Technology-Delivered Intervention Strategies to Bolster HIV Testing

A citizen science approach to develop a digital intervention to reduce HIV stigma and promote HIV self-testing among adolescents and young adults: a mixed methods analysis from Kazakhstan

INTRODUCTION

Kazakhstan has one of the fastest-growing HIV epidemics in the world, with increasing rates among adolescents and young adults (AYA). Innovative strategies are needed to increase HIV testing uptake and decrease HIV stigma among AYA. Citizen science, defined as the active engagement of the general public in scientific research tasks, promotes and facilitates community engagement throughout the research process. This citizen science study used crowdsourcing to engage AYA in Kazakhstan to develop a digital intervention to reduce HIV stigma and promote HIV self-testing. Our objectives in this paper are to describe the approach used, its feasibility and acceptability, and AYA motivations for and lessons learned collaborating on the study.

METHODS

From October 2021 to July 2022, in collaboration with a Community Collaborative Research Board and a Youth Advisory Board, we developed an open call requesting multimedia submissions to reduce HIV testing stigma. Eligible submissions were separated by age group (13-19 or 20-29 years) and judged by a panel composed of AYA (n = 23), healthcare professionals (n = 12), and representatives from the local government and non-governmental organizations (n = 17). Each entry was reviewed by at least four judges and ranked on a 5-point scale. The top 20 open call contestants were asked to submit self-recordings sharing their motivation for and experience participating in the contest and lessons learned. Descriptive statistics were calculated for quantitative data. Qualitative data were coded using open coding.

RESULTS

We received 96 submissions from 77 youth across Kazakhstan. Roughly, three-quarters (n = 75/96) of entries met judging eligibility criteria. Of the eligible entries, over half (n = 39/75) scored 3.5 or higher on a 5-point scale (70.0%). The most frequent types of entries were video (n = 36/96, 37.5%), image (n = 28/96, 29.2%) and text (n = 24/96, 25.0%). AYA's primary motivations for collaborating on the study included a desire to improve society and help youth. The main challenges included creating content to address complex information using simple language, finding reliable information online and technological limitations.

CONCLUSIONS

Crowdsourcing was feasible and highly acceptable among AYA in Kazakhstan. Citizen science approaches hold great promise for addressing the increasingly complex health and social challenges facing communities today.

Men's Willingness to Receive Text Messages and Talk with an HIV counselor from the National HIV Hotline in Tanzania for Support with Linkage to Care Following HIV self-testing

Background

Tanzania faces a significant burden of HIV, with particular challenges in reaching men and ensuring timely linkage to care. To address these issues, HIV self-testing (HIVST) has been implemented to increase HIV testing and the National HIV Hotlines are being considered as a strategy to facilitate linkage to care. This study aimed to assess the willingness of Tanzanian men to receive support from use the National HIV Hotline via mobile phones for HIVST and linkage to care.

Methods

Data from 505 men from the baseline survey of a cluster-randomized controlled trial conducted in June 2019 with 18 social networks or "camps" in Dar es Salaam, Tanzania. Participants were 18-year-old or older male camp members who were HIV-negative at the time of enrolment. Logistic regression models were used to assess factors associated with men's comfort with talking with an HIV counselor over the phone.

Results

There were 505 heterosexual male participants enrolled in the study with an average age of 29 years. Logistic regression demonstrated that comfortability texting a friend about HIV self-testing (OR =3.37, 95% CI [1.97 - 5.76], being comfortable texting a friend about HIV (OR = 3.84, 95% CI [2.20 - 6.72], previous history of receiving HIV related text messages (aOR = 0.55, 95% CI [0.31 - 0.99] were significantly associated with men's s comfortability talking to a HIV counselor on the National HIV Hotline following HIVST. The factors such as participants' comfortability texting friend about HIVST (OR = 2.52, 95% CI [1.49 - 4.25]) and comfortability texting friend about HIV (OR = 2.96, 95% CI [1.83 - 4.80] were significantly associated with the probability of participant's comfortability receiving text message from HIV counselor following HIVST.

Conclusion

These findings suggest an effort to develop and implement a user-friendly digital health intervention that promote comfortability, address private concerns, and deliver tailored support and information to individuals following HIV self-testing.

Digital Interventions to Enhance PrEP Uptake and Adherence Through Stigma Reduction

PURPOSE OF REVIEW

Although pre-exposure prophylaxis (PrEP) is effective for reducing risk of HIV transmission, stigma persists as a barrier to HIV prevention. Digital technologies present opportunities to access hard-to-reach populations and increase the efficiency of established interventions. This review examines current digital interventions addressing stigma to improve PrEP-related outcomes.

RECENT FINDINGS

Digital technologies are increasingly used for HIV prevention and include a wide range of formats. Recent interventions focused on stigma and PrEP tend to engage mobile phone-related technology and focus on younger populations with particular attention to men who have sex with men and transgender women. Digital interventions that address stigma are promising for improving PrEP-related outcomes. No single technology currently demonstrates consistent superiority. Limited access to PrEP and heightened stigma in under-resourced countries present challenges for interventions supporting diverse communities. Further research should examine how digital interventions can reduce stigma beyond the individual level to enhance PrEP use and explore opportunities to improve and integrate approaches to stigma measurement.

Potential application of conversational agents in HIV testing uptake among high-risk populations

Human Immunodeficiency Virus (HIV) continues to be a significant public health problem, with ~1.2 million Americans living with HIV and ~14% unaware of their infection. The Centers for Disease Control and Prevention recommends that patients 13 to 64 years of age get screened for HIV at least once, and those with higher risk profiles screen at least annually. Unfortunately, screening rates are below recommendations for high-risk populations, leading to problems of delayed diagnosis. Novel technologies have been applied in HIV research to increase prevention, testing and treatment. Conversational agents, with potential for integrating artificial intelligence and natural language processing, may offer an opportunity to improve outreach to these high-risk populations. The feasibility, accessibility and acceptance of using conversational agents for HIV testing outreach is important to evaluate, especially amidst a global coronavirus disease 2019 pandemic when clinical services have been drastically affected. This viewpoint explores the application of a conversational agent in increasing HIV testing among high-risk populations.

The future of HIV testing in eastern and southern Africa: Broader scope, targeted services

In this Policy Forum, Anna Grimsrud and colleagues discuss the future of HIV testing in eastern and southern Africa, using insights gleaned from a 2021 expert consultation.

Potential Role of Conversational Agents in Encouraging PrEP Uptake

Approximately 1.2 million people are living with HIV, with many of them unaware of their infection. Pre-exposure prophylaxis (PrEP) is available to minimize transmission among those at high risk for infection, including men who have sex with men, people who inject drugs, and female sex workers. Despite its availability, there is low usage of PrEP. To address this problem, various digital tools have been examined in HIV research. Among those, conversational agents are still underused and their capacity warrants examination to reach at-risk populations. In this paper, we discuss the potential of conversational agents in increasing uptake of PrEP by addressing barriers experienced among those at high risk for infection.

Interventions to enhance testing, linkage to care, and treatment initiation for hepatitis C virus infection: a systematic review and meta-analysis

BACKGROUND

Despite the goal set by WHO to eliminate hepatitis C virus (HCV) as a public health threat, uptake of HCV testing and treatment remains low. To achieve this target, evidence-based interventions are needed to address the barriers to care for people with, or at risk of, HCV infection. We aimed to assess the efficacy of interventions to improve HCV antibody testing, HCV RNA testing, linkage to HCV care, and treatment initiation.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE (PubMed), Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and PsycINFO without language restrictions for reports published between database inception and July 21, 2020, assessing the following primary outcomes: HCV antibody testing; HCV RNA testing; linkage to HCV care; and direct-acting antiviral treatment initiation. We also searched key conference abstracts. We included randomised and non-randomised studies assessing non-pharmaceutical interventions that included a comparator or control group. Studies were excluded if they enrolled only paediatric populations (aged <18 years) or if they conducted the intervention in a different health-care setting to that of the control or comparator. Authors were contacted to clarify study details and to obtain additional population-level data. Data were extracted from the records identified into a pre-piloted and standardised data extraction form and a random-effects meta-analysis was used to pool the effects of the interventions on study outcomes. This study is registered in PROSPERO, CRD42020178035.

FINDINGS

Of 15 342 unique records identified, 142 were included, which reported on 148 unique studies (47 randomised controlled trials and 101 non-randomised studies). Medical chart reminders, provider education, and point-of-care antibody testing significantly improved at least three study outcomes compared with a comparator or control. Interventions that simplified HCV testing, including dried blood spot testing, point-of-care antibody testing, reflex RNA testing, and opt-out screening, significantly improved testing outcomes compared with a comparator or control. Enhanced patient and provider support through patient education, provider care coordination, and provider education also significantly improved testing outcomes compared with a comparator or control. Integrated care and patient navigation or care coordination significantly improved linkage to care and the uptake of direct-acting antiviral treatment compared with a comparator or control.

INTERPRETATION

Several interventions to improve HCV care that address several key barriers to HCV care were identified. New models of HCV care must be designed and implemented to address the barriers faced by the population of interest. Further high-quality research, including rigorously designed randomised studies, is still needed in key populations.

FUNDING

None.

Technology-Based Interventions to Promote the HIV Preexposure Prophylaxis (PrEP) Care Continuum: Protocol for a Systematic Review

BACKGROUND

Preexposure prophylaxis (PrEP) is a promising biomedical intervention for HIV prevention. Researchers have proposed the PrEP care continuum to guide and evaluate PrEP implementation programs. Technology-based interventions (TBIs) have been widely used in HIV prevention and treatment programs, including for the promotion of the PrEP care continuum. The rapid development of new interventions using technology and electronic health methods emphasizes the need for a review of the effectiveness of these TBIs.

OBJECTIVE

The aim of this systematic review is to summarize the effectiveness and acceptability of TBIs used to promote the HIV PrEP care continuum.

METHODS

We will conduct a systematic literature search in PubMed, Embase, MEDLINE, PsycINFO, Web of Science, CINAHL, and the Cochrane Central Register of Controlled Trials following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Only intervention studies (ie, studies meeting the criteria of randomized controlled trials or quasi-experimental studies) evaluating the effectiveness of TBIs will be included. We will search the National Institutes of Health Research Portfolio Online Reporting Tools (NIH RePORT) for interventions involving PrEP. At least 2 reviewers will independently screen and select the studies, extract the data, and evaluate the quality of the studies, and discrepancies will be resolved by a senior author. We will provide a narrative synthesis of the included studies and present details about the study populations, interventions, and PrEP-related outcomes of significance.

RESULTS

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021249562). As of August 2021, we have completed the initial search and identified 1213 records. Study screening and data extracting are in progress. We expect the results to be ready by summer 2022.

CONCLUSIONS

The findings of this review will summarize successful experiences and lessons learned from the existing literature and therefore inform the design and implementation of intervention studies for PrEP care promotion.

TRIAL REGISTRATION

PROSPERO CRD42021249562; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=249562.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33045.

Individualized Provider Feedback Increased HIV and HCV Screening and Identification in a New York City Emergency Department

Efforts to end the HIV and hepatitis C virus (HCV) epidemics begin with ascertainment of a person's infection status through screening. Despite its importance as a site of testing, missed opportunities for screening in the Emergency Department (ED) are common. We describe the impact of implementing an individualized provider feedback intervention on HIV and HCV testing in a quaternary ED. We conducted an interrupted time series analysis to evaluate the impact of the intervention on weekly HIV and HCV screening in an observational cohort of patients seeking care in the ED. The intervention included a physician champion individualized feedback with peer comparisons to all providers in the ED and an existing HIV/HCV testing and response team. Data were abstracted from the electronic medical record (EMR) for 30 weeks before, during, and after implementing the intervention. We used Poisson regression analysis to estimate changes in the weekly counts and rates of HIV and HCV testing. The incidence rate ratios (IRRs) of HIV testing were 1.94 [95% confidence interval (CI) 1.85-2.04] and 1.38 (95% CI 1.31-1.45) times higher for the intervention and post-intervention period compared with the pre-intervention period. The IRRs of HCV testing was 6.96 (95% CI 6.40-7.58) and 4.70 (95% CI 4.31-5.13) for the intervention and post-intervention periods. There were no meaningful differences in demographic characteristics during the observation period. The intervention meaningfully increased HIV and HCV testing volume and positive case detection, including testing in high-risk groups like young adults and individuals without prior testing. Although diminished, the intervention effect sustained in the 30-week period following implementation.