Benchmarking of mobile applications focused on HIV prevention and controlAbstract
Objective To map content and evaluate the usability of mobile applications (apps) aimed at HIV prevention and control.
Methods Benchmarking of apps in Portuguese, English, and Spanish was conducted. They are available on the Google Play Store and the App Store using search terms related to HIV. The inclusion criteria covered apps focused on HIV prevention and control, intended for the general population. Those intended for specific population groups, or related to other objectives, were excluded. The apps were selected by two nurses using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, and then evaluated for usability using the validated System Usability Scale questionnaire.
Results A total of 1,001 apps were identified, of which 22 met the inclusion criteria. Most of the apps were in English, and only four were in Portuguese. A lack of Brazilian apps targeting key populations, such as men who have sex with men, sex workers, and transgender people, was observed. The most frequently used features were reminders, texts, calendars, and diaries. The average usability score for the apps was 72.9, which is considered acceptable. Apps focused on pre-exposure prophylaxis were predominant. No apps were identified that offered post-exposure prophylaxis or specific immunization.
Conclusion The apps analyzed have potential as educational tools, although they have limitations in their focus on key populations and in their use of combined prevention strategies. Adopting mobile technologies can contribute to fighting HIV, especially if they are targeted to the needs of vulnerable populations.
Keywords
Mobile applications; Educational technology; Health education; HIV; Nursing informatics
Resumo
Objetivo Mapear conteúdos e avaliar a usabilidade de aplicativos móveis (apps) direcionados a prevenção e controle do HIV.
Métodos Foram realizados benchmarking de apps em português, inglês e espanhol. Eles estão disponíveis nas plataformas Google Play e App Store, usando termos de busca relacionados ao HIV. Os critérios de inclusão abrangeram apps voltados à prevenção e controle do HIV destinados à população geral. Foram excluídos aqueles destinados a grupos populacionais específicos ou relacionados a outros objetivos. Os apps foram selecionados por duas enfermeiras com auxílio do checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses, sendo então avaliados quanto à usabilidade usando o questionário validado System Usability Scale.
Resultados Foram identificados 1.001 apps, dos quais 22 atenderam aos critérios de inclusão. A maioria dos apps estavam em inglês e só quatro em português. Foi observada uma carência de apps brasileiros e direcionados a populações-chave, tais como homens que fazem sexo com homens, profissionais do sexo e pessoas trans. Os recursos mais frequentes foram lembretes, textos, calendários e diários. A usabilidade média dos apps foi de 72,9, sendo considerada aceitável. Apps com foco na profilaxia pré-exposição foram predominantes. Não foram identificados apps contemplando profilaxia pós-exposição ou imunização específica.
Conclusão Os apps analisados têm potencial como ferramentas educativas, embora haja limitações quanto ao foco em populações-chave e estratégias combinadas de prevenção. Adotar tecnologias móveis pode contribuir para enfrentar o HIV, especialmente se direcionadas às necessidades das populações em vulnerabilidade.
Descritores
Aplicativos móveis; Tecnologia educacional; Educação em saúde; HIV; Informática em enfermagem
Resumen
Objetivo Mapear contenidos y evaluar la usabilidad de aplicaciones móviles (apps) dirigidas a la prevención y al control del VIH.
Métodos Se realizó un benchmarking de apps en portugués, inglés y español, que están disponibles en las plataformas Google Play y App Store, utilizando términos de búsqueda relacionados con el VIH. Los criterios de inclusión abarcaron apps destinadas a la prevención y al control del VIH dirigidas al público general. Se excluyeron aquellas destinadas a grupos específicos de personas o relacionadas con otros objetivos. Las apps fueron seleccionadas por dos enfermeras con la ayuda de la checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses, y luego se evaluaron respecto a su usabilidad, mediante el cuestionario validado System Usability Scale.
Resultados Se identificaron 1001 apps, de las cuales 22 cumplieron los criterios de inclusión. La mayoría de las apps estaba en inglés y solo cuatro en portugués. Se observó una escasez de apps brasileñas y dirigidas a públicos clave, como hombres que tienen relaciones sexuales con hombres, profesionales del sexo y personas transgénero. Los recursos más frecuentes fueron recordatorios, textos, calendarios y diarios. La usabilidad promedio de las apps fue de 72,9, lo que se considera aceptable. Predominaron las apps centradas en la profilaxis preexposición. No se identificaron apps que contemplaran la profilaxis posexposición o la inmunización específica.
Conclusión Las apps analizadas tienen potencial como herramientas educativas, aunque existen limitaciones en cuanto al enfoque en públicos clave y estrategias combinadas de prevención. La adopción de tecnologías móviles puede contribuir para hacer frente al VIH, especialmente si se orientan a las necesidades de las personas vulnerables.
Descriptores
Aplicaciones móviles; Tecnología educacional; Educación en salud; VIH; Informática aplicada a la enfermería
Introduction
Over more than four decades, HIV infection has resulted in more than 40 million deaths worldwide. The epidemic remains a significant public health concern despite scientific advances such as rapid diagnostics and effective antiretroviral therapies (ART).(1)
Given its epidemiological relevance, global targets have been established, namely: to include controlling Acquired Immunodeficiency Syndrome (AIDS) as a public health threat by 2030 and reduce new annual infections to fewer than 370,000 cases by 2025. However, global statistics reveal that 1.3 million people contracted the virus in 2023. The number of new infections is three times higher than expected, indicating that the epidemic still needs to be fought.(2,3)
To achieve these goals, efforts have focused on strengthening preventive measures, developing innovative vaccines and immunotherapies, and searching for a definitive cure. In this context, HIV prevention is understood as a set of strategies aimed at reducing the transmission of the virus and protecting people from infection, applying biomedical, behavioral, and structural interventions.(4,5)
Educational technologies (ETs) have shown promising results in supporting preventive practices.(6,7)Among these technologies, mobile applications (apps) have gained prominence. These tools offer functionalities such as data capture, storage, data sharing, service personalization, and access anytime, anywhere, and are defined by the use of mobile technologies to promote health.(8-10)
Apps have the potential to overcome geographical and temporal barriers, increase health literacy, and improve access to services, contributing to equity in healthcare. They complement traditional strategies by providing health information, encouraging safe sexual behaviors and promoting the use of preventive products.(11,12)Thus, actions such as equipping and informing people susceptible to HIV and those living with HIV (PLHIV) strengthen HIV prevention and control.
To broaden the discussion on developing new apps for public use to prevent and control HIV, the following is necessary: evaluating the performance and usability of existing applications to understand their content and limitations, and contributing to recognizing the real need for new mobile technologies to address this epidemic.
Therefore, this study aimed to map the content and evaluate the usability of apps targeted at HIV prevention and control.
Methods
This benchmarking was a systematic study to identify apps focused on HIV prevention and control, and evaluate their content and usability. Benchmarking is a technique that allows for analyzing the performance and results of resources or technologies to promote improvements and innovations. This approach is useful for identifying best practices and supporting development tools with robust evidence and improved functionality.(13,14)
Although benchmarking originated in the management field to improve business processes, it has been used in the health sciences to evaluate available apps and to suggest the development of improved technologies.(15,16)
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was adapted to map apps and synthesize their content and functionality. The six stages covered were as follows: 1) defining analytical objectives; 2) choosing search terms; 3) establishing inclusion and exclusion criteria; 4) defining the information to be extracted; 5) analysis of the results; and 6) presentation of results and discussion.
The following question was structured to identify content and usability: what are the content and usability levels in the developed apps that contribute to preventing and controlling HIV?
To answer this research question, apps related to HIV prevention and control were identified using the terms HIV, VIH (Spanish translation of HIV), and AIDS, which are also used in individual searches. The choice of these descriptors is justified as identifying a greater number of apps on the HIV topic is possible.
The apps were selected based on their title and brief description. They were then selected based on the following inclusion criteria: apps in Portuguese, English, and Spanish, and about HIV prevention and control aimed at the general population (highlighting people who are susceptible to HIV and those diagnosed with HIV), capable of providing information on sexual health and support for self-care.
Apps intended solely for healthcare professionals, scientific events or conferences, dating apps, and apps that were unavailable for download or access were excluded, since the objective of the apps selected for the study was to promote both sexual health for HIV prevention and clinical and educational support for PLHIV, aiming to reduce transmissibility and improve infection control.
Search, selection, and download occurred between September and November 2024 and were independently conducted by two doctoral-level nurses specializing in health promotion. The research was conducted on the Google Play Store (Android operating system) and App Store (iOS operating system) using two devices: iPhone 13 (iOS) and Xiaomi i9 (Android). A search was performed for each selected term, with three searches on each online store.
Each reviewer created an information matrix in the Microsoft Excel® spreadsheet containing the following: name, release year, language, developer, version, update year, age rating, number of downloads, rating (by stars), content, and features. The divergent apps were discussed, and a final decision (regarding exclusion or retention) was reached after double-checking according to the eligibility criteria.
The eligible apps were downloaded and tested for ten days to improve their use. After a better understanding of the apps’ functionality, the two reviewers independently assessed their usability.
The System Usability Scale (SUS) questionnaire, translated and adapted for Brazil (2022) was used to evaluate usability. This instrument measures efficiency, effectiveness, and satisfaction, with responses to questions on a Likert scale (1-5; strongly disagree to agree). Odd-numbered answers had 1 subtracted from their sum, while even-numbered answers had 5 subtracted from their sum, multiplying the result by 2.5. The score ranges from 0-100, and was classified as unacceptable (<50), borderline (50-67), acceptable (68-84), or excellent (>84).(17,18)Discrepancies between the evaluators’ responses were resolved through critical discussion until a consensus was reached.
The project was not reviewed by a research ethics committee because it used publicly available data, did not involve human subjects, and had no conflict of interest. The apps evaluated for features and usability are listed in the results below.
Results
The initial investigation identified 421 apps for the HIV (178), AIDS (223), and VIH (20) terms in the App Store. On Google Play, 680 apps were identified for HIV (242), AIDS (242), and HIV (196). Many of them had no connection to HIV and/or AIDS. At the end of the selection process, 22 apps remained (Figure 1).
Among the apps analyzed, English was the predominant language, followed by Spanish. Only four were available in Portuguese (two of them offered support in all three languages). This finding points to a lack of Brazilian apps focused on HIV prevention. The first identified release occurred in 2014; there was an increase from 2020 onwards, with a higher concentration in 2023. The app eSidajoc did not specify the release year, making it impossible to check for updates. The HIV/HCV Education app has not been updated (Chart 1).
Regarding age classification, 50% (n=11) of them offered free access, and 45.4% required a minimum age (17 years). The iOS platform imposed stricter age range criteria compared to Android. Most apps did not provide a star rating. Among the apps that presented user ratings, five stars was the most frequent rating. Regarding the number of downloads, 50% (n=11) did not report, 31.8% (n=7) reported more than 1,000, and 9.09% (n=2) exceeded 100,000.
For better understanding, the content has been grouped into five categories and 12 thematic areas. Each application could integrate more than one category and/or axis. The category “Safe sex practices” encompassed the following themes: sexual life manager (n=6), support for PrEP use (n=8), and monitor test results (n=3) and vaccines (n=2), covering the largest number of apps, mainly those that support PrEP. The two apps with vaccine registration features do not ensure information about eligibility for immunization.
The category “Information on HIV/AIDS and other STIs” included the following axes: information on HIV/AIDS (n=5) and HIV/AIDS and other STIs (n=5). The third category, “Information about services,” included specialized HIV/AIDS services (n=2), testing centers (n=2), and other health services (n=3). “Communication” provided support to PLHIV (n=2) and chat among PLHIV (n=2). Finally, the category “Change in lifestyle behaviors” presented the axis of quitting smoking (n=1). No app was found about post-exposure prophylaxis (PEP), nor targeted at the key populations of HIV or adolescents.
No developer was responsible for more than one application. Regarding the resources offered, several elements were found, such as: reminders (n=9), texts (n=13), calendar (n=6), diary (n=5), exam record (n=5), images (n=8), games (n=3), audios (n=3), medication records (n=5), website access (n=4), call center (n=1), locator (n=5), videos (n=2), chat (n=3), vaccine registration (n=2), script for medical consultation (n=1), flowchart (n=1), agenda (n=4), algorithms for accessing Instagram (n=1), algorithm for accessing purchase services (n=1), query history (n=1), Clinical calculator (n=2) and questionnaire for patient characterization (n=1) (Chart 2).
The app evaluations showed borderline (31.8%; n=7), acceptable (40.9%; n=9), and excellent (27.3%; n=6) usability. The overall average usability score of 72.9 was acceptable. No application was found to have unacceptable usability (Chart 2).
Discussion
The development, diffusion, and adoption of mobile technologies in healthcare have grown significantly. In the context of HIV, mobile apps offer access to health information, registration and monitoring of patients’ clinical data, support for rapid decision-making, and support in diagnoses. These tools also promote patient empowerment through self-management of their own health, in addition to strengthening preventive and self-care actions.(19)
The predominance of apps in English(16,20) and the lack of tools developed in Brazil highlight barriers to accessing the HIV prevention technology. An uneven distribution in app development in Brazil was also observed, with 90.5% of digital health initiatives developed in the South and Southeast regions.(21)A documentary research (2021) identified Brazilian apps related to HIV, but many are not available for viewing or download, possibly due to the exclusion or deactivation of platforms.(22)
Most of the apps analyzed focus on safe sex practices, with an emphasis on supporting the use of PrEP. Texts, reminders, and images have been the most frequent resources according to a study on the use of apps for diabetes, which is considered a chronic condition like HIV infection.(23)However, no app was found that targeted only key populations, such as men who have sex with men, sex workers, transgender people, drug-injecting users, and prison populations.(24,25)
Addressing and controlling HIV transmission are complex processes involving various interrelated factors, including individual, social, and care-related aspects, as well as valuing human rights and understanding vulnerability. This concept refers to the possibility of people being exposed to infection, resulting from individual, collective, and contextual conditions that increase susceptibility to HIV. The vulnerability concept also highlights the influence of inequalities in access to and availability of protective methods, such as PrEP and PEP, which are highly effective and fundamental to preventing transmission and promoting infection control when used appropriately.(26,27)
In this context, new evidence points to the need to strengthen the protagonism of individuals in their contexts of sexual interaction, as this is the central element in preventing and controlling HIV. Therefore, it is essential to move beyond a conception of combination prevention centered on the provision of a universal basket of methods. This offer must be articulated with an impact on public health, promoting human rights and equity. This proposal culminates in the prioritization of needs and greater dialogue with the demands and daily lives of populations most vulnerable to HIV.(25)
It is undeniable that mobile technology can improve healthcare. However, it is important to consider the life context of users to prevent and control HIV. In this scenario, there are no apps to prevent HIV that establish a systematic methodological pathway for key populations, such as adolescents or pregnant women living with HIV. Furthermore, no apps were identified that address PEP, guiding people who practice anal sex about immunization against Hepatitis B and A and against Human Papillomavirus (HPV). Only Smiling instead of Smoking-HIV has been identified as an integrator in harm reduction.(5,27)
In this context, we also highlight the recognition of information categories related to HIV/AIDS and other STIs, as well as content about services, within the dimension of health education. For HIV prevention, educational actions contribute to individuals reflecting critically on their vulnerability and adopting safe sexual practices.(28,29)
When prevention is not possible, it is essential to focus on infection control. In this scenario, dialogue and communication are crucial for reframing affective dimensions and reducing vulnerabilities in sexual and reproductive health, as well as enhancing treatment, contributing to reducing the viral load and transmissibility of HIV.(30,31)In the communication category, the analyzed apps that address the axes “Support PLHIV” and “Chat between PLHIV” show potential to foster dialogue between users, promoting the protagonism of PLHIV in their care pathways.(32)
We highlight the Preparedxs (among the component apps of the sample) as the only one with usability measured in a study applicable to the general population. The app’s performance was rated as excellent, highlighting its potential as a tool to support self-care and treatment adherence.(32)
Offering mobile technology to the population is a valid and promising strategy. However, it is crucial to establish quality criteria to ensure the safety and effectiveness of their use. In this sense, the literature points to validated instruments for quality analysis (such as the SUS questionnaire) for evaluating the usability of health app attributes.(16)Few benchmarking studies evaluating the usability of apps for preventing and controlling HIV were found in the literature, despite the rapid proliferation of these apps.
Benchmarking studies that systematically evaluate the usability of apps for preventing and controlling HIV are also scarce, despite the rapid proliferation of these technologies. In this context, some studies individually investigated the feasibility and acceptability of an app designed and developed to prevent HIV or to support PLHIV in self-care and adherence to ART.(32,33)Research with benchmarking techniques was used to evaluate the quality of care services for PLHIV.(34,35)Benchmarking studies with mobile apps are important because this technology can quickly become obsolete as new evidence emerges, requiring constant updating and improvement.(36)
As a limitation of the present study, we highlight that the included apps were restricted to three languages. Furthermore, the usability evaluation was conducted solely by the researchers, without direct participation from healthcare system users. This was a limitation, although also a suggestion for future studies. Thus, including user perception will be fundamental to measuring and reflecting the real difficulties in using these technologies. Furthermore, the SUS instrument lacks criteria for a broader quality analysis, although it is valid.
Conclusion
The applications (apps) focused on HIV prevention and control were evaluated for content and usability, with particular emphasis on sex life management apps, informational apps about HIV/AIDS, and pre-exposure prophylaxis apps. These tools have the potential to promote health education, reduce stigma, and strengthen preventive strategies. Acceptable usability prevailed in these apps. There is a lack of educational technology aimed at key populations and a scarcity of apps that combine prevention strategies, such as post-exposure prophylaxis and immunization. To face the HIV epidemic, more inclusive and comprehensive technological development is needed, although gaps limit the reach of combined prevention and reduce the potential impact of apps.
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Source: Adapted from Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews, PRISMA-ScR.