Despite important gaps in our understanding of the HIV epidemic among adolescents (age, 10-19 years), available data indicate that this age group experiences high rates of new HIV infection, has less access to treatment, and is more likely to discontinue treatment and die from HIV-related causes than other age groups [1,2]. More than 80% of adolescents living with HIV (ALHIVs) are in sub-Saharan Africa, where, despite considerable progress, treatment coverage remains challenging: By 2016, less than 50% of ALHIVs received treatment [1-3]. Between 2010 and 2016, HIV-related mortality among adolescents decreased by 5% globally and 14% in Eastern and Southern Africa; however, in Western and Central Africa, the related mortality increased by 15% [2].

In 2016, nearly 50% of HIV-related deaths among adolescents in Western and Central Africa occurred in Nigeria [2]. One contributing factor to the high mortality may be poor treatment retention among ALHIVs. A 2016 study of youth (age, 14-24 years) initiating antiretroviral therapy (ART) in Nigeria found that they were less likely to remain in treatment at 12 months (46% vs 53%) and more likely to experience treatment disruptions (>3 months between clinic visits) in their first year on ART than older adults (relative risk=1.15, P=.008) [4].

Fear of stigma or disclosure, lack of social support, and limited knowledge about the disease, compounded by the physical, social, and psychological changes of adolescence, create numerous challenges to successful treatment [5-10]. For example, adolescence is a time when relationships outside of the immediate family, such as those with peers, become very important [11]; however, because of HIV-related stigma and discrimination, ALHIVs rarely disclose their status to their peers for fear of losing them, which can negatively impact their psychosocial well-being and treatment [12-13].

Evidence of effective interventions to improve treatment outcomes among ALHIVs, particularly in low- and middle-income countries, is limited [14-15]. ALHIVs are also less likely than adults or younger children to be targeted with interventions to improve health outcomes [14,15]; however, some intervention strategies designed for adults may be effective for ALHIVs. Emerging evidence supports group counseling and structured support groups as effective ways to improve adherence and retention among adults [16-21]. Digital health interventions such as mobile phone reminders improved adherence among adults in some low- and middle-income countries [22-27]. Two recent studies targeting youth in South Africa and the United States demonstrated that online social network interventions could be acceptable and feasible in this population [28-29].

According to a 2014 survey, 89% of Nigerians aged ≥ 18 years owned a mobile phone [30]. A 2012 study in Nigeria found that more than half of the females aged 12-30 years owned a phone, and almost all who did not own a mobile phone had access to one [31]. The rapid increase in mobile phone use in Nigeria indicates the potential of digital health strategies to help meet the support needs of ALHIVs.

In this study, we aimed to develop and test the feasibility and acceptability of a structured support group intervention—SMART (Social Media to promote Adherence and Retention in Treatment) Connections—which is delivered through a social media platform to improve retention in HIV health services and ART adherence among ALHIVs aged 15-19 years in periurban southern Nigeria.

A total of 41 adolescents enrolled in the study and completed a baseline interview, of whom 38 started the intervention and 35 completed the endpoint questionnaire. A flow chart describing the identification, enrollment, and follow-up of participants is presented in Figure 4.

Several individuals initially deemed eligible according to clinical records were later found to be ineligible due to incorrect age information in their medical records. Of those confirmed to meet eligibility criteria, 13 parents or guardians refused to allow their child to participate, 5 of whom stated they had not yet disclosed their child’s HIV status to him or her.

Participants were nearly equally divided by sex (Table 1). About half of the participants were enrolled in school, mostly in secondary school, and one-quarter were employed. All participants had a home or primary residence. Most participants had been on ART for >4 years; 90% (37 of 41) had at least one CD4 cell count test recorded in their medical record, but only 73% (30 of 41) had a viral load test recorded in their medical record (Table 1). Among those with a recorded viral load, half were virally suppressed (Table 1). All participants who were not virally suppressed had viral loads >5000 copies/mL (data not shown).

Three-quarters of all participants lived with one or both parents, and the rest lived with other family members, including one participant who was married and lived with the spouse (Table 2). The majority (68%) reported that at least one parent knew of their HIV status; fewer participants had other family members who knew their status, and only 3 (7%) reported that a close friend knew their status. Six participants stated they were in romantic relationships, and all but one participant reported that their partner knew their HIV status; 5 of the 6 participants knew their partner’s HIV status.

This online support-group intervention was feasible to implement and highly acceptable among the ALHIVs who participated in the study. We obtained important information on specific challenges and ways to improve the intervention in order to enhance delivery and participation.

The level of active participation varied, within and across groups, which is similar to in-person support groups [21]. Group participation appeared to correlate with facilitator activity, although other factors such as logistic issues also played a role in individual participation within groups. Notably, the facilitator with the lowest overall participation performed the worst on timely and complete posting of sessions. In the future, experienced, dynamic facilitators with adequate mastery of intervention delivery should be recruited; however, even participants with low active participation reported high levels of satisfaction and appear to have benefitted from the intervention. With social media, the ability to follow conversations may allow those who are not comfortable commenting, to learn from others in the group [39,40]. Basic literacy was an important factor to the success of the intervention. Education levels are relatively high in southern Nigeria; 75.9% of women aged 15-49 years have completed some secondary school or higher education [41]. As such, implementing this intervention for individuals with low education levels could prove more difficult.

The time taken for identification and enrolment of adolescents through health facilities was longer than anticipated. Although Nigeria bears the second-highest burden of HIV on the continent in terms of absolute numbers of people infected [42], its prevalence is relatively low, with higher pockets of concentration in certain geographic areas [43]. According to the recently conducted AIDS Indicator Survey in Akwa Ibom State (2017), HIV prevalence among adolescents aged 15-19 years is 1.5% [44]. Facility staff attempted, without success, to reach several patients through their recorded contact information, which highlights the challenge of poor retention in health care services among this age group. Although inclusion of fewer eligible participants than anticipated complicated study enrollment, it supports the potential role of an online intervention that does not require individuals to live near each other or travel to a designated location and could connect people across a broader geographic area.

We also faced a few challenges during implementation of the study. Considering the limitations of the study phones, future interventions should use smartphones, which are increasingly popular and affordable, even in low- and middle-income countries [45]. Network coverage problems also limited use of the intervention among some participants. Despite these challenges, most subjects participated in most sessions.

Surprisingly, all participants who voiced an opinion preferred online support groups, either alone or in combination with an in-person group, but none of them preferred in-person groups alone. The global trend toward use of and comfort with social media among young people seems to have reached youths in periurban and rural southern Nigeria [46].

This study had a few limitations. The nonprobability sample prevents generalization of the results beyond the study sample. Social desirability bias may play a role in participants’ responses to questions about the intervention. In addition, we adapted only 5 of 14 sessions from Positive Connections; therefore, we do not know if participation may change with a longer curriculum. Moreover, we could not determine if facilitators drove participation or group member participation drove facilitator engagement.

In conclusion, this feasibility study demonstrated that an online support group intervention was both feasible and acceptable among ALHIVs in southern Nigeria. Our results provide guidance on changes required to enhance participation. Based on these findings, we have adapted the intervention and expanded it to include the remaining Positive Connections topics. A subsequent randomized controlled trial will test the cost-effectiveness of this revised intervention to improve HIV treatment outcomes.