E-VOLUTION is a two-way text messaging intervention, originally developed by Washington University School of Medicine and piloted at Project ARK, a Ryan White HIV/AIDS Program (RWHAP) funded organization in St. Louis, Missouri. The intervention focuses on improving health outcomes for youth, particularly young Black men who have sex with men (MSM). E-VOLUTION was designed for people ages 18-29 who have HIV and are receiving clinical care but require support to remain adherent. A 2015 RWHAP Part F Special Projects of National Significance (SPNS) initiative, aimed at demonstrating and evaluating the use of social media to improve engagement, retention, and health outcomes along the HIV care continuum, supported this intervention. E-VOLUTION was evaluated and found to improve viral suppression and retention in care rates.. E-VOLUTION was evaluated and found to improve viral suppression and retention in care rates.
St. Louis, MO
Young MSM of color continue to be disproportionately impacted by HIV,1 and experience less favorable outcomes across the HIV care continuum.2 Stigma, discrimination, and socioeconomic barriers all contribute to these health disparities.3 Young people are among the most frequent users of social media and mobile technology, providing an opportunity to develop approaches to health promotion that use media platforms that are accessible and appealing to youth. Text messaging is a particularly useful medium as it is used frequently by young people and lends itself to two-way communication between health service providers and their clients.4
“These disparities highlighted a need to implement a novel approach, specific to the young adult population that supplements existing services available to those living with HIV.”
Two-way text messages are managed by a text messaging platform called Epharmix and are automatically sent to clients who opt in. They include daily medication reminders, biweekly mood check-ins, appointment reminders, and housing/social services check-ins. Automation allows for greater efficiency and reduces staff burden. Clients respond to the text prompts that trigger alerts to medical case managers. These real-time alerts provide staff with opportunities to address issues quickly before they become a crisis. The responses populate a dashboard and provide rich data, including common reasons for missed appointments or medications, which may help inform quality improvement projects.
Once alerted to clients’ responses, medical case managers then respond with timely follow-up. Medical case managers also engage in monthly two-way exchanges with clients. This helps fortify a sense of human connection between clients and care providers. It also empowers clients to self-manage their needs and encourages them to be more informed and involved in their care.
“Cell phones have become indispensable tools in teen communication and 1 in 3 adolescents sends more than 100 text messages a day.”
Between February 2017 and February 2018, 100 participants participated in the E-VOLUTION intervention. Most participants were Black (93%), MSM (83%), and the average age was 23 years old. During the pilot, 89,681 automated text messages were sent, resulting in 450 alerts. The most common alerts related to missed medications, missed appointments, and requests for housing assistance. Clients who texted with their medical case managers at least monthly were more likely to stay engaged in care and attend 12-month medical appointments.
|Evaluation data||Clients’ medical data|
Percentage of clients retained in care
Percentage of clients who were virally suppressed
Selection of text message platform. For E-VOLUTION, Washington University used a two-way text messaging platform developed by Epharmix Inc. It was important to select an application that was agnostic to cell carrier or phone type (iPhone versus Android). It was also critically important to ensure privacy and security. The Epharmix application is encrypted and allows for fully secure communication of personal health information. E-VOLUTION program staff worked closely with their privacy officer to ensure that all protected health information was handled in accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations. Program-specific policies were then developed to guide application use and reduce the risk of unintentional disclosure of participant information.
Staffing. Several key staff members were essential to the successful development and implementation of E-VOLUTION:
- A project coordinator helped guide the overall intervention, providing support to program staff and conducting ongoing evaluation activities.
- Medical case managers were central to integrating the intervention into existing workflows. Staff had experience serving youth with HIV, including those with a new diagnosis of HIV. Case managers should have some skill and comfort using the text messaging application, so individual and group training was provided to ensure proficiency.
- Dashboard oversight may be provided by a medical case manager, registered nurse, or other staff member who can monitor the incoming alerts and forward the incoming information to the correct clinical team member.
- Intervention staff also worked closely with information technology staff and the Washington University privacy officer to ensure that the intervention was planned and implemented seamlessly and in accordance with privacy regulations.
Youth advisory committee. Project staff sought feedback and input from young people with HIV by forming a youth advisory committee. During group meetings and one-on-one key-informant interviews, young people had an opportunity to see demonstrations, try out the technology, and provide feedback on usability. They also helped develop marketing materials that would appeal to their peers.
Participant recruitment. Participants were recruited from within the Project ARK client population. Electronic health record reports helped determine clients eligible for the intervention. Medical case managers presented the intervention to potential participants during their medical or case management appointments. Promotional items, such as posters, were displayed in clinical areas, and postcards were distributed by case managers and other staff.
In addition to ongoing maintenance costs associated with E-VOLUTION, there were some upfront technology costs that may not be incurred at every site that implements this intervention. For example, medical case managers may already be equipped with agency-issued cell phones, or sites may already have HIPAA-compliant text messaging platforms built into their electronic health records that could be adapted for E-VOLUTION. A more sustainable option would be computer-based, providing a text messaging platform without the need for a mobile phone.
- Components of E-VOLUTION may be adapted to a variety of settings and client needs. For example, several two-way text message platforms provide secure messaging suitable for healthcare settings. Intervention staff should work closely with information technology and privacy staff to select the right platform for the institution, purpose, and client population. It is important to adapt the language of the text messages and response options to the population’s language of choice.
- Successfully launching and recruiting clients for E-VOLUTION depends on educating medical staff on the program and securing buy-in from clinical leadership. It also requires adequate staff training on the purpose and strategies involved as well as the texting platform itself. During the pilot at Project ARK, case management staff were provided with iPhones as well as training on boundaries around phone use, phone hours of operation, emergency procedures, and HIPAA regulations.
- Many of the young participants lost or changed phone service frequently. This posed a barrier, preventing them from receiving text messages. It is important for case managers to maintain updated contact information, including alternative methods such as an email address or social media account, for clients.
- It is important to establish a thorough informed consent process that clearly explains the risks and benefits associated with text messaging personal health information.
- Communication between clients and case managers also improved. Case managers reported being more effective at their work, allowing them to work more closely with clients who needed support. Clients reported that they felt more supported during the intervention, and that arranging appointments, transportation, and other assistance was easier via text.
“Allow for nonspecific labeling of sensitive topics—for example in the message, ‘Did you take your medication today?’ allow the participant to choose an alternative, innocuous word, such as ‘vitamins’ or ‘walk.’”
Brooks RA, Swendeman D, Hannay J. Special Projects of National Significance Social Media Initiative: Improving health outcomes along the HIV care continuum in youth and young adults living with HIV. Health Promot Pract. 2020; 21(5):690-692. doi.org/10.1177/1524839920944806.
Gerke DR, Glotfelty J, Schlueter J, Freshman M, Plax K. E-VOLUTION: A text messaging-powered intervention—connection, support, and HIV eradication. Health Promot Pract. 2020; 21 (5):716-726. doi:10.1177/1524839920936242.
- Centers for Disease Control and Prevention. HIV Surveillance Report, 2020; vol. 33. cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2022
- Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2020. HIV Surveillance Supplemental Report 2022;27(No. 3). Revised edition. cdc.gov/hiv/ library/reports/hiv-surveillance.html. Published August 2022
- Babel RA, Wang P, Alessi EJ, Raymond HF, Wei C. Stigma, HIV risk, and access to HIV prevention and treatment services among men who have sex with men (MSM) in the United States: A scoping review. AIDS Behav. 2021;25(11):3574–3604. doi:10.1007/s10461-021-03262-4
- Lenhart A, Smith A, Anderson M, Duggan M, Perrin A. Teens, Technology and Friendships. Pew Research Center; 2015. pewresearch.org/internet/2015/08/06/teens-technology-and-friendships