Currently submitted to: Journal of Medical Internet Research
Date Submitted: Jun 2, 2026
Open Peer Review Period: Jun 4, 2026 - Jul 30, 2026
(currently open for review)
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Left behind by digital health. A seven-year population study of technology adoption, HIV status, and the emerging prevention paradox in rural South Africa
ABSTRACT
Background:
Digital health programs in sub-Saharan Africa often assume broad mobile reach, yet population-level evidence on who can use specific technologies, and who is excluded, remains limited. Without accurate denominators, digital interventions may reinforce inequities by missing people least engaged with conventional healthcare.
Objective:
We assessed technology adoption, disparities, and trajectories in a high-HIV-burden rural South African population to inform equitable digital health implementation.
Methods:
We analyzed 309,151 person-years from the Africa Health Research Institute demographic surveillance platform in rural KwaZulu-Natal, South Africa (2017 to 2023). We measured adoption of seven technologies (calls and SMS, internet, WhatsApp, email, mobile banking, entertainment, and health tracking) and constructed a five-tier Digital Adoption Ladder from offline (T0) to digital-health ready (T4). We quantified disparities by HIV status, gender, and their intersection using logistic regression, and tracked temporal trajectories including the COVID-19 period.
Results:
In 2023, 61.3% of records were classified as offline (T0) under the harmonized coding rules, and only 2.9% reached digital-health readiness (T4). Among tested individuals, people living with HIV showed higher adoption across all technologies (odds ratios 1.13 to 1.57) than HIV-negative individuals, with 56.0% connected versus 44.6%. Females also showed higher adoption than males (odds ratios 1.24 to 1.80). Intersectional analysis identified HIV-positive females as the most connected group (58.1%) and HIV-negative males as the least connected (38.4%), a 20-percentage-point gap. This pattern emerged after 2019 and defines a prevention paradox: a group important for HIV testing, PrEP, and prevention outreach is also the least reachable through digital channels.
Conclusions:
Digital health implementation should adopt a floor-up strategy: start with SMS (reaching approximately 39%), add WhatsApp where connectivity exists, and reserve apps for the small minority able to use them. HIV-negative males require targeted outreach through non-health channels to prevent digital exclusion from weakening HIV prevention.
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