In this systematic review, we evaluated the utilization of self-care technology-based methods by HIV-positive individuals to improve ARV adherence. Despite the fact that “forgetfulness” is commonly cited as a cause of non-adherence 
, the use of technology-based methods that solely remind patients to take ARVs at dosing times do not seem to be the most effective methods of enhancing adherence. As noted in qualitative studies, only a small proportion of individuals reported the use of reminder devices or found these methods helpful. The exclusive use of these electronic reminder devices has been shown to lead to slight improvements in ARV adherence 
, deterioration in quality of life 
, and a paradoxical effect on HIV viral load 
. These devices may be useful in those who are memory-impaired 
or in those whose “forgetfulness” is actually due to not remembering. The explanation for this seemingly contradictory evidence may lie in investigating the underlying cause of the reported “forgetfulness”, such as stigma, depression, drug and alcohol use, lack of social support, etc.
Results of both qualitative and quantitative studies indicate that participants are interested in using technology-based methods, but are most receptive toward the provision of a combination of reminders along with information regarding HIV treatment and enhanced communication with providers. In fact, quantitative intervention studies that include a fusion of individualized counseling sessions with a provider or a peer, as well as the choice
of an adherence aid seemed to produce the most beneficial effects on adherence 
. This need for additional support was most evident in two-by-two factorial design studies where the efforts of medication managers and peers resulted in higher reporting of 100% adherence; however, the use of medication reminder devices did not produce this effect 
. In two studies, the combined use of education and technology-based methods did not enhance ARV adherence 
. We believe that the reason for this neutral result may be that one study 
, may not have had enough power to detect a statistically significant difference. In the second study 
, the study population consisted of individuals with alcohol problems; therefore, this risk factor may have impeded adherence and needed to have been addressed more thoroughly.
In order to provide context to the results of this review, we included qualitative studies where participants provided narratives of using technology-based methods. Furthermore, we included pilot and multi-component studies that incorporated the use of technology-based strategies. Therefore, the results of our study should be viewed in light of methodological differences across studies. Many studies examined interventions with multiple components; therefore, we cannot tease apart the independent effect of technology-base methods for improving adherence. Additionally, many studies relied on patient self-report to assess adherence which tends to over-estimate the actual level of adherence and is prone to the problem of recall bias. Lastly, we cannot rule out publication bias in that studies with negative results are less likely to be published.
Based on this review, it seems that the optimal characteristics of adherence-enhancing interventions that include a self-care technology-based method may involve: 1) tools that are easy to use, familiar to the patient, and that do not attract much attention (such as a personal mobile telephone) 
; 2) individually-tailored methods that are customized based on the patient's specific reasons for ARV non-adherence (such as the choice of technology-based methods) 
; 3) multiple components, including the periodic involvement of providers and peers that provide education and support 
; 4) multi-function strategies that include components to increase information (e.g., HIV treatment knowledge and consequences of non-adherence), motivation (e.g., treatment benefits and concerns), and behavioral skills (e.g., methods of enhancing adherence) 
Currently, there are several ongoing projects listed in Clinicaltrials.gov or the NIH Research Portfolio Online Reporting Tools (RePORT) that examine the effect of self-care technology-based methods of improving ARV adherence 
. The tools utilized focus on mobile telephones, such as use of automated text messaging and reminders 
; computer-delivered programs 
; and Web-based applications 
. The computer interventions include programs designed to promote health literacy in a tailored and interactive manner 
and electronic versions of an intervention entitled Life Step 
. Web-based interventions consist of online peer support programs 
and behavioral health modules 
. Therefore, it is apparent that much of the forth-coming studies have taken a tailored approach to the use of technology to enhance information, motivation, and behavioral skills. However, more research incorporating the above-mentioned characteristics of adherence-enhancing self-care technology-based interventions is needed to examine rules for adapting the technology to the individual and the optimal amount of each intervention component.
In 2008, an estimated $13.7 billion was spent on HIV programs 
; however, less than half of those requiring HIV treatment are receiving ARVs 
. Therefore, as we move toward the goal of universal access for HIV therapy 
, the consideration for careful budgeting and comprehensive utilization of existing resources is exceedingly important. Individually-tailored multi-component interventions including self-care technology-based methods may empower HIV-positive individuals, aid over-burdened clinics, and have the potential to result in cost-containment, while improving ARV adherence. Future research should focus on standardizing these interventions and testing the efficacy of simple, individually-tailored, multi-function technologies, which allow for the periodic involvement of health care providers.