Wellness Web 2.0 is a text message-based intervention that offers health education tools, appointment reminders, and navigation services to increase linkage to and retention in care for youth and young adults with HIV. The Coastal Bend Wellness Foundation, a Federally Qualified Health Center (FQHC) in Corpus Christi, TX received funding from the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) Social Media Initiative to develop, implement, and evaluate Wellness Web 2.0, from 2015–2019. Clients across 27 counties in South Texas enrolled in the Wellness Web 2.0 program had improvements in linkage to HIV medical care and viral suppression.
Corpus Christi, TX
San Antonio, TX
Over half of people with newly diagnosed HIV in Texas’s Health Region 11 in South Texas are under the age of 34.1 Youth and young adults face significant challenges in managing their HIV, including the effects of stigma on their social support systems, ability to access care, and medication adherence.2 With a large majority of young people now using smartphones, virtual HIV care—through text messages, social media, and other mobile platforms—can offer more resources, ongoing support, and educational tools for them. To increase linkage to and retention in care among these youth and young adults with HIV, the Coastal Bend Wellness Foundation developed, implemented, and evaluated the Wellness Web 2.0 program, which consists of a text-message adaptation of the evidence-based intervention Anti-Retroviral Treatment and Access to Services (ARTAS), health education text messages, and appointment reminders. The Coastal Bend Wellness Foundation worked in partnership with the San Antonio AIDS Foundation in San Antonio, TX and the Laredo Health Department in Laredo, TX so that Wellness Web 2.0 was available to clients in 27 counties in South Texas.
ARTAS, a Centers for Disease Control and Prevention evidence-based intervention, incorporates strength-based case management services to help link people with recently diagnosed HIV to medical care and supportive services. ARTAS consists of five sessions over a three-month time frame with intervention staff who focus on building trust, setting health goals, and supporting clients to adhere to HIV care. Wellness Web 2.0 adapted ARTAS to be an SMS-based service, rather than the originally intended in-person format. This mobile adaptation allows ARTAS content to be delivered using bidirectional text message communication between an intervention staff member and a client.
The text message component of Wellness Web 2.0 allows for convenient, continuous care separate from ARTAS. A Wellness Web 2.0 clinic staff member is available seven days a week, from 8:30 am to 12:30 pm, to answer client inquiries. This helps clients easily access care when they most need it.
In order to increase retention in care, upon completion of the ARTAS module, clients can opt to continue receiving 12 weeks of educational texts through the Wellpass platform, a messaging service used to distribute health-related text messages. These one-way push notifications, which were curated by the HRSA-supported UCARE4LIFE research study and sent from intervention staff, include information on basic HIV health literacy, medication adherence, risk reduction and more. Following the 12-week period, clients work with intervention staff to determine the frequency with which they continue to receive similar educational texts.
During the 18-month evaluation period, 118 participants enrolled in Wellness Web 2.0. At the time of enrollment, 33% were people with newly diagnosed HIV who had not yet been linked to care, 12% were people with newly diagnosed HIV but already linked to care, and 55% were identified as either having a gap in care or not being virally suppressed. Following enrollment in Wellness Web 2.0, outcomes were measured every six months over an 18-month time period.
Source: Coastal Bend Wellness Foundation. Wellness Web 2.0: Use of Social Media to Improve Engagement, Retention, and Health Outcomes along the HIV Care Continuum. March 2020.
Pre-implementation planning. Pre-implementation activities include outlining staff roles, developing processes to collect client-level data for evaluation purposes while ensuring confidentiality, conducting a community assessment, and developing a technology infrastructure.
Staffing. The following staff members are crucial to the execution of Wellness Web 2.0:
o The Project Director supervises day-to-day operations. This individual manages all Wellness Web 2.0 implementation activities, from pre-implementation to developing infrastructure and clinical policy.
o The Project Coordinator, or Social Media Coordinator, oversees social media platforms and initiatives, including marketing tactics, digital campaigns, and social media trends.
o Social Media Specialists engage daily with all Wellness Web 2.0’s social media platforms to expand its reach and to curate engaging health education text messages for clients. These specialists manage the automated messages and deliver the mobile version of ARTAS directly to clients.
o The Data Manager oversees data collection and management for evaluation purposes.
Staff training. All staff members complete training courses to deliver Wellness Web 2.0 interventions properly, as well as to enhance their ability to work with diverse populations. The following courses are required: ARTAS Training, Wellness Web 2.0 Training, HIV Navigation Services, and Motivational Interviewing 101 and 201.
Input from youth and young adults. South Texas Teen Leadership and Development (STTLD) and Youth Network Out Together (YNOT) offered insights on how Wellness Web 2.0 could improve its outreach and implementation strategies. STTLD is a nonprofit that focuses on equal health care opportunities for young adults living in primarily rural areas, and YNOT offers a space for LGBTQ+ youth to discuss a range of topics, including stigma and health disparities affecting their communities. The Coastal Bend Wellness Foundation recruited 50 high schoolers from these two organizations to review and provide feedback on a survey tracking media usage and intervention marketing materials. The team also held a group discussion on HIV awareness and stigma in their communities.
Administrative infrastructure. Implementation of Wellness Web 2.0 requires protocols and procedures for client screening and enrollment, consent forms, and a system for offering free smartphones to clients who need them.
To successfully replicate and sustain Wellness Web 2.0, providers must assess their current mobile health and information technology capacity. Potential costs include hardware or software, ongoing software maintenance, and subscription costs based on the projected number of staff and clients using the system. To ensure that all clients have access to text messages, sites implementing Wellness Web 2.0 could consider using non-RWHAP funds to provide cell phones for those who need them.
- Wellness Web 2.0 uses SMS communication between participants and intervention staff to ensure direct care and communication. It may be helpful to have case management staff be able to text clients, instead of relying solely on intervention staff to be the liaisons.
- Clients reported that the text message appointment reminders were particularly important in helping them stay engaged in care.
- Scheduling mobile ARTAS sessions within the appropriate time frame posed a challenge, as clients had busy schedules. Flexibility of intervention staff to meet after hours or on weekends helps to meet this challenge.
- For clients who have fallen out of care, it is important to adapt conversations and supports to address the reasons they discontinued care in the first place.
- Clients may not feel inclined to respond to what seems like an automated message. Tailored messages can be a more effective way to build rapport and elicit responses from clients.
- Coastal Bend Wellness Foundation. Wellness Web 2.0: Use of Social Media to Improve Engagement, Retention, and Health Outcomes along the HIV Care Continuum. March 2020.
- Vanable PA, Carey MP, Blair DC, Littlewood RA. Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS Behav. 2006; 10(5):473-82. doi: 10.1007/s10461-006-9099-1