Evaluation of a Computer-Based HIV Education Program for Adults Living with HIV

  • Shrinidhi Subramaniam
  • Carol-Ann Getty
  • August F. Holtyn
  • Andrew Rodewald
  • Brian Katz
  • Brantley P. Jarvis
  • Jeannie-Marie S. Leoutsakos
  • Michael Fingerhood
  • Kenneth SilvermanEmail author
Original Paper


This study evaluated a computer-delivered HIV and antiretroviral treatment education program in adults (N = 102) living with detectable HIV viral loads (> 200 copies/mL). The self-paced program provided immediate feedback for responses and financial incentives for responding correctly. The program was divided into three courses and a test of content from all three courses was delivered before and after participants completed each course. Test scores on the content delivered in Courses 1, 2 and 3 improved only after participants completed training on the relevant course. Initial test scores were positively correlated with health literacy and academic achievement; were negatively correlated with viral load; and were lowest for participants living in poverty. Education, academic achievement, and health literacy were related to how much participants learned following each course. Computer-based education is a convenient, effective approach to promoting an understanding of HIV and its treatment.


Instructional technology Health education Medication adherence Multiple-probe design Fluency training 



The preparation of this publication was supported by the National Institute of Allergy and Infectious Diseases and the National Institute on Drug Abuse of the National Institutes of Health under Award Nos. R01AI117065 and T32DA07209.

Compliance with Ethical Standards

Conflict of interest

The authors have no conflicts of interest to report.

Ethical Approval

All procedures performed in this study were approved by the Johns Hopkins School of Medicine Institutional Review Board.

Supplementary material

10461_2019_2474_MOESM1_ESM.docx (43 kb)
Supplementary material 1 (DOCX 43 kb)


  1. 1.
    Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. Department of Health and Human Services, Washington, DC. 2017. AdultandAdolescentGL.pdf. Accessed 30 June 2018.
  2. 2.
    World Health Organization. Consolidated Guidelines on the use of antiretroviral drugs for treating and preventing HIV infections: recommendations for a public health approach. 2nd ed. Author, Geneva. 2016. Accessed 30 June 2018.
  3. 3.
    Leone S, Gregis G, Quinzan G, et al. Causes of death and risk factors among HIV-infected persons in the HAART era: analysis of a large urban cohort. Infection. 2011;39(1):13–20.CrossRefGoogle Scholar
  4. 4.
    Montaner JS, Lima VD, Barrios R, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010;376(9740):532–9.CrossRefGoogle Scholar
  5. 5.
    Gebo KA, Fleishman JA, Conviser R, et al. Contemporary costs of HIV health care in the HAART era. AIDS. 2010;24(17):2705–15.CrossRefGoogle Scholar
  6. 6.
    Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Eng J Med. 2016;375(9):830–9.CrossRefGoogle Scholar
  7. 7.
    Das M, Chu PL, Santos GM, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5(6):1–9.CrossRefGoogle Scholar
  8. 8.
    Montaner JS, Wood E, Kerr T, et al. Expanded highly active antiretroviral therapy coverage among HIV-positive drug users to improve individual and public health outcomes. J Acquir Immune Defic Syndr. 2010;55:S5–9.CrossRefGoogle Scholar
  9. 9.
    Crepaz N, Tang T, Marks G, Mugavero MJ, Espinoza L, Hall HI. Durable viral suppression and transmission risk potential among persons with diagnosed HIV infection: United States, 2012–2013. Clin Infect Dis. 2016;63(7):976–83.CrossRefGoogle Scholar
  10. 10.
    Kay ES, Batey DS, Mugavero MJ. The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future. AIDS Res Ther. 2016;13(35):1–7.Google Scholar
  11. 11.
    Center for HIV Surveillance, Epidemiology and Evaluation. Baltimore City HIV Annual Epidemiological Profile. Maryland Department of Health, Baltimore, MD. 2017. Accessed 18 Dec 2018.
  12. 12.
    Bangsberg DR, Ragland K, Monk A, Deeks SG. A single tablet regimen is associated with higher adherence and viral suppression than multiple tablet regimens in HIV+ homeless and marginally housed people. AIDS. 2010;24(18):2835–40.CrossRefGoogle Scholar
  13. 13.
    Metsch LR, Feaster DJ, Gooden L, et al. Effect of patient navigation with or without financial incentives on viral suppression among hospitalized patients with HIV infection and substance use: a randomized clinical trial. JAMA. 2016;316(2):156–70.CrossRefGoogle Scholar
  14. 14.
    Ford N, Nachega JB, Engel ME, Mills EJ. Directly observed antiretroviral therapy: a systematic review and meta-analysis of randomised clinical trials. Lancet. 2009;374(9707):2064–71.CrossRefGoogle Scholar
  15. 15.
    Pop-Eleches C, Thirumurthy H, Habyarimana JP, et al. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS. 2011;25(6):825–34.CrossRefGoogle Scholar
  16. 16.
    Thompson MA, Mugavero MJ, Amico KR, et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med. 2012;156(11):817–33.CrossRefGoogle Scholar
  17. 17.
    Kalichman SC, Benotsch E, Suarez T, Catz S, Miller J, Rompa D. Health literacy and health-related knowledge among persons living with HIV/AIDS. Am J Prev Med. 2000;18(4):325–31.CrossRefGoogle Scholar
  18. 18.
    Zhou G, Li X, Qiao S, Shen Z, Zhou Y. Influence of side effects on ART adherence among PLWH in China: the moderator role of ART-related knowledge. AIDS Behav. 2018;22(3):961–70.CrossRefGoogle Scholar
  19. 19.
    Yathiraj AB, Unnikrishnan B, Ramapuram JT, et al. HIV-related knowledge among PLWHA attending a tertiary care hospital at coastal South India—a facility-based study. J Int Assoc Provid AIDS Care. 2017;16(6):615–9.CrossRefGoogle Scholar
  20. 20.
    Flickinger TE, Saha S, Moore RD, Beach MC. Higher quality communication and relationships are associated with improved patient engagement in HIV care. J Acquir Immune Defic Syndr. 2013;63(3):362–6.CrossRefGoogle Scholar
  21. 21.
    Goujard C, Bernard N, Sohier N, et al. Impact of a patient education program on adherence to HIV medication. J Acquir Immune Defic Syndr. 2003;34(2):191–4.CrossRefGoogle Scholar
  22. 22.
    Brock TP, Smith SR. Using digital videos displayed on personal digital assistants (PDAs) to enhance patient education in clinical settings. Int J Med Inform. 2007;76(11–12):829–35.CrossRefGoogle Scholar
  23. 23.
    Henny KD, Wilkes AL, McDonald CM, Denson DJ, Neumann MS. A rapid review of eHealth interventions addressing the continuum of HIV care (2007–2017). AIDS Behav. 2018;22(1):43–63.CrossRefGoogle Scholar
  24. 24.
    Marsch LA, Bickel WK. Efficacy of computer-based HIV/AIDS education for injection drug users. Am J Health Behav. 2004;28(4):316–27.CrossRefGoogle Scholar
  25. 25.
    Barrett BH, Beck R, Binder C, et al. The right to effective education. Behav Anal. 1991;14(1):79–82.CrossRefGoogle Scholar
  26. 26.
    Silverman K, Lindsley OR, Porter KL. Overt responding in computer-based training. Curr Psychol. 1990;9(4):373–84.CrossRefGoogle Scholar
  27. 27.
    Prue DM, Fairbank JA. Performance feedback in organizational behavior management: a review. J Organ Behav Manag. 1981;3(1):1–16.Google Scholar
  28. 28.
    Koffarnus MN, DeFulio A, Sigurdsson SO, Silverman K. Performance pay improves engagement, progress, and satisfaction in computer-based job skills training of low-income adults. J Appl Behav Anal. 2013;46(2):395–406.CrossRefGoogle Scholar
  29. 29.
    Getty C, Subramaniam S, Holtyn AF, Jarvis BP, Rodewald A, Silverman K. Evaluation of a computer-based training program to teach adults at risk for HIV about pre-exposure prophylaxis. AIDS Educ Prev. 2018;30(4):287–300.CrossRefGoogle Scholar
  30. 30.
    Spaan P, van Luenen S, Garnefski N, Kraaij V. Psychosocial interventions enhance HIV medication adherence: a systematic review and meta-analysis. J Health Psychol. 2018. Scholar
  31. 31.
    McLellan AT, Kushner H, Metzger D, Peters R, Smith I, Grissom G, et al. The fifth edition of the Addiction Severity Index. J Subst Abuse Treat. 1992;9(3):199–213.CrossRefGoogle Scholar
  32. 32.
    Wilkinson G. WRAT-3 Wide Range Achievement Test. Wilmington, DE: Wide Range Inc.; 1993.Google Scholar
  33. 33.
    Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults. J Gen Int Med. 1995;10(10):537–41.CrossRefGoogle Scholar
  34. 34.
    Beck AT, Steer RA, Brown GK. Beck depression inventory-II. San Antonio. 1996;78(2):490–8.Google Scholar
  35. 35.
    Horner RD, Baer DM. Multiple-probe technique: a variation of the multiple baseline. J Appl Behav Anal. 1978;11(1):189–96.CrossRefGoogle Scholar
  36. 36.
    Johnson KR, Layng TJ. Breaking the structuralist barrier: literacy and numeracy with fluency. Am Psychol. 1992;47(11):1475–90.CrossRefGoogle Scholar
  37. 37.
    Binder C. Behavioral fluency: evolution of a new paradigm. Behav Anal. 1996;19(2):163–97.CrossRefGoogle Scholar
  38. 38.
    Denning P, DiNenno E. Characteristics associated with HIV infection among heterosexuals in urban areas with high AIDS prevalence-24 cities, United States, 2006–2007. 2010. Accessed 30 June 2018.
  39. 39.
    Oldenburg CE, Perez-Brumer AG, Reisner SL. Poverty matters: contextualizing the syndemic condition of psychological factors and newly diagnosed HIV infection in the United States. AIDS. 2014;28(18):2763–9.CrossRefGoogle Scholar
  40. 40.
    Ayotte BJ, Allaire JC, Bosworth H. The associations of patient demographic characteristics and health information recall: the mediating role of health literacy. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2009;16(4):419–32.CrossRefGoogle Scholar
  41. 41.
    Kalichman SC, Pope H, White D, et al. The association between health literacy and HIV treatment adherence: further evidence from objectively measured medication adherence. J Int Assoc Physicians AIDS Care (Chic). 2008;7(6):317–23.CrossRefGoogle Scholar
  42. 42.
    Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14(5):267–73.CrossRefGoogle Scholar
  43. 43.
    Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr. 2000;25(4):337–44.CrossRefGoogle Scholar
  44. 44.
    Paasche-Orlow MK, Cheng DM, Palepu A, Meli S, Faber V, Samet JH. Health literacy, antiretroviral adherence, and HIV-RNA suppression. J Gen Intern Med. 2006;21(8):835–40.CrossRefGoogle Scholar
  45. 45.
    Kalichman SC, Cherry C, Kalichman MO. Randomized clinical trial of HIV treatment adherence counseling interventions for people living with HIV and limited health literacy. J Acquir Immune Defic Syndr. 2013;63(1):42–50.CrossRefGoogle Scholar
  46. 46.
    Miller TA. Health literacy and adherence to medical treatment in chronic and acute illness: a meta-analysis. Patient Educ Couns. 2016;99(7):1079–86.CrossRefGoogle Scholar
  47. 47.
    Nebel IT, Klemm T, Fasshauer M. Comparative analysis of conventional and an adaptive computer-based hypoglycaemia education programs. Patient Educ Couns. 2004;53(3):315–8.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Shrinidhi Subramaniam
    • 1
    • 3
  • Carol-Ann Getty
    • 1
    • 2
    • 4
  • August F. Holtyn
    • 1
  • Andrew Rodewald
    • 1
  • Brian Katz
    • 1
    • 5
  • Brantley P. Jarvis
    • 1
    • 6
  • Jeannie-Marie S. Leoutsakos
    • 1
  • Michael Fingerhood
    • 1
  • Kenneth Silverman
    • 1
    Email author
  1. 1.Department of Psychiatry and Behavioral Sciences, Center for Learning and HealthJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Psychology DepartmentUlster UniversityColeraineUK
  3. 3.California State University, StanislausTurlockUSA
  4. 4.King’s College LondonLondonUK
  5. 5.West Virginia UniversityMorgantownUSA
  6. 6.Knowesis, LLCFairfaxUSA

Personalised recommendations