# Improving Pre-Exposure Prophylaxis Adherence in People at Risk for HIV: Secondary Analysis of a Digital Health Intervention to Enhance User Engagement

## TL;DR

This study examines how a digital health app can improve HIV prevention pill adherence among high-risk young people, finding that higher app engagement correlates with better adherence, but a more expensive enhanced version did not significantly improve outcomes.

## Contribution

The study introduces a novel digital health intervention (P3+) with in-app coaching and evaluates its engagement and cost-effectiveness compared to a standard version.

## Key findings

- Participants in the enhanced P3+ arm showed higher engagement with the app, including more log-ins and time spent.
- Higher user engagement was significantly associated with better PrEP adherence at 3 months.
- Despite increased engagement, the P3+ intervention did not significantly improve PrEP adherence compared to the standard P3 arm.

## Abstract

Although highly effective HIV pre-exposure prophylaxis (PrEP) is available, its usage and adherence among young men who have sex with men and young transgender women remain low, reducing its overall effectiveness. The study included a 3-arm randomized clinical trial of Prepared, Protected, emPowered (P3), a comprehensive PrEP adherence digital health intervention, compared to an enhanced version, P3+, which incorporates in-app adherence coaching.

This study aims to analyze data from study participants in the P3/P3+ intervention arms to understand how different levels of user engagement with the app’s features were associated with adherence to PrEP as well as the costs of each intervention and their relative cost-effectiveness.

Descriptive statistics for study variables at baseline were calculated. To examine the differences in intervention engagement and acceptability by arm, independent samples 2-tailed t tests for continuous variables and a chi-square analysis for categorical variables were conducted. To examine the effect of arm and engagement categories on PrEP adherence at 3 months, three logistic regression analyses were conducted: (1) the effect of arm on PrEP adherence, (2) the effect of predefined engagement categories (high vs moderate and low) on PrEP adherence, and (3) the interaction effect of arm and predefined engagement categories on PrEP adherence, along with the main effects of arm and predefined engagement categories. The study team calculated the average cost per participant and the incremental cost-effectiveness for PrEP adherence and engagement measures.

A total of 163 participants were randomized to the P3 intervention (82 to the P3 arm and 81 to the P3+ arm). Participants in the P3+ arm earned higher incentives (US $90.6 vs $75.4; P=.04), had more app log-ins (96.6 vs 76.1; P=.01), used the app on more days (63.3 d vs 53.2 d; P=.04), and spent more time in the intervention (378.8 min vs 186.66 min; P<.001) compared to those in the P3 arm. There was no significant association between intervention arm and PrEP adherence at 3 months (P=.99). Engagement category (high vs moderate or low) was significantly associated with PrEP adherence at 3 months (P=.003). The overall average total monthly cost of P3 was US $1118 (SD $305.1). Average total monthly cost per P3 participant was $280 (SD $118.5), with an additional cost for P3+ of $72.

This study highlights the critical role of user engagement in enhancing PrEP adherence among young individuals at high risk for HIV. While the P3+ intervention led to increased engagement, this did not translate into significantly better adherence compared to the standard P3 arm. This, coupled with the increased cost and complexity of P3+ delivery, indicates that further studies are necessary to determine whether this intensified intervention is the appropriate fit.