Mobile Technology for Healthy Aging Among Older HIV-Positive Black Men Who Have Sex with Men: Qualitative Study

Background People living with HIV are living longer in the United States as a result of antiretroviral therapy. Black men who have sex with men (MSM) are disproportionally affected by HIV and have low rates of engagement in HIV care and treatment. Mobile technology holds promise as an intervention platform; however, little is known regarding its use among older black MSM living with HIV. Objective The goal of this study was to explore mobile technology use and narratives of aging with HIV among older black MSM to inform mobile health intervention development. Methods A total of 12 black MSM living with HIV, aged 50 years or older, completed in-person, semistructured interviews exploring the issues of aging, HIV care engagement, and mobile technology use. The interviews were audiotaped, transcribed, and analyzed using qualitative research methods. Results Men appreciated having survived the AIDS epidemic, but some expressed discomfort and ambivalence toward aging. Men described various levels of engagement in HIV care and treatment; challenges included social isolation and need for support that was not focused on HIV. Almost all described using mobile technology to engage in health care, whereas some referenced important barriers and challenges to technology use. Conclusions Findings highlighted a high level of interest toward a mobile technology–based intervention targeting older black men but also identified barriers and challenges to using mobile technology for health care engagement. Mobile technology is well incorporated into older black MSM’s lives and shows potential as an intervention platform for addressing aging issues to enhance engagement in HIV care and treatment.


Background
Black gay, bisexual, and other men who have sex with men (MSM) are among the most disproportionately impacted by HIV and have some of the worst HIV care and treatment outcomes [1][2][3]. Due to biomedical advances such as antiretroviral therapy (ART), HIV has gone from a terminal disease to a manageable, chronic illness. A high rate of adherence (ie, >95%) to ART is required for suppression of HIV, and retention in HIV care prevents opportunistic illnesses [4]. Black MSM accounted for 26.00% (10,343) of the 39,782 new HIV diagnoses in the United States in 2016 [5]. Black MSM show the least favorable HIV care engagement outcomes relative to other racial or ethnic groups of MSM with suboptimal adherence to ART [3,6,7]. On the basis of current diagnoses rates, it is estimated that 1 in 2 black MSM will be diagnosed with HIV during their lifetime [8].
The population of individuals living with HIV is growing, aging, and experiencing a widening spectrum of diseases and conditions that compromise successful aging [9]. By 2030, as many as 73% (7503) of people living with HIV will be older than 50 years [10]. People living with HIV age earlier due to HIV infection; they exhibit multimorbidity, polypharmacy, and geriatric syndromes at a rate equivalent to those observed much later in life in HIV-uninfected persons [11][12][13]. Chronic inflammation and immune activation among those living with HIV are likely important in the high prevalence of aging-related conditions among individuals living with HIV [14,15]. The accelerated or premature aging has a deleterious impact on quality of life [11]. Despite an increased focus on aging with HIV and the subsequent decline in the quality of life, evidence for older black MSM living with HIV remains scant. Research is needed to inform innovative interventions that maximize functioning and quality of life as more people are living longer with HIV [16,17].
Mobile technology use among black Americans has increased with the ubiquity of mobile devices. According to a recent poll, the vast majority of black Americans own mobile devices and access the internet: 98% own a cell phone and 75% own a smartphone [18,19]. Black Americans were also more likely than whites to rely on their mobile phone for Web access [19]. Furthermore, the use of mobile technology for health, or mobile health (mHealth), is on the rise among seniors in the United States [20][21][22]. mHealth is a promising intervention platform, given its capabilities to mitigate traditional intervention barriers with older populations (eg, mobility) while transcending social and cultural barriers (eg, HIV stigma) [23,24].
Mobile phone-based HIV interventions have been developed for young black MSM [25,26]. However, mHealth interventions remain underdeveloped for aging populations, perhaps due to misconceptions about user capability despite evidence to the contrary [27][28][29]. A recent study showed that older black men indicated high willingness to participate in mHealth interventions, despite never having participated in them [30]. Furthermore, older black men were willing to participate in mHealth if they were offered more information about the topic or if they trusted that the research targeted and benefitted racial/ethnic minorities [30]. Another study found that the association between age and technology use was mediated by the effect of computer-related anxiety, self-efficacy, and confidence, suggesting that interventions that address these psychological factors can improve use of mHealth among older adults [31].

Objectives
To our knowledge, there are no technology-based interventions specifically developed for improving HIV care and treatment among older black MSM [25,32,33,34]. Research must first characterize the needs and preferences of older black MSM living with HIV who are increasingly in need of viable innovations adaptable to various social and behavioral factors that promote healthy aging. Formative research can help identify critical factors that could affect intervention feasibility, acceptability, and retention/attrition. Therefore, the goals of this study are to explore using qualitative research methods, to assess the issues involved in aging with HIV, and to understand the unique needs and preferences among black MSM to inform mHealth intervention development for enhancing HIV treatment outcomes.

Participants
Participants were recruited using purposive sampling to participate in a one-time in-person interview to explore the role of mobile technology in care engagement among older black MSM living with HIV. During a 3-month period, recruiters distributed study materials containing a dedicated study phone number at AIDS service and community-based organizations serving black MSM in (blinded for review) and social venues (eg, local bars and cafes). Potential participants were screened by trained research staff on the phone for eligibility. Individuals were eligible if they identified as black or African-American and as cisgender men at the time of the study, were currently living with HIV, owned a personal mobile telephone device, and were aged 50 years or older. We chose this age threshold because overwhelming evidence demonstrates that aging syndromes (eg, frailty and HIV-associated neurocognitive disorders) occur earlier (ie, by age 50 years) in people living with HIV. HIV status was verified by a letter of diagnosis or by a labeled pill bottle of their HIV medicine.
Eligible participants were interviewed in a private room located at a community-based research site accessible by public transportation. An interview guide was used to explore overlaps among the topics of aging, HIV care and treatment, and mobile technology. Sample interview questions include "In a typical day, what do you use your mobile phone to do," "What does aging mean to you," "What does living with HIV mean to you," and "How do you use your mobile phone in your health care?" Each interview lasted approximately 1.5 hours and was audiotaped and transcribed for analysis. All study procedures and materials were approved by the lead author's institutional human research review board.

Approach
The main goal of the study was to explore the intersection of aging, living with HIV, and mobile technology to inform mHealth intervention development for improving HIV care engagement among older black men living with HIV. Qualitative analysis entailed reading all transcripts, highlighting sections of texts to derive themes based on narratives of aging and technology use in the context of HIV, and care engagement. Next, each transcript was summarized, and themes and subthemes emerged under the domains of mobile technology use in general and for HIV care engagement and aging with HIV as a black man. The themes and subthemes were reviewed by the senior author and coauthors (with supporting excerpts

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Overview
A total of 12 black cisgender men (mean 57.7 [SD 6.5] years) living with HIV participated in one-on-one, semistructured interviews. Of these, 9 men reported receiving or applying for social security disability benefits; 3 men had full-time employment. The annual household income ranged from less than US $10,000 to $55,000. Moreover, 6 men (50%, 6/12) reported having a primary relationship partner. All men reported taking antiretroviral medications currently. The length of time on ART ranged from 3 to over 22 years.
We identified 4 major themes (with subthemes): (1) use of mobile technology, (2) use of mobile technology in HIV care, (3) the meanings associated with aging with HIV, and (4) mHealth design implications. In the following sections, we first present how men described using mobile phone technology, particularly with respect to HIV care engagement, and the barriers and challenges to its use. We present how men engaged in HIV care and treatment, including barriers and challenges the men referenced. Next, we present findings of what it means to age with HIV. Finally, we present mHealth design needs and considerations.

Use of Mobile Technology
Mobile technology literacy, reliance, and habits ranged widely. Some participants described being very technologically savvy and reliant on their phone. Some had at least two mobile devices. For example, a 50-year-old participant reported having 2 mobile phones, 1 for business purposes and the other to listen to music. Another participant also reported owning 2 mobile phones, an iPhone and an Android (ie, the Obama phone for eligible Medicaid recipients in California); he preferred the iPhone but has the other phone because he could not always pay for the service on the iPhone. He explained that he mostly used texting as a form of communication but used an iPad for email. He has other apps on his phone for accessing the news (eg, Huffington Post and BBC), social media (eg, YouTube), and dating sites (eg, Grindr). Other than calling and texting, the most common use of the mobile phone was to listen to music. One man explained that it is easy to use music apps relative to other features:

Challenges to Mobile Technology Use
Participants perceived the following barriers or challenges to using mobile technology: having low technology literacy, feeling uncomfortable using mobile technology, having limited access to data (affordability of data plans), and having privacy concerns. Some lamented being unfamiliar with features and described frustrating experiences, including the use of social media apps. One man referred to feeling overwhelmed when using Facebook: Of the 12 men, 6 men between the ages of 50 and 69 reported using social media apps. Of these 6 men, 2 referred to using both Facebook and Instagram or Twitter and Instagram. Moreover, 1 participant mentioned that he was "not very tech savvy" and used his phone primarily for texting, calling, and listening to music:

It can be a headache, my phone. I'm not all that savvy when it comes to technology and what not. But I use it for the basic necessities. I'm not glued to my phone daily.
Despite frustrations, many participants described that they "cannot live without the phone." A 66-year-old man with an iPhone described still learning how to use all of the features and occasional challenges. However, he described his phone as indispensable to everyday life. He used mobile apps to stream music, email, and keep track of his appointments. He also owned a tablet at home that he used to surf the Web.
Frustration with using mobile technology was almost always related with unfamiliarity with various features and navigating certain bells and whistles. Other challenges to using mobile technology included the hassle of having to register a user name and password. For example:

Use of Mobile Technology in HIV Care
Regarding use of technology related to health care, most participants reported using mobile apps in addition to making phone calls to engage in health care. In addition, 1 man indicated that he kept track of his medical appointments by setting reminders on his mobile phone devices. He explained that he used a pharmacy app to keep track of his medication refills and will receive a text alert when his medications are ready for pickup. He mentioned that he receives his lab test results via email and discusses them with his doctor. Some men used their mobile phone to Google information on symptoms or to stay on top of medical news such as the newest ART. One participant expressed: It is important to note that although many participants were reliant on and somewhat proficient with advanced mobile technology features, there were a few men who used the bare minimum. A few men were unable to access apps and other features because they did not own a smartphone, highlighting barriers to mobile technology for health care.
Despite a wide range in proficiency, almost all described mobile technology use in HIV care engagement. A 68-year-old man described not being too savvy and having an outdated phone but also showed some advanced use of technology for engaging in health care: he explained that he accessed all of his labs and physicians via their websites. Another man described his technology use to be very minimal; he nevertheless described using the app from his pharmacy, which sends him a reminder for prescription refills. Another man described using various apps, such as housing apps to find housing and a music app. He stays organized by using the calendar on his phone to set reminders. A 64-year-old man described using his mobile phone to research medications, conduct banking, and find social support group meeting times. He referred to using several apps, including the calendar on his phone, and social media (eg, WhatsApp and Facebook).

Loss of Opportunity
For several men, living through the HIV epidemic meant a loss of real opportunity and time to think and plan ahead. For the most part, these men accepted the widely held belief in the early days of the epidemic that they would never have to face getting older because they would die of AIDS first. For some, expecting to die young precluded putting hopes on one's future, as a 57-year-old man expressed:

Avoidance
Some men held the idea that aging meant becoming infirm, being an invalid, and growing surly and mean over time. This was in contrast with how they viewed themselves currently, representing a separation between aging as a negative concept and their self-perception. One participant described aging as "gray hair, disappointment at what you have not achieved, going forward with what you have, and trying to make the best of the rest of your life." Another 50-year-old participant expressed his dismay when someone younger referred to him as Pops:

Acceptance
In contrast, some men appeared to accept the idea of getting older and the inevitability of death. Many were thankful that they were able to manage HIV as a chronic disease, emphasizing the pointlessness in dwelling on the negative. A 63-year old described viewing aging with HIV as just part of life: Another man described how he maintains perspective on living with a chronic but manageable disease like HIV in terms of how things could be so much worse:

There's a lot of other things could be going on if I lived in a different part of the world. What is it like living in a poor neighborhood in Libya? What is it like in Syria for kids right now? Some people would do anything to be in my position or live on this planet. So I don't take it lightly, but I appreciate that it could be so much worse.
Some men understood aging in the context of surviving or defying HIV and expressed pride in having survived HIV. A 68-year-old man expressed appreciation for being alive when so many of his peers died during the AIDS epidemic:

Well, I was diagnosed in '85, so I've pretty much got the kinks out of the HIV craziness because I-many years of craziness around HIV, many years. So now I just take my medication. Actually, my relationship with HIV is, I'm really glad. Last Tuesday was my 68th birthday, so I'm really glad to be alive.
In addition, 1 man cited having a fighter attitude and admitted that he still looked forward to living a healthy and full life:

Willingness and Acceptability
There was a moderate level of acceptability of a mobile technology-based tool, such as an app, that would be designed for older men living with HIV to support care engagement. One participant appreciated the mHealth research focus on older

Connecting With Similar Others
Overall, 4 of the participants reported belonging to a social support group of older men living with HIV. Acceptance of older age appeared to be associated with being connected with similar others. Furthermore, 1 man explained that socializing with similar others helped him learn about or understand some of his own aging experiences: Health concerns among older men living with HIV were mostly unrelated to HIV but rather on the lack of guidance and focus on healthy aging. Men expressed a need for targeted messages that focus on their resilience in having survived the epidemic and on friends and family. Men who had been living with and managing their HIV for many years indicated that social support should not focus solely on HIV but rather on overall health and addressing barriers to healthy aging. These men emphasized that social spaces for older men living with HIV should have a positive spin on golden years because they felt that the focus these days was all on being and staying undetectable. Social groups that focus on healthy aging (physical and mental health) and the golden years may be a way to attract men who would otherwise be averse to interventions that focus solely on HIV:

Concerns About Confidentiality
A majority of the participants mentioned using passcodes on their mobile devices. A few men appeared reticent to use an app that would contain personal health data due to concerns about confidentiality. Furthermore, 1 man explained his concern about a loss of confidentiality trumping his desire to access his medical information in 1 central place on his mobile device:  [35]. Many men aging and living with HIV may lack visible and positive role models, perhaps due to the death of peers and social isolation exacerbated by social factors related to HIV stigma, aging, or both [36][37][38].
Findings also showed a wide range in the level of comfort and skill in using mobile technology. Many older black men relied heavily on their mobile phones to access entertainment such as music. The findings were encouraging of leveraging mobile technology as an HIV intervention platform: older black men relied on their mobile phones specifically in their HIV care, such as ordering their medications via drugstore apps or calling their providers to schedule appointments. Several reported using self-management apps (eg, calendar) and functionality (eg, reminders) to organize HIV care and treatment. Finally, we found evidence of acceptability of an mHealth intervention in the form of an app for enhancing HIV care and treatment among older black MSM.
These findings show where needs of older black MSM are similar to or different from those of young black MSM [39]. Similar to young black MSM, older black men considered confidentiality and privacy in mobile technology to be paramount [39]. Younger black men preferred a holistic approach to health in an mHealth intervention rather than one solely focused on HIV [39]. Similarly, older black men desired access to information on successful aging and health concerns unrelated to HIV. Regardless of age, men cited self-management as an important reason for using mobile technology. In contrast, although younger men relied heavily on apps [39], our findings with older men showed variability in the level of reliance on and comfort with using certain mobile phone features. Although some younger black men wanted to seek experienced sponsors for guidance and support [39], older black men were more varied on their desire for Web-based social connections. Future mHealth research should explore how a mentorship model facilitated by mHealth may be appropriate for connecting younger and older black MSM toward achieving better health.

Implications for Intervention
Our findings point to specific content areas that an mHealth HIV intervention should address with older black MSM.
Interventions that promote positive conceptions of aging with HIV may be particularly impactful. Promoting ideas about resiliency and the golden years may help men who otherwise avoid the topic incorporate holistic and dynamic models of aging into their self-concepts. Social isolation among the elderly is common, but among those living with HIV who are also sexual and/or gender minorities, social ties may be even more tenuous [40,41]. Areas for focus include information on healthy aging, connecting socially to similar others, and self-help aspects such as managing psychosocial distress. Men who wish to connect in person with others for social support may already belong to formal groups; those who are more socially isolated may want the option of connecting remotely to potential social groups at first. Thus, access to existing social support networks should be remote as well as in person [18]. Since many older men had been engaged in care and treatment for some time, content around HIV may be deemed irrelevant. In addition, some men expressed being tired of HIV prevention and health intervention messaging solely on HIV. mHealth interventions should focus on helping users define and achieve goals of aging along with promoting HIV care engagement.
Findings also guide the design of mHealth features. App features should be easy to navigate and focus on being operable right off the shelf, minimizing user burdens and cognitive loads. For example, usernames could be set to mobile telephone numbers rather than a unique username that may be hard for many to remember. The number of features should also be minimal, with a focus on simplicity and enhancing user experience. The tool should include reminding and camera functions the users are most likely to be familiar operating. Additional features may include day planners. Incorporating mobile phone capabilities such as music, social media, and video streaming may be a viable way to engage older black men [42].

Limitations
The findings are limited to a small sample size due to the pilot nature of the study. This study did not extensively explore how challenges to using mobile technology might be associated with specific aging-related cognitive, physical, perception, and motivation barriers to mobile technology [21]. Given the goal of the study, the small sample size, and sampling method, findings cannot be generalized. Eligibility for the study participation included owning a mobile phone, although ownership of a smartphone was not a criterion. A small minority of participants did not own a smartphone, even as smartphone devices are affordable through safety net, state-subsidized programs. Even as rates of adoption increase among older racial/ethnic and sexual and gender minorities, researchers are cautioned to consider existing constraints on mobile technology access.

Conclusions
Adoption of digital technology among older black MSM living with HIV is likely influenced by a multitude of issues [22]. This study adds to the scant literature specific to older black MSM living with HIV, a population showing health disparities and for whom no mHealth interventions exist [42]. Mobile technology for promoting healthy aging with HIV among older black MSM appears acceptable and is likely to be feasible based on extant digital technology for advancing black men's health [18]. mHealth interventions for older black men living with HIV can educate and promote healthy concepts of aging with HIV and support self-management skills and behavior around HIV care, such as adhering to ART [18]. It is paramount that future research to develop mHealth interventions work with black MSM to explore culturally relevant mHealth strategies rather than apply a one-size-fits-all approach.