Clinic-Integrated Smartphone App (JomPrEP) to Improve Uptake of HIV Testing and Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Malaysia: Mixed Methods Evaluation of Usability and Acceptability

Preliminary evaluation of a gamified smartphone intervention (O2O-PEP) for enhancing HIV post-exposure prophylaxis uptake in men who have sex with men: pilot feasibility study

BACKGROUND

Addressing the burden of human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) has become a major priority. Over the years, post-exposure prophylaxis (PEP) has proven efficacy in preventing HIV transmission. However, the widespread underutilization of PEP undermines its protective potential. To address this issue, we developed an innovative, gamified mini-app embedded in WeChat, known as O2O-PEP (online-to-offline collaborative model for HIV postexposure prophylaxis), that targets PEP uptake.

OBJECTIVE

We aimed to conduct a pilot feasibility study to assess the feasibility, acceptability, and preliminary efficacy of O2O-PEP in promoting PEP uptake among Chinese MSM.

METHODS

A single-arm, pre-post feasibility study combing quantitative and qualitative methods for data collection was performed in Qingdao, China. Eligible MSM were invited to use the O2O-PEP for 2 weeks. The mini-app provides an online-to-offline service model, enabling MSM to access PEP-related character-based narratives, share on moments, sexual transmitted disease picture test quizzes, e-Consultation, and referrals to offline PEP service providers. Additionally, gamification features, such as reward-based engagement and social support, are incorporated to enhance user motivation. Intervention feasibility was tested by looking at participant engagement data. The acceptability of the intervention was explored with System Usability Scale (SUS) and in-depth interviews. Preliminary efficacy was measured by assessing HIV PEP knowledge and HIV PEP uptake.

RESULTS

A total of twenty Chinese MSM were successfully enrolled. All participants completed baseline outcome measures, and 19 (19/20, 95%) completed outcome measures at 2 weeks. Participants had a mean age of 29.65 years (SD 9.17). PEP knowledge scores increased from 7.79 (SD 1.69) at baseline to 9.68 (SD 2.86) at the two-week follow-up, reflecting a large Cohen's d effect size of 0.8. One participant successfully accessed PEP within 12 h after engaging in condomless anal sex with a stranger during the intervention period. On average, participants spent 35.84 min using the mini-app over a two-week period, though app usage declined over the study period. Acceptability ratings ranged from moderate to extreme across several dimensions, including satisfaction, usability, recommendation of the mini-app to others, and user-friendliness. Ratings for the difficulty of using O2O-PEP was somewhat lower. Regarding the SUS score, 89.5% of participants rated the mini-app within the acceptable usability range (≥ 50), indicating that the majority found the mini-app to be user-friendly. Qualitative analysis of follow-up assessments identified areas where O2O-PEP needed to be improved to enhance user engagement, including a desire to additional functions of psychological and sexual transmitted diseases counseling.

CONCLUSIONS

This study pioneers the application of gamification to PEP uptake, demonstrating the feasibility and acceptability of O2O-PEP. A further efficacy trial is currently underway.

TRIAL REGISTRATION

This study was prospectively registered at the Chinese Clinical Trial Registry (No. ChiCTR2200062538) on 11 Augst, 2022.

Evidence on Digital HIV Self-Testing From Accuracy to Impact: Updated Systematic Review

BACKGROUND

HIV self-testing has gained momentum following the approval of self-testing methods and novel technological advancements. Digital HIV self-testing involves completing an oral or blood-based HIV self-test with support from a digital innovation.

OBJECTIVE

We conducted a systematic review on the existing data analyzing digital HIV self-testing accuracy while updating research on digital HIV self-test acceptability, preference, feasibility, and impact.

METHODS

We searched Embase and PubMed for records on HIV self-testing with digital support. Included studies significantly incorporated a form of digital innovation throughout the HIV self-test process and reported quantitative data. For accuracy measures, the search spanned January 1, 2013, to October 15, 2024; for patient-centered and impact outcomes, we updated existing literature (June 16, 2021, to October 15, 2024) reported in a previous systematic review. Studies' quality was assessed using the QUADAS 2 Tool, Newcastle-Ottawa Scale, and Cochrane Risk of Bias Tool 2.

RESULTS

Fifty-five studies (samples ranging 120-21,035, median 1267 participants) were summarized from 19 middle- to high-income countries. Seven studies reported on the accuracy of HIV self-testing with innovations from >5000 participants. Diagnostic performance metrics, including point estimates of specificity, sensitivity, positive predictive value, and negative predictive value were measured (n=3), and ranged from: 96.8% to 99.9%, 92.9% to 100.0%, 76.5% to 99.2%, and 99.2% to 100.0%, respectively. The percentage of invalid test results for oral and blood-based self-tests ranged from 0.2% to 12.7% (n=4). Fifty-one studies reported data on metrics beyond accuracy, including acceptability, preference, feasibility, and impact outcomes from >30,000 participants. Majority (38/51, 74.5%) were observational studies, while 25.5% (13/51) reported data from randomized controlled trials. Acceptability and preference outcomes varied from 64.5% to 99.0% (14/51) and 4.6% to 99.3% (8/51), respectively. Feasibility outcomes included test uptake (30.9% to 98.2%; 28/51), response rate (26.0% to 94.8%; 7/51), and visits to web-based providers (43.0% to 70.7%; n=4). Impact outcomes assessed new infections (0.0% to 25.8%; 31/51), first-time testers (2.0% to 53.0%; 26/51), result return proportions (22.1% to 100.0%; 24/51), linkage to care as both connections to confirmatory testing and counseling (53.0% to 100.0%; 16/51), and referrals for treatment initiation (44.4% to 98.1%; 8/51). The quality of studies varied, though they generally demonstrated low risk of bias.

CONCLUSIONS

Digital innovations improved the accuracy of HIV self-test results, and were well-accepted and preferred by participants. Operationally, they were found to be feasible and reported impacting the HIV self-testing process. These findings are in favor of the use of digital HIV self-test innovations as a promising support tool and suggest that digital HIV self-tests' service delivery models hold promise in not only facilitating HIV testing but also impacting operational outcomes that are crucial to reaching Joint United Nations Program on HIV/AIDS targets in middle- to high-income countries.

TRIAL REGISTRATION

PROSPERO CRD42020205025; https://www.crd.york.ac.uk/prospero/CRD42020205025.

Exploring and Predicting HIV Preexposure Prophylaxis Adherence Patterns Among Men Who Have Sex With Men: Randomized Controlled Longitudinal Study of an mHealth Intervention in Western China

Background

Preexposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV infection. However, the efficacy of PrEP is highly dependent on adherence. Meanwhile, adherence changes over time, making it difficult to manage effectively.

Objective

Our study aimed to explore and predict the patterns of change in PrEP adherence among men who have sex with men (MSM) and evaluate the impact of the WeChat-based reminder intervention on adherence, thus providing more information for PrEP implementation strategies.

Methods

From November 2019 to June 2023, in a randomized controlled longitudinal study of the PrEP demonstration project in Western China (Chongqing, Sichuan, and Xinjiang) based on a mobile health (mHealth) reminder intervention, participants were randomly divided into reminder and no-reminder groups, with those in the reminder group receiving daily reminders based on the WeChat app. Participants were followed up and self-reported their medication adherence every 12 weeks for a total of 5 follow-up visits. We used the growth mixture model (GMM) to explore potential categories and longitudinal trajectories of adherence among MSM, and patterns of change in PrEP adherence were predicted and evaluated based on the decision tree.

Results

A total of 446 MSM were included in the analysis. The GMM identified 3 trajectories of adherence: intermediate adherence group (n=34, 7.62%), low adherence ascending group (n=126, 28.25%), and high adherence decline group (n=286, 64.13%). We included 8 variables that were significant in the univariate analysis in the decision tree prediction model. We found 4 factors and 8 prediction rules, and the results showed that HIV knowledge score, education attainment, mHealth intervention, and HIV testing were key nodes in the patterns of change in adherence. After 10-fold cross-validation, the final prediction model had an accuracy of 75%, and the classification accuracy of low and intermediate adherence was 78.12%.

Conclusions

The WeChat-based reminder intervention was beneficial for adherence. A short set of questions and prediction rules, which can be applied in future large-scale validation studies, aimed at developing and validating a short adherence assessment tool and implementing it in PrEP practices among MSM.

Role of HIV self-testing in strengthening HIV prevention services

HIV self-testing, which has been increasingly available since 2016, can substantially enhance the uptake of HIV testing, especially for key populations. Clinical trials have explored the application of self-testing in various HIV prevention strategies, including post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), and voluntary medical male circumcision. Research indicates that self-testing can facilitate PrEP initiation and improve adherence and continuation. However, evidence on the effectiveness of linkage to PrEP post HIV self-testing is mixed, underscoring the need to further understand contextual factors and optimal implementation strategies. Studies on linking voluntary medical male circumcision post HIV self-testing show no statistically significant difference compared with standard voluntary medical male circumcision demand creation strategies. There is a shortage of trials examining the role of self-testing in PrEP reinitiation, PEP initiation, or PEP follow-up. Evidence for the use of HIV prevention models that support self-testing is accumulating, but there is a need for further research in different contexts and among different populations to assess its value when scaled up to contribute to reducing HIV infections globally.

Development and application of Breadth-Depth-Context (BDC), a conceptual framework for measuring technology engagement with a qualified clinical data registry

Objectives

Despite the proliferation of dashboards that display performance data derived from Qualified Clinical Data Registries (QCDR), the degree to which clinicians and practices engage with such dashboards has not been well described. We aimed to develop a conceptual framework for assessing user engagement with dashboard technology and to demonstrate its application to a rheumatology QCDR.

Materials and Methods

We developed the BDC (Breadth-Depth-Context) framework, which included concepts of breadth (derived from dashboard sessions), depth (derived from dashboard actions), and context (derived from practice characteristics). We demonstrated its application via user log data from the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry to define engagement profiles and characterize practice-level factors associated with different profiles.

Results

We applied the BDC framework to 213 ambulatory practices from the RISE registry in 2020-2021, and classified practices into 4 engagement profiles: not engaged (8%), minimally engaged (39%), moderately engaged (34%), and most engaged (19%). Practices with more patients and with specific electronic health record vendors (eClinicalWorks and eMDs) had a higher likelihood of being in the most engaged group, even after adjusting for other factors.

Discussion

We developed the BDC framework to characterize user engagement with a registry dashboard and demonstrated its use in a specialty QCDR. The application of the BDC framework revealed a wide range of breadth and depth of use and that specific contextual factors were associated with nature of engagement.

Conclusion

Going forward, the BDC framework can be used to study engagement with similar dashboards.

Chemsex and Harm Reduction Practices Among Men Who Have Sex with Men in Malaysia: Findings from a Qualitative Study

Chemsex is a form of sexualized drug use commonly practiced among MSM with psychoactive substances, such as methamphetamine. While this phenomenon has gained global attention in the past two decades, there is a dearth of empirical data to inform culturally competent interventions. The current work investigates the socio-contextual factors related to chemsex and harm reduction practices among Malaysian MSM. Between February and August 2022, we conducted six online focus group sessions with Malaysian MSM who had engaged in chemsex during the previous 6 months (N = 22). We queried participants about perceived benefits and harms, harm reduction practices, and informational needs. Most participants' first chemsex experience occurred in a casual sexual encounter, often facilitated by mobile technology. Participants reported engaging in harm reduction practices before (e.g. medication reminders), during (e.g. peer support), and after (e.g. rest) chemsex. These findings have implications for future efforts to develop and implement tailored interventions to address the specific and acute needs of Malaysian MSM engaging in chemsex.

Telehealth Models for PrEP Delivery: A Systematic Review of Acceptability, Implementation, and Impact on the PrEP Care Continuum in the United States

Pre-exposure prophylaxis (PrEP) is pivotal in curbing HIV transmission and is integral to the national plan to end the HIV epidemic in the United States (US). Nonetheless, widespread PrEP adoption faces barriers. Telehealth delivery models for PrEP, or telePrEP, can enhance PrEP access and adherence by providing flexible care remotely. This study presents a systematic review of telePrEP programs in the US, aiming to describe model characteristics and summarize clinical, implementation, and equity outcomes. We reviewed studies published from 2012 to 2023. We included articles that described telePrEP systems in the US and measured PrEP care continuum outcomes (awareness, initiation, uptake, adherence) or acceptability of the intervention by program users. Eight articles describing six distinct telePrEP initiatives met our inclusion criteria. Studies described models implemented in community-based, academic, and commercial settings, with most programs using a direct-to-client telePrEP model. Across studies, clients reported high acceptability of the telePrEP programs, finding them easy to use, convenient, and helpful as a tool for accessing HIV prevention services. No programs were offering injectable PrEP at the time these studies were conducted. Data was limited in measuring PrEP retention rates and the reach of services to underserved populations, including Black and Latinx communities, transgender individuals, and cis-gender women. Findings underscore the potential of telePrEP to bolster the reach of PrEP care and address structural barriers to access. As telehealth models for PrEP care gain prominence, future research should concentrate on refining implementation strategies, enhancing equity outcomes, and expanding services to include injectable PrEP.

High Interest in the Use of mHealth Platform for HIV Prevention among Men Who Have Sex with Men in Nepal

Mobile technology growth in Nepal offers promising opportunities for using mobile health (mHealth) interventions to facilitate HIV prevention efforts. However, little is known about access and utilization of communication technology and their willingness to use mHealth for HIV prevention services in Nepal. We conducted a cross-sectional respondent-driven sampling survey of 250 MSM in Kathmandu Valley of Nepal from October to December 2022. We collected information on participant characteristics, HIV risk-related behaviors, ownership, or access to and frequency of use of communication technology (phones, tablets, laptops, and computers), and willingness to use mHealth to access HIV prevention services. Descriptive, bivariate, and multivariate linear regression analyses were performed. Almost all participants had smartphones with the internet (231/250, 92.4%) and accessed the internet daily (219/250, 87.6%) on the smartphone (236/250, 94.4%). The median score for willingness to use mHealth for HIV prevention was 10 (IQR: 3 to 17). Willingness to use mHealth was higher among those participants with a high school or above education (β = 0.223, p = < 0.001), had experienced violence (β = 0.231, p = 0.006), and had moderate to severe depressive symptoms (β = 0.223, p = < 0.001). However, monthly income above NPR 20,000 (USD 150) (β= -0.153, p = 0.008), disclosure of their sexual orientation to anyone (β= -0.159, p = < 0.007), and worry about being negatively judged by health care workers (β= -0.136, p = 0.023) were less willing to use mHealth strategies. The findings from this study suggest that there is a high willingness for utilizing mHealth interventions for HIV prevention in MSM population who are at higher risk of HIV acquisition.

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.

Preferences for mHealth Intervention to Address Mental Health Challenges Among Men Who Have Sex With Men in Nepal: Qualitative Study

BACKGROUND

Men who have sex with men (MSM) are disproportionately burdened by poor mental health. Despite the increasing burden, evidence-based interventions for MSM are largely nonexistent in Nepal.

OBJECTIVE

This study explored mental health concerns, contributing factors, barriers to mental health care and support, and preferred interventions to improve access to and use of mental health support services among MSM in Nepal.

METHODS

We conducted focus groups with MSM in Kathmandu, Nepal, in January 2023. In total, 28 participants took part in 5 focus group sessions. Participants discussed several topics related to the mental health issues they experienced, factors contributing to these issues, and their suggestions for potential interventions to address existing barriers. The discussions were recorded, transcribed, and analyzed using Dedoose (version 9.0.54; SocioCultural Research Consultants, LLC) software for thematic analysis.

RESULTS

Participants reported substantial mental health problems, including anxiety, depression, suicidal ideation, and behaviors. Contributing factors included family rejection, isolation, bullying, stigma, discrimination, and fear of HIV and other sexually transmitted infections. Barriers to accessing services included cost, lack of lesbian, gay, bisexual, transgender, intersex, queer, and asexual (LGBTIQA+)-friendly providers, and the stigma associated with mental health and sexuality. Participants suggested a smartphone app with features such as a mental health screening tool, digital consultation, helpline number, directory of LGBTIQA+-friendly providers, mental health resources, and a discussion forum for peer support as potential solutions. Participants emphasized the importance of privacy and confidentiality to ensure mobile apps are safe and accessible.

CONCLUSIONS

The findings of this study have potential transferability to other low-resource settings facing similar challenges. Intervention developers can use these findings to design tailored mobile apps to facilitate mental health care delivery and support for MSM and other marginalized groups.

Paradata: Measuring Engagement in Digital HIV Interventions for Sexual and Gender Minorities

PURPOSE OF REVIEW

The goal of this review was to examine online engagement using paradata (i.e., intervention usage metrics) as part of the reporting of online behavioral HIV prevention and care interventions' findings. We underscore the importance of these data in examining intervention engagement and effectiveness.

RECENT FINDINGS

We focused on studies indexed in PubMed and published between April 1, 2017, and June 30, 2023, that reported the development and testing of online behavioral interventions for HIV prevention and/or care. Of the 689 extracted citations, 19 met the study criteria and provided engagement data - only six studies tested the association between engagement and intervention outcomes. Of these, four studies found a positive association between participants' engagement and improvements in HIV-related outcomes. Increasing attention is being paid to the collection and reporting of paradata within HIV online behavioral interventions. While the current evidence suggests a dose-response relationship due to user engagement on HIV outcomes, greater efforts to systematically collect, report, and analyze paradata are warranted.

Optimizing usability of a mobile health intervention for Spanish-speaking Latinx people with HIV through user-centered design: a post-implementation study

Objective

Latinx people comprise 30% of all new human immunodeficiency virus (HIV) infections in the United States and face many challenges to accessing and engaging with HIV care. To bridge these gaps in care, a Spanish-language mobile health (mHealth) intervention known as ConexionesPositivas (CP) was adapted from an established English-language platform called PositiveLinks (PL) to help improve engagement in care and reduce viral nonsuppression among its users. We aimed to determine how CP can address the challenges that Latinx people with HIV (PWH) in the United States face.

Materials and methods

We conducted a post-implementation study of the CP mHealth platform, guided by principles of user-centered design. We enrolled 20 Spanish-speaking CP users in the study, who completed the previously validated System Usability Scale (SUS) and semistructured interviews. Interviews were transcribed and translated for analysis. We performed thematic coding of interview transcripts in Dedoose.

Results

The SUS composite score was 75, which is within the range of good usability. Four categories of themes were identified in the interviews: client context, strengths of CP, barriers to use and dislikes, and suggestions to improve CP. Positive impacts included encouraging self-monitoring of medication adherence, mood and stress, connection to professional care, and development of a support system for PWH.

Discussion

While CP is an effective and easy-to-use application, participants expressed a desire for improved personalization and interactivity, which will guide further iteration.

Conclusion

This study highlights the importance of tailoring mHealth interventions to improve equity of access, especially for populations with limited English proficiency.

An mHealth-Delivered Sexual Harm Reduction Tool (PartyPack) for Men Who Have Sex With Men in Malaysia: Usability Study

BACKGROUND

Chemsex-the use of psychoactive drugs to enhance the sexual experience-is an increasing phenomenon globally. Despite the increasing burden and associated harms of chemsex, evidence-based interventions (ie, behavioral and pharmacological) for chemsex users are nonexistent.

OBJECTIVE

In this study, we assessed the usability and acceptability of a mobile health (mHealth)-delivered safer chemsex package ("PartyPack") as a sexual harm reduction strategy among men who have sex with men in Malaysia-a setting where chemsex is becoming increasingly prevalent.

METHODS

This study is part of a larger smartphone app-based intervention (ie, JomPrEP; University of Connecticut) designed to improve access to HIV prevention services among Malaysian men who have sex with men. A total of 50 participants were recruited from the Greater Kuala Lumpur region of Malaysia to use the JomPrEP app, which included a feature allowing participants to order PartyPack, for 30 days (March-April 2022). The usability and acceptability of the PartyPack were assessed using self-report, app analytics, and exit interviews (n=20).

RESULTS

Overall, 8% (4/50) of participants reported having engaged in chemsex in the past 6 months; however, engagement in condomless sex (34/50, 68%) and group sex (9/50, 18%) was much higher. A total of 43 (86%) participants ordered PartyPack, of which 27 (63%) made multiple orders during the 30 days. Most participants (41/43, 95%) reported being satisfied with the PartyPack order feature in the app, with 91% (39/43) indicating the order and tracking process was easy. Thematic data exploration further revealed important information for understanding (eg, items included in the package, use of mHealth platform to order package, and discreetness of the PartyPack box and order and delivery) and refining the logistical preferences (eg, using branded items and allowing customization during order).

CONCLUSIONS

Our findings provide strong evidence of the usability and acceptability of a mHealth-delivered safer chemsex package as a potential sexual harm reduction tool among this underserved population. Replication in a study with a larger sample size to test the efficacy of the PartyPack is warranted.