title: Epic Allies: Development of a Gaming App to Improve Antiretroviral Therapy Adherence Among Young HIV-Positive Men Who Have Sex With Men.
abstract: BACKGROUND
  In the United States, the human immunodeficiency virus (HIV) disproportionately affects young men who have sex with men (YMSM). For HIV-positive individuals, adherence to antiretroviral therapy (ART) is critical for achieving optimal health outcomes and reducing secondary transmission of HIV. However, YMSM often struggle with ART adherence. Novel mobile phone apps that incorporate game-based mechanics and social networking elements represent a promising intervention approach for improving ART adherence among YMSM.
  
  
  OBJECTIVE
  This study used a multiphase, iterative development process to create an ART adherence app for YMSM.
  
  
  METHODS
  The three-phase development process included: (1) theory-based concept development jointly by public health researchers and the technology team, (2) assessment of the target population's ART adherence needs and app preferences and development and testing of a clickable app prototype, and (3) development and usability testing of the final app prototype.
  
  
  RESULTS
  The initial theory-based app concept developed in Phase One included medication reminders, daily ART adherence tracking and visualization, ART educational modules, limited virtual interactions with other app users, and gamification elements. In Phase Two, adherence needs, including those related to information, motivation, and behavioral skills, were identified. Participants expressed preferences for an ART adherence app that was informational, interactive, social, and customizable. Based on the findings from Phase Two, additional gaming features were added in Phase Three, including an interactive battle, superhero app theme, and app storyline. Other features were modified to increase interactivity and customization options and integrate the game theme. During usability testing of the final prototype, participants were able to understand and navigate the app successfully and rated the app favorably.
  
  
  CONCLUSIONS
  An iterative development process was critical for the development of an ART adherence game app that was viewed as highly acceptable, relevant, and useful by YMSM.
authors.affiliation: Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, United States. sara.legrand@duke.edu.
authors.forename: Sara
authors.identifier: http://orcid.org/0000-0002-2590-516X
authors.initials: S
authors.lastname: LeGrand
authors.forename: Kathryn Elizabeth
authors.identifier: http://orcid.org/0000-0002-8522-3240
authors.initials: KE
authors.lastname: Muessig
authors.forename: Tobias
authors.identifier: http://orcid.org/0000-0002-9547-4131
authors.initials: T
authors.lastname: McNulty
authors.forename: Karina
authors.identifier: http://orcid.org/0000-0002-7393-3421
authors.initials: K
authors.lastname: Soni
authors.forename: Kelly
authors.identifier: http://orcid.org/0000-0002-5293-1961
authors.initials: K
authors.lastname: Knudtson
authors.forename: Alex
authors.identifier: http://orcid.org/0000-0002-1708-5173
authors.initials: A
authors.lastname: Lemann
authors.forename: Nkechinyere
authors.identifier: http://orcid.org/0000-0003-4193-8743
authors.initials: N
authors.lastname: Nwoko
authors.forename: Lisa B
authors.identifier: http://orcid.org/0000-0002-2421-923X
authors.initials: LB
authors.lastname: Hightow-Weidman
keywords: HIV; health knowledge, attitudes, practice; medication adherence; men who have sex with men; mobile applications; serious games; video games; youth