Internet based HIV prevention research targeting rural MSM: feasibility, acceptability, and preliminary efficacy

Effectiveness of eHealth interventions for HIV prevention, testing and management: An umbrella review

BACKGROUND

Human immunodeficiency virus (HIV) infection has become a major contributor to the global burden of disease. Globally, the number of cases of HIV continues to increase. Electronic health (eHealth) interventions have emerged as promising tools to support disease self-management among people living with HIV. The purpose of this umbrella review is to systematically evaluate and summarize the evidence and results of published systematic reviews and meta-analyses on the effectiveness of eHealth interventions for HIV prevention, testing and management.

METHODS

PubMed, Embase and the Cochrane Library were searched for reviews. The methodological quality of the included studies was assessed using AMSTAR-2.

RESULTS

A total of 22 systematic reviews were included. The methodological quality of the reviews was low or critically low. EHealth interventions range from Internet, computer, or mobile interventions to websites, programs, applications, email, video, games, telemedicine, texting, and social media, or a combination of them. The majority of the reviews showed evidence of effectiveness (including increased participation in HIV management behaviours, successfully changed HIV testing behaviours, and reduced risk behaviours). EHealth interventions were effective in the short term.

CONCLUSIONS

Ehealth interventions have the potential to improve HIV prevention, HIV testing and disease management. Due to the limitations of the low methodological quality of the currently available systematic reviews, more high-quality evidence is needed to develop clear and robust recommendations.

Developing an mHealth program to improve HIV care continuum outcomes among young Black gay and bisexual men

BACKGROUND

Young Black gay and bisexual men (YBGBM) in the United States face significant disparities in HIV care outcomes. Mobile health (mHealth) interventions have shown promise with improving outcomes for YBGBM across the HIV care continuum.

METHODS

We developed an mHealth application using human-centered design (HCD) from 2019-2021 in collaboration with YBGBM living with HIV and with HIV service providers. Our HCD process began with six focus groups with 50 YBGBM and interviews with 12 providers. These insights were used to inform rapid prototyping, which involved iterative testing and refining of program features and content, with 31 YBGBM and 12 providers. We then collected user feedback via an online survey with 200 YBGBM nationwide and usability testing of a functional prototype with 21 YBGBM.

RESULTS

Focus groups and interviews illuminated challenges faced by YBGBM living with HIV, including coping with an HIV diagnosis, stigma, need for social support, and a dearth of suitable information sources. YBGBM desired a holistic approach that could meet the needs of those newly diagnosed as well as those who have been living with HIV for many years. Program preferences included video-based content where users could learn from peers and experts, a range of topics, a community of people living with HIV, and tools to support their health and well-being. Providers expressed enthusiasm for an mHealth program to improve HIV care outcomes and help them serve clients. Rapid prototyping resulted in a list of content topics, resources, video characteristics, community features, and mHealth tools to support adherence, retention, goal setting, and laboratory results tracking, as well as tools to help organization staff to support clients. Online survey and usability testing confirmed the feasibility, acceptability, and usability of the content, tools, and features.

CONCLUSIONS

This study demonstrates the potential of a video-based mHealth program to address the unique needs of YBGBM living with HIV, offering support and comprehensive information through a user-friendly interface and videos of peers living with HIV and of experts. The HCD approach allowed for continuous improvements to the concept to maximize cultural appropriateness, utility, and potential effectiveness for both YBGBM and HIV service organizations.

Latent Class Analysis of Online Platforms for Partner-Seeking and Sexual Behaviors Among Men Who Have Sex with Men from Central Kentucky

Little is known whether engagement in sexual behaviors associated with potential HIV risks differs by subgroups of men who have sex with men (MSM), who are distinct regarding patterns of use of online tools for partner-seeking. Using latent class analysis, we revealed four classes of app-using MSM (n = 181, 18-34 y.o., 82.4% identified as White and non-Hispanic) residing in Central Kentucky: the Grindr/Tinder class; the Poly App Use class of MSM-oriented apps; the General Social Media class, and the Bumble class. Unadjusted penalized logistic regressions showed associations of the Poly App Use class with increased numbers of receptive anal sex partners and reporting condomless receptive anal sex. Adjusting for other covariates, poly app users versus others were more likely to be older (25-34 vs. 18-24, AOR = 3.81, 95%CI = 1.70-9.03), to report past six-month illicit drug use (AOR = 2.93, 95%CI = 1.25-7.43) and to have ever used pre-exposure prophylaxis (AOR = 2.79, 95%CI = 1.10-7.12). Poly app users had behavior profiles associated with an elevated HIV risk and also reported HIV-related protective behaviors likely indicating increased risk awareness among this class. Our findings warrant differentiation of behavior profiles by patterns of app use and suggest not to generalize sexual behaviors associated with potential HIV risks to all app-using MSM.

Leveraging Resilience-supportive Strategies to Enhance Protective Factors in Young Sexual Minority Men: A Scoping Review of HIV Behavioral Interventions Implemented in High-income Countries

Behavioral HIV interventions focused on strengthening young sexual minority men's (SMM) internal (assets) and external (resources) protective factors are promising, yet their evaluation as resilience-supportive strategies to minimize or negate HIV-related risks remain understudied. The objective of this scoping review was to describe resilience-supportive intervention strategies that have been used to achieve desired HIV behavioral outcomes and to identify how these strategies have been evaluated using a resilience analytic framework. Our scoping review uncovered 271 peer-reviewed articles, of which 38 were eligible for inclusion based on our review criteria. The majority of interventions relied on social support strategies as their primary resilience-supportive strategy. A third of interventions reviewed analyzed their findings from a deficits-focused model, another third used compensatory resilience models, and the remaining interventions employed a hybrid (i.e., deficit and compensatory model) strategy. None of the interventions evaluated their intervention effects using a risk-protective model. From our synthesis regarding the current state of research around resilience-informed interventions, we propose strategies to inform the design of resilience-supportive approaches and make recommendations to move the field forward on how to develop, implement, and measure young SMM's resiliency processes.

Efficacy of a Telehealth Delivered Couples' HIV Counseling and Testing (CHTC) Intervention to Improve Formation and Adherence to Safer Sexual Agreements Among Male Couples in the US: Results from a Randomized Control Trial

This paper reports the results of a randomized controlled trial (RCT) to assess the efficacy of Nexus, a telehealth delivered intervention that combines Couples' HIV counseling and testing (CHTC) with home-based HIV-testing, examining the impact of the intervention on the couples' formation and adherence to safer sexual agreements. Between 2016 and 2018, 424 couples were recruited online from the U.S and randomized to the intervention arm (a telehealth delivered CHTC session with two home HIV-testing kits) or a control arm (two home HIV-testing kits), with study assessments at baseline, 3 and 6 months. Outcomes were the formation and adherence to safer sexual agreements, dyadic discordance in sexual agreements, breakage of sexual agreements, and perceptions of PrEP. Couples in the intervention arm had significantly greater odds of reporting a safer sexual agreement (3 months OR 1.87, p-value 0.005, and 6 months OR 1.84, p-value 0.007), lower odds of reporting discordant sexual agreements at 6 months (OR 0.62, p-value 0.048), and a significantly lower odds of reporting breaking their sexual agreement (3 months OR 0.51, p-value 0.035, and 6 months OR 0.23, p-value 0.000). By 6 months, couples in the intervention arm were less likely to say PrEP was beneficial to one (RRR 0.33, P = 0.000) or both of them (RRR 0.29, P = 0.000) than being beneficial to neither of the partners. The high levels of acceptability and efficacy of the intervention demonstrate strong potential for the scale-up of this efficacious intervention that is delivered through a low-cost telehealth platform.

Online Sexual Health Information Seeking Patterns Differentiated by Social Location and Physical Location among Gay and Bisexual Men in Ontario, Canada

Objective

This research aimed to understand the varying needs of diverse gay and bisexual men (GBM) in relation to online sexual health information-seeking dependent upon differing social sociodemographic variables and geographic location.

Methods

A total of 1802 GBM in Ontario participated in this study. Multivariable regressions were conducted to analyze differences in information-seeking based on ethnicity group, HIV status, recent sexual behavior and regionality (urban and rural location).

Results

There were significant differences in online sexual health information-seeking content based on these demographic variables.

Conclusions

Implications for sexual health outreach and service provision for diverse GBM are discussed as well.

eHealth Interventions to Address HIV and Other Sexually Transmitted Infections, Sexual Risk Behavior, Substance Use, and Mental Ill-health in Men Who Have Sex With Men: Systematic Review and Meta-analysis

Background

Men who have sex with men experience disproportionately high levels of HIV and other sexually transmitted infections (STIs), sexual risk behavior, substance use, and mental ill-health. These experiences are interrelated, and these interrelations are potentiated by structural conditions of discrimination, stigma, and unequal access to appropriate health services, and they magnify each other and have intersecting causal pathways, worsening both risk for each condition and risk for the negative sequelae of each condition. eHealth interventions could address these issues simultaneously and thus have wide-ranging and greater effects than would be for any 1 outcome alone.

Objective

We systematically reviewed the evidence for the effectiveness of eHealth interventions in addressing these outcomes separately or together.

Methods

We searched 19 databases for randomized trials of interactive or noninteractive eHealth interventions delivered via mobile phone apps, internet, or other electronic media to populations consisting entirely or principally of men who have sex with men to prevent HIV, STIs, sexual risk behavior, alcohol and drug use, or common mental illnesses. We extracted data and appraised each study, estimated meta-analyses where possible by using random effects and robust variance estimation, and assessed the certainty of our findings (closeness of the estimated effect to the true effect) by using GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

Results

We included 14 trials, of which 13 included active versus control comparisons; none reported mental health outcomes, and all drew from 12 months or less of follow-up postintervention. Findings for STIs drew on low numbers of studies and did not suggest consistent short-term (<3 months postintervention; d=0.17, 95% CI –0.18 to 0.52; I²=0%; 2 studies) or midterm (3-12 months postintervention, no meta-analysis, 1 study) evidence of effectiveness. Eight studies considering sexual risk behavior outcomes suggested a short-term, nonsignificant reduction (d=–0.14, 95% CI –0.30 to 0.03) with very low certainty, but 6 studies reporting midterm follow-ups suggested a significant impact on reducing sexual risk behavior (d=–0.12, 95% CI –0.19 to –0.05) with low certainty. Meta-analyses could not be undertaken for alcohol and drug use (2 heterogeneous studies) or for HIV infections (1 study for each of short-term or midterm follow-up), and alcohol outcomes alone were not captured in the included studies. Certainty was graded as low to very low for most outcomes, including all meta-analyses.

Conclusions

To create a comprehensive eHealth intervention that targets multiple outcomes, intervention evaluations should seek to generalize both mechanisms and components that are successfully used to achieve change in 1 outcome over multiple outcomes. However, additional evaluations of interventions seeking to address outcomes other than sexual risk behavior are needed before development and evaluation of a joined-up intervention.

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.

Sexual and Gender Minority Youth and Sexual Health Education: A Systematic Mapping Review of the Literature

PURPOSE

To synthesize the diverse body of literature on sexual and gender minority youth (SGMY) and sexual health education.

METHODS

We conducted a systematic search of the literature on SGMY and sexual health education, including SGMY perspectives on sexual health education, the acceptability or effectiveness of programs designed for SGMY, and SGMY-specific results of sexual health education programs delivered to general youth populations.

RESULTS

A total of 32 articles were included. Sixteen qualitative studies with SGMY highlight key perspectives underscoring how youth gained inadequate knowledge from sexual health education experiences and received content that excluded their identities and behaviors. Thirteen studies examined the acceptability or effectiveness of sexual health interventions designed for SGMY from which key characteristics of inclusive sexual health education relating to development, content, and delivery emerged. One study found a sexual health education program delivered to a general population of youth was also acceptable for a subsample of sexual minority girls.

CONCLUSIONS

Future research on SGMY experiences should incorporate populations understudied, including younger adolescents, sexual minority girls, and transgender persons. Further, the effectiveness of inclusive sexual health education in general population settings requires further study.

Factors Associated with Never Testing for HIV: Directions for Targeted Testing Interventions Among Men Who Have Sex with Men

Men who have sex with men (MSM) and who are unaware of their HIV infection contribute to onward HIV transmission and are more likely to progress to severe illness. We therefore assessed determinants of never testing for HIV among MSM living in the Netherlands. Between April and July 2019, 950 HIV-negative and 122 never-tested MSM completed a cross-sectional survey on sociodemographics, HIV testing behavior, and sexual risk taking, which was distributed through gay networking sites/apps. In never-tested MSM, median age was 37 (interquartile range = 22-51) years and 37 (30%) reported recent sexual risk behavior. Never testing was associated with younger age [adjusted odds ratio (aOR) per year increase = 0.98, 95% confidence interval (CI) = 0.97-1.00, p = 0.015], having sex with men and women (aOR = 2.85, 95% CI = 1.57-5.62, p = 0.001), and not knowing others living with HIV (aOR = 3.85, 95% CI = 2.35-6.32, p < 0.001) in multi-variable logistic regression analysis. A significant interaction effect between education level and residential area was observed (p = 0.001). Among higher-educated MSM, those living outside a large urban area had higher odds of never testing compared to those living in an urban area (aOR = 6.26, 95% CI = 2.42-16.24, p < 0.001). Lower-educated MSM had higher odds of never testing irrespective of residential area (large urban area: aOR = 12.06, 95% CI = 4.00-36.38; outside large urban area: aOR 9.29, 95% CI = 3.64-23.76; p < 0.001 for both). Among MSM recently exposed to sexual risk, never testing was associated with having sex with men and women (aOR = 2.80, 95% CI = 1.09-7.18, p = 0.032) and not knowing others with HIV (aOR = 4.91, 95% CI = 1.97-12.24, p = 0.001). To conclude, testing interventions for those never tested should be tailored to residential area and education level, and inclusive of bisexuality.

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.

A Qualitative Study of Community-Based HIV/AIDS Prevention Interventions, Programs, and Projects for Rural and Remote Regions in Canada: Implementation Challenges and Lessons Learned

CONTEXT

Fifteen percent to 20% of the Canadian and American populations live outside urban areas, and despite growing regional HIV/AIDS-related health disparities, there is little published research specific to rural or remote (rural/remote) HIV/AIDS prevention programming.

OBJECTIVE

To document implementation challenges, lessons learned, and evaluation approaches of promising and proven HIV/AIDS prevention programs and interventions developed and delivered by organizations with rural/remote catchment areas in Canada to provide a foundation for information sharing among agencies.

DESIGN

Qualitative study design, using a community-based participatory research approach. We screened Canadian community-based organizations with an HIV/AIDS prevention mandate to determine whether they offered services for rural/remote populations and invited organizational representatives to participate in semistructured telephone interviews. Interviews were audio-recorded and transcribed. Content analysis was used to identify categories in the interview data.

SETTING

Canada, provinces (all except Prince Edward Island), and territories (all except Nunavut).

PARTICIPANTS

Twenty-four community-based organizations.

RESULTS

Screening calls were completed with 74 organizations, of which 39 met study criteria. Twenty-four (62%) interviews were conducted. Populations most frequently served were Indigenous peoples (n = 13 organizations) and people who use drugs (n = 8 organizations) (categories not mutually exclusive). Key lessons learned included the importance of involving potential communities served in program development; prioritizing community allies/partnerships; building relationships; local relevancy and appropriateness; assessing community awareness or readiness; program flexibility/adaptability; and addressing stigma. Evaluation activities were varied and used for funder reporting and organizational learning.

CONCLUSIONS

Rural/remote HIV/AIDS programs across Canada expressed similar challenges and lessons learned, suggesting that there is potential for knowledge exchange, and development of a community of practice. Top-down planning and evaluation models may fail to capture program achievements in rural/remote contexts. The long-term engagement practices that render rural/remote programs promising do not always conform to planning and implementation requirements of limited funding.

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.

Using Digital Communication Technology to Increase HIV Testing Among Men Who Have Sex With Men and Transgender Women: Systematic Review and Meta-Analysis

BACKGROUND

HIV continues to disproportionately affect men who have sex with men (MSM) and transgender women (TW). Undiagnosed HIV is a major driver of HIV transmission rates, and increasing the uptake of regular HIV testing and facilitating timely initiation of HIV treatment is a global HIV prevention priority. However, MSM and TW experience a range of barriers that limit their access to testing and other prevention services. Given their growing ubiquity, digital communication technologies are increasingly being used to support HIV prevention efforts, and a growing number of studies have trialed the use of digital technology to promote HIV testing among MSM and TW.

OBJECTIVE

We undertook a systematic review and meta-analysis to assess the impact of digital communication technology on HIV testing uptake among MSM and TW. Subanalyses aimed to identify the features and characteristics of digital interventions associated with greater impact.

METHODS

A systematic literature review was undertaken using select databases and conference repositories. Studies describing the use of a digital technology-internet-enabled devices, including phones, tablets, and computers-to increase HIV testing uptake among MSM or TW using either randomized or observational cohort design with measurement of HIV testing rates measured pre- and postintervention, and published in English between 2010 and 2018 were included. Pooled effect estimates were calculated using a random effects meta-analysis. Subanalyses calculated effect estimates grouped by selected features of digital interventions.

RESULTS

A total of 13 randomized or observational studies were included in the final review. Digital interventions most commonly used mainstream, existing social media platforms (n=7) or promotion through online peer educators (n=5). Most interventions (n=8) were categorized as interactive and allowed user engagement and most directly facilitated testing (n=7) either by providing self-testing kits or referral to testing services. A total of 1930 participants were included across the 13 studies. HIV testing uptake among MSM and TW exposed to digital interventions was 1.5 times higher than that of unexposed MSM and TW (risk ratio [RR] 1.5; 95% CI 1.3-1.7). Subanalyses suggested an increased impact on HIV testing uptake among interventions that were delivered through mainstream social media-based platforms (RR 1.7; 95% CI 1.3-2.1), included direct facilitation of HIV testing (RR 1.6; 95% CI 1.4-1.9), were interactive (RR 1.6; 95% CI 1.4-1.8), and involved end users in the design process (RR 1.6; 95% CI 1.3-2.0).

CONCLUSIONS

These findings provide broad support for the integration of technology with existing approaches to promote and facilitate HIV testing among MSM and TW. Our findings identified key features that may be associated with greater impact on HIV testing uptake and can be used to inform future development efforts given the growing interest and application of digital technologies in HIV prevention.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42017070055; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017070055.

HIV prevalence, testing and treatment among men who have sex with men through engagement in virtual sexual networks in Kenya: a cross-sectional bio-behavioural study

INTRODUCTION

In Kenya, men who have sex with men (MSM) are increasingly using virtual sites, including web-based apps, to meet sex partners. We examined HIV testing, HIV prevalence, awareness of HIV-positive status and linkage to antiretroviral therapy (ART), for HIV-positive MSM who solely met partners via physical sites (PMSM), compared with those who did so in virtual sites (either solely via virtual sites (VMSM), or via both virtual and physical sites (DMSM)).

METHODS

We conducted a cross-sectional bio-behavioural survey of 1200 MSM, 15 years and above, in three counties in Kenya between May and July 2019, using random sampling of physical and virtual sites. We classified participants as PMSM, DMSM and VMSM, based on where they met sex partners, and compared the following between groups using chi-square tests: (i) proportion tested; (ii) HIV prevalence and (iii) HIV care continuum among MSM living with HIV. We then performed multivariable logistic regression to measure independent associations between network engagement and HIV status.

RESULTS

177 (14.7%), 768 (64.0%) and 255 (21.2%), of participants were classified as PMSM, DMSM and VMSM respectively. 68.4%, 70.4% and 78.5% of PMSM, DMSM and VMSM, respectively, reported an HIV test in the previous six months. HIV prevalence was 8.5% (PMSM), 15.4% (DMSM) and 26.7% (VMSM), p < 0.001. Among those living with HIV, 46.7% (PMSM), 41.5% (DMSM) and 29.4% (VMSM) were diagnosed and aware of their status; and 40.0%, 35.6% and 26.5% were on antiretroviral treatment. After adjustment for other predictors, MSM engaged in virtual networks remained at a two to threefold higher risk of prevalent HIV: VMSM versus PMSM (adjusted odds ratio 3.88 (95% confidence interval (CI) 1.84 to 8.17) p < 0.001); DMSM versus PMSM (2.00 (95% CI 1.03 to 3.87), p = 0.040).

CONCLUSIONS

Engagement in virtual networks is associated with elevated HIV risk, irrespective of individual-level risk factors. Understanding the difference in characteristics among MSM-seeking partners in different sites will help HIV programmes to develop subpopulation-specific interventions.

The Effectiveness of Electronic Health Interventions for Promoting HIV-Preventive Behaviors Among Men Who Have Sex With Men: Meta-Analysis Based on an Integrative Framework of Design and Implementation Features

Background

The disproportionately high prevalence of HIV among men who have sex with men (MSM) is a global concern. Despite the increasing utilization of electronic health (eHealth) technology in the delivery of HIV prevention interventions, few studies have systematically explored its effectiveness and association with various intervention characteristics.

Objective

This study aimed to conduct a meta-analysis of the effectiveness of eHealth technology–based interventions for promoting HIV-preventive behaviors among MSM and to determine effectiveness predictors within a framework integrating design and implementation features.

Methods

A systematic literature search using terms related to eHealth technology, HIV, the MSM population, and an experimental study design was performed using 5 databases (ie, MEDLINE, PsycINFO, EMBASE, Web of Science, and ProQuest Dissertations & Theses) and other sources (eg, bibliographies of relevant reviews and JMIR Publications). First, primary meta-analyses were conducted to estimate the effectiveness of eHealth interventions (d₊) in changing 3 HIV-preventive behaviors among MSM: unprotected anal intercourse (UAI), HIV testing, and multiple sex partnership (MSP). Moderation analyses were then conducted to examine a priori effectiveness predictors including behavioral treatment components (eg, theory use, tailoring strategy use, navigation style, and treatment duration), eHealth technology components (eg, operation mode and modality type), and intervention adherence.

Results

A total of 46 studies were included. The overall effect sizes at end point were small but significant for all outcomes (UAI: d₊=−.21, P<.001; HIV testing: d₊=.38, P<.001; MSP: d₊=−.26, P=.02). The intervention effects on UAI were significantly larger when compared with preintervention groups than with concurrent groups. Greater UAI reductions were associated with the increased use of tailoring strategies, provision of feedback, and tunneling navigation in interventions with a concurrent group, whereas reductions were associated with the use of self-paced navigation in interventions with a preintervention group. Greater uptake of HIV testing was associated with longer treatment duration; computer-mediated communication; and the use of messaging, social media, or a combined technology modality. Higher intervention adherence consistently predicted larger effects on UAI and HIV testing.

Conclusions

This study provided empirical evidence for the effectiveness of eHealth interventions in promoting HIV-preventive behaviors among MSM. Features of treatment content and eHealth technology might best predict the intervention effects on UAI and HIV testing, respectively. Most importantly, intervention adherence tended to play an important role in achieving better effectiveness. The findings could help inform the development of efficacious interventions for HIV prevention in the future.

HIV risk behavior and HIV testing among rural and urban men who have sex with men in Zhejiang Province, China: A respondent-driven sampling study

BACKGROUND

Currently, human immunodeficiency virus (HIV) sentinel surveillance among men who have sex with men (MSM) in China conducted in large and medium-sized cities, and no HIV sentinel surveillance conducted in rural areas. HIV testing and intervention is predominantly conducted in urban areas, there have been a limited number of studies in rural areas MSM, it is necessary to conduct the investigation of HIV risk sexual behavior, HIV testing among rural and urban MSM.

METHOD

Between December 2013 and August 2015, a cross-sectional study was conducted in rural and urban areas in Zhejiang Province using respondent-driven sampling (RDS). Participants completed face-to-face interviewer-administered questionnaire surveys and were tested for HIV.

RESULTS

A total of 710 MSM participants were recruited, of whom 36.1% were from rural areas. The overall HIV prevalence was 16.6%, and was considerably lower among MSM living in rural areas (3.9%) than those living in urban areas (24.2%). 61.1% participants had not condom use with male sexual behavior in the past 6 months (86.7% in rural areas and 46.7% in urban areas). The social demographic and behavioral characteristics had significance difference among rural and urban MSM. Multivariate logistic regression revealed that, compared to men living in urban areas, MSM living in rural areas MSM were more likely to use dating apps to find sexual partners, were more likely to engage in bisexual behavior, and had lower condom use. 43.0% participants had been tested for HIV in the past year (41.8% in rural areas and 43.6% in urban areas). Multivariate logistic regression also revealed that among participants living in rural areas, having rural health insurance and not accepting HIV intervention were associated with lower HIV testing rates, while a higher monthly income and through use of internet to find sexual partner were associated with higher rates of HIV testing.

CONCLUSION

High risk behavior was prevalent, and HIV testing rates were low among MSM living in rural areas compare to urban areas in Zhejiang Province, therefore, preventative intervention measures should be immediately among rural MSM urgently to reduce HIV transmission and to promote HIV testing.

HIV Testing Among Chinese Men Who Have Sex with Men: The Roles of HIV Knowledge, Online Social Life, and Sexual Identity Concerns

HIV testing is critical for timely care and controlling the HIV epidemic among men who have sex with men (MSM), particularly for regions with increasing infection rates such as China. This study investigated HIV testing and associated demographic, psychosocial, and risk behavior factors among internet-using Chinese MSM (n = 332). Most participants received HIV testing before (74.1%), which was associated with more HIV knowledge, online social life, and more frequent condomless anal sex. Among MSM who tested previously (n = 246), 48.4% reported regular HIV testing, which was associated with a greater online social life and less sexual identity concerns (internalized homonegativity and concealment motivation). Findings suggest a two-step approach to engage MSM who never tested for HIV and who do not undergo regular testing. Strategies to promote testing should enhance HIV knowledge, sex education, and online MSM community building. Interventions to increase acceptance and positivity of sexual identity are crucial to regular testing.

Acceptability and potential impact of delivering sexual health promotion information through social media and dating apps to MSM in England: a qualitative study

Background

Increasing rates of sexually transmitted infections (STIs) in men-who-have-sex-with-men (MSM) in England is a pressing public health concern. Interventions targeting MSM, including information provision that effectively promotes sexual health, are needed. To support such intervention development, it is necessary to understand acceptable ways of delivering sexual health information. We explored the acceptability and potential uses and impacts of delivering sexual health information to MSM through social media and geosocial networking apps or dating apps.

Methods

Semi-structured interviews were conducted in person or by telephone with 25 MSM resident in England recruited via dating apps and social media advertisements. Interviews explored sexual health information sources, perceptions and uses. Attitudes towards sexual health promotion through social media and dating apps were then discussed. The data were analysed using thematic analysis.

Results

Sexual health information delivery through social media and dating apps was considered acceptable. Receiving information when browsing social media was viewed positively by most, as people have time to absorb information. In contrast, concerns were expressed that sharing or commenting on social media sexual health information may lead to judgements and discrimination. While social media reaches a high proportion of the population, dating apps can easily target MSM. However, tensions exist between the ability to provide information at an opportune time through dating apps, when users are connecting with new sexual partners, with the potential to adversely affect the app user’s experience. Hypothetical and actual uses and impacts of sexual health information ranged from no impact to reading information, sharing with peers, and increased awareness, to influencing healthcare-seeking, decision-making and risk-taking behaviours. Ensuring that information is engaging, positive in tone, not too clinical, focused on building social norms and delivered by trusted organisations were viewed as important for supporting its use.

Conclusions

Overall, these findings support the development of new interventions that use dating apps and social media for sexual health promotion.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7558-7) contains supplementary material, which is available to authorized users.

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

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

Measuring Acceptability and Engagement of The Keep It Up! Internet-Based HIV Prevention Randomized Controlled Trial for Young Men Who Have Sex With Men

HIV disproportionately impacts young men of color who have sex with men. Keep It Up! (KIU!) is an online intervention that addresses the needs of this population. The study objective was to examine intervention acceptability and engagement. Outcomes of interests were qualitative and quantitative acceptability and engagement measures, content ratings, and paradata. On average, participants rated content (4 out of 5 stars) and acceptability (3.5 out of 4) highly. Compared to White participants, Black participants found KIU! more useful, engaging, and acceptable; Latino participants found KIU! more engaging; and other non-White participants found KIU! more engaging and acceptable. Participants with high school or less education found KIU! more useful, engaging, acceptable, and deserving of five stars than college graduates (p values = .047, <.001, .002, .01) and graduate degree holders (p values = .04, .001, <.001, .004). KIU! is a promising prevention tool for highest risk populations.

Recruiting vulnerable populations to participate in HIV prevention research: findings from the Together 5000 cohort study

PURPOSE

The aim of the article was to examine factors associated with completing enrollment milestones in the Together 5000 cohort of at-risk men (n = 8661), transmen (n = 53), and transwomen (n = 63) who have sex with men.

METHODS

Between 2017 and 2018, participants completed an online enrollment survey and were offered opportunities to complete an incentivized secondary online survey as well as self-administered at-home HIV testing (OraSure). We explored factors associated with completing each study component.

RESULTS

In total, 8777 individuals completed our enrollment survey, 6166 (70.3%) completed the secondary survey, and 5010 returned the at-home HIV test kit that was mailed to them (81.3% of those mailed a kit). In our multivariable models, those who were White, with more years of education, were more likely to complete study components, although the magnitude of these associations was small. For example, 50.9% of those enrolled, 47.9% of those completing the secondary survey, and 46.8% of those completing HIV testing were persons of color-a statistically significant, but meaningfully insignificant decline.

CONCLUSIONS

These findings highlight the need for researchers to identify barriers that may prevent persons of color and younger individuals from participating in research studies.

Feasibility and Acceptability of an Online Positive Affect Intervention for Those Living with Comorbid HIV Depression

Positive affect has unique beneficial effects on psychological and physical health, independent of the effects of negative affect. Interventions that explicitly target positive affect show promise for improving health outcomes in a number of chronic illnesses. In this article, we present pilot data on the acceptability and feasibility of an online intervention to increase positive affect in those living with comorbid human immunodeficiency virus (HIV) and depression. The intervention was rated both acceptable and feasible by participants. Six of nine participants completed the intervention and the subsequent follow-up assessment and a post-intervention phone call. We also present outcomes of planned comparisons of intervention effects on emotion, which indicate that positive affect increased significantly in the intervention group. Based upon results of the current study, future research should continue the development of positive affect interventions for people living with comorbid HIV and depression.

Online Intervention as Strategy to Reach Men Who Have Sex With Other Men and Who Use Substances in a Sexual Context. Development of the MONBUZZ.ca Project

Men who have sex with men (MSM) use more psychoactive substances and a greater variety of them compared to their heterosexual peers. In this population, substance use is particularly characterized by polydrug use, binge, and sexualized substance use. MSM who use substances do not recognize themselves in public health messages targeting substance users. In addition, they recognize their problematic substance use later than heterosexuals and, as a result, they use addiction services later in their addiction trajectories. When accessing addiction services, the links between drug use and sexual life are rarely considered. Because of this profile, online interventions are a promising way to reach this hard-to-reach population. Currently available online interventions targeting MSM address the topics of substance use and sexual life separately. To deal with this situation, our team wanted to develop an online intervention platform for MSM who use substances in a sexual context. Given that online addiction interventions do not address sex and that MSM drug use is highly related to sexual activity, we first explored the literature related to online interventions targeting MSM and HIV risk behaviors, as well as online interventions targeting general population in order to: (1) identify relevant (or personalized) intervention methods; (2) describe the approaches used; and (3) describe their effects. Second, we turned to the literature to develop the MONBUZZ.ca project in collaboration with community organizations. The results of the narrative review provided a critical portrait of online interventions for MSM and guided the development process of MONBUZZ.ca. We discuss issues of co-development of a research and brief intervention tool based on promising practices as well as challenges of its implementation and evaluation.

The Effect of a Text Messaging Based HIV Prevention Program on Sexual Minority Male Youths: A National Evaluation of Information, Motivation and Behavioral Skills in a Randomized Controlled Trial of Guy2Guy

There is a paucity of literature documenting how the constructs of the Information-Motivation-Behavioral Skills (IMB) model are affected by exposure to technology-based HIV prevention programs. Guy2Guy, based on the IMB model, is the first comprehensive HIV prevention program delivered via text messaging and tested nationally among sexual minority adolescent males. Between June and November 2014, 302 14-18 year old gay, bisexual, and/or queer cisgender males were recruited across the US on Facebook and enrolled in a randomized controlled trial testing Guy2Guy versus an attention-matched control program. Among sexually inexperienced youth, those in the intervention were more than three times as likely to be in the "High motivation" group at follow-up as control youth (aOR = 3.13; P value = 0.04). The intervention effect was not significant when examined separately for those who were sexually active. HIV information did not significantly vary by experimental arm at 3 months post-intervention end, nor did behavioral skills for condom use or abstinence vary. The increase in motivation to engage in HIV preventive behavior for adolescent males with no prior sexual experience is promising, highlighting the need to tailor HIV prevention according to past sexual experience. The behavioral skills that were measured may not have reflected those most emphasized in the content (e.g., how to use lubrication to reduce risk and increase pleasure), which may explain the lack of detected intervention impact.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov ID# NCT02113956.

SMOOTH: Self-Management of Open Online Trials in Health analysis found improvements were needed for reporting methods of internet-based trials

BACKGROUND AND OBJECTIVES

The growth of trials conducted over the internet has increased, but with little practical guidance for their conduct, and it is sometimes challenging for researchers to adapt the conventions used in face-to-face trials and maintain the validity of the work. The aim of the study is to systematically explore existing self-recruited online randomized trials of self-management interventions and analyze the trials to assess their strengths and weaknesses, the quality of reporting, and the involvement of lay persons as collaborators in the research process.

STUDY DESIGN AND SETTINGS

The Online Randomized Controlled Trials of Health Information Database was used as the sampling frame to identify a subset of self-recruited online trials of self-management interventions. The authors cataloged what these online trials were assessing, appraised study quality, extracted information on how trials were run, and assessed the potential for bias. We searched out how public and patient participation was integrated into online trial design and how this was reported. We recorded patterns of use for registration, reporting, settings, informed consent, public involvement, supplementary materials, and dissemination planning.

RESULTS

The sample included 41 online trials published from 2002 to 2015. The barriers to replicability and risk of bias in online trials included inadequate reporting of blinding in 28/41 (68%) studies; high attrition rates with incomplete or unreported data in 30/41 (73%) of trials; and 26/41 (63%) of studies were at high risk for selection bias as trial registrations were unreported. The methods for (23/41, 56%) trials contained insufficient information to replicate the trial, 19/41 did not report piloting the intervention. Only 2/41 studies were cross-platform compatible. Public involvement was most common for advisory roles (n = 9, 22%), and in the design, usability testing, and piloting of user materials (n = 9, 22%).

CONCLUSION

This study catalogs the state of online trials of self-management in the early 21st century and provides insights for online trials development as early as the protocol planning stage. Reporting of trials was generally poor and, in addition to recommending that authors report their trials in accordance with CONSORT guidelines, we make recommendations for researchers writing protocols, reporting on and evaluating online trials. The research highlights considerable room for improvement in trial registration, reporting of methods, data management plans, and public and patient involvement in self-recruited online trials of self-management interventions.

HIV Risk Behaviors and Utilization of Prevention Services, Urban and Rural Men Who Have Sex with Men in the United States: Results from a National Online Survey

Rural men who have sex with men (MSM) are heavily affected by HIV, and many lack culturally competent HIV prevention resources. Rural MSM may find sexual partners on the internet, which may also be a way to deliver prevention services to them. To understand the differences between rural and urban MSM with respect to HIV risk factors and behaviors and the utilization of online HIV prevention services, we used data from the 2012 Web-Based HIV Behavioral Survey (WHBS). Using WHBS data collected between June and August 2012, we compared the characteristics of MSM with positive or unknown HIV infection status who had sex with a male in the past 12 months, from rural vs urban areas using Chi square tests and median tests. We used logistic regression and calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to compare self-reported HIV risk behaviors, HIV/STI testing behaviors, use of prevention services, and perceived discrimination. Of the 8166 MSM included in our analysis, 3583 (44%) were from rural areas, and 4583 (56%) were from urban areas. Compared to urban MSM, rural MSM were less likely to ever test for HIV (aPR = 0.94, CI 0.92-0.95), to be tested for HIV in the last year (aPR = 0.83, CI 0.79-0.87), or to receive free condoms (aPR = 0.83, CI 0.79-0.86) or individual prevention counseling in the past year (aPR = 0.86, CI 0.78-0.95). Rural MSM were less likely to have been tested in the last year for syphilis, gonorrhea, or chlamydia (aPR = 0.70, CI 0.62-0.78; aPR = 0.72, CI 0.64-0.81; aPR = 0.75, CI 0.67-0.85, respectively). Rural MSM also reported perceiving less tolerance of gays and bisexuals within their community (aPR = 0.80, CI 0.77-0.84). HIV prevalence is lower among MSM in rural areas compared to MSM in urban areas, but rural MSM report that they are more likely to face intolerance and are less likely to use basic HIV prevention services compared to urban MSM. Therefore, this hard-to-reach population could benefit from prevention services offered through the internet.

Linking young men who have sex with men (YMSM) to STI physicians: a nationwide cross-sectional survey in China

BACKGROUND

Many young men who have sex with men (YMSM) are reluctant to seek health services and trust local physicians. Online information seeking may encourage YMSM to identify and see trustworthy physicians, obtain sexual health services, and obtain testing for sexually transmitted infections (STIs). This study examined online STI information seeking behaviors among Chinese YMSM and its association with offline physician visits.

METHODS

We conducted a nationwide online survey among YMSM through WeChat, the largest social media platform in China. We collected information on individual demographics, sexual behaviors, online STI information seeking, offline STI testing, and STI physician visits. We examined the most commonly used platforms (search engines, governmental websites, counseling websites, generic social media, gay mobile apps, and mobile medical apps) and their trustworthiness. We assessed interest and willingness to use an MSM-friendly physician finder function embedded within a gay mobile app. Logistic regression models were used to examine the correlation between online STI information searching and offline physician visits.

RESULTS

A total of 503 men completed the survey. Most men (425/503, 84.5%) searched for STI information online. The most commonly used platform to obtain STI information were search engines (402/425, 94.5%), followed by gay mobile apps (201/425, 47.3%). Men reported high trustworthiness of information received from gay mobile apps. Men also reported high interest (465/503, 92.4%) and willingness (463/503, 92.0%) to use a MSM-friendly physician finder function within such apps. Both using general social media (aOR =1.14, 95%CI: 1.04-1.26) and mobile medical apps (aOR =1.16, 95%CI: 1.01-1.34) for online information seeking were associated with visiting a physician.

CONCLUSION

Online STI information seeking is common and correlated with visiting a physician among YMSM. Cultivating partnerships with the emerging mobile medical apps may be useful for disseminating STI information and providing better physician services to YMSM.

Linking young men who have sex with men (YMSM) to STI physicians: a nationwide cross-sectional survey in China

BACKGROUND

Many young men who have sex with men (YMSM) are reluctant to seek health services and trust local physicians. Online information seeking may encourage YMSM to identify and see trustworthy physicians, obtain sexual health services, and obtain testing for sexually transmitted infections (STIs). This study examined online STI information seeking behaviors among Chinese YMSM and its association with offline physician visits.

METHODS

We conducted a nationwide online survey among YMSM through WeChat, the largest social media platform in China. We collected information on individual demographics, sexual behaviors, online STI information seeking, offline STI testing, and STI physician visits. We examined the most commonly used platforms (search engines, governmental websites, counseling websites, generic social media, gay mobile apps, and mobile medical apps) and their trustworthiness. We assessed interest and willingness to use an MSM-friendly physician finder function embedded within a gay mobile app. Logistic regression models were used to examine the correlation between online STI information searching and offline physician visits.

RESULTS

A total of 503 men completed the survey. Most men (425/503, 84.5%) searched for STI information online. The most commonly used platform to obtain STI information were search engines (402/425, 94.5%), followed by gay mobile apps (201/425, 47.3%). Men reported high trustworthiness of information received from gay mobile apps. Men also reported high interest (465/503, 92.4%) and willingness (463/503, 92.0%) to use a MSM-friendly physician finder function within such apps. Both using general social media (aOR =1.14, 95%CI: 1.04-1.26) and mobile medical apps (aOR =1.16, 95%CI: 1.01-1.34) for online information seeking were associated with visiting a physician.

CONCLUSION

Online STI information seeking is common and correlated with visiting a physician among YMSM. Cultivating partnerships with the emerging mobile medical apps may be useful for disseminating STI information and providing better physician services to YMSM.

The clinical effectiveness of individual behaviour change interventions to reduce risky sexual behaviour after a negative human immunodeficiency virus test in men who have sex with men: systematic and realist reviews and intervention development

BACKGROUND

Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited.

OBJECTIVES

To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention.

DATA SOURCES

All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014.

REVIEW METHODS

A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation.

RESULTS

Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from 'goals and planning' and 'identity' groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation.

LIMITATIONS

There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity.

CONCLUSIONS

Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention.

FUTURE WORK

There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42014009500.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Online interventions to address HIV and other sexually transmitted and blood-borne infections among young gay, bisexual and other men who have sex with men: a systematic review

Introduction

Globally, young gay, bisexual and other men who have sex with men (gbMSM) continue to experience disproportionately high rates of HIV and other sexually transmitted and blood‐borne infections (STBBIs). As such, there are strong public health imperatives to evaluate innovative prevention, treatment and care interventions, including online interventions. This study reviewed and assessed the status of published research (e.g. effectiveness; acceptability; differential effects across subgroups) involving online interventions that address HIV/STBBIs among young gbMSM.

Methods

We searched Medline, Embase, PsycINFO, CINAHL, and Google Scholar to identify relevant English‐language publications from inception to November 2016. Studies that assessed an online intervention regarding the prevention, care, or treatment of HIV/STBBIs were included. Studies with <50% gbMSM or with a mean age ≥30 years were excluded.

Results

Of the 3465 articles screened, 17 studies met inclusion criteria. Sixteen studies assessed interventions at the “proof‐of‐concept” phase, while one study assessed an intervention in the dissemination phase. All of the studies focused on behavioural or knowledge outcomes at the individual level (e.g. condom use, testing behaviour), and all but one reported a statistically significant effect on ≥1 primary outcomes. Twelve studies described theory‐based interventions. Twelve were conducted in the United States, with study samples focusing mainly on White, African‐American and/or Latino populations; the remaining were conducted in Hong Kong, Peru, China, and Thailand. Thirteen studies included gay and bisexual men; four studies did not assess sexual identity. Two studies reported including both HIV+ and HIV− participants, and all but one study included one or more measure of socio‐economic status. Few studies reported on the differential intervention effects by socio‐economic status, sexual identity, race or serostatus.

Conclusion

While online interventions show promise at addressing HIV/STBBI among young gbMSM, to date, little emphasis has been placed on assessing: (i) potential differential effects of interventions across subgroups of young gbMSM; (ii) effectiveness studies of interventions in the dissemination phase; and (iii) on some “key” populations of young gbMSM (e.g. those who are: transgender, from low‐income settings and/or HIV positive). Future research that unpacks the potentially distinctive experiences of particular subgroups with “real world” interventions is needed.

Feasibility and Preliminary Effectiveness of the Homework Intervention Strategy (eHIS) Program to Enhance Male Condom Use: Research Protocol

BACKGROUND

Although condoms are effective in reducing the risk of sexually transmitted infections (STIs) and unintended pregnancy, they are still often not used consistently and correctly. Negative impact on sensation and pleasure, ruining the mood, causing problems with maintaining erection, and condom slippage or breakage are some of the reasons given by men explaining why they do not want to use condoms. Although many interventions promoting condom use exist, some of them delivered online are complex and time- and resource-intensive. The Homework Intervention Strategy (eHIS) program, adapted from the existing face-to-face Kinsey Institute Homework Intervention Strategy (KIHIS) program, aims to address these issues by encouraging men to focus on sensation and pleasure when trying different types of condoms and lubricants in a low-pressure situation (on their own, without a partner present).

OBJECTIVE

The objectives of this study are to assess the feasibility, acceptability, and users' engagement with the eHIS program, its preliminary effectiveness in increasing condom use frequency and consistency, as well as the feasibility of the program's evaluation approach, including choice of measures and participant recruitment and retaining strategies (primary outcomes). Secondary outcomes include condom use experience, condom use attitudes, condom use self-efficacy, condom use errors and problems, and condom fit-and-feel. All of these will be analyzed in the context of participants' demographics, sexual history, and previous condom use.

METHODS

The study has a pre-post-test, within-subjects design. Men aged 18 to 69 and living in the United Kingdom are recruited through posters, leaflets, social media, and emails. Study participants are asked to complete T1 (baseline) measures before entering the eHIS website. After completing the T1 measures, they can order a free condoms and lubricants kit and have access to the eHIS website for 4 weeks. During that time they are asked to practice using different types of condoms and lubricants on their own in a no-pressure situation. Following T1, participants are asked to complete the T2 and T3 measures at 4 and 10 weeks, respectively.

RESULTS

Data collection for the study is completed. Data analysis is in progress and is expected to be completed by February 2018.

CONCLUSIONS

This brief, home-based, self-guided program may lead to increased consistent and correct condom use. Online delivery can make the program an easily accessible and low-cost health promotion intervention, which has the potential to reach a wide and diverse audience. If results of the current study show the program's feasibility and preliminary effectiveness in changing condom use related outcomes, a larger scale randomized controlled trial (RCT) will be conducted.

TRIAL REGISTRATION

Research Registry: researchregistry2325; http://www.researchregistry.com/browse-the-registry.html# home/registrationdetails/58da6cad1d7ab0314337d076/ (Archived by WebCite at http://www.webcitation.org/6vXs6S9XW).

Correlates of Never Testing for HIV Among Sexually Active Internet-Recruited Gay, Bisexual, and Other Men Who Have Sex with Men in the United States

In the United States, gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by the HIV/AIDS epidemic. Despite great strides in HIV prevention, including biobehavioral HIV prevention strategies such as pre-exposure prophylaxis and treatment as prevention, there has been relatively low uptake of these strategies. The success of biobehavioral prevention strategies requires HIV testing but a subset of GBMSM have never been tested. To optimize prevention efforts, we sought to understand the characteristics of GBMSM who report never testing for HIV. A sample of GBMSM was recruited online in 2012 to complete a cross-sectional survey of sexual behavior and sexual health. Bivariate and multivariable analyses were used to identify characteristics of "never testing for HIV." Of the 1170 participants, 151 (13%) reported never testing for HIV. In multivariable analyses, younger age, less education, endorsing a non-gay sexual identity, living in rural areas, not having a primary partner, living in unstable housing, and reporting regular condom use during anal sex were independently associated with never testing. We conclude that, despite a substantial focus on HIV testing among GBMSM in the United States, a proportion of sexually active, adult GBMSM report never having tested for HIV in their lifetimes. The current study illustrates the importance of addressing individual and structural factors that serve as barriers to HIV testing among GBMSM. Addressing these barriers will improve access to HIV testing and other biobehavioral HIV prevention strategies and, ultimately, alleviate disparities in HIV/AIDS in the United States.

The emergence of ethical issues in the provision of online sexual health outreach for gay, bisexual, two-spirit and other men who have sex with men: perspectives of online outreach workers

BACKGROUND

Mobile applications and socio-sexual networking websites are used by outreach workers to respond synchronously to questions and provide information, resources, and referrals on sexual health and STI/HIV prevention, testing, and care to gay, bisexual and other men who have sex with men (GB2M). This exploratory study examined ethical issues identified by online outreach workers who conduct online sexual health outreach for GB2M.

METHODS

Semi-structured individual interviews were conducted between November 2013 and April 2014 with online providers and managers (n = 22) to explore the benefits, challenges, and ethical implications of delivering online outreach services in Ontario, Canada. Interviews were digitally recorded and transcribed verbatim. Thematic analyses were conducted, and member-checking, analyses by multiple coders, and peer debriefing supported validity and reliability.

RESULTS

Four themes emerged on the ethical queries of providing online sexual health outreach for GB2M: (a) managing personal and professional boundaries with clients; (b) disclosing personal or identifiable information to clients; (c) maintaining client confidentiality and anonymity; and (d) security and data storage measures of online information. Participants illustrated familiarity with potential ethical challenges, and discussed ways in which they seek to mitigate and prevent ethical conflict.

CONCLUSIONS

Implications of this analysis for outreach workers, researchers, bioethicists, and policy-makers are to: (1) understand ethical complexities associated with online HIV prevention and outreach for GB2M; (2) foster dialogue to recognize and address potential ethical conflict; and (3) identify competencies and skills to mitigate risk and promote responsive and accessible online HIV outreach.

Gay Men's Understanding and Education of New HIV Prevention Technologies in Vancouver, Canada

Effective rollout of HIV treatment-based prevention such as pre-exposure prophylaxis and treatment as prevention has been hampered by poor education, limited acceptability, and stigma among gay men. We undertook a thematic analysis regarding the education sources and acceptability of these New Prevention Technologies (NPTs) using 15 semistructured interviews with gay men in Vancouver, Canada, who were early adopters of NPTs. NPT education was derived from a variety of sources, including the Internet, health care providers, community organizations, sexual partners, and peers; participants also emphasized their own capacities as learners and educators. Acceptable forms of NPT education featured high-quality factual information, personal testimony, and easy access. Stigma was highlighted as a major barrier. For public health, policy makers, and gay communities to optimize the personal and population benefits of NPTs, there is a need for increased community support and dialogue, antistigma efforts, early NPT adopter testimony, and personalized implementation strategies.

What Men Who Have Sex With Men in Peru Want in Internet-Based Sexual Health Information

We aimed to gather information among gay men regarding their preferences for online sexual health information; 1,160 Peruvian MSM, 18 years or older, completed an online survey hosted on www.tunexo.org . The mean age was 26.8 years. Around 90% had post-high school education. The self-reported HIV prevalence was 12.3%. The acceptability of sexual health content was greater in the most highly educated group. The highest rated topics and services of interest were those related to improving sexual and mental health. The least educated group was significantly more interested in "getting prevention messages on mobiles" compared to men with the highest level of education (71% vs. 52%; p < 0.001). Men's sexual health was of more interest to the 30-39-year-old group compared to the 18-24-year-old one (97% vs. 87%; p = 0.005). Future Web-based interventions related to sexual health among targeted groups of MSM in Peru can be tailored to meet their preferences.

Acting within an increasingly confined space: A qualitative study of sexual behaviours and healthcare needs among men who have sex with men in a provincial Tanzanian city

Objective

To explore risk perceptions, sexual practices and healthcare needs among men who have sex with men in the provincial city of Tanga in northern Tanzania. Previous research suggests that HIV/STIs are increasing problems for this population. Yet, few studies have been conducted outside the urban area of Dar es Salaam, which has limited our knowledge about the HIV/STI risk factors and healthcare needs among men who have sex with men who live outside major metropolitan areas.

Method

During three months in 2013, 10 in-depth interviews with men who have sex with men were conducted in Tanga. Data were interpreted through qualitative content analysis.

Results

The theme that emerged was labelled “Acting within an increasingly confined space”. The theme reflects the interference of stigma in men’s lives, and in the face of potential discrimination, men perceived their sexual and healthcare choices as limited. This created obstacles for forming romantic and sexual relationships, insisting on consistent condom use with sexual partners, maintaining open and conducive relationships with family, and accessing healthcare services when required.

Conclusions

Sexual stigma is a concern as it contributes to HIV/STI risk-related behaviours among men who have sex with men. Priority should be given to programmes that support same-sex practicing men in their efforts to make informed choices regarding their sexual health. Creating safe cyber networks provides an opportunity to reach this population with targeted sexual health education messages. Such programmes might be even more urgent in smaller towns and rural areas where gay specific initiatives are more limited than in urban areas.

Home-Based HIV Testing and Counseling for Male Couples (Project Nexus): A Protocol for a Randomized Controlled Trial

BACKGROUND

HIV prevalence remains high among men who have sex with men (MSM) in the United States, yet the majority of research has focused on MSM as individuals, not as dyads, and has discussed HIV risks primarily in the context of casual sex. Nexus is an online prevention program that combines home-based HIV testing and couples HIV testing and counseling (CHTC). It allows partners in dyadic MSM relationships to receive HIV testing and care in the comfort of their designated residence, via video-based chat. By using video-based technologies (eg, VSee video chat), male couples receive counseling and support from a remote online counselor, while testing for HIV at home.

OBJECTIVE

This randomized control trial (RCT) aims to examine the effects of video-based counseling combined with home-based HIV testing on couples' management of HIV risk, formation and adherence to explicit sexual agreements, and sexual risk-taking.

METHODS

The research implements a prospective RCT of 400 online-recruited male couples: 200 self-reported concordant-negative couples and 200 self-reported discordant couples. Couples in the control arm will receive one or two home-based HIV self-testing kits and will be asked to report their results via the study's website. Couples in the experimental arm will receive one or two home-based HIV self-testing kits and will conduct these tests together under the facilitation of a remotely located counselor during a prescheduled VSee-based video CHTC session. Study assessments are taken at baseline, as well as at 3- and 6-month follow-up sessions.

RESULTS

Project Nexus was launched in April 2016 and is ongoing. To date, 219 eligible couples have been enrolled and randomized.

CONCLUSIONS

Combining home-based HIV testing with video-based counseling creates an opportunity to expand CHTC to male couples who (1) live outside metro areas, (2) live in rural areas without access to testing services or LGBTQ resources, or (3) feel that current clinic-based testing is not for them (eg, due to fears of discrimination associated with HIV and/or sexuality).

TRIAL REGISTRATION

ClinicalTrials.gov NCT02335138; https://clinicaltrials.gov/ct2/show/NCT02335138 (Archived by WebCite at http://www.webcitation.org/6qHxtNIdW).

Culturally Competent Sexual Healthcare as a Prerequisite for Obtaining Preexposure Prophylaxis: Findings from a Qualitative Study

PURPOSE

Men who have sex with men (MSM) experience stigma in healthcare settings, which impedes disclosure of sexual behavior, potentially limiting uptake of preexposure prophylaxis (PrEP). The purpose of this study was to describe the context of this limitation and explore geographical variability.

METHODS

To understand how discomfort in healthcare settings affects PrEP utilization, we conducted two online focus groups with geographically diverse samples of MSM.

RESULTS

Respondents identified primary care providers as preferred sources for PrEP, but potential uptake was limited by barriers to establishing nonjudgmental relationships with these providers.

CONCLUSION

Improved patient-provider communication about sexual behaviors might increase PrEP use among MSM.

Usability and Acceptability of a Mobile Comprehensive HIV Prevention App for Men Who Have Sex With Men: A Pilot Study

Background

Men who have sex with men (MSM) are the group most impacted by the human immunodeficiency virus (HIV) epidemic and the only subgroup in the United States among which new HIV diagnoses are not decreasing. To achieve the US National HIV/AIDS (acquired immunodeficiency syndrome) Strategy goals of reducing new diagnoses by 25%, high (eg, 30-50%) coverage of multiple HIV prevention interventions is needed in both urban and rural areas. Mobile phone “apps” are an important channel through which prevention services could be provided at scale and at low marginal cost.

Objective

The aim of this study was to evaluate the usability and acceptability of a theory-based Android mobile phone app for HIV prevention.

Methods

The app included self-assessment tools; prevention recommendations; commodity (condoms, HIV self-tests) ordering; reminders to MSM for basic HIV prevention services, HIV testing, condom use, screening for preexposure prophylaxis (PrEP) and nonoccupational postexposure prophylaxis (nPEP); and prevention and treatment provider locators. The study recruited HIV-negative, Android-using MSM in Atlanta and Seattle who were asked to use the app for 4 months and complete a post-use survey. We measured the use of the app and its features, ordering of commodities, self-report of establishing an HIV testing plan, being HIV tested in the community, and starting PrEP or using nPEP. Usability was assessed using the system usability scale (SUS).

Results

A total of 121 MSM were enrolled (59.5%, 72/121 from Atlanta; 40.5%, 49/121 from Seattle). Median age was 28. Nearly half (48.8%, 59/121) were nonwhite, and most (85.9%, 104/121) were gay-identified. Most had tested for HIV in the past (85.1%, 103/121), and 52 (43.0%, 52/121) had a plan to test for HIV regularly. Men used the app for an average of 17.7 minutes over the first 4 months. Over the 4-month period, over half ordered condoms (63.6%, 77/121) and HIV test kits (52.8%, 64/121) on the app. Eight of 86 (9%) PrEP-eligible MSM started PrEP during the 4-month period; of those, 6 of the 8 reported that the app influenced their decision to start PrEP. The mean SUS was 73 (above average).

Conclusions

A theory-based mobile phone app was acceptable to MSM and was rated as having above-average usability. Most men used the commodity-ordering features of the app during the 4-month evaluation period, and nearly 1 in 10 PrEP-eligible men started PrEP, with most attributing their decision to start PrEP in part to the app. A broader, randomized controlled study of the impact of the app on uptake of prevention behaviors for MSM is warranted.

The Harnessing Online Peer Education (HOPE) Intervention for Reducing Prescription Drug Abuse: A Qualitative Study

Social media technologies are newly emerging tools that can be used to address the growing prescription drug epidemic. In this study, we sought to determine the feasibility and acceptability of using social media to reduce complications of opioid use among patients experiencing chronic pain. Specifically, we evaluated the utility of the Harnessing Online Peer Education (HOPE) social media intervention to reduce the risk of addiction and overdose among non-cancer pain patients receiving chronic opioid therapy. University of California, Los Angeles (UCLA) patients receiving chronic opioid therapy and UCLA staff were invited to participate in interviews regarding the HOPE intervention. Questions focused on resources used to manage pain, the limitations and benefits of these approaches, and the likelihood of using an online community to reduce complications of opioid therapy. Using an open-coding process, three topics were identified for the patients: 1) online social support is important for improving outcomes, 2) offline social support is helpful for some patients but has limitations, and 3) a tailored, online peer support intervention is needed. Interviews with staff confirmed these results. The HOPE social media intervention and other online communities appear to be an acceptable technology for patients on chronic opioid therapy.

Safe Sex Messages Within Dating and Entertainment Smartphone Apps: A Review

Background

Smartphone apps provide a new platform for entertainment, information distribution, and health promotion activities, as well as for dating and casual sexual encounters. Previous research has shown high acceptability of sexual health interventions via smartphone apps; however, sexual health promotion apps were infrequently downloaded and underused. Integrating sexual health promotion into established apps might be a more effective method.

Objective

The objective of our study was to critically review popular sex-related apps and dating apps, in order to ascertain whether they contain any sexual health content.

Methods

Part 1: In January 2015, we used the term “sexual” to search for free apps in the Apple iTunes store and Android Google Play store, and categorized the sexual health content of the 137 apps identified. Part 2: We used the term “dating” to search for free geosocial-networking apps in the Apple iTunes and Android Google Play stores. The apps were downloaded to test functionality and to determine whether they included sexual health content.

Results

Part 1: Of the 137 apps identified, 15 (11.0%) had sexual health content and 15 (11.0%) contained messages about sexual assault or violence. The majority of the apps did not contain any sexual health content. Part 2: We reviewed 60 dating apps: 44 (73%) targeting heterosexual users, 9 (15%) targeting men who have sex with men (MSM), 3 (5%) targeting lesbian women, and 4 (7%) for group dating. Only 9 dating apps contained sexual health content, of which 7 targeted MSM.

Conclusions

The majority of sex-related apps and dating apps contained no sexual health content that could educate users about and remind them of their sexual risks. Sexual health practitioners and public health departments will need to work with app developers to promote sexual health within existing popular apps. For those apps that already contain sexual health messages, further study to investigate the effectiveness of the content is needed.

Brief interventions to prevent sexually transmitted infections suitable for in-service use: A systematic review

BACKGROUND

Sexually transmitted infections (STIs) are more common in young people and men who have sex with men (MSM) and effective in-service interventions are needed.

METHODS

A systematic review of randomized controlled trials (RCTs) of waiting-room-delivered, self-delivered and brief healthcare-provider-delivered interventions designed to reduce STIs, increase use of home-based STI testing, or reduce STI-risk behavior was conducted. Six databases were searched between January 2000 and October 2014.

RESULTS

17,916 articles were screened. 23 RCTs of interventions for young people met our inclusion criteria. Significant STI reductions were found in four RCTs of interventions using brief one-to-one counselling (2 RCTs), video (1 RCT) and a STI home-testing kit (1 RCT). Increase in STI test uptake was found in five studies using video (1 RCT), one-to-one counselling (1 RCT), home test kit (2 RCTs) and a web-based intervention (1 RCT). Reduction in STI-risk behavior was found in seven RCTs of interventions using digital online (web-based) and offline (computer software) (3 RCTs), printed materials (1 RCT) and video (3 RCTs). Ten RCTs of interventions for MSM met our inclusion criteria. Three tested for STI reductions but none found significant differences between intervention and control groups. Increased STI test uptake was found in two studies using brief one-to-one counselling (1 RCT) and an online web-based intervention (1 RCT). Reduction in STI-risk behavior was found in six studies using digital online (web-based) interventions (4 RCTs) and brief one-to-one counselling (2 RCTs).

CONCLUSION

A small number of interventions which could be used, or adapted for use, in sexual health clinics were found to be effective in reducing STIs among young people and in promoting self-reported STI-risk behavior change in MSM.

The HOPE social media intervention for global HIV prevention in Peru: a cluster randomised controlled trial

BACKGROUND

Social media technologies offer new approaches to HIV prevention and promotion of testing. We examined the efficacy of the Harnessing Online Peer Education (HOPE) social media intervention to increase HIV testing among men who have sex with men (MSM) in Peru.

METHODS

In this cluster randomised controlled trial, Peruvian MSM from Greater Lima (including Callao) who had sex with a man in the past 12 months, were 18 years of age or older, were HIV negative or serostatus unknown, and had a Facebook account or were willing to create one (N=556) were randomly assigned (1:1) by concealed allocation to join intervention or control groups on Facebook for 12 weeks. For the intervention, Peruvian MSM were trained and assigned to be HIV prevention mentors (peer-leaders) to participants in Facebook groups. The interventions period lasted 12 weeks. Participants in control groups received an enhanced standard of care, including standard offline HIV prevention available in Peru and participation in Facebook groups (without peer leaders) that provided study updates and HIV testing information. After accepting a request to join the groups, continued participation was voluntary. Participants also completed questionnaires on HIV risk behaviours and social media use at baseline and 12 week follow-up. The primary outcome was the number of participants who received a free HIV test at a local community clinic. The facebook groups were analysed as clusters to account for intracluster correlations. This trial is registered with ClinicalTrials.gov, number NCT01701206.

FINDINGS

Of 49 peer-leaders recruited, 34 completed training and were assigned at random to the intervention Facebook groups. Between March 19, 2012, and June 11, 2012, and Sept 26, 2012, and Dec 19, 2012, 556 participants were randomly assigned to intervention groups (N=278) or control groups (N=278); we analyse data for 252 and 246. 43 participants (17%) in the intervention group and 16 (7%) in the control groups got tested for HIV (adjusted odds ratio 2·61, 95% CI 1·55–4·38). No adverse events were reported.

INTERPRETATION

Development of peer-mentored social media communities seemed to be an efficacious method to increase HIV testing among high-risk populations in Peru. Results suggest that the HOPE social media intervention could improve HIV testing rates among MSM in Peru.

FUNDING

National Institute of Mental Health.

Project SMART: Preliminary Results From a Test of the Efficacy of a Swedish Internet-Based HIV Risk-Reduction Intervention for Men Who Have Sex With Men

In Sweden, 57 % of HIV transmission occurs among MSM, and other sexually transmitted infections are increasing, supporting the need for innovative interventions. The Internet is a potentially useful HIV-prevention platform, but there is a lack of such programs in Sweden. The purpose of this exploratory study was to test the efficacy of the Internet-based SMART intervention to decrease HIV sexual risks in Swedish MSM. The intervention was adapted from the Wyoming Rural AIDS Prevention Project to the Swedish context, which was guided by the Information-Motivation-Behavioral (IMB) skills model and consisted of six sessions. A total of 112 men responded to a pretest questionnaire and were randomly assigned to the SMART intervention or to a waitlist group. Fifty-four men dropped out, leaving a final sample of 58 participants. Twenty-five were assigned to the SMART intervention and 33 to a waitlist group. One month post intervention, the number of casual anal sex partners significantly decreased (t = 2.19, p = .04). Compared with the waitlist group, men in the intervention group increased their HIV knowledge (β = 0.70, p = .01), their belief of condom use as an act of responsibility (β = 1.19, p = .04), their willingness to use a condom with every new partner all the time (β = 1.39, p = .03), and their confidence in using condoms in challenging situations (β = 1.65, p = .02). Condom use was not analyzed due to the small sample size. Despite the small sample, high drop-out, and short follow-up, the study provides support for the efficacy of the Internet interventions, the SMART intervention specifically, for reducing the proportion of casual anal sex partners and improving the three cognitive components of the IMB model for Swedish MSM.

Use of the Internet to Meet Sexual Partners, Sexual Risk Behavior, and Mental Health in Transgender Adults

The purpose of this study was to examine the use of the internet to meet sexual partners among transgender individuals and examine correlates of this use, including sexual risk behavior, discrimination experiences, and mental health. A sample of 166 transgender adults (112 male-to-female transgender women and 54 female-to-male transgender men) were recruited in community venues and anonymously completed measures assessing these variables. Most participants (64.5 %) were HIV-negative, 25.2 % were HIV-positive, and 10.3 % did not know their HIV status. Overall, 33.7 % of participants reported having met a sexual partner over the internet, which did not differ significantly between transgender women and men. Among these individuals, transgender women reported significantly more lifetime internet sexual partners (median = 3) than transgender men (median = 1). Use of the internet to meet sexual partners was associated with lower self-esteem but not with depression, anxiety, somatic distress or discrimination experiences. Among transgender women, use of the internet to meet sexual partners was associated with each of the 11 sexual risk behaviors examined, including having multiple partners, sex under the influence of drugs, number of unprotected anal or vaginal sex acts, and history of commercial sex work. The use of the internet to meet partners was not associated with sexual risk behavior among transgender men (0/11 variables assessed). Although the internet is a common mode of meeting sexual partners among some transgender adults, it may also be a potential venue for prevention interventions targeting transgender individuals at particularly high risk for HIV acquisition.

Reducing cyberbullying: A theory of reasoned action-based video prevention program for college students

Few studies have evaluated the effectiveness of cyberbullying prevention/intervention programs. The goals of the present study were to develop a Theory of Reasoned Action (TRA)-based video program to increase cyberbullying knowledge (1) and empathy toward cyberbullying victims (2), reduce favorable attitudes toward cyberbullying (3), decrease positive injunctive (4) and descriptive norms about cyberbullying (5), and reduce cyberbullying intentions (6) and cyberbullying behavior (7). One hundred sixty-seven college students were randomly assigned to an online video cyberbullying prevention program or an assessment-only control group. Immediately following the program, attitudes and injunctive norms for all four types of cyberbullying behavior (i.e., unwanted contact, malice, deception, and public humiliation), descriptive norms for malice and public humiliation, empathy toward victims of malice and deception, and cyberbullying knowledge significantly improved in the experimental group. At one-month follow-up, malice and public humiliation behavior, favorable attitudes toward unwanted contact, deception, and public humiliation, and injunctive norms for public humiliation were significantly lower in the experimental than the control group. Cyberbullying knowledge was significantly higher in the experimental than the control group. These findings demonstrate a brief cyberbullying video is capable of improving, at one-month follow-up, cyberbullying knowledge, cyberbullying perpetration behavior, and TRA constructs known to predict cyberbullying perpetration. Considering the low cost and ease with which a video-based prevention/intervention program can be delivered, this type of approach should be considered to reduce cyberbullying.

Online Outreach Services Among Men Who Use the Internet to Seek Sex With Other Men (MISM) in Ontario, Canada: An Online Survey

BACKGROUND

Men who use the Internet to seek sex with other men (MISM) are increasingly using the Internet to find sexual health information and to seek sexual partners, with some research suggesting HIV transmission is associated with sexual partnering online. Aiming to "meet men where they are at," some AIDS service organizations (ASOs) deliver online outreach services via sociosexual Internet sites and mobile apps.

OBJECTIVE

To investigate MISM's experiences and self-perceived impacts of online outreach.

METHODS

From December 2013 to January 2014, MISM aged 16 years or older were recruited from Internet sites, mobile apps, and ASOs across Ontario to complete a 15-minute anonymous online questionnaire regarding their experience of online outreach. Demographic factors associated with encountering online outreach were assessed using backward-stepwise multivariable logistic regression (P<.05 was considered significant).

RESULTS

Of 1830 MISM who completed the survey, 8.25% (151/1830) reported direct experience with online outreach services. Encountering online outreach was more likely for Aboriginal versus white MISM, MISM from Toronto compared with MISM from either Eastern or Southwestern Ontario, and MISM receiving any social assistance. MISM who experienced online outreach felt the service provider was friendly (130/141, 92.2%), easy to understand (122/140, 87.1%), helpful (115/139, 82.7%), prompt (107/143, 74.8%), and knowledgeable (92/134, 68.7%); half reported they received a useful referral (49/98, 50%). Few MISM felt the interaction was annoying (13/141, 9.2%) or confusing (18/142, 12.7%). As a result of their last online outreach encounter, MISM reported the following: better understanding of (88/147, 59.9%) and comfort with (75/147, 51.0%) their level of sexual risk; increased knowledge (71/147, 48.3%); and feeling less anxious (51/147, 34.7%), better connected (46/147, 31.3%), and more empowered (40/147, 27.2%). Behaviorally, they reported using condoms more frequently (48/147, 32.7%) and effectively (35/147, 23.8%); getting tested for HIV (43/125, 34.4%) or STIs (42/147, 28.6%); asking for their partners' HIV statuses (37/147, 25.2%); and serosorting (26/147, 17.7%). Few MISM reported no changes (15/147, 10.2%) and most would use these services again (98/117, 83.8%). Most MISM who did not use online outreach said they did not need these services (1074/1559, 68.89%) or were unaware of them (496/1559, 31.82%).

CONCLUSIONS

This is the first online outreach evaluation study of MISM in Canada. Online outreach services are a relatively new and underdeveloped area of intervention, but are a promising health promotion strategy to provide service referrals and engage diverse groups of MISM in sexual health education.