Crowdsourcing HIV Test Promotion Videos: A Noninferiority Randomized Controlled Trial in China

Factors associated with HIV pre-exposure prophylaxis use among Asian men who have sex with men in Sydney and Melbourne, Australia: a cross-sectional study

Background

Asian-born MSM are a priority population as Australia aims to end HIV transmission, but they reported additional barriers to access PrEP and other HIV prevention methods. This study investigates factors associated with PrEP use among Asian MSM in Sydney and Melbourne, Australia, to inform strategies to improve PrEP uptake in this population.

Methods

This was a sub-analysis of a community-based cross-sectional survey conducted from March to June 2021. We recruited participants online in Sydney and Melbourne, Australia. Univariable and multivariable logistic regression analyses were performed to identify the factors associated with PrEP use in the last six months and lifetime. Latent class analyses were used to identify subgroups of Asian MSM sharing similar characteristics related to their risk practices for HIV.

Findings

Overall, 870 Asian MSM were included: 288 Oceanian-born Asian MSM and 582 Asian-born MSM. Three latent classes were identified: 1) Asian-born MSM who recently arrived in Australia with limited English, were less likely to use PrEP and at higher risk of HIV infection (e.g., had condomless anal sex with a casual sex partner in the last six months) (4.6%); 2) Asian MSM who were at lower risk of HIV infection and less likely to use PrEP (69.3%) and; 3) Asian MSM who were at substantial risk of HIV infection and more likely to use PrEP (26.1%). Compared to Oceanian-born Asian MSM, those who were born in Southeast Asia (adjusted odds ratio (aOR) = 0.5, 95% confidence interval (CI) 0.3-0.7) and South Asia (aOR = 0.4, 95% CI 0.2-0.8) were less likely to ever use PrEP. Compared to Oceanian-born Asian MSM, those who were born in Southeast Asia (aOR = 0.4, 95% CI 0.3-0.7), Northeast Asia (aOR = 0.5, 95% CI 0.3-0.8) and South Asia (aOR = 0.4, 95% CI 0.2-0.7) were less likely to use PrEP in the last six months.

Interpretation

To end HIV transmission in Australia, it will be necessary to develop strategies to improve PrEP access for the significant minority of Asian-born MSM who are at substantial risk of HIV infection.

Funding

EPFC and JJO are supported by an Australian National Health and Medical Research Council (NHMRC) Emerging Leadership Investigator Grant (EPFC: GNT1172873 and JJO: GNT1193955). CKF is supported by an Australian National Health and Medical Research Council (NHMRC) Leadership Investigator Grant (GNT1172900).

Social innovation in health training to engage researchers in resource-limited settings: process description and evaluation

Research on social innovations in health has increased in recent years. However, little training is geared toward enhancing social innovation research capacity. Most health training for low- and middle-income countries (LMICs) is developed by individuals in high-income countries, disregarding LMIC researchers' wisdom and insights and the communities' needs. Our team organized a multi-phase investigation involving a series of surveys and co-creation group discussions to assess individuals' training needs that directly informed a subsequent co-created training workshop series. We conducted a Hennessy-Hicks Training Needs Assessment among the Social Innovation in Health Initiative (SIHI) network and formed a co-creation group comprising SIHI fellows to design related training workshops. We ran a final evaluation survey and analyzed the workshop series' strengths, weaknesses and threats. Descriptive and thematic analysis were employed to analyze survey data and open-ended responses. The final evaluation survey captured data from 165 learners in 35 countries, including 26 LMICs. Most participants (67.3%, 111/165) rated the training workshop series as excellent, and 30.3% (50/165) rated it as good on a five-point scale. The need for writing research grants and manuscripts was rated the highest priority. Learners were interested in community-engaged research and diversity, equity and inclusion. This workshop illustrated how co-creation could be an effective tool for developing training materials tailored for LMIC researchers. We also offer a template for conducting a needs assessment and subsequent training workshops for LMICs. The ground-up, locally developed courses may be more effective than externally developed training programs intended for LMICs.

Digital, Crowdsourced, Multilevel Intervention to Promote HIV Testing Among Men Who Have Sex With Men: Cluster Randomized Controlled Trial

BACKGROUND

Despite great efforts in HIV prevention worldwide, HIV testing uptake among men who have sex with men (MSM) remains suboptimal. The effectiveness of digital, crowdsourced, multilevel interventions in improving HIV testing is still unclear.

OBJECTIVE

The aim of this study was to evaluate the effect of a digital, crowdsourced, multilevel intervention in improving HIV testing uptake among MSM in China.

METHODS

We conducted a 2-arm cluster randomized controlled trial among MSM in 11 cities in Shandong province, China, from August 2019 to April 2020. Participants were men who were HIV seronegative or had unknown serum status, had anal sex with a man in the past 12 months, and had not been tested for HIV in the past 3 months. Participants were recruited through a gay dating app and community-based organizations from preselected cities; these cities were matched into 5 blocks (2 clusters per block) and further randomly assigned (1:1) to receive a digital, crowdsourced, multilevel intervention (intervention arm) or routine intervention (control arm). The digital multilevel intervention was developed through crowdsourced open calls tailored for MSM, consisting of digital intervention images and videos, the strategy of providing HIV self-testing services through digital tools, and peer-moderated discussion within WeChat groups. The primary outcome was self-reported HIV testing uptake in the previous 3 months. An intention-to-treat approach was used to examine the cluster-level effect of the intervention in the 12-month study period using generalized linear mixed models and the individual-level effect using linear mixed models.

RESULTS

A total of 935 MSM were enrolled (404 intervention participants and 531 controls); 751 participants (80.3%) completed at least one follow-up survey. Most participants were younger than 30 years (n=601, 64.3%), single (n=681, 72.8%), had a college degree or higher (n=629, 67.3%), and had an HIV testing history (n=785, 84%). Overall, the proportion of testing for HIV in the past 3 months at the 3-, 6-, 9-, and 12-month follow-ups was higher in the intervention arm (139/279, 49.8%; 148/266, 55.6%; 189/263, 71.9%; and 171/266, 64.3%, respectively) than the control arm (183/418, 43.8%; 178/408, 43.6%; 206/403, 51.1%; and 182/397, 48.4%, respectively), with statistically significant differences at the 6-, 9-, and 12-month follow-ups. At the cluster level, the proportion of participants who had tested for HIV increased 11.62% (95% CI 0.74%-22.5%; P=.04) with the intervention. At the individual level, participants in the intervention arm had 69% higher odds for testing for HIV in the past 3 months compared with control participants, but the result was not statistically significant (risk ratio 1.69, 95% CI 0.87-3.27; P=.11).

CONCLUSIONS

The intervention effectively improved HIV testing uptake among Chinese MSM. Our findings highlight that digital, crowdsourced, multilevel interventions should be made more widely available for HIV prevention and other public health issues.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900024350; http://www.chictr.org.cn/showproj.aspx?proj=36718.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-04860-8.

Using social marketing theory as a framework for understanding barriers and facilitators of human papillomavirus screening in women: A qualitative study

BACKGROUND

Human papillomavirus (HPV) is known as the common sexually transmitted disease and the cause of cervical cancer. The HPV test is being proposed as the primary screening tool for cervical cancer. This study aimed to identify barriers and facilitators of screening based on the social marketing model in designing interventions and planning to increase HPV screening.

MATERIALS AND METHODS

This qualitative directed content analysis was conducted between December 2020 to September 2021 to identify the key concepts of social marketing theory (i.e., the four P's: product, price, place, and promotion) in Mashhad, Iran. Semistructured interviews were fulfilled with 24 individuals (10 women with HPV and 14 key informants) after obtaining participants' consent, who were initially purposively sampled and snowball sampling was then used to facilitate further recruitment. Data analysis was carried out simultaneously with data collection.

RESULTS

Following the code extraction, four main categories (themes) and 10 subcategories extracted. Subcategories included knowledge on screening, screening benefits, and motivational factors for screening (product), individual inhibitors, environmental inhibitors, and facility problems related to price, place of service delivery, and service delivery channels (place) and health promotion and education.

DISCUSSION

Lack of knowledge about HPV and screening, negative attitudes toward sexually transmitted diseases, taboo about sexual issues in society, fear of the reaction of spouse and family members, lack of proper policies and information and communication challenges, high costs of screening, access barriers to facilities such as difficult transportation have been challenges of health systems. It is suggested that HPV screening as a standard method for detection of cervical cancer be considered and the barriers to access are removed.

Tracking adaptation strategies of an HIV prevention intervention among youth in Nigeria: a theoretically informed case study analysis of the 4 Youth by Youth Project

BACKGROUND

Although many behavioral interventions are adapted, little is known about the reasons for adaptations and the process and outcomes influencing adaptations. To address this gap, we explored the adaptations made to promote HIV prevention services, including HIV self-testing (HIVST), among Nigerian youth.

METHODS

The main objective of this qualitative case study design was to document the adaptations made over time using the Framework for Reporting Adaptations and Modifications - Expanded (FRAME). Between 2018 and 2020, we organized four participatory activities as part of the 4 Youth by Youth project to increase the uptake of HIVST services in Nigeria-an open call, a designathon, a capacity-building bootcamp and a pilot feasibility trial. We also began the process of implementing a final intervention using a pragmatic randomized control trial (RCT). The open call solicited creative strategies to promote HIVST among Nigerian youth and then had experts evaluate them. The designathon brought together youth teams to further develop their HIVST service strategies into implementation protocols. Teams determined to be exceptional were invited to a four-week capacity-building bootcamp. The five teams that emerged from the bootcamp were supported to pilot their HIVST service strategies over a 6-month period. The adapted intervention is currently being evaluated in a pragmatic RCT. We transcribed meeting reports and conducted document reviews of study protocols and training manuals.

RESULTS

Sixteen adaptations were identified and categorized into three domains: (1) modifications to the content of the intervention (i.e. photo verification system and/or Unstructured Supplementary Service Data (USSD) system to verify HIVST); (2) modifications to the delivery the intervention (i.e. implement participatory learning community sessions to provide supportive supervision and technical support); (3) modifications to the evaluation processes (i.e. economic evaluation to estimate the cost of implementing intervention on a larger scale). Frequent reasons for adaptation included increasing intervention reach, modifying interventions to enhance their appropriateness and fit with the recipient, and increasing the intervention's feasibility and acceptability. Most adaptations were planned and reactive, and the need for modifications was determined by the youths, 4YBY program staff, and advisory group.

CONCLUSIONS

Findings suggest that the nature of adaptations made throughout the implementation process reflects the necessity of evaluating services in context while adjusting to specific challenges as they are identified. Further research is needed to understand the effect of these adaptations on the overall intervention effect as well as the quality of youth engagement.

Integrating Human-Centered Design Methods Into a Health Promotion Project: Supplemental Nutrition Assistance Program Education Case Study for Intervention Design

BACKGROUND

Human-centered design, or design thinking, offers an extensive toolkit of methods and strategies for user-centered engagement that lends itself well to intervention development and implementation. These methods can be applied to the fields of public health and medicine to design interventions that may be more feasible and viable in real-world contexts than those developed with different methods.

OBJECTIVE

The design team aimed to develop approaches to building food skills among caregivers of children aged 0-5 years who are eligible for a federal food assistance program while they were in the grocery store.

METHODS

They applied 3 specific human-centered design methods-Extremes and Mainstreams, Journey Mapping, and Co-Creation Sessions-to collaboratively develop intervention approaches to enhance Supplemental Nutrition Assistance Program Education (SNAP-Ed) reach and impact across food retail settings. Extremes and Mainstreams is a specific kind of purposive sampling that selects individuals based on characteristics beyond demographics. Journey Mapping is a visual tool that asks individuals to identify key moments and decision points during an experience. Co-Creation Sessions are choreographed opportunities for individuals to explicitly contribute to the design of a solution alongside research or design team members.

RESULTS

Ten caregivers with diverse lived experiences were selected to participate in remote design thinking workshops and create individual journey maps to depict their grocery store experiences. Common happy points and pain points were identified. Nine stakeholders, including caregivers, SNAP-Ed staff, and grocery store dieticians, cocreated 2 potential intervention approaches informed by caregivers' experiences and needs: a rewards program and a meal box option.

CONCLUSIONS

These 3 human-centered design methods led to a meaningful co-design process where proposed interventions aligned with caregivers' wants and needs. This case study provides other public health practitioners with specific examples of how to use these methods in program development and stakeholder engagement as well as lessons learned when adapting these methods to remote settings.

Demand creation for HIV testing services: A systematic review and meta-analysis

BACKGROUND

HIV testing services (HTS) are the first steps in reaching the UNAIDS 95-95-95 goals to achieve and maintain low HIV incidence. Evaluating the effectiveness of different demand creation interventions to increase uptake of efficient and effective HTS is useful to prioritize limited programmatic resources. This review was undertaken to inform World Health Organization (WHO) 2019 HIV testing guidelines and assessed the research question, "Which demand creation strategies are effective for enhancing uptake of HTS?" focused on populations globally.

METHODS AND FINDINGS

The following electronic databases were searched through September 28, 2021: PubMed, PsycInfo, Cochrane CENTRAL, CINAHL Complete, Web of Science Core Collection, EMBASE, and Global Health Database; we searched IAS and AIDS conferences. We systematically searched for randomized controlled trials (RCTs) that compared any demand creation intervention (incentives, mobilization, counseling, tailoring, and digital interventions) to either a control or other demand creation intervention and reported HTS uptake. We pooled trials to evaluate categories of demand creation interventions using random-effects models for meta-analysis and assessed study quality with Cochrane's risk of bias 1 tool. This study was funded by the WHO and registered in Prospero with ID CRD42022296947. We screened 10,583 records and 507 conference abstracts, reviewed 952 full texts, and included 124 RCTs for data extraction. The majority of studies were from the African (N = 53) and Americas (N = 54) regions. We found that mobilization (relative risk [RR]: 2.01, 95% confidence interval [CI]: [1.30, 3.09], p < 0.05; risk difference [RD]: 0.29, 95% CI [0.16, 0.43], p < 0.05, N = 4 RCTs), couple-oriented counseling (RR: 1.98, 95% CI [1.02, 3.86], p < 0.05; RD: 0.12, 95% CI [0.03, 0.21], p < 0.05, N = 4 RCTs), peer-led interventions (RR: 1.57, 95% CI [1.15, 2.15], p < 0.05; RD: 0.18, 95% CI [0.06, 0.31], p < 0.05, N = 10 RCTs), motivation-oriented counseling (RR: 1.53, 95% CI [1.07, 2.20], p < 0.05; RD: 0.17, 95% CI [0.00, 0.34], p < 0.05, N = 4 RCTs), short message service (SMS) (RR: 1.53, 95% CI [1.09, 2.16], p < 0.05; RD: 0.11, 95% CI [0.03, 0.19], p < 0.05, N = 5 RCTs), and conditional fixed value incentives (RR: 1.52, 95% CI [1.21, 1.91], p < 0.05; RD: 0.15, 95% CI [0.07, 0.22], p < 0.05, N = 11 RCTs) all significantly and importantly (≥50% relative increase) increased HTS uptake and had medium risk of bias. Lottery-based incentives and audio-based interventions less importantly (25% to 49% increase) but not significantly increased HTS uptake (medium risk of bias). Personal invitation letters and personalized message content significantly but not importantly (<25% increase) increased HTS uptake (medium risk of bias). Reduced duration counseling had comparable performance to standard duration counseling (low risk of bias) and video-based interventions were comparable or better than in-person counseling (medium risk of bias). Heterogeneity of effect among pooled studies was high. This study was limited in that we restricted to randomized trials, which may be systematically less readily available for key populations; additionally, we compare only pooled estimates for interventions with multiple studies rather than single study estimates, and there was evidence of publication bias for several interventions.

CONCLUSIONS

Mobilization, couple- and motivation-oriented counseling, peer-led interventions, conditional fixed value incentives, and SMS are high-impact demand creation interventions and should be prioritized for programmatic consideration. Reduced duration counseling and video-based interventions are an efficient and effective alternative to address staffing shortages. Investment in demand creation activities should prioritize those with undiagnosed HIV or ongoing HIV exposure. Selection of demand creation interventions must consider risks and benefits, context-specific factors, feasibility and sustainability, country ownership, and universal health coverage across disease areas.

A differentiated digital intervention to improve antiretroviral therapy adherence among men who have sex with men living with HIV in China: a randomized controlled trial

BACKGROUND

Antiretroviral therapy (ART) adherence is still suboptimal among some key populations, highlighting the need for innovative tailored strategies. This randomized controlled trial (RCT) aimed to evaluate the effect of a differentiated digital intervention on ART adherence among men who have sex with men (MSM) living with HIV in China.

METHODS

The two-armed parallel RCT was conducted at one HIV clinic in Jinan of China from October 19, 2020, to June 31, 2021. Men were referred by health providers to join the study and then choose one of three digital strategies-text message, only instant message, or instant message plus social media. They were assigned in a 1:1 ratio to the intervention arm or control arm using block randomization, and inside each arm, there were three groups depending on the type of delivering the message. The groups were divided according to participants' preferred digital strategies. The intervention arm received ART medication messages, medication reminders, peer education, and involved in online discussion. The control arm received messages on health behavior and nutrition. The primary outcome was self-reported optimal ART adherence, defined as not missing any doses and not having any delayed doses within a one-month period. Secondary outcomes included CD4 T cell counts, viral suppression, HIV treatment adherence self-efficacy, and quality of life. Intention-to-treat analysis with generalized linear mixed models was used to evaluate the intervention's effect.

RESULTS

A total of 576 participants were enrolled, including 288 participants assigned in the intervention arm and 288 assigned in the control arm. Most were ≤ 40 years old (79.9%) and initiated ART ≤ 3 years (60.4%). After intervention, the proportion of participants achieving optimal ART adherence in the intervention arm was higher than in the control arm (82.9% vs 71.1%). The differentiated digital intervention significantly improved ART adherence (RR = 1.74, 95%CI 1.21-2.50). Subgroup analysis showed one-to-one instant message-based intervention significantly improved ART adherence (RR = 2.40, 95% CI 1.39-4.17).

CONCLUSIONS

The differentiated digital intervention improved ART adherence among MSM living with HIV in China, which could be integrated into people living with HIV (PLWH) management and further promoted in areas where PLWH can access text messaging and instant messaging services.

TRIAL REGISTRATION

ChiCTR2000041282. Retrospectively registered on 23 December 2020.

Evidence and implication of interventions across various socioecological levels to address HIV testing uptake among men who have sex with men in the United States: A systematic review

Objectives

Strengthening HIV testing uptake is critical to curtail the HIV epidemics among men who have sex with men in the United States. Despite the implementation of various interventions to promote HIV testing among men who have sex with men, few aggregated evidence is presented to reflect the "lessons learned" and inform future directions. The objective of this systematic review is to comprehensively summarize published studies that described, tested, and evaluated outcomes (e.g. efficacy, effectiveness, acceptability, feasibility and/or qualitative opinions) associated with an HIV testing intervention and identify gaps as well as opportunities to inform the design and implementation of future interventions to enhance HIV testing uptake among men who have sex with men in the United States.

Methods

We followed the PRISMA guidelines and conducted a systematic review of articles (published by 23 July 2021) by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO).

Results

Among the total number of 3505 articles found through multiple databases, 56 papers were included into the review. Interventional modules that demonstrated acceptability, feasibility and efficacy to improve HIV testing uptake among men who have sex with men include: HIV self-testing, interpersonal-level (e.g. peer-led, couple-based) interventions, personalized interventions and technology-based interventions (e.g. mHealth). Aggregated evidence also reflects the lack of individualized interventions that simultaneously address time-varying needs across multiple socioecological levels (e.g. individual, interpersonal, community, structural and societal).

Conclusion

Development of interventions to improve HIV testing rates and frequency of men who have sex with men has proliferated in recent years. Our review presents important implications in sustaining and improving interventions to address HIV testing uptake among men who have sex with men in the United States.

Engaging Remote Aboriginal Communities in COVID-19 Public Health Messaging via Crowdsourcing

Health comunication is a critical component of pandemic mitigation, but mainstream prevention messaging often lacks social, cultural and linguistic relevance to vulnerable populations. This community case study presents a novel, highly participatory pandemic prevention communication campaign that engaged individuals in remote Aboriginal communities of the Northern Territory of Australia directly in prevention messaging via crowdsourcing, and distributed videos to remote area post-codes via targeted Facebook advertising. Facebook metrics, administrative campaign data and national statistics are used to assess campaign reach and engagement. The case study discusses lessons learned from the campaign, including how seeking unscripted COVID-19 prevention video messaging can support community ownership of pandemic messaging, rapid content generation, and a high level of Facebook user engagement. It also discusses the effectiveness of targeting remote area post-codes via Facebook advertising both to reach the target audience, and to support quality improvement assessments to inform health communication decision-making in a low resource setting.

Effect of a Popular Web Drama Video Series on HIV and Other Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in Singapore: Community-Based, Pragmatic, Randomized Controlled Trial

Background

Gay, bisexual, and other men who have sex with men (GBMSM) are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBMSM are increasing worldwide, they remain suboptimal in a variety of settings. While many studies have attempted to evaluate the efficacy of a variety of community-based campaigns, including peer and reminder-based interventions on HIV/STI testing, however few have attempted to do so for a web drama series.

Objective

This study evaluates the effectiveness of a popular web drama video series developed by a community-based organization in Singapore for GBMSM on HIV and other STI testing behaviors.

Methods

The study is a pragmatic, randomized controlled trial to evaluate a popular web drama video series developed by a community-based organization in Singapore for GBMSM. A total of 300 HIV-negative, GBMSM men in Singapore aged 18 to 29 years old were recruited and block-randomized into the intervention (n=150) and control arms (n=150). Primary outcomes included changes in self-reported intention to test for, actual testing for, and regularity of testing for HIV, syphilis, chlamydia or gonorrhea, while secondary outcomes include changes in a variety of other knowledge-based and psychosocial measures at the end of the study period.

Results

Overall, 83.3% (125/150) of participants in the intervention arm completed the proof of completion survey, compared to 88.7% (133/150) in the control arm. We found improvements in self-reporting as a regular (at least yearly) tester for HIV (15.9% difference, 95% CI, 3.2% to 28.6%; P=.02), as well as chlamydia or gonorrhea (15.5% difference, 95% CI, 4.2% to 26.9%; P=.009), indicating that the intervention had positively impacted these outcomes compared to the control condition. We also found improvements in participants’ intentions to test for HIV (16.6% difference, 95% CI, 4.3% to 28.9%; P=.009), syphilis (14.8% difference, 95% CI, 3.2% to 26.4%; P=.01), as well as chlamydia or gonorrhea (15.4% difference, 95% CI, 4.2% to 26.6%; P=.008), in the next 3 months, indicating that the intervention was effective in positively impacting intention for HIV and other STI testing among participants.

Conclusions

There are clear benefits for promoting intentions to test regularly and prospectively on a broad scale through this intervention. This intervention also has potential to reach GBMSM who may not have access to conventional HIV and other STI prevention messaging, which have typically been implemented at sex-on-premises venues, bars, clubs, and in sexual health settings frequented by GBMSM. When coupled with community or population-wide structural interventions, the overall impact on testing will likely be significant.

Trial Registration

ClinicalTrials.gov NCT04021953; https://clinicaltrials.gov/ct2/show/NCT04021953

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2019-033855

Digital approaches to enhancing community engagement in clinical trials

Digital approaches are increasingly common in clinical trial recruitment, retention, analysis, and dissemination. Community engagement processes have contributed to the successful implementation of clinical trials and are crucial in enhancing equity in trials. However, few studies focus on how digital approaches can be implemented to enhance community engagement in clinical trials. This narrative review examines three key areas for digital approaches to deepen community engagement in clinical trials—the use of digital technology for trial processes to decentralize trials, digital crowdsourcing to develop trial components, and digital qualitative research methods. We highlight how digital approaches enhanced community engagement through a greater diversity of participants, and deepened community engagement through the decentralization of research processes. We discuss new possibilities that digital technologies offer for community engagement, and highlight potential strengths, weaknesses, and practical considerations. We argue that strengthening community engagement using a digital approach can enhance equity and improve health outcomes.

'Bringing testing closer to you': barriers and facilitators in implementing HIV self-testing among Filipino men-having-sex-with-men and transgender women in National Capital Region (NCR), Philippines - a qualitative study

OBJECTIVES

Our study identified barriers and facilitators in implementing HIV self-testing (HIVST), including the perceptions of men-having-sex-with-men (MSM) and transgender women (TGW) on HIVST. Furthermore, we explored the current knowledge, practices and potential of HIVST among the MSM and TGW populations.

DESIGN

Qualitative in-depth key informant interviews were administered using semistructured interviews administered in both English and Filipino. Thematic analysis of the findings was done after transcribing all audio recordings.

SETTING

The study was done in the National Capital Region (NCR), Philippines using online video conferencing platforms due to mobility restrictions and lockdowns caused by the COVID-19 pandemic.

PARTICIPANTS

All study participants were either MSM or TGW, 18-49 years old and residing/working in NCR. Exclusion criteria include biologically born female and/or currently on pre-exposure prophylaxis, antiretroviral therapy medications or an HIV-positive diagnosis.

RESULTS

Twenty informants were interviewed, of which 75% were MSM, and most of them preferred the use of HIVST. Facilitators and barriers to the use of HIVST were grouped into three main themes: Acceptability, distribution and monitoring and tracking. Convenience and confidentiality, overcoming fears and normalisation of HIV testing services (HTS) in the country were the participants' perceived facilitators of HIVST. In contrast, lack of privacy and maintenance of confidentiality during kit delivery were perceived as barriers in HIVST implementation. Moreover, social media was recognised as a powerful tool in promoting HIVST. The use of a welcoming tone and positive language should be taken into consideration due to the prevalent HIV stigma.

CONCLUSIONS

The identified facilitators and barriers from the study may be considered by the Philippine HTS programme implementers. The HIVST strategy may complement the current HTS. It will be very promising to involve the MSM and TGW communities and other key populations to know their HIV status by bringing testing closer to them.

Recommendations for the Development of HIV Prevention Interventions Among Latino Young Sexual Minority Groups

Introduction

Epidemiological trends in the USA have shown an increase in HIV incidence among adolescent men who have sex with men (AMSM). Sexual and ethnic minorities in this group are at increased risk for infection. The use of health services and information delivered or enhanced through the Internet or related technologies-known as eHealth-is an important strategy to reduce HIV disparities and to engage with some minority populations such as Spanish-speaking Latino AMSM. Despite the new opportunities that eHealth provides, little is known about the implementation of such interventions for HIV prevention among Spanish-speaking Latino AMSM.

Method

A systematic literature review was conducted to examine eHealth HIV prevention interventions targeted to Spanish-speaking Latino AMSM. A systematic search using PubMed database was conducted to identify peer-reviewed publications between January 1, 2006, and May 31, 2019. Eligible publications were those including (1) adolescents ages 13 to 18 years old as its main population, (2) described and tested HIV prevention interventions, (3) AMSM, (4) eHealth interventions, and (5) Latino/Hispanic participants.

Results

A total of n = 52 publications were identified. From those, only n = 12 (27.3%) were targeted to AMSM (13-18 years old) and Latino/Hispanic populations, and there was no evidence of interventions addressing eHealth HIV prevention interventions targeted to Spanish-speaking Latino AMSM.

Conclusions

Results indicate the scarcity of scientific evidence of eHealth interventions targeted to populations at increased risk for infection. Further, there is a call for the development of culturally and linguistically congruent eHealth HIV prevention interventions for Spanish-speaking Latino youth and to consider implementation and methodological approaches for these populations.

Willingness of Chinese Men Who Have Sex With Men to Use Smartphone-Based Electronic Readers for HIV Self-testing: Web-Based Cross-sectional Study

BACKGROUND

The need for strategies to encourage user-initiated reporting of results after HIV self-testing (HIVST) persists. Smartphone-based electronic readers (SERs) have been shown capable of reading diagnostics results accurately in point-of-care diagnostics and could bridge the current gaps between HIVST and linkage to care.

OBJECTIVE

Our study aimed to assess the willingness of Chinese men who have sex with men (MSM) in the Jiangsu province to use an SER for HIVST through a web-based cross-sectional study.

METHODS

From February to April 2020, we conducted a convenience web-based survey among Chinese MSM by using a pretested structured questionnaire. Survey items were adapted from previous HIVST feasibility studies and modified as required. Prior to answering reader-related questions, participants watched a video showcasing a prototype SER. Statistical analysis included descriptive analysis, chi-squared test, and multivariable logistic regression. P values less than .05 were deemed statistically significant.

RESULTS

Of 692 participants, 369 (53.3%) were aged 26-40 years, 456 (65.9%) had ever self-tested for HIV, and 493 (71.2%) were willing to use an SER for HIVST. Approximately 98% (483/493) of the willing participants, 85.3% (459/538) of ever self-tested and never self-tested, and 40% (46/115) of unwilling participants reported that SERs would increase their HIVST frequency. Engaging in unprotected anal intercourse with regular partners compared to consistently using condoms (adjusted odds ratio [AOR] 3.04, 95% CI 1.19-7.74) increased the odds of willingness to use an SER for HIVST. Participants who had ever considered HIVST at home with a partner right before sex compared to those who had not (AOR 2.99, 95% CI 1.13-7.90) were also more willing to use an SER for HIVST. Playing receptive roles during anal intercourse compared to playing insertive roles (AOR 0.05, 95% CI 0.02-0.14) was associated with decreased odds of being willing to use an SER for HIVST. The majority of the participants (447/608, 73.5%) preferred to purchase readers from local Centers of Disease Control and Prevention offices and 51.2% (311/608) of the participants were willing to pay less than US $4.70 for a reader device.

CONCLUSIONS

The majority of the Chinese MSM, especially those with high sexual risk behaviors, were willing to use an SER for HIVST. Many MSM were also willing to self-test more frequently for HIV with an SER. Further research is needed to ascertain the diagnostic and real-time data-capturing capacity of prototype SERs during HIVST.

Determinants of Recent HIV Self-Testing Uptake Among Men Who Have Sex With Men in Jiangsu Province, China: An Online Cross-Sectional Survey

Background: To help inform regarding HIV self-testing (HIVST) upscale, we assessed the determinants of recent HIVST uptake among men who have sex with men (MSM) in Jiangsu province, China. Methods: We conducted a convenience online survey from March to April, 2020 among men aged ≥16 years, who had ever had sex with other men. Statistical analysis included Pearson's chi-square test, bivariate correlation, and multivariable logistic regression. p < 0.05 was considered statistically significant. Results: Of the total 692 participants, 69.5% (481) were aged between 18 and 40 years, and 65.9% (456) had reportedly ever self-tested. Using HIVST for first HIV test (aOR = 1.98, 95% CI: 1.21-3.26), perceiving HIVST as more private (aOR = 1.41, 95% CI: 0.85-2.35), and users not needing to go to a health facility (aOR = 1.68, 95% CI: 1.20-2.34) were associated with recent HIVST as facilitating factors. Conclusion: HIVST uptake rate has increased among Jiangsu MSM and can be further promoted by healthcare workers routinely recommending HIVST to their clients.

Increasing Men's Engagement in HIV Testing and Treatment Programs Through Crowdsourcing: A Mixed-Methods Analysis in Eswatini

BACKGROUND

Sub-Saharan African HIV programs have had limited success in engaging men. Crowdsourcing contests may be a useful method to spur men's engagement in HIV services. We evaluated contributions and social media response to a crowdsourcing contest focused on increasing men's engagement in Eswatini HIV services.

METHODS

We conducted a crowdsourcing contest to gain insight from the public on how HIV campaigns can more effectively engage young (20-40 years old) men in HIV services. Eligible submissions included images, songs, videos, and Internet memes. We used standard qualitative methods to examine textual themes from submissions. We examined social media response using Facebook analytics, comparing the number of people reached through crowdsourced HIV messages and the number of people reached through conventional HIV messages.

RESULTS

We received 144 submissions from 83 participants. They represented 55 towns and all 4 regions of Eswatini. The contest page gained 461 followers on Facebook. Emergent themes included appealing to men's roles as protectors by suggesting that they need to take care of their own health to continue safeguarding their families. Crowdsourced messages reached a mean of 88 individuals across 4 posts; conventional messages reached a mean of 75 individuals across 4 posts.

CONCLUSIONS

Crowdsourcing contest submissions provided insight on how to encourage men to engage in Eswatini HIV services. Crowdsourcing contests can be effective in collecting messages from men to create more locally relevant communication materials for HIV programs.

The Holistic Health Status of Chinese Homosexual and Bisexual Adults: A Scoping Review

Background: Same-sex marriage is currently not legalized in China, despite the considerably large number of homosexual and bisexual Chinese populations. At the same time, their holistic health status remains unclear. This is the first scoping review conducted to comprehensively examine all the available literature and map existing evidence on the holistic health of homosexual and bisexual Chinese. Methods: This scoping review used the framework of Arksey and O'Malley and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews (PRISMA-ScR). A comprehensive search strategy was carried out across 20 English (EN) and Chinese (both traditional and simplified) electronic databases from January 1, 2001, to May 31, 2020. Two reviewers conducted the reference screening and study selection independently and consulted a third senior reviewer whenever a consensus must be achieved. Data extraction was conducted using a structured data form based on the Cochrane template, after which a narrative synthesis of the findings was performed. Results: A total of 2,879 references were included in the final analysis, with 2,478 research articles, 167 reviews, and 234 theses. Regarding the study populations, the vast majority of studies centered on men only (96.46%), especially men who have sex with men (MSM). Only 1.32% of the studies targeted female sexual minorities. The geographical distribution of all research sites was uneven, with most of them being conducted in mainland China (95.96%), followed by Hong Kong (2.05%), Taiwan (2.02%), and Macau (0.06%). Regarding the specific study focus in terms of the health domain, around half of the studies (45.93%) focused on sexual health only, and an additional quarter of the studies (24.15%) investigated both sexual health and social well-being. Meanwhile, the studies focusing on mental health only accounted for approximately 15% of the total. Conclusions: This scoping review revealed that previous research focused more on male than female sexual minorities, on disease-centered surveys than person-centered interventions, and investigations on negative health conditions than positive health promotion. Therefore, investigations centered on the female sexual minorities and corresponding person-centered interventions are highly needed. Review Registration: The protocol of this review has been registered within Open Science Framework (https://osf.io/82r7z) on April 27, 2020.

Increasing the HIV testing among MSM through HIV test result exchange mechanism: study protocol for a cluster randomized controlled trial

Background

HIV testing is an essential gateway to HIV prevention and treatment thus controlling the HIV epidemic. More innovative interventions are needed to increase HIV testing among men who have sex with men (MSM) since their testing rate is still low. We proposed an online HIV test results exchange mechanism whereby the one without a certified online HIV report will be asked to test HIV for exchanging HIV report with others. The exchange mechanism is developed as an extension to the existing online HIV testing service system. Through the extended system, MSM can obtain certified online HIV reports and exchange their reports with friends via WeChat. This study aims to assess effectiveness of the exchange mechanism to increase the HIV testing rate among MSM.

Methods

This study will use a cluster randomized controlled trial (RCT) design. Participants are recruited based on the unit of individual social network, the sender and the receivers of the HIV report. An individual social network is composed of one sender (ego) and one or more receivers (alters). In this study, MSM in an HIV testing clinic are recruited as potential egos and forwarded online reports to their WeChat friends voluntarily. Friends are invited to participate by report links and become alters. Ego and alters serve as a cluster and are randomized to the group using the certified online HIV report with exchange mechanism (intervention group) or without exchange mechanism (control group). Alters are the intervention targeting participants. The primary outcome is HIV testing rate. Other outcomes are sexual transmitted infections, sexual behaviors, HIV testing norms, stigma, risk perception and HIV report delivery. The outcomes will be assessed at baseline and follow-up questionnaires. Analysis will be according to intention to treat approach and using mixed-effect models with networks and individuals as random effects.

Discussion

This is the first study to evaluate the effectiveness of an HIV test result exchange mechanism to increase the HIV testing among MSM. This assessment of the intervention will also provide scientific evidence on other potential effects. Findings from this study will yield insights for sustainability driven by communities' intrinsic motivation.

Trail registration: ClinicalTrials.gov NCT03984136. Registered 12 June 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06484-y.

Technology-Delivered Intervention Strategies to Bolster HIV Testing

Since the beginning of the HIV epidemic, there have been more than 75 million cases. Currently, there about 1.2 million living with HIV in the USA. Despite current testing recommendations, test rates continue to be suboptimal. Investigators have studied the use of digital technology to promote HIV testing, especially among high-risk populations. PURPOSE OF REVIEW: This non-systematic review provides an overview of the scientific research between 2015 and 2020 focused on the use of digital technology to bolster HIV testing and suggests novel technologies for exploration. RECENT FINDINGS: A total of 40 studies were included in the review that span a wide range of available technology. Studies effectively increased HIV testing among study participants. Generally, participants in the intervention/exposure groups had significantly higher rates of HIV test uptake compared to participants in the comparison groups at study follow-up. For a variety of reasons (e.g., differences in ways the technologies were used and study design), no digital tool clearly performed better than others, but each have the capacity to increase outreach and self-testing. An exploration of the potential use of nascent technologies is also discussed, as well as the authors' experiences using a number of these technologies in our research.

Strategies for enhancing uptake of HIV self-testing among Nigerian youths: a descriptive analysis of the 4YouthByYouth crowdsourcing contest

INTRODUCTION

Youth are often the intended beneficiaries of HIV programs but are rarely involved in program design. Engaging youth in program design is one potential way of identifying promising approaches for HIV service delivery. The purpose of this study is to examine the feasibility of using a crowdsourcing contest to solicit ideas on ways to promote HIV self-testing (HIVST) services among Nigerian youths.

METHODS

From October-November, 2018 Nigerian youth 10-24 years old submitted ideas to a crowdsourcing contest on how to promote HIVST among their peers. Submissions were scored on feasibility, desirability, and impact, with an integer score of 1 (low) to 3 (high) in each domain. The three-domain scores were added to calculate a total score (3-9). The demographic characteristics of contestants were calculated using descriptive statistics.

RESULTS

Nine-hundred and three entries were received, 831 had unique valid responses, and 769 were eligible for scoring. Youth submitted ideas on paper (44.9%), Google Forms (39.4%), WhatsApp (9.6%), and email (6.1%). Participants' ages were 10-14 years (37%), 15-19 years (44%), and 20-24 years (22%).Approximately half were female (51.2%). Mean scores were 1.4/3.0 (SD=0.6) for feasibility, 1.4/3.0 (SD=0.6) for desirability, 1.2/3.0 (SD=0.5) for impact, and 4.0/9.0 (SD=1.5) overall. Eight percent of submissions had an overall score >7. A disproportionate share of these high-quality submissions came from email and Google submissions.

CONCLUSION

The 4 Youth by Youth crowdsourcing contest engaged a broad audience and is a feasible way to elicit potential strategies to distribute HIVST kits to other youth. Several high-quality ideas require further evaluation.

Improving HIV Self-Testing Social Network Interventions: The Role of Sexual Behavior Disclosure Among Chinese Men Who Have Sex with Men

We assessed if same-sex sexual behavior disclosure of index men who have sex with men (MSM) was related to number of HIV self-testing (HIVST) kits requested by index participants, and number of test results successfully uploaded by alters in a network-based HIVST intervention. Index participants are men who accessed and distributed HIVST kits and alters are index's social contacts who received kits. We analyzed treatment arm data [N = 106, mean age = 27 (SD = 5.3)] of an intervention conducted among MSM in Guangzhou, China, May 2019-December 2019. Index MSM who disclosed sexual behavior to their family tended to request more kits [adjusted incidence rate ratio (aIRR) 1.42, 95% CI 1.06, 1.90, p < .05]. Index men who disclosed sexual behavior to their family (aIRR 2.47, 95% CI 1.17, 5.24, p < .05) tended to yield an increase in number of alter test results uploaded. Findings have implications for the development of network-based interventions for key populations.

Crowdsourcing to design a marketing package to promote a WHO digital mental health intervention among Chinese young adults

BACKGROUND

Digital mental health is an emerging field that can leverage technology and mobile apps to deliver mental health treatment to populations in areas with limited mental health services. Despite widespread availability of these apps, uptake remains low. Enhanced marketing is necessary to increase public engagement. There is growing recognition that mental health intervention beneficiaries should be engaged in all phases of treatment development, adaptation, and delivery. Crowdsourcing - consulting the public to solve problems and sharing the solutions - can foster community-informed ideas for public health, but has yet been applied to digital mental health marketing.

OBJECTIVE

With the goal of engaging potential intervention beneficiaries in digital mental health dissemination, the current project implemented a digital mental health crowdsourcing designathon for Chinese college students in Macao SAR, China and evaluated the feasibility of the contest and the products. The contest asked participants to design marketing packages for Step-by-Step, a scalable WHO digital mental health intervention focusing on depression.

METHODS

Designathon participants, recruited from a global health class, were sorted into teams with balanced areas of expertise. Two judging panels - one of experts in relevant fields and another of Chinese college students - evaluated the marketing packages and selected finalists. The designathon was held in-person over four days and involved debriefing, workshops, a contest, and an awards ceremony. A parallel mixed-methods approach was applied, including qualitative feedback from judges and participants alongside quantitative data on participant satisfaction and depressive symptoms to enrich our understanding of the event. Additionally, based on judges' feedback given to participants, the communication packages of the contest were ranked.

RESULTS

49 participants (8 teams of 6-7 members each) were involved in the designathon. Using a cutoff score of 10 on the Patient Health Questionnaire-9 (PHQ-9), 11.4% of participants had moderate or higher depressive symptoms. All teams successfully produced complete digital mental health marketing packages. Four finalists' packages were selected quantitatively with judges' scores and the top finalist's package was described by judges' comments as simple, thoughtful, and appealing, although not informative enough. Participants were overall satisfied with the designathon, but some mentioned that time was insufficient and that organization/instruction clarity could have been improved.

CONCLUSIONS

The designathon is a novel, feasible strategy to collect crowd input for the dissemination of a mental health intervention. Compared with traditional communication strategies, this bottom-up approach included and engaged potential intervention beneficiaries to take an active role in creating digital mental health marketing communication. Future contests should allow participants more time and reconsider aspects of event organization.

Leveraging Crowdsourcing for Human Immunodeficiency Virus Testing Posters: A Visual Content Analysis and Cognitive Responses Among Chinese Men Who Have Sex With Men

INTRODUCTION

Extensive marketing and advertising research has informed a deep understanding of the link between visual design and consumer behaviors, providing a useful framework for assessing associations between human immunodeficiency virus (HIV)-related health posters and viewer responses.

METHODS

Crowdsourced posters included finalist submissions from a series of nationwide crowdsourcing contests. Centers for Disease Control (CDC) images were sampled from an online poster database maintained by the National Center for acquired immune deficiency syndrome (AIDS). Once coded according to a set of 27 visual features, posters were shown to an online sample of Chinese men who have sex with men-a group currently experiencing the highest HIV incidence in China-to assess their viewer response.

RESULTS

The CDC posters were more likely to use positive facial expressions (65%; 95% confidence interval [CI], 40.9-83.7] vs 12.5%; 95% CI, 2.2-4%) and an educational messaging style (85%; 95% CI, 61.1-96% vs 31.3%; 95% CI, 12.1-58.5). Crowdsourced posters exhibited better craftsmanship than CDC posters (more design simplicity, image diversity, color choice, design quality, and moderate use of text) used more visual metaphors (56.3%; 95% CI, 30.6-79.2 vs 5%; [95% CI, 0.2-26.9%]). Several differences in visual complexity were identified but these lacked statistical significance.

CONCLUSION

Crowdsourced posters were of higher craftsmanship, possibly due to their ability to recruit skills of professional designers. The CDC posters' use of positive visual reinforcement (smiling faces) and educational messaging may be a legacy of their role in the early days of the epidemic in disseminating basic HIV/AIDS knowledge and dispelling misinformation. Crowdsourcing posters' used more metaphors, suggesting better ability to leverage in-group codes and language.

Development and Evaluation of an Online Education-Entertainment Intervention to Increase Knowledge of HIV and Uptake of HIV Testing among Colombian Men Who Have Sex with Men (MSM)

Using a community-based participatory approach, we developed a film to promote HIV testing among young men who have sex with men (MSM) in Bogotá. Using a 5-step process to develop the intervention, we conducted 11 focus groups with MSM (n = 141) to receive community feedback at each step. To evaluate the intervention we recruited 300 young MSM to complete a baseline survey in December 2017. Between February–June 2018, 63 participants watched the film and completed a post-viewing survey, which showed the intervention was acceptable for the target population. Between August–December 2018, 48 MSM who watched the film and 47 who did not (control group) completed a follow-up survey. To obtain preliminary evidence of the efficacy of the intervention, we assessed the main effect of time (baseline vs. follow-up) and the interaction between time and group (intervention vs. control) on HIV testing uptake and intentions, and knowledge of HIV transmission dynamics and HIV-related rights. Knowledge of HIV rights increased from baseline to follow-up in the intervention group only. HIV Knowledge increased for both groups. HIV testing intentions increased significantly more for non-gay-identified men in the intervention group, but the overall effect of the intervention was not significant. Testing uptake did not change.

Reconstructing the social network of HIV key populations from locally observed information

Traditional surveys only provide local observations about the topological structure of isolated individuals. This study aims to develop a novel data-driven approach to reconstructing the social network of men who have sex with men (MSM) communities from locally observed information by surveys. A large social network consisting of 1075 users and their public relationships was obtained manually from BlueD.com. We followed the same survey-taking procedure to sample locally observed information and adapted an Exponential Random Graph Model (ERGM) to model the full structure of the BlueD social network (number of local nodes N = 1075, observed average degree k = 6.46). The parameters were learned and then used to reconstruct the MSM social networks by two real-world survey datasets in Hong Kong (N = 600, k = 5.61) and Guangzhou (N = 757, k = 5). Our method performed well on reconstructing the BlueD social network, with a high accuracy (90.3%). In conclusion, this study demonstrates the feasibility of using parameters learning methods to reconstruct the social networks of HIV key populations. The method has the potential to inform data-driven intervention programs that need global social network structures.

A qualitative examination of affect and ideology within mass media interventions to increase HIV testing with gay men garnered from a systematic review

OBJECTIVES

Increasing appropriate HIV testing among men who have sex with men (MSM) is crucial to HIV prevention. Mass media interventions are effective in promoting testing, but to date, there has been little examination of their active content.

DESIGN

We conducted a qualitative analysis of intervention materials (n = 69) derived from a systematic review of mass media interventions designed to improve testing with MSM.

METHODS

Visual data were analysed for their affective and ideological content using a novel method drawing on concepts from semiotics (i.e., broadly speaking, the analysis of signs).

RESULTS

Whilst affect was not explicitly theorized or examined in any of the studies, there are clearly identifiable affective elements implicitly at play in these interventions. Four thematic categories of affect/ideology were identified including (1) sexual desire and the 'pornographication' of the gay/bisexual male subject; (2) narratives of romance and love; (3) fear, threat, and regret; and (4) 'flattened' affect.

CONCLUSIONS

This is the first study to examine and detail the affective and ideological aspects of intervention content in this field. Using analytic techniques such as those reported here, in addition to approaches that focus on the manner in which intervention content address more proximal determinants of behaviour, can provide a rich and potentially more useful evidence base to assist with future interventions.

Modelling the impact of an HIV testing intervention on HIV transmission among men who have sex with men in China

OBJECTIVES

An intervention developed through participatory crowdsourcing methods increased HIV self-testing among men who have sex with men [MSM; relative risk (RR) = 1.89]. We estimated the long-term impact of this intervention on HIV transmission among MSM in four cities (Guangzhou, Shenzhen, Jinan and Qingdao).

METHODS

A mathematical model of HIV transmission, testing and treatment among MSM in China was parameterized using city-level demographic and sexual behaviour data and calibrated to HIV prevalence, diagnosis and antiretroviral therapy (ART) coverage data. The model was used to project the HIV infections averted over 20 years (2016-2036) from the intervention to increase self-testing, compared with current testing rates.

RESULTS

Running the intervention once would avert < 2.2% infections over 20 years. Repeating the intervention (RR = 1.89) annually would avert 6.4-10.7% of new infections, while further increases in the self-testing rate (hypothetical RR = 3) would avert 11.7-20.7% of new infections.

CONCLUSIONS

Repeated annual interventions would give a three- to seven-fold increase in long-term impact compared with a one-off intervention. Other interventions will be needed to more effectively reduce the HIV burden in this population.

Social innovation in sexual health: a scoping review towards ending the HIV epidemic

As donor financial support decreases, ending the HIV epidemic in Asia will require novel and sustainable approaches. Social innovation, a community-engaged process that links social change and health improvement, may be useful for helping to end the HIV epidemic in Asia. A scoping review to examine social innovation strategies in sexual health for the Asian region was conducted. The research identified focused on three types of social innovation: (1) microfinance; (2) social entrepreneurship; and (3) social enterprise. Microfinance provides financial opportunities (e.g. banking services, job opportunities) to spur local entrepreneurship and healthier behaviours. Social entrepreneurship uses business principles and tools (e.g. crowdsourcing, human-centred design) to improve health. Social enterprise is a business with a social mission. Further research is needed to measure the efficacy and cost-effectiveness of social innovation strategies in improving HIV services.

Impact of providing free HIV self-testing kits on frequency of testing among men who have sex with men and their sexual partners in China: A randomized controlled trial

BACKGROUND

The HIV epidemic is rapidly growing among men who have sex with men (MSM) in China, yet HIV testing remains suboptimal. We aimed to determine the impact of HIV self-testing (HIVST) interventions on frequency of HIV testing among Chinese MSM and their sexual partners.

METHODS AND FINDINGS

This randomized controlled trial was conducted in 4 cities in Hunan Province, China. Sexually active and HIV-negative MSM were recruited from communities and randomly assigned (1:1) to intervention or control arms. Participants in the control arm had access to site-based HIV testing (SBHT); those in the intervention arm were provided with 2 free finger-prick-based HIVST kits at enrollment and could receive 2 to 4 kits delivered through express mail every 3 months for 1 year in addition to SBHT. They were encouraged to distribute HIVST kits to their sexual partners. The primary outcome was the number of HIV tests taken by MSM participants, and the secondary outcome was the number of HIV tests taken by their sexual partners during 12 months of follow-up. The effect size for the primary and secondary outcomes was evaluated as the standardized mean difference (SMD) in testing frequency between intervention and control arms. Between April 14, 2018, and June 30, 2018, 230 MSM were recruited. Mean age was 29 years; 77% attended college; 75% were single. The analysis population who completed at least one follow-up questionnaire included 110 (93%, 110/118) in the intervention and 106 (95%, 106/112) in the control arm. The average frequency of HIV tests per participant in the intervention arm (3.75) was higher than that in the control arm (1.80; SMD 1.26; 95% CI 0.97-1.55; P < 0.001). This difference was mainly due to the difference in HIVST between the 2 arms (intervention 2.18 versus control 0.41; SMD 1.30; 95% CI 1.01-1.59; P < 0.001), whereas the average frequency of SBHT was comparable (1.57 versus 1.40, SMD 0.14; 95% CI -0.13 to 0.40; P = 0.519). The average frequency of HIV tests among sexual partners of each participant was higher in intervention than control arm (2.65 versus 1.31; SMD 0.64; 95% CI 0.36-0.92; P < 0.001), and this difference was also due to the difference in HIVST between the 2 arms (intervention 1.41 versus control 0.36; SMD 0.75; 95% CI 0.47-1.04; P < 0.001) but not SBHT (1.24 versus 0.96; SMD 0.23; 95% CI -0.05 to 0.50; P = 0.055). Zero-inflated Poisson regression analyses showed that the likelihood of taking HIV testing among intervention participants were 2.1 times greater than that of control participants (adjusted rate ratio [RR] 2.10; 95% CI 1.75-2.53, P < 0.001), and their sexual partners were 1.55 times more likely to take HIV tests in the intervention arm compared with the control arm (1.55, 1.23-1.95, P < 0.001). During the study period, 3 participants in the intervention arm and none in the control arm tested HIV positive, and 8 sexual partners of intervention arm participants also tested positive. No other adverse events were reported. Limitations in this study included the data on number of SBHT were solely based on self-report by the participants, but self-reported number of HIVST in the intervention arm was validated; the number of partner HIV testing was indirectly reported by participants because of difficulties in accessing each of their partners.

CONCLUSIONS

In this study, we found that providing free HIVST kits significantly increased testing frequency among Chinese MSM and effectively enlarged HIV testing coverage by enhancing partner HIV testing through distribution of kits within their sexual networks.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800015584.

Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review

Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.

Mass media and communication interventions to increase HIV testing among gay and other men who have sex with men: Social marketing and visual design component analysis

Mass media and communication interventions can play a role in increasing HIV testing among gay, bisexual and other men who have sex with men (GBMSM). Despite the key role of social marketing principles and visual design within intervention development of this type, evidence is limited regarding interventions’ social marketing mix or visual design. As part of a systematic review, intervention content was assessed using social marketing theory and social semiotics. Data were extracted on the nature of the intervention, mode of delivery, use of imagery, content and tone and the eight key characteristics of social marketing. Data were synthesised narratively. Across the 19 included studies, reference to social marketing principles was often superficial. Common design features were identified across the interventions, regardless of effectiveness, including: the use of actors inferred to be GBMSM; use of ‘naked’ and sexually explicit imagery; and the use of text framed as statements or instructions. Our results suggest that effective interventions tended to use multiple modes of delivery, indicating high social marketing complexity. However, this is only part of intervention development, and social marketing principles are key to driving the development process. We identified consistent aspects of intervention design, but were unable to determine whether this is based on evidence of effectiveness or a lack of originality in intervention design. An openness to novel ideas in design and delivery is key to ensuring that evidence-informed interventions are effective for target populations.

Association of nitrite inhalants use and unprotected anal intercourse and HIV/syphilis infection among MSM in China: a systematic review and meta-analysis

Background

Nitrite inhalant use is very common among men who have sex with men (MSM) in China. However, there is lack of national representative data on use among Chinese MSM, and the mechanism of how nitrite inhalant use impacts HIV infection in MSM is unclear. This meta-analysis aims to understand the characteristics of Chinese MSM nitrite inhalant users and to determine the associations between nitrite inhalant use and sexual behaviors, the prevalence of HIV, and the prevalence of syphilis.

Methods

We searched PubMed, Web of Science, Chinese National Knowledge Infrastructure, Chinese Wanfang Data, and VIP Chinese Journal Database for relevant literature published from January 1985 to December 2017.

Results

Fifteen eligible studies, with a total of 18,981 Chinese MSM participants, were included. Compared with nitrite inhalant nonusers, users were more likely to be younger, have a higher level of education, and seek sexual partners using the Internet. Nitrite inhalant users were more likely to engage in high-risk sexual behaviors, including condomless anal intercourse (odds ratio [OR] = 1.33), group sex (OR = 2.26), and commercial intercourse (OR = 1.50). Nitrite inhalants users had a higher prevalence of HIV (OR = 1.83), higher prevalence of syphilis (OR = 1.38) and had higher lifetime HIV testing rates (OR = 1.33) compared with nonusers (each p < 0.05).

Conclusions

Nitrite inhalant users have higher HIV and syphilis prevalence by increasing levels of high-risk sexual behaviors. China should expand HIV testing, treatment as prevention (TasP), and Pre-exposure prophylaxis (PrEP) among MSM, especially among nitrite inhalants using MSM, to reduce their risk of HIV infection and transmission.

How to make your research jump off the page: Co-creation to broaden public engagement in medical research

Nina Finley and co-authors discuss public involvement in planning and reporting medical research.

HIV Self-Testing Programs to Men Who Have Sex With Men Delivered by Social Media Key Opinion Leaders and Community-Based Organizations are Both Effective and Complementary: A National Pragmatic Study in China

BACKGROUND

Social media key opinion leaders (SMKOLs) and community-based organizations (CBOs) are 2 leading delivery strategies for HIV self-testing (HIVST). This study compared respondent characteristics, linkage to care, antiretroviral treatment, and cost of HIVST among men who have sex with men (MSM) recruited via SMKOLs and CBOs in China.

METHODS

Between January and December 2018, SMKOLs distributed HIVST advertisements to MSM through WeChat public platforms; simultaneously, CBOs distributed HIVST program messages to local MSM. All participants were required to pay a deposit to apply for the HIVST kit and had their deposit refunded after completing an online survey and uploading HIVST results. Trained staff provided HIV referral services by telephone and WeChat.

RESULTS

One thousand seven hundred forty-three [63.0% (1743/2766)] and 1023 [37.0% (1023/2766)] individuals met criteria via SMKOLs and CBOs, respectively. MSM reached by SMKOLs had a lower HIV seropositive rate [2.1% (33/1561) vs. 12.5% (100/803)] and higher proportion received antiretroviral treatment [94.4% (31/33) vs. 29.0% (29/100)] compared with CBO-recruited MSM (all P < 0.05). The average number of HIVST respondents recruited by each investigator in SMKOL-strategy was higher than that of CBO-strategy (290 vs. 49). The SMKOLs had lower cost of per person tested (USD 13.18 vs. USD 101.21) and per newly identified HIV infection case (USD 632.66 vs. USD 812.70).

CONCLUSIONS

SMKOLs have lower cost of per person tested, whereas CBOs can reach MSM subpopulations with higher HIV seropositive rates. Both recruitment methods are efficient and should be used as complementary HIVST delivery strategies to address low HIV testing coverage among Chinese MSM.

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.

Crowdsourcing to promote hepatitis C testing and linkage-to-care in China: a randomized controlled trial protocol

Background

Hepatitis C virus (HCV) is a growing public health problem with a large disease burden worldwide. In China many people living with HCV are unaware of their hepatitis status and not connected to care and treatment. Crowdsourcing is a technique that invites the public to create health promotion materials and has been found to increase HIV testing uptake, including in China. This trial aims to evaluate crowdsourcing as a strategy to improve HCV awareness, testing and linkage-to-care in China.

Methods

A randomized controlled, two-armed trial (RCT) is being conducted in Shenzhen with 1006 participants recruited from primary care sectors of The University of Hong Kong-Shenzhen Hospital. Eligible participants are ≥30 years old; a resident in Shenzhen for at least one month after recruitment; no screening for HCV within the past 12 months and not known to have chronic HCV; and, having a WeChat social media account. Allocation is 1:1. Both groups will be administered a baseline and a follow-up survey (4-week post-enrollment). The intervention group will receive crowdsourcing materials to promote HCV testing once a week for two weeks and feedback will be collected thereafter, while the control group will receive no promotional materials. Feedback collected will be judged by a panel and selected to be implemented to improve the intervention continuously.

Those identified positive for HCV antibodies will be referred to gastroenterologists for confirmation and treatment. The primary outcome will be confirmed HCV testing uptake, and secondary outcomes include HCV confirmatory testing and initiation of HCV treatment with follow-ups with specialist providers. Data will be collected on Survey Star^@ via mobile devices.

Discussion

This will be the first study to evaluate the impact of crowdsourcing to improve viral hepatitis testing and linkage-to-care in the health facilities. This RCT will contribute to the existing literature on interventions to improve viral hepatitis testing in primary care setting, and inform future strategies to improve HCV care training for primary care providers in China.

Trial registration

Chinese Clinical Trial Registry. ChiCTR1900025771. Registered September 7th, 2019, http://www.chictr.org.cn/showprojen.aspx?proj=42788

Promoting routine syphilis screening among men who have sex with men in China: study protocol for a randomised controlled trial of syphilis self-testing and lottery incentive

BACKGROUND

Men who have sex with men (MSM) bear a high burden of syphilis infection. Expanding syphilis testing to improve timely diagnosis and treatment is critical to improve syphilis control. However, syphilis testing rates remain low among MSM, particularly in low- and middle-income countries. We describe the protocol for a randomised controlled trial (RCT) to assess whether provision of syphilis self-testing services can increase the uptake of syphilis testing among MSM in China.

METHODS

Four hundred forty-four high-risk MSM will be recruited online and randomized in a 1:1:1 ratio to (1) standard syphilis self-testing arm; (2) a self-testing arm program enhanced with crowdsourcing and a lottery-based incentive, and (3) a standard of care (control). Self-testing services include a free syphilis self-test kit through the mail at monthly intervals. Participants in the lottery incentive arm will additionally receive health promotion materials generated from an open crowdsourcing contest and be given a lottery draw with a 10% chance to win 100 RMB (approximately 15 US Dollars) upon confirmed completion of syphilis testing. Syphilis self-test kits have step-by-step instructions and an instructional video. This is a non-blinded, open-label, parallel RCT. Participants in each arm will be followed-up at three and 6 months through WeChat (a social media app like Facebook messenger). Confirmation of syphilis self-test use will be determined by requiring participants to submit a photo of the used test kit to study staff via secure data messaging. Both self-testing and facility-based testing will be ascertained by sending a secure photographic image of the completed kit through an existing digital platform. The primary outcome is the proportion of participants who tested for syphilis in the past 3 months.

DISCUSSION

Findings from this study will provide much needed insight on the impact of syphilis self-testing on promoting routine syphilis screening among MSM. The findings will also contribute to our understanding of the safety, effectiveness and acceptability of syphilis self-testing. These findings will have important implications for self-testing policy, both in China and internationally.

TRIAL REGISTRATION

ChiCTR1900022409 (10 April, 2019).

Crowdsourcing Methods to Enhance HIV and Sexual Health Services: A Scoping Review and Qualitative Synthesis

BACKGROUND

Crowdsourcing is increasingly used to improve community engagement in HIV and sexual health research. In this scoping review, we reviewed studies using crowdsourcing approaches in HIV and sexual health research to identify strengths, opportunities for expansion, and limitations of such approaches.

METHODS

We searched CINAHL, Web of Science, Embase, and PubMed. Studies were included if they involved crowdsourcing activities, were in the field of HIV or sexual health, and described the methodology in sufficient detail. We conducted a qualitative synthesis of eligible articles.

RESULTS

Our search strategy yielded 431 nonduplicate articles. After screening, 16 articles met the inclusion criteria, including 4 publications that described research from high-income countries, 7 from middle-income countries, 1 from a low-income country, and 4 that had a global focus. There were 4 categories of crowdsourcing: open contests, hackathons, open forums, and incident reporting systems. We identified common phases for data acquisition and dissemination: (1) preparation; (2) problem framing and crowd solicitation; (3) judging submissions; and (4) sharing selected submissions. Strengths of using crowdsourcing approaches include greater innovation due to crowd heterogeneity, encouragement of multisectoral collaboration, empowerment of vulnerable populations, cost-effectiveness, and relevance to local cultures and styles. Weaknesses among some methods include reliance on the internet, temporal transience, and difficulty in sustaining long-term community engagement.

CONCLUSIONS

Crowdsourcing may be useful for HIV implementation research. Further research on crowdsourcing related to HIV and sexual health is needed.

The 4 youth by youth HIV self-testing crowdsourcing contest: A qualitative evaluation

INTRODUCTION

Crowdsourcing, a participatory approach to solicit ideas from a large group of diverse individuals, provides an opportunity to nurture youth participation in HIV self-testing service design. The objective of this study was to describe the responses to a crowdsourcing contest aimed at soliciting ideas on how to promote HIV self-testing (HIVST) among young people in Nigeria.

METHODS

The "4 Youth by Youth" HIV Self-Testing Crowdsourcing contest was an online and off-line contest that asked Nigerian youth (10-24 years old) for ideas in response to the following: How might we promote HIVST among young people in Nigeria? All data were collected and analyzed between October 2018, and June 2019. Ideas and perceptions generated from the crowdsourcing contest were qualitatively analyzed using thematic content analysis. Specifically, four reviewers analyzed whether the ideas generated were desirable (appealing to young people), feasible (easy to implement) and impactful (will significantly influence HIVST uptake among young people).

RESULTS

A total of 903 entries were received in response to the contest prompt. Participants submitted entries in various forms: online form (39.7%), offline Dropbox (44.6%), email (6.1%) and WhatsApp (9.7%). Of the total entries, 85% (n = 769/903) entries were eligible and were scored as having either high, moderate or low level of feasibility, impact and desirability, on a 3-point Likert scale. A significant portion of the entries were given a score of 3 for feasibility (4.9%), desirability (7.1%), impact (3.0%) or a total overall score of 7 or more (8.2%). The three main themes that emerged from the entries include:1) Peer-to-peer distribution and leveraging on existing infrastructures 2) Youth-Oriented Branding of the HIVST Kit 3) Mobile platforms and social media technology.

CONCLUSION

The "4 Youth by Youth" Self-Testing contest engaged a broad audience of young people to generate ideas and perspectives on how to promote HIVST. This process informed the development of youth innovated implementation strategies to increase uptake of HIVST among adolescents and youth at risk for HIV.

Local and national stakeholders' perceptions towards implementing and scaling up HIV self-testing and secondary distribution of HIV self-testing by Option B+ patients as an assisted partner service strategy to reach men in Haiti

HIV self-testing (HIVST), which allows people to test in private, is an innovative testing strategy that has been shown to increase HIV testing among men. Delivering HIVST kits to men via women is one promising assisted partner service strategy. Little research has been conducted on HIVST secondary distribution to men by women living with HIV (WLWH) in the Caribbean and other settings. The purpose of this study was to assess the perspectives of WLWH, their male partners, and healthcare professionals on the perceived advantages and disadvantages of HIVST, and recommendations for implementing HIVST in Haiti, with a focus on secondary distribution of HIVST to men by WLWH. Sixteen key informant interviews and nine focus groups with 44 healthcare workers, 31 Option B+ clients, and 13 men were carried out in Haiti. Key informants were representatives of the Ministry of Health and of a non-governmental agency involved in HIV partner services. Focus group members included program leads and staff members from the HIV care and treatment program, the Option B+ program, the community health service program, and the HIV counseling and testing services from 2 hospitals. Perceived HIVST advantage included an increase in the number of people who would learn their HIV status and start treatment. The perceived disadvantages were lack of support to ensure self-testers initiate treatment, uncertainty about male partner's reaction, risk of violence towards women delivering HIVST kits after receiving an HIVST kit from a woman, and the inability of women to counsel a man in case his self-test result is positive. Recommendations for integrating HIVST and secondary distribution of HIVST by WLWH included coupling HIVST distribution with public information, education, and communication through media and social marketing, relying on community health workers to mediate use of HIVST and ensure linkage to care, piloting HIVST programs on a small scale. HIVST is an appropriate and feasible strategy HIV prevention for men and women; however, more research is needed on how best to implement different strategies for this approach in the Caribbean.

"Getting to Zero" Among Men Who Have Sex with Men in China: a Review of the HIV Care Continuum

PURPOSE OF REVIEW

To review the literature on progress towards UNAIDS 90-90-90 targets for HIV prevention and treatment among men who have sex with men (MSM) in China.

RECENT FINDINGS

China has made progress towards UNAIDS 90-90-90 targets among MSM. However, socio-structural barriers, including HIV-related stigma and homophobia, persist at each stage of the HIV care continuum, leading to substantial levels of attrition and high risk of forward HIV transmission. Moreover, access to key prevention tools, such as pre-exposure prophylaxis, is still limited. Multilevel interventions, many using digital intervention, have been shown effective in pragmatic randomized controlled trials in China. Multilevel interventions incorporating digital health have led to significant improvement in engagement of Chinese MSM in the HIV care continuum. However, interventions that address socio-structural determinants, including HIV-related stigma and discrimination, towards Chinese MSM are needed.

'Informed and empowered': a mixed-methods study of crowdsourcing contests to promote uptake of HIV self-testing kits among African Americans

OBJECTIVE

HIV self-testing (HIVST) kits are a viable alternative to testing in clinical settings, but research on the effective ways of promoting uptake of HIVST kits has been lacking. The present study examines crowdsourcing contests as community engagement to promote uptake of HIVST kits among African Americans in the southern region of the US.

METHODS

This mixed-methods study design evaluated two contests through qualitative assessment of contest entries. The first contest elicited ideas on how to promote HIVST kits. The second contest sought branding ideas for a pop-up HIVST booth. Qualitative data were digitally transcribed and analysed using MAXQDA software and axial coding.

RESULTS

The study participants (n = 296) were mostly African American (n = 258, 87%) and between 18 and 25 years of age (n = 84, 28%). Contestants suggested making HIVST kits available in community sites and highlighting kits as potential sources of knowledge, relief and empowerment.

CONCLUSION

Crowdsourcing contests are a beneficial community engagement tool to identify new ways to promote uptake of HIVST kits.

Crowdsourcing to Improve HIV and Sexual Health Outcomes: a Scoping Review

PURPOSE OF REVIEW

This review synthesizes evidence on the use of crowdsourcing to improve HIV/sexual health outcomes.

RECENT FINDINGS

We identified 15 studies, including four completed randomized controlled trials (RCTs), one planned RCT, nine completed observational studies, and one planned observational study. Three of the four RCTs suggested that crowdsourcing is an effective, low-cost approach for improving HIV testing and condom use among key populations. Results from the observational studies revealed diverse applications of crowdsourcing to inform policy, research, and intervention development related to HIV/sexual health services. Crowdsourcing can be an effective tool for informing the design and implementation of HIV/sexual health interventions, spurring innovation in sexual health research, and increasing community engagement in sexual health campaigns. More research is needed to examine the feasibility, acceptability, and effectiveness of crowdsourcing interventions, particularly in low- and middle-income countries.

Effect of a web drama video series on HIV and other sexually transmitted infection testing among gay, bisexual and queer men: study protocol for a community-based, pragmatic randomised controlled trial in Singapore: the People Like Us (PLU) Evaluation Study

INTRODUCTION

Gay, bisexual and queer (GBQ) men are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBQ men are increasing worldwide, they remain suboptimal in a variety of settings.

METHODS AND ANALYSIS

The study is a pragmatic randomised controlled trial designed to evaluate an online video series developed by a community-based organisation in Singapore for GBQ men. A total of 300 HIV-negative GBQ men in Singapore aged 18-29 years old will be recruited for this study. Participants will subsequently be randomised into the intervention arm (n=150) and the control arm (n=150). The intervention arm (n=150) will be assigned the intervention along with sexual health information via a pamphlet, while the control group (n=150) will be assigned only the sexual health information via a pamphlet. Participants should also not have watched the video prior to their participation in this study, which will be ascertained through a questionnaire. Primary outcomes for this evaluation are changes in self-reported intention to test for, actual testing for and regularity of testing for HIV, syphilis, chlamydia and gonorrhoea at the 3 and 6 months after intervention. Secondary outcomes include changes in self-reported risk perception for HIV and other STIs, knowledge of HIV, knowledge of risks associated with acquiring STIs, knowledge of HIV pre-exposure prophylaxis, consistent condom use for anal sex with casual partners, incidence of STIs, connectedness to the lesbian, gay, bisexual and transgender community, self-concealment of sexual orientation, perceived homophobia, internalised homophobia, HIV testing self-efficacy and HIV testing social norms.

ETHICS AND DISSEMINATION

The study has been approved by the National University of Singapore Institutional Review Board (S-19-059) and registered at ClinicalTrials.gov. The results will be published in peer-reviewed academic journals and disseminated to community-based organisations and policymakers.

TRIAL REGISTRATION NUMBER

NCT04021953.

Growth Trajectories of Peer Norms, Self-efficacy and Condom Use Behavior Among Sexually Active Chinese Men Who Have Sex with Men: Latent Class Analysis and Growth Mixture Modeling

Data from a randomized controlled trial in 2015 were used to estimate the growth trajectories of peer norms, self-efficacy, and condom use behavior, and to identify associated sociodemographic and behavioral factors among a sample of 804 Chinese men who have sex with men (MSM). Latent class analysis and growth mixture modeling were conducted using Mplus. Two growth trajectories were estimated for each outcome variable with good model fit. The growth trajectories of peer norms were related to age (β = - 0.066, p < 0.05). The growth trajectories of self-efficacy were related to age (β = 0.057, p < 0.01) and using a condom during first sexual encounter with another man (β = 0.777, p < 0.001). The growth trajectories of condom use behavior were related to income (β = 0.366, p < 0.01) and having casual male partners (β = - 1.016, p < 0.001). Predictors for the growth factors within each latent class were also estimated. For subsets of MSM who are older, richer, used a condom during their first sexual encounter with another man, and do not have a casual male partner, condom videos may not have sufficient efficacy and other interventions may be necessary.

Gender Identity and Sexual Orientation in Chinese Men Who Have Sex with Men: A Latent Class Analysis

Men who have sex with men (MSM) are a diverse population yet are often treated as a monolithic risk group. In China, MSM have long been characterized as a "bridge population" of closeted men who are married to (or will marry) women due to sociocultural expectations. Latent class models can inform a more nuanced yet empirical characterization of this population. In total, 1424 eligible respondents recruited online provided self-reported behavioral data. Nine items related to constructs including sexual behaviors, sexual orientation, and gender identity informed the latent class model. Logistic regression was used to measure associations between latent class membership and HIV-related sexual and health-seeking behaviors. Model fit indicated a population structure made up of four classes that we characterized as "Gender nonconforming" (4.3%), "Closeted-unmarried" (29.9%), "Closeted-married" (24.6%), and "Out" (41.2%). Members of the "gender nonconforming" class were more likely to report HIV-related risk behaviors, and "Closeted-unmarried" class members were less likely to report health-seeking behaviors, both relative to "Out" members. The largest latent class was made up of members of the "Out" class, an enlightening revision of a population traditionally viewed as largely closeted men. Two types of "closeted" classes emerged, distinguished by divergent tendencies regarding marriage and health seeking. Findings suggest that current understandings of Chinese MSM are simplistic (regarding closeted behaviors) and too narrow (in its definition of MSM as cisgender men). A more nuanced understanding of MSM subgroups and their heterogeneous risk behaviors will be critical for provision of more meaningful prevention services.

Crowdsourcing in health and medical research: a systematic review

Background

Crowdsourcing is used increasingly in health and medical research. Crowdsourcing is the process of aggregating crowd wisdom to solve a problem. The purpose of this systematic review is to summarize quantitative evidence on crowdsourcing to improve health.

Methods

We followed Cochrane systematic review guidance and systematically searched seven databases up to September 4th 2019. Studies were included if they reported on crowdsourcing and related to health or medicine. Studies were excluded if recruitment was the only use of crowdsourcing. We determined the level of evidence associated with review findings using the GRADE approach.

Results

We screened 3508 citations, accessed 362 articles, and included 188 studies. Ninety-six studies examined effectiveness, 127 examined feasibility, and 37 examined cost. The most common purposes were to evaluate surgical skills (17 studies), to create sexual health messages (seven studies), and to provide layperson cardio-pulmonary resuscitation (CPR) out-of-hospital (six studies). Seventeen observational studies used crowdsourcing to evaluate surgical skills, finding that crowdsourcing evaluation was as effective as expert evaluation (low quality). Four studies used a challenge contest to solicit human immunodeficiency virus (HIV) testing promotion materials and increase HIV testing rates (moderate quality), and two of the four studies found this approach saved money. Three studies suggested that an interactive technology system increased rates of layperson initiated CPR out-of-hospital (moderate quality). However, studies analyzing crowdsourcing to evaluate surgical skills and layperson-initiated CPR were only from high-income countries. Five studies examined crowdsourcing to inform artificial intelligence projects, most often related to annotation of medical data. Crowdsourcing was evaluated using different outcomes, limiting the extent to which studies could be pooled.

Conclusions

Crowdsourcing has been used to improve health in many settings. Although crowdsourcing is effective at improving behavioral outcomes, more research is needed to understand effects on clinical outcomes and costs. More research is needed on crowdsourcing as a tool to develop artificial intelligence systems in medicine.

Trial registration

PROSPERO: CRD42017052835. December 27, 2016.