- McGill researchers developed a chatbot to provide information to people living with HIV
- Study participants said the chatbot provided more reliable answers than search engines
- Advantages included a perception of non-judgment, confidentiality and speed
For many people in Canada and other high-income countries, HIV infection is a treatable and mostly manageable condition. For some people, HIV treatment (antiretroviral therapy; ART) can be as simple as taking one pill once daily or having injections on a regular basis. When used as directed, ART helps to suppress HIV and keeps it suppressed. This allows the immune system to largely rebuild itself, and the risk of AIDS-related infections and cancers becomes extremely rare. As a result, studies indicate that many ART users will have near-normal life expectancy.
However, for ART to provide these benefits, it must be taken as prescribed. Also, people need to keep appointments with clinics and undergo laboratory and other assessments from time to time so that they and their doctors can stay abreast of any developments. ART users also have to acquire some knowledge about managing their condition and the medications that they take.
Unfortunately, some people with HIV face challenges that can have an impact on medication-taking, including the following:
- not understanding the need for good medication-taking habits
- fear of potential side effects from treatment
- disruptions to their routines caused by life circumstances (financial issues)
- mental health issues such as depression and addiction
- worries about the presence of medicines inadvertently disclosing their HIV status to others
- problems communicating with care providers
Technological solutions
Research has found that web-based counselling services can help people adhere to ART and deal with simple side effects. One study in British Columbia found that text messages sent once a week were useful in helping people maintain adherence to ART and viral suppression.
Some researchers think that artificial intelligence (AI)–powered conversation programs— chatbots—can provide assistance to people with medical issues. In the current era, there has been a focus on testing the use of chatbots to provide limited health-related information in several fields, including cancer, diabetes and mental health.
Researchers in South Africa found that chatbots were helpful for people undergoing rapid HIV self-testing. In Malaysia, another study found that users considered chatbots to be an acceptable way of providing information about HIV self-testing and HIV pre-exposure prophylaxis (PrEP).
Enter Marvin in Montreal
A team of researchers at McGill University in Montreal cooperated with patients and other stakeholders to develop a chatbot they called Marvin. This chatbot can converse via text, in English or French, and offer advice and information on the following issues:
- taking ART – time management, dosing, storage of medicines, common drug interactions, identifying medicines
- ART management while travelling – advice about immigration restrictions in some countries due to HIV status, vaccination requirements, how to adjust medication schedules due to differences in time zones, how to transport ART safely
- general HIV-related topics – the chatbot could access a knowledgebase to discuss common HIV-related symptoms, ways that HIV is transmitted and how transmission can be prevented, recommended routine vaccinations
- medication reminders – at the user’s request, the chatbot can send daily reminders to take medicines. These can be customized, changed or deleted at any time. A medication reminder can be getting the chatbot to send a message such as “time for a walk.” This type of message avoids disclosing the person’s HIV status.
The chatbot study
After developing Marvin, the Montreal researchers conducted a study to assess how useful it was. Participants were asked to have 20 “conversations” with Marvin on the following specific topics:
- advice for taking ART
- advice for travelling with ART
- vaccination recommendations for people with HIV
Participants interacted with Marvin via Facebook Messenger. This free messaging app could be accessed via smartphone, tablet or another device. The data from the study and the chatbot were stored on the McGill University computer servers.
After 20 conversations, participants then completed questionnaires, and some participated in focus groups via the Zoom platform. A few participants were interviewed individually. In total, there were 28 participants—23 men and 5 women.
Results
According to the researchers, participants found Marvin to be “a reliable source of medical knowledge and information, as it was validated by expert health professionals. Users found that responses were accurate and more trustworthy than what they would normally find on common [internet] search engines.”
For most participants, Marvin was easy to use and helped to eliminate “the need to wait for their next clinic appointment” where they could ask their healthcare provider questions.
Marvin provided answers instantly. Users found this helpful, particularly when they wanted a quick response. The researchers stated that “travel-related content was especially appreciated by some participants, as they would not usually see their doctor before travelling.”
As Marvin was non-human, the researchers said that users found it “emotionally safe.” That is, it put participants at ease, as they could confide confidential information. Participants felt that Marvin was nonjudgmental, which encouraged them to ask questions that they otherwise might not have asked their healthcare provider.
Many users appreciated the confidential characteristics of the chatbot service.
Most users found Marvin easy to use. According to the researchers, several participants stated that “using Marvin was like chatting with a friend.” The creators of Marvin included programming around what they called “emphatic elements,” such as the “smiley emoji” and encouraging words and phrases.
Areas for improvement
Although participants were satisfied with the chatbot, the researchers stated that participants found that Marvin’s conversations “were superficial and not answered in a useful way.” Participants wanted the chatbot to be able to discuss a wider range of health-related topics, including the following:
- diet and nutrition
- exercise
- further information on HIV treatment
- new treatments
- emerging infections
- HIV PrEP
- pregnancy and breastfeeding
- sexual health and sexually transmitted infections
- support for healthcare access, such as scheduling appointments and vaccinations
- referrals to psychologists
- socio-economic issues
- immigration support
Input/output
Some participants found that Marvin had difficulty understanding the initial questions asked. This forced participants to rephrase their questions. One participant encouraged the researchers to help the chatbot learn other languages.
Different ways of delivering information
Although Marvin was designed as a chatbot and therefore delivered information via text, some users recommended that future versions be enhanced so that it can deliver answers via images and video.
Memory
Some participants suggested that Marvin be given the capacity to remember conversations. This would save participants from having to explain their background (such as health issues and medications they are on) repeatedly over a short period of time. Researchers will have to balance this request from patients against the fact that from time to time doctors prescribe a change in medication.
Proactivity
Marvin was developed so that participants first had to ask a question to initiate conversation. However, some users want a future version of Marvin to be more proactive (to ask questions and initiate conversation).
Engagement beyond participants
Some people who used Marvin found it engaging and used it to facilitate discussions around health with their friends. Access to Marvin (facilitated by participants) helped to address issues raised by participants’ friends.
Knowledge base
According to the researchers, “participants indicated that there are other, more comprehensive sources of information…. [including CATIE.ca].” However, readers should note that Marvin was designed with built-in limitations to test ideas on certain topics.
Trust and other issues
One participant found a discrepancy in the response from Marvin and what their doctor said about managing ART schedules when travelling. This participant preferred Marvin’s advice. Another participant stated that he would trust what his doctor said over what the chatbot advised.
Another area of trust arose with the Facebook Messenger app. Many participants expressed a lack of trust with the platform. What’s more, the researchers found that “Facebook is simply not the preferred social media of many participants.” This revealed a need to make the chatbot available on multiple platforms. Patients suggested WhatsApp (also owned by Facebook) and to create a Marvin app that could be installed on devices. An alternative would be to access Marvin via a clinic website.
The challenge of technology
In the 21st century, it is difficult for people to fully engage with society, media, government and healthcare services without knowing something about how to use devices such as smartphones or tablets, the internet and computers. Some participants did not have pre-existing knowledge about Facebook Messenger; this is not surprising, as the researchers found that it is not a preferred platform. The researchers stated that “the inherent technological aspect of a chatbot is also a barrier to some individuals.”
To help participants use Marvin, researchers held training sessions. However, future iterations of the chatbot and future experiments with it will need videos and tutorials to help make it more accessible. Such interventions will be necessary, as the researchers stated that “some participants struggled with chatbot technology and social media due to gaps in digital literacy.”
Expanding the user population
Participants who had been living with HIV for several years noted that Marvin would probably be more useful for people who were recently diagnosed with HIV and who were new to ART.
Participants also noted that because of Marvin’s knowledge of HIV prevention, future users could include people who do not have HIV.
The chatbot will see you now
The Montreal research team appears to be at the forefront of chatbot research designed to be an assistant for people with HIV. The chatbot obviously cannot replace a healthcare provider. The study provided the researchers with a lot of information to help them design the next version of Marvin. The researchers disclosed that a future version of Marvin will have many more topics that can be discussed as its knowledgebase expands.
As processing chips become more complex, so will computers and computing devices that depend upon them. It is a natural evolution for chatbots to have increased capacity to converse with people and provide timely and accurate health-related information. The 21st century is only in its infancy; it is likely that computers and artificial intelligence will become more sophisticated in the future. One application will be providing information assistance to people with health conditions such as HIV. The McGill University research points to one way of integrating AI into the everyday lives of people with HIV. Researchers need to continue to be mindful of issues related to ethics, personal safety, confidentiality and protection of personal data. A future version of Marvin will have its own web interface and likely an app for installation on phones and tablets.
AI and virtual robots cannot replace the warmth of human connection between patients interacting with other humans. Virtual medical information assistants will not be suitable for everyone. However, some people will find chatbots handy, particularly between appointments with their healthcare providers.
—Sean R. Hosein
REFERENCE:
Ma Y, Achiche S, Tu G, et al. The first AI-based Chatbot to promote HIV self-management: A mixed methods usability study. HIV Medicine. 2024; in press.