Johns Hopkins University Press

In the U.S., Black women living with HIV/AIDS (WLHA) are affected disproportionately by interpersonal violence, which often co-occurs with adverse mental health and/or substance use, and exacerbates existing poor HIV care outcomes. Peer navigation has been successful in improving HIV care; however, HIV clinics often lack resources for sustainability and may not account for socio-structural barriers unique to Black WLHA. To address this gap, we developed LinkPositively, a culturally-tailored, trauma-informed WebApp for Black WLHA affected by interpersonal violence to improve HIV care outcomes. Using focus group data from nine Black WLHA and peer navigators, we developed LinkPositively. Core components include: virtual peer navigation to facilitate skill-building to cope with barriers and navigate care; social networking platform for peer support; educational and self-care tips; GPS-enabled resource locator for HIV care and support service agencies; and medication self-monitoring/reminder system. If efficacious, LinkPositively will shift the HIV prevention and care paradigm for Black WLHA.

Key words

Webapp, HIV care, peer navigation, social networking, Black women, interpersonal violence [End Page 166]

Though there have been significant advances in HIV prevention and care in recent years, Black women continue to be disproportionately affected by HIV in the United States (U.S.).1,2 In 2018, Black women accounted for 58% of all new HIV infections in women, despite only constituting 13% of the U.S. female population.3 Black women are 15 times more likely to be diagnosed with HIV than White women.4 Black WLHA are less likely than Latinx and White WLHA to be linked to HIV care within 90 days of diagnosis (64% vs. 69% and 74%)5 and only 56% are retained in care.3 While WLHA overall are less likely to be virally suppressed than men, Black WLHA are less likely to be virally suppressed compared with White WLHA.6,7

Concurrently, Black women are disproportionately affected by interpersonal violence, defined as physical, sexual, and/or psychological abuse by any type of perpetrator, regardless of gender, race/ethnicity, and/or type of relationship. Whereas the national prevalence of lifetime violence victimization by an intimate partner (i.e., [ex-]spouse, boyfriend, partner), also known as intimate partner violence (IPV), among U.S. adult women is 45%,8 Black women report 35% higher lifetime IPV victimization prevalence than White women.9 Moreover, although national data estimate the lifetime prevalence of rape among Black women at 21%,8 this is likely underestimated given studies utilizing community-based samples reporting prevalence rates of rape as high as 54%.1012 Women living with HIV experience high rates of adulthood interpersonal violence (67%),13 lifetime IPV (55%),14,15 and past year IPV (27%).16 Interpersonal violence victimization among WLHA is associated with decreased antiretroviral therapy (ART) adherence13,14,17,18,19 and reduced viral suppression.15,18,20 Women with a history of violence victimization are eight times less likely to be virally suppressed than women without a history of violence victimization.21

Compounding HIV and interpersonal violence, WLHA face co-occurring syndemic conditions (substance use, mental health conditions) and socio-structural barriers to care (HIV stigma, medical mistrust, unmet housing and transportation needs), to greater extents than HIV-negative and male HIV-positive individuals,2224 affecting retention in care and ART adherence.23,2529 Black WLHA are also more likely to experience these syndemic conditions and socio-structural barriers than their White counterparts.30,31 HIV stigma is one of the most frequently noted barriers to retention in HIV care and ART adherence among Black WLHA.30,32,33 Similarly, medical mistrust has been found to predict lower ART adherence3436 and experiences of racism and the quality of provider relationships have affected engagement in HIV care among Black Americans living with HIV.34 In contrast, social support may mitigate the impact of socio-structural barriers on HIV care outcomes among Black WLHA. Higher perceived social support is associated with fewer depressive symptoms as well as ART adherence,3739 fewer HIV-related health symptoms,40 less HIV stigma,41,42 and greater perceived ability to engage in HIV care29 and HIV self-management.43

Peer navigation has been highlighted as a successful model of care in improving outcomes along the HIV care continuum.44 Peer navigators (PNs) are individuals living with HIV, who are medication-adherent role models with shared lived experiences as their clients.44 Peer navigators provide social support and positive modeling of engagement-supportive behaviors to their clients.45 Peer navigators have been found to help build self-efficacy in patient-provider communication and decrease medical [End Page 167] mistrust, offsetting the negative impact of socio-structural barriers.45 Studies show that increased linkage to and retention in care among WLHA, facilitated by a PN, is feasible, acceptable, and efficacious in the U.S. and other countries,4648 and can improve ART adherence49,50 and viral suppression.51,52 Further, social support group participation with HIV-positive peers has demonstrated benefits for WLHA, related to mental health, relationships, and socio-structural barriers.53,54

Utility of technology-based interventions

With increased Internet access and smartphone ownership, technology-based interventions have become an appealing and feasible option for improving health.55 Particularly in the era of the COVID-19 pandemic, technology-based interventions are important channels to provide services to vulnerable populations while mitigating the risks of in-person services in the context of COVID-19.56,57 Further, with reduced or no in-person support, technology-based interventions and programs including telehealth may help buffer the effects of loneliness and social isolation.56,58 Finally, technology-based interventions are perceived to be more confidential, lead to more efficient and perceived safer care, and feel more empowering for women with a history of interpersonal violence.5961

In the realm of HIV care, technology-based interventions primarily employ mobile apps or are SMS-based (text message-based). Such interventions have been developed for WLHA outside the U.S.,62,63 older WLHA in the U.S.,64 pregnant WLHA,65,66 people living with HIV (PLWH) regardless of gender,67 transgender WLHA,68,69 and for HIV prevention;70,71 to our knowledge, none have been developed for cisgender WLHA, Black WLHA, or WLHA who have experienced interpersonal violence. The existing technology-based interventions have demonstrated effectiveness in decreasing viral load, improving engagement in care, and increasing ART adherence.72,73,74,75 As noted, technology-based interventions among WLHA in the U.S. are limited, though a majority of U.S. women (91%) use the Internet, including 87% of Black women.74 Smartphone use is also very common among Black individuals overall (80%).75 However, technology-based interventions have focused neither on the syndemic conditions nor the unique barriers faced by WLHA76,77 despite interest in, advantages, and acceptability of technology-based interventions, particularly for increasing social support.78,79

Responding to this need, we developed the web-based application (or WebApp) entitled LinkPositively, a culturally relevant, gender-specific mHealth intervention tailored for Black WLHA who have experienced interpersonal violence, to improve HIV care outcomes through peer navigation, informal social support through social peer networking, resource location assistance, educational tips, and ART self-monitoring and reminders. The present paper aims to describe the conceptualization of the Link-Positively WebApp, the elicitation of feedback on the WebApp conceptualization from Black WLHA who have experienced interpersonal violence and PNs, and the responsive creation of the LinkPositively WebApp.


LinkPositively WebApp theoretical underpinnings

The conceptualization of the Link-Positively WebApp relied on the Theory of Triadic Influence, a multilevel social cognitive theory that hypothesizes three "streams of influence" (individual, social, and structural) [End Page 168] act simultaneously to affect health behaviors.80 Articulated to relevant dynamics of engaging Black WLHA affected by interpersonal violence with poor ART adherence, the relevant streams of influence LinkPositively aims to target are individual-level (i.e., ethnic minority, interpersonal violence) and social-structural level (e.g., HIV stigma, medical mistrust) barriers known to decrease engagement in HIV care. Simultaneously, Syndemic Theory is employed as a key framework for understanding co-occurring and synergistic epidemic conditions, which are exacerbated by the inequitable social, economic, environmental, and political milieu in which a population is immersed.81 In addition to being HIV-positive, WLHA experience interpersonal violence and co-occurring mental health conditions and substance abuse as key syndemic factors that contribute to poor engagement in HIV care and poor ART adherence among Black WLHA.

Principles of trauma-informed care (TIC) serve as the foundation of LinkPositively, embedded within the Theory of Triadic Influence and Syndemic Theory. Trauma-informed care is based on Trauma Theory, which asserts that if traumatic memories cannot be processed, then they are stored as physiological reactions to stimuli, situations, or states of arousal that recall the traumatic experience.82 Individuals with a history of traumatic life events, including interpersonal violence, may become distressed or re-traumatized by health care experiences.83 Trauma-informed care aims to meet the unique needs of violence survivors84 and has been applied in contexts of substance use, mental health and physical health care,85 HIV prevention, and to a lesser extent, HIV treatment.86

LinkPositively conceptualization

The LinkPositively WebApp is conceptualized as a multi-component, culturally-tailored, and trauma-informed mHealth intervention designed to primarily increase retention in HIV care, ART adherence, and viral suppression for Black WLHA affected by interpersonal violence. Specifically, LinkPositively will provide Black WLHA with formal support through peer navigators, together with informal support through peer support networks, to foster a robust support network that offsets the negative effects of interpersonal violence on HIV outcomes.

The five components of LinkPositively include: (1) virtual peer navigation to facilitate skill-building to cope with histories of interpersonal violence, barriers, and navigate care; (2) social networking platform to enable peer support; (3) educational and self-care tips that are received daily and also searchable; (4) GPS-enabled resource locator, similar to Yelp, to find nearby HIV care and support service agencies; and (5) medication self-monitoring and reminder system. The five components of LinkPositively will achieve improvements in HIV care, ART adherence, and viral suppression, directly by improving self-efficacy for coping, accessing and building social support networks, and using ancillary support services (e.g., interpersonal violence, mental health, substance abuse services), and indirectly by reducing HIV stigma and medical mistrust (Figure 1). The WebApp format is accessible through, and responsive to (e.g., resizing depending on the device), any Internet browser on a smartphone, tablet, or computer. LinkPositively is developed as a mobile-responsive website instead of a native app (e.g., an Android or iOS app) for several reasons: (1) Black WLHA with any smartphone device may access the intervention as long as they have an Internet browser on their phone; (2) websites have less maintenance than native apps, improving the long-term [End Page 169]

Figure 1. LinkPositively WebApp conceptual model.
Click for larger view
View full resolution
Figure 1.

LinkPositively WebApp conceptual model.

sustainability of the intervention; and (3) websites are less costly to develop than native apps, while still being able to deploy our proposed interactive components, accessible 24 hours per day as long as there is Internet access.

It is important to note that among Black adults, smartphone devices play a more central role in providing Internet access, compared with laptops and desktop computers.75 Black adults are more likely than Whites to rely on their smartphones for seeking health information. Additionally, smartphone ownership among Black adults (80%) approximates that of White and Hispanic adults (82% and 79%, respectively).75 Although smartphones help bridge Internet access gaps, other data show that Blacks, Hispanics, and lower-income smartphone users are about twice as likely as Whites to have canceled or cut off service because of the expense.75

LinkPositively WebApp components

Virtual peer navigation

Virtual peer navigation occurs over five weeks, inclusive of one intake session, comprising needs assessment, goal-setting, and linkage to services, and four educational sessions. Educational sessions focus on: a) increasing emotional awareness and understanding trauma and co-occurring syndemic conditions, b) cultivating emotional regulation and distress tolerance, c) activating social support networks, and d) addressing the impact of interpersonal violence on socio-structural barriers and strategies to overcome them. Participants will be matched with a trained and trauma-informed virtual PN, based on similar life experiences. All peer navigation sessions occur through video calls, a platform linked to using the WebApp. Participants will be able to text/call their virtual PN during and after the sessions. At the back end of the site, PNs will be able to enter case notes on the peer navigation sessions and check-ins, set notifications and appointment reminders, and send their assigned participants direct messages that will show up only on that participant's profile.

Social networking platform

Informal social networking occurs through a social networking platform or feed like that of Facebook. Participants are able to create a customizable profile (avatar image, name, about me section) and disclose information they wish to share about themselves. Within the feed, women have the opportunity to [End Page 170] share information, stories, and successes, as well as ask questions and advice from other women via posts. Women can interact with each other through comment and reaction (emoji) functions, and all feed activity is inaccessible by PNs, to ensure privacy and allow all women to engage with one another without the presence of PNs.

Educational and self-care tips

Brief educational, self-care, and healthy living tips are integrated into the social networking feed, as well as tips for best strategies for overcoming the effects of interpersonal violence, mental health conditions and substance use, and Black WLHA experiences with medical mistrust and HIV stigma. A new educational tip is featured at the top of the social networking platform or feed daily. Tips will rotate daily, such that one to two daily tips will appear in the participant's feed. Educational tips are also available in a searchable educational tips database, providing women with resources and advice in real time as they need it.

GPS-enabled resource locator

Resource location assistance is provided by a resource database, which includes local, state-level, and national resources relating to HIV care, mental health, violence, food insecurity, financial insecurity, legal aid, and other ancillary support service agencies. Women are able to search the resource locator database in a specified radius, by type of service or location, and all service descriptions include eligibility (including insurance requirements), hours, contact information, types of services offered, and alterations to operations due to COVID-19. By clicking on the address, the smartphone's GPS mapping app will be enabled to show the participant's location relative to the agency location. Women will have the option to comment and rate the agency (similar to Yelp functionality).

Medication self-monitoring and reminder system

HIV medication self-monitoring and reminders will be employed using a calendar function, on which women can schedule HIV medication reminders during their first virtual PN session. Women will receive automated medication reminders and be prompted to respond in real time to a question about whether or not they took their medications that day. Virtual PNs can also send reminder notifications to women through the WebApp or via text message. Women also have the option of tracking other behaviors or experiences, such as mood, doctor's appointments, or nutritional intake, and set reminders as desired.

Elicitation focus groups: Participants and procedure

Between March and April 2020, Black WLHA in San Diego and Oakland, California were recruited to participate in three elicitation focus groups (two for Black WLHA and one for peer navigators) to inform the development of the LinkPositively WebApp. We used multiple recruitment methods, including venue-based (e.g., at local HIV and ancillary support service organizations), flyer advertisements through HIV community advisory board members, phone contact with participants from previous HIV studies who provided permission to be contacted about participation in future studies, and word-of-mouth referrals. Participants were eligible if they (1) self-identified as a woman; (2) self-identified as African American, Black, or of African descent; (3) were aged 18 or older; (4) were living with HIV/AIDS; (5) resided in San Diego County, California, or Alameda County, California; (6) had ever experienced interpersonal violence, defined as physical, sexual, and/or psychological abuse by an intimate partner, family member, friend, or another person; (7) willing and able to give informed consent; and (8) able to understand English. [End Page 171] For focus groups of PNs, women must have had previous experience acting as a peer navigator to other WLHA. Interested participants were screened for eligibility via phone. Eligible participants were invited to participate in one of the scheduled focus groups.

The first focus group with WLHA was conducted in person and the remaining focus groups were conducted via Zoom videoconferencing due to physical distancing restrictions from the COVID-19 pandemic. Three female research team members were present at each focus group, including a facilitator, a note-taker, and a student observer. Each focus group lasted approximately 90 minutes and participants were compensated $50 upon completion. All study procedures were approved by the Institutional Review Board of the University of California, San Diego.

The focus group guide was developed based on the proposed LinkPositively WebApp features, needs surrounding the use of a technology-based intervention, and needs regarding HIV care. Topics for the focus groups with WLHA included: comfort with technology, use of technology in everyday life, safety considerations when using technology, barriers and facilitators to retention in HIV care and ART adherence, the impact of violence on HIV care, and solicitation of options and recommendation for WebApp features based on mock-ups of each feature. Topics for the focus group with PNs included: solicitation of options and recommendation for the virtual peer navigation component of the WebApp and feedback on each of the 5 sessions that will serve to improve self-efficacy for coping, navigating social support networks, and tools to utilize support services effectively, all while addressing HIV stigma and medical mistrust.


In total, nine participants attended three focus groups, including six Black WLHA and three Black WHLA PNs. Participants in the WLHA focus groups were between the ages of 44 and 69 and participants in the PN focus group were between the ages of 44 and 62 (data not shown). All participants identified as Black or African American, cisgender women, with none identifying as multiracial or Hispanic/Latinx. Of WLHA participants, 50% (n=3) attended some trade or vocational school or completed a bachelor's degree, while 33.3% (n=2) had not completed high school, and 16.7% (n=1) had completed high school. Of those with available data (n=2/3), PNs had completed at least some vocational or trade school. One of the WLHA participants were employed at the time of focus groups; none of the PNs were employed. Similarly, one of the WLHA and no PNs were in a relationship with an intimate partner at the time of focus groups.

Lifetime experiences of violence were assessed among focus group participants, indicating high prevalence of interpersonal violence experiences. Of WLHA, 83.3% (n=5/6) had experienced physical violence, 83.3% (5/6) experienced threats of physical violence, 67.7% (4/6) had experienced sexual assault, 33.3% (2/6) had experienced rape, 50.0% (3/6) had experienced threats of rape, 83.3% (5/6) had experienced emotional or psychological abuse, and 100.0% (6/6) had experienced attempts from others to control their behavior (e.g., where they go, who they see). Perpetrators were most commonly former intimate partners (83.3%, 5/6) and family members (33.3%, 2/6). Peer navigators with available data (n=2) had experienced physical violence (100%, 2/2, threats of physical violence (100%, 2/2), sexual assault (100%, 2/2), rape (50%, 1/2), threats of [End Page 172] rape (50%, 1/2), emotional/psychological abuse (100%, 2/2), and controlling behaviors (100%, 2/2). Perpetrators were most commonly a former intimate partner (100%, 2/2) or a family member (50%, 1/2).

All respondents (WLHA and PNs) reported themselves "somewhat" to "very able" to use mobile applications and websites in general and had previously used a mobile application or website to find out information about HIV (83.3% [5/6] of WLHA, 100% [2/2] of PNs) or track HIV care (83.3% [5/6] of WLHA, 100% [2/2] of PNs). Women living with HIV were very comfortable (50%, 1/2), somewhat comfortable (33.3%, 2/6), or not comfortable at all (16.7%, 1/6) with using a mobile application or website to track their HIV care, while 100% (2/2) of PNs were very comfortable doing so.

Results from the focus groups were compiled to assess salience of recommendations across groups, as well as feasibility of integration to the WebApp (Table 1).

LinkPositively WebApp adaptation

Responsive to recommendations made by focus group participants, including Black WLHA and PNs, we undertook adaptation of the conceptualized LinkPositively WebApp to increase the culturally-tailored, gender-specific, and trauma-informed nature of the intervention (see Figure 2 for screenshots of components of the culturally-tailored LinkPositively WebApp). Additions fell into three broad categories: content, safety, and personalization. PNs also provided thoughts on their ability to navigate the peer navigation dashboard and interact with potential participants.

An essential element of the elicitation phase was to identify content and materials of interest and relevance to Black WLHA to be integrated into the WebApp. Women provided guidance both on topical content of interest, as well as how they would like content to be accessible to them. While the initial proposed topics for the educational tip component of the WebApp focused on syndemic conditions and their corollaries—including mental health, self-care, medication adherence, substance use, and violence—women encouraged the addition of topics that addressed their lives more holistically. Participants asked for information on their health such as nutrition and exercise, but also content relevant to their understanding of HIV, such as which medications to take, how to understand their labs, what HIV would look like as they aged, and news on current HIV research. Women requested guidance on how to have conversations with partners about their partners going on PrEP, how to disclose their status to loved ones, questions to ask their doctor, and responses to common misconceptions about HIV, in order be armed with knowledge. These topics were integrated into the educational tip database in response, as were related topics. Further, women wanted to have information presented to them on their WebApp feed, rather than having to seek it out in the educational tip database. This prompted an alteration to the WebApp to display a new tip to participants each day, to engage them with content and knowledge. Additional suggestions included having topics posed for discussion on the WebApp feed, interactive comments, and a glossary for technical terminology. Finally, variety in the form of content was requested, including videos, links to articles, and integration of materials for printing, saving, or sharing.

The second major area of feedback concerned the safety and confidentiality of participants engaging in the testing of the LinkPositively WebApp. While safety features had been integrated from the conceptualization of LinkPositively to keep consistent with [End Page 173]

Click for larger view
View full resolution
Table 1.


[End Page 176]

Figure 2. Screenshots of LinkPositively WebApp Components
Click for larger view
View full resolution
Figure 2.

Screenshots of LinkPositively WebApp Components

[End Page 177]

a trauma-informed care approach, it was vital to the research team that we understood what made Black WLHA feel safe, not simply what we thought would make them feel safe. For example, a PN participant expressed concern over women having adequate private space to use the app:

… having the privacy or having a safe space in their environment to be able to use technology, to be able to have a meeting or group or … one-on-one interaction … they might have a violent partner … it's scary, you know, when you trying to keep the women safe and give her … all kind of plans … so it's trying to give her services but … who's protecting her to be able to access these services?

Another participant, from a WLHA group, pointed out:

… me being on the webpage, and somebody looking over your shoulder with all the HIV this and that actually on the page might not be something that I want to do … you know, and somebody is over my shoulder or on the bus or what have you, so I have that issue with the app—going on the webpage and LinkPositively [app] you know.

Women responded positively to the possibility of a "safety exit" feature, which was proposed in the original conceptualization of LinkPositively prior to focus groups. This feature allows women to quickly exit the WebApp by clicking a button labeled "Exit Now," causing them to be redirected to an unrelated page (e.g.,, should they worry about inadvertent HIV disclosure. Women provided no comments for revision of the safety exit option; however, further discussion regarding this by the research team also prompted the integration of a feature to log women out of the WebApp automatically, in order to reduce the likelihood of a non-participant accessing their information or learning of their participation. Women also stressed the importance of choices around disclosure and confidentiality within the WebApp-features, such as being able to upload a picture or select an illustrated avatar, being able to use a username or their own name on their profile, and choosing the extent to which they post, and engage in comments and reactions to others' posts, on the WebApp feed. Women also appreciated the "trigger warning" feature that warned other users that the post contained potentially upsetting content, to help themselves and others avoid content that could cause re-traumatization.

Thirdly, focus group participants emphasized the importance of an intervention customized for Black WLHA by Black WLHA. In each focus group, women shared that felt they had few resources and services intended specifically for Black WLHA, and how that contributed to mistrust and hesitance to access services. As one participant in a WHLA focus group said,

… you kind of get tired of not seeing yourself represented or you know, you want the support but then again, the issues are very different [between cultural groups]. I mean … cultures have differences and we can all relate to your own culture and what those things are … those idiosyncrasies, the differences in disclosure, … relationships … you know so there are a lot of things that we have [that are different]—being able to do this together and this for us [Black women], I'm really looking forward to it. [End Page 178]

They expressed great enthusiasm about the customized content and emphasized that culturally competent and personalized development of the WebApp was previously unheard of among participants. Several WebApp features of this were integrated already, such as the centering of imagery of Black women of a variety of ages, and backgrounds and themes of empowerment. However, other features that allowed women to make the app feel like their own were suggested, and integrated: visual customization of the WebApp backgrounds, choosing how to receive notifications, and personalization of calendar notes. The LinkPositively WebApp, tailored to Black women in this regard, was identified as being an important positive change for participants who felt stigmatized and ignored:

I can't imagine the impact of … coming to the doctors and being a Black woman … and [the doctor] saying, hey, this is something just for Black women, why don't you check it out? I would have been all over this page, in my home, the privacy, my own time. I would learn faster without the stress of being on my cellphone maybe in public or whatever you know, and maybe … I would of gotten medicine sooner, because diagnosis is one thing, but then the diagnosis to getting in care can take forever, and that's a very critical time for women because you're getting diagnosed with something that is so stigmatic … our community is probably the harshest about the stigma … but then a doctor will give you this and say there are Black women who are positive in this city that are on this page right here and can answer any question you want to know. Some just got diagnosed yesterday or today like you, and some have been diagnosed for 20 years … I think it would be a huge encouragement for women to take their life and their health and their self-care into their own hands instantly, instantly.

Finally, PNs provided insights into their perceived ability to engage with women through the LinkPositively WebApp. PNs expressed their priority of confidentiality and access, noting that women would need to be taught how to use the WebApp, and that considerations for access to technology and technological literacy are paramount. Upon seeing the WebApp system, PNs felt that it would be easy to use to communicate with WLHA, and that the system could help to build social support networks and improve HIV care outcomes among WLHA.


LinkPositively provides a new model to address the complex co-occurrence of interpersonal violence, syndemic co-morbidities, and socio-structural barriers in the engagement of the HIV care continuum for Black WLHA. A 2015 systematic review revealed no technology-based HIV self-management studies conducted in the U.S. specifically designed and culturally-tailored for use with Black WLHA.76 We successfully demonstrated that it is possible to develop a WebApp system through engagement and integration of feedback from target end users. In this process, we were also able to account for direct (self-efficacy for coping, social support) and indirect (HIV stigma, medical mistrust) socio-structural mechanisms of change, specific to Black WLHA affected by interpersonal violence. Further, we anticipate that the culturally-tailored, gender-responsive, and trauma-informed intervention will be acceptable to [End Page 179] Black WLHA and feasible to implement as a scalable intervention to improve HIV care continuum outcomes among Black WLHA. Next steps will include beta testing of the LinkPositively WebApp, followed by a randomized, controlled pilot study of the LinkPositively WebApp among Black WLHA in California.

LinkPositively responds to disparities in the HIV care continuum among Black WLHA affected by interpersonal violence. LinkPositively will be a first-of-its-kind mobile phone app with five innovative virtual components. For women, the virtual nature of peer navigation, informal social support, education and self-care tips, resource locator, and medication reminders will likely facilitate retention in care and ART adherence. For providers, the virtual PN approach is an invaluable option for resource-constrained settings. If demonstrated to be efficacious in a subsequent large-scale trial, LinkPositively will shift the HIV treatment paradigm for Black WLHA in the U.S.

Jamila K. Stockman, Katherine M. Anderson, Kiyomi Tsuyuki, and Keith J. Horvath

JAMILA K. STOCKMAN is an Associate Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and Director of the Disparities Core of the UC San Diego Center for AIDS Research. KATHERINE M. ANDERSON is a Clinical Research Coordinator at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and a PhD Student at Emory University, Rollins School of Public Health in the Department of Behavioral, Social, and Health Education Sciences. KIYOMI TSUYUKI is an Assistant Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health. KEITH J. HORVATH is an Associate Professor at San Diego State University in the Department of Psychology .

Please address correspondence to Jamila K. Stockman, Division of Infectious Diseases and Global Public Health, Department of Medicine, School of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA 92093-0507; phone: (858) 822-4652, fax: (858) 534-7566, email:


This research was supported by the National Institute of Mental Health (NIMH Grant #R34MH122014). K. Tsuyuki was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA Grant #K01AA025009) and the National Institute on Minority Health and Health Disparities (NIMHD Grant #L60MD012089). All authors acknowledge support by the UC San Diego Center for AIDS Research (Grant #P30AI036214). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies. We thank the study participants who generously provided formative data for this research. We also thank WORLD (Women Organized to Respond to Life-Threatening Diseases) for their support on this project.


1. Demeke HB, Johnson AS, Wu B, et al. Unequal declines in absolute and relative disparities in HIV diagnoses among black women, United States, 2008 to 2016. Am J Public Health. 2018 Nov;108(Suppl 4):S299–303. PMid:30383429
2. Bradley ELP, Williams AM, Green S, et al. Disparities in incidence of human immunodeficiency virus infection among black and white women—United States, 2010–2016. MMWR Morb Mortal Wkly Rep. 2019 May 10;68(18):416–8. PMid:31071070
3. Centers for Disease Control and Prevention. HIV surveillance report, 2018 (Updated);31. Atlanta, GA: Centers for Disease Control and Prevention (CDC), 2018. Available at:
4. Centers for Disease Control and Prevention (CDC). Estimated HIV incidence and prevalence in the United States, 2010–2016. HIV Surveillance Supplemental Report 2019;24(1). Atlanta, GA: CDC, 2019. Available at:
5. Lima AC, Jeffries WLT, Zhang Kudon H, et al. HIV testing, positivity, and receipt of services among Black, White, and Hispanic women participating in HIV prevention programs funded by the Centers For Disease Control and Prevention, 2015. Womens Health Issues. 2018 Jul–Aug;28(4):358–66. Epub 2018 Jun 27. PMid:29958775
6. Geter A, Sutton MY, Armon C, et al. Trends of racial and ethnic disparities in virologic suppression among women in the HIV Outpatient Study, USA, 2010–2015. PloS One. 2018 Jan 2;13(1):e0189973. PMid:29293632
7. Geter A, Sutton MY, Armon C, et al. Disparities in viral suppression and medication adherence among women in the USA, 2011–2016. AIDS and Behav. 2019 Nov;23(11):3015–23. PMid:30968277
8. Breiding MJ, Smith SG, Basile KC, et al. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—national intimate partner and sexual violence Survey, United States, 2011. 2014 Sep 5;63(8):1–18. Atlanta, GA.: U.S. Centers for Disease Control and Prevention, 2014.
9. Hien D, Ruglass L. Interpersonal partner violence and women in the United States: an overview of prevalence rates, psychiatric correlates and consequences and barriers to help seeking. Int J Law Psychiatry. 2009 Jan–Feb;32(1):48–55. PMid:19101036
10. Draughon JE, Lucea MB, Campbell JC, et al. Impact of intimate partner forced sex on HIV risk factors in physically abused African American and African Caribbean women. J Immigr Minor Health. 2015 Oct;17(5):1313–21. PMid:25248623
11. Basile KC, Smith SG, Fowler DN, et al. Sexual violence victimization and associations with health in a community sample of African American women. J Aggress Maltreat Trauma. 2016;25(3):231–53. Epub 2016 Feb 1. PMid:29606850
12. Campbell JC, Lucea MB, Stockman JK, et al. Forced sex and HIV risk in violent relationships. Am J Reprod Immunol. 2013 Feb;69 Suppl 1(0 1):41–4. Epub 2012 Oct 16. PMid:23066950
13. Cohen MH, Cook JA, Grey D, et al. Medically eligible women who do not use HAART: the importance of abuse, drug use, and race. Am J Public Health. 2004 Jul;94(7): 1147–51. PMid:15226135
14. Dale S, Cohen M, Weber K, et al. Abuse and resilience in relation to HAART medication adherence and HIV viral load among women with HIV in the United States. AIDS Patient Care STDs. 2014 Mar;28(3):136–43. PMid:24568654
15. Machtinger EL, Wilson TC, Haberer JE, et al. Psychological trauma and PTSD in HIV-positive women: a meta-analysis. AIDS Behav. 2012 Nov;16(8):2091–100. PMid:22249954
16. Illangasekare S, Tello M, Hutton H, et al. Clinical and mental health correlates and risk factors for intimate partner violence among HIV-positive women in an inner-city HIV clinic. Women's Health Issues. 2012 Nov–Dec;22(6):e563–9. PMid:22939089
17. Lopez EJ, Jones DL, Villar-Loubet OM, et al. Violence, coping, and consistent medication adherence in HIV-positive couples. AIDS Educ Prev. 2010 Feb;22(1):61–8. PMid:20166788
18. Hatcher AM, Smout EM, Turan JM, et al. Intimate partner violence and engagement in HIV care and treatment among women: A systematic review and meta-analysis. AIDS. 2015 Oct 23;29(16):2183–94. PMid:26353027
19. Leddy AM, Weiss E, Yam E, et al. Gender-based violence and engagement in biomedical HIV prevention, care and treatment: a scoping review. BMC Public Health. 2019 Jul 8;19(1):897. PMid:31286914
20. Rose RC, House AS, Stepleman LM. Intimate partner violence and its effects on the health of African American HIV-positive women. Psychol Trauma. 2010;2(4):311–7.
21. Espino SR, Fletcher J, Gonzalez M, et al. Violence screening and viral load suppression among HIV-positive women of color. AIDS Patient Care and STDS. 2015 Jan 1;29 (Suppl 1):S36–41. PMid:25561308
22. Shokoohi M, Bauer GR, Kaida A, et al. Social determinants of health and self-rated health status: a comparison between women with HIV and women without HIV from the general population in Canada. PloS One. 2019 Mar 21;14(3):e0213901. PMid:30897144
23. Aziz M, Smith KY. Challenges and successes in linking HIV-Infected women to care in the United States. Clin Infect Dis. 2011 Jan 15;52 Suppl 2:S231–7. PMid:21342912
24. Colbert AM, Kim KH, Sereika SM, et al. An examination of the relationships among gender, health status, social support, and HIV-related stigma. J Assoc Nurses AIDS Care. 2010 Jul–Aug;21(4):302–13. PMid:20116295
25. Dandachi D, May SB, Davila JA, et al. The Association of unmet needs with subsequent retention in care and HIV suppression among hospitalized patients with HIV who are out of care. J Acquir Immune Defic Syndr. 2019 Jan 1;80(1):64–72. PMid:30272637
26. Giles ML, MacPhail A, Bell C, et al. The barriers to linkage and retention in care for women living with HIV in an high income setting where they comprise a minority group. AIDS Care. 2019 Jun;31(6):730–6. PMid:30754996
27. Sangaramoorthy T, Jamison AM, Dyer TV. HIV stigma, retention in care, and adherence among older Black women living with HIV. J Assoc Nurses AIDS Care. 2017 Jul–Aug;28(4):518–31. PMid:28366556
28. Sevelius JM, Patouhas E, Keatley JG, et al. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med. 2014 Feb;47(1):5–16 PMid:24317955
29. McDoom MM, Bokhour B, Sullivan M, et al. How older Black women perceive the effects of stigma and social support on engagement in HIV care. AIDS Patient Care STDs. 2015 Feb;29(2):95–101. PMid:25494607
30. Geter A, Sutton MY, Hubbard McCree D. Social and structural determinants of HIV treatment and care among black women living with HIV infection: a systematic review: 2005–2016. AIDS Care. 2018 Apr;30(4):409–16. PMid:29376409
31. Beckett M, Collins R, Burnam M, et al. Mental health and substance abuse issues among people with HIV: lessons from HCSUS. Santa Monica, CA: RAND Corporation, 2007. Available at:
32. Lipira L, Williams EC, Huh D, et al. HIV-related stigma and viral suppression among African-American women: exploring the mediating roles of depression and ART nonadherence. AIDS Behav. 2019 Aug;23(8):2025–36. PMid:30343422
33. Turan B, Rice WS, Crockett KB, et al. Longitudinal association between internalized HIV stigma and antiretroviral therapy adherence for women living with HIV: the mediating role of depression. AIDS. 2019 Mar 1;33(3):571–6. PMid:30702521
34. Gaston GB, Alleyne-Green B. The impact of African Americans' beliefs about HIV medical care on treatment adherence: a systematic review and recommendations for interventions. AIDS Behav. 2013 Jan;17(1):31–40. PMid:23010941
35. Pellowski JA, Price DM, Allen AM, et al. The differences between medical trust and mistrust and their respective influences on medication beliefs and ART adherence among African-Americans living with HIV. Psychol Health. 2017 Sep;32(9):1127–39. PMid:28475365
36. Kalichman SC, Eaton L, Kalichman MO, et al. Race-based medical mistrust, medication beliefs and HIV treatment adherence: test of a mediation model in people living with HIV/AIDS. J Behav Med. 2016 Dec;39(6):1056–64. PMid:27392477
37. Edwards LV. Perceived social support and HIV/AIDS medication adherence among African American women. Qual Health Res. 2006 May;16(5):679–91. PMid:16611972
38. Vyavaharkar M, Moneyham L, Tavakoli A, et al. Social support, coping, and medication adherence among HIV-positive women with depression living in rural areas of the southeastern United States. AIDS Patient Care STDs. 2007 Sep;21(9):667–80. PMid:17919094
39. Gonzalez J, Penedo F, Antoni M, et al. Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDS. Health Psychol. 2004 Jul;23(4):413–8. PMid:15264978
40. Ashton E, Vosvick M, Chesney M, et al. Social support and maladaptive coping as predictors of the change in physical health symptoms among persons living with HIV/AIDS. AIDS Patient Care STDS. 2005 Sep;19(9):587–98. PMid:16164385
41. Vyavaharkar M, Moneyham L, Corwin S, et al. HIV-disclosure, social support, and depression among HIV-infected African American women living in the rural southeastern United States. AIDS Educ Prev. 2011 Feb;23(1):78–90. PMid:21341962
42. Vyavaharkar M, Moneyham L, Corwin S, et al. Relationships between stigma, social support, and depression in HIV-infected African American women living in the rural southeastern United States. J Assoc Nurses AIDS Care. 2010 Mar–Apr;21(2):144–52. PMid:19879778
43. Webel AR, Cuca Y, Okonsky JG, et al. The impact of social context on self-management in women living with HIV. Soc Sci Med. 2013 Jun;87:147–54. PMid:23631790
44. The Obama White House. National HIV/AIDS strategy for the United States—updated to 2020. Washington, DC: The Obama White House, 2015. Available at:
45. AIDS United. Best practices for integrating peer navigators into HIV Models of Care. Washington, DC: AIDS United, 2015. Available at:
46. Cabral HJ, Davis-Plourde K, Sarango M, et al. Peer support and the HIV continuum of care: results from a multi-site randomized clinical trial in three urban clinics in the United States. AIDS Behav. 2018 Aug;22(8):2627–39. PMid:29306990
47. Okeke NL, Ostermann J, Thielman NM. Enhancing linkage and retention in HIV care: a review of interventions for highly resourced and resource-poor settings. Curr HIV/AIDS Rep. 2014 Dec;11(4):376–92. PMid:25323298
48. Higa DH, Marks G, Crepaz N, et al. Interventions to improve retention in HIV primary care: a systematic review of U.S. studies. Curr HIV/AIDS Repo. 2012 Dec;9(4):313–25. PMid:22996171
49. Simoni JM, Pantalone DW, Plummer MD, et al. A randomized controlled trial of a peer support intervention targeting antiretroviral medication adherence and depressive symptomatology in HIV-positive men and women. Health Psychol. 2007 Jul;26(4):488–95. PMid:17605569
50. Deering KN, Shannon K, Sinclair H, et al. Piloting a peer-driven intervention model to increase access and adherence to antiretroviral therapy and HIV care among street-entrenched HIV-positive women in Vancouver. AIDS Patient Care and STDs. 2009 Aug;23(8):603–9. PMid:19591602
51. Cunningham WE, Weiss RE, Nakazono T, et al. Effectiveness of a peer navigation intervention to sustain viral suppression among HIV-positive men and transgender women released from jail: the LINK LA randomized clinical trial. JAMA Intern Med. 2018 Apr 1;178(4):542–53. PMid:29532059
52. Reback CJ, Kisler KA, Fletcher JB. A novel adaptation of peer health navigation and contingency management for advancement along the HIV care continuum among transgender women of color. AIDS Behav. 2019 Jun 11; 10.1007/s10461-019-02554-0.
53. Warren-Jeanpiere L, Dillaway H, Hamilton P, et al. Life begins at 60: identifying the social support needs of African American women aging with HIV. J Health Care Poor Underserved. 2017 Feb;28(1):389–405. PMid:28239009
54. Paudel V, Baral KP. Women living with HIV/AIDS (WLHA), battling stigma, discrimination and denial and the role of support groups as a coping strategy: a review of literature. Reprod Health. 2015 Jun 2;12:53. PMid:26032304
55. McKay FH, Cheng C, Wright A, et al. Evaluating mobile phone applications for health behaviour change: a systematic review. J Telemed Telecare.2018 Jan;24(1):22–30. PMid:27760883
56. Taylor CB, Fitzsimmons-Craft EE, Graham AK. Digital technology can revolutionize mental health services delivery: the COVID-19 crisis as a catalyst for change. Int J Eat Disord. 2020 Jul;53(7):1155–7. PMid:32449523
57. Whitelaw S, Mamas MA, Topol E, et al. Applications of digital technology in COVID-19 pandemic planning and response. Lancet Digit Health. 2020 Aug;2(8):e435–40.
58. Saltzman LY, Hansel TC, Bordnick PS. Loneliness, isolation, and social support factors in post-COVID-19 mental health. Psychol Trauma. 2020 Aug;12(S1):S55–7. PMid:32551762
59. Bacchus LJ, Bullock L, Sharps P, et al. Infusing technology into perinatal home visitation in the United States for women experiencing intimate partner violence: exploring the interpretive flexibility of an mHealth intervention. J Med Internet Res. 2016 Nov 17;18(11):e302. PMid:27856405
60. Glass N, Eden KB, Bloom T, et al. Computerized aid improves safety decision process for survivors of intimate partner violence. J Interpers Violence. 2010 Nov;25(11): 1947–64. PMid:20040709
61. Koziol-McLain J, Vandal AC, Nada-Raja S, et al. A web-based intervention for abused women: The New Zealand isafe randomised controlled trial protocol. BMC Public Health. 2015 Jan 31;15:56. PMid:25637195
62. Ye M, Kagone M, Sie A, et al. Promoting access equity and improving health care for women, children and people living with HIV/AIDS in Burkina Faso through mHealth. J Public Health (Oxf). 2018 Dec 1;40(suppl_2):ii42–51. PMid:30551129
63. da Costa TM, Barbosa BJ, Gomes e Costa DA, et al. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform. 2012 Apr;81(4):257–69. PMid:22296762
64. Njie-Carr VPS, Jones-Parker H, Massey C, et al. Leveraging community engagement to develop a mobile health application for older women with HIV infection. J Obstet Gynecol Neonatal Nurs. 2018 Nov;47(6):833–43. PMid:30278158
65. Coleman J, Bohlin KC, Thorson A, et al. Effectiveness of an SMS-based maternal mHealth intervention to improve clinical outcomes of HIV-positive pregnant women. AIDS Care. 2017 Jul;29(7):890–7. PMid:28107805
66. Ishola AG, Chipps J. The use of mobile phones to deliver acceptance and commitment therapy in the prevention of mother-child HIV transmission in Nigeria. J Telemed Telecare. 2015 Dec;21(8):423–6. PMid:26391511
67. Kalichman SC, Cherry C, Kalichman MO, et al. Mobile health intervention to reduce HIV transmission: a randomized trial of behaviorally enhanced HIV treatment as prevention (B-TasP). J Acquir Immune Defic Syndr. 2018 May 1;78(1):34–42. PMid:29406429
68. LeGrand S, Muessig KE, Platt A, et al. Epic allies, a gamified mobile phone app to improve engagement in care, antiretroviral uptake, and adherence among young men who have sex with men and young transgender women who have sex with men: protocol for a randomized controlled trial. JMIR Res Protoc. 2018 Apr 5;7(4):e94. PMid:29622527
69. Hightow-Weidman LB, Muessig KE, Pike EC, et al. building community through a mobile-optimized, online health promotion intervention. Health Educ Behav. 2015;42(4):493–9. PMid:25588932
70. Sun CJ, Anderson KM, Mayer L, et al. Findings from formative research to develop a strength-based HIV prevention and sexual health promotion mHealth intervention for transgender women. Transgend Health. 2019;4(1):350–8. PMid:32042925
71. Linnemayr S, MacCarthy S, Kim A, et al. Behavioral economics-based incentives supported by mobile technology on HIV knowledge and testing frequency among Latino/a men who have sex with men and transgender women: protocol for a randomized pilot study to test intervention feasibility and acceptability. Trials. 2018 19(1): 540. PMid:30290851
72. Lester RT, Ritvo P, Mills EJ, et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet. 2010 Nov 27;376(9755):1838–45.
73. Kurth AE, Spielberg F, Cleland CM, et al. Computerized counseling reduces HIV-1 viral load and sexual transmission risk: findings from a randomized controlled trial. J Acquir Immune Defic Syndr. 2014 Apr 15;65(5):611–20. PMid:24384803
74. Pew Research Center. Internet/Broadband fact sheet. Washington, DC: Pew Research Center, 2019. Available at:
75. Perrin A, Turner E. Smartphones help Blacks, Hispanics bridge some—but not all—digital gaps with whites. Washington, DC: Pew Research Center, 2019. Available at:
76. Tufts K, Johnson K, Shepherd J, et al. Novel interventions for HIV self-management in African American women: a systematic review of mHealth interventions. J Assoc Nurses AIDS Care. 2015 Mar–Apr;26(2):139–50. PMid:25283352
77. Anand T, Nitpolprasert C, Phanuphak N. Online-to-offline models in HIV service delivery. Curr Opin HIV AIDS. 2017 Sep;12(5):447–57. PMid:28682799
78. Blackstock OJ, Shah PA, Haughton LJ, et al. HIV-infected women's perspectives on the use of the internet for social support: a potential role for online group-based interventions. J Assoc Nurses AIDS Care. 2015 Jul–Aug;26(4):411–9. PMid:25749532
79. Messias DKH, Moneyham L, Murdaugh C, et al. HIV/AIDS peer counselors' perspectives on intervention delivery formats. Clin Nurs Res. 2006 Aug;15(3):177–96. PMid:16801358
80. Flay BR, Snyder F, Petraitis J. The theory of Triadic Influence. In: DiClemente RJ, Crosby RA, Kegler MC. Emerging Theories in Health Promotion Practice and Research. San Francisco, CA: Jossey-Bass, 2009.
81. Singer M. AIDS and the health crisis of the U.S. urban poor; the perspective of critical medical anthropology. Soc Sci Med. 1994 Oct;39(7):931–48.
82. van der Kolk BA, Hostetler A, Herron N, et al. Trauma and the development of borderline personality disorder. Psychiatr Clin North Am. 1994 Dec;17(4):715–30.
83. Coles J, Jones K. "Universal Precautions": perinatal touch and examination after childhood sexual abuse. Birth. 2009 Sep;36(3):230–6. PMid:19747270
84. Rosenberg L. Addressing trauma in mental health and substance use treatment. The J Behav Health Serv Res. 2011 Oct;38(4):428–31. PMid:21874392
85. Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs. 2015;36(9):698–709. PMid:26440873
86. Sales JM, Swartzendruber A, Phillips AL. Trauma-informed HIV prevention and treatment. Curr HIV/AIDS Rep. 2016 Dec;13(6):374–82. PMid:27704251