The Feasibility and Acceptability of Using Technology-Based Daily Diaries with HIV-Infected Young Men Who have Sex with Men: A Comparison of Internet and Voice Modalities

Burden and Inattentive Responding in a 12-Month Intensive Longitudinal Study: Interview Study Among Young Adults

BACKGROUND

Intensive longitudinal data (ILD) collection methods have gained popularity in social and behavioral research as a tool to better understand behavior and experiences over time with reduced recall bias. Engaging participants in these studies over multiple months and ensuring high data quality are crucial but challenging due to the potential burden of repeated measurements. It is suspected that participants may engage in inattentive responding (IR) behavior to combat burden, but the processes underlying this behavior are unclear as previous studies have focused on the barriers to compliance rather than the barriers to providing high-quality data.

OBJECTIVE

This study aims to broaden researchers' knowledge about IR during ILD studies using qualitative analysis and uncover the underlying IR processes to aid future hypothesis generation.

METHODS

We explored the process of IR by conducting semistructured qualitative exit interviews with 31 young adult participants (aged 18-29 years) who completed a 12-month ILD health behavior study with daily evening smartphone-based ecological momentary assessment (EMA) surveys and 4-day waves of hourly EMA surveys. The interviews assessed participants' motivations, the impact of time-varying contexts, changes in motivation and response patterns over time, and perceptions of attention check questions (ACQs) to understand participants' response patterns and potential factors leading to IR.

RESULTS

Thematic analysis revealed 5 overarching themes on factors that influence participant engagement: (1) friends and family also had to tolerate the frequent surveys, (2) participants tried to respond to surveys quickly, (3) the repetitive nature of surveys led to neutral responses, (4) ACQs within the surveys helped to combat overly consistent response patterns, and (5) different motivations for answering the surveys may have led to different levels of data quality.

CONCLUSIONS

This study aimed to examine participants' perceptions of the quality of data provided in an ILD study to contribute to the field's understanding of engagement. These findings provide insights into the complex process of IR and participant engagement in ILD studies with EMA. The study identified 5 factors influencing IR that could guide future research to improve EMA survey design. The identified themes offer practical implications for researchers and study designers, including the importance of considering social context, the consideration of dynamic motivations, and the potential benefit of including ACQs as a technique to reduce IR and leveraging the intrinsic motivators of participants. By incorporating these insights, researchers might maximize the scientific value of their multimonth ILD studies through better data collection protocols.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/36666.

A Trauma-Informed, Geospatially Aware, Just-in-Time Adaptive mHealth Intervention to Support Effective Coping Skills Among People Living With HIV in New Orleans: Development and Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

In 2020, Greater New Orleans, Louisiana, was home to 7048 people living with HIV-1083 per 100,000 residents, 2.85 times the US national rate. With Louisiana routinely ranked last in indexes of health equity, violent crime rates in Orleans Parish quintupling national averages, and in-care New Orleans people living with HIV surviving twice the US average of adverse childhood experiences, accessible, trauma-focused, evidence-based interventions (EBIs) for violence-affected people living with HIV are urgently needed.

OBJECTIVE

To meet this need, we adapted Living in the Face of Trauma, a well-established EBI tailored for people living with HIV, into NOLA GEM, a just-in-time adaptive mobile health (mHealth) intervention. This study aimed to culturally tailor and refine the NOLA GEM app and assess its acceptability; feasibility; and preliminary efficacy on care engagement, medication adherence, viral suppression, and mental well-being among in-care people living with HIV in Greater New Orleans.

METHODS

The development of NOLA GEM entailed identifying real-time tailoring variables via a geographic ecological momentary assessment (GEMA) study (n=49; aim 1) and place-based and user-centered tailoring, responsive to the unique cultural contexts of HIV survivorship in New Orleans, via formative interviews (n=12; aim 2). The iOS- and Android-enabled NOLA GEM app leverages twice-daily GEMA prompts to offer just-in-time, in-app recommendations for effective coping skills practice and app-delivered Living in the Face of Trauma session content. For aim 3, the pilot trial will enroll an analytic sample of 60 New Orleans people living with HIV individually randomized to parallel NOLA GEM (intervention) or GEMA-alone (control) arms at a 1:1 allocation for a 21-day period. Acceptability and feasibility will be assessed via enrollment, attrition, active daily use through paradata metrics, and prevalidated usability measures. At the postassessment time point, primary end points will be assessed via a range of well-validated, domain-specific scales. Care engagement and viral suppression will be assessed via past missed appointments and self-reported viral load at 30 and 90 days, respectively, and through well-demonstrated adherence self-efficacy measures.

RESULTS

Aims 1 and 2 have been achieved, NOLA GEM is in Beta, and all aim-3 methods have been reviewed and approved by the institutional review board of Tulane University. Recruitment was launched in July 2023, with a target date for follow-up assessment completion in December 2023.

CONCLUSIONS

By leveraging user-centered development and embracing principles that elevate the lived expertise of New Orleans people living with HIV, mHealth-adapted EBIs can reflect community wisdom on posttraumatic resilience. Sustainable adoption of the NOLA GEM app and a promising early efficacy profile will support the feasibility of a future fully powered clinical trial and potential translation to new underserved settings in service of holistic survivorship and well-being of people living with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05784714; https://clinicaltrials.gov/ct2/show/NCT05784714.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47151.

Adolescent Perceptions of Technology-Based Sexual and Reproductive Health Services: A Systematic Review

Technology-based services, including telehealth, text messaging, and the internet are increasingly popular methods for adolescents and young adults (AYA) to access sexual and reproductive health (SRH) information and healthcare. This systematic review examined AYA perceptions of privacy and confidentiality of technology-based SRH services. The PubMed, Scopus, and PsycINFO were systematically searched in May 2021 to capture relevant qualitative or quantitative articles from the past 10 years. Included studies had AYA (i.e., mean age, 13-26-years with <10% of the sample outside this range), technology-based services for SRH, and outcomes of perceived privacy or confidentiality. Twenty-eight articles were included (N = 8638 AYA). Most studies utilized the internet and mobile apps to address human immunodeficiency virus infection (HIV), sexually transmitted infections, and general SRH topics. Most AYA reported that these services were private and confidential, with minimal differences across SRH topic addressed. More interactive services had greater concerns (e.g., family or friends seeing notifications). Most AYA considered technology-based SRH to be confidential and private. As technology will likely remain an integrated part of healthcare delivery, improving the privacy and confidentiality of these services can facilitate AYA's independent and autonomous engagement in SRH care, and potentially improve their SRH outcomes.

Refining a Multicomponent Intervention to Increase Perceived HIV Risk and PrEP Initiation: Focus Group Study Among Black Sexual Minority Men

Background

Increased preexposure prophylaxis (PrEP) initiation is needed to substantially decrease HIV incidence among Black sexual minority men (BSMM). However, BSMM perceive others as PrEP candidates instead of themselves and are less likely than other groups to use PrEP if prescribed. Peers and smartphone apps are popular HIV prevention intervention tools typically used independently. However, they could be useful together in a multicomponent strategy to improve perceived HIV risk and PrEP initiation for this group. Information regarding attitudes and preferences toward this multicomponent strategy is limited.

Objective

The goal of this study is to obtain attitudes and perspectives regarding the design of a multicomponent intervention that uses a smartphone app and a peer change agent (PCA) to increase perceived HIV risk and PrEP initiation. The intervention will be refined based on thematic findings for a culturally responsive approach.

Methods

Data were obtained guided by life course theory and the health belief model using 12 focus groups and 1 in-depth interview among HIV-negative BSMM from Baltimore, MD, between October 2019 and May 2020 (n=39). Groups were stratified by the following ages: 18 to 24 years, 25 to 34 years, and 35 years and older. Participants were provided details regarding an existing mobile app diary to self-monitor sexual behaviors and a hypothetical PCA with whom to review the app. Facilitators posed questions regarding perceived HIV risk, attitudes toward the app, working with a PCA, and preferences for PCA characteristics and approaches.

Results

Most participants identified as homosexual, gay, or same gender-loving (26/38, 68%), were employed (26/38, 69%), single (25/38, 66%), and interested in self-monitoring sexual behaviors (28/38, 68%). However, themes suggested that participants had low perceived HIV risk, that self-monitoring sexual behaviors using a mobile app diary was feasible but could trigger internalized stigma, and that an acceptable PCA should be a possible self for BSMM to aspire to but they still wanted clinicians to “do their job.”

Conclusions

HIV-negative BSMM have dissonant attitudes regarding perceived HIV risk and the utility of a mobile app and PCA to increase perceived HIV risk and PrEP initiation. Future research will explore the feasibility, acceptability, and preliminary impact of implementing the multicomponent intervention on perceived HIV risk and PrEP initiation among BSMM in a pilot study.

Daily Predictors of ART Adherence Among Young Men Living with HIV Who Have Sex with Men: A Longitudinal Daily Diary Study

Improving adherence to antiretroviral therapy (ART) is essential for limiting HIV disease progression among young sexual minority men living with HIV. Daily diaries allow for a detailed examination of how fluctuations in psychosocial factors are associated with adherence over time. Across three cities in the United States, this study collected 60 days of quantitative data from 44 young men (between 16 and 24 years of age) living with HIV who have sex with men. Lagged transition models explored the associations of mood, stress, social support, substance use, and condomless intercourse with daily ART adherence. Baseline levels of illicit substance use and condomless intercourse, and a higher proportion of days with stress or marijuana use, were associated with lower ART adherence. Lapses in adherence predicted non-adherence the following day. Findings suggest prospective data collection may identify different predictors of adherence compared to retrospective recall. Lapse-management strategies are needed to improve adherence following a missed dose.

Event-Level Association Between Daily Alcohol Use and Same-Day Nonadherence to Antiretroviral Therapy Among Young Men Who Have Sex With Men and Trans Women Living With HIV: Intensive Longitudinal Study

BACKGROUND

Young trans women (TW) and men who have sex with men (MSM) are disproportionately impacted by HIV. Optimizing adherence to antiretroviral therapy (ART) is one mechanism by which public health experts aim to achieve favorable HIV health outcomes while reducing disease transmission. However, alcohol use is prevalent among young TW and MSM and threatens optimal adherence. In addition, the daily variations in alcohol use and ART adherence and their association with each other are poorly understood, warranting more appropriate methodological approaches, such as analysis of ecological momentary assessment (EMA) data.

OBJECTIVE

The aim of this analysis is to characterize the association between daily alcohol use and same-day ART nonadherence captured by an EMA study of young MSM and TW living with HIV in San Francisco.

METHODS

Young MSM and TW enrolled in the Health eNav digital HIV care navigation intervention were included in the analytic sample (N=113). Data on alcohol and ART use were collected by daily EMA surveys administered via text messaging and were analyzed over 30 days of follow-up. A multivariable mixed-effects logistic regression model adjusting for baseline sociodemographic characteristics was specified to investigate whether daily alcohol use was associated with same-day ART nonuse.

RESULTS

Daily alcohol use was associated with higher same-day ART nonuse. On average, participants drank alcohol on 15.20 (SD 8.93) days and used ART on 15.19 (SD 10.16) days out of 30 days. Daily alcohol use was associated with 1.89 (95% CI 1.14-3.15) times the adjusted odds of same-day ART nonuse for each participant.

CONCLUSIONS

Results are consistent with other analyses of daily alcohol and ART use and underscore the importance of individually targeted interventions that are sensitive to each participant's dynamic risk environment.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16406.

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

PURPOSE OF REVIEW

In recent years, researchers have been adopting and using ecological momentary assessment (EMA) methods via technology devices for real-time measurement of exposures and outcomes in HIV research. To assess and critically evaluate how EMA methods are currently being used in HIV research, we systematically reviewed recent published literature (October 2017-October 2019) and searched select conference databases for 2018 and 2019.

RECENT FINDINGS

Our searches identified 8 published articles that used EMA via smartphone app, a handheld Personal Digital Assistant, and web-based survey programs for real-time measurement of HIV-related exposures and outcomes in behavioral research. Overall trends include use of EMA and technology devices to address substance use, HIV primary prevention (e.g., condom use and preexposure prophylaxis), and HIV treatment (medication adherence). This review supports the use of EMA methods in HIV research and recommends that researchers use EMA methods to measure psychosocial factors and social contexts and with Black and Latinx samples of gay and bisexual men, transgender women, and cisgendered women to reflect current HIV disparities in the U.S.A.

Willingness of MSM Living with HIV to Take Part in Video-Groups: Application of the Technology Readiness and Acceptance Model

Group-based programs are important for the psychosocial care of people living with HIV; however, programs are often limited by geography and availability. Video-groups, conducted via group-based video-conferencing on video-phones or computer, offer the benefits of group-based programs while overcoming barriers to attendance. This study sought to explore if, and how, the Technology Readiness and Acceptance Model (TRAM) could be used to explain the willingness of men to take part in video-groups. The TRAM was used as the guiding framework for thematic qualitative analysis. Among 106 participants, there was a general willingness to participate in video-groups. TRAM constructs were present in the data-with perceived usefulness (extent that participating in a technology-based program would facilitate group intervention behaviors) and insecurity (distrust/skepticism of technology) emerging as the most salient themes. The TRAM alone did not account for concerns related to group settings or the level of privacy needed when talking about HIV.

eHealth to Enhance Treatment Adherence Among Youth Living with HIV

PURPOSE OF REVIEW

Multiple reviews have examined eHealth/mHealth interventions to address treatment adherence, including those focusing on youth living with HIV (YLWH). This review synthesizes results of prior reviews and recent studies (last 5 years) to provide a path forward for future research, acknowledging both lessons learned and gaps to be addressed.

RECENT FINDINGS

Recent studies provide further evidence for the feasibility and acceptability of technology-based HIV interventions. Formative research of more comprehensive smartphone applications and pilot studies of computer-delivered interventions provide additional guidance on YLWH's preferences for intervention components and show promising preliminary efficacy for impacting treatment adherence. Expanding access to technology among YLWH, in the United States (US) and globally, supports the continued focus on eHealth/mHealth interventions as a means to reduce disparities in clinical outcomes. Future research should lend greater focus to implementation and scale-up of interventions through the use of adaptive treatment strategies that include costing analyses, measuring and maximizing engagement, fostering information sharing between researchers, and building upon sustainable platforms.

Social Inequity and Structural Barriers to Completion of Ecological Momentary Assessments for Young Men Who Have Sex With Men and Trans Women Living With HIV in San Francisco

Background

Ecological momentary assessments (EMAs) administered via text messaging facilitate real-time data collection. With widespread cell phone access, EMAs are becoming more available to even the most disenfranchised communities, such as those living with HIV. However, structural barriers disproportionately burden young men who have sex with men (MSM) and trans women (TW) living with HIV and threaten participation in HIV research.

Objective

We aim to identify structural barriers to completing EMA text surveys nested within a digital HIV care intervention for young MSM and TW living with HIV in San Francisco.

Methods

A total of 10,800 EMA text messages were delivered daily over 90 days to 120 participants enrolled in the Health eNav intervention (2017-2018) at the San Francisco Department of Public Health. EMA surveys inquired about participants’ daily affect, sexual behaviors, substance use, and treatment adherence. Survey completion was calculated after 30, 60, and 90 days of follow-up. We described characteristics of nonstarters (those who provided less than four complete responses to the first seven EMA surveys) and analyzed structural correlates of days to first weeklong or more EMA survey noncompletion using multivariable Cox proportional hazards regression. Qualitative interviews were used to evaluate the acceptability of EMA surveys.

Results

Participants completed 4384 of 10,800 (40.59%) EMA surveys. Completion of 70% or more of EMA surveys was attained by 56 of 120 participants (46.7%) at 30 days of follow-up, 40/120 (33.3%) at 60 days of follow-up, and 30/120 (25.0%) by the end of the 90-day study period. Twenty-eight participants (23.3%) were identified as nonstarters, and were more likely to be recently incarcerated (prevalence ratio [PR] 2.3, 95% CI 1.3-4.4), forego basic needs for HIV medications (PR 2.4, 95% CI 1.3-4.5), and be diagnosed with HIV in the last year (PR 2.2, 95% CI 1.1-4.1). Adjusting for nonstarters, young MSM and TW living in temporary/transitional housing (adjusted hazard ratio [aHR] 1.8, 95% CI 1.1-3.0), foregoing HIV medications to afford basic needs (aHR 1.7, 95% CI 1.1-2.7), and having less than a college education (aHR 3.5, 95% CI 1.4-9.0) had greater hazard of weeklong or more EMA survey noncompletion. Overall, there was high acceptability of the EMA surveys.

Conclusions

Although access to and use of technology is increasingly ubiquitous, this analysis demonstrates persisting gaps in EMA completion by socioeconomic factors such as incarceration, education level, housing, and competing needs for young MSM and TW living with HIV in San Francisco. Moreover, those recently diagnosed with HIV were more likely to experience an immediate drop-off in completing EMA surveys. EMAs are feasible for individuals not experiencing social inequity and structural barriers. HIV prevention technologies addressing these barriers and leveraging similar methodology may prove effective for young MSM and TW living with HIV.

Avoidant Coping Mediates the Relationship Between Self-Efficacy for HIV Disclosure and Depression Symptoms Among Men Who Have Sex with Men Newly Diagnosed with HIV

HIV diagnosis presents a critical opportunity to reduce secondary transmission, improve engagement in care, and enhance overall well-being. To develop relevant interventions, research is needed on the psychosocial experiences of newly diagnosed individuals. This study examined avoidant coping, self-efficacy for HIV disclosure decisions, and depression among 92 newly diagnosed men who have sex with men who reported recent sexual risk behavior. It was hypothesized that avoidant coping would mediate the relationship between self-efficacy and depression. Cross-sectional surveys were collected from participants 3 months after HIV diagnosis. To test for mediation, multiple linear regressions were conducted while controlling for HIV disclosure to sexual partners. Self-efficacy for HIV disclosure decisions showed a negative linear relationship to depression symptoms, and 99% of this relationship was mediated by avoidant coping. The index of mediation of self-efficacy on depression indicated a small-to-medium effect. Higher self-efficacy was related to less avoidant coping, and less avoidant coping was related to decreased depression symptoms, all else held constant. These findings highlight the role of avoidant coping in explaining the relationship between self-efficacy for HIV disclosure decisions and depression.

Health Technology-Enabled Interventions for Adherence Support and Retention in Care Among US HIV-Infected Adolescents and Young Adults: An Integrative Review

The objective of this integrative review was to describe current US trends for health technology-enabled adherence interventions among behaviorally HIV-infected youth (ages 13-29 years), and present the feasibility and efficacy of identified interventions. A comprehensive search was executed across five electronic databases (January 2005-March 2016). Of the 1911 identified studies, nine met the inclusion criteria of quantitative or mixed methods design, technology-enabled adherence and or retention intervention for US HIV-infected youth. The majority were small pilots. Intervention dose varied between studies applying similar technology platforms with more than half not informed by a theoretical framework. Retention in care was not a reported outcome, and operationalization of adherence was heterogeneous across studies. Despite these limitations, synthesized findings from this review demonstrate feasibility of computer-based interventions, and initial efficacy of SMS texting for adherence support among HIV-infected youth. Moving forward, there is a pressing need for the expansion of this evidence base.