JMIR FORMATIVE RESEARCH

Suzuki et al

Original Paper

A Mobile Medication Support App and Its Impact on People Living
With HIV: 12-Week User Experience and Medication Compliance
Pilot Study
Mai Suzuki1, MD, PhD; Kou Yamanaka2, MD, PhD; Shinichi Fukushima1, MA; Mayu Ogawa1, MD; Yuki Nagaiwa1,
MD; Toshio Naito1, MD, PhD
1

Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan

2

Shinjuku Higashiguchi Clinic, Tokyo, Japan

Corresponding Author:
Toshio Naito, MD, PhD
Department of General Medicine
Juntendo University Faculty of Medicine
3-1-3 Hongo Bunkyo-ku
Tokyo, 113-0033
Japan
Phone: 81 3 3813 3111
Email: naito@juntendo.ac.jp

Abstract
Background: The continuity of care between hospital visits conducted through mobile apps creates new opportunities for people
living with HIV in situations where face-to-face interventions are difficult.
Objective: This study investigated the user experience of a mobile medication support app and its impact on improving
antiretroviral therapy compliance and facilitating teleconsultations between people living with HIV and medical staff.
Methods: Two clinics in Japan were invited to participate in a 12-week trial of the medication support app between July 27,
2018, and March 31, 2021. Medication compliance was assessed based on responses to scheduled medication reminders; users,
including people living with HIV and medical staff, were asked to complete an in-app satisfaction survey to rate their level ofsatisfaction with the app and its specific features on a 5-point Likert scale.
Results: A total of 10 people living with HIV and 11 medical staff were included in this study. During the trial, the medication
compliance rate was 90%, and the mean response rates to symptom and medication alerts were 73% and 76%, respectively.
Overall, people living with HIV and medical staff were satisfied with the medication support app (agreement rate: mean 81%
and 65%, respectively). Over 80% of medical staff and people living with HIV were satisfied with the ability to record medications
taken (9/11 and 8/10 medical staff and people living with HIV, respectively), record symptoms of concern (10/11 and 8/10),and
inquire about drug combinations (8/10, 10/10). And further, 90% of people living with HIV were satisfied with the function forcommunication with medical staff (9/10).
Conclusions: Our preliminary results demonstrate the feasibility of the medication support app in improving medication
compliance and enhancing communication between people living with HIV and medical staff.
(JMIR Form Res 2023;7:e43527) doi: 10.2196/43527
KEYWORDS
human immunodeficiency virus; HIV; acquired immunodeficiency syndrome; mobile health; mHealth; medication compliance;
satisfaction survey

Introduction
According to recent statistics, there were an estimated 30,000
people living with HIV infections within Japan in 2018, andthe diagnostic rate, antiretroviral therapy (ART) coverage rate,
https://formative.jmir.org/2023/1/e43527

XSL• FO
RenderXand viral suppression rate were around 86%, 80%, and 75%,
respectively [1]. Engagement with HIV care may be hinderedby stigma, confidentiality concerns, and insufficient support
networks [2]. New measures are necessary to ensure continuityof care and to facilitate symptom and medication monitoring
JMIR Form Res 2023 | vol. 7 | e43527 | p. 1
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
for people living with HIV between hospital visits, particularly
during periods when access to HIV care services may be
disrupted, such as during the COVID-19 pandemic [3].
Mobile-based apps have been shown to promote the link
between HIV care at home and ART adherence [3-5], but reportsof physicians’ experiences and testimonies regarding
patient-centric apps are scarce [6]. This study investigated theuser experience of a mobile medication support app that aims
to improve ART compliance and facilitate teleconsultations
between people living with HIV and medical staff. Preliminary
user satisfaction results and the features resulting in higher
satisfaction, as rated by medical staff and people living with
HIV, were reported.

Methods
Participants
Two clinics (Shinjuku Higashiguchi Clinic and Juntendo
University Hospital) were invited to participate in a 12-week
trial of a mobile medication support app between July 27, 2018,
and March 31, 2021. Eligible people living with HIV had tofulfill all of the following criteria: be diagnosed with HIV andbe receiving ART; be aged between 20 and 90 years; have accessto devices that can connect to the medication support app; beable to use the app unassisted; and provide written, informed
consent. At project initiation, the medical staff registered eligible
people living with HIV to use the app.

Ethics Approval
All of the data used for this study were deidentified. Informed
consent was obtained from all participants, and this study was

https://formative.jmir.org/2023/1/e43527

XSL• FO
RenderX

Suzuki et al
approved by the Research Ethics Committee of Juntendo
University Hospital (institutional review board number: 18-061).

Medication Support App
The mobile medication support app, Medical Care Station(Embrace Co, Ltd), is a private social networking system thatwas developed for medical and nursing care use only. It was
initially designed as a tool for communication between patients,
patients’ families, and health care professionals in the homeand medical care settings. The technical features of the app
include direct patient–medical staff communication via text
messages, daily medication reminders, and educational HIV
information provision.
The five key functions of the app that were assessed in thisstudy were (1) recording symptoms of concern, (2) recording
medication status, (3) confirming drug combinations, (4)checking disease progress, and (5) providing teaching materials
about the disease. Direct patient–medical staff communication
included reporting symptoms of concern, inquiring about andconfirming drug combinations, and checking the progressionof disease conditions. The medication reminders were scheduled
as each patient logged on to the app, and the time when patients
took their pills was registered. A pop-up reminder appearedwith an alert when it was time to take a medication; themedications taken were also recorded. The HIV educationmaterials covered several topics, including the effectivenessand adverse events of each ART medication, the importance ofgood medical adherence, and nutritional information.
Representative screenshots of the user interface within the app
are shown in Figure 1.

JMIR Form Res 2023 | vol. 7 | e43527 | p. 2
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Suzuki et al

Figure 1. Representative screenshots of the user interface. (A) The message showing the time of medication and details of the medicine (the name of
the medicine, dose, and timing). If the patient takes the pills, they click “done”; if no pills were taken, they click “skipped.” (B) The message asking
about the patient’s condition during the week. The patient can send a message about their condition to health care professionals directly through thisapp. (C) By clicking a red icon, patients can access the information and education tool for antiretroviral therapy. (D) Representative screenshots of users
recording symptoms of concern. When users have concerning symptoms, they can consult a physician directly by using this app. Users can either selectfrom the list of symptoms or input the symptoms directly into the blank space, with descriptive text.

Outcome Measures
Data on the frequency and content of communications (ie, direct
messages), baseline and posttreatment viral load, CD4 cell count,and ART compliance were collected. At the end of the 12-weekperiod, users (people living with HIV and medical staff) wereasked to complete the self-administered, in-app satisfaction
survey to rate their level of satisfaction on a 5-point Likert scale(strongly agree, agree, neutral, disagree, and strongly disagree).
The questionnaires included 1 section on the overall experience
with the app and 5 subsections on the five key features of theapp—(1) recording symptoms of concern, (2) recording
medication status, (3) confirming drug combinations, (4)checking disease progress, and (5) distributing teachingmaterials about the disease. All data were collected andorganized by using Microsoft Excel (Microsoft Corporation).

Results
A total of 10 people living with HIV and 11 medical staff
participated in this study. The mean age of people living withHIV was 44 years, and the average disease duration was 6.2
https://formative.jmir.org/2023/1/e43527

XSL• FO
RenderX

years (Table 1). A total of 12 educational notices requiring users
to respond by selecting functions that appear on the screen or
by texting were sent during the study period. The mean response
rates to the notices for symptoms of concern and drug-druginteraction concerns were 73% and 76%, respectively. Specificsymptoms of concern that were reported by people living with
HIV in response to the notices are detailed in Table S1 in
Multimedia Appendix 1. Concerns about drug-drug interaction
were reported by 5 users, mainly on health supplements orremedies for sleep problems, colds, and depression (Table S2
in Multimedia Appendix 1). Overall, the mean total number ofposts made by people living with HIV was 121.6 (range 19-143),
averaging 10.1 posts per week (Table 1).
The average response time to daily medication reminders wasapproximately 4 hours, and the medication compliance rate was
90%, based on users’ (people living with HIV) responses to the
ART reminders (Table 1). The mean CD4 cell counts at baseline
and at 12 weeks were 491.9 (SD 190.5) cells per μL and 585.4(SD 269.4) cells per μL, and after 12 weeks, viral loads
decreased (2/10, 20%) or were undetected (7/10, 70%) in the
majority of people living with HIV (Table 1). The CD4 cell
JMIR Form Res 2023 | vol. 7 | e43527 | p. 3
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
count and viral load of each user before and after using the app
are summarized in Table S3 in Multimedia Appendix 1.
Overall, people living with HIV and medical staff agreed that
their overall experience with the app was satisfactory (agreement
rate: mean 81% and 65%, respectively; Tables S4 and S5 in
Multimedia Appendix 1). The agreement rate for each of the
key features of the app is presented in Figure 2. The features
most preferred by people living with HIV were the confirmation

Suzuki et alfunction for taking drug combinations (agree: 100%, 10/10),
the confirmation function for the progression of medical
conditions (90%, 9/10), and the function for communication
with medical staff (90%, 9/10; Figure 2A). The features most
preferred by medical staff were the recording function for
symptoms of concern (91%, 10/11), followed by the recording
function for tracking medications taken (82%, 9/11) and theconfirmation function for taking drug combinations (80%, 8/10;
Figure 2B).

Table 1. Patients’ (people living with HIV: N=10) characteristics and app usage–related outcomes.
Characteristics

Value

Demographics
Age (years), mean (SD; range)

44 (11.2; 27-65)

Sex, nMale

9Female1

HIV duration (years), mean (SD; range)

6.2 (3.1; 0.3-9)

App usage (12 weeks), mean (range)
Duration of using the app (days)

84.4 (84-85)

Response time to medication reminder (h:min)

3:57 (0:11-30:28)

aDrug compliance (%)

90 (1.2-100)

Total number of posts

121.6 (19-143)

Number of posts made via the app per week

10.1 (1.6-16)

Outcome measures
CD4 cell count (cells/μL), mean (range)
Baseline

491.9 (201-821)

12 weeks585.4 (170-957)

Change in viral load among people living with HIV, na

Increased

1

Decreased2

Undetected

7

Based on responses to the reminder.

https://formative.jmir.org/2023/1/e43527

XSL• FO
RenderX

JMIR Form Res 2023 | vol. 7 | e43527 | p. 4
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Suzuki et al

Figure 2. Agreement rate for each of the key features of the app. (A) Features most preferred by people living with HIV; (B) Features most preferredby medical staff.

Discussion
Principal Findings
The HIV mobile health (mHealth) medication support app
demonstrated promising results, with a large proportion ofparticipating users—people living with HIV and medical
staff—finding the key features to be satisfactory and worth
recommending. The app’s abilities to provide alerts and track
medications taken were found useful by both the people livingwith HIV and the medical staff in this study, since these not
only allow people living with HIV to inquire about the safety
or appropriateness of concomitant drug use but also assist
medical staff in capturing data on the medication status andtreatment adherence of people living with HIV. The medication
compliance rate was 90%, based on users’ (people living withHIV) responses to the ART reminders in this study. Findings
from randomized controlled trials and meta-analyses have shownthat people living with HIV who receive weekly message
reminder messages have significantly improved antiretroviraladherence and rates of viral suppression when compared with
control individuals [4,5,7,8]. The app’s feature for facilitating
direct patient-staff communication was welcomed by people
living with HIV, and the underlying reason may be that thepeople living with HIV felt more comfortable and secure whena personal consultation with the medical staff was available.
This was evident from the high agreement rates for the “I felt
a sense of security to be monitored by medical staff” and “I felt
a sense of security when I was able to consult at home” items
https://formative.jmir.org/2023/1/e43527

XSL• FO
RenderX

for each of the app’s functions. Our study demonstrated thefeasibility of this app in improving medication compliance andcommunication between people living with HIV and medical
professionals.
The app’s function for recording the symptoms of concern was
originally set up to assist medical staff in monitoring diseaseprogression or improvement; nevertheless, it was also welcomedby people living with HIV. It is possible that this function assists
people living with HIV to become more aware of their healthstatus and, accordingly, explains the high agreement rate forthe confirmation function for the progression of medical
conditions.
The limitations of this pilot study include its small sample sizeand possible recruitment bias. Users who were comfortable withusing mobile apps were more inclined to participate; therefore,
the satisfaction rates among this study’s users may be overstated
due to the users’ greater mobile app literacy. Althoughpreliminary, it is encouraging to note that active users (people
living with HIV) of the HIV app had positive improvements inboth viral load and CD4 cell count. These findings are consistent
with those of recent reports that also found that mHealth apps
are feasible and acceptable interventions for improving ART
adherence in people living with HIV and providing linkage to
HIV care [9]. However, these findings should be confirmed inlarger, well-controlled studies.

JMIR Form Res 2023 | vol. 7 | e43527 | p. 5
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Conclusion
Our medication support app may improve patient–medical staff

Suzuki et al
communication and ART treatment compliance by providing
the support needed for self-management and the remotemonitoring of medical concerns among people living with HIV.

Acknowledgments
The authors would like to thank FORTE Science Communications (Tokyo, Japan) for English editing.
This work was supported by Ministry of Health, Labour and Welfare (MHLW) Research on HIV/AIDS (program grant number:
JPMH21HB1005).

Data Availability
The data sets generated and analyzed during this study are not publicly available due to privacy and ethical restrictions. The datathat support the findings of this study are included in this published article and its supplementary information files, where possible.

Authors' Contributions
MS, KY, and TN contributed to the conception and design of this study. KY and SF were responsible for data collection. MS
analyzed the data and drafted the manuscript. The manuscript was critically reviewed by KY and TN. All authors approved thefinal version of the manuscript. TN supervised the entire study.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Supplement tables.
[DOCX File , 37 KB-Multimedia Appendix 1]

References
1.
2.

3.
4.

5.

6.

7.

8.

9.

Japan | HIV/AIDS data hub for the Asia-Pacific Region. HIV AIDS Asia Pacific Research Statistical Data Information
Resources AIDS Data Hub. URL: https://www.aidsdatahub.org/country-profiles/japan [accessed 2021-07-09]
Mathenjwa T, Adeagbo O, Zuma T, Dikgale K, Zeitlin A, Matthews P, et al. Development and acceptability of a tablet-based
app to support men to link to HIV care: Mixed methods approach. JMIR Mhealth Uhealth 2020 Nov 24;8(11):e17549[FREE Full text] [doi: 10.2196/17549] [Medline: 33231558]
Smith E, Badowski ME. Telemedicine for HIV care: Current status and future prospects. HIV AIDS (Auckl) 2021 Jun
10;13:651-656 [FREE Full text] [doi: 10.2147/HIV.S277893] [Medline: 34140812]
Wang Z, Zhu Y, Cui L, Qu B. Electronic health interventions to improve adherence to antiretroviral therapy in people livingwith HIV: Systematic review and meta-analysis. JMIR Mhealth Uhealth 2019 Oct 16;7(10):e14404 [FREE Full text] [doi:10.2196/14404] [Medline: 31621641]
Catalani C, Philbrick W, Fraser H, Mechael P, Israelski DM. mHealth for HIV treatment & prevention: A systematic reviewof the literature. Open AIDS J 2013 Aug 13;7:17-41 [FREE Full text] [doi: 10.2174/1874613620130812003] [Medline:
24133558]
Engler K, Vicente S, Ma Y, Hijal T, Cox J, Ahmed S, et al. Implementation of an electronic patient-reported measure of
barriers to antiretroviral therapy adherence with the Opal patient portal: Protocol for a mixed method type 3 hybrid pilot
study at a large Montreal HIV clinic. PLoS One 2021 Dec 30;16(12):e0261006 [FREE Full text] [doi:10.1371/journal.pone.0261006] [Medline: 34969046]
Fonner VA, Kennedy S, Desai R, Eichberg C, Martin L, Meissner EG. Patient-provider text messaging and video calling
among case-managed patients living with HIV: Formative acceptability and feasibility study. JMIR Form Res 2021 May
27;5(5):e22513 [FREE Full text] [doi: 10.2196/22513] [Medline: 34042596]
Guo Y, Xu Z, Qiao J, Hong YA, Zhang H, Zeng C, et al. Development and feasibility testing of an mHealth (text message
and WeChat) intervention to improve the medication adherence and quality of life of people living with HIV in China:
Pilot randomized controlled trial. JMIR Mhealth Uhealth 2018 Sep 04;6(9):e10274 [FREE Full text] [doi: 10.2196/10274][Medline: 30181109]
Escobar-Viera C, Zhou Z, Morano JP, Lucero R, Lieb S, McIntosh S, et al. The Florida Mobile Health Adherence Projectfor people living with HIV (FL-mAPP): Longitudinal assessment of feasibility, acceptability, and clinical outcomes. JMIR
Mhealth Uhealth 2020 Jan 08;8(1):e14557 [FREE Full text] [doi: 10.2196/14557] [Medline: 31913127]

https://formative.jmir.org/2023/1/e43527

XSL• FO
RenderX

JMIR Form Res 2023 | vol. 7 | e43527 | p. 6
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Suzuki et al

Abbreviations
ART: antiretroviral therapy
mHealth: mobile health

Edited by A Mavragani; submitted 14.10.22; peer-reviewed by T Mathenjwa, M Goyette; comments to author 02.02.23; revised version
received 20.03.23; accepted 06.04.23; published 22.06.23
Please cite as:
Suzuki M, Yamanaka K, Fukushima S, Ogawa M, Nagaiwa Y, Naito T
A Mobile Medication Support App and Its Impact on People Living With HIV: 12-Week User Experience and Medication Compliance
Pilot StudyJMIR Form Res 2023;7:e43527
URL: https://formative.jmir.org/2023/1/e43527
doi: 10.2196/43527
PMID: 37021843©Mai Suzuki, Kou Yamanaka, Shinichi Fukushima, Mayu Ogawa, Yuki Nagaiwa, Toshio Naito. Originally published in JMIR
Formative Research (https://formative.jmir.org), 22.06.2023. This is an open-access article distributed under the terms of theCreative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The
complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright andlicense information must be included.

https://formative.jmir.org/2023/1/e43527

XSL• FO
RenderX

JMIR Form Res 2023 | vol. 7 | e43527 | p. 7
(page number not for citation purposes)