Acceptability of the LetSync App Wireframes for an mHealth Intervention to Improve HIV Care Engagement and Treatment Among Black Partnered Sexual Minority Men: Findings from In-Depth Qualitative Interviews

Background HIV disparities continue to be a significant challenge affecting Black sexual minority men in the United States. Inadequate engagement and retention of patients in HIV care has been associated with poor health outcomes. Interventions to improve sustained commitment to HIV care are needed. Mobile health interventions can help facilitate access to and use of HIV health services, particularly among individuals at risk for disengaging with care. Objective We designed the LetSync app wireframes for a mobile health intervention using a couple-centered design approach to improve HIV engagement and treatment among Black sexual minority men and their partners. The objective of this study was to gauge future app user interest and elicit feedback to improve the design, development, and usability of the LetSync app. Methods We conducted in-depth interviews with 24 Black sexual minority men to assess the acceptability of the LetSync app wireframes between May 2020 and January 2021. Participants reviewed the LetSync app wireframes and provided feedback regarding perceived usefulness and interest in future app use and suggestions for improvement. Results Participants indicated interest in the future LetSync app and noted that the wireframes’ features were acceptable and usable. In our study, the future LetSync app was frequently referred to as a potential resource that could help facilitate users’ engagement in HIV care through the following mechanisms: enable scheduling of appointments and timely reminders for clinic visits; help improve HIV medication adherence; encourage and motivate participants to ask questions to their health care provider and stay engaged in conversations during clinic visits; facilitate effective communication by assisting couples with planning, coordination, and management of daily routines; help participants understand their partner’s health needs, including access to and use of health care services; and facilitate participants’ ability to improve their relationship skills, partner support, and self-efficacy in managing conflict. In addition to near-universal interest in potential daily app use, study participants indicted that they would recommend the LetSync app to other family members, friends, and people in their social networks who are living with HIV. Conclusions Our findings revealed considerable interest in future app use for HIV care management, which could possibly increase the chance of the LetSync app being successfully adopted by Black sexual minority men in couples. Owing to its interactive and couple-centered approach, the LetSync app could help improve communication between Black sexual minority men and their partners and health providers. In addition, the LetSync app could provide an acceptable modality for these men to receive support in accessing HIV care services.


Introduction
Background HIV disparities continue to be a significant challenge for Black people in the United States, particularly among Black gay, bisexual, and other men who have sex with men. In 2019, Black men accounted for 68% of the HIV incidence, with over 80% of new infections attributed to sexual minority men [1]. For Black sexual minority men, the substantial disparities in HIV can be seen through the intersection of inequities resulting from discrimination based on sexual orientation and ethnicity or racial background, especially as it pertains to access to and use of HIV care services. In 2019, approximately 59% of Black sexual minority men were retained in care at some point, and approximately one-fourth of them missed at least one medical appointment [2]. Declining retention rates pertaining to HIV care are disconcerting, as they suggest lapses in the access to and use of HIV prevention and treatment services in this population.

Partner Support and HIV Care Engagement
Engagement and retention of patients in HIV care is the most significant component of therapy necessary to decrease HIV transmission and achieve viral suppression and is crucial for optimal HIV health management [3]. Among other key factors, social and partner support has been shown to be associated with improved HIV health outcomes among sexual minority men [4]. In a study investigating couple-level dynamics and multilevel challenges among Black sexual minority men, participants described HIV care as a collaborative process, which they felt was most effective when partners coordinated with each other to solve problems they faced regarding access to and use of HIV care services [5]. In another study that examined dyadic coordination regarding access to HIV care, although there were variations in preference regarding the extent of involvement, partner involvement was reported as playing a significant role in facilitating HIV care engagement and treatment among Black sexual minority male couples [6]. As part of our formative work, we conducted a study investigating mobile technology use among older Black sexual minority men living with HIV, in which participants showed considerable interest toward mobile technology, and several reported having used mobile technology interventions to engage in HIV care services [7]. This suggests that mobile health (mHealth) interventions could play a supportive role in improving self-care and health outcomes for Black sexual minority men living with HIV, particularly for those at risk for disengaging from care.

The Role of mHealth in HIV Prevention and Treatment
Forgetfulness and lack of family support have been reported as significant barriers to treatment adherence and HIV care engagement [8]. In a study conducted among sexual minority men in the United States, forgetfulness was found to be a significant factor associated with missed treatment doses and clinic visits among participants [9]. As various features of the LetSync app intervention (digital pill case and appointment minder) would allow app users to set up reminders to take their daily doses, attend clinic visits, and pick up their medication refills, the LetSync app intervention could help improve antiretroviral therapy treatment adherence and HIV care engagement. In addition, the my action plan feature would be instrumental in facilitating effective communication by assisting couples with the planning, coordination, and management of physician or clinic appointments and couples' daily routines. Findings from these studies demonstrate a need for developing mHealth interventions focused on improving HIV care engagement and treatment adherence for partnered Black sexual minority men. In recent years, the tremendous increase in access to and use of mobile technology in the United States has been directly correlated with increased innovation in health technologies, including the development of mHealth interventions for chronic disease management. Currently, mHealth interventions are increasingly being used to improve health outcomes across the HIV care continuum and have been shown to facilitate HIV prevention (increased HIV testing, condom use, and sexual health) [10,11] and improve HIV medication adherence [12]. In a recent review of studies of Black sexual minority men living with HIV in the United States, mHealth interventions were significantly associated with improvements in antiretroviral therapy adherence and viral suppression among participants [13].

Study Justification and Objective
Despite the emergence of mHealth and studies of lifestyle behavior changes, very few mHealth interventions have developed a mobile app to address HIV care engagement and treatment adherence among Black sexual minority men. So far, most HIV-related mHealth interventions focused mainly on either electronic and web-based interventions or one-way messaging such as SMS text messages, emails, or surveys [13,14]. SMS text messages are generally shown to be effective in improving medication adherence across a variety of populations and settings. However, some studies have shown that combining SMS text messages with other features (social media contact and app-based self-monitoring-all features that are possible within the architecture of an app) shows promise for increasing the effectiveness of health interventions [15].
Although mobile-based HIV interventions have been developed for Black sexual minority men, most of the interventions developed so far have targeted individual users (single individuals rather than individuals in couples). To the best of our knowledge, this is the first study to develop a mobile app intervention aimed at improving HIV care engagement among Black sexual minority male couples. We designed the LetSync app wireframes for an mHealth intervention using a couple-centered design approach to improve HIV engagement and treatment among Black sexual minority men and their partners. The objective of this study was to gauge future app user interest and elicit feedback to improve the design, development, and usability of the LetSync app. Findings will be used to inform the design and development of a dyadic mHealth app intervention aimed at improving HIV care and treatment among Black sexual minority men in couples.

Overview
On the basis of formative studies [5][6][7], we designed the LetSync app wireframes for an mHealth intervention to improve HIV engagement and treatment among Black sexual minority men. We assessed the acceptability of the LetSync app wireframes among Black sexual minority men. Participants were recruited from web-based platforms by trained personnel between May 2020 and January 2021. This study was part of a large project exploring the use of mobile technology to increase engagement in HIV care among Black sexual minority men in couples.

Recruitment
Owing to the shelter-in-place mandate related to the COVID-19 pandemic, recruitment was primarily conducted via web-based platforms (including dating apps and social media). Purposive sampling was used to recruit participants into this study. Detailed information regarding web-based recruitment procedures is described elsewhere [16]. In addition, the research team used a snowball sampling technique (through word of mouth) and worked with local community-based organizations to recruit other qualifying couples to participate in the study. Potential participants were invited to a phone screening to determine eligibility. Participants were eligible if (1) one or both partners were Black or African American, observed as male at birth, sexual minority men, and living with HIV; (2) they were in a relationship with a primary partner for at least 2 months; (3) both had a personal mobile phone; and (4) they were aged 18 years and older.

Data Collection
The LetSync app wireframe assessment was conducted using one-on-one, in-depth, semistructured interviews with 24 Black sexual minority men in couples, regarding topics that were related to intervention development and the unique health needs of partnered Black sexual minority men living with HIV. Interviews were conducted via teleconference and lasted for approximately 1 hour. The LetSync app wireframes were hosted on an Adobe XD website supported by InVisionApp Inc. Interview questions (Multimedia Appendix 1) pertaining to the LetSync app wireframes assessed user interest and gathered feedback regarding future app features, which included specific designs to support dyadic interactions among Black sexual minority male couples, as informed by previous studies [5,7]. During the interviews, participants were asked to provide their perceptions and reactions regarding the following aspects of the LetSync app wireframes features: engagement (interactivity, potential user interest, and recommendations), functionality (performance, navigation, and ease of use), esthetics (appearance, layout, and visual appeal), and information quality (content appropriateness and suggestions for improvement). The wireframe assessment portion of the interviews proceeded as follows:

Data Analysis
Interviews were recorded, transcribed verbatim by a professional service, and subsequently coded using Dedoose software (version 9.0.62; SocioCultural Research Consultants), a secure, web-based, qualitative analytic software that is ideal for team-based coding. Data were analyzed using both inductive and deductive codes, first relying on the semistructured interview guide to generate thematic areas of content that would need to be defined and rigorously coded. This process was also augmented by inductive coding, where open coding was used to capture emergent themes and, later, define them. First, 4 members of the research team (HCK, DJB, EAA, and RW) independently reviewed the transcripts line by line to identify thematic content to be captured in our coding scheme and then used deductive and inductive codes to create a codebook, defining each code. The codebook was then applied to 1 pair of interview transcripts, with the entire team working together to discuss and apply the codes. Discrepancies were resolved through group consensus, and codes were revised as necessary.
Once all members of the team felt confident to consistently apply the codes, interview transcripts were assigned to a primary coder and a secondary coder, who reviewed the coding decisions of the primary coder. Divergent opinions around code applications between the primary and secondary coders were discussed and resolved at regular analysis meetings of the large team. All transcripts were coded using Dedoose. Coded excerpts were extracted from Dedoose and were reviewed for consistency by multiple team members.

Ethics Approval and Informed Consent
This study received ethics approval from the institutional review board of University of California, San Francisco (institutional review board protocol 15-18042). Informed consent was obtained on the web via Qualtrics (Qualtrics International Inc) from all participants included in the study.

Participants' Demographic Characteristics
In total, 24 participants reviewed the LetSync app wireframes via Zoom or phone in 2021 (Table 1). Most participants in our study (21/24, 88%) identified as Black or African American, and three-fourths (18/24, 75%) of the couples were not married. Participants in our study sample had been in an intimate relationship for approximately 2 (IQR 0.54-16.88) years. Half (12/24, 50%) of the participants were middle-aged men, and approximately three-fourths (17/24, 71%) of the participants lived with their spouses or partner. Most participants (18/24, 75%) attended college, and all (24/24, 100%) had access to the internet.  Overall, participants indicated interest in the future LetSync app and noted that the wireframes' features were acceptable and usable. Participants thought that the app wireframes were intuitive and that the layout and imagery were appropriate. In this section, we have reported participants' feedback about three main features of the LetSync app wireframes, including (1) appointment minder, (2) digital pill case, and (3) my action plan. In addition, we have also presented findings regarding the study participants' interest in future app use and suggestions for improvements.

Overview
Participants expressed interest in using the appointment minder feature for planning and health management in the future. In addition to ease of use, study participants liked this feature because they believed it would be extremely helpful for organizing activities and scheduling clinic visits. Participants appreciated the idea of having an appointment card that could be incorporated into their calendar schedules: Yeah. That sounds good. I think that would help...probably help people that use the tool to make their appointments.
Participants preferred the appointment minder be interactive. In addition to the date and name of the provider, participants envisioned this feature as having a built-in function that would allow them to specify the type of appointment (eg, laboratory work, x-ray, and physical examination) to aid in preappointment preparations (eg, fasting). Knowing the type of appointment would be instrumental in helping them prepare and organize questions that they would like to ask their providers during visits: Others felt that this feature would enable them to stay engaged in conversations and help them remember the things they needed to discuss with their providers during clinic visits. In addition, participants thought that the app could help them document their experiences regarding medication side effects or challenges they might encounter regarding access to and use of health care, potentially playing a significant role in improving care delivery:

Suggestions for Improvement
Participants stated that they would prefer the appointment minder feature to also include generic questions or standard prompts. They envisioned this feature as having built-in prompts or questions that were tailored to the participants' health conditions, which they could use as a guide to organize or develop questions that they should ask their providers during clinic visits. They felt that they would find this feature even more helpful if it incorporated typical follow-up response questions that were tailored to treatment side effects, laboratory results, and specific medical procedures or health conditions:

Overview
Participants indicated that they would like to use my action plan in the future to set overall goals for health management. In addition to my action plan's potential to facilitate organizing and planning, participants liked the feature's ability to help them prioritize goals and activities. They liked the idea of being able to document plans for both short-term and long-term goals such as taking medication daily, calling the physician about medication side effects, and scheduling follow-up appointments with their providers: In addition, participants were enthusiastic about the goal-setting function of this feature. They liked the idea of being able to create a step-by-step action plan to remind them about the various small actions that they needed to follow to achieve their health goals in a timely manner. Some participants felt that this feature would help to organize activities, especially when preparing for long trips or traveling. They envisioned my action plan as being able to help them prioritize health-related responsibilities such as packing their medication, taking medication on time, and arranging for prescription refills at pharmacies near their destination: Although some participants appreciated the feature's potential to help with organizing activities and health care plans, they were less enthusiastic about using this feature in the future, as they felt that they could access similar information such as refilling prescriptions, appointment schedules, and health plans from other provider-based mHealth platforms such as MyChart: Well, that's actually, that seems like a pretty good work flow map. But a lot that was mentioned on there, I can go to MyChart and deal with that. [PID P4201]

Suggestions for Improvement
Although participants reported interest in using this feature in the future, they suggested having the goal-setting feature in my action plan arranged in descending order, starting from least likely to remember to most likely. A participant explained this as follows:

Overview
Participants provided positive feedback regarding the digital pill case feature. They thought that digital pill case, including the color-coded before or after display buttons, would help monitor their daily medication doses and improve treatment adherence. Participants commented that they particularly liked the feature's ability to use color-coded buttons as a reminder for when they have not taken their medication on time. They also liked the idea of the app creating a log after they have taken their daily doses and having their medication schedule incorporated into their calendars: When asked whether they would prefer the app to send a follow-up message for a status update 30 minutes after taking their medication, participants stated that although this could be a good feature to have, they thought regular prompts might be somewhat cumbersome:

That would be good -it may be a little -it may be a little too much. [PID P2002]
When asked whether they would like this feature to synchronize with their alarm or calendars and whether they would like having pop-up reminders that display over the top of the screen to notify them when it is time to take their medication, participants indicated that they would like that function and thought that it would be a very useful and effective reminder:

Suggestions for Improvement
Some participants indicated that they would like a more refined visual display of digital pill case. They envisioned this feature as having the ability to accommodate all the applicable medications that were specific to each user's individual and unique health conditions:

App User Interest
Overall, participants indicated considerable interest in using this app in the future. They envisioned themselves using the app daily and thought that the app would be useful in helping them manage HIV care. They stated that they would recommend the LetSync app to other family members, friends, and people in their social networks who are HIV positive: I mean, all of these seem like they're very, very helpful. I think just what it is that some of them I could see myself using day-to-day-to-day. [PID P3702] Participants liked the appearance (color and background images) of the app wireframes and felt that the app's features and contents were appropriate. However, some thought that the app's imagery looked somewhat provocative and said that they would not feel comfortable using the app in public spaces:

I think the overall look is good. The only thing-this first picture?If I was in public, I wouldn't want to click on that because it looks like it was going be a sex ad...Just because it's an intimate image. [PID P0902]
Although participants were enthusiastic about the app, they indicated a need for a more refined app presentation in terms of visual display and navigation, and they wanted the ability to personalize the aspects of the app both functionally (including tracking goals, medication adherence, and health progress) and esthetically (including adding imagery and modifying app features and colors) to make it their own. In addition, some participants commented about the amount of text on the app wireframe and suggested using less text and incorporating more icons or images instead:

Looks -I just now figured out what the silhouette was. I wasn't even looking at the silhouette, I was looking at the foreground first for the -for the words. And text-heavy maybe? Is what I would suggest -is what I would say. Cause I didn't -it may benefit from icons of some sort. [PID P2002]
When asked about which features they were likely to use the most, most participants (20/24, 83%) expressed that they thought that all the features would be useful and commented that they look forward to using the app. They thought that they could use the app to help improve medication adherence and communication with their partners and for planning activities both for short term and long term: Hmm, hmm, I would say all of them. I would use all of them. I may use more than others, but I would -I think all of them look pretty useful. [PID P1802] Although participants envisioned the app as being a useful resource for HIV health management, others thought that the app would not be helpful for them but pointed out that perhaps their partners or other people in their social networks might find it useful. Many of these individuals (22/24, 92%) already had systems in place for taking medications and setting appointment reminders, and they did not want to replace these routines: Overall, participants agreed that they would feel comfortable with using this app for HIV care management if there were security measures in place to ensure that notifications or pop-up reminders were discreet and as long as they would be able to share health information with their partners voluntarily.

Principal Findings
Informed by formative studies, the LetSync app will be specifically designed to support individual and dyadic processes involved in optimal HIV care for partnered Black sexual minority men [5,6]. We developed the LetSync app wireframes to test potential features and elicit information that could be used to inform processes for designing and developing LetSync, an app for couples, to improve HIV care management among Black sexual minority men and their partners. In this study, we assessed the acceptability of the app wireframes among Black sexual minority male couples in 4 cities in the United States. The study provided preliminary data that helped us evaluate the potential interest in using the eventual app, elicit feedback about potential app features, and identify suggestions for app improvement. Overall, participants reported high acceptability of the app wireframes and indicated considerable interest in using the LetSync app in the future. In addition to near-universal interest in potential daily app use, most study participants (20/24, 83%) indicated that they would recommend the LetSync app to other family members, friends, and people in their social networks who are living with HIV. Our findings are consistent with those of previous studies that have shown participants' interest in mHealth-based technologies as an acceptable resource for HIV care management and medication adherence among sexual minority male couples [11,17].
In our study, the future LetSync app was frequently referred to as a potential resource that could help facilitate users' engagement in HIV care through the following mechanisms: (1) enable scheduling of appointments and timely reminders for clinic visits; (2) help improve HIV medication adherence (the app would allow them to set up reminders to take their daily doses and pick up medication refills); (3) encourage and motivate participants to ask questions and stay engaged in conversations during clinic visits; (4) facilitate effective communication by assisting couples with planning, coordination, and management of daily routines; (5) help participants understand their partner's health needs, including access to and use of health care services; and (6) facilitate participants' ability to improve their relationship skills, partner support, and self-efficacy in managing conflict.
In addition, study participants were enthusiastic about the app features and envisioned the future LetSync app to be instrumental in facilitating targeted strategies for HIV health management. Participants liked that the app would enable them to share health goals and reminders more effectively with their partners, while also including features that allowed them to maintain privacy from their partners when needed. In our previous study investigating dyadic coordination in HIV care management among Black male couples, although there were variations regarding the degree of involvement, most participants (17/24, 71%) reported being involved in their partners' health care in terms of HIV care engagement, coordination or scheduling of clinic appointments, and providing partner support [6]. Parallel to our previous study, the findings of this study clearly indicate that designing a user-centered mHealth app with features that would enable partners to share health management goals could lead to significant improvements in coordinated HIV care among Black male couples. These findings are consistent with those of other studies that have shown the importance of couples' engagement in everyday use of technology in preventing chronic disease progression and improving health management [18].
Examining participants' preferences regarding the various features of the app wireframes revealed the need to ensure the development of an app that would be interactive and user centered. In our study, participants indicated that they would prefer the option to personalize the app regarding functionality, visual display, navigation, and esthetics. This finding is consistent with those of acceptability studies of apps among Black sexual minority men in the United States. For example, in a 2014 study evaluating the acceptability of an mHealth intervention to improve access to HIV prevention and care services, a key finding was the participants' desire for customization depending on individual health needs and preferences for receiving app-related alerts and messages [17].

Limitations
This study has several limitations. The findings obtained from the purposive sample of Black sexual minority men with HIV recruited via social networking and dating apps may not be generalizable to those who are not actively involved in these platforms. Participants in this study were recruited via web-based platforms and interviewed using internet-based methods, and therefore, generalizability of the findings may be limited to selected groups of Black sexual minority men with regular access to the internet and smartphones and those who are comfortable with the technology used. In addition, participants' perceptions about the potential features of the LetSync app were based on the initial app wireframes. However, based on the information provided to participants, they were able to conceptualize its general structure and purpose, so that they could provide meaningful feedback about its acceptability and potential usefulness. Regardless of the limitations, the LetSync app provides an innovative approach to HIV care-an intervention that could provide Black sexual minority men and their partners with behavioral skills to effectively manage HIV and improve HIV health outcomes. In addition, insight gained from this study will be used to improve the app's usability and likelihood of adoption among Black sexual minority men with HIV. Given that the LetSync app is being developed to be compatible with smartphones, the app would provide increased accessibility to users and would allow flexibility of use among Black sexual minority men and their partners throughout the United States.

Comparison With Previous Studies
Couple-based mHealth interventions could provide an opportunity for Black sexual minority men and their partners to enhance the knowledge and skills necessary to work together to manage HIV in their relationships [19]. This study builds on formative studies that revealed interest for mobile app use among Black sexual minority men and their partners and provided insights regarding the importance of partner involvement in HIV care management in this population. By developing tailored HIV care plans using the appointment minder feature, enhancing problem-solving skills using my action plan, and cultivating HIV medication adherence using digital pill case, the LetSync app could offer a unique opportunity for couples to support each other in reaching common HIV health management goals.
Parallel to our findings, in HIV-related mHealth studies, participants expressed a preference for customizable app features [20], personalized reminders [14], motivation for medication-taking behaviors, and social support connection or networking features [21]. Although mHealth interventions including SMS text messages, emails, and social media platforms have been shown to improve HIV prevention and treatment among sexual minority men, they primarily used one-way messaging approaches, which often lacked the interactive and personalization features needed for delivering care that is tailored to each participant's specific health needs and HIV management goals [15,22].
In addition, all the reviewed mHealth HIV intervention studies were limited in scope, as they focused mainly on individual-centered interventions, with none of them focusing on developing an mHealth app aimed at improving HIV care engagement and treatment among partnered Black sexual minority men in the United States. Our study focuses on developing a couple-centered mobile app that addresses multiple aspects along the HIV continuum of care, including facilitating engagement and retention in HIV care for partnered individuals, improving medication adherence, and strengthening problem-solving skills to improve HIV health management goals among partnered Black sexual minority men.

Conclusions
Our findings revealed considerable interest in app use among Black sexual minority men in couples, which would possibly increase the chance of the LetSync app being successfully adopted by participants. In addition, the study findings revealed specific areas of the app wireframes that need improvement-information that will help inform the development of app features that Black men would find as helpful and appropriate to use (with their partners) for HIV care management. For Black men who struggle with poor communication with partners or providers, the LetSync app could help increase ease in communicating health needs to their partners and providers and could provide an acceptable couple-centered modality for these men to receive support in accessing HIV care services. During interviews, participants viewed the appointment minder feature as a potential resource to help improve transparency between couples. They felt that this feature could allow easy sharing of health information and planning of clinic visits and daily activities. In addition, participants thought that the LetSync app could help prevent schedule-related conflicts and unnecessary arguments between couples. Participants were also enthusiastic about the feature's potential to help couples build trust and foster strong relationships. They also thought that appointment minder would enable them to better understand their partners' health needs and could help them formulate targeted strategies to provide physical, mental, and emotional support tailored to their partners, particularly during stressful medical situations.