A Systematic Review of Recent Methodological Approaches for Using Ecological Momentary Assessment to Examine Outcomes in U.S. Based HIV Research

Mobile Health Tool to Capture Social Determinants of Health and Their Impact on HIV Treatment Outcomes Among People Who Use Drugs: Pilot Feasibility Study

Background

Active substance use, food or housing insecurity, and criminal legal system involvement can disrupt HIV care for people living with HIV and opioid use disorder (OUD). These social determinants of health are not routinely captured in clinical settings.

Objective

We evaluated whether real-time reports of social and behavioral factors using a smartphone app could predict viral nonsuppression and missed care visits to inform future mobile health interventions.

Methods

We enrolled 59 participants from the AIDS Linked to the Intravenous Experience (ALIVE) Study in Baltimore, Maryland, into a 12-month substudy between February 2017 and October 2018. Participants were eligible if they had OUD and had either a measured HIV RNA ≥1000 copies/mL or a ≥1-month lapse in antiretroviral therapy in the preceding 2 years. Participants received a smartphone and reported HIV medication adherence, drug use or injection, and several disruptive life events, including not having a place to sleep at night, skipping a meal due to lack of income, being stopped by police, being arrested, or experiencing violence on a weekly basis, through a survey on a mobile health app. We described weekly survey completion and investigated which factors were associated with viral nonsuppression (HIV RNA ≥200 copies/mL) or a missed care visit using logistic regression with generalized estimating equations adjusted for age, gender, smartphone comfort, and drug use.

Results

Participants were predominantly male (36/59, 61%), Black (53/59, 90%), and had a median of 53 years old. At baseline, 16% (6/38) were virally unsuppressed. Participants completed an average of 23.3 (SD 16.3) total surveys and reported missing a dose of antiretroviral therapy, using or injecting drugs, or experiencing any disruptive life events on an average of 13.1 (SD 9.8) weekly surveys over 1 year. Reporting use of any drugs (adjusted odds ratio [aOR] 2.3, 95% CI 1.4-3.7), injecting drugs (aOR 2.3, 95% CI 1.3-3.9), and noncompletion of all surveys (aOR 1.6, 95% CI 1.1-2.2) were associated with missing a scheduled care visit over the subsequent 30 days. Missing ≥2 antiretroviral medication doses within 1 week was associated with HIV viral nonsuppression (aOR 3.7, 95% CI: 1.2-11.1) in the subsequent 30 days.

Conclusions

Mobile health apps can capture risk factors that predict viral nonsuppression and missed care visits among people living with HIV who have OUD. Using mobile health tools to detect sociobehavioral factors that occur prior to treatment disengagement may facilitate early intervention by health care teams.

Using Geographic Momentary Assessment to Explore Spatial Environment Influences on Wellbeing in People With HIV

Place-based socio-economic and racial inequities contribute to health disparities among people with HIV (PWH). We used geographic ecological momentary assessment (GEMA) methodologies to explore the interplay between psychosocial outcomes in daily diaries and community spatial measures among PWH in New Orleans. PWH (N = 69) were recruited from a clinic-based cohort study. Micro-longitudinal data were collected via smartphone-based daily diaries and geospatial tracking over 14 days. First, correlations were run between diary derived outcomes (e.g., feeling safe in current location, stress), and spatial measures (e.g., violent crime, alcohol outlets, and vacant lots) within a half-mile buffer around each diary point to understand the real time associations between mood and space. Next, we fit multilevel models, controlling for between-person effects, to assess within-person associations between accumulative spatial daily violence exposure (50m, 100m and 200m buffers), and measures of daily mood and coping. Violent crime, alcohol outlets and vacant lots were inversely correlated with feeling safe and positively correlated with perceived ease of obtaining drugs. Vacant lots were positively associated with stress and inversely correlated with positive mood. Within individuals, higher daily accumulated violence exposure was associated with increased rumination at the 50m buffer level, decreased trust in oneself and others at the 100m buffer, and decreased ratio of positive/negative mood at all buffers. Our results emphasize the intricate interplay between mental wellness, coping mechanisms, and spatial measures in PWH. Future research and interventions for PWH should consider how spatial factors may influence PWH in terms of mental health and care engagement.

Psychometric Properties of Measuring Antiretroviral Therapy Adherence Among Young Latino Sexual Minority Men With HIV: Ecological Momentary Assessment and Electronic Pill Dispenser Study

Background

Increasing HIV rates among young Latino sexual minority men (YLSMM) warrant innovative and rigorous studies to assess prevention and treatment strategies. Ecological momentary assessments (EMAs) and electronic pill dispensers (EPDs) have been used to measure antiretroviral therapy (ART) adherence repeatedly in real time and in participants' natural environments, but their psychometric properties among YLSMM are unknown.

Objective

The study's objective was to assess the concurrent validity, acceptability, compliance, and behavioral reactivity of EMAs and EPDs among YLSMM with HIV.

Methods

A convenience sample of 56 YLSMM with HIV with suboptimal ART adherence, aged 18-34 years, was recruited into a 28-consecutive-day EMA study. Concurrent validity was analyzed by comparing median ART adherence rates and calculating Spearman correlations between ART adherence measured by EMA, EPD, and baseline retrospective validated 3-item and single-item measures. Acceptability was assessed in exit interviews asking participants to rate EMA and EPD burden. Compliance was assessed by computing the percent lost to follow-up, the percent of EMAs missed, and the percentage of days the EPD was not opened that had corresponding EMA data self-reporting adherence to ARTs. Behavioral reactivity was assessed by computing the median change in ART adherence during the study period, using generalized mixed models to assess whether the cumulative number of EMAs completed and days of EPD use predicted ART adherence over time, and by asking participants to rate perceived reactivity using a Likert scale.

Results

EMA ART adherence was significantly correlated with baseline validated 3-item (r=0.41, P=.003) and single-item (r=0.52, P<.001) measures, but correlations were only significant for participants that reported EMA was not burdensome. Correlations for EPD ART adherence were weaker but significant (r=0.36, P=.009; r=0.34, P=.01, respectively). Acceptability was high for EMAs (48/54, 89%) and EPDs (52/54, 96%) per self-report. Loss to follow-up was 4% (2/56), with the remaining participants completing 88.6% (1339/1512) of study-prompted EMAs. The percentage of missed EMA surveys increased from 5.8% (22/378) in week 1 of the study to 16.7% (63/378) in week 4. Of 260 days when EPDs were not opened, 68.8% (179) had a corresponding EMA survey self-reporting ART adherence. Reactivity inferred from the median change in ART adherence over time was 8.8% for EMAs and -0.8% for EPDs. Each completed EMA was associated with 1.03 odds (95% CI 1-1.07) of EMA ART adherence over time, and each day of EPD use with 0.97 odds (95% CI 0.96-0.99) of EPD ART adherence over time. Self-reported perceived behavioral reactivity was 39% for EMAs and 35% for EPDs.

Conclusions

This study provides evidence of concurrent validity with retrospective validated measures for EMA- and EPD-measured ART adherence among YLSMM, when participant burden is carefully considered, without significant behavioral reactivity. While acceptability and compliance of EMAs and EPDs were high overall, noncompliance increased over time, suggesting respondent fatigue.

Implementing ecological momentary assessments to measure violence and adolescent HIV transmission risk: Lessons from Johannesburg, South Africa

Ecological Momentary Assessment (EMA) is an important methodology to understand risky behaviour and holds promise for HIV research. EMA is still novel in sub-Saharan Africa. We describe challenges and lessons learned on a novel study implementing mobile phone EMAs with adolescent boys in South Africa. The Tsamaisano study was a longitudinal study from 2020-2023 to recruit adolescent boys aged 15-19 years; including those without HIV and those perinatally infected and living with HIV. Participants were prompted to complete 52 weekly mobile phone survey on emotional state, exposure to and perpetration of violence, and sexual risk behaviour. Surveys were delivered using a random algorithm to choose the day. We incorporated mechanisms to assess challenges and optimize survey completion: weekly team meetings with youth representation and real-time data monitoring. Additionally, 20 frequent vs infrequent survey submitters participated in qualitative interviews about barriers and recommendations. Real-time monitoring indicated low (defined as <50%) survey completion in the first months of study implementation. To ensure that both the adolescent participant and their caregiver understood the commitment required for successful EMA, we created and implemented a guided discussion around mobile phone access during the enrolment visit. We identified a need for increased and ongoing technical support; addressed by creating technical guides, implementing a standard two-week check-in call after enrolment, adding an automated request button for call-back assistance, creating a WhatsApp messaging stream, and reaching out to all participants failing to submit two sequential surveys. Entry-level smartphones, including those initially distributed by the study, did not have capacity for certain updates and had to be replaced with more expensive models. Participants struggled with randomly allocated survey days; completion improved with set completion days and targeted reminder messages. Together, these steps improved survey completion from 40% in December 2020 to 65% in April 2022. We describe key lessons learned to inform future study designs with mobile phone EMAs, drawing on our experience implementing such among adolescent boys, including persons living with HIV, in a low-and-middle income setting. The key lessons learned through the Tsamaisano study are important to inform future study designs with EMA utilizing mobile phone, electronic data collection among adolescent boys in low-and-middle-income settings.

HIV Prevention and Care Among Black Cisgender Sexual Minority Men and Transgender Women: Protocol for an HIV Status-Neutral Cohort Study Using an Observational-Implementation Hybrid Approach

BACKGROUND

Black cisgender gay, bisexual, and other sexual minority men (SMM) and transgender women (TW) continue to be heavily affected by HIV. Further research is needed to better understand HIV prevention and care outcomes in this population. In particular, there is a need for research examining the impact of substance use and sleep health on HIV prevention and treatment outcomes among Black SMM and TW.

OBJECTIVE

This paper outlines the study methods being used in the recently launched follow-up study to the Neighborhoods and Networks (N2) study, which we refer to as N2 Part 2 (N2P2). N2P2 aims to address this gap in the literature, build off the findings of the original N2 study, and identify socioenvironmental determinants of health, including whether neighborhood and network factors mediate and moderate these relationships.

METHODS

Building on the N2 cohort study in Chicago from 2018 to 2022, N2P2 used a prospective longitudinal cohort design and an observational-implementation hybrid approach. With sustained high levels of community engagement, we aim to recruit a new sample of 600 Black SMM and TW participants residing in the Chicago metropolitan statistical area. Participants are asked to participate in 3 study visits across an 18-month study period (1 visit every 9 months). Four different forms of data are collected per wave: (1) an in-person survey, (2) biological specimen collection, (3) a daily remote ecological momentary assessment for 14 days after each study visit, and (4) data from electronic health records. These forms of data collection continue to assess neighborhood and network factors and specifically explore substance use, sleep, immune function, obesity, and the implementation of potential interventions that address relevant constructs (eg, alcohol use and pre-exposure prophylaxis adherence).

RESULTS

The N2P2 study was funded in August 2021 by the National Institute of Drug Abuse (R01DA054553 and R21DA053156) and National Heart, Lung, and Blood Institute (R01HL160325). This study was launched in November 2022. Recruitment and enrollment for the first wave of data collection are currently ongoing.

CONCLUSIONS

The N2P2 study is applying innovative methods to comprehensively explore the impacts of substance use and sleep health on HIV-related outcomes among an HIV status-neutral cohort of Black SMM and TW in Chicago. This study is applying an observational-implementation hybrid design to help us achieve findings that support rapid translation, a critical priority among populations such as Black SMM and TW that experience long-standing inequities with regard to HIV and other health-related outcomes. N2P2 will directly build off the findings that have resulted from the original N2 study among Black SMM and TW in Chicago. These findings provide a better understanding of multilevel (eg, individual, network, and neighborhood) factors that contribute to HIV-related outcomes and viral suppression among Black SMM and TW.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48548.

Reliability and Validity of Noncognitive Ecological Momentary Assessment Survey Response Times as an Indicator of Cognitive Processing Speed in People's Natural Environment: Intensive Longitudinal Study

BACKGROUND

Various populations with chronic conditions are at risk for decreased cognitive performance, making assessment of their cognition important. Formal mobile cognitive assessments measure cognitive performance with greater ecological validity than traditional laboratory-based testing but add to participant task demands. Given that responding to a survey is considered a cognitively demanding task itself, information that is passively collected as a by-product of ecological momentary assessment (EMA) may be a means through which people's cognitive performance in their natural environment can be estimated when formal ambulatory cognitive assessment is not feasible. We specifically examined whether the item response times (RTs) to EMA questions (eg, mood) can serve as approximations of cognitive processing speed.

OBJECTIVE

This study aims to investigate whether the RTs from noncognitive EMA surveys can serve as approximate indicators of between-person (BP) differences and momentary within-person (WP) variability in cognitive processing speed.

METHODS

Data from a 2-week EMA study investigating the relationships among glucose, emotion, and functioning in adults with type 1 diabetes were analyzed. Validated mobile cognitive tests assessing processing speed (Symbol Search task) and sustained attention (Go-No Go task) were administered together with noncognitive EMA surveys 5 to 6 times per day via smartphones. Multilevel modeling was used to examine the reliability of EMA RTs, their convergent validity with the Symbol Search task, and their divergent validity with the Go-No Go task. Other tests of the validity of EMA RTs included the examination of their associations with age, depression, fatigue, and the time of day.

RESULTS

Overall, in BP analyses, evidence was found supporting the reliability and convergent validity of EMA question RTs from even a single repeatedly administered EMA item as a measure of average processing speed. BP correlations between the Symbol Search task and EMA RTs ranged from 0.43 to 0.58 (P<.001). EMA RTs had significant BP associations with age (P<.001), as expected, but not with depression (P=.20) or average fatigue (P=.18). In WP analyses, the RTs to 16 slider items and all 22 EMA items (including the 16 slider items) had acceptable (>0.70) WP reliability. After correcting for unreliability in multilevel models, EMA RTs from most combinations of items showed moderate WP correlations with the Symbol Search task (ranged from 0.29 to 0.58; P<.001) and demonstrated theoretically expected relationships with momentary fatigue and the time of day. The associations between EMA RTs and the Symbol Search task were greater than those between EMA RTs and the Go-No Go task at both the BP and WP levels, providing evidence of divergent validity.

CONCLUSIONS

Assessing the RTs to EMA items (eg, mood) may be a method of approximating people's average levels of and momentary fluctuations in processing speed without adding tasks beyond the survey questions.

Understanding health behaviours in context: A systematic review and meta-analysis of ecological momentary assessment studies of five key health behaviours

Ecological Momentary Assessment (EMA) involves repeated, real-time sampling of health behaviours in context. We present the state-of-knowledge in EMA research focused on five key health behaviours (physical activity and sedentary behaviour, dietary behaviour, alcohol consumption, tobacco smoking, sexual health), summarising theoretical (e.g., psychological and contextual predictors) and methodological aspects (e.g., study characteristics, EMA adherence). We searched Ovid MEDLINE, Embase, PsycINFO and Web of Science until February 2021. We included studies focused on any of the aforementioned health behaviours in adult, non-clinical populations that assessed ≥1 psychological/contextual predictor and reported a predictor-behaviour association. A narrative synthesis and random-effects meta-analyses of EMA adherence were conducted. We included 633 studies. The median study duration was 14 days. The most frequently assessed predictors were 'negative feeling states' (21%) and 'motivation and goals' (16.5%). The pooled percentage of EMA adherence was high at 81.4% (95% CI = 80.0%, 82.8%, k = 348) and did not differ by target behaviour but was somewhat higher in student (vs. general population) samples, when EMAs were delivered via mobile phones/smartphones (vs. handheld devices), and when event contingent (vs. fixed) sampling was used. This review showcases how the EMA method has been applied to improve understanding and prediction of health behaviours in context.

Qualitative Identification of Intervention Preferences to Support Men's Engagement and Retention in TB Care in South Africa

Globally and in South African specifically, men account for 56% and 62% of all tuberculosis (TB) cases, respectively. Men are at increased risk of not accessing TB testing or treatment, and having poor treatment outcomes. Unfortunately, no interventions exist to address these issues. Toward the development of targeted, patient-centered TB care and support interventions, we used semistructured interviews to explored men's social network composition, TB testing behaviors, disclosure and treatment support, clinical experiences, and TB's influence on daily living. Data were analyzed using a thematic approach guided by the Network Individual Resource Model to identify mental and tangible resources influential and preferred during engagement in TB treatment. Men emphasized the desire for peer-to-peer support to navigate TB-related stigma and unhealthy masculinity norms. Men advocated for awareness events to educate communities about their challenges with TB. Men strongly suggested that interventions be delivered in familiar locations where men congregate. Since 2022, no TB treatment support interventions have included the preferred components or delivery modes described by men in our study. To improve men's TB-related health outcomes, the global TB community must identify and address men's unique challenges when designing interventions.

Response Patterns to Weekly Short Message Service Health Surveys Among Diverse Youth at High Risk for Acquiring HIV

HIV researchers use short messaging service (SMS)-based surveys to monitor health behaviors more closely than what would be possible with in-person assessment. Benefits are tempered by nonresponse to completing surveys. Understanding response patterns and their associated study participant characteristics would guide more tailored use of SMS-based surveys for HIV studies. We examined response to weekly 7-item SMS surveys administered as part of an HIV prevention trial. Using Mixture hidden Markov models (MHMM), we identified the underlying response patterns shared by subgroups of participants over time and quantified the association between these response patterns and participant characteristics. Three underlying response patterns were identified; responders, responders with phone-related errors, and non-responders. Non-responders versus responders were more likely to be younger, male, cis-gender, Black and Latinx participants with histories of homelessness, incarceration, and social support service utilization. Responders with phone-related errors compared to non-responders were more likely to be Black, Latinx, female, students, and have a history of incarceration and social support service utilization. More nuanced results from MHMM analyses better inform what strategies to use for increasing SMS response rates, including assisting in securing phone ownership/service for responders with phone-related errors and identifying alternative strategies for non-responders. Actively collecting and monitoring non-delivery notification data available from SMS gateway service companies offers another opportunity to identify and connect with participants when they are willing but unable to respond during follow-up.

Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis

BACKGROUND

Poor adherence to oral HIV pre-exposure prophylaxis (PrEP) diminishes its clinical and public health benefits. This study synthesises evidence regarding discontinuation, adherence, and reinitiation of PrEP among geographically diverse PrEP users.

METHODS

We did a systematic review and meta-analysis evaluating studies published in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to Dec 18, 2020. We included longitudinal studies that presented data for PrEP discontinuation, defined as investigator-reported loss to follow-up or participant self-reported PrEP stoppage. Data were extracted from published reports and assessed for risk of bias. We used a random-effects meta-analysis to pool estimates of discontinuation and I2 and τ2 to evaluate heterogeneity. This study is registered with PROSPERO, CRD42020155675.

FINDINGS

We identified 4129 records, of which 59 articles were included (n=43 917 participants). 41·0% (95% CI 18·8-63·5) of participants discontinued PrEP within 6 months, with the highest rates in observational studies. The discontinuation rate in sub-Saharan Africa (47·5%, 95% CI: 29·4-66·4%) was higher than in other regions (p<0·001). Discontinuation rates were lower in studies with adherence interventions than in those without (24·7% vs 36·7%, p=0·015). Gay or bisexual men who have sex with men and transgender women offered daily or non-daily dosing options had lower discontinuation rates than those offered daily dosing alone (21·6% vs 31·5%; p<0·001). The pooled suboptimal adherence within 6 months was 37·7% (95% CI 8·4-66·9). Among people who discontinued PrEP, 47·3% (95% CI 31·5-63·2) reinitiated PrEP within 1 year of PrEP initiation. The included studies had poor quality in terms of study design, with a moderate risk of bias.

INTERPRETATION

Strategies to encourage reinitiating PrEP for new or persistent risk should be a focus of future PrEP implementation strategies.

FUNDING

National Institutes of Health and Nature Science Foundation of China.

PrEP Use, Sexual Behaviour, and PrEP Adherence Among Men who have Sex with Men Living in Wales Prior to and During the COVID-19 Pandemic

We examined PrEP use, condomless anal sex (CAS), and PrEP adherence among men who have sex with men (MSM) attending sexual health clinics in Wales, UK. In addition, we explored the association between the introduction of measures to control transmission of SARS-CoV-2 on these outcomes. We conducted an ecological momentary assessment study of individuals in receipt of PrEP in Wales. Participants used an electronic medication cap to record PrEP use and completed weekly sexual behaviour surveys. We defined adherence to daily PrEP as the percentage of CAS episodes covered by daily PrEP (preceded by ≥ 3 days of PrEP and followed by ≥ 2 days). Sixty participants were recruited between September 2019 and January 2020. PrEP use data prior to the introduction of control measures were available over 5785 person-days (88%) and following their introduction 7537 person-days (80%). Data on CAS episodes were available for 5559 (85%) and 7354 (78%) person-days prior to and following control measures respectively. Prior to the introduction of control measures, PrEP was taken on 3791/5785 (66%) days, there were CAS episodes on 506/5559 (9%) days, and 207/406 (51%) of CAS episodes were covered by an adequate amount of daily PrEP. The introduction of pandemic-related control measures was associated with a reduction in PrEP use (OR 0.44, 95%CI 0.20–0.95), CAS (OR 0.35, 95%CI 0.17–0.69), and PrEP adherence (RR = 0.55, 95%CI 0.34–0.89) and this may have implications for the health and wellbeing of PrEP users and, in addition to disruption across sexual health services, may contribute to wider threats across the HIV prevention cascade.

Examining HIV Risk and Exchange Sex Among Current and Formerly Homeless Young Adults

This study investigated HIV risk among homeless and formerly homeless young adults by examining risky sex behaviors (e.g., condomless sex, exchange sex, and sex with multiple persons) using 90-day and daily recall methods. Data came from a sample of young adults (aged 18–27) with current (n = 101) or past (n = 109) homelessness experience in Los Angeles, California, recruited between 2017 and 2019. Baseline surveys queried demographics and sexual history. Daily retrospective surveys queried sexual events. Multiple logistic regressions were used to test the effects of demographic characteristics including homelessness history, relationship status, substance use, and sexual history on risky sex outcomes. In this sample, 26% reported never using a condom during anal or vaginal sex in the past 90 days, 5% reported testing positive for HIV, 82% had limited to no knowledge of preexposure prophylaxis, and 8% reported having had exchange sex during a 7-day measurement period, with those experiencing homelessness more likely to report. The study suggests supportive housing can reduce the occurrence of exchange sex but that HIV prevention services are still needed in homeless and housing programs to promote safe sexual practices.

Geolocation, ethics, and HIV research

The HIV epidemic continues to disproportionally affect marginalized populations. Digital tools, including global positioning system and ecologic momentary assessment, have been studied as methods for improving data collection and interventions among HIV-affected communities. Although people living with HIV and populations at high risk have found it acceptable to use digital technologies for HIV research, concerns over privacy and trust have also been expressed. This paper explores and describes the use of geolocation technology data (e.g., location-based social media) in HIV research as well as the ethical and implementation considerations that warrant examination prior to use. Transparent and clear language in consent forms might improve participant trust in the project and investigators' ability to keep participant data secure and private. With respect to institutional review boards, a committee member who is knowledgeable about digital technologies and consumer protections may offer guidance in assessing adequate protections in study protocols. As technology used in research continues to evolve, investigators and the research community must continue to examine the ethical challenges that emerge to address participant concerns.

Assessing the Real-time Influence of Racism-Related Stress and Suicidality Among Black Men: Protocol for an Ecological Momentary Assessment Study

BACKGROUND

Suicide is the third leading cause of death among Black adults aged 18-35 years. Although men represent a majority of suicide deaths among Black adults, less is known regarding the extent to which unique cultural stressors, such as racism-related stress (eg, racial discrimination), are salient in exacerbating suicide risk among Black men. Moreover, few studies examine the daily influence of racism-related stressors on suicide outcomes using real-time smartphone-based approaches. Smartphone-based mobile health approaches using ecological momentary assessments (EMA) provide an opportunity to assess and characterize racism-related stressors as a culturally sensitive suicide risk factor among Black young adult men.

OBJECTIVE

The goal of this study is to describe a protocol development process that aims to capture real-time racism-related stressors and suicide outcomes using a smartphone-based EMA platform (MetricWire).

METHODS

Guided by the Interpersonal Theory of Suicide (ITS), we developed a brief EMA protocol using a multiphased approach. First, we conducted a literature review to identify brief measures previously used in EMA studies, with special emphasis on studies including Black participants. The identified measures were then shortened to items with the highest construct validity (eg, factor loadings) and revised to reflect momentary or daily frequency. Feasibility and acceptability of the study protocol will be assessed using self-report survey and qualitative responses. To protect participants from harm, a three-tier safety protocol was developed to identify participants with moderate, elevated, and acute risk based on EMA survey response to trigger outreach by the study coordinator.

RESULTS

The final EMA protocol, which will be completed over a 7-day period, is comprised of 15 questions administered 4 times per day and a daily questionnaire of 22 items related to sleep-related impairment and disruption, as well as racism-related stress. Study recruitment is currently underway. We anticipate the study will be completed in February 2023. Dissemination will be conducted through peer-reviewed publications and conference presentations.

CONCLUSIONS

This protocol will address gaps in our understanding of Black men's suicide outcomes in the social contexts that they regularly navigate and will clarify the temporal role of racism-related stressors that influence suicidal outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/31241.

Design and Delivery of Real-Time Adherence Data to Men Who Have Sex with Men Using Antiretroviral Pre-exposure Prophylaxis via an Ingestible Electronic Sensor

Once daily tenofovir/emtricitabine when used for pre-exposure prophylaxis (PrEP) is effective in preventing HIV acquisition but requires consistent medication adherence. The use of ingestible technologies to monitor PrEP adherence can assist in understanding the impact of behavioral interventions. Digital pill systems (DPS) utilize an ingestible radiofrequency emitter integrated onto a gelatin capsule, which permits direct, real-time measurement of medication adherence. DPS monitoring may lead to discovery of nascent episodes of PrEP nonadherence and allow delivery of interventions that prevent the onset of sustained nonadherence. Yet, the acceptance and potential use of DPS in high-risk men who have sex with men (MSM; i.e., those who engage in condomless sex and use substances) is unknown. In this investigation, we conducted individual, semi-structured qualitative interviews with 30 MSM with self-reported non-alcohol substance use to understand their responses to the DPS, willingness and perceived barriers to its use, and their perceptions of its potential utility. We also sought to describe how MSM would potentially interact with a messaging system integrated into the DPS. We identified major themes around improved confidence of PrEP adherence patterns, safety of ingestible radiofrequency sensors, and design optimization of the DPS. They also expressed willingness to interact with messaging contingent on DPS recorded ingestion patterns. These data demonstrate that MSM who use substances find the DPS to be an acceptable method to measure and record PrEP adherence.

Utility of Short Message Service (SMS) for Remote Data Collection for HIV in Low- and Middle-Income Countries

PURPOSE OF REVIEW

Short message system (SMS) communication is widespread in low- and middle-income countries (LMICs), and may be a viable approach to address challenges with in-person data collection for HIV-related research and monitoring and evaluation. We reviewed the literature to characterize potential benefits and challenges with using SMS for remote data capture, including examples from HIV and sexual and reproductive health.

RECENT FINDINGS

In our review, we found that studies that have used SMS to capture sensitive, self-reported data found this was an acceptable and feasible strategy, and may reduce social desirability bias of self-reported data; but studies are limited. Shared phones and privacy concerns have been described as challenges, but can be addressed with enhanced security features. Response rates to SMS surveys varied significantly by topic, population, and setting. SMS may improve generalizability and precision of health and behavior data for HIV in research and programs, but use in LMICs is limited. SMS systems should be carefully designed to overcome potential implementation hurdles.