Developing a Mobile App (LYNX) to Support Linkage to HIV/Sexually Transmitted Infection Testing and Pre-Exposure Prophylaxis for Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

Feasibility Testing a Meditation App for Professionals Working With Youth in the Legal System: Protocol for a Hybrid Type 2 Effectiveness-Implementation Pilot Randomized Controlled Trial

BACKGROUND

Probation officers and other professionals who work with youth in the legal system often experience high chronic workplace stress, which can contribute over time to elevations in anxiety, depression, and workplace burnout. Emotion dysregulation appears to function as a common mechanism underlying these elevations, and growing evidence suggests it can be improved with mindfulness meditation. Implemented successfully, app-based meditation programs could provide professionals with real-time tools for mitigating the effects of chronic workplace stress.

OBJECTIVE

This paper describes the protocol for a hybrid type 2 effectiveness-implementation pilot randomized controlled trial (RCT) of Bodhi AIM+, a meditation app adapted with and for professionals who work with youth in the legal system. The adaptation process and implementation plan, as well as the pilot RCT design, were guided by theoretically driven implementation science frameworks. The primary outcome of the pilot RCT is app adherence (ie, ongoing app usage per objective analytics data).

METHODS

The RCT will be fully remote. Officers and other professionals who work with youth in the legal system (N=50) will be individually randomized to use the meditation app or an active control app matched for time and structure. All participants will be asked to follow a 30-day path of brief audio- or video-guided content and invited to use additional app features as desired. In-app analytics will capture the objective usage of each feature. An adaptive engagement design will be employed to engage nonusers of both apps, whereby analytics data indicating nonuse will trigger additional support (eg, text messages promoting engagement). Mental health outcomes and potential moderators and covariates will be self-reported at baseline, posttest, and 6 months. Participants will also complete 1-week bursts of ecological momentary assessment (EMA) at baseline and over the last week of the intervention to capture the mechanistic target (ie, emotion regulation) in real time. All participants will be invited to complete qualitative posttest interviews. Descriptive statistics will be calculated for quantitative data. Qualitative data will be analyzed using a combined deductive-inductive approach. The quantitative and qualitative data will be incorporated into a mixed methods triangulation design, allowing for the evaluation of app adherence and other implementation outcomes as well as related barriers and facilitators to implementation.

RESULTS

Enrollment into the trial started in December 2024 and is currently underway. Study results are anticipated to be available in 2026.

CONCLUSIONS

Completion of this pilot trial will inform a future, fully powered RCT to formally evaluate the effectiveness and implementation of Bodhi AIM+. Its use of implementation science methods, coupled with digital technology, positions the present study not only to help make meditation tools available to an important workforce at scale but also to inform broader efforts at implementing and evaluating health apps within workplace settings.

TRIAL REGISTRATION

ClincialTrials.gov NCT06555172; https://clinicaltrials.gov/study/NCT06555172.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/71867.

The Effects of MyChoices and LYNX Mobile Apps on HIV Testing and Pre-Exposure Prophylaxis Use by Young US Sexual Minority Men: Results From a National Randomized Controlled Trial

BACKGROUND

Young sexual minority men have among the highest rates of HIV in the United States; yet, the use of evidence-based prevention strategies, including routine HIV testing and pre-exposure prophylaxis (PrEP), remains low. Mobile apps have enormous potential to increase HIV testing and PrEP use among young sexual minority men.

OBJECTIVE

This study aims to assess the efficacy of 2 theory- and community-informed mobile apps-LYNX (APT Mobility) and MyChoices (Keymind)-to improve HIV testing and PrEP initiation among young sexual minority men.

METHODS

Between October 2019 and May 2022, we implemented a 3-arm, parallel randomized controlled trial in 9 US cities to test the efficacy of the LYNX and MyChoices apps against standard of care (SOC) among young sexual minority men (aged 15-29 years) reporting anal sex with cisgender male or transgender female in the last 12 months. Randomization was 1:1:1 and was stratified by site and participant age; there was no masking. The co-primary outcomes were self-reported HIV testing and PrEP initiation over 6 months of follow-up.

RESULTS

A total of 381 young sexual minority men were randomized. The mean age was 22 (SD 3.2) years. Nearly one-fifth were Black, non-Hispanic (n=67, 18%), Hispanic or Latino men (n=67, 18%), and 60% identified as gay (n=228). In total, 200 (53%) participants resided in the Southern United States. At baseline, participants self-reported the following: 29% (n=110) had never had an HIV test and 85% (n=324) had never used PrEP. Sociodemographic and behavioral characteristics did not differ by study arm. Compared to SOC (n=72, 59%), participants randomized to MyChoices (n=87, 74%; P=.01) were more likely to have received at least 1 HIV test over 6 months of follow-up; those randomized to LYNX also had a higher proportion of testing (n=80, 70%) but it did not reach the a priori threshold for statistical significance (P=.08). Participants in both MyChoices (n=23, 21%) and LYNX (n=21, 20%) arms had higher rates of starting PrEP compared to SOC (n=19, 16%), yet these differences were not statistically significant (P=.52).

CONCLUSIONS

In addition to facilitating earlier treatment among those who become aware of their HIV status, given the ubiquity of mobile apps and modest resources required to scale this intervention, a 25% relative increase in HIV testing among young sexual minority men, as seen in this study, could meaningfully reduce HIV incidence in the United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03965221; https://clinicaltrials.gov/study/NCT03965221.

Prepared, Protected, EmPowered (P3): Primary Results of a Randomized Controlled Trial Using a Social Networking, Gamification, and Coaching App to Promote Pre-exposure Prophylaxis (PrEP) Adherence for Sexual and Gender Minority (SGM) Youth Living in the United States

The population-level reductions in HIV incidence attributed to pre-exposure prophylaxis (PrEP) have not been fully realized among sexual, gender, and racial/ethnic minority youth. P3 (Prepared, Protected, emPowered) is a comprehensive mobile application (app) intervention developed to support PrEP adherence through gamification, medication tracking, and social engagement. A randomized controlled trial was conducted with 246 young men who have sex with men (YMSM) and young transgender women who have sex with men (YTWMSM) currently on or planning to begin PrEP. Participants were randomized in a 1:1:1 ratio to: standard of care (SOC), P3 app (P3), or P3 app plus in-app adherence coaching (P3+). Adherence was measured at 3- and 6- months post enrollment by emtricitabine-triphosphate (FTC-TP) and tenofovir-diphosphate (TFV-DP) levels in dried blood spots consistent with PrEP use > 4 days/week. The primary outcome was the difference in the proportion adherent comparing P3/P3+ to SOC. P3/P3+ was associated with a higher proportion adherent compared to SOC for both outcome measures. At 3 months, the estimated increase in the proportion adherent was 0.13 (95% CI: 0.00, 0.27, p: 0.05) and 0.12 (95% CI: -0.03, 0.26, p: 0.11) for TFV-DP and FTC-TP, respectively. Estimated adherence was higher, but not statistically different, in P3+ compared to P3, for both TFV-DP and FTC-TP. Receipt of P3 (P3 or P3+) is associated with an increase in PrEP adherence among YMSM and YTWSM at 3 months. Additional analyses to discern the role of app usage and sociodemographic and behavioral factors on intervention effects are warranted.

Studying the Digital Intervention Engagement-Mediated Relationship Between Intrapersonal Measures and Pre-Exposure Prophylaxis Adherence in Sexual and Gender Minority Youth: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Improving adherence to pre-exposure prophylaxis (PrEP) via digital health interventions (DHIs) for young sexual and gender minority men who have sex with men (YSGMMSM) is promising for reducing the HIV burden. Measuring and achieving effective engagement (sufficient to solicit PrEP adherence) in YSGMMSM is challenging.

OBJECTIVE

This study is a secondary analysis of the primary efficacy randomized controlled trial (RCT) of Prepared, Protected, Empowered (P3), a digital PrEP adherence intervention that used causal mediation to quantify whether and to what extent intrapersonal behavioral, mental health, and sociodemographic measures were related to effective engagement for PrEP adherence in YSGMMSM.

METHODS

In May 2019, 264 YSGMMSM were recruited for the primary RCT via social media, community sites, and clinics from 9 study sites across the United States. For this secondary analysis, 140 participants were eligible (retained at follow-up, received DHI condition in primary RCT, and completed trial data). Participants earned US currency for daily use of P3 and lost US currency for nonuse. Dollars accrued at the 3-month follow-up were used to measure engagement. PrEP nonadherence was defined as blood serum concentrations of tenofovir-diphosphate and emtricitabine-triphosphate that correlated with ≤4 doses weekly at the 3-month follow-up. Logistic regression was used to estimate the total effect of baseline intrapersonal measures on PrEP nonadherence, represented as odds ratios (ORs) with a null value of 1. The total OR for each intrapersonal measure was decomposed into direct and indirect effects.

RESULTS

For every US $1 earned above the mean (US $96, SD US $35.1), participants had 2% (OR 0.98, 95% CI 0.97-0.99) lower odds of PrEP nonadherence. Frequently using phone apps to track health information was associated with a 71% (OR 0.29, 95% CI 0.06-0.96) lower odds of PrEP nonadherence. This was overwhelmingly a direct effect, not mediated by engagement, with a percentage mediated (PM) of 1%. Non-Hispanic White participants had 83% lower odds of PrEP nonadherence (OR 0.17, 95% CI 0.05-0.48) and had a direct effect (PM=4%). Participants with depressive symptoms and anxiety symptoms had 3.4 (OR 3.42, 95% CI 0.95-12) and 3.5 (OR 3.51, 95% CI 1.06-11.55) times higher odds of PrEP nonadherence, respectively. Anxious symptoms largely operated through P3 engagement (PM=51%).

CONCLUSIONS

P3 engagement (dollars accrued) was strongly related to lower odds of PrEP nonadherence. Intrapersonal measures operating through P3 engagement (indirect effect, eg, anxious symptoms) suggest possible pathways to improve PrEP adherence DHI efficacy in YSGMMSM via effective engagement. Conversely, the direct effects observed in this study may reflect existing structural disparity (eg, race and ethnicity) or behavioral dispositions toward technology (eg, tracking health via phone apps). Evaluating effective engagement in DHIs with causal mediation approaches provides a clarifying and mechanistic view of how DHIs impact health behavior.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT03320512; https://clinicaltrials.gov/study/NCT03320512.

Adaptation of a HIV Prevention Mobile App for Transmasculine People: A Pilot Acceptability and Feasibility Study

Purpose

Using a community-engaged approach, we adapted a human immunodeficiency virus (HIV) prevention smartphone app, Transpire, to meet the HIV and sexually transmitted infection (STI) prevention needs of transgender men and other transmasculine people. We conducted a pilot study to assess the feasibility and acceptability of the app among participants in two cities in the southeastern United States.

Methods

Participants were recruited online and through community partners. Eligible and consenting participants used the Transpire app for 3 months and completed surveys at the beginning and end of the follow-up period. Transpire gave participants access to HIV and STI prevention information; the ability to order HIV and STI at-home self-test kits, condoms, and lube; and mental health and substance use resources. The primary feasibility outcome was the System Usability Scale (SUS), which measures the usability of technology-based products.

Results

Sixty participants were enrolled. Most were 18-24 years old (n=33, 55%) and identified as non-Hispanic white (n=46, 77%). The mean SUS score was 72.4, which meets established criteria for acceptability. Fifteen (32%) participants conducted an HIV test during the 3-month follow-up period and 2 (4%) initiated pre-exposure prophylaxis.

Conclusions

Following a community-engaged adaptation process, the Transpire app was found to be acceptable in a pilot study conducted among transmasculine participants. These pilot data indicate that app-based interventions have the potential to increase awareness of and access to sexual health resources for transmasculine people. Additional studies will be needed to assess the efficacy of Transpire or similar apps to improve sexual health outcomes.

mHealth-Based Gamification Interventions Among Men Who Have Sex With Men in the HIV Prevention and Care Continuum: Systematic Review and Meta-Analysis

Background

In the past few years, a burgeoning interest has emerged in applying gamification to promote desired health behaviors. However, little is known about the effectiveness of such applications in the HIV prevention and care continuum among men who have sex with men (MSM).

Objective

This study aims to summarize and evaluate research on the effectiveness of gamification on the HIV prevention and care continuum, including HIV-testing promotion; condomless anal sex (CAS) reduction; and uptake of and adherence to pre-exposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and antiretroviral therapy (ART).

Methods

We comprehensively searched PubMed, Embase, the Cochrane Library, Web of Science, Scopus, and the Journal of Medical Internet Research and its sister journals for studies published in English and Chinese from inception to January 2024. Eligible studies were included when they used gamified interventions with an active or inactive control group and assessed at least one of the following outcomes: HIV testing; CAS; and uptake of and adherence to PrEP, PEP, and ART. During the meta-analysis, a random-effects model was applied. Two reviewers independently assessed the quality and risk of bias of each included study.

Results

The systematic review identified 26 studies, including 10 randomized controlled trials (RCTs). The results indicated that gamified digital interventions had been applied to various HIV outcomes, such as HIV testing, CAS, PrEP uptake and adherence, PEP uptake, and ART adherence. Most of the studies were conducted in the United States (n=19, 73%). The most frequently used game component was gaining points, followed by challenges. The meta-analysis showed gamification interventions could reduce the number of CAS acts at the 3-month follow-up (n=2 RCTs; incidence rate ratio 0.62, 95% CI 0.44-0.88). The meta-analysis also suggested an effective but nonstatistically significant effect of PrEP adherence at the 3-month follow-up (n=3 RCTs; risk ratio 1.16, 95% CI 0.96-1.38) and 6-month follow-up (n=4 RCTs; risk ratio 1.28, 95% CI 0.89-1.84). Only 1 pilot RCT was designed to evaluate the effectiveness of a gamified app in promoting HIV testing and PrEP uptake. No RCT was conducted to evaluate the effect of the gamified digital intervention on PEP uptake and adherence, and ART initiation among MSM.

Conclusions

Our findings suggest the short-term effect of gamified digital interventions on lowering the number of CAS acts in MSM. Further well-powered studies are still needed to evaluate the effect of the gamified digital intervention on HIV testing, PrEP uptake, PEP initiation and adherence, and ART initiation in MSM.

Pre-exposure prophylaxis access, uptake and usage by young people: a systematic review of barriers and facilitators

Background

Young people's sexual health decision-making, including decisions to access and adhere to HIV prevention strategies such as Pre-Exposure Prophylaxis (PrEP), are influenced by a range of internal and external factors. Synthesizing these factors is essential to guide the development of youth-focused PrEP health promotion strategies to contribute to international goals of ending HIV transmission.

Objective

To understand the individual, interpersonal, sociocultural and systemic barriers and facilitators to PrEP access, uptake and use experienced by young people 24 years and younger.

Design

A systematic review that adhered to the Preferred Reporting Items of Systematic Review and Meta-Analysis Protocols.

Data Sources and Methods

Eight databases (PubMed, Scopus, Cochrane, Medline, CINAHL, JBI, EMBASE, Web of Science) were systematically searched using terms related to young people, HIV and PrEP use. A narrative synthesis approach was used to delineate key barriers and facilitators to PrEP access, uptake and use.

Results

Of 11,273 returned articles, 32 met the eligibility criteria for inclusion: 18 from the United States, 10 from African nations and two from Brazil. Barriers and facilitators to PrEP access, uptake and use experienced by young people were identified across intrapersonal, interpersonal, community and systems levels. These factors are described under four overarching themes that relate to knowledge, side effects and perceptions of risk; attitudes and perceptions of family and partners; community attitudes and stigma; and negative healthcare provider experiences and difficulties navigating complex costly healthcare systems.

Conclusion

Findings suggest individual-level factors need consideration alongside the impacts of healthcare systems and broader systemic sociocultural structures within young people's relationships when developing PrEP health promotion strategies and services. Without considering these wider external implications to access, uptake and use of PrEP, global targets towards the elimination of HIV transmission will likely remain out of reach.

Registration

This review was registered with Prospero (CRD42022296550).

A feasibility study of the use of HIV self-tests in young men who have sex with men

Studies on HIV self-testing (HIV-ST) have been limited to adults (age 18+). The study assessed use of HIV-ST among a diverse group of young men who have sex with men (YMSM) in the United States (US) and assessed differences in uptake by demographic characteristics and requirements for parental consent. This study demonstrated feasibility of HIV-ST for YMSM as young as 14 years of age, which suggests potential for increasing HIV testing in this young age group and promoting health equity.

Adolescents Living With or at Risk for HIV: A Pooled Descriptive Analysis of Studies From the Adolescent Medicine Trials Network for HIV/AIDS Interventions

PURPOSE

This study aims to describe the cohort of Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) research program participants and evaluate whether the ATN's recently completed 5-year cycle recruited study participants who parallel the populations most impacted by HIV in the United States.

METHODS

Harmonized measures across ATN studies collected at baseline were aggregated for participants aged 13-24 years. Pooled means and proportions stratified by HIV status (at risk for or living with HIV) were calculated using unweighted averages of study-specific aggregate data. Medians were estimated using a weighted median of medians method. Public use 2019 Centers for Disease Control and Prevention surveillance data for state-level new HIV diagnoses and HIV prevalence among US youth aged 13-24 years were obtained for use as reference populations for ATN at-risk youth and youth living with HIV (YLWH), respectively.

RESULTS

Data from 3,185 youth at-risk for HIV and 542 YLWH were pooled from 21 ATN study phases conducted across the United States. Among ATN studies tailored to at-risk youth, a higher proportion of participants were White and a lower proportion were Black/African American and Hispanic/Latinx compared to youth newly diagnosed with HIV in the United States in 2019. Participants in ATN studies tailored to YLWH were demographically similar to YLWH in the United States.

DISCUSSION

The development of data harmonization guidelines for ATN research activities facilitated this cross-network pooled analysis. These findings suggest the ATN's YLWH are representative, but that future studies of at-risk youth should prioritize recruitment strategies to enroll more participants from African American and Hispanic/Latinx populations.

Adaptation and Utilization of a Postmarket Evaluation Model for Digital Contact Tracing Mobile Health Tools in the United States: Observational Cross-sectional Study

BACKGROUND

Case investigation and contact tracing are core public health activities used to interrupt disease transmission. These activities are traditionally conducted manually. During periods of high COVID-19 incidence, US health departments were unable to scale up case management staff to deliver effective and timely contact-tracing services. In response, digital contact tracing (DCT) apps for mobile phones were introduced to automate these activities. DCT apps detect when other DCT users are close enough to transmit COVID-19 and enable alerts to notify users of potential disease exposure. These apps were deployed quickly during the pandemic without an opportunity to conduct experiments to determine effectiveness. However, it is unclear whether these apps can effectively supplement understaffed manual contact tracers.

OBJECTIVE

The aims of this study were to (1) evaluate the effectiveness of COVID-19 DCT apps deployed in the United States during the COVID-19 pandemic and (2) determine if there is sufficient DCT adoption and interest in adoption to meet a minimum population use rate to be effective (56%). To assess uptake, interest and safe use covariates were derived from evaluating DCTs using the American Psychological Association App Evaluation Model (AEM) framework.

METHODS

We analyzed data from a nationally representative survey of US adults about their COVID-19-related behaviors and experiences. Survey respondents were divided into three segments: those who adopted a DCT app, those who are interested but did not adopt, and those not interested. Descriptive statistics were used to characterize factors of the three groups. Multivariable logistic regression models were used to analyze the characteristics of segments adopting and interested in DCT apps against AEM framework covariates.

RESULTS

An insufficient percentage of the population adopted or was interested in DCTs to achieve our minimum national target effectiveness rate (56%). A total of 17.4% (n=490) of the study population reported adopting a DCT app, 24.7% (n=697) reported interest, and 58.0% (n=1637) were not interested. Younger, high-income, and uninsured individuals were more likely to adopt a DCT app. In contrast, people in fair to poor health were interested in DCT apps but did not adopt them. App adoption was positively associated with visiting friends and family outside the home (odds ratio [OR] 1.63, 95% CI 1.28-2.09), not wearing masks (OR 0.52, 95% CI 0.38-0.71), and adopters thinking they have or had COVID-19 (OR 1.60, 95% CI 1.21-2.12).

CONCLUSIONS

Overall, a small percentage of the population adopted DCT apps. These apps may not be effective in protecting adopters' friends and family from their maskless contacts outside the home given low adoption rates. The public health community should account for safe use behavioral factors in future public health contact-tracing app design. The AEM framework was useful in developing a study design to evaluate DCT effectiveness and safety.

Dispositifs de dépistage des infections sexuellement transmissibles à domicile : quelle prise en compte des populations LGBT ?

INTRODUCTION

Every days, more than one million people are infected with a sexually transmitted infection worlwide. In France, screening mainly rely on medical laboratories, private or public, with e prescription. Those tests face structural ans social barriers for LGBT people that could be partially lifted using at home self sampling. Using a narrative review, we will study how the needs of those populations are adressed in existing at home self sampling interventions.

PURPOSE OF RESEARCH

Describe the adaptation of home sampling system to MSM, WSW and transgender peoples.

RESULTS

Nine interventions met our inclusion criteria, eight in English spoken countries. Studies did not systematically reported data on sexual orientation. Transgender people, when identified, were rarely a larger group enough to be the subject of sub-analysis. Infections tested were CT and NG for three intervention, HIV only for one, CT,NG and HIV for five, and one also add HCV.

CONCLUSIONS

Standing as a complement to physical testing services, at home self-sampling intervention could benefit from an advertisement to WSW and from the integration of wider sexual health services.

Evidence and implication of interventions across various socioecological levels to address HIV testing uptake among men who have sex with men in the United States: A systematic review

Objectives

Strengthening HIV testing uptake is critical to curtail the HIV epidemics among men who have sex with men in the United States. Despite the implementation of various interventions to promote HIV testing among men who have sex with men, few aggregated evidence is presented to reflect the "lessons learned" and inform future directions. The objective of this systematic review is to comprehensively summarize published studies that described, tested, and evaluated outcomes (e.g. efficacy, effectiveness, acceptability, feasibility and/or qualitative opinions) associated with an HIV testing intervention and identify gaps as well as opportunities to inform the design and implementation of future interventions to enhance HIV testing uptake among men who have sex with men in the United States.

Methods

We followed the PRISMA guidelines and conducted a systematic review of articles (published by 23 July 2021) by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO).

Results

Among the total number of 3505 articles found through multiple databases, 56 papers were included into the review. Interventional modules that demonstrated acceptability, feasibility and efficacy to improve HIV testing uptake among men who have sex with men include: HIV self-testing, interpersonal-level (e.g. peer-led, couple-based) interventions, personalized interventions and technology-based interventions (e.g. mHealth). Aggregated evidence also reflects the lack of individualized interventions that simultaneously address time-varying needs across multiple socioecological levels (e.g. individual, interpersonal, community, structural and societal).

Conclusion

Development of interventions to improve HIV testing rates and frequency of men who have sex with men has proliferated in recent years. Our review presents important implications in sustaining and improving interventions to address HIV testing uptake among men who have sex with men in the United States.

Evidence and implication of interventions across various socioecological levels to address pre-exposure prophylaxis uptake and adherence among men who have sex with men in the United States: a systematic review

BACKGROUND

Pre-exposure prophylaxis (PrEP) represents a proven biomedical strategy to prevent HIV transmissions among men who have sex with men (MSM) in the United States (US). Despite the design and implementation of various PrEP-focus interventions in the US, aggregated evidence for enhancing PrEP uptake and adherence is lacking. The objective of this systematic review is to synthesize and evaluate interventions aimed to improve PrEP uptake and adherence among MSM in the US, and identify gaps with opportunities to inform the design and implementation of future PrEP interventions for these priority populations.

METHODS

We followed the PRISMA guidelines and conducted a systematic review of articles (published by November 28, 2021) with a focus on PrEP-related interventions by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO). Details of PrEP interventions were characterized based on their socioecological level(s), implementation modalities, and stage(s) of PrEP cascade continuum.

RESULTS

Among the 1363 articles retrieved from multiple databases, 42 interventions identified from 47 publications met the inclusion criteria for this review. Most individual-level interventions were delivered via text messages and/or apps and incorporated personalized elements to tailor the intervention content on participants' demographic characteristics or HIV risk behaviors. Interpersonal-level interventions often employed peer mentors or social network strategies to enhance PrEP adoption among MSM of minority race. However, few interventions were implemented at the community-, healthcare/institution- or multiple levels.

CONCLUSIONS

Interventions that incorporate multiple socioecological levels hold promise to facilitate PrEP adoption and adherence among MSM in the US given their acceptability, feasibility, efficacy and effectiveness. Future PrEP interventions that simultaneously address PrEP-related barriers/facilitators across multiple socioecological levels should be enhanced with a focus to tackle contextual and structural barriers (e.g., social determinants of health, stigma or medical mistrust) at the community- and healthcare/institution-level to effectively promote PrEP use for MSM of color.

Public Health Implications of Adapting HIV Pre-exposure Prophylaxis Programs for Virtual Service Delivery in the Context of the COVID-19 Pandemic: Systematic Review

BACKGROUND

The novel coronavirus disease COVID-19 caused by SARS-CoV-2 threatens to disrupt global progress toward HIV epidemic control. Opportunities exist to leverage ongoing public health responses to mitigate the impacts of COVID-19 on HIV services, and novel approaches to care provision might help address both epidemics.

OBJECTIVE

As the COVID-19 pandemic continues, novel approaches to maintain comprehensive HIV prevention service delivery are needed. The aim of this study was to summarize the related literature to highlight adaptations that could address potential COVID-19-related service interruptions.

METHODS

We performed a systematic review and searched six databases, OVID/Medline, Scopus, Cochrane Library, CINAHL, PsycINFO, and Embase, for studies published between January 1, 2010, and October 26, 2021, related to recent technology-based interventions for virtual service delivery. Search terms included "telemedicine," "telehealth," "mobile health," "eHealth," "mHealth," "telecommunication," "social media," "mobile device," and "internet," among others. Of the 6685 abstracts identified, 1259 focused on HIV virtual service delivery, 120 of which were relevant for HIV prevention efforts; 48 pertained to pre-exposure prophylaxis (PrEP) and 19 of these focused on evaluations of interventions for the virtual service delivery of PrEP. Of the 16 systematic reviews identified, three were specific to PrEP. All 35 papers were reviewed for outcomes of efficacy, feasibility, and/or acceptability. Limitations included heterogeneity of the studies' methodological approaches and outcomes; thus, a meta-analysis was not performed. We considered the evidence-based interventions found in our review and developed a virtual service delivery model for HIV prevention interventions. We also considered how this platform could be leveraged for COVID-19 prevention and care.

RESULTS

We summarize 19 studies of virtual service delivery of PrEP and 16 relevant reviews. Examples of technology-based interventions that were effective, feasible, and/or acceptable for PrEP service delivery include: use of SMS, internet, and smartphone apps such as iText (50% [95% CI 16%-71%] reduction in discontinuation of PrEP) and PrEPmate (OR 2.62, 95% CI 1.24-5.5.4); telehealth and eHealth platforms for virtual visits such as PrEPTECH and IowaTelePrEP; and platforms for training of health care workers such as Extension for Community Healthcare Outcomes (ECHO). We suggest a virtual service delivery model for PrEP that can be leveraged for COVID-19 using the internet and social media for demand creation, community-based self-testing, telehealth platforms for risk assessment and follow-up, applications for support groups and adherence/appointment reminders, and applications for monitoring.

CONCLUSIONS

Innovations in the virtual service provision of PrEP occurred before COVID-19 but have new relevance during the COVID-19 pandemic. The innovations we describe might strengthen HIV prevention service delivery during the COVID-19 pandemic and in the long run by engaging traditionally hard-to-reach populations, reducing stigma, and creating a more accessible health care platform. These virtual service delivery platforms can mitigate the impacts of the COVID-19 pandemic on HIV services, which can be leveraged to facilitate COVID-19 pandemic control now and for future responses.

Optimizing an mHealth Intervention to Improve Uptake and Adherence to HIV Pre-exposure Prophylaxis in Young Transgender Women: Protocol for a Multi-Phase Trial

BACKGROUND

Vulnerable adolescents and emerging adults (aged 18-29 years), particularly young transgender women, are among the fastest-growing HIV positive populations worldwide. Thailand has the highest adult HIV seroprevalence in Asia, with a rate of infection among this population of 18%. Widespread technology offers opportunities for innovative mobile health (mHealth) interventions. Pre-exposure prophylaxis (PrEP) is an efficacious HIV prevention strategy recommended for at-risk individuals. PrEP is highly effective when taken as prescribed, but uptake and adherence have been low, with high discontinuation rates among youth.

OBJECTIVE

We propose to develop and pilot a multi-component, technology-based intervention to promote PrEP usage. We will adapt an existing 2-session, technology-delivered, motivational interviewing-based intervention to focus on PrEP use in transgender women in Thailand. We call this the Motivational Enhancement System for PrEP Uptake and Adherence (MES-PrEP). We will also refine and enhance YaCool, a mobile app with integrated text messaging developed and used clinically by our Thai team. The new version of the app is called Enhanced YaCool, and it enables self-management of gender and sexual health (including PrEP). Our primary aim is to develop and assess the preliminary efficacy of this mHealth intervention.

METHODS

We will utilize a multiphase optimization strategy (MOST) to identify the most effective intervention component or combination of components to improve PrEP usage in Thai transgender women. The study includes two phases: phase I (R21) includes qualitative interviews with key stakeholders to explore barriers and facilitators of PrEP usage through thematic analysis to inform intervention adaptation. Following this, we will adapt and beta-test MES-PrEP and Enhanced YaCool for functionality and feasibility using a community advisory board of HIV-negative Thai transgender women. In phase II (R33), we will conduct a MOST design-based trial to evaluate the feasibility, acceptability, and preliminary efficacy of MES-PrEP and Enhanced YaCool. Eighty HIV-negative participants who are currently taking PrEP and 80 participants who are not will be randomized to four conditions: (1) standard PrEP counseling (the control condition); (2) MES-PrEP and standard PrEP counseling; (3) Enhanced YaCool and standard PrEP counseling; and (4) MES-PrEP, Enhanced YaCool, and standard PrEP counseling. Feasibility and acceptability of the intervention will be assessed through usage patterns and the System Usability Scale. Preliminary impact will be assessed by evaluating the proportion of participants who initiate PrEP and their level of adherence to PrEP. Assessments will be at baseline and 1, 3, 6, 9, and 12 months postintervention. Biomarkers of adherence to PrEP, HIV, and other sexually transmitted infections will be collected.

RESULTS

Upon project completion, we will have an optimized mHealth intervention to support the use of PrEP by transgender women that will be ready for testing in a larger efficacy trial.

CONCLUSIONS

Even though transgender women in Thailand face increasing risks of HIV, few interventions have targeted them. Effective developmentally and culturally tailored interventions are needed to prevent HIV transmission in this high-risk population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05262426; https://clinicaltrials.gov/ct2/show/NCT05262426.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37659.

Interest in mobile HIV prevention apps among sexual and gender minority persons living in the rural southern United States: A qualitative study (Preprint)

Background

Mobile health (mHealth) interventions, including smartphone apps, have been found to be an effective means of increasing the uptake of HIV prevention tools, including HIV and sexually transmitted infection (STI) tests and pre-exposure prophylaxis. However, most HIV prevention mHealth apps tested in the United States have been tested among populations living in areas surrounding urban centers. Owing to reduced access to broadband internet and reliable cellular data services, it remains unclear how accessible and effective these interventions will be in rural areas. In addition, gay and bisexual men who have sex with men and gender minority populations in rural areas experience enhanced stigma when compared with their more urban counterparts, and these experiences might affect their willingness and interest in mHealth apps.

Objective

This study aimed to conduct online focus groups with men who have sex with men and transgender and gender diverse populations in the rural southern United States to assess their interest in mHealth HIV prevention apps and the features that they would be the most interested in using.

Methods

Focus group participants were recruited from a larger pool of sexual and gender minority respondents to a web-based research survey. The participants indicated that they would be willing to participate in an online focus group discussion. Focus groups were conducted via secure Zoom (Zoom Video Communications Inc) videoconferencing. During the focus group discussions, participants were asked to discuss their experiences with HIV and STI prevention and how these experiences were affected by living in a rural area. They were then shown screenshots of a new app to promote HIV and STI prevention among rural populations and asked to provide their opinions on the app’s features. The transcripts of the discussions were reviewed and coded using a constant comparative approach.

Results

A total of 6 focus groups were conducted with 26 participants. Most participants were cisgender gay and bisexual men who have sex with men (19/26, 73%); the remaining participants were transgender men (2/26, 8%), were nonbinary people (2/26, 8%), or had multiple gender identities (3/26, 12%). Participants reported numerous barriers to accessing HIV and STI prevention services and accurate information about HIV and STI prevention options. Overall, the participants reported a high degree of interest in mHealth interventions for HIV and STI prevention and suggested several recommendations for the features of an app-based intervention that would be the most useful for rural residents.

Conclusions

These focus group discussions indicate that rural residence is not a major barrier to mHealth HIV and STI prevention intervention implementation and that there is a high degree of interest in these approaches to HIV and STI prevention.

Establishing a Working Definition of User Experience for eHealth Interventions of Self-reported User Experience Measures With eHealth Researchers and Adolescents: Scoping Review

BACKGROUND

Across eHealth intervention studies involving children, adolescents, and their parents, researchers have measured user experience to assist with intervention development, refinement, and evaluation. To date, no widely accepted definitions or measures of user experience exist to support a standardized approach for evaluation and comparison within or across interventions.

OBJECTIVE

We conduct a scoping review with subsequent Delphi consultation to identify how user experience is defined and measured in eHealth research studies, characterize the measurement tools used, and establish working definitions for domains of user experience that could be used in future eHealth evaluations.

METHODS

We systematically searched electronic databases for published and gray literature available from January 1, 2005, to April 11, 2019. We included studies assessing an eHealth intervention that targeted any health condition and was designed for use by children, adolescents, and their parents. eHealth interventions needed to be web-, computer-, or mobile-based, mediated by the internet with some degree of interactivity. We required studies to report the measurement of user experience as first-person experiences, involving cognitive and behavioral factors reported by intervention users. We appraised the quality of user experience measures in included studies using published criteria: well-established, approaching well-established, promising, or not yet established. We conducted a descriptive analysis of how user experience was defined and measured in each study. Review findings subsequently informed the survey questions used in the Delphi consultations with eHealth researchers and adolescent users for how user experience should be defined and measured.

RESULTS

Of the 8634 articles screened for eligibility, 129 articles and 1 erratum were included in the review. A total of 30 eHealth researchers and 27 adolescents participated in the Delphi consultations. On the basis of the literature and consultations, we proposed working definitions for 6 main user experience domains: acceptability, satisfaction, credibility, usability, user-reported adherence, and perceived impact. Although most studies incorporated a study-specific measure, we identified 10 well-established measures to quantify 5 of the 6 domains of user experience (all except for self-reported adherence). Our adolescent and researcher participants ranked perceived impact as one of the most important domains of user experience and usability as one of the least important domains. Rankings between adolescents and researchers diverged for other domains.

CONCLUSIONS

Findings highlight the various ways in which user experience has been defined and measured across studies and what aspects are most valued by researchers and adolescent users. We propose incorporating the working definitions and available measures of user experience to support consistent evaluation and reporting of outcomes across studies. Future studies can refine the definitions and measurement of user experience, explore how user experience relates to other eHealth outcomes, and inform the design and use of human-centered eHealth interventions.

Adaptation of a Theory-Based Social Networking and Gamified App-Based Intervention to Improve Pre-Exposure Prophylaxis Adherence Among Young Men Who Have Sex With Men in Bangkok, Thailand: Qualitative Study

BACKGROUND

HIV disproportionately affects young Thai men who have sex with men (YMSM). Recent studies report a high incidence and prevalence of HIV among Thai YMSM. The Thai national guidelines have recommended pre-exposure prophylaxis (PrEP) since 2014 for key populations; free PrEP has been piloted since 2019. Smartphone-based mobile health (mHealth) interventions provide an optimal platform for innovative PrEP adherence interventions for Thai YMSM.

OBJECTIVE

This study aims to adapt the P3 (Prepared, Protected, emPowered) app, developed with YMSM and transwomen in the United States to improve PrEP adherence and persistence for YMSM in Thailand. The app aims to provide daily adherence support and addresses gaps in staff available for large-scale PrEP rollout needed to see population-level effects of HIV prevention.

METHODS

We conducted focus group discussions (FGDs) with YMSM and key informant interviews (KIIs) with PrEP care providers in Bangkok, Thailand, to investigate PrEP adherence facilitators and barriers, preferences for functions and features in mHealth apps among YMSM, and how to best adapt the P3 app to the Thai context. We conducted four FGDs with 4-8 participants per group and 15 KIIs.

RESULTS

For FGDs, 23 YMSM participated with a mean age of 20 years (range 18-21), 96% (22/23) enrolled in full-time education, and all owned smartphones. The mean age of KII participants was 40 (range 26-60) years; most were state health service providers, with the majority being counselors (6/15, 40%) and physicians (6/15, 40%). Overall, the facilitators and barriers for PrEP adherence identified were similar to those of MSM and YMSM globally including the United States. Key themes included general recommendations for improving mHealth apps in Thailand, such as presenting reliable information in an appealing format, minimizing privacy risks, and addressing connectivity challenges. Additional themes focused on P3 Thailand adaptations and were related to cultural and stylistic preferences, engagement strategies, and recommendations for new functions. To develop the adapted app, P3 Thailand, these findings were balanced with resource limitations resulting in the prioritization of minor modifications: changes in app esthetics (color scheme, iconography, and imagery) and changes in the presentation of information in two of the app's features. FGDs identified similar PrEP adherence facilitators and barriers to those already addressed within the app.

CONCLUSIONS

The core elements of the P3 app address major PrEP facilitators and barriers for Thai YMSM; however, changes to the app features, including stylistic presentation, were needed to appropriately customize the app to the Thai context. Given the similarities of facilitators and barriers for PrEP adherence globally, adapting existing PrEP mHealth solutions based on input from end users and key informants provides a promising approach. However, partnerships with local app designers and developers can improve the adaptation process and final product.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04413708; http://clinicaltrials.gov/ct2/show/NCT04413708.

Toward Greater Pre-exposure Prophylaxis Equity: Increasing Provision and Uptake for Black and Hispanic/Latino Individuals in the U.S

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition and is a critical tool in the Ending the HIV Epidemic in the U.S. initiative. However, major racial and ethnic disparities across the pre-exposure prophylaxis continuum, secondary to structural inequities and systemic racism, threaten progress. Many barriers, operating at the individual, network, healthcare, and structural levels, impede PrEP access and uptake within Black and Hispanic/Latino communities. This review provides an overview of those barriers and the innovative and collaborative solutions that health departments, healthcare organizations, and community partners have implemented to increase PrEP provision and uptake among disproportionately affected communities. Promising strategies at the individual and network levels focus on increasing patient support throughout the PrEP continuum, positioning and training community members to expand knowledge of and interest in PrEP, and leveraging mobile technologies to support PrEP uptake. Healthcare-level solutions include expanding the venues and types of healthcare professionals that can provide PrEP, and structural- and policy-level options focus on financial assistance programs and health insurance expansion. Key research gaps include demonstrating that pilot studies and interventions remain effective at scale and across varied contexts. Although the last 2 decades have provided effective tools to end the HIV epidemic, realizing this vision for the U.S. will require addressing persistent and pervasive HIV-related disparities in Black and Hispanic/Latino communities. Federal, state, and local partners should expand efforts to address longstanding health and structural inequities and partner with disproportionately affected communities to rapidly expand PrEP scale-up.

Scaling Up CareKit: Lessons Learned from Expansion of a Centralized Home HIV and Sexually Transmitted Infection Testing Program

BACKGROUND

Despite advances in implementing human immunodeficiency virus (HIV)/sexually transmitted infection (STI) services for men who have sex with men (MSM), many remain underserved because of barriers like stigma, low facility coverage, and provider competency. This article describes the implementation of centralized nationwide mailed HIV/STI home testing (CareKit).

METHODS

The Emory Center for AIDS Research developed CareKit for research study participants to request HIV self-test kits, STI specimen collection kits, and condom/lubricant packs to be shipped to any mailing address in the United States. Sexually transmitted infection kits were customized according to study needs and could include materials to collect whole blood, dried blood spots, urine sample, and rectal and pharyngeal swab samples for syphilis, gonorrhea, and chlamydia testing. Specimens were mailed back to a central Clinical Laboratory Improvement Amendments-approved laboratory for testing, and results were returned to participants.

RESULTS

CareKit was used by 12 MSM studies and mailed 1132 STI kits to 775 participants between January 2018 and March 2020. Participants returned 507 (45%) STI kits, which included 1594 individual specimens. Eighty-one kits (16%) had at least one positive STI test result: pharyngeal chlamydia (n = 7), pharyngeal gonorrhea (n = 11), rectal chlamydia (n = 15), rectal gonorrhea (n = 12), genital chlamydia (n = 6), genital gonorrhea (n = 1), and syphilis (n = 54). In this same 2-year period, 741 HIV self-test kits were mailed to 643 MSM.

CONCLUSIONS

CareKit successfully met studies' needs for home HIV/STI testing and diagnosed many STIs. These processes continue to be adapted for research and programs. The ability to mail home test kits has become increasingly important to reach those who may have limited access to health care services, particularly during the COVID-19 pandemic.

Patient-generated data in the management of HIV: a scoping review

OBJECTIVES

Patient-generated data (PGData) are an emergent research area and may improve HIV care. The objectives of this scoping review were to synthesise, evaluate and make recommendations based on the available literature regarding PGData use in HIV care.

DESIGN

Scoping review.

DATA SOURCES

Embase, Medline, CINAHL Plus, Web of Science, Scopus, PsycINFO and Emcare databases.

ELIGIBILITY CRITERIA

Studies involving PGData use within HIV care for people living with HIV and/or healthcare professionals (HCPs) published before February 2021.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a table and the Mixed Methods Appraisal Tool was used to assess empirical rigour. We used thematic analysis to evaluate content.

RESULTS

11 articles met the eligibility criteria. Studies were observational, predominantly concerned hypothetical or novel digital platforms, mainly conducted in high-income settings, and had small sample sizes (range=10-160). There were multiple definitions of PGData. In the majority of studies (n=9), participants were people living with HIV, with a few studies including HCPs, informatics specialists or mixed participant groups. Participants living with HIV were aged 23-78 years, mostly men, of diverse ethnicities, and had low educational, health literacy and income levels.We identified four key themes: (1) Perceptions of PGData and associated digital platforms; (2) Opportunities; (3) Anticipated barriers and (4) Potential impact on patient-HCP relationships.

CONCLUSIONS

Use of PGData within HIV care warrants further study, especially with regard to digital inequalities, data privacy and security. There is a need for longitudinal data on use within HIV in a variety of settings with a broad range of users, including impact on clinical outcomes. This will allow greater understanding of the role of PGData use in improving the health and well-being of people living with HIV, which is increasingly pertinent as digital healthcare becomes more widespread as a result of COVID-19.

DOT Diary: Developing a Novel Mobile App Using Artificial Intelligence and an Electronic Sexual Diary to Measure and Support PrEP Adherence Among Young Men Who Have Sex with Men

Young men who have sex with men (YMSM) are highly vulnerable to HIV. While pre-exposure prophylaxis (PrEP) has demonstrated effectiveness, adherence has been low among YMSM and difficult to measure accurately. In collaboration with a healthcare company, we configured an automated directly-observed therapy (aDOT) platform for monitoring and supporting PrEP use. Based on interest expressed in focus groups among 54 YMSM, we combined aDOT with an electronic sexual diary to provide feedback on level of protection during sex and to motivate app use. In an 8-week optimization pilot with 20 YMSM in San Francisco and Atlanta, the app was found to be highly acceptable, with median System Usability Scale scores in the "excellent" range (80/100). App use was high, with median PrEP adherence of 91% based on aDOT-confirmed dosing. Most (84%) participants reported the app helped with taking PrEP. These promising findings support further evaluation of DOT Diary in future effectiveness studies.

Using the Patient Portal Sexual Health Instrument in Surveys and Patient Questionnaires Among Sexual Minority Men in the United States: Cross-sectional Psychometric Validation Study

Background

Patient portal modules, including electronic personal health records, health education, and prescription refill ordering, may be leveraged to address the sexually transmitted infection (STI) burden, including HIV, among gay, bisexual, and other sexual minority men (SMM). Theoretical frameworks in the implementation sciences highlight examining constructs of innovation attributes and performance expectations as key determinants of behavioral intentions and the use of new web-based health technologies. However, behavioral intentions to use patient portals for HIV and other STI prevention and care among SMM is understudied.

Objective

The aim of this study is to develop a brief instrument for measuring attitudes focused on using patient portals for STI prevention and care among a nationwide sample of SMM.

Methods

A total of 12 items of the American Men’s Internet Survey-Patient Portal Sexual Health Instrument (AMIS-PPSHI) were adapted from a previous study. Psychometric analyses of the AMIS-PPSHI items were conducted among a randomized subset of 2018 AMIS participants reporting web-based access to their health records (N=1375). Parallel analysis and inspection of eigenvalues in a principal component analysis (PCA) informed factor retention in exploratory factor analysis (EFA). After EFA, Cronbach α was used to examine the internal consistency of the scale and its subscales. Confirmatory factor analysis (CFA) was used to assess the goodness of fit of the final factor structure. We calculated the total AMIS-PPSHI scale scores for comparisons within group categories, including age, STI diagnosis history, recency of testing, serious mental illness, and anticipated health care stigma.

Results

The AMIS-PPSHI scale resulting from EFA consisted of 12 items and had good internal consistency (α=.84). The EFA suggested 3 subscales: sexual health engagement and awareness (α=.87), enhancing dyadic communication (α=.87), and managing sexual health care (α=.79). CFA demonstrated good fit in the 3-factor PPSHI structure: root mean square error of approximation=0.061, comparative fit index=0.964, Tucker-Lewis index=0.953, and standardized root mean square residual=0.041. The most notable differences were lower scores on the enhanced dyadic communication subscale among people living with HIV.

Conclusions

PPSHI is a brief instrument with strong psychometric properties that may be adapted for use in large surveys and patient questionnaires in other settings. Scores demonstrate that patient portals are favorable web-based solutions to deliver health services focused on STI prevention and care among SMM in the United States. More attention is needed to address the privacy implications of interpersonal use of patient portals outside of traditional health settings among persons with HIV.

Embedding a Linkage to Preexposure Prophylaxis Care Intervention in Social Network Strategy and Partner Notification Services: Results From a Pilot Randomized Controlled Trial

BACKGROUND

Increased preexposure prophylaxis (PrEP) uptake among black men who have sex with men and black transgender women (BMSM/TW) is needed to end the HIV epidemic. Embedding a brief intervention in network services that engage individuals in HIV transmission networks for HIV/ sexually transmitted infections testing may be an important strategy to accelerate PrEP uptake.

SETTING

Partner Services PrEP study is a pilot, randomized, control trial to improve linkage to PrEP care among BMSM/TW presenting for network services in Chicago, IL, from 2015 to 2017.

METHODS

BMSM/TW (N = 146) aged 18-40 years were recruited from network services (partners services and social network strategy services). Intervention participants developed an individualized linkage plan based on the information-motivation-behavioral skills model and received minibooster sessions. Control participants received treatment as usual. Sociodemographic, behavioral, and clinical factors were examined at baseline and 3- and 12-month postintervention. Intent-to-treat analyses examined linkage to PrEP care within 3-month postintervention (primary outcome). Secondary outcomes were PrEP initiation, time to linkage to PrEP care, and time to PrEP initiation.

RESULTS

Compared with control participants, a significantly greater proportion of the intervention participants were linked to PrEP care within 3 months (24% vs. 11%; P = 0.04) and initiated PrEP (24% vs. 11%; P = 0.05). Among those linked to PrEP care within the study period, intervention participants were linked significantly sooner than control participants [median (interquartile range) days, 26.5 (6.0-141.8) vs. 191.5 (21.5-297.0); P = 0.05].

CONCLUSION

Study results support the preliminary efficacy of Partner Services PrEP to improve linkage to PrEP care and PrEP initiation among BMSM/TW.

Online recruitment of youth for mHealth studies

BACKGROUND

Social networking sites and apps have emerged as an opportunity to engage in research young men who have sex with men (YMSM) at risk of HIV infection who may not be otherwise reached by in-person recruitment efforts. This paper highlights lessons learned, best practices and on-going recruitment challenges in the iTech network of the NIH Adolescent Trials Network for HIV Interventions.

METHODS

Recruitment was conducted for four randomized controlled trials (RCTs) of mHealth HIV prevention interventions for YMSM living in 10 US cities. Advertising was purchased on Facebook, Instagram, Snapchat, Twitter and Grindr. Users who clicked on banner ads were taken directly to a study-specific eligibility screener and if eligible, were asked to provide contact information for follow-up by respective study site staff. Ad and screening metrics (impressions, clicks, cost per click (CPC), click-through rate (CTR), number screened, number eligible, number who provided contact information and cost per eligible contact) were compared across platforms, studies and geographic areas (where available). Screening metrics were also calculated for in-person recruitment efforts.

RESULTS

Grindr and Snapchat ads produced the highest CTRs as compared to Facebook ads. However, these ads had the lowest proportions of users who initiated eligibility screeners and ultimately Facebook ads yielded the lowest cost per eligible contact across studies. Instagram ads yielded the highest proportions of eligible contacts who were racial/ethnic minorities and under the age of 18. Geographic variability in cost per eligible contact was observed for studies with identical eligibility criteria running concurrently in different regions, driven by both advertising costs and the screening and eligibility rates. Despite lower eligibility rates, the total numbers of eligible contacts were higher for online advertising campaigns, as compared to other recruitment efforts, for all studies except P3. Ads recruiting for P3 had the highest cost per eligible contact, likely due to this study having the most stringent eligibility criteria of the studies described.

CONCLUSIONS

We implemented a successful online advertising strategy to recruit YMSM at high risk for HIV infection into four RCTs of mHealth interventions. This report provides a framework for evaluation of data from future online recruitment efforts across platforms and geographic areas, regardless of inevitable changes in the digital marketing space.

The ongoing HIV epidemic in American youth: challenges and opportunities

The incidence of human immunodeficiency virus (HIV) infection has been decreasing in the United States overall, except among youth, and in particular among Black and Latinx young men who have sex with men (MSM). In this review we summarize key drivers of the HIV epidemic among youth, as well as novel interventions geared specifically towards combating the epidemic among high-risk populations. Many factors driving the HIV epidemic among youth are related to systemic inequities, including lack of access to healthcare, inadequate education, and internalized and experience homophobia and racism. Developmentally, youth may feel that they are invulnerable and be willing to engage in risks. Moreover, HIV is often invisible for youth given advances in treatment and community stigma, limiting open discussion of risk and new preventive modalities. Outcomes from the HIV treatment cascade suggest that youth are less likely to be aware of their HIV infection status, less likely to link to and be engaged in care, and less likely to be virologically suppressed than older MSM and other populations of people living with HIV. Importantly, pre-exposure prophylaxis (PrEP) has been shown to be an effective tool for prevention of HIV infection that also appears to have disproportionately poor uptake among youth. Barriers to PrEP utilization appear to be quite heterogeneous, and include patient-, provider-, and structural-level barriers. Interventions important in improving HIV prevention will thus have to be multipronged and developed for culturally diverse populations. Cognitive behavioral therapy-based interventions are promising strategies as they are able to address a diverse array of barriers. New formulations of PrEP will also likely be instrumental in improving adherence. Since youth spend considerable amounts of time accessing digital media, the deployment of apps and other mobile phone-based interfaces offer unique opportunities to increase education and to facilitate HIV prevention for at risk youth. Multiple studies are underway to better inform the optimal delivery of treatment and prevention services for this complex and diverse population, and include novel sociobiological interventions and new modes of medication delivery that may lend themselves to overcoming obstacles specific to youth.

Mobile apps for HIV prevention: how do they contribute to our epidemic response for adolescents and young adults?

Mobile health (mHealth) tools to address the HIV epidemic have proliferated in recent years. Yet when applied to the United States (US) epidemic, which is driven by new HIV infections among men who have sex with men (MSM), it is not clear how mHealth tools fit in the overall portfolio of biobehavioral prevention interventions and clinical services proven to be efficacious. Adolescent and young adult MSM are particularly vulnerable and reducing HIV incidence among this priority population will require substantial levels of uptake of multiple prevention strategies (i.e., HIV testing, condom use, sexually transmitted infection (STI) testing, pre-exposure prophylaxis (PrEP), and treatment for those with HIV infection). Starting from the premise that adolescents are avid consumers of technology, this paper considers the particular strengths and opportunities of mHealth tools to address HIV prevention and provides examples of mHealth approaches that have been tested or are in development in these areas. Even after mHealth interventions are proven effective, there will be important intervening steps before such tools can be deployed and integrated into existing prevention programs given the diverse landscape of prevention service delivery. We anticipate some of the likely barriers to broad implementation of proven mHealth interventions in the context of the US public health funding and service delivery infrastructure and provide recommendations to increase efforts for future scale-up and dissemination.

HIV self-testing and STI self-collection via mobile apps: experiences from two pilot randomized controlled trials of young men who have sex with men

BACKGROUND

Young men who have sex with men (YMSM) are disproportionately impacted by HIV and other sexually transmitted infections (STIs) in the United States (US) and have low rates of HIV/STI testing. Provision of HIV self-testing and STI self-collection can increase testing rates, and access to these kits through mobile applications (apps) could help facilitate YMSM using HIV self-testing and STI self-collection.

METHODS

Data for this study comes from two pilot randomized controlled trials (RCTs) of mobile apps within the Adolescent Trials Network-LYNX and MyChoices-aimed to increase HIV/STI testing among YMSM (age 15-24) who had not recently tested for HIV and were at high risk for HIV acquisition across five US cities. Both apps include the ability to order a HIV self-test with rapid results and a kit for STI self-collection and mailing of samples for syphilis, gonorrhea and chlamydia to a lab for testing. Using assessments of app users (n=80) at pre-randomization and at 3- and 6-months post-randomization and online interview data from a purposive sample of app users (n=37), we report on experiences and lessons learned with HIV self-testing and STI self-collection kits ordered via the apps.

RESULTS

Participants were on average 20.7 years of age (SD =2.4), and 49% were non-White or multiple race/ethnicity. Sixty-three percent had a prior HIV test. Over half (58%) had a prior STI test, but only 3% had tested within the past 3 months. Nearly two-thirds ordered an HIV self-testing kit; of whom, 75% reported using at least one self-test kit over the study period. STI self-collection kit ordering rates were also high (54%); however, STI self-collection kit return rates were lower (13%), but with a high positivity rate (5.3%). Both HIV self-testing and STI self-collection kits were highly acceptable, and 87% reported that it was extremely/very helpful to be able to order these kits through the apps. The most common reason for not ordering the HIV/STI kits was preferring to test at a clinic. In interviews, participants expressed feeling empowered by being able to test at home; however, they also raised concerns around STI sample collection.

CONCLUSIONS

HIV self-testing and STI self-collection kit ordering via mobile apps is feasible, acceptable and may show promise in increasing testing rates among YMSM. The LYNX and MyChoices apps are currently being tested in a full-scale efficacy trial, and if successful, these innovative mobile apps could be scaled up to efficiently increase HIV/STI testing among youth across the US.

Engaging youth in mHealth: what works and how can we be sure?

BACKGROUND

Youth participating in mobile health (mHealth) intervention trials often engage with the technologies [e.g., applications (app) or mobile-optimized websites] only partially, often prematurely discontinuing use altogether. Limited engagement can impact the interventions effect on behavior change and compromise researchers' ability to test and estimate the true efficacy of their interventions. While mHealth interventions have been shown to be feasible and acceptable to youth, across diverse health conditions, strategies to increase engagement have been less well studied. Specifically, within HIV prevention and care mHealth interventions, there is not consensus as to which components represent the "key ingredients" to support maximal engagement of youth. Further, successful intervention evaluation requires the ability to systematically track users' engagement with intervention components (i.e., paradata) to evaluate its effects on behavior change.

METHODS

As part of the Adolescent Medicine Trials Network UNC/Emory Center for Innovative Technology (iTech) portfolio of HIV/AIDS Interventions, we present diverse strategies used across five mHealth protocols seeking to promote youth engagement, track and measure engagement through paradata, and incorporate these components into mHealth intervention evaluations.

RESULTS

We describe the importance of defining and measuring engagement using case studies from iTech to illustrate how different research teams select mHealth features to promote youth engagement over time, taking into account features embedded in the technology design, key mechanisms of change and trial outcomes (e.g., HIV testing, pre-exposure prophylaxis uptake and adherence, HIV treatment adherence). Finally, we discuss how the research teams plan to evaluate engagement's role on their intervention's outcomes.

CONCLUSIONS

Based on this synthesis, we discuss strategies to enhance mHealth engagement during intervention development and design, ensure its monitoring and reporting throughout the trial, and evaluate its impact on trial outcomes.

Adapting technology-based HIV prevention and care interventions for youth: lessons learned across five U.S. Adolescent Trials Network studies

BACKGROUND

U.S. sexual and gender minority youth experience individual, interpersonal, and structural-level barriers to HIV prevention and care. Innovative, youth-driven approaches to mobile and electronic interventions that support use of new biomedical prevention, testing, and treatment options may address these barriers. Adapting evidence-based interventions for youth must balance core intervention components with responsiveness to the distinct needs of end-users.

METHODS

The UNC/Emory Center for Innovative Technology (iTech) adapts and evaluates technology-based interventions for youth living with or at risk for HIV. We analyzed formative research (focus groups and individual usability sessions) across five iTech studies: two apps promoting HIV testing and pre-exposure prophylaxis (PrEP), one app promoting behavioral risk reduction and PrEP, one PrEP adherence app, and one mobile-optimized website for increasing viral suppression, with the aim of informing best practices for technology-based intervention development. Each study presented prototypes of adapted mHealth interventions to samples of their target end-user population for use and/or evaluation.

RESULTS

One hundred and thirty-eight youth across seven geographically diverse sites provided feedback during the intervention adaptation process. We found high interest in and acceptability of all five intervention prototypes. Cross-study themes included: (I) Desire for multiple privacy protections (e.g., password, fingerprint) to keep HIV status, sexual identity, and sexual behavior confidential. (II) Strong but varied preferences for the look and feel of platforms. Imagery should be discrete but representative. Participants valued customizable platforms and positive themes, motivational language, and humor. Youth wanted information presented using multiple modalities (e.g., text, video, image) to increase engagement. (III) Youth preferred engagement features and functions consistent with familiar platforms (e.g., Snapchat, Instagram). Gamification features that resulted in tangible versus virtual rewards were predicted to increase engagement. Intervention messaging functions were perceived as useful; customization was desired as a way to control frequency, mode (e.g., SMS, in-app message, push notification), and content. (IV) Youth voiced varied preferences for platform content including: featuring young role models from the lesbian, gay, bisexual, transgender, queer and/or questioning (LGBTQ) community, incorporating mental health resources, and maintaining a holistic health-focus (not HIV-centric).

CONCLUSIONS

We found high acceptability and consistent feedback in youths' evaluations of these mHealth interventions; divergence was most commonly found in preferred content versus features and functions. Identifying broadly accepted aspects of mHealth interventions for youth supports the feasibility of adaptation (versus de novo creation) and should guide the focus of future formative research phases. Continued research is needed to better understand how to balance usability preferences with finite resources for customization.

A Review of HIV Pre-exposure Prophylaxis Streamlining Strategies

PURPOSE OF REVIEW

Standard care for HIV pre-exposure prophylaxis (PrEP) in the USA creates substantial burdens for patients, clinicians, and the healthcare system; to optimize uptake, there is a need for innovative strategies to streamline its provision.

RECENT FINDINGS

Our review, structured by the expanded chronic care model, identified eleven promising strategies to streamline PrEP care. Approaches ranged widely in mechanism of action. Using text messages to support care was the only strategy with clinical trial evidence supporting its use. Other modalities such as patient navigation, telemedicine PrEP models, alternate dosing availability, same-day prescription, and provider training have promising pilot or associational data and seem likely to lower barriers to entering into or remaining in care. Many of the strategies have established success in related domains such as HIV care, meriting consideration in evaluating their use for PrEP. Making PrEP care less burdensome will be an important part of bringing it to scale. Text message interventions have proven efficacy and merit broad adoption. Encouraging preliminary evidence for other strategies indicates the importance of building a stronger evidence base to clarify the effect of each strategy. Ongoing development of an evidence base should not delay the use of these promising strategies; instead, it calls for careful consideration for how each program may best match its environment to facilitate PrEP prescribing and use.

Association of age with healthcare needs and engagement among Nigerian men who have sex with men and transgender women: cross-sectional and longitudinal analyses from an observational cohort

INTRODUCTION

Young men who have sex with men (MSM) and transgender women (TGW) face stigmas that hinder access to healthcare. The aim of the study was to understand age-related determinants of healthcare needs and engagement among MSM and TGW.

METHODS

The TRUST/RV368 cohort provides integrated prevention and treatment services for HIV and other sexually transmitted infections (STIs) tailored to the needs of sexual and gender minorities. MSM and TGW aged ≥16 years in Abuja and ≥18 years Lagos, Nigeria, completed standardized behavioural questionnaires and were tested for HIV, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) every three months for up to 18 months. Logistic regression was used to estimate adjusted odds ratios (aORs) for associations of age and other factors with outcomes of interest upon enrolment, including HIV care continuum steps - HIV testing, ART initiation and viral suppression <1000 copies/mL. Cox proportional hazards models were used to calculate adjusted hazard ratios (aHRs) for associations with incident infections.

RESULTS

Between March 2013 and February 2019, 2123 participants were enrolled with median age 23 (interquartile range 21 to 27) years. Of 1745 tested, 865 (49.6%) were living with HIV. HIV incidence was 11.6/100 person-years [PY], including 23.1/100PY (95% CI 15.5 to 33.1) among participants aged 16 to 19 years and 23.8/100 PY (95% CI 13.6 to 39.1) among TGW. Compared to participants aged ≥25 years, those aged 16 to 19 years had decreased odds of prior HIV testing (aOR 0.40 [95% CI 0.11 to 0.92]), disclosing same-sex sexual practices to healthcare workers (aOR 0.53 [95% CI 0.36 to 0.77]) and receiving HIV prevention information (aOR 0.60 [95% CI 0.41 to 0.87]). They had increased odds of avoiding healthcare (aOR 1.94 [95% CI 1.3 to 2.83]) and engaging in transactional sex (aOR 2.76 [95% CI 1.92 to 3.71]). Age 16 to 19 years was independently associated with increased incidence of HIV (aHR 4.09 [95% CI 2.33 to 7.49]), NG (aHR 3.91 [95% CI 1.90 to 8.11]) and CT (aHR 2.74 [95% CI 1.48 to 5.81]).

CONCLUSIONS

Young MSM and TGW demonstrated decreased healthcare engagement and higher incidence of HIV and other STIs as compared to older participants in this Nigerian cohort. Interventions to address unique obstacles to healthcare engagement by adolescents and young adults are needed to curb the spread of HIV and other STIs among MSM and TGW in Nigeria.

Youth-friendly services and a mobile phone application to promote adherence to pre-exposure prophylaxis among adolescent men who have sex with men and transgender women at-risk for HIV in Thailand: a randomized control trial

INTRODUCTION

Strategies are needed to curb the increasing HIV incidence in young men who have sex with men (YMSM) and transgender women (YTGW) worldwide. We assessed the impact of youth-friendly services (YFS) and a mobile phone application (app) on adherence to pre-exposure prophylaxis (PrEP) in YMSM and YTGW in Thailand.

METHODS

A randomized control trial was conducted in YMSM and YTGW aged 15 to 19 years. Participants were provided daily oral tenofovir disoproxil fumerate/emtricitabine (TDF/FTC), condoms and randomized to receive either YFS or YFS plus a PrEP app (YFS + APP), whose features included self-assessment of HIV acquisition risk, point rewards and reminders for PrEP and clinic appointments. Clinic visits occurred at zero, one, three and six months and telephone contact at two, four and five months. HIV testing was performed at every clinic visit. PrEP adherence was evaluated with intracellular tenofovir diphosphate (TFV-DP) concentrations in dried blood spot (DBS) samples at months 3 and 6. The primary endpoint assessed was "PrEP adherence" defined as TFV-DP DBS concentrations ≥700 fmol/punch (equivalent to ≥4 doses of TDF/week).

RESULTS

Between March 2018 and June 2019, 489 adolescents were screened at three centres in Bangkok. Twenty-seven (6%) adolescents tested positive for HIV and 200 (41%) adolescents participated in the study. Of these, 147 were YMSM (74%) and 53 YTGW (26%). At baseline, median age was 18 years (IQR 17 to 19), 66% reported inconsistent condom use in the past month. Sexually transmitted infection prevalence was 23%. Retention at six months was 73%. In the YFS + APP arm, median app use duration was three months (IQR 1 to 5). PrEP adherence at month 3 was 51% in YFS and 54% in YFS + APP (p-value 0.64) and at month 6 was 44% in YFS and 49% in YFS + APP (p-value 0.54). No HIV seroconversions occurred during 75 person years of follow-up.

CONCLUSIONS

Youth-friendly PrEP services enabled good adherence among half of adolescent PrEP users. However, the mobile phone application tested did not provide additional PrEP adherence benefit in this randomized trial. Adolescent risk behaviours are dynamic and require adaptive programmes that focus on "prevention-effective adherence."

Patient Portals as Highly Acceptable Tools to Support HIV Preventative Behaviors Among Adolescent and Young Sexual Minority Men

PURPOSE

The purpose of this study was to present perceptions about using patient portals to manage HIV and sexually transmitted infection (STI) test results and to communicate with sexual partners among a 2018 nationwide sample of adolescent and young sexual minority men (YSMM) aged 15-25 years.

METHODS

Univariate and bivariate analyses were conducted on cross-sectional online survey data.

RESULTS

Participants gave high or moderate value to portals that provide tips for sexual health (95.1% [1,168/1,228]), ability to locate HIV/STI testing centers (96.9% [1,190/1,228]), and ability to order home-based HIV/STI testing (96% [1,179/1,228]). Perceived health engagement and dyadic communication benefits of use were sustained at or above 94%. YSMM with a history of HIV/STI diagnosis were less willing to share online results with main (93% vs. 97%; Χ² = 5.13; p = .02) and nonmain (70% vs. 77%; Χ² = 5.17; p = .02) sexual partners.

CONCLUSIONS

Patient portals represent highly acceptable spaces to deliver comprehensive sexual health services and could support communication on HIV/STI testing with sex partners among YSMM.

The Feasibility, Acceptability and Preliminary Impact of Mobile Application to Increase Repeat HIV Testing Among Sexual Minority Men

We pilot tested the Status Update Project (SUP) mobile app intervention to promote repeat HIV testing among HIV-negative US MSM. Participants (Mean age = 29 years; 51% racial/ethnic minority; 63% single) who were eligible and enrolled were randomized to either the SUP mobile app or a no-treatment condition, with assessments at baseline and month 4 and 8. Eighty-three percent of men were retained at the 8-month follow up. Among men randomized to the SUP arm, the app's ease and simplicity, health information, HIV testing locator, and HIV test reminders were most liked. At month 4, men randomized to the SUP arm were more likely to be repeat testers compared to those in the control arm (RR = 4.4; 95% CI 0.9, 19.9), although differences diminished by month 8 (RR = 1.2; 95% CI 0.8, 2.0). These findings add to our understanding of how mHealth interventions may play an important role in encouraging repeat HIV testing among MSM.

A Mobile Sexual Health App on Empowerment, Education, and Prevention for Young Adult Men (MyPEEPS Mobile): Acceptability and Usability Evaluation

BACKGROUND

HIV incidence among young adult men who have sex with men (MSM), particularly among black and Latino men, continues to rise. As such, continued HIV prevention interventions for young MSM of color are of utmost importance. Male Youth Pursuing Empowerment, Education and Prevention around Sexuality (MyPEEPS) Mobile is a comprehensive HIV prevention and sexual health education smartphone app initially created to promote sexual health and HIV prevention among adolescent sexual minority young men aged 13 to 18 years.

OBJECTIVE

The objective of this study was to critically appraise the acceptability and usability of MyPEEPS Mobile for young adult MSM aged 19 to 25 years.

METHODS

Study participants used the mobile app, completed usability questionnaires and in-depth interviews, and reported their experience using the app. Analysis of interview data was guided by the Unified Theory of Acceptance and Use of Technology (UTAUT) to better understand the usability and acceptability of this intervention for young adults. Interview data were coded using the following constructs from the UTAUT model: performance expectancy, effort expectancy, and social influence.

RESULTS

A total of 20 young adult MSM (n=10 in Chicago, Illinois, and n=10 in New York, New York) were enrolled in the study. Participants reported that MyPEEPS Mobile was free of functional problems (Health Information Technology Usability Evaluation Scale scores and Post-Study System Usability Questionnaire scores consistent with high usability), easy to use, and useful, with an engaging approach that increased acceptability, including the use of avatars and animation, and inclusive representation of the diverse identities by race and ethnicity, gender identity, and sexual orientation. Recommended areas for improving MyPEEPS Mobile for the target demographic included more adult-oriented graphics, advanced educational content, scenarios for youth with more sexual experience, and search function to increase accessibility of key content.

CONCLUSIONS

Overall, young adult MSM aged 19 to 25 years described the MyPEEPS Mobile as educational, informative, and usable for their sexual health education and HIV prevention needs, and they provided actionable recommendations to optimize its use and applicability for this age group.

Pilot Study of a Multilevel Mobile Health App for Substance Use, Sexual Risk Behaviors, and Testing for Sexually Transmitted Infections and HIV Among Youth: Randomized Controlled Trial

BACKGROUND

Preventing and reducing substance use disorders, sexually transmitted infections (STIs)/HIV, and teen pregnancy, and the associated risk behaviors (ie, substance use and sexual risk behaviors) among youth remain public health priorities in the United States. Equally important is improving the uptake of STI/HIV testing among the youth. Mobile health (mHealth) apps may be a solution to ameliorate these public health concerns; however, few mHealth preventive interventions have demonstrated efficacy in reducing substance use or sexual risk behaviors or improving the uptake of STI/HIV testing among the youth, particularly in clinic settings.

OBJECTIVE

This small-scale study aimed to examine the feasibility of conducting a pilot randomized controlled trial (RCT). We evaluated the effects of Storytelling 4 Empowerment (S4E), relative to enhanced usual practice, on the potential mechanisms by which behavior change occurs, namely clinician-youth risk communication, prevention knowledge, and substance use and sexual risk refusal self-efficacy. We also assessed the ability to measure targeted outcomes of past 30-day substance use (ie, alcohol, tobacco, and other drug use), condomless sex, and alcohol or drug use before sex, as well as the uptake of STI/HIV testing.

METHODS

Employing community-based participatory research principles, 50 youths aged 13 to 21 years were recruited from a youth-centered community health clinic in Southeast Michigan, randomized sequentially to either S4E or enhanced usual practice, and assessed at baseline, immediately postintervention, and 30 days postintervention. S4E consists of 3 modules, including alcohol and drug use, tobacco, and STI/HIV.

RESULTS

Relative to youth in the enhanced usual practice group, S4E participants demonstrated higher youth-clinician risk communication (mean 3.22, SD 1.67) and increases in prevention knowledge (∆ score mean 0.36, SD 0.51) and self-efficacy (∆ score mean 0.16, SD 0.47). In addition, youth in the S4E group showed reductions in the proportions of past 30-day overall substance use (Cohen h=0.71, 95% CI 0.15 to 1.27), as well as past 30-day alcohol (Cohen h=0.71, 95% CI 0.15 to 1.27), tobacco (Cohen h=0.17, 95% CI -0.39 to 0.73), and drug use (Cohen h=1.28, 95% CI 0.72 to 1.84). The results also suggest a reduction in the proportion of youths who reported past 30-day condomless sex (Cohen h=0.18, 95% CI -0.38 to 0.74) and alcohol use before sex (Cohen h=0.44, 95% CI -0.12 to 1.00). Finally, the findings also demonstrated an increase in the proportion of youths who reported STI/HIV testing over time (Cohen h=0.16, 95% CI -0.39 to 0.72).

CONCLUSIONS

The findings suggest the feasibility of a small-scale pilot RCT. S4E demonstrated shifts in the hypothesized direction, reducing substance use, sexual risk behaviors, and improving the uptake of STI/HIV testing among youth in a clinic setting. The findings suggest that a larger RCT may be warranted.

TRIAL REGISTRATION

ClinicalTrails.gov NCT03855410, https://clinicaltrials.gov/ct2/show/NCT03855410.

Mobile health promotion of human immunodeficiency virus self-testing in the United States

BACKGROUND

Human immunodeficiency virus (HIV) self-testing could overcome barriers associated with traditional HIV testing and increase people's awareness of their serostatus. Mobile health, which utilizes mobile wireless technology, could alleviate concerns associated with HIV self-testing and increase access to this screening test.

METHODS

We conducted a PubMed, Google Scholar, and Google search to identify research studies and public health programs in the United States that used mobile health to provide HIV self-testing kits for participants. Nine research studies and two public health programs in the United States met the inclusion criteria and were included in the narrative review.

RESULTS

Mobile health interventions delivered through online platforms and smartphone apps tailored towards high-risk populations could promote HIV self-testing distribution, pre- and post-test counseling, and linkage to follow-up care.

CONCLUSIONS

Given mobile health's potential to encourage HIV self-testing, prevention, and treatment among high-risk communities, we included recommendations that incorporated this mode of HIV self-testing into public health programs to appropriately address the HIV epidemic in the United States.

A Systematic Review of eHealth Interventions Addressing HIV/STI Prevention Among Men Who Have Sex With Men

A systematic review was conducted to summarize and appraise the eHealth interventions addressing HIV/STI prevention among men who have sex with men (MSM), and characterize features of successful eHealth interventions. Fifty-five articles (17 pilots and 38 full efficacy trials) were included with the predominance of web-based interventions in the United States-based settings. Intervention modalities include web-based, short message service (SMS)/text messges/email reminder, online video-based, computer-assisted, multimedia-based, social network, live chat and chat room, virtual simulation intervention, and smartphone applications. Forty-nine eHealth interventions achieved a short-term behaviour change among participants. Four studies were conducted with 12-month follow-ups; and only one of them could maintain the behaviour change over this longer time period which could be due to the lack of booster interventions. Our study suggests that eHealth interventions can achieve short term behaviour change among MSM, however limited interventions could maintain behaviour change over 12 months. Further eHealth intervention strategies to promote HIV prevention among MSM should be conducted and rigorously evaluated.

Implementation Strategies to Increase PrEP Uptake in the South

PURPOSE OF REVIEW

Seven years after TDF/FTC was approved for pre-exposure prophylaxis to reduce risks of HIV infection, there have been large increases in the number of persons using PrEP in the USA. However, recent data on pre-exposure prophylaxis (PrEP) use at the state level indicate that people living in the Southern United States are underserved by PrEP relative to their epidemic need. We sought to review possible reasons for inequitable uptake of PrEP in the South and identify implementation approaches to increase PrEP uptake in the South.

RECENT FINDINGS

Published literature, data on the locations of PrEP service providers, recent data on PrEP utilization from pharmacy prescription databases, HIV surveillance data and government data on healthcare providers, and health literacy indicate a confluence of factors in the South that are likely limiting PrEP uptake. A variety of approaches are needed to address the complex challenges to PrEP implementation in the South. These include considering alternative PrEP provision strategies (e.g., pharmacy-based PrEP, telemedicine-delivered PrEP), conducting gain-based stigma-reduction campaigns, increasing capacity for reimbursement for PrEP medications and services through policy change to expand Medicaid and to preserve access to Affordable Care Act-compliant health plans, expanding STI screening programs and improving integration of PrEP offering with delivery of positive STI results, using mHealth tools to screen groups at highest risk for HIV (e.g., men who have sex with men) periodically to increase correct perception of risk, and streamlining clinical procedures to allow same-day PrEP starts for patients without obvious medical contraindications. Overcoming the structural, capacity, and policy challenges to increasing PrEP uptake in the South will require innovations in clinical approaches, leveraging technologies, and policy changes. The South has unique challenges to achieving equitable PrEP uptake, and addressing key barriers to expanded PrEP use will require multisectoral responses.