We conducted a longitudinal qualitative descriptive study and secondary analysis using interviews and questionnaire data from adults aging with HIV who participated in a 6-month online CBE intervention (Tele-Coaching CBE Study) [42]. Our qualitative design was supported by quantitative (questionnaire) data collected at baseline, month 2 (after initial exposure to the intervention), and month 6 (post intervention).

The telecoaching CBE study was a prospective longitudinal mixed-method intervention study designed to evaluate the implementation of a 6-month online telecoaching CBE program for adults aging with HIV, delivered in collaboration with the Toronto YMCA [42]. Participants were community-dwelling adults living with HIV who self-identified as safe to engage in exercise based on the Physical Activity Readiness Questionnaire. Recruitment occurred through the Ontario HIV Treatment Network Cohort Study and community-based organizations in Toronto [42,43].

In phase 1 (intervention phase), participants were expected to engage in 60 minutes of exercise thrice weekly. Sessions were supervised biweekly by a YMCA personal trainer via Zoom, and participants were asked to attend monthly online self-management sessions for 6 months. In phase 2 (independent phase), participants continued with unsupervised exercise thrice weekly for 6 months. Participants were provided with a WPAM (Fitbit Inspire 2; Fitbit Inc) to track steps, distance, calories burned, and active minutes. Throughout both phases, participants received a YMCA online membership that provided access to synchronous group exercise classes via Zoom and recorded workouts (also called Avatar Workouts), YMCA Virtuagym website, and the Sweat for Good YMCA app. An engagement coordinator assisted participants with the setup of the technology and was available to provide support as needed throughout the intervention.

Investigators of the online CBE study conducted qualitative interviews via Zoom with a subset of participants at baseline (time point 1 [T1]) and postintervention (time point 2 [T2]) to explore their experiences and perceived impact of the intervention [44]. Full protocol details for the online CBE study have been published [42]. In our study, we focus on interview data pertaining to participants’ experiences with technology during phase 1 of the telecoaching CBE study.

Technology was integral to the online CBE study, serving roles in (1) intervention delivery, (2) facilitating engagement in physical activity, and (3) measuring outcomes. For the purpose of this study, we defined technology as the tools (hardware, software, networks, and web applications) and processes (methods and strategies used for instruction, assessment, and physical activity tracking) used in the telecoaching CBE study. Key technological components included Zoom software (Zoom Communications, Inc) and a webcam for online personal training sessions and self-management education sessions; Sweat for Good YMCA app and YMCA Virtuagym website for live group exercise classes, prerecorded workouts, and recorded personalized workouts created by a personal trainer; WPAM (Fitbit Inspire 2) for motivation and measurement of physical activity; and technology-supported assessments, including online fitness assessments and interviews via Zoom, administration of patient-reported outcome measures via Qualtrics web-based survey software, body composition scale, and Fitbit app for syncing activity data [42]. In this study, we focused on experiences with technology pertaining to components of the intervention delivery.

Eligible participants for the telecoaching CBE study were required to have access to (1) a cell phone, tablet, laptop, or desktop computer; (2) internet access via Wi-Fi or a wired connection; (3) a webcam; and (4) a personal space for exercise. A subset of the participants in the telecoaching CBE study was invited to participate in the qualitative component of the study. Women living with HIV were purposively recruited to the qualitative study to enhance gender diversity within the sample.

In our study, we included community-dwelling adults aging with HIV (≥18 y) in Toronto, Canada, who considered themselves medically stable and who were safe to participate in the telecoaching CBE study and completed at least one qualitative interview at either baseline (T1) or postintervention (T2).

We consulted with 3 community experts who self-identified as living with HIV. These consultations provided contextual insights into exercise and technology experiences within both in-person CBE and online CBE interventions. We met with each community expert via Zoom to discuss their experiences related to exercise engagement, intervention process, technology usability, and feasibility. These consultations provided foundational information for understanding the intervention and technology use and ensured our analysis and interpretation of interview data were informed by persons living with HIV.

We had a fixed sample of 11 participants from the online CBE study who completed at least one interview at T1 or T2. Of these, 8 participants completed both T1 and T2 interviews, 2 participants completed the T1 interview only, and 1 participant completed the T2 interview only. This sample size is comparable to those of prior qualitative studies examining technology experiences in telehealth exercise interventions among individuals with chronic conditions [51,52].

Ethics approval for this study (protocol 47552) and the broader telecoaching CBE study (protocol 40410) was obtained from the University of Toronto Health Sciences Research Ethics Board. All participants in the telecoaching CBE study who completed an interview provided written or verbal informed consent. Data sources including transcripts and questionnaires were deidentified, meaning participant data were identified using a participant number to ensure confidentiality of participants. Participants received a CAD $30 (US $23) electronic gift card for their participation in each interview.

Of the 11 participants (median age 52, IQR 45-60 y), 6 (55%) identified as women, 5 (45%) identified as heterosexual, and 6 (55%) identified as Black. The majority of participants (n=9, 82%) had an undetectable viral load. Five (45%) participants reported living with ≥3 concurrent health conditions in addition to HIV. Exercise behavior among participants prior to the intervention varied. Three (27%) participants did not engage in exercise in the past week, 5 (45%) engaged in 1 to 2 days, and 3 (27%) engaged in 5 or 7 days of ≥30 minutes of moderate to vigorous intensity exercise in the past week. Table 1 provides participant characteristics.

At baseline, most participants had access to a cell phone (n=10, 91%), a laptop with a webcam (n=9, 82%), and reliable Wi-Fi access (n=9, 82%). All participants (100%) reported they were comfortable using web browsers, online meeting tools, WPAMs, and fitness apps at baseline. Table 2 provides participant characteristics regarding access to, skills in, and use of technology.

Participants’ experiences with technology during the online CBE intervention varied. We organized our findings into four interrelated components: (1) preparations for technology, (2) interactions with technology, (3) facilitators and satisfaction with technology, and (4) challenges and frustrations with technology. Participants’ experiences with technology were shaped by both intrinsic contextual factors, such as their prior exposure and anticipated comfort with technology, and extrinsic contextual factors, including the COVID-19 pandemic and availability of technological and social support. These factors affected how participants engaged with the technology (uptake and usage) in the study, as well as the benefits and challenges they experienced (Figure 1). Below, we present each component with supportive quotations identified by participant number and interview time point.

Interview data revealed participants had inconsistent experiences with uptake and usage of technology over the duration of the intervention. Some participants experienced increasing levels of technology fatigue and burden over the course of the intervention. Some participants found technology a challenge at both T1 and T2. For 1 participant, by T2, their concerns evolved into frustrations with the technology expressing technology fatigue and burden, particularly with the requirement to download and sync their physical activity each week for the study:

Although participants attempted to problem-solve their challenges, frustrations continued with efforts to use the Fitbit. The requirement to sync their Fitbit data weekly became a burden and at times resulted in disengagement and frustration. In contrast, another participant was optimistic with using the Fitbit at T1:

By T2, this participant’s expectations appeared to have been met, and they expressed their intent to continue using the technology beyond the study:

Another participant expressed uncertainty about technology usage in T1 and had an indifferent attitude toward the Fitbit and its role in the intervention, stating:

However, by T2 their perspectives regarding the Fitbit had changed:

This participant experienced a learning curve but was able to reduce barriers and increase usability of the Fitbit with continued use. Overall, initial attitudes toward the technology did not always predict participants’ engagement with participants’ engagement or satisfaction during the study. Some participants encountered technology fatigue around repetitive tasks such as Fitbit syncing, while others reported increased comfort and motivation.

Experiences with technology uptake and usage among adults aging with HIV were characterized by 4 components: (1) preparations for technology, (2) interactions with technology, (3) facilitators and satisfaction with technology, and (4) challenges and frustrations with technology. Experiences with technology interacted with intrinsic contextual factors (prior exposure linked to anticipated comfort or challenges with technology) and extrinsic contextual factors (COVID-19 pandemic; and technological and social support). Some participants experienced increasing technology burden and fatigue over time, others maintained neutral perspectives throughout, while others developed intentions for continued use postintervention.

Technology in the online CBE intervention included a combination of digital tools and platforms, including WPAMs (Fitbit Inspire 2), a videoconferencing platform (Zoom), webcams, the Sweat for Good YMCA app, and YMCA Virtuagym website. Participants demonstrated variation in experiences with technology uptake and usage across different technologies, with preferences emerging for specific types of technology and modes of delivery. Synchronous coaching sessions via Zoom achieved relatively high amounts of uptake following initial setup, likely facilitated by prior exposure gained during the COVID-19 pandemic [53]. The widespread adoption of Zoom during the COVID-19 pandemic likely created a foundational level of comfort that translated well to the synchronous coaching sessions, with participants expressing appreciation for the flexibility and immediate feedback available through this platform [26,53]. In contrast, participants in this study had variable experiences with the Sweat for Good YMCA app and WPAMs. While WPAMs were primarily used for real-time monitoring of physical activity metrics such as step counts and sleep patterns, the Sweat for Good YMCA app was used to administer asynchronous exercise content. Participants had varied preferences for synchronous or asynchronous tools that had implications for engagement with technology within the intervention. This has direct implications for considerations of technology uptake and usage in digital intervention design, suggesting the need to align online CBE interventions with user preferences for both the type of technology and the mode of delivery. Hence, it is important to recognize that adults aging with HIV may respond differently to synchronous tools that offer real-time human connection versus asynchronous tools that require greater independence [17,18,26].

All participants recruited for the telecoaching CBE study were required to have access to and comfort with the usage of technology. Despite all participants reporting comfort with different forms of technology at baseline, participants expressed challenges with uptake and usage of technology in the intervention. Of the 11 participants, 6 (66%) had prior exposure to a WPAM; however, this was insufficient for sustained uptake and usage of the Fitbit Inspire 2. Additionally, participants voiced inconsistent usage of more complex platforms, such as the Sweat for Good YMCA app. The disconnect between high baseline comfort and subsequent struggles with technology may reflect the requirement for participants to simultaneously navigate multiple technology platforms in the intervention that exceeded individual comfort with each component of the technology [18,26]. These findings suggest that technological complexity, rather than basic digital technology skills, posed a greater barrier to sustained use among adults living with HIV [39]. Future interventions should move beyond one-time onboarding to include tailored, continuous support that addresses and simplifies multiplatform navigation and adapts to participants’ evolving needs among adults aging with HIV [17,39,54]. Additionally, future CBE interventions may consider offering a broader range of WPAMs, such as commercially available smartwatches and fitness trackers. Tailoring digital health wearables based on individual preferences, digital health literacy, and accessibility may provide customizable feedback and enhance usability and sustained use over time.

Participants highlighted several facilitators and points of satisfaction with the technology used in the online CBE intervention, including flexible access to workouts, real-time interaction with personal trainers, and digital tools for self-monitoring physical activity. Zoom was consistently highlighted for its convenience and flexibility, supporting real-time interaction with personal trainers, accountability, and routine building, factors shown to improve exercise adherence among adults aging with HIV [17,54,55]. The WPAM served as a motivator for some, enabling self-monitoring of physical activity, steps, and sleep, which some participants found satisfying and empowering. Similar to prior studies, gamification features of WPAMs and real-time feedback supported users’ sense of progress and enhanced intrinsic motivation among adults aging with HIV [30,32,40]. The Sweat for Good YMCA app provided asynchronous, on-demand workouts that aligned with participants’ preferences for flexibility and autonomy, reinforcing the importance of choice between synchronous and asynchronous formats among adults aging with HIV [55]. These findings suggest that digital tools and processes can support engagement in exercise among adults aging with HIV when designed to be adaptable, user-friendly, and reinforced through personalized feedback and social accountability [18,41,55]. Future interventions should leverage these features by integrating reliable self-monitoring technologies and offering multiple modes of delivery to enhance engagement in online CBE interventions among adults aging with HIV.

Challenges and frustrations with technology use in this study included device syncing failures and navigation difficulties with the Sweat for Good YMCA app and connectivity problems with Zoom videoconferencing. WPAMs were valued for their feedback features but also generated frustration when step counts were perceived as inaccurate or syncing required repeated effort. This aligns with systematic measurement errors in consumer WPAM devices and the importance of balancing the motivational benefits of self-monitoring technology against potential user frustration from technical limitations for adults aging with HIV [40,56]. Participants described difficulty finding exercises to match their activity levels due to navigation difficulties on the Sweat for Good YMCA app. While Zoom was generally reliable, several participants reported audio lag and video freezing, issues commonly experienced in online digital health interventions with synchronous videoconferencing among adults aging with HIV [26,39,55]. Difficulties with device accuracy, navigation of fitness apps, and technical troubleshooting are widely reported in studies involving adults living with HIV using WPAMs or engaging in online exercise interventions [17,44,55]. While these technical experiences are not unique to this sample population, they occur within a context shaped by the challenges of aging with HIV, including health unpredictability, stigma, and the risk of loneliness [57-60]. Embedding lived experiences into intervention design and ongoing technical support are essential strategies to overcome digital barriers and promote uptake and usage with online CBE interventions among adults aging with HIV.

Changes in experiences with technology over time demonstrated initial attitudes toward technology that did not always predict sustained use with the technology. Some participants experienced increasing technology burden and fatigue, others maintained neutral perspectives throughout, while others developed optimistic intentions for continued use postintervention. Participants used Zoom consistently throughout, as evidenced by consistent usability responses on the Telehealth Indicator Questionnaire, likely due to its relative simplicity, prior exposure, and use as a communication platform with their personal trainer. While the use of WPAMs and the Sweat for Good YMCA app may have declined, this may be attributed to persistent technical issues and limited adaptability. This mirrored patterns of engagement with digital health technology seen in adults aging with HIV [32,55,61]. Some participants reported feeling overwhelmed by syncing requirements, app navigation, and inconsistent device feedback in the online CBE intervention, factors that diminished motivation and created friction in maintaining regular technology use. This aligns with research that prolonged exposure to poorly optimized tools can lead to emotional and cognitive fatigue, especially among users managing multimorbidity [19,41]. Positive changes in technology use were most apparent in self-directed components, suggesting that asynchronous, exploratory technology use may become more rewarding over time as users gain confidence. For adults aging with HIV, these findings reinforce the need for sustained technical support and simplified interface design, as digital interventions must be responsive, flexible, and grounded in lived experience to facilitate long-term engagement in online CBE interventions [17,18,55].

A strength of this study was the longitudinal observational design involving both interview and questionnaire data, allowing for an in-depth understanding of participants’ experiences with technology over time. Interview and questionnaire data were analyzed separately, with the questionnaires used descriptively to provide context to the interview findings. We conducted a collaborative content analysis among the team, allowing for diverse perspectives to be integrated throughout coding and interpretation. This iterative, team-based process supported reflexivity and rigor in the analysis. Additionally, input from community experts living with HIV helped ground the analysis in the lived experiences of the HIV community.

Our study sample size was fixed based on the existing data in the telecoaching CBE study. Reaching thematic saturation was not a goal of our study. However, in the results, we indicate the participants via participant number and time point alongside interview quotes to indicate the contribution of participant perspectives across the breadth of categories. Other strategies to enhance rigor included our inclusion of all available interview and questionnaire data for participants across the study. Collectively, we believe we were able to capture an ample description of participants’ perspectives related to experiences with uptake and usage, enabling us to achieve our study objectives.

Regarding study limitations, the interviews were not solely focused on technology; hence, the amount of data and depth of insights specific to technology use was limited. Not all participants completed interviews at T1 and T2 or the Telehealth Indicator Questionnaire at T2, which limited the ability to explore participants’ changes in technology experiences over time. Our sample was drawn from community-dwelling adults living with HIV in Toronto, a large urban center with strong digital infrastructure, limiting transferability to rural or remote settings with greater barriers to connectivity and access to the internet. Additionally, future work should examine sex and gender differences in technology experiences and engagement within online CBE interventions among adults aging with HIV to promote equitable access, engagement, and effectiveness [62].

Experiences with technology uptake and usage among adults aging with HIV were characterized by 4 components, including preparations for technology use, interactions with the technology, facilitators and satisfaction with technology, and challenges and frustrations with technology. Experiences with technology interacted with intrinsic contextual factors (prior exposure linked to anticipated comfort or challenges with technology) and extrinsic contextual factors (COVID-19 pandemic and technological and social support). Among adults aging with HIV, changes in technology experiences over time highlighted the unpredictability of initial impressions, with some participants expressing technology fatigue and burden, whereas others maintained consistent attitudes of usage over time with intentions to continue using digital tools and processes beyond the intervention. Findings with experiences of technology uptake and usage in this study underscore the importance of incorporating personalized and tailored onboarding and sustained technological support with an online CBE intervention to promote engagement in physical activity among adults aging with HIV.