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Dietrich JJ, Hornschuh S, Madi P, Ramsammy CW, Tsotetsi L, Tshabalala G, Nkala-Dlamini B, Violari A, Kidman R. Implementing ecological momentary assessments to measure violence and adolescent HIV transmission risk: Lessons from Johannesburg, South Africa. PLOS DIGITAL HEALTH 2024; 3:e0000283. [PMID: 38306387 PMCID: PMC10836659 DOI: 10.1371/journal.pdig.0000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/04/2023] [Indexed: 02/04/2024]
Abstract
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.
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Affiliation(s)
- Janan Janine Dietrich
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
- African Social Sciences Unit of Research and Evaluation (ASSURE), a division of the Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Phumla Madi
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Candice W. Ramsammy
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lerato Tsotetsi
- African Social Sciences Unit of Research and Evaluation (ASSURE), a division of the Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Busisiwe Nkala-Dlamini
- Department of Social Work, Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa
| | - Avy Violari
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rachel Kidman
- Program in Public Health, State University of New York at Stony Brook, Stony Brook, New York, United States of America
- Department of Family, Population and Preventive Medicine, State University of New York at Stony Brook, Stony Brook, New York, United States of America
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Dietrich JJ, Benadé GL, Mulaudzi M, Kagee A, Hornschuh S, Makhale LM, Lemos MP, Lazarus E, Andrasik MP, Horvath KJ. "You Are on the Right Track With the App:" Qualitative Analysis of Mobile Phone Use and User Feedback Regarding Mobile Phone Sexual Risk Assessments for HIV Prevention Research. Front Digit Health 2021; 3:576514. [PMID: 34713080 PMCID: PMC8521804 DOI: 10.3389/fdgth.2021.576514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Accurate self-report of sexual behavior assists in identifying potential HIV exposure in HIV prevention trials. Brief mobile phone assessments, completed daily or after sexual activity, can improve the validity and reliability of self-reported sexual behavior and allow for remote survey completion outside of the clinic setting. We conducted a qualitative study to better understand participants mobile phone use and to explore their perspectives on how to improve an existing mobile application-based sexual risk assessment. Methods: Sexually active, HIV seronegative men (n = 14) and women (n = 15) aged 18–39 years were recruited through an HIV counseling and testing clinic and community outreach in Soweto, South Africa. We conducted qualitative research through four age-stratified focus group discussions (FGDs) and analyzed a brief socio-demographics and mobile phone access questionnaire. All participants completed a sexual risk assessment before the FGD. Using a framework analytic approach, data were coded with Nvivo software. Results: All participants had access to mobile phones and internet, and 27 (93.1%) were able to download applications on their personal phones. Participants preferred mobile risk assessments to be offered in a choice of South African languages, using formal language (as opposed to emojis), with straight-forward wording and limited to five to 10 questions. Most participants found it acceptable to complete the assessment once a week, on a weekday, while a few were willing to complete it after each sexual encounter. It was suggested that a message reminder to complete the assessment should be sent at least daily until it is completed. The majority agreed that a password-protected application with a discreet logo was ideal for privacy, ease of use and flexibility for completion in any setting. A concern with this format, however, was the potential data use requirement. Participants expressed privacy concerns with using SMS, WhatsApp and other social media for risk assessments. Most agreed on an airtime incentive between ZAR5-10 (USD 0.29–0.58) per survey. Participants encouraged researchers to provide feedback to them about their sexual risk. Conclusions: Completion of mobile phone sexual risk assessments can be optimized with minimal incentives by ensuring that questionnaires are simple, brief, infrequent and have trusted privacy measures.
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Affiliation(s)
- Janan J Dietrich
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
| | - Gabriella L Benadé
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mamakiri Mulaudzi
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashraf Kagee
- Department of Psychology, Faculty of Arts and Social Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lerato M Makhale
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maria P Lemos
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Erica Lazarus
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michele P Andrasik
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Keith J Horvath
- Department of Psychology, San Diego State University, San Diego, CA, United States
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Lemos MP, Nandi V, Dragavon J, Fleming I, Krishnan K, Musuruana M, Kramer M, Glantz H, Andrasik M, Coombs RW, McElrath MJ, Tieu HV. HIV-1 Nucleic Acids Identify Rectal HIV Exposures in Self-Collected Rectal Swabs, Whereas Y-Chromosome Single Tandem Repeat Mixtures Are Not Reliable Biomarkers of Condomless Receptive Anal Intercourse. J Acquir Immune Defic Syndr 2021; 88:138-148. [PMID: 34506358 PMCID: PMC8439546 DOI: 10.1097/qai.0000000000002748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND To focus interventions, biomarkers of HIV-1 exposure could help in identifying subpopulations at highest risk of acquisition. We assessed whether Y-chromosome single tandem repeat (YSTR) mixtures obtained from rectal swabs could serve as a biomarker of condomless receptive anal intercourse (CRAI) among men who have sex with men and transgender women and evaluated the feasibility of detecting HIV-1 virions to assess exposures. METHODS Twenty-nine sexually active HIV-seronegative men who have sex with men and one transgender woman from New York City answered on-site and mobile app sexual behavior questionnaires. They were randomized to collecting self-administered rectal swabs every morning or after receptive anal intercourse (RAI). YSTR profiles were assessed from blood sample and swabs; HIV-1 exposure was measured by conducting quantitative polymerase chain reaction in swabs. RESULTS After 2 months, the daily mobile survey had 135%-201% more instances of anal sex acts and 170%-193% more RAI than on-site surveys. Daily mobile reporting had 11%-35% less CRAI events than those reported on-site (Pdaily = 0.001; Pper-sex = 0.047). The daily swabbing arm reported less RAI (P < 0.001) and CRAI (P < 0.038) and had 2.95 lower odds of detecting YSTR mixtures (P = 0.021) than the per-sex-event arm. Surprisingly, YSTR detection was not significantly modified by report of bowel movements and lubricant, enema, or condom use. No participant became HIV-1 infected, yet HIV-1 total nucleic acids were detected in 6 independent episodes of CRAI in 2 participants taking pre-exposure prophylaxis. CONCLUSIONS YSTR mixtures demonstrated 80% specificity but only 30% sensitivity as a biomarker of CRAI in self-collected rectal swabs. However, detection of HIV-1 exposures in self-collected swabs may help in identifying those needing further HIV risk reduction strategies.
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Affiliation(s)
- Maria P. Lemos
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Vijay Nandi
- Laboratory of Data Analytics, Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY
| | - Joan Dragavon
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Ira Fleming
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Keertana Krishnan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Martin Musuruana
- Laboratory of Data Analytics, Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY
| | - Madeline Kramer
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Hayley Glantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Michele Andrasik
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Robert W. Coombs
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
- Department of Pathology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - M. Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Hong-Van Tieu
- Laboratory of Infectious Disease Prevention, Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY
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Dietrich JJ, Hornschuh S, Khunwane M, Makhale LM, Otwombe K, Morgan C, Huang Y, Lemos M, Lazarus E, Kublin JG, Gray GE, Laher F, Andrasik M. A mixed methods investigation of implementation barriers and facilitators to a daily mobile phone sexual risk assessment for young women in Soweto, South Africa. PLoS One 2020; 15:e0231086. [PMID: 32324753 PMCID: PMC7179867 DOI: 10.1371/journal.pone.0231086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 03/17/2020] [Indexed: 11/24/2022] Open
Abstract
Background The HIV epidemiology in South Africa reveals stark age and gender disparities, with young women being the most vulnerable to HIV acquisition in 2017. Evaluation of HIV exposure is a challenge in HIV prevention research. Intermittent in-clinic interviewer-administered risk behaviour assessments are utilised but may be limited by social desirability and recall biases. We piloted a mobile phone application for daily self-report of sexual risk behaviour in fifty 18–25 year old women at risk of HIV infection enrolled in HIV Vaccine Trials Network 915 (HVTN 915) in Soweto, South Africa. Through a mixed-methods investigation, we explored barriers and facilitators to completing daily mobile phone surveys among HVTN 915 study participants and staff. Methods We analysed quantitative data on barriers and facilitators to mobile phone study completion collected during the larger HVTN 915 study as well as two post-study focus group discussions (FGDs) with fifteen former participants with a median age of 24 years (IQR 23–25) and six individual in-depth interviews (IDIs) with HVTN 915 staff. FGDs and IDIs utilised semi-structured interview guides, were audio-recorded, transcribed verbatim and translated to English. After coding, thematic analysis was performed. Results The main facilitator for daily mobile phone survey completion assessed across 336 follow-up visits for 49 participants was the daily short message system (SMS) reminders (93%, 312/336). Across 336 visits, 31/49 (63%) retained participants reported barriers to completion of daily mobile phone surveys: forgetting (20%, 12/49), being too busy (19%, 11/49) and the survey being an inconvenience (15%, 9/49). Five main themes were identified during the coding of IDIs and FGDs: (1) facilitators of mobile phone survey completion, such as daily SMS reminders and follow up calls for non-completers; (2) barriers to mobile phone survey completion, including partner, time-related and technical barriers; (3) power of incentives; (4) response bias in providing sensitive information, and (5) recommendations for future mobile phone based interventions. Conclusion Despite our enthusiasm to use innovation to optimise sexual risk assessments, technical and practical solutions are required to improve implementation. We recommend further engagement with participants to optimise this approach and to further understand social desirability bias and study incentives in sexual risk reporting.
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Affiliation(s)
- Janan J. Dietrich
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, Western Cape, South Africa
- * E-mail:
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Mamakiri Khunwane
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Lerato M. Makhale
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Cecilia Morgan
- Vaccine and Infectious Disease Division (VIDD), Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Yunda Huang
- Vaccine and Infectious Disease Division (VIDD), Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Maria Lemos
- Vaccine and Infectious Disease Division (VIDD), Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Erica Lazarus
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - James G. Kublin
- Vaccine and Infectious Disease Division (VIDD), Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Glenda E. Gray
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Office of the President, South African Medical Research Council, Cape Town, Western Cape, South Africa
| | - Fatima Laher
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Michele Andrasik
- Vaccine and Infectious Disease Division (VIDD), Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
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