Development of a Tailored HIV Prevention Intervention for Single Young Men Who Have Sex With Men Who Meet Partners Online: Protocol for the myDEx Project

Tailoring a Skills-Based Serostatus Disclosure Intervention for Transgender Women in South Africa: Protocol for a Usability and Feasibility Study

BACKGROUND

Transgender women have few interventions to support their HIV prevention and treatment outcomes in South Africa. Further, increased focus should be on intervention development that will reduce HIV transmission within HIV-discordant partnerships, especially for transgender women who navigate gender, sexuality, and relationship stigma. The Speaking Out and Allying Relationships (SOAR) intervention has been developed for sexual minority men to address these outcomes in South Africa. It is a behavioral intervention that is delivered in groups via videoconference to develop coping skills to manage HIV-related stress, assist with disclosure to partners, and establish and maintain safer sex practices with partners. Tailoring SOAR may be feasible for transgender women to support their HIV care while reducing transmission within their relationships.

OBJECTIVE

This study aims to (1) adapt SOAR for transgender women and test its usability, then (2) assess its feasibility.

METHODS

To achieve aim 1, we will use a human-centered design approach to tailor the existing SOAR intervention for transgender women. Interviews and a survey will be administered to transgender women (N=15) to assess intervention preferences. Findings will be used to tailor content like roleplays, scenarios, and media to align with transgender women's lived experiences navigating HIV and relationships. Afterward, we will conduct a usability test with 7 (47%) of the 15 participants to determine intervention understanding and satisfaction. Participants will be transgender women living with HIV and in a relationship with a man who has unknown HIV status or is HIV-negative. All participants will be recruited using community-based approaches. In aim 2, we will examine SOAR feasibility using a 1-arm pilot study. Transgender women (N=20) will be recruited using aim 1 methods and eligibility criteria, with participants completing feasibility surveys and interviews, as well as behavioral and biomedical assessments.

RESULTS

Intervention adaptation began in May 2023 with interviews. Feasibility pilot testing was conducted with 14 transgender women, with study completion in January 2025.

CONCLUSIONS

Transgender women need more intervention options that engage their relationships since these can present barriers to HIV treatment outcomes like hindering viral suppression in South Africa. Delivering an existing yet tailored intervention via videoconference expands its reach to transgender women and allows them to engage with others and learn new skills in a secure setting like their homes. SOAR has the potential to improve relationship dynamics and reduce violence, which will in turn enhance HIV treatment and prevention engagement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52121.

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.

A Latent Profile Analysis of Online Dating Patterns Among Single Young Men Who Have Sex with Men

Despite the increased use of geosocial networking applications for finding sexual partners among young men who have sex with men (YMSM), few studies have examined the intricate patterns of online dating behaviors. In order to advance understanding of online dating patterns among YMSM, various factors, including how frequently and how much time is spent within partner-seeking sites, need to be examined concurrently. Therefore, we used latent profile analysis to identify online dating patterns and logistic regressions to examine their associations with sexual behaviors and relationship characteristics among single YMSM (N = 180; ages 18-24). We found three online dating patterns: discouraged users (N = 93, 52%), date seekers (N = 67, 37%), and instant lovers (N = 20, 11%). Discouraged users were less likely to seek sexual sensational activities, while date seekers were more likely to seek sexual sensational activities. Moreover, instant lovers were less likely to pursue committed romantic relationships, while they reported a higher number of condomless anal intercourse. Given that online dating patterns are not homogeneous, HIV prevention interventions may benefit from tailored approaches based on YMSM's different online dating profiles.

E-health interventions targeting STIs, sexual risk, substance use and mental health among men who have sex with men: four systematic reviews

Background

Human immunodeficiency virus/sexually transmitted infections, sexual risk, substance (alcohol and other legal and illegal drugs) use and mental ill health constitute a ‘syndemic’ of mutually reinforcing epidemics among men who have sex with men. Electronic health (e-health) interventions addressing these epidemics among men who have sex with men might have multiplicative effects. To our knowledge, no systematic review has examined the effectiveness of such interventions on these epidemics among men who have sex with men.

Objective

The objective was to synthesise evidence addressing the following: (1) What approaches and theories of change do existing e-health interventions employ to prevent human immunodeficiency virus/sexually transmitted infections, sexual risk, alcohol/drug use or mental ill health among men who have sex with men? (2) What factors influence implementation? (3) What are the effects of such interventions on the aforementioned epidemics? (4) Are such interventions cost-effective?

Data sources

A total of 24 information sources were searched initially (October–November 2018) [the following sources were searched: ProQuest Applied Social Sciences Index and Abstracts; Campbell Library; EBSCO Cumulative Index to Nursing and Allied Health Literature Plus, Wiley Online Library The Cochrane Library; Centre for Reviews and Dissemination databases (the Database of Abstracts of Reviews of Effects and the NHS Economic Evaluation Database); the Health Technology Assessment database; Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) database of health promotion research (Bibliomap); ProQuest Dissertations & Theses Global; OvidSP EconLit; OvidSP EMBASE; OvidSP Global Health; OvidSP Health Management Information Consortium; ProQuest International Bibliography of the Social Sciences; Ovid MEDLINE ALL; OvidSP PsycINFO; Web of Science Science Citation Index Expanded; Elsevier Scopus; OvidSP Social Policy & Practice; Web of Science Social Sciences Citation Index Expanded; ProQuest Sociological Abstracts; ClinicalTrials.gov; World Health Organization International Clinical Trials Registry Platform; EPPI-Centre Trials Register of Promoting Health Interventions; and the OpenGrey database], and an updated search of 19 of these was conducted in April 2020. Reference lists of included reports were searched and experts were contacted.

Review methods

Eligible reports presented theories of change and/or process, outcome and/or economic evaluations of e-health interventions offering ongoing support to men who have sex with men to prevent human immunodeficiency virus/sexually transmitted infections, sexual risk behaviour, alcohol/drug use and/or common mental illnesses. References were screened by title/abstract, then by full text. Data extraction and quality assessments used existing tools. Theory and process reports were synthesised using qualitative methods. Outcome and economic data were synthesised narratively; outcome data were meta-analysed.

Results

Original searches retrieved 27 eligible reports. Updated searches retrieved 10 eligible reports. Thirty-seven reports on 28 studies of 23 interventions were included: 33 on theories of change, 12 on process evaluations, 16 on outcome evaluations and one on an economic evaluation. Research question 1: five intervention types were identified – ‘online modular’, ‘computer games’ and ‘non-interactive’ time-limited/modular interventions, and open-ended interventions with ‘content organised by assessment’ and ‘general content’. Three broad types of intervention theories of change were identified, focusing on ‘cognitive/skills’, ‘self-monitoring’ and ‘cognitive therapy’. Research question 2: individual tailoring based on participant characteristics was particularly acceptable, and participants valued intervention content reflecting their experiences. Research question 3: little evidence was available of effects on human immunodeficiency virus or sexually transmitted infections. The analysis did not suggest that interventions were effective in reducing instances of human immunodeficiency virus or sexually transmitted infections. The overall meta-analysis for sexually transmitted infections reported a small non-significant increase in sexually transmitted infections in the intervention group, compared with the control group. Meta-analyses found a significant impact on sexual risk behaviour. The findings for drug use could not be meta-analysed because of study heterogeneity. Studies addressing this outcome did not present consistent evidence of effectiveness. Trials did not report effects on alcohol use or mental health. Research question 4: evidence on cost-effectiveness was limited.

Limitations

The quality of the eligible reports was variable and the economic synthesis was limited to one eligible study.

Conclusions

There is commonality in intervention theories of change and factors affecting receipt of e-health interventions. Evidence on effectiveness is limited.

Future work

Future trials should assess the impact of interventions on multiple syndemic factors, among them sexual risk, substance use and mental health; incorporate sufficient follow-up and sample sizes to detect the impact on human immunodeficiency virus/sexually transmitted infections; and incorporate rigorous process and economic evaluations.

Study registration

This study is registered as PROSPERO CRD42018110317.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

A skills-based sero-status HIV disclosure intervention for sexual minority men in South Africa: A protocol for intervention adaptation and pilot randomized controlled trial (Preprint)

Background

Gay, bisexual, and other men who have sex with men (GBMSM) living with HIV have low antiretroviral treatment adherence in South Africa due to limited skills in managing disclosure and prevention behaviors with sexual and romantic partners. As a result, there is a high HIV transmission risk within HIV-discordant partnerships, but an existing intervention may address these outcomes, if adapted effectively. Healthy Relationships (HR) is a behavioral intervention that was originally delivered in groups and in person over 5 sessions to develop coping skills for managing HIV-related stress and sexually risky situations, enhance decision-making skills for HIV disclosure to partners, and establish and maintain safer sex practices with partners. HR effectively improves prevention behaviors but has yet to be tailored to a non-US context.

Objective

We aim to adapt HR into a new culturally grounded intervention entitled Speaking Out & Allying Relationships for GBMSM and then assess its feasibility in Eastern Cape, South Africa.

Methods

The study will have 2 aims. For aim 1—adaptation—we will use a human-centered design approach. Initial intervention tailoring will involve integrating Undetectable=Untransmittable and pre-exposure prophylaxis education, developing intervention content for a videoconference format, and designing role-plays and movies for skill building based on preliminary data. Afterward, interviews and surveys will be administered to GBMSM to assess intervention preferences, and a focus group will be conducted with health care providers and information technology experts to assess the intervention’s design. Finally, a usability test will be performed to determine functionality and content understanding. Participants will be GBMSM living with HIV (n=15) who are in a relationship and health care providers and information technology (n=7) experts working in HIV care and programming with this population. For aim 2, we will examine the feasibility of the adapted intervention by using a pilot randomized control design. There will be 60 individuals per arm. Feasibility surveys and interviews will be conducted with the intervention arm, and behavioral and biomedical assessments for relationship and treatment adherence outcomes will be collected for both arms. All participants will be GBMSM living with HIV who are in a relationship with an HIV-negative or unknown status partner.

Results

Intervention adaptation began in August 2021. Initial tailoring and the refining of GBMSM intervention preferences were completed in December 2021. Usability and feasibility assessments are due to be completed by March 2022 and February 2024, respectively.

Conclusions

GBMSM need efficacious interventions that tackle partnership dynamics, HIV prevention, and treatment outcomes for antiretroviral treatment adherence and viral suppression in South Africa. Harnessing everyday technology use for social networking (eg, videoconferences), Undetectable=Untransmittable education, and pre-exposure prophylaxis to update an existing intervention for South African GBMSM has the potential to strengthen relationship communication about HIV treatment and prevention and, in turn, improve outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36845

Correlates of engagement within an online HIV prevention intervention for single young men who have sex with men: The myDEx project (Preprint)

Background

Objective

Methods

Results

Conclusions

Trial Registration

eHealth Interventions to Address Sexual Health, Substance Use, and Mental Health Among Men Who Have Sex With Men: Systematic Review and Synthesis of Process Evaluations

Background

Men who have sex with men (MSM) face disproportionate risks concerning HIV and other sexually transmitted infections, substance use, and mental health. These outcomes constitute an interacting syndemic among MSM; interventions addressing all 3 together could have multiplicative effects. eHealth interventions can be accessed privately, and evidence from general populations suggests these can effectively address all 3 health outcomes. However, it is unclear how useable, accessible, or acceptable eHealth interventions are for MSM and what factors affect this.

Objective

We undertook a systematic review of eHealth interventions addressing sexual risk, substance use, and common mental illnesses among MSM and synthesized evidence from process evaluations.

Methods

We searched 19 databases, 3 trials registers, OpenGrey, and Google, and supplemented this by reference checks and requests to experts. Eligible reports were those that discussed eHealth interventions offering ongoing support to MSM aiming to prevent sexual risk, substance use, anxiety or depression; and assessed how intervention delivery or receipt varied with characteristics of interventions, providers, participants, or context. Reviewers screened citations on titles, abstracts, and then full text. Reviewers assessed quality of eligible studies, and extracted data on intervention, study characteristics, and process evaluation findings. The analysis used thematic synthesis.

Results

A total of 12 reports, addressing 10 studies of 8 interventions, were eligible for process synthesis. Most addressed sexual risk alone or with other outcomes. Studies were assessed as medium and high reliability (reflecting the trustworthiness of overall findings) but tended to lack depth and breadth in terms of the process issues explored. Intervention acceptability was enhanced by ease of use; privacy protection; use of diverse media; opportunities for self-reflection and to gain knowledge and skills; and content that was clear, interactive, tailored, reflective of MSM’s experiences, and affirming of sexual-minority identity. Technical issues and interventions that were too long detracted from acceptability. Some evidence suggested that acceptability varied by race or ethnicity and educational level; findings on variation by socioeconomic status were mixed. No studies explored how intervention delivery or receipt varied by provider characteristics.

Conclusions

Findings suggest that eHealth interventions targeting sexual risk, substance use, and mental health are acceptable for MSM across sociodemographic groups. We identified the factors shaping MSM’s receipt of such interventions, highlighting the importance of tailored content reflecting MSM’s experiences and of language affirming sexual-minority identities. Intervention developers can draw on these findings to increase the usability and acceptability of integrated eHealth interventions to address the syndemic of sexual risk, substance use, and mental ill health among MSM. Evaluators of these interventions can draw on our findings to plan evaluations that explore the factors shaping usability and acceptability.

Theories of change for e-health interventions targeting HIV/STIs and sexual risk, substance use and mental ill health amongst men who have sex with men: systematic review and synthesis

BACKGROUND

Sexual risk, substance use, and mental ill health constitute a syndemic of co-occurring, mutually reinforcing epidemics amongst men who have sex with men (MSM). Developed since 1995, e-health interventions offer accessible, anonymous support and can be effective in addressing these outcomes, suggesting the potential value of developing e-health interventions that address these simultaneously amongst MSM. We conducted a systematic review of e-health interventions addressing one or more of these outcomes amongst MSM and in this paper describe the theories of change underpinning relevant interventions, what these offer and how they might complement each other.

METHODS

We identified eligible reports via expert requests, reference-checking and database and Google searches. Results were screened for reports published in 1995 or later; focused on MSM; reporting on e-health interventions providing ongoing support to prevent HIV/STIs, sexual risk behaviour, substance use, anxiety or depression; and describing intervention theories of change. Reviewers assessed report quality, extracted intervention and theory of change data, and developed a novel method of synthesis using diagrammatic representations of theories of change.

RESULTS

Thirty-three reports on 22 intervention theories of change were included, largely of low/medium-quality. Inductively grouping these theories according to their core constructs, we identified three distinct groupings of theorised pathways. In the largest, the 'cognitive/skills' grouping, interventions provide information and activities which are theorised to influence behaviour via motivation/intention and self-efficacy/perceived control. In the 'self-monitoring' grouping, interventions are theorised to trigger reflection, self-reward/critique and self-regulation. In the 'cognitive therapy' grouping, the theory of change is rooted in cognitive therapy techniques, aiming to reframe negative emotions to improve mental health.

CONCLUSIONS

The synthesised theories of change provide a framework for developing e-health interventions that might holistically address syndemic health problems amongst MSM. Improving reporting on theories of change in primary studies of e-health interventions would enable a better understanding of how they are intended to work and the evidence supporting this. The novel diagrammatic method of theory of change synthesis used here could be used for future reviews where interventions are driven by existing well-defined behaviour and behaviour change theories.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018110317.

Parents ASSIST (Advancing Supportive and Sexuality-Inclusive Sex Talks): Iterative Development of a Sex Communication Video Series for Parents of Gay, Bisexual, and Queer Male Adolescents

Effective parent-child sex communication enhances heterosexual youths' efficacy to engage in health promotive behaviors, yet there is scarce research on parent-child sex communication with gay, bisexual, and queer (GBQ) sons during adolescence. Our aim is to describe the development of Parents ASSIST, a web-based series of animated videos for parents of GBQ adolescent males focused on (a) parental education about sexual health topics pertinent to this population's same-sex concerns, (b) modeling of communication skills for parents to broach and sustain inclusive discussions at home, and (c) norming the role of providers as reliable sources of support when parents seek GBQ-related health information. Community-based advisory boards, comprised of parents and health care providers, respectively, informed the intervention development. Based on study notes and the research team's reflections, we present lessons learned that focus on content-based and logistical challenges that arose during the intervention development process. This study extends practice and patient education by providing an innovative, primary intervention that partners with parents of an underserved youth population.

Rectal Douching and Microbicide Acceptability among Young Men who Have Sex with Men

Men who have sex with men (MSM) commonly report engaging in rectal douching (RD) practices prior to receptive anal intercourse. Researchers are interested in the possibility of designing a RD with a microbicide component. In our analyses, we examined whether YMSM who engaged in RD behaviors differ in HIV prevention behaviors from their non-RD peers. We then examined whether RD frequency was associated with rectal microbicide acceptability. Half the participants (47.8%) reported having ever douched. Participants were more likely to douche if they were racial/ethnic minorities (AOR = 2.24, p = 0.02) and had recently tested for HIV (AOR = 1.96, p = 0.04). Greater douching frequency was associated with racial/ethnic minorities (β = 0.20, p = 0.009) and recent HIV testing (β = 0.19, p < 0.01). Participants who reported frequently douching indicated greater microbicide acceptability (β = 0.32, p < 0.001). Designing behaviorally congruent products remains a priority in next generation Pre-Exposure Prophylaxis (PrEP) and a rectal douche might be an additional tool if found to be efficacious.

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.

Engagement in mHealth behavioral interventions for HIV prevention and care: making sense of the metrics

BACKGROUND

Engagement is the primary metric by which researchers can assess whether participants in a mHealth intervention used and interacted with the intervention's content as intended over a pre-specified period to result in behavior change. Paradata, defined as the process data documenting users' access, participation, and navigation through a mHealth intervention, have been associated with differential treatment outcomes in mHealth interventions. Within behavioral mHealth interventions, there has been an increase in the number of studies addressing the HIV prevention and care continuum in recent years, yet few have presented engagement metrics or examined how these data could inform design modifications, promote continued engagement, and supplement primary intervention efficacy and scale-up efforts.

METHODS

We review common paradata metrics in mHealth interventions (e.g., amount, frequency, duration and depth of use), using case studies from four technology-driven HIV interventions to illustrate their utility in evaluating mHealth behavioral interventions for HIV prevention and care. Across the four case studies, participants' ages ranged between 15 and 30 years and included a racially and ethnically diverse sample of youth. The four case studies had different approaches for engaging young men who have sex with men: a tailored brief intervention, an interactive modular program, a daily tool to monitor and self-regulate treatment adherence, and an online platform promoting social engagement and social support. Each focused on key outcomes across the HIV prevention and care continuum [e.g., safer sex behaviors, HIV testing, antiretroviral therapy (ART) adherence] and collected paradata metrics systematically.

RESULTS

Across the four interventions, paradata was utilized to identify patterns of use, create user profiles, and determine a minimum engagement threshold for future randomized trials based on initial pilot trial data. Evidence of treatment differences based on paradata analyses were also observed in between-arm and within-arm analyses, indicating that intervention exposure and dosage might influence the strength of the observed intervention effects. Paradata reflecting participants' engagement with intervention content was used to suggest modifications to intervention design and navigation, to understand what theoretically-driven content participants chose to engage with in an intervention, and to illustrate how engagement was linked to HIV-related outcomes.

CONCLUSIONS

Paradata monitoring and reporting can enhance the rigor of mHealth trials. Metrics of engagement must be systematically collected, analyzed and interpreted to meaningfully understand a mHealth intervention's efficacy. Future mHealth trials should work to identify suitable engagement metrics during intervention development, ensure their collection throughout the trial, and evaluate their impact on trial outcomes.

Electronic and other new media technology interventions for HIV care and prevention: a systematic review

INTRODUCTION

Electronic and other new media technologies (eHealth) can facilitate large-scale dissemination of information and effective delivery of interventions for HIV care and prevention. There is a need to both monitor a rapidly changing pipeline of technology-based care and prevention methods and to assess whether the interventions are appropriately diversified. We systematically review and critically appraise the research pipeline of eHealth interventions for HIV care and prevention, including published studies and other funded projects.

METHODS

Two peer-reviewed literature databases were searched for studies describing the development, trial testing or implementation of new technology interventions, published from September 2014 to September 2018. The National Institutes of Health database of grants was searched for interventions still in development. Interventions were included if eHealth was utilized and an outcome directly related to HIV treatment or prevention was targeted. We summarized each intervention including the stage of development, eHealth mode of delivery, target population and stage of the HIV care and prevention continua targeted.

RESULTS AND DISCUSSION

Of 2178 articles in the published literature, 113 were included with 84 unique interventions described. The interventions utilize a variety of eHealth technologies and target various points on the prevention and care continua, with greater emphasis on education, behaviour change and testing than linkage to medical care. There were a variety of interventions for HIV care support but none for PrEP care. Most interventions were developed for populations in high income countries. An additional 62 interventions with funding were found in the development pipeline, with greater emphasis on managing HIV and PrEP care.

CONCLUSIONS

Our systematic review found a robust collection of eHealth interventions in the published literature as well as unpublished interventions still in development. In the published literature, there is an imbalance of interventions favouring education and behaviour change over linkage to care, retention in care, and adherence, especially for PrEP. The next generation of interventions already in the pipeline might address these neglected areas of care and prevention, but the development process is slow. Researchers need new methods for more efficient and expedited intervention development so that current and future needs are addressed.

Seeing Is Believing? Unique Capabilities of Internet-Only Studies as a Tool for Implementation Research on HIV Prevention for Men Who Have Sex With Men: A Review of Studies and Methodological Considerations

BACKGROUND

In 2014, Grov et al published a comprehensive review cataloguing both men who have sex with men's (MSM's) sexual behavior transitions in online environments from the 1990s through 2013, as well as researchers' efforts in tandem to use the internet to engage MSM into research, treatment, and prevention.

METHODS

In this article, we discuss historical events and research having occurred in the half decade since the Grov et al publication.

RESULTS

Notable transitions include MSM's expanded use of geosocial networking apps, as well as other forms of social media accessed primarily through mobile devices, as well as the addition of biomedical prevention strategies (eg, pre-exposure prophylaxis and undetectable = untransmittable) to the proverbial HIV prevention toolkit. In tandem, researchers have rapidly expanded their employment of internet-mediated methods for the recruitment and engagement of key populations for HIV research, treatment, and prevention. In this article, we discuss methodological considerations for using the internet to conduct HIV prevention research with MSM: (1) sources of recruitment (eg, geosocial apps, Facebook, crowdsourced online panels); (2) design (eg, cross sectional, longitudinal, diaries); (3) incentives (including disincentivizing fraudulent participants and/or spam bots); (4) confidentiality; and (5) representativeness.

CONCLUSION

We conclude by discussing future directions in HIV prevention research in light of forthcoming technologies such as fifth generation (5G) mobile networks, combined use of self-collected biological data alongside self-report, and the utility of metadata and metaresearch to document, evaluate, and inform best practices.

Acceptability and Preliminary Efficacy of an Online HIV Prevention Intervention for Single Young Men Who Have Sex with Men Seeking Partners Online: The myDEx Project

Prevention of new cases of HIV among young gay, bisexual and other men who have sex with men (YGBMSM; ages 18-24) remains a priority. We developed and pilot tested an online intervention (myDEx) using a pilot randomized trial design with 180 online-recruited single YGBMSM who reported recent unprotected anal intercourse, self-reporting as HIV negative or status-unaware, and who met sexual partners through online dating applications. myDEx participants reported higher overall satisfaction (d = 0.46) and willingness to recommend the intervention to friends (d = 0.48) than controls. myDEx participants were less likely to report foregoing condoms to achieve an emotional connection with a partner (d =0 .43), and more likely to report greater emotional regulation during their partner-seeking behaviors (d = 0.44). myDEx participants reported fewer partners with whom they had condomless receptive anal sex (d = 0.48). Our pilot results demonstrate the potential of the myDEx intervention, suggesting that a larger efficacy trial may be warranted in the future.

Young men who have sex with men's awareness, acceptability, and willingness to participate in HIV vaccine trials: Results from a nationwide online pilot study

BACKGROUND

New cases of human immunodeficiency virus (HIV) among young men who have sex with men (YMSM) underscore the need to examine their willingness to use biomedical prevention methods, including an acceptable and efficacious HIV vaccine. We examined whether YMSM's vaccine altruism and vaccine-related socials concerns factors were associated with HIV vaccine acceptability across two vaccine efficacy scenarios, and their awareness and willingness to participate in HIV vaccine research.

METHODS

This secondary analysis uses data from a mHealth trial with YMSM at heightened HIV risk (N = 137; 50% racial/ethnic minority; M = 21.7 years). Most YMSM (91.2%) had tested for HIV, and 17.5% (N = 24) reported a prior STI.We used paired-samples t-test to compare differences in efficacy acceptability (50% vs 85%), followed by multivariable regressions examining whether vaccine attitudes (altruism and social concerns) were associated with vaccine acceptability and awareness and willingness to participate in HIV vaccine trials. We controlled for age, education, race/ethnicity, prior HIV testing, and STI diagnosis in our analyses.

RESULTS

Acceptability for the HIV vaccine with 85% efficacy (M = 8.86; SD = 1.76) was greater than acceptability in the 50% efficacy scenario (M = 7.60; SD = 2.58). Altruistic attitudes were associated with greater vaccine acceptability at 50% (β = 0.62) and 85% (β = 0.59) efficacy. Higher educational attainment was negatively associated with a vaccine with 50% efficacy (β = -0.20, but not for 85% efficacy. Greater vaccine-related social concerns were negatively associated with HIV vaccine research awareness (AOR = 0.38 (95% CI: 0.22, 0.67). Willingness to participate in a HIV vaccine trial was positively associated with age (β = 0.18) and altruism (β = 0.60), and negatively associated with education (β = -0.21).

CONCLUSIONS

YMSM find HIV vaccines as an acceptable prevention modality and are willing to participate in HIV vaccine trials. Findings highlight the need to consider YMSM's altruistic and social concerns attitudes in HIV vaccine research and explore how to leverage these attitudes in research campaigns. ClinicalTrials.gov Identifier: NCT02842060.

Cognitive and Emotional Factors Associated with Sexual Risk-Taking Behaviors Among Young Men Who Have Sex with Men

Young men who have sex with men (YMSM) between the ages of 13 and 24 account for a disproportionate number of new HIV infections in the U.S. Recognizing the unique developmental circumstances that YMSM face and building on the dual-process model, it is important to consider the role of cognitive and emotional factors as well as self-efficacy to negotiate safer sex when understanding experiences of sexual risk-taking among YMSM. This article used structural equation modeling to examine how the decisional balance to use condoms (a cognitive factor) and limerence (an emotional factor) are both directly and indirectly associated with sexual risk-taking behaviors (the number of insertive and receptive condomless anal intercourse partners), with indirect effects occurring via limited self-efficacy to negotiate safer sex. Data were from a cross-sectional online survey of YMSM (aged 18-24) in the U.S. who did not report being in a romantic relationship. Analysis included a sample of 1084 single YMSM who had never tested positive for HIV and who had engaged in anal intercourse in the previous 2 months. Results indicated that the decisional balance to use condoms was both directly and indirectly associated with reduced sexual risk-taking behaviors. Limerence was not directly associated with sexual risk-taking behaviors; however, it was indirectly associated with sexual risk-taking behavior through limited self-efficacy to negotiate safer sex. These findings highlight the importance of considering both cognitive and emotional factors, as well as self-efficacy to use condoms, in the development and implementation of HIV prevention interventions for YMSM.

Preferences for an HIV prevention mobile phone app: a qualitative study among men who have sex with men in China

BACKGROUND

Men who have sex with men (MSM) have a disproportionate burden of HIV infection. Mobile phone apps provide a promising means of improving HIV prevention among MSM. But this has received little examination in China. The objective of this study was to explore MSM's preferences for an HIV prevention mobile phone app.

METHODS

Qualitative semi-structured personal interviews were conducted with 19 MSM to determine their preferences for features and content to inform the design of an app aimed at HIV prevention in China.

RESULTS

Five categories were identified under the main category preferences for features of the app: target population, attributes, language used, potential user access, and perceived usefulness. Five categories were identified under the main category preferences for content of the app: functions to facilitate HIV testing behavior, HIV post-exposure prevention, warning against substance use, psychological support, and areas for communication.

CONCLUSIONS

Findings suggest that the design of an app targeting MSM in China should use an integrated framework addressing behavioral and psychological aspects, satisfy common needs of potential users, avoid perpetuating negative stereotypes and stigma, and avoid possible increase of risk behavior due to using the app.

Insights in Public Health: In What Ways are Hawaii's HIV Prevention Services Engaging Gay Male Couples and Using Technology?

Partner-oriented services and Health Information and Communication technology (HICT) in the forms of mHealth (eg, smartphone applications), eHealth (eg, interactive websites), telemedicine, and social media play an important and growing role in HIV prevention. Accordingly, the present study sought to describe: (1) the primary and secondary HIV prevention services available in Hawai'i, (2) the prevention services that are available for gay male couples and partners, and (3) the prevention services that use HICT. Information about prevention services and use of HICT were obtained from websites and phone calls made to 19 organizations in the state, including the Hawai'i Department of Health. Overall, partner-oriented services were limited and only 1 couples-based service was currently being offered. Technology, namely social media, was used by 14 organizations, primarily to increase HIV awareness and advertise events. These findings may inform how best to adapt and better leverage the use of innovative technological tools to help expand access to HIV testing and counseling, sexual health education, and case management services for gay male couples and other MSM populations in the state.