebook account will be registered to which only three study staff - the principal investigator, Lisa Dulli, 
the intervention design lead, Kate Plourde, and the lead quantitative data analyst, Katherine Ridgeway - will 
have access. This study account will be listed as a co-administrator for each of the study Facebook groups. The 
two study staff will not engage in the groups; they will only run the weekly use analytics and download use 
data to a secure FHI 360 server. Although Grytics does allow the members’ usernames of the group to be 
displayed, when the data are downloaded, their usernames will be manually stripped by the PI or analyst and 
their participants’ study identification numbers will replace the usernames in the dataset. At the conclusion of 
the study, the Grytics account will be closed. No Facebook group data will remain on Grytics or on the study 
Facebook account; the only record will be the de-identified data on the FHI 360 server. 
In-depth interviews 
IDIs will be conducted by trained interviewers, experience in IDI administration, after obtaining informed 
consent. The interviewer will audio-record the interview, in addition to taking notes during the interaction. The 
digital audio recording will then be translated and transcribed into a Microsoft Word file, which will be pass-
word protected and uploaded to the study SharePoint site for data analysis. A separate folder will be created 
on SharePoint with access limited to study staff within FHI 360. 
Analyses 
All analyses for this study will be descriptive in nature because of the small sample size for the feasibility study 
and the convenience sampling strategy. No statistical significance testing will be conducted. For quantitative 
data from structured questionnaires, medical data abstraction forms and Facebook groups, tables will be 
presented grouped by topics with measures of central tendency presented (mean, median, mode) or 
proportions as appropriate to the measure. 
Structured questionnaires and clinical data 
Descriptive analyses of pre- and posttest data will be presented. As appropriate for the different outcomes, 
data will be presented to describe changes from baseline to endline. 
Participation data 
Descriptive analyses of participation in structured moderated sessions, posts and comments/reactions by 
group and by sex will be presented.  

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 19 of 28 
In-depth interviews 
Data analysis will begin during data collection by transcribing (and translating where needed) each audio-taped 
IDI. When necessary and possible, IDIs will be simultaneously transcribed and translated from the original 
language to English. All transcripts will be typed into a word processing program and password-protected; 
some transcripts may be handwritten first. Transcripts will be stored on password-protected computers. All 
data will be uploaded directly to a designated SharePoint folder. Data management logs may be created track 
and monitor data collection and transcription.  
As soon as possible after the IDIs are conducted, transcript text will be read carefully by the study investigators 
in order to: (1) ask any questions of the text that may be unclear; (2) point out areas in which interviewing and 
transcription techniques could be improved; and (3) identify recurrent themes and areas for future probing. 
Data-derived codes developed through inductive coding and retrieving will be used during analysis. A priori 
codes for retrieving text for key concepts related to the overall objectives also will be applied to the data. 
Investigators will determine a coding frame to be used based on the topic guides and the first few IDIs 
available for analysis. New codes will be added as necessary during transcript analysis. A qualitative data 
software program, such as QSR NVivo or a similar program, will be used to organize all qualitative data and 
prepare the data for analysis. Procedures will be put into place to check for inter-coding discrepancies. Once all 
the transcripts have been coded, textual coding reports will be produced. Data reduction techniques will be 
used to examine codes in detail for sub-themes and patterns across the IDIs. Summary reports will be 
developed and recommendations for intervention adaptations will be made.  
Project Management and Study Team Roles 
Dr. Lisa Dulli, Scientist II, FHI 360 Health Services Research will serve as Principal Investigator (PI) for this 
research. She will be responsible for overall fiscal and administrative, issues as well as study development and 
implementation, and for overseeing analyses and reporting of study results. Kate Murray, Research Associate 
II, FHI 360 will serve as study manager and support Dulli with logistical, budgeting, administrative issues. She 
will also provide quantitative and qualitative data analysis support to Kathleen Ridgeway, Research Associate I, 
FHI 360, who will serve as lead analyst for the study. Dr. Donna McCarraher, Director Reproductive, Mother, 
Newborn and Child Health (RMNCH), FHI 360, will provide topical expertise for ALHIV to the study. Dr. Mario 
Chen will support data analyses as needed. In Nigeria, Dr. Ogha Okpokam, Technical Assistant for SIDHAS, FHI 
360, will provide support to both intervention and study implementation by serving as the primary point of 
contact for FHI 360 Nigeria and liaising with both SHERO and the local organization contracted to collect data. 
Kate Plourde, Technical Officer, FHI 360 is leading development of the m/eHealth intervention, including 
adaptation of the Positive Connections support group curriculum for an online medium. Study recruitment, 
enrollment and data collection activities have been contracted to CPRH. 
Ethical Issues 
This study aims to examine the feasibility and acceptability of an mHealth intervention to increase retention in 
care and improve adherence to ART among adolescents, ages 15 to 19 years, living with HIV. Prior to study 
implementation, all study staff, including individuals who participate in data collection activities or 
intervention implementation, will have completed an approved research ethics training curriculum. The study 
will be submitted for ethical review and received approval from both the University of Uyo Institutional Health 
Research Ethics Committee (IHREC) and FHI 360’s Protection of Human Subjects Committee (PHSC) prior to 
collecting data. 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 20 of 28 
Considerations for inclusion of minors 
Minors between the ages of 15 to 17 years will be actively recruited into this study based on the need for 
effective interventions to improve retention in HIV treatment services and ART adherence among this age 
group. 
Informed consent 
All participants will be provided information on the intervention, on the scope and nature of the interviews to 
be conducted, the medical record data that will be recorded and the intervention data that will collected. We 
will obtain written informed consent to participate before any data collection is conducted, including data 
collection through Facebook groups, if they agree to participate. If the adolescent is less than 18 years of age 
and not emancipated, we will seek parental consent to participate and adolescent assent. If parental consent is 
required, the study staff will request that the potential participant’s parent/guardian be contacted to provide 
informed consent. If the potential participant refuses, he/she will not be eligible to participate. If the potential 
participant accepts, the study staff will ask that the parent/guardian come to the health facility for the consent 
process. If the potential participant and parent/guardian prefer, the study staff can arrange to meet the parent 
at the patient’s home. In cases where adolescents are younger than 18 years of age, if the adolescent is an 
emancipated minor through marriage or living independently from his/her parents/guardians, we will seek 
informed consent directly from the participant. It is important to note that the informed consent forms 
(including parental consent and adolescent assent) will not contain a reference to HIV for privacy purposes 
since a copy will be given to the participant/parent; however, both the provider who refers the adolescent to 
the study staff and the study staff who gains informed consent and interviews the participant will verbally tell 
the individual that the study is for adolescents living with HIV and the support group that is part of the 
intervention is to support ALHIV.  
Risks to Participation 
We do not anticipate any serious physical, mental, or social risks due to participation in this research. The 
greatest risk of participation in the study is inadvertent breach of confidentiality. Measures will be taken to 
protect the confidentiality of the participants. For data collection – all interviews will be conducted in a private 
setting, data will be recorded on password protected devices, uploaded to a secure server and all data will be 
de-identified, with a separate file containing identifying information kept on a separate, password protected 
computer.  
With regard to participation in the intervention under study, participants will be offered telephones to 
participate, but the participant can refuse the phone if he or she thinks it would cause concern among others. 
Also, the phones will be one of the more typical feature phone sold to Nigerian consumers that meets our 
intervention needs so that those who have the phone won’t be identified with the intervention or research.  
The virtual support groups, as with face-to-face groups commonly implemented, carry some risk that fellow 
group members or facilitators could disclose personal information to people outside of the group. Facilitators 
will be trained on issues of confidentiality, which is part of the curriculum being implemented. Group members 
will be brought together to set ground rules for participation which will include at a minimum the need to keep 
group discussions confidential. In terms of the platform to be used for communication among group members, 
we will use Facebook which provides secret groups that are not searchable or joinable by outsiders. Group 
membership will be strictly controlled by the main group administrator who is the facilitator. Group members 
will be instructed in logging into the application, logging out after use to prevent others with access to their 
phone from seeing the group and in locking their phones using its security features to avoid others gaining 
access to the phone without their permission. They will be instructed not to save passwords on their phone 
with a password manager, or to share their Facebook password with others. In the event that the facilitator or 
other group member(s) learn that a group member has intentionally permitted access to the Facebook group 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 21 of 28 
posts to a person outside the group, the facilitator will immediately remove the individual from the group until 
he/she can determine if the breach of confidentiality has actually taken place. If it is determined that the 
breach did in fact occur, then the person will not be invited back to be a member of the Facebook group and 
will be permanently blocked to protect the privacy of the other members. The facilitator and local study 
coordinator, would bring together all other members of the group, or those who may have been affected by 
the breach, in an in-person group to discuss the breach and how to handle the situation. Alternately, if the 
breach only affects one or a few members, the study staff and facilitator may contact the participants 
individually. If a participant prefers, the facilitator may meet with them individually instead of with the full 
group. Any such incident would be reported as soon as possible to both the local and FHI 360 ethics 
committees, per FHI 360 PHSC policy. 
With regard to interview procedures, it is possible that some participants may be uncomfortable when asked 
about sensitive topics during the structured or in-depth interviews. To minimize the potential for any adverse 
events, study staff will conduct interviews in a private location. As part of the consent process, participants will 
be informed that they can refuse to answer any question and they can terminate an interview or their 
participation in the study at any time without penalty. 
Additionally, in the case that a participant discloses a need for psychosocial support during an interview, 
referrals for additional psychosocial supportive services or other health services will be made as needed. A list 
of resources will be developed for the study sites. If these services are not available or accessible to the study 
participants, an alternative strategy will be developed to provide supportive services. In case of an emergency, 
such as disclosure of suicidal ideation or severe depression, the potential participant will be referred 
immediately to the health care provider on site. Additionally, monthly debriefings will be held throughout the 
study to enable study staff to share experiences and support each other. They will also give feedback on how 
participants are receiving the intervention, any related questions, and share techniques for increasing rapport 
and gathering accurate information.  
Anticipated benefits to participation 
Participants in the study may directly benefit from participating in the m/eHealth intervention. The 
intervention is designed to lead to improvements in HIV treatment retention and adherence that could lead to 
improved health. Additionally, the intervention is designed to increase access to social support from other 
ALHIV, a problem for many ALHIV who fear disclosing their HIV status to others. Although we are not powered 
to measure these outcomes for the feasibility phase, the intervention, if successful could lead to better health 
and psychosocial well-being. 
Compensation 
Although cell phone ownership is high in Nigeria (89% in 2015)31, it is possible that adolescents who participate 
in this study may not have access to their own phones and may share them with others, such as a sibling or a 
parent. Because this study is a feasibility study to see if ALHIV who can access the intervention do use it and 
what they think of it, the study will provide each ALHIV participant with a cellular phone for participation that 
he/she may keep at the end of the study. The phones that will be provided will be consistent with typical 
feature phones found in the community and will have no distinguishing characteristic that would identify the 
phone as part of a study or intervention. The value of the phones to be provided is estimated to be between 
10,000 to 15,000 Nigerian Naira (approximately (US$30-45). In addition to the telephone, participants will 
receive 500 Naira (US$1.5) of airtime per month and a travel reimbursement of 1,500 Naira (US$4.5) for each 
trip for participating in each interview (baseline and endline) and for the initial study group meeting. The travel 
reimbursement of 1,500 Naira is a standard rate set by the SIDHAS project. 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 22 of 28 
Participant privacy and confidentiality 
The collection of identifying information is required for this study. Personal identifiers (name, date of birth, 
telephone number, medical record number, address, phone number and phone number for a next of 
kin/additional contact) will be recorded in a separate, password-protected file with access only by study 
investigators and study staff. These will be associated with unique study identifiers, which will be the only 
identification recorded on data collection instruments. Once data collection, cleaning and data analysis are 
complete, the file containing the identifying information will be destroyed, leaving only a final, de-identified 
dataset. 
Anticipated Outputs and Results Dissemination 
Results from this study will inform the refinement of the study intervention. Necessary changes to improve 
feasibility and accessibility will be made prior to the next stage, an outcome evaluation study, to be 
implemented later this same calendar year. The outcome study will undergo a separate review process. 
As part of the reporting for the feasibility study, the study investigators will work with USAID-Washington, 
USAID-Nigeria and SIDHAS staff to determine a set of criteria, prior to final data analysis, that would indicate 
the intervention is not feasible and the team will not move forward with the outcome study.  
A report of feasibility study findings will be disseminated to stakeholders, including USAID, in the form of a 
document or presentation once data analysis is complete.

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 23 of 28 
Timeline: 
  
2016 
2017 
 Activity 
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov 
USAID approval of study concept 
 
X 
  
  
  
  
  
  
  
  
  
  
  
  
 
 
Identify and execute contract with local research partners 
  
  
 
  
  
X  
  
  
  
  
  
  
  
  
 
 
Convene stakeholder meetings 
  
  
  
X 
  
  
  
  
  
  
  
  
  
  
 
 
Develop/adapt intervention components 
  
  
X 
X 
X  
X  
  
  
  
  
  
  
  
  
 
 
Develop feasibility study protocol, DCIs, ICF 
 
 
X 
 X 
X  
  
  
  
  
  
  
  
  
  
 
 
Technical review of study documents 
 
 
  
  
X  
  
  
  
  
  
  
  
  
  
 
 
Ethics review and approval of feasibility study (FHI 360) 
(submit by Jan 4) 
  
  
  
 
  
X  
  
  
  
  
  
  
  
  
 
 
Ethics review and approval of feasibility study (IRB in Nigeria) 
  
  
  
  
 
X 
 X 
  
  
  
  
  
  
  
 
 
Develop training materials for study 
implementation/SOPs/databases, etc. 
  
  
  
  
X 
X 
  
  
  
  
  
  
  
  
 
 
Train study personnel (e.g. data collectors) 
  
  
  
  
  
 
X 
  
  
  
  
  
  
  
 
 
Train intervention staff and put all necessary intervention 
elements in place 
  
  
  
  
  
 
X 
  
  
 X 
  
  
  
  
 
 
Feasibility study enrollment  
  
  
  
  
  
  
 
 
  
 X 
 X 
  
  
  
 
 
Baseline data collection 
  
  
  
  
  
  
 
 
 
X 
 X 
  
  
  
 
 
Intervention implementation (3 months or 6 sessions) 
  
  
  
  
  
  
  
 
 
 
 X 
 X 
X 
  
 
 
Endline Data collection 
  
  
  
  
  
  
  
 
 
 
 
  
 X 
X 
 
 
Clean and analyze data 
  
  
  
  
  
  
  
  
 
 
 
 
X 
X  
 
 
Report feasibility findings and incorporate in to intervention 
for outcome evaluation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 24 of 28 
Appendix 1: Facebook data policy 
Appendix 2: Safety at Facebook 
Appendix 3: What are the privacy settings for groups? 
Appendix 4: How do I remove or block someone from a group? 
 
*Appendices in separate files.

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 25 of 28 
References 
1. 
UNAIDS. Fact sheet: Adolescents, young people and HIV. [Internet]. 2012; 
http://www.unaids.org/en/media/unaids/contentassets/documents/factsheet/2012/20120417_FS_
adolescentsyoungpeoplehiv_en.pdf. Accessed May 10, 2016. 
2. 
UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva: Joint United 
Nations Programme on HIV/AIDS;2013. 
3. 
UNICEF. Towards an AIDS-Free Generation. Children and AIDS: Sixth Stocktaking Report, 2013. New 
York, New York: United Nations Children’s Fund;2013. 
4. 
WHO. HIV and adolescents: Guidance for HIV testing and counselling and care for adolescents living 
with HIV. [Internet]. 2013; 
http://apps.who.int/iris/bitstream/10665/94334/1/9789241506168_eng.pdf?ua=1. Accessed May, 
2016. 
5. 
Chandler C, Ngoksin A. Lost in transitions: Current issues faced by adolescents living with HIV in Asia 
Pacific. Bangkok: UNICEF;2013. 
6. 
Denison JA, Banda H, Dennis AC, et al. "The sky is the limit": adhering to antiretroviral therapy and 
HIV self-management from the perspectives of adolescents living with HIV and their adult 
caregivers. Journal of the International AIDS Society. 2015;18:19358. 
7. 
Lamb MR, Fayorsey R, Nuwagaba-Biribonwoha H, et al. High attrition before and after ART initiation 
among youth (15-24 years of age) enrolled in HIV care. AIDS (London, England). 2014;28(4):559-568. 
8. 
Mavhu W, Berwick J, Chirawu P, et al. Enhancing psychosocial support for HIV positive adolescents 
in Harare, Zimbabwe. PloS one. 2013;8(7):e70254. 
9. 
Koenig LJ, Nesheim S, Abramowitz S. Adolescents with perinatally acquired HIV: emerging behavioral 
and health needs for long-term survivors. Current opinion in obstetrics & gynecology. 
2011;23(5):321-327. 
10. 
Bhana A, Mellins CA, Petersen I, et al. The VUKA family program: piloting a family-based 
psychosocial intervention to promote health and mental health among HIV infected early 
adolescents in South Africa. AIDS care. 2014;26(1):1-11. 
11. 
Hickey MD, Salmen CR, Omollo D, et al. Implementation and Operational Research: Pulling the 
Network Together: Quasiexperimental Trial of a Patient-Defined Support Network Intervention for 
Promoting Engagement in HIV Care and Medication Adherence on Mfangano Island, Kenya. Journal 
of acquired immune deficiency syndromes (1999). 2015;69(4):e127-134. 
12. 
Holstad MM, Essien JE, Ekong E, Higgins M, Teplinskiy I, Adewuyi MF. Motivational groups support 
adherence to antiretroviral therapy and use of risk reduction behaviors in HIV positive Nigerian 
women: a pilot study. African journal of reproductive health. 2012;16(3):14-27. 
13. 
Kaihin R, Kasatpibal N, Chitreechuer J, Grimes RM. Effect of an Empowerment Intervention on 
Antiretroviral Drug Adherence in Thai Youth. Behavioral medicine (Washington, DC). 2015;41(4):186-
194. 
14. 
Luque-Fernandez MA, Van Cutsem G, Goemaere E, et al. Effectiveness of patient adherence groups 
as a model of care for stable patients on antiretroviral therapy in Khayelitsha, Cape Town, South 
Africa. PloS one. 2013;8(2):e56088. 
15. 
Lester RT, Ritvo P, Mills EJ, et al. Effects of a mobile phone short message service on antiretroviral 
treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet (London, England). 
2010;376(9755):1838-1845. 
16. 
Orrell C, Cohen K, Mauff K, Bangsberg DR, Maartens G, Wood R. A Randomized Controlled Trial of 
Real-Time Electronic Adherence Monitoring With Text Message Dosing Reminders in People Starting 
First-Line Antiretroviral Therapy. Journal of acquired immune deficiency syndromes (1999). 
2015;70(5):495-502. 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 26 of 28 
17. 
Pop-Eleches C, Thirumurthy H, Habyarimana JP, et al. Mobile phone technologies improve 
adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of 
text message reminders. AIDS (London, England). 2011;25(6):825-834. 
18. 
Rodrigues R, Shet A, Antony J, et al. Supporting adherence to antiretroviral therapy with mobile 
phone reminders: results from a cohort in South India. PloS one. 2012;7(8):e40723. 
19. 
Sabin LL, Bachman DeSilva M, Gill CJ, et al. Improving Adherence to Antiretroviral Therapy With 
Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. 
Journal of acquired immune deficiency syndromes (1999). 2015;69(5):551-559. 
20. 
Uzma Q, Emmanuel F, Ather U, Zaman S. Efficacy of Interventions for Improving Antiretroviral 
Therapy Adherence in HIV/AIDS Cases at PIMS, Islamabad. Journal of the International Association of 
Physicians in AIDS Care (Chicago, Ill : 2002). 2011;10(6):373-383. 
21. 
Belzer ME, Kolmodin MacDonell K, Clark LF, et al. Acceptability and Feasibility of a Cell Phone 
Support Intervention for Youth Living with HIV with Nonadherence to Antiretroviral Therapy. AIDS 
patient care and STDs. 2015;29(6):338-345. 
22. 
Dowshen N, Kuhns LM, Gray C, Lee S, Garofalo R. Feasibility of interactive text message response 
(ITR) as a novel, real-time measure of adherence to antiretroviral therapy for HIV+ youth. AIDS and 
behavior. 2013;17(6):2237-2243. 
23. 
Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral 
therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text 
message reminders. Journal of medical Internet research. 2012;14(2):e51. 
24. 
Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A Randomized Controlled Trial of 
Personalized Text Message Reminders to Promote Medication Adherence Among HIV-Positive 
Adolescents and Young Adults. AIDS and behavior. 2016;20(5):1049-1059. 
25. 
Gaysynsky A, Romansky-Poulin K, Arpadi S. "My YAP Family": Analysis of a Facebook Group for 
Young Adults Living with HIV. AIDS and behavior. 2015;19(6):947-962. 
26. 
Henwood R, Patten G, Barnett W, et al. Acceptability and use of a virtual support group for HIV-
positive youth in Khayelitsha, Cape Town using the MXit social networking platform. AIDS care. 
2016;28(7):898-903. 
27. 
Munoz M, Bayona J, Sanchez E, et al. Matching social support to individual needs: a community-
based intervention to improve HIV treatment adherence in a resource-poor setting. AIDS and 
behavior. 2011;15(7):1454-1464. 
28. 
Achieng L, Musangi H, Ong'uti S, et al. An observational cohort comparison of facilitators of 
retention in care and adherence to anti-eetroviral therapy at an HIV treatment center in Kenya. PloS 
one. 2012;7(3):e32727. 
29. 
DOS. Nigeria Country Operational Plan (COP) 2016 Strategic Direction Summary In: State Do, ed. 
Washington, DC: United States Government Emergency Plan for AIDS Relief (PEPFAR); 2016. 
30. 
IYWG. Positive Connections: Leading Information and Support Groups for Adolescents Living with 
HIV. Durham, NC: FHI 360; 2013. 
31. 
Poushter J, Oates R. Cell Phones in Africa: Communication Lifeline. 2015. 
http://www.pewglobal.org/2015/04/15/cell-phones-in-africa-communication-lifeline/. 
32. 
Akinfaderin-Agarau F, Chirtau M, Ekponimo S, Power S. Opportunities and limitations for using new 
media and mobile phones to expand access to sexual and reproductive health information and 
services for adolescent girls and young women in six Nigerian states. African journal of reproductive 
health. 2012;16(2):219-230. 
33. 
Garett R, Smith J, Young SD. A Review of Social Media Technologies Across the Global HIV Care 
Continuum. Current opinion in psychology. 2016;9:56-66. 
34. 
Lelutiu-Weinberger C, Pachankis JE, Gamarel KE, Surace A, Golub SA, Parsons JT. Feasibility, 
Acceptability, and Preliminary Efficacy of a Live-Chat Social Media Intervention to Reduce HIV Risk 
Among Young Men Who Have Sex With Men. AIDS and behavior. 2015;19(7):1214-1227. 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 27 of 28 
35. 
Tanner AE, Mann L, Song E, et al. weCARE: A Social Media-Based Intervention Designed to Increase 
HIV Care Linkage, Retention, and Health Outcomes for Racially and Ethnically Diverse Young MSM. 
AIDS education and prevention : official publication of the International Society for AIDS Education. 
2016;28(3):216-230. 
36. 
Young SD. Social media technologies for HIV prevention study retention among minority men who 
have sex with men (MSM). AIDS and behavior. 2014;18(9):1625-1629. 
37. 
Young SD, Cumberland WG, Lee SJ, Jaganath D, Szekeres G, Coates T. Social networking technologies 
as an emerging tool for HIV prevention: a cluster randomized trial. Annals of internal medicine. 
2013;159(5):318-324. 
38. 
Young SD, Cumberland WG, Nianogo R, Menacho LA, Galea JT, Coates T. The HOPE social media 
intervention for global HIV prevention in Peru: a cluster randomised controlled trial. The lancet HIV. 
2015;2(1):e27-32. 
39. 
Young SD, Zhao M, Teiu K, Kwok J, Gill H, Gill N. A social-media based HIV prevention intervention 
using peer leaders. Journal of consumer health on the Internet. 2013;17(4):353-361. 
40. 
Facebook. What are the privacy settings for groups? 2016; 
https://www.facebook.com/help/220336891328465?helpref=popular_topics. Accessed December 
6. 
41. 
NPC. National and State Population and Housing Tables: 2006 Census Priority Tables Vol.1. National 
Population Commission, Nigeria;2006. 
42. 
MA C, JR I, DB C, et al. Self-reported adherence to antiretroviral medications among participants in 
HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working 
Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG). AIDS care. 
2000;12(3):255-266. 
43. 
Sherbourne CD, Stewart A. The MOS Social Support Survey. Santa Monica, CA: RAND Corporation; 
1993. 
44. 
Burgoyne RW, Saunders DS. Perceived support in newly registered HIV/AIDS clinic outpatients. AIDS 
care. 2000;12(5):643-650. 
45. 
Huynh AK, Kinsler JJ, Cunningham WE, Sayles JN. The role of mental health in mediating the 
relationship between social support and optimal ART adherence. AIDS care. 2013;25(9):1179-1184. 
46. 
Wu X, Chen J, Huang H, Liu Z, Li X, Wang H. Perceived stigma, medical social support and quality of 
life among people living with HIV/AIDS in Hunan, China. Applied nursing research : ANR. 
2015;28(2):169-174. 
47. 
Yu Y, Yang JP, Shiu CS, et al. Psychometric testing of the Chinese version of the Medical Outcomes 
Study Social Support Survey among people living with HIV/AIDS in China. Applied nursing research : 
ANR. 2015;28(4):328-333. 
48. 
George S, Bergin C, Clarke S, Courtney G, Codd MB. Health-related quality of life and associated 
factors in people with HIV: an Irish cohort study. Health and quality of life outcomes. 
2016;14(1):115. 
49. 
Abrefa-Gyan T, Cornelius LJ, Okundaye J. Socio-Demographic Factors, Social Support, Quality of Life, 
and HIV/AIDS in Ghana. Journal of evidence-informed social work. 2016;13(2):206-216. 
50. 
Abrefa-Gyan T, Wu L, Lewis MW. Social support and support groups among people with HIV/AIDS in 
Ghana. Social work in health care. 2016;55(2):144-160. 
51. 
Dafaalla M, Farah A, Bashir S, et al. Validity and reliability of Arabic MOS social support survey. 
SpringerPlus. 2016;5(1):1306. 
52. 
Soares A, Biasoli I, Scheliga A, et al. Validation of the Brazilian Portuguese version of the Medical 
Outcomes Study-Social Support Survey in Hodgkin's lymphoma survivors. Supportive care in cancer : 
official journal of the Multinational Association of Supportive Care in Cancer. 2012;20(8):1895-1900. 
53. 
OA A, KM M, P R, SJ H, BO T. Contemporary issues on the epidemiology and antiretroviral adherence 
of HIV-infected adolescents in sub-Saharan Africa: a narrative review. Journal of the International 
AIDS Society. 2015;18(1). 

Protocol: Feasibility study of an online support group intervention among ALHIV in Nigeria 
PHSC #930307; Version 3.0; August 2, 2017 
Page 28 of 28 
54. 
Solutions S-HCfIH. AUDIT-C.  http://www.integration.samhsa.gov/images/res/tool_auditc.pdf. 
Accessed December 12, 2016. 
55. 
Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test 
Guidelines for Use in Primary Care Second Edition. Geneva: World Health Organization;2001. 
56. 
PERC S. Personal Health Questionnaire Depression Scale (PHQ-8). [Internet]. 2013; 
http://patienteducation.stanford.edu/research/phq.pdf.