Internet-based peer support interventions for people living with HIV: A scoping review.

Peer support interventions for people living with HIV and AIDS (PLWHA) are effective, but their associated time and material costs for the recipient and the health system make them reachable for only a small proportion of PLWHA. Internet-based interventions are an effective alternative for delivering psychosocial interventions for PLWHA as they are more accessible. Currently, no reviews are focusing on internet-based interventions with peer support components. This scoping review aims to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We conducted a systematic scoping review of academic literature following methodological guidelines for scoping reviews, and 28 articles met our criteria. We summarized the main characteristics of the digital peer support interventions for PLWHA and how they implemented peer support in a virtual environment. Overall the reported outcomes appeared promising, but more robust evidence is needed.

Introduction

Human Immunodeficiency Virus (HIV) affects more than 37.7 million people worldwide and its prevalence is still increasing [1]. The primary HIV treatment is Antiretroviral Therapy (ART) which works to suppress replication of the virus resulting in improved immune response and reduced viral load. However, inadequate adherence to ART is associated with morbidity and mortality [2-4].

Because of the essential role of adherence in the success of ART, a myriad of research has been carried out to understand ART adherence. Among factors that predict HIV treatment adherence, an important role has been found in psychosocial factors such as social support [5-7], HIV stigma [6, 8, 9], stress and depression [7, 10–14], violence [15, 16] and alcohol and other drug consumption [17-19], which increase the probability of a disadvantageous outcome by adding substance abuse stigma [20]. Consequently, different psychosocial interventions have been developed to address treatment adherence, and they have increasingly been demonstrated to enhance HIV adherence and improve health in people living with HIV/AIDS (PLWHA) [10, 11, 19, 21–26]. Peer support is the support provided by people who share life experiences [27]. Applied to interventions, peer support typically includes group meetings, support networks (either virtual or in-person), or peer-mentoring [28]. Peer support has been a common and effective strategy for people living with stigmatized conditions [29-32]. Peer support is also efficient in lowering the overall costs of medical provision [31-33].

Specifically, in PLWHA, peer support interventions have shown to address internalized stigma [34-38] adequately, reduce depressive symptomatology [34] and stress [35-39], enhance the quality of life and wellness [40], and improve treatment adherence [41-48].

Peer support interventions are recommended in official health guidelines such as the Center for Disease and Prevention [49] and the British HIV Association [50].

However, these services are rarely offered in HIV clinics due to existing structural barriers, such as a lack of mental health services and difficulties in accessing services [51, 52]. Against this scenario, internet-based interventions have proliferated. These are easy to access by many people due to resource-saving and flexible delivery [53]. Additionally, internet-based interventions offer anonymity, are easily accessible, and are also scalable [51, 54–56]. Therefore, they have been suggested as an alternative to overcome the barriers mentioned above [57, 58].

Recent reviews of internet-based interventions have significantly impacted outcomes, including adherence, viral load, mental health, and social support for PLWHA [59, 60].

However, none of the reviews has focused on peer support interventions delivered virtually.

We conducted a scoping review to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We chose the scoping review methodology developed by Peters and colleagues [61] since it allows comprehensive identification of the types and nature of psychosocial interventions for PLWHA, based on peer support and delivered through the internet described in the published literature [61]. Specifically, this review aims to answer the following questions: 1) What internet-based peer support interventions are available for PLWHA? What are their main characteristics? 2) How do the available interventions integrate peer support?

To our knowledge, this is the first systematic effort to provide such an overview.

Methods

Protocol and registration

We conducted a systematic scoping review of the peer-reviewed academic literature following the Joanna Briggs Institute (JBI) methodological guidance for scoping review [62] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews [63] Our pre-registered protocol containing the detailed methods is available at Open Science Framework (http://osf.io/r729p) (S1 Appendix).

Eligibility criteria

We included studies about psychosocial interventions designed explicitly for PLWHA and AIDS, based on peer support and delivered through technological devices and/or the internet. For this scoping review, any comparator was relevant for inclusion, and studies without a comparator were also assessed for eligibility. All available publications were eligible for inclusion (e.g., articles -any design, excluding systematic and scoping reviews-articles in conference proceedings, websites, chapters in textbooks). This scoping review had no limitations regarding the time of publication and duration of the intervention and no language restriction. S1 and S2 Appendices show the eligibility criteria and the search strategy.

Information sources

A comprehensive literature research of electronic bibliographic databases was conducted in PUBMED, Web of Science (WOS), and CINAHL Complete (through EBSCO). This selection was made according to our institutional availability/accessibility; for this reason, some databases were excluded (e.g., EMBASE, Cochrane). All databases and sources of information were consulted on March 10, 2022. The reference lists of 13 relevant reviews on the topic were screened [19, 25, 26, 64–73].

Search

We developed the search strategy using the PRESS (Peer Review of Electronic Search Strategies) checklist [74], which was adapted to three databases. This step was conducted by the investigators (S.C.C. & A.G.C.) without the collaboration of a librarian due to institutional limitations. The words used were related to telemedicine or internet-delivered interventions (i.e., ehealth, digital health, mobile health), HIV or AIDS, and peer support or support group (for the complete search string, see S3 Appendix) were searched in the articles’ title. No other limitation was applied to the search.

Sources of evidence selection

The database and manual searches were exported into Microsoft Excel [75]. Duplicate papers were removed. Two reviewers (S.C.C. & A.G.C.) independently screened each article for inclusion by title, excluding articles that failed the eligibility criteria. Then, the same two reviewers independently screened the article by abstract using a Google form questionnaire containing details to inform decision-making about inclusion/exclusion. Disagreements between reviewers were resolved through an iterative consensus process involving multiple rounds of deliberative discussion.

Data charting process

The authors developed a Google form questionnaire with detailed instructions (S.C.C. & A.G.C.) and were approved by the research team to achieve the charting process. This form was guided by the objectives of the present review, being the items related to articles’ characterization and their conceptualization of peer support. To ensure internal consistency, some articles were codified in duplicate by two authors (S.C.C. & A.G.C.) and the rest was done independently by the same researchers.

Data items

First, articles’ data were sought regarding study characterization: 1) year of publication; 2) location of the study; 3) study design/article type; 4) population; 5) name of the intervention; and 6) type of technology used. Then, the articles were revised to identify their conceptualization of the peer support component of the intervention (i.e., peer support application).

Synthesis of results

Data was summarized in a narrative account following the guidelines for scoping reviews [76].

Results

Selection of sources of evidence

The initial search yielded 517 articles, and 15 more were found by manual search from reviews’ citations. After the removal of duplicate titles, 416 articles were left. Then, two authors (S.C.C. & A.G.C.) screened titles and abstracts, and 28 articles were included in the review and went through the codification process (Fig 1).

Fig 1

PRISMA flowchart.

Characteristics of sources of evidence

As shown in Table 1, of the total of included articles, 13 were published during 2017–2019 [77-89], eight during 2020–2022 [90-97], four during the 2014–2016 period [98-101], two were published during 2008–2010 [102, 103], and one during 2011–2013 [104].

Table 1

Characterization of included articles.

Articles’ Characteristics
Year of Publication	n (%)
2008–2010	2 (7.14)
2011–2013	1 (3.57)
2014–2016	4 (14.28)
2017–2019	13 (46.42)
2020–2022	8 (28.57)
Location
China	2 (7.14)
Kenya	3 (10.71)
Malaysia	1 (3.57)
Nigeria	1 (3.57)
South Africa	3 (10.71)
Tanzania	1 (3.57)
Uganda	1 (3.57)
UK	2 (7.14)
USA	12 (42.85)
Zambia	2 (7.14)
Type of Study
Pilota	8 (28.57)
Other Clinical Trialsb	7 (25)
Protocolc	5 (17.85)
Qualitative	5 (17.85)
Randomized Clinical Trial	2 (7.14)
Randomized Clinical Trial	1 (3.57)

a Pilot,feasibility and acceptability trials.

bAll types of clinical trial designs (e.g. pre-post, with no control group).

c Protocols for Randomized Controlled Trials and other designs.

The majority of articled revised were studies conducted in the United States (12) [77, 80–82, 84, 88, 90, 94, 95, 99, 100, 104], three were from Kenya [86, 92, 102] and three from South Africa [85, 93, 101]. Locations like China, the United Kingdom and Zambia had two studies included in this review [79, 87, 91, 96, 98, 103] and, from the total of articles included, only one article was from Malaysia, Nigeria, Tanzania and Uganda [78, 83, 89, 97].

Regarding the study type, eight of the included articles corresponded to pilot studies [77, 79, 86, 88, 92, 101, 102, 104], while seven articles explicitly indicate a clinical trial type of design [83, 85, 86, 90, 95, 96, 98], as well as five protocols [80–82, 93, 94] and five qualitative studies [87, 91, 99, 100, 103]. Only two Randomized Controlled Trials [78, 97], and one cohort study [89].

Peer support interventions

Table 2 summarizes the total of interventions included and reviewed in this work. Only 20 of the total of 28 mentioned a specific name for the intervention.

Table 2

Interventions’ name.

Interventions’ Name
Reference
Winstead-Derlega et al., 2012	Positive Project
Broaddus et al., 2015	My YAP Family
Henwood et al., 2016	Khaya HIV Positive
Flickinger et al., 2017	Positive Links
Westergaard et al., 2017	mPeer2Peer
Dulli et al., 2018	SMART Connections
Horvath et al., 2018	Thrive With Me
Hacking et al., 2019	The Virtual Mentors Program
Horvath et al., 2019	YouTHrive
Ivanova et al., 2019	ELIMIKA
Knudson et al., 2019	China MP3 (Multi-component HIV Intervention Packages for Chinese MSM)
Navarra et al., 2019	ACCESS (Adherence Connection for Counseling, Education, and Support)
Tun et al., 2019	CBHTC+ (Intervention within Sauti project)
Hay et al., 2020	4MNetwork
MacCarthy et al., 2020	SITA (SMS as an Incentive To Adhere)
Ochoa et al., 2021	LINX App / LINX App Plus
Simpson et al., 2021	Insaka
Steinbock et al., 2022	End+dDisparities ECHO Collaborative
Stockman et al., 2021	LinkPositively
Zanoni et al., 2022	InTSHA (Interactive Transition Support for Adolescents Living With HIV using Social Media)
Mo & Coulson, 2008	Unnamed
Wools-Kaloustian et al., 2009
Mi et al., 2015
Abdulrahman et al., 2017
Senn et al., 2017
Rotheram et al., 2019
St Clair-Sullivan et la., 2019
Chory et al., 2022

Interventions’ main characteristics

The total of interventions included were codified according to their characteristics such as target population, eHealth type and the objective of each intervention. Table 3 summarizes the information of these categories.

Table 3

Main characteristics of the included interventions.

Interventions’ Main Characteristics
Reference	Target Population	Digital Health Tool	Interventions’ Objective
Winstead-Derlega et al., 2012	Rural adults (18 or older)	iPod preprogrammed with peer health videos	Improve treatment adherence and reduce the perception of stigma
Broaddus et al., 2015	Young adults (16–25 years)	Private Facebook group	Improve patient well-being
Henwood et al., 2016	Adolescents and young adults (12–25 years)	Chat-room through MXit social networking platform	Retain youth throughout the continuum of care and provide ongoing social support within a peer learning environment
Flickinger et al., 2017	Adults (18 or older), attending a university clinic	Smartphone App	Improve treatment adherence
Westergaard et al., 2017	Adults (18 or older), history of substance abuse	Smartphone App	Support HIV treatment for patients who had been marginally engaged in care
Dulli et al., 2018	Adolescents (15–19 years), on ART treatment	Private Facebook group	Improve HIV knowledge, social support, and treatment adherence
Horvath et al., 2018	Men (MSMd), suboptimal adherence to treatment	Website and SMS	Assess the impact of the intervention on the target population
Hacking et al., 2019	Adolescents and young adults (12–25 years), newly diagnosed HIV positive, not in treatment	Smartphone communication (SMS, phone call or WhatsApp)	Improve treatment adherence by referring patients to an adherence club
Horvath et al., 2019	Adolescents and young adults (15–24 años)	Website	Enhance treatment adherence and improve other outcomes (e.g. decreased viral load)
Ivanova et al., 2019	Adolescents and young adultos (15–24 years), all level of treatment	Website	Improve treatment adherence
Knudson et al., 2019	Men (MSM) newly diagnosed HIV positive	SMS	Facilitate engagement in care and initiation of antiretroviral therapy
Navarra et al., 2019	Adolescents and young adults (16–29 years), belonging to ethnic minority (African Americans and Hispanics/Latinos)	Mobile platform	Improve treatment adherence
Tun et al., 2019	Female sex workers (FSW)	WhatsApp	Improve treatment adherence
Hay et al., 2020	Mothers	WhatsApp	Improve social support (informational, emotional, and practical support)
MacCarthy et al., 2020	Adolescents and young adults (15–24 years), taking ART	SMS	Improve treatment adherence
Ochoa et al., 2021	Adults (18 or older), male Black or African American, belonging to a sexual minority	Web based mobile App	Provide social and legal resources and peer support
Simpson et al., 2021	Adolescent pregnant women (28–34 weeks of pregnancy)	Smartphone (message platform)	Assess the feasibility and acceptability of this mobile phone-based support group intervention
Steinbock et al., 2022	Adolescents and young adults (13–24 years), men (MSM) with men of color, Black/African American and Latina women, and transgender people	Videoconferences	Improve rates of viral suppression
Stockman et al., 2021	Adults (18 or older) Woman with African American, Black, or of African descent and experience of interpersonal violence	Web based App	Improve retention in care, treatment adherence, and viral suppression
Zanoni et al., 2022	Adolescents (15–19 years), with perinatally acquired HIV	Smartphone (websites, phone call, WhatsApp)	Evaluate the retention in care during the transition from pediatric to adult care
Mo & Coulson, 2008	Adults	Website	Improve social support
Wools-Kaloustian et al., 2009	Adults, stable in cART treatment	Website	Improve treatment adherence
Mi et al., 2015	Adults (18 or older), men (MSM)	Website, online sessions (discussion and counseling)	Promote safe sex behaviors and access to HIV services
Abdulrahman et al., 2017	Adults	SMS, phone call	Enhance treatment adherence and improve other outcomes (e.g. decreased viral load)
Senn et al., 2017	Adults (18 or older), black men (MSM)	Smartphone App	Improve retention in care and treatment adherence
Rotheram et al., 2019	Adolescents and young adults, all level of treatment	Website, SMS, and phone call	Promote retention in care during treatment continuum in youth
St Clair-Sullivan et la., 2019	Adolescents and young adults (16–24 years), currently receiving HIV care	Smartphone communication (WhatsApp and Facebook)	Identify barriers to HIV care and the acceptability and of mHealth to improve treatment adherence
Chory et al., 2022	Children and adolescents (10–19 years), on ART treatment	WhatsApp	Enhance treatment adherence, reduce stigma and improve mental health

dMen who have Sex with other Men.

Target population. All the interventions were exclusively conducted for PLWHA. Of the total of interventions reviewed, 10 of them were orientated to an adult population (18 years or older) [77, 78, 88, 94, 95, 98, 99, 102–104], nine were tailored for children, adolescents, and young adults [79–81, 84–86, 90, 97, 101], three interventions were exclusively designed for adolescents [83, 93, 96], and only one was made exclusive for young adults [100]. Finally, four interventions were orientated to other populations (e.g., mothers, female sex workers, men who have sex with other men [MSM]) [82, 87, 89, 91].

Type of digital health. The interventions used a myriad of digital tools to be delivered. The use of social networking platforms such as Facebook and WhatsApp was one of the most frequent strategies (n = 7) of the reviewed studies [79, 83, 85, 92, 93, 100, 101], as well as the use of websites (n = 7) [80–82, 86, 98, 102, 103]. The development of a smartphone App was also present in 4 interventions [77, 88, 96, 99], along with the use of SMS and phone calls to establish communication between peers [78, 81, 85, 93]. Only three studies developed a web-based platform [84, 94, 95], two used SMS communication exclusively [87, 97], and two interventions were delivered via videoconference [90, 98]. Only one intervention showed the participants´ videos made by peers [104].

Interventions’ goals. The most common objectives were treatment adherence (n = 14) [78, 80, 82–86, 88, 89, 92, 95, 99, 102, 104], and social support (n = 7) [77, 83, 91, 94, 96, 101, 103]. Five of the interventions were dedicated to retention in care [87, 88, 93, 95, 101], and four to viral load suppression [78, 80, 90, 95]. Two interventions were oriented to stigma reduction [92, 104] and the other two to increase HIV knowledge [83, 98]. Finally, the aims of well-being [100], mental health [92], and legal support [94] were included only once each.

Peer support implementation

The role of peer support was incorporated differently in the revised interventions. Some interventions combined more than one strategy to implement peer support. The communication via posts in a group board or online forums was one of the most common interventions (n = 7) [79–82, 94, 99, 103], followed by the use of peer counselors (n = 5) [78, 81, 84, 87, 98] and the use of SMS or WhatsApp to establish contact between peers (n = 5) [81, 88, 91–93]. Implementing trained peers to provide psychosocial and logistical support was also a strategy for four of the revised interventions [77, 85, 86, 102], and the use of online support groups was also frequently presented in the interventions [83, 90, 100, 101]. Two of the reviewed studies used online focus groups [96, 97], one implemented peer education [89], and only one used videos made by peers [104]. At last, one intervention generated a strategy of matched peers who had similar trauma experiences [95]. As an important component, three of the reviewed interventions incorporated peer support anonymously [79, 96, 99]. Table 4 summarizes the type of peer support implemented by each intervention.

Table 4

Description of how the peer support was implemented.

Peer Support Implementation
Reference	Peer Support Type
Winstead-Derlega et al., 2012	Peer messages delivered through videos
Broaddus et al., 2015	Online support groups
Henwood et al., 2016	Online and face to face support groups
Flickinger et al., 2017	Interaction through a community message board (CMB) with anonymous usernames
Westergaard et al., 2017	Peer trained to deliver intensive psychosocial and logistical support
Dulli et al., 2018	Support groups moderated by trained peers
Horvath et al., 2018	Online forum, social network posts
Hacking et al., 2019	Peer as trained mentees that contact recently diagnosed people to attend an adherence club
Horvath et al., 2019	Online forum, messages and social network posts
Ivanova et al., 2019	Peer as trained mentees that contact diagnosed people to participated in an adherence intervention
Knudson et al., 2019	Face to face counseling and contact with via SMS
Navarra et al., 2019	Peers trained as coaches
Tun et al., 2019	Peer education
Hay et al., 2020	WhatsApp groups
MacCarthy et al., 2020	Focus group
Ochoa et al., 2021	Online forum
Simpson et al., 2021	Focus group, first interviews and SMS communication
Steinbock et al., 2022	Online support group
Stockman et al., 2021	Match with a trained and trauma-informed virtual peer, communication via smartphone
Zanoni et al., 2022	WhatsApp groups
Mo & Coulson, 2008	Messages posted at an online board
Wools-Kaloustian et al., 2009	Instructors that mediates between medical attention and patients giving advices
Mi et al., 2015	Online peer counseling and giving information via website
Abdulrahman et al., 2017	Online peer counseling
Senn et al., 2017	SMS texting with participants
Rotheram et al., 2019	Social media forums and coaching via SMS, phone, or in-person
St Clair-Sullivan et la., 2019	Online support forum
Chory et al., 2022	WhatsApp groups

Discussion

Summary

This review aimed to systematically scope the empirical literature on peer-support psychosocial interventions for PLWHA. More specifically, we aimed to 1) identify the existent digital peer support interventions currently available for PLWHA; 2) summarize the main characteristics of the available interventions 3) examine how the interventions implemented peer support in a virtual environment.

Twenty-eight studies were identified in a systematic search across peer-reviewed journals.

Papers were primarily pilot studies and protocols published in North America or Africa within the last 5 years. This recent increase in papers reflects the growing interest in developing peer-support eHealth interventions for PLWHA. Even though only three studies were RCT, the relatively large number of RCT protocols suggests that this field will continue growing in the coming years. Participants were mainly HIV+ adults predominantly from minority ethnic, racial and/or sexual backgrounds. None of the studies was conducted in Latin America, which is problematic considering the high prevalence of HIV (approximately 1.8 million people in 2017) [105, 106], the difficulties presented in achieving the 90-90-90 targets designated by UNAIDS [107], and the tendency for late treatment initiation [105].

Social networks and messaging apps (such as Facebook or WhatsApp) were the most frequently used digital health tools, which is consistent with research suggesting the increasing validity of psychosocial interventions using social networks for different populations [108-110]. Considering the ongoing massification of both smartphones [111-113] and access to the internet worldwide [114, 115], this is a positive finding and suggests that there are indeed eHealth interventions that could be more widely accessed.

The most common peer activity was the participation in social networking posting, peer counseling, and peer discussions and conversations through WhatsApp or other social messaging services, which are considered to be an asynchronous form of technology [116].

Interestingly, very few interventions [78, 96–98] incorporating face-to-face synchronic interaction were identified. Even though numerous studies have shown that synchronous technologies (such as real-time video conferencing) are a valid method to deliver group psychosocial interventions [116, 117], real-time activities present constraints (i.e., scheduling) that can be overcome with asynchronous technologies[116].

Also, digital support emerges as a promising approach to complement healthcare [118, 119]. For instance, through digital peer support, patients may have more efficient access to both health care services and HIV-related information (e.g., whether and how often the person should seek medical assistance based on symptoms).

It is worth noting that although internet-based interventions may help ease difficulties in access for some PLWHA—access to these interventions may be limited for some populations and marginalized groups (e.,g., older people, people with severe mental health conditions, people with specific disabilities,) [120-122]. Likewise, the risk of digital exclusion may make a strong point for face to face services.

Limitations

Our scoping review has two main limitations. Firstly, it was conducted only in 3 databases (PUBMED, Web of Science, and CINAHL Complete). The selection of these databases was due to a limited institutional budget; for this reason, some databases were excluded (e.g., EMBASE, Cochrane).

Secondly, and also due to institutional limitations, we did not count with the collaboration of a librarian, which may have had an impact on the expertise in designing and refining the main gsearch of our paper.

Conclusion

In this review we have summarized the digital peer support interventions currently available for PLWHA, their main characteristics, and the way in which they implemented peer support in a virtual environment.

Overall the reported outcomes appeared promising, especially regarding potential improvements in treatment adherence and enhanced perceived social support. Future research should focus on continuing collecting data through RCTs studies in diverse social contexts. Having robust diverse evidence of the effectiveness of this type of interventions may help expand the scope and the impact of different treatments.

Pre-registration protocol at open science framework.

Protocol developed by the researchers following the Open Science Framework guidelines.

(DOCX)

Click here for additional data file.

Eligibility criteria.

List of the eligibility criteria used to assess the articles for inclusion.

(DOCX)

Click here for additional data file.

String of search.

Full string of search implemented in PUBMED. The string of search was adapted to each database.

(DOCX)

Click here for additional data file.

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.

Checklist completed by the researchers following PRISMA guidelines.

(DOCX)

Click here for additional data file.

15 Feb 2022

Internet-based peer support interventions for people living with HIV: A Scoping Review

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Introduction:

Paragraph 2. The authors fail to consider the impact of violence and even more importantly alcohol and other drug use on HIV adherence. Substance use stigma also intersects with HIV stigma to worsen outcomes A variety of interventions have been developed to address these issues to improve likelihood of adherence. The literature review should be expanded to reflect this. Some articles of relevance include:

Regenauer, K.S., Myers, B., Batchelder, A.W., Magidson, J.F. (2020). “That person stopped being human”: Intersecting HIV and substance use stigma among patients and providers in South Africa. Drug and Alcohol Dependence, 216, 108322. https://doi.org/10.1016/j.drugalcdep.2020.108322.

Myers, B., Lombard, C., Joska, J.A. Abdullah, F., Naledi, T., Lund, C., Petersen Williams, P., Stein, D.J., Sorsdahl, K.R. Associations Between Patterns of Alcohol Use and Viral Load Suppression Amongst Women Living with HIV in South Africa. AIDS Behav (2021). https://doi.org/10.1007/s10461-021-03263-3

Abrahams N, Mhlongo S, Dunkle K, Chirwa E, Lombard C, Seedat S, Kengne AP, Myers B, Peer N, Garcia-Moreno C, Jewkes R. Increase in HIV incidence in women exposed to rape. AIDS. 2021 Mar 15;35(4):633-642. doi: 10.1097/QAD.0000000000002779

Relatedly, Some additional interventions to address psychosocial risks to adherence (specifically related to alcohol and other drugs) should be mentioned:

Zule, W., Myers, B., Carney, T., Novak, S., McCormick, K., & Wechsberg, W.M. (2014). Alcohol and drug use outcomes among vulnerable women living with HIV: results from the Western Cape Women’s Health CoOp. AIDS Care 26: 1494-9.

Belus, J., Rose, A.I., Anderson, L., Ciya, N., Joska, J., Myers, B., Safren, S.A., Magidson, J. (2020). Adapting a behavioral intervention for alcohol use and HIV medication adherence for lay counselor delivery in Cape Town, South Africa. A case series. Cognitive Behavioral Practice. https://doi.org/10.1016/j.cbpra.2020.10.003.

Magidson, J. F., Joska, J. A., Belus, J. M., Andersen, L. S., Regenauer, K. S., Rose, A. L., Myers, B., Majokweni, S., O’Cleirigh, C. and Safren, S. A. Project Khanya: Results from a pilot randomized type 1 hybrid effectiveness-implementation trial of a peer-delivered behavioural intervention for ART adherence and substance use in HIV care in South Africa. J Int AIDS Soc. 2021; 24(S2):e25720.

Paragraph 3. There has been some other work around peer support interventions for HIV, including a recent systematic review that is worth acknowledging. These do not offer internet/digital interventions so worth distinguishing this previous review from the current one. Please see below

Satinsky, E.N., Kleinman, M.B., Tralka, H.R., Jack, H.E., Myers, B., Magidson, J.F. (2021). Peer-delivered services for substance use in low- and middle-income countries: A systematic review. International Journal of Drug Policy, 95, 103252. https://doi.org/10.1016/j.drugpo.2021.103252

Magidson, J. F., Joska, J. A., Belus, J. M., Andersen, L. S., Regenauer, K. S., Rose, A. L., Myers, B., Majokweni, S., O’Cleirigh, C. and Safren, S. A. Project Khanya: Results from a pilot randomized type 1 hybrid effectiveness-implementation trial of a peer-delivered behavioural intervention for ART adherence and substance use in HIV care in South Africa. J Int AIDS Soc. 2021; 24(S2):e25720.

Magidson, J.F., Joska, J., Regenauer, K.S., Satinsky, E., Andersen, L., Seitz-Brown, C.J., Borba, C.P.C., Safren, S.A., Myers, B. (2019). “Someone who is in this thing that I am suffering from”: The role of peers and other facilitators for task sharing substance use treatment in South African HIV care." International Journal of Drug Policy 70: 61-69.

Paragraph 5. It is worth noting that although internet-based interventions may help ease difficulties in access for some PLWH- access to these interventions may be limited for economically deprived populations and marginalised groups. – ie there is a risk of digital exclusion- so these could be an adjunct for face to face services. There is a large literature now from COVID-19 mental health services that highlights the risk of digital exclusion in both high and lower income settings. This is especially important given that poorer countries still have a higher prevalence of HIV. I recommend expanding on this caveat in the discussion section too.

Final paragraph of the introduction: I think you mean to write the “no specificity or broadness of the research question rather than specificity- please revise accordingly.

Methods

1. Did you follow a scoping review framework- eg Joanna Briggs?

2. I am not sure what is meant by “lack of extension in the area of interest- please clarify (search strategy)

Results

1. Intervention goals- it is worth noting that none of these interventions addressed underlying psychosocial factors known to adversely impact adherence and outcomes (e.g mental health, AOD use, violence)

2. Study findings- how was treatment adherence measured? Confidence in taking medication is a weak proxy for adherence? Any impact on viral load? My takeaway would be the need for more robust studies with more objective measures of adherence and HIV outcomes

Discussion: I think you can make a stronger statement about the lack of robust designs, the heterogeneity of the approaches and the need for RCTs that provide evidence (objective) of the impact of these kinds of interventions on HIV treatment engagement, ART use and viral load. Also need to demonstrate that these approaches offer add on value beyond face to face interventions.

I think you need to soften your statements about the findings being in line with what is known about the effectiveness of face to face peer interventions. At best the studies included in your review suggest these are feasible and acceptable interventions and show some promise but the field is nascent and more evidence is needed.. The discussion would benefit from a review of the quality of the included studies so as to identify next steps for research

Reviewer #2: I appreciate the opportunity to review this manuscript and read it with great interest. The authors are to be commended for having undertaken this work. Regrettably, the methods have several weaknesses, which raise considerable doubts about the internal validity of the results of the review. However, if the methods of the review are improved such that the results have internal validity, the results could be trusted and would be of interest to readers.

I find that this is not a well conducted scoping review. Methodological guidelines for conducting scoping reviews exist, and to earn the distinction ‘scoping review’, these guidelines should be followed. The authors state that they used PRISMA for scoping reviews, but this is a reporting tool, not a methods guide. Still, the PRISMA items help show what is missing to make this a review with results that readers can trust. For example, the authors fail to: Specify characteristics of the sources of evidence used as eligibility criteria and provide a rationale; Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. The authors refer to a protocol, but the ‘protocol’ only includes a table (the same as table 2 in the manuscript) and no description of pre-specified review methods. Table 2 in the manuscript describes population, exposure, comparison, outcomes, study design, which is what one would expect to find in a review about effect. This is not a review about effect, thus this demonstrates the researchers’ unfamiliarity with the methods of scoping reviews. Additionally, they excluded family publications derived from the same study, and included only “the study with the most robust evidence, i.e. RCT” (page 11), which gives a distorted (incomplete) presentation of evidence on internet-based peer support interventions. RCT is a robust design for investigating questions about effect, but, again, the researchers did not conduct a review about effect. It is strange that the researchers decided to use the Popay et al (2006) narrative synthesis method, and not the methods described in guidance publications on scoping reviews, e.g. Arksey and O’Malley 2005; Levac et al 2010; Armstrong et al 2011; Peters et al 2015.

The literature search appears to be neither exhaustive nor systematic (see e.g. PRESS checklist). It is strange that EMBASE was not searched. Table 1, which shows search terms, reveals that the search strategy was poor and not systematic and thus cannot be viewed as ensuring all eligible studies were identified. This is demonstrated by the fact that only 234 records were identifies in the database searches. This is several thousand fewer identified records than similar systematic reviews on the same topic. The eligibility criteria are inadequate, missing specification of e.g. study participants and definition/operationalization of the exposure. How was digital health understood? How was peer support understood? Given the central exposure in the review is peer support intervention, and the authors repeatedly refer to “peer support components”, it is a weakness that they do not specify peer support. The Peers for Progress program identify four key functions, or components, for peer-support: assistance in daily management, social and emotional support, linkage to clinical care and community resources, and ongoing support related to chronic disease. It is questionable whether the nine included interventions in fact are peer support interventions. Another underlying premise of peer-support is personalized interaction, which is difficult to achieve with digital communication and therefore needs to be addressed here.

Additionally, I find that the researchers’ rational for a review on internet-based peer support is weak (they write for example that there is a “lack of extension of the area of interest” page 10), their categories in Table 3 are not consistent (e.g. they specify ‘pilot’ as a study design, ‘study location’ is a mix of countries and cities). When they report on ‘study findings’ they mix study designs such as RCTs and qualitative studies when reporting on effect, when, obviously, qualitative studies do not assess effects. In the discussion section, they make claims about mechanisms that support the interventions, when there is no information about mechanisms in the results section. Similarly, in the discussion section, they discuss anonymity as an advantage of internet-based peer support interventions, when there is no information about anonymity in the results section. In the limitations, they mention exclusions that are not mentioned in the methods section and they state that their inability to conduct meta-analyses is a limitation, which is completely irrelevant because they (state they) conducted a scoping review. Lastly, I find that the review is poorly written, marred with language errors, and the unclear language impedes understanding.

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12 Apr 2022

Response to Reviewer 1:

Thank you for your review of our paper. We have answered each of your points below. (See cover letter-response to reviewer).

Response to Reviewer 2:

Dear reviewer 2,

We would like to thank you for your detailed feedback. We have significantly improved our knowledge

regarding the development of scoping reviews and we have re-conducted every step of the process

again.

Please find the details of the changes below.(See cover letter-response to reviewer).

19 May 2022

Internet-based peer support interventions for people living with HIV: A Scoping Review

PONE-D-21-30570R1

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19 Aug 2022

PONE-D-21-30570R1

Internet-based peer support interventions for people living with HIV: A Scoping Review

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