Smart-ART: Enhancing HIV Medication Adherence in Pregnant Women with IoT-Enabled Medication Boxes
Main Article Content
Rikawarastuti Rikawarastuti
Hariyanti Hariyanti
Muhammad Yusro
Ari Apriyansa
Rosyid Ridlo Al Hakim
Yanuar Zulardiansyah Arief
Background: HIV testing and antiretroviral therapy (ART) coverage among pregnant women living with HIV in Indonesia remain suboptimal. Inadequate ART adherence may compromise treatment effectiveness and viral suppression, potentially increase the risk of mother-to-child HIV transmission and highlighting the need for technology-assisted adherence monitoring.
Aims: This study aimed to develop Smart-ART and assess its technical functionality and preliminary feasibility for monitoring ART adherence among pregnant women living with HIV.
Methods: Smart-ART was developed using the Rapid Application Development (RAD) approach. The system comprised an IoT-enabled medication box, a patient-facing mobile application, and a provider-facing telemonitoring interface. Technical functionality was assessed through functional testing. A 30-day pilot pre–post evaluation was subsequently conducted among 15 pregnant women living with HIV receiving ART at an urban community health center. ART adherence was operationalized as the proportion of scheduled medication events completed within one hour of the initial medication reminder, supported by photographic confirmation and review by HIV care coordinators.
Results: Among the 15 participants, mean ART adherence was 70.0% at baseline and 96.2% after 30 days of Smart-ART use, corresponding to a mean increase of 26.2 percentage points (p < 0.001). All participants showed higher adherence during the Smart-ART period than at baseline. Functional testing demonstrated that the system generated scheduled medication reminders through the pillbox and application and enabled participants to submit photographic evidence of medication intake for review by HIV care coordinators. The provider interface enabled remote access to medication-event records and adherence status. Intermittent internet connectivity was identified as an implementation limitation that may affect continuous telemonitoring and data synchronization.
Conclusion: Smart-ART demonstrated technical feasibility and was associated with improved ART adherence in this 30-day pilot evaluation. The single-arm pre–post design, small sample, short follow-up, and single healthcare setting limit causal inference and generalizability. Larger controlled studies with longer follow-up are needed to determine clinical effectiveness, usability, scalability, and implementation feasibility.
Abadiga, M., Hasen, T., Mosisa, G., & Abdisa, E. (2020). Adherence to antiretroviral therapy and associated factors among Human immunodeficiency virus positive patients accessing treatment at Nekemte referral hospital, west Ethiopia, 2019. PLoS ONE, 15(5), e0232703. https://doi.org/10.1371/JOURNAL.PONE.0232703
Achappa, B., Madi, D., Bhaskaran, U., Ramapuram, J. T., Rao, S., & Mahalingam, S. (2013). Adherence to antiretroviral therapy among people living with HIV. North American Journal of Medical Sciences, 5(3), 220–223. https://doi.org/10.4103/1947-2714.109196
al Adawiyah, R., Boettiger, D., Applegate, T. L., Probandari, A., Marthias, T., Guy, R., & Wiseman, V. (2022). Supply-side readiness to deliver HIV testing and treatment services in Indonesia: Going the last mile to eliminate mother-to-child transmission of HIV. PLOS Global Public Health, 2(8), e0000845. https://doi.org/10.1371/JOURNAL.PGPH.0000845
Armini, L. N., Setiawati, E. P., Arisanti, N., & Hilmanto, D. (2023). Evaluation of Process Indicators and Challenges of the Elimination of Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B in Bali Province, Indonesia (2019–2022): A Mixed Methods Study. Tropical Medicine and Infectious Disease, 8(11), 492. https://doi.org/10.3390/TROPICALMED8110492
Carr, A., Mackie, N. E., Paredes, R., & Ruxrungtham, K. (2023). HIV drug resistance in the era of contemporary antiretroviral therapy: A clinical perspective. Antiviral Therapy, 28(5). https://doi.org/10.1177/13596535231201162;WGROUP:STRING:PUBLICATION
Chilaka, V. N., & Konje, J. C. (2021). HIV in pregnancy – An update. European Journal of Obstetrics and Gynecology and Reproductive Biology, 256, 484–491. https://doi.org/10.1016/j.ejogrb.2020.11.034
Fauk, N. K., Mwanri, L., Hawke, K., Mohammadi, L., & Ward, P. R. (2022). Psychological and Social Impact of HIV on Women Living with HIV and Their Families in Low-and Middle-Income Asian Countries: A Systematic Search and Critical Review. International Journal of Environmental Research and Public Health, 19(11), 6668. https://doi.org/10.3390/IJERPH19116668/S1
Fedlu, A., Alie, B., Mohammed, A. S., Adem, F., & Hassen, A. (2020). Adherence to Antiretroviral Treatment for Prevention of Mother-to-Child Transmission of HIV in Eastern Ethiopia: A Cross-Sectional Study. HIV/AIDS - Research and Palliative Care, 12, 725–733. https://doi.org/10.2147/HIV.S274012
Haberer, J. E., Baijuka, R., Tumuhairwe, J. B., Tindimwebwa, E. B., Tinkamanyire, J., Tuhanamagyezi, E., Musoke, L., Garrison, L. E., DelSignore, M., Musinguzi, N., & Asiimwe, S. (2022). Implementation of Electronic Adherence Monitors and Associated Interventions for Routine HIV Antiretroviral Therapy in Uganda: Promising Findings. Frontiers in Digital Health, 4, 899643. https://doi.org/10.3389/FDGTH.2022.899643/TEXT
Hansana, V., Sanchaisuriya, P., Durham, J., Sychareun, V., Chaleunvong, K., Boonyaleepun, S., & Schelp, F. P. (2013). Adherence to Antiretroviral Therapy (ART) among People Living With HIV (PLHIV): a cross-sectional survey to measure in Lao PDR. BMC Public Health, 13, 617-. https://doi.org/10.1186/1471-2458-13-617
Iacob, S. A., Iacob, D. G., & Jugulete, G. (2017). Improving the adherence to antiretroviral therapy, a difficult but essential task for a successful HIV treatment-clinical points of view and practical considerations. Frontiers in Pharmacology, 8, 299234. https://doi.org/10.3389/FPHAR.2017.00831/BIBTEX
Inzaule, S. C., Hamers, R. L., Calis, J., Boerma, R., Sigaloff, K., Zeh, C., Mugyenyi, P., Akanmu, S., & De Wit, T. F. R. (2018). When prevention of mother-To-child HIV transmission fails: Preventing pretreatment drug resistance in African children. AIDS, 32(2), 143–147. https://doi.org/10.1097/QAD.0000000000001696
Kaya, Ş. M., Erdem, A., & Güneş, A. (2021). A Smart Data Pre-Processing Approach to Effective Management of Big Health Data in IoT Edge. Smart Homecare Technology and TeleHealth, 8, 9–21. https://doi.org/10.2147/SHTT.S313666
Lumbantoruan, C., Kermode, M., Giyai, A., Ang, A., & Kelaher, M. (2018). Understanding women’s uptake and adherence in Option B+ for prevention of mother-to-child HIV transmission in Papua, Indonesia: A qualitative study. PLoS One, 13(6). https://doi.org/http://dx.doi.org/10.1371/journal.pone.0198329
Minaam, D. S. A., & Abd-ELfattah, M. (2018). Smart drugs:Improving healthcare using Smart Pill Box for Medicine Reminder and Monitoring System. Future Computing and Informatics Journal, 3(2), 443–456. https://doi.org/10.1016/J.FCIJ.2018.11.008
Moomba, K., & van Wyk, B. (2019). Social and economic barriers to adherence among patients at Livingstone General Hospital in Zambia. African Journal of Primary Health Care and Family Medicine, 11(1). https://doi.org/10.4102/phcfm.v11i1.1740
Msefula, M. C., & Umar, E. (2024). Correlates of Depression in ART Adherence among Youths in Lilongwe, Malawi. Tropical Medicine and Infectious Disease, 9(1). https://doi.org/10.3390/tropicalmed9010002
Nasir, Z., Asif, A., Nawaz, M., & Ali, M. (2023). Design of a Smart Medical Box for Automatic Pill Dispensing and Health Monitoring. Engineering Proceedings, 32(1). https://doi.org/10.3390/engproc2023032007
Nurhayati, N., Amin bin Sahari, M., Tominanto, & Laksono, D. Y. (2022). Implementation of the Rapid Application Development Method for Designing An Outpatient Online Registration System In An Independent Doctor’s Practice. International Conference on Nursing and Health Sciences, 3(1), 249–260. http://jurnal.globalhealthsciencegroup.com/index.php/PICNHS/article/view/1154
Nurmisih, N., Hindriati, T., Imelda, I., Rosmaria, R., & Harianja, R. R. (2022). Determination of Factors Associated With Adherence of Pregnant Women to HIV Screening in Indonesia: A Single-Center Study. Journal of Research Development in Nursing and Midwifery, 19(1), 39–41. https://doi.org/10.29252/jgbfnm.19.1.39
Petersen, M. L., Wang, Y., Van Der Laan, M. J., Guzman, D., Riley, E., & Bangsberg, D. R. (2007). Pillbox Organizers Are Associated with Improved Adherence to HIV Antiretroviral Therapy and Viral Suppression: A Marginal Structural Model Analysis.
Pratiwi, M., Mayola, L., Kris, V., Laoli, H., Arsyah, U. I., & Pratiwi, N. (2022). Medical Record Information System with Rapid Application Development (RAD) Method. Journal of Information System and Technology Research, 1(2), 124–130. https://doi.org/https://doi.org/10.55537/jistr.v1i2.170
Rosli, E., & Husaini, Y. (2018). Design and Development of Smart Medicine Box. IOP Conference Series: Materials Science and Engineering, 341, 012004. https://doi.org/10.1088/1757-899X/341/1/012004
Sahay, S., Reddy, K. S., & Dhayarkar, S. (2011). Optimizing adherence to antiretroviral therapy. Indian Journal of Medical Research, 134(6), 835–849. https://doi.org/10.4103/0971-5916.92629
Schnall, R., Radix, A., Scott Batey, D., Kay, E., Bruce, J., Belkind, U., & Hripcsak, M. (2026, July 4). Designing For Choice In HIV Prevention: Translating Multi-Stakeholder Evidence Into A Patient-Facing mHealth Ecosystem For Prep. IH 2026 - Proceedings of the 2026 ACM Interactive Health Conference. https://doi.org/10.1145/3786579.3804959
Siregar, K. N., Hanifah, L., & Rikawarastuti. (2020). Rapid Assessment of The Program Performance For The Elimination of HIV Transmission From Mother To Child In Makassar City And Maros District South Sulawesi.
Siregar, K. N., Hanifah, L., Rikawarastuti, & Wahyuniar, L. (2021). Prevention of HIV Transmission from Mother to Child: Challenges to the Successful Program Implementation and Practice in Indonesia. Journal of the International Association of Providers of AIDS Care (JIAPAC), 20. https://doi.org/10.1177/23259582211040701
Terefe, B., Kebede, A., & Muche, G. A. (2021). Process Evaluation of Prevention of Mother-to-Child Transmission of HIV Service at Gondar City Administration Governmental Health Facilities, Northwest Ethiopia: A Mixed Approach Case Study Evaluation Design. HIV/AIDS - Research and Palliative Care, 13, 1127–1147. https://doi.org/10.2147/HIV.S340103
Wariki, W. M. V., Ota, E., Mori, R., Wiysonge, C. S., Horvath, H., & Read, J. S. (2017). Interventions for preventing mother-to-child HIV transmission: protocol of an overview of systematic reviews. BMJ Open, 7(6), e014332. https://doi.org/10.1136/BMJOPEN-2016-014332
World Health Organization. (2022). Governance for the validation of elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus: An overview of validation structures and responsibilities at national, regional and global levels. World Health Organization.
Zewude, S. B., & Ajebe, T. M. (2022). Magnitude of optimal adherence and predictors for a low level of adherence among HIV/AIDS-infected adults in South Gondar zone, Northwest Ethiopia: a multifacility cross-sectional study. BMJ Open, 12(1), e056009. https://doi.org/10.1136/BMJOPEN-2021-056009
