Study Title: Developing a Smartphone App to Improve Treatment Adherence among South African Adolescents Living with HIV

Study Implementers: University of Cape Town (South Africa), Duke University School of Nursing (USA), and Florida State University (USA)

Study Sponsor: U.S. National Institute of Mental Health

Grant #: 1K01MH118072-01A1

Principal Investigator: Dr. Marta Mulawa (Duke University)

Co-Investigators: Dr. Jackie Hoare (University of Cape Town) and Dr. Lisa Hightow-Weidman (Florida State University)

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Adolescents are disproportionally affected by HIV1 and repeatedly demonstrate lower levels of ART adherence compared to adults.2-3 Suboptimal adherence is associated with increased morbidity, mortality, and the forward transmission of HIV.4-6 Despite the recognition that adolescents face unique challenges7-8 and regularly demonstrate poor adherence,9-10 recent reviews of interventions to improve ART adherence among adolescents have described the current evidence as both “sparse” and “lacking in its quality.”11-12

Developmental theories and research suggest that adolescents are particularly sensitive to the social networks in which they are embedded.13-15 Social networks have been shown to influence adolescent behaviors including substance use,16-19 diet,20-21 and adherence to medications for chronic diseases.22-23 While little is known about the relationship between social network-level factors and ART adherence among adolescents, social networks are likely to influence ART adherence in this population. Thus, there is a critical need to identify social network level factors associated with adolescent ART adherence so that they can be targeted by novel interventions. With access to mobile phone technology increasing among youth in settings like South Africa,24-25 mHealth interventions hold promise as an effective way to reach young people in HIV prevention and care interventions.26-27


The purpose of this study is to customize and pilot MASI (MAsakhane Siphucule Impilo Yethu, Xhosa for “Let’s empower each other and improve our health”), an app-based intervention to promote adherence to HIV treatment among adolescents living with perinatally-acquired HIV in Cape Town, South Africa.

MASI is built using the HealthMpowerment platform. Through an anonymous interactive discussion forum, MASI provides opportunities for participants to interact with each other and trained peer mentors to receive and provide social support. Through the health tracker, MASI provides opportunities for participants to self-monitor their treatment adherence and schedule tailored reminders.

MASI also supports goal-setting and action planning by guiding participants through activities where they can identify goals, select action items, and receive tailored feedback on the action plan. Finally, through numerous activities (including quizzes, self-assessments, and goal-setting activities), multi-media resources, and an Ask the Expert area of the app, MASI provides opportunities for participants to review comprehensive health information in engaging formats.


Identify the relationship between social network-level factors (structural and functional characteristics) and clinical outcomes including viral suppression and ART adherence among adolescents living with HIV in Cape Town, South Africa. Dr. Mulawa added a custom tablet-based social network assessment to collect egocentric network data among a cohort of adolescents with HIV. She analyzed these egocentric network data (n = 100) to explore the relationship between social network-level factors and clinical outcomes.


Iteratively customize the HMP app to promote ART adherence among adolescents living with HIV by engaging their social networks. Dr.
Mulawa and her team adapted the HMP app for South African adolescents, resulting in MASI (MAsakhane Siphucule Impilo Yethu; Xhosa for ‘Let’s empower each other and improve our health”). Informed by the findings of Aim 1, Dr. Mulawa’s team then conducted in-depth
interviews (IDIs) with adolescents (n = 15) to further customize MASI, for this population. Dr. Mulawa and her team then conducted a usability study with 12 participants. Participants installed the MASI app on their phones and used it for daily for 3 weeks. At their follow up visit, they were then asked about their experiences using the app, app
content, app improvements, etc.


Pilot test MASI with 50 adolescents and young adults to (a) assess its feasibility and acceptability and (b) explore preliminary effects on ART adherence and social support.
From participant feedback collected in aim 2, the team further tailored and updated the app to reflect the unique needs of the population
and enhance optimization in the South African setting. 50 adolescents and young adults are
currently being randomized to MASI or comparison condition (information-only version of MASI), and will be completing assessments at baseline, 3-month, and
6-month follow-up.

App Highlights

Health Tracker

Track and layer behaviors with medication tracking to see patterns and meet adherence goals. Participants can also use the calendar and analytics to support self-monitoring and get feedback on their progress.

Screenshots of health tracker


Forum discussions and polls foster community support and peer-to-peer sharing within the app.

Screenshots of forum

Resources & Activities

Provides educational content across a range of health topics, as well as supports app engagement and behavior change through information and skill-building.

Screenshots of activities and resources

Ask the Expert

Health care providers answer anonymous user questions and connect users to resources

Screenshots of ask the expert


Coming soon!

What’s Next

The MASI study team will analyze the pilot RCT data to further improve the MASI app and study. Findings from the RCT will guide development of an R01 proposal that rigorously evaluates the effectiveness of the mHealth
intervention on ART adherence and HIV clinical outcomes.

Research Team

This study is approved the University of Cape Town Human Research Ethics Committee (HREC Ref: 606/2020) and the Duke University Health System Institutional Review Board (Protocol ID: Pro00103309).

Duke University PI:
Marta Mulawa, PhD, MHS
Duke University School of Nursing

University of Cape Town Site PI:
Jacqueline Hoare, MBChB, PhD
University of Cape Town
Department of Psychiatry and Mental Health

University of Cape Town Research Manager:
Bulelwa Mtukushe
University of Cape Town
Department of Psychiatry and Mental Health

University of North Carolina Co-I:
Lisa Hightow-Weidman, MD, MPH
Professor, Division of Infectious Diseases


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