The use of web-based diaries in sexual risk behaviour research: a systematic review

A Multicomponent Intervention (POSSIBLE) to Improve Perceived Risk for HIV Among Black Sexual Minority Men: Feasibility and Preliminary Effectiveness Pilot Study

BACKGROUND

Increased pre-exposure prophylaxis (PrEP) use is urgently needed to substantially decrease HIV incidence among Black sexual minority men. Low perceived risk for HIV (PRH) is a key unaddressed PrEP barrier for Black sexual minority men. Peers and smartphone apps are popular intervention tools to promote community health behaviors, but few studies have used these together in a multicomponent strategy. Therefore, we designed a multicomponent intervention called POSSIBLE that used an existing smartphone app called PrEPme (Emocha Mobile Health, Inc) and a peer change agent (PCA) to increase PRH as a gateway to PrEP.

OBJECTIVE

This paper aims to describe the feasibility and preliminary impact of POSSIBLE on PRH and willingness to accept a PrEP referral among Black sexual minority men.

METHODS

POSSIBLE was a theoretically guided, single-group, 2-session pilot study conducted among Black sexual minority men from Baltimore, Maryland between 2019 and 2021 (N=69). POSSIBLE integrated a PCA and the PrEPme app that allows users to self-monitor sexual risk behaviors and chat with the in-app community health worker to obtain PrEP service information. PRH was assessed using the 8-item PRH scale before and after baseline and follow-up study visits. At the end of each study visit, the PCA referred interested individuals to the community health worker to learn more about PrEP service options.

RESULTS

The average age of participants was 32.5 (SD 8.1, range 19-62) years. In total, 55 (80%) participants were retained for follow-up at month 1. After baseline sessions, 29 (42%) participants were willing to be referred to PrEP services, 20 (69%) of those confirmed scheduled appointments with PrEP care teams. There were no statistically significant differences in PRH between baseline and follow-up visits (t122=-1.36; P=.17).

CONCLUSIONS

We observed no statistically significant improvement in PRH between baseline and month 1. However, given the high retention rate and acceptability, POSSIBLE may be feasible to implement. Future research should test a statistically powered peer-based approach on PrEP initiation among Black sexual minority men.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04533386; https://clinicaltrials.gov/study/NCT04533386.

Protocol to acquire time series data on adverse reactions following vaccination using a smartphone or web-based platform

Data collection on adverse reactions in recipients after vaccination is vital to evaluate potential health issues, but health observation diaries are onerous for participants. Here, we present a protocol to collect time series information using a smartphone or web-based platform, thus eliminating the need for paperwork and data submission. We describe steps for setting up the platform using the Model-View-Controller web framework, uploading lists of recipients, sending notifications, and managing respondent data. For complete details on the use and execution of this protocol, please refer to Ikeda et al. (2022).¹.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Inconsistent Sexual Behavior Reporting Among Youth Affected by Perinatal HIV Exposure in the United States

We examined reporting agreement of oral, vaginal, and anal sex in adolescents and young adults living with perinatally-acquired HIV and those perinatally HIV-exposed and uninfected in the Pediatric HIV/AIDS Cohort Study Adolescent Master Protocol (AMP) and AMP Up studies. Agreement between fixed constructs (e.g., age at first sex) and prevalence of logical inconsistencies (e.g., reclaimed virginity status) over time were assessed. Internal consistency was also examined using an attention check question and questions regarding condom use in the prior three months. Those who reported having anal sex in adolescence had a higher proportion of inconsistent responses compared to vaginal and oral sex measures. At their most recent survey, 84% of young adults correctly answered an attention check question and 74% agreed within the survey on condom use in the prior three months. In bivariate analyses, HIV status was not associated with responding inconsistently. Increased time between surveys, male sex, and younger age at first survey were associated with multiple measures of inconsistency over time, while lower cognitive scores, having less than a high school diploma, and negatively answering post-survey acceptability questions were associated with incorrectly answering an attention check question.

Reducing bias in trials from reactions to measurement: the MERIT study including developmental work and expert workshop

BACKGROUND

Measurement can affect the people being measured; for example, asking people to complete a questionnaire can result in changes in behaviour (the 'question-behaviour effect'). The usual methods of conduct and analysis of randomised controlled trials implicitly assume that the taking of measurements has no effect on research participants. Changes in measured behaviour and other outcomes due to measurement reactivity may therefore introduce bias in otherwise well-conducted randomised controlled trials, yielding incorrect estimates of intervention effects, including underestimates.

OBJECTIVES

The main objectives were (1) to promote awareness of how and where taking measurements can lead to bias and (2) to provide recommendations on how best to avoid or minimise bias due to measurement reactivity in randomised controlled trials of interventions to improve health.

METHODS

We conducted (1) a series of systematic and rapid reviews, (2) a Delphi study and (3) an expert workshop. A protocol paper was published [Miles LM, Elbourne D, Farmer A, Gulliford M, Locock L, McCambridge J, et al. Bias due to MEasurement Reactions In Trials to improve health (MERIT): protocol for research to develop MRC guidance. Trials 2018;19:653]. An updated systematic review examined whether or not measuring participants had an effect on participants' health-related behaviours relative to no-measurement controls. Three new rapid systematic reviews were conducted to identify (1) existing guidance on measurement reactivity, (2) existing systematic reviews of studies that have quantified the effects of measurement on outcomes relating to behaviour and affective outcomes and (3) experimental studies that have investigated the effects of exposure to objective measurements of behaviour on health-related behaviour. The views of 40 experts defined the scope of the recommendations in two waves of data collection during the Delphi procedure. A workshop aimed to produce a set of recommendations that were formed in discussion in groups.

RESULTS

Systematic reviews - we identified a total of 43 studies that compared interview or questionnaire measurement with no measurement and these had an overall small effect (standardised mean difference 0.06, 95% confidence interval 0.02 to 0.09; n = 104,096, I² = 54%). The three rapid systematic reviews identified no existing guidance on measurement reactivity, but we did identify five systematic reviews that quantified the effects of measurement on outcomes (all focused on the question-behaviour effect, with all standardised mean differences in the range of 0.09-0.28) and 16 studies that examined reactive effects of objective measurement of behaviour, with most evidence of reactivity of small effect and short duration. Delphi procedure - substantial agreement was reached on the scope of the present recommendations. Workshop - 14 recommendations and three main aims were produced. The aims were to identify whether or not bias is likely to be a problem for a trial, to decide whether or not to collect further quantitative or qualitative data to inform decisions about if bias is likely to be a problem, and to identify how to design trials to minimise the likelihood of this bias.

LIMITATION

The main limitation was the shortage of high-quality evidence regarding the extent of measurement reactivity, with some notable exceptions, and the circumstances that are likely to bring it about.

CONCLUSION

We hope that these recommendations will be used to develop new trials that are less likely to be at risk of bias.

FUTURE WORK

The greatest need is to increase the number of high-quality primary studies regarding the extent of measurement reactivity.

STUDY REGISTRATION

The first systematic review in this study is registered as PROSPERO CRD42018102511.

FUNDING

Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research Programme.

Improving routine immunization data quality using daily short message system reporting platform: An experience from Nasarawa state, Nigeria

Routine immunization (RI) delivery was declared a public health concern in Nigeria in 2017 because of persistently low immunization coverage rates reported in independent surveys. However, administrative coverage rates remain high, suggesting serious data quality issues. We posit that a shorter timespan between service provision and data reporting can improve the monitoring of RI data, and developed a short message system (SMS) text reporting strategy to generate daily RI data points from health facilities (HFs). The goal was to assess whether daily data collection produces complete, reliable and internally consistent data points. The SMS reporting platform was piloted between December 2017 and April 2018 in two Local Government Areas (LGAs, equivalent to districts) of Nasarawa state, Nigeria. The 145 healthcare workers from 55 HFs received one mobile phone and pre-configured SIM card, and were trained to send data through predefined codes. Healthcare workers compiled the data after each vaccination session and transmitted them via SMS. We analyzed completeness, number of weekly sessions, and supportive supervision conducted. During the pilot phase, we received data from 85% (n = 47) of the 55 HFs. We expected 66 fixed-post sessions and 30 outreach sessions per week, but received data for 33 fixed-post and 8 outreach weekly session on average. More HFs reported on Tuesdays compared to other days of the week. When assessing internal consistency, we observed that the reported number of children vaccinated was sometimes higher than the number of doses available from opening a given number of vaccine vials. When found, this discrepancy was noted for all antigens during fixed-post and outreach vaccination sessions. Despite these initial discrepancies, transmitting RI data sessions via texting is feasible and can provide real-time updates to the performance of the RI services at the HF level.

DOT Diary: Developing a Novel Mobile App Using Artificial Intelligence and an Electronic Sexual Diary to Measure and Support PrEP Adherence Among Young Men Who Have Sex with Men

Young men who have sex with men (YMSM) are highly vulnerable to HIV. While pre-exposure prophylaxis (PrEP) has demonstrated effectiveness, adherence has been low among YMSM and difficult to measure accurately. In collaboration with a healthcare company, we configured an automated directly-observed therapy (aDOT) platform for monitoring and supporting PrEP use. Based on interest expressed in focus groups among 54 YMSM, we combined aDOT with an electronic sexual diary to provide feedback on level of protection during sex and to motivate app use. In an 8-week optimization pilot with 20 YMSM in San Francisco and Atlanta, the app was found to be highly acceptable, with median System Usability Scale scores in the "excellent" range (80/100). App use was high, with median PrEP adherence of 91% based on aDOT-confirmed dosing. Most (84%) participants reported the app helped with taking PrEP. These promising findings support further evaluation of DOT Diary in future effectiveness studies.

A mixed methods investigation of implementation barriers and facilitators to a daily mobile phone sexual risk assessment for young women in Soweto, South Africa

Background

The HIV epidemiology in South Africa reveals stark age and gender disparities, with young women being the most vulnerable to HIV acquisition in 2017. Evaluation of HIV exposure is a challenge in HIV prevention research. Intermittent in-clinic interviewer-administered risk behaviour assessments are utilised but may be limited by social desirability and recall biases. We piloted a mobile phone application for daily self-report of sexual risk behaviour in fifty 18–25 year old women at risk of HIV infection enrolled in HIV Vaccine Trials Network 915 (HVTN 915) in Soweto, South Africa. Through a mixed-methods investigation, we explored barriers and facilitators to completing daily mobile phone surveys among HVTN 915 study participants and staff.

Methods

We analysed quantitative data on barriers and facilitators to mobile phone study completion collected during the larger HVTN 915 study as well as two post-study focus group discussions (FGDs) with fifteen former participants with a median age of 24 years (IQR 23–25) and six individual in-depth interviews (IDIs) with HVTN 915 staff. FGDs and IDIs utilised semi-structured interview guides, were audio-recorded, transcribed verbatim and translated to English. After coding, thematic analysis was performed.

Results

The main facilitator for daily mobile phone survey completion assessed across 336 follow-up visits for 49 participants was the daily short message system (SMS) reminders (93%, 312/336). Across 336 visits, 31/49 (63%) retained participants reported barriers to completion of daily mobile phone surveys: forgetting (20%, 12/49), being too busy (19%, 11/49) and the survey being an inconvenience (15%, 9/49). Five main themes were identified during the coding of IDIs and FGDs: (1) facilitators of mobile phone survey completion, such as daily SMS reminders and follow up calls for non-completers; (2) barriers to mobile phone survey completion, including partner, time-related and technical barriers; (3) power of incentives; (4) response bias in providing sensitive information, and (5) recommendations for future mobile phone based interventions.

Conclusion

Despite our enthusiasm to use innovation to optimise sexual risk assessments, technical and practical solutions are required to improve implementation. We recommend further engagement with participants to optimise this approach and to further understand social desirability bias and study incentives in sexual risk reporting.

Increased Likelihood of Pregnancy Using an App-Connected Ovulation Test System: A Randomized Controlled Trial

Background: Women trying to conceive are increasingly using fertility-tracking software applications to time intercourse. This study evaluated the difference in conception rates between women trying to conceive using an application-connected ovulation test system, which measures urinary luteinizing hormone and an estrogen metabolite, versus those trying without using ovulation testing.

Materials and Methods: This home-based study involved 844 volunteers aged 18–40 years seeking to conceive. Volunteers randomized to the test arm were required to use the test system for the duration of the study while those randomized to the control arm were instructed not to use ovulation testing. Pregnancy rate differences across one and two cycles between the two groups were examined.

Results: Volunteers in the test (n = 382) and control arms (n = 403) had similar baseline demographics. The proportion of women pregnant after one cycle was significantly greater in the test arm (25.4%) compared with the control arm (14.7%; p < 0.001). After two cycles, there continued to be a greater proportion of women pregnant in the test arm compared with the control arm (36.2% vs. 28.6%; p = 0.026). In the test arm, volunteers had intercourse less frequently per cycle compared with those not using ovulation testing (9 [range: 1–60] vs. 10 [range: 1–50]; p = 0.027), but were more likely to target intercourse to a particular part of their cycle compared with those not using ovulation testing (88.5% vs. 57.8%; p < 0.001).

Conclusion: Using the test system to time intercourse within the fertile window increases the likelihood of conceiving within two menstrual cycles.

Patterns in On-time, Daily Submission of a Short Web-Based Personal Behavior Survey in a Longitudinal Women's Health Study

We evaluated compliance with submitting a short Web-based personal behavior survey daily during a 10-week study (n = 52 women/3419 diaries). Time-stamped forms revealed that 50% of diaries were submitted within 24 hours of the email prompt, and 19% were missing or submitted more than 3 days late. Late submissions may affect data quality.

A Mobile Application to Collect Daily Data on Preexposure Prophylaxis Adherence and Sexual Behavior Among Men Who Have Sex With Men: Use Over Time and Comparability With Conventional Data Collection

BACKGROUND

We studied the use of a mobile application (app) to measure human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) adherence and sexual behavior, assessed determinants of app use, and we compared data in app and questionnaires.

METHODS

Men who have sex with men participating in the Amsterdam PrEP project (AMPrEP) on daily or event-driven PrEP at the Public Health Service of Amsterdam completed the data on sexual risk behavior and PrEP adherence through a standard questionnaire every 3 months and on a daily basis using the project's app. Regression analyses were used to assess factors associated with app use. Among those who reported 90% or greater of data in the app, the number of PrEP pills taken and number of unknown casual sex partners were compared between the app and the questionnaires by Wilcoxon signed-rank test.

RESULTS

Of all participants (n = 374), 94% (352 of 374) reported data in the app at least once; 72% (261 of 362) reported data ≥90% of the days in the sixth month and 62% (222 of 359) in the 12th month following PrEP initiation.Factors associated with reporting data in the app were using daily PrEP and recent initiation of PrEP. The reported numbers of pills taken and unknown sexual partners were comparable between app and questionnaires.

CONCLUSIONS

The AMPrEP app was used frequently, especially by those using a daily PrEP regimen. Data collected by app regarding adherence and sexual risk behavior were consistent with questionnaire data among those who used the app consistently. An app is a promising tool to measure PrEP adherence and sexual risk behavior.

Mobile Phone Questionnaires for Sexual Risk Data Collection Among Young Women in Soweto, South Africa

Recall and social desirability bias undermine self-report of paper-and-pencil questionnaires. Mobile phone questionnaires may overcome these challenges. We assessed and compared sexual risk behavior reporting via in-clinic paper-and-pencil and mobile phone questionnaires. HVTN 915 was a prospective cohort study of 50 adult women in Soweto, who completed daily mobile phone, and eight interviewer-administered in-clinic questionnaires over 12 weeks to assess sexual risk. Daily mobile phone response rates were 82% (n = 3486/4500); 45% (n = 1565/3486) reported vaginal sex (median sex acts 2 (IQR: 1-3)) within 24 h and 40% (n = 618/1565) consistent condom. Vaginal sex reporting was significantly higher via mobile phone across all visits (p < 0.0001). There was no significant difference in condom use reporting by mobile phone and in-clinic paper-based questionnaires across all visits (p = 0.5134). The results show high adherence and reporting of sex on the mobile phone questionnaire. We demonstrate feasibility in collecting mobile phone sexual risk data.

Do Diary Studies Cause Behavior Change? An Examination of Reactivity in Sexual Risk and Substance Use in Young Men Who Have Sex with Men

Behavioral diaries are frequently used for observing sexual and substance use behaviors, but participating in diary studies may cause behavior change. This study examined change in sexual and substance use behaviors among young men who have sex with men (YMSM) in a two-month diary study compared to control. An analytic sample of 324 YMSM was randomized to receive daily diaries, weekly diaries, or no diaries (control) for 2 months. Half of the diary participants were randomized to receive automated weekly feedback. Between-subjects analyses found no evidence of change in sexual or substance use behaviors from baseline to 2-month follow-up when comparing the diary conditions to control. Within-persons growth mixture models of all diary data showed significant decreases in condomless anal sex (CAS) and illicit drug use. Weekly automated feedback had no effect on behavior change. Findings provide evidence of change in CAS and illicit drug use amongst diary participants.

Measuring sexual behaviour in Malawi: a triangulation of three data collection instruments

BACKGROUND

There is a need for valid approaches to measure sexual interactions to assess the impact of behavioural interventions and to predict the impact of behaviour changes. Different methods of asking about sexual behaviour often yield conflicting answers and men often report higher levels of heterosexual activity than women. To better understand self-reported sexual behaviour data and how best to collect it, we analyzed data collected as part of a larger project (ST IMPACTS) on the social and behavioural impact of introducing community-level HIV self-testing (HIVST) with counseling (semi-supervised with pre- and generic post-test counseling provided on delivery or collection of test kits) in an urban Malawian setting.

METHODS

Information on sexual behaviour was collected from HIV self-testers over a three-month period. Three different methods were used: retrospective face-to-face interviews (FTFI); audio computer assisted self-interviews (ACASI) and a prospective coital diary. Both retrospective instruments were used before and after the three-month study period. Frequency and cross-tabulation, as well as scatterplots, were used for exploratory analyses. Chi-square tests were used to test for differences in proportions. Spearman's correlation coefficient was used to explore associations between both continuous and ordinal variables and Wilcoxon's paired sample and Mann-Whitney test was used to test for differences in such variables or between variables.

RESULTS

There was reasonable agreement between the two retrospective methods although both yielded inconsistent answers e.g. with lower reported numbers of life-time sexual partners at the end than at the beginning of the study period. The diary method elicited higher reported levels of sex with multiple partners than both retrospective instruments which may be due to inadequate recall. Over the study period 37.4% of men and 19.7% of women reported multiple sexual partners using the diary. There was no clear relationship between reported sexual behaviour and HIV status (prevalence 9.6%).

CONCLUSIONS

Diaries may therefore have higher validity for sensitive behaviour reporting and thus be the preferred method in similar African contexts in measuring sexual behaviours.

Validation of the HIV Risk Assessment of Sexual Partnerships (H-RASP): Comparison to a 2-Month Prospective Diary Study

The HIV Risk Assessment of Sexual Partnerships (H-RASP) was developed in order to create a retrospective measure of sexual risk-taking that can account for the differing contexts of sexual partnership(s) within a specified period of time. In order to validate the H-RASP relative to other methods of measuring sexual risk-taking, measurements from the H-RASP were compared to data from a prospective diary study of 95 young men who have sex with men over the same two-month period. We found that the H-RASP was not significantly different at measuring participants' total number of sexual partners and total number of anal sex partners in comparison with the diaries. The two measures were significantly different in measurement of total number of condomless anal sex (CAS) partners and number of CAS acts within partnerships, such that participants on average estimated more CAS partners and acts in the H-RASP. The two measures shared 40.8% of variance on measurement of CAS partners and 44.6% of variance on CAS acts within partnerships. These results suggest that even though the H-RASP is not a perfect replication of prospective diary data, it captures a moderate proportion of the same variance, and, in the case of CAS acts within partnerships, a proportion of the variance that likely would not be measured by retrospective measures that do not ask about behaviors specific to partnerships.

Use of a Prospective Sex Diary to Study Anal Lubricant and Enema Use Among High Risk Men Who Have Sex With Men-Implications for Human Immunodeficiency Virus Prevention

Longitudinal data on episodes of receptive anal intercourse (RAI), lubricant, and enema use in 41 sexually active men who have sex with men were collected using a prospective sex diary. Data on 550 episodes of RAI showed that lubricants were used in 489 (88.9%) of 550 episodes and enemas were used in 165 (30%) of 550 RAI episodes.

Comparing 3-month recall to daily reporting of sexual behaviours

OBJECTIVES

This study aimed to examine discrepancies between self-report methods and methodological issues related to sexual risk taking. We examined sexual behaviour assessed via 3-month electronic recall and by daily electronic reporting among a large cohort of patients attending STI clinics.

METHODS

STI clinic attenders (N= 628) aged 15 to 60 years reported on demographic information (at baseline), penile-vaginal sex acts, condom-unprotected penile-vaginal sex and STI history using 3-month recall and daily reports. Additionally, interviewer-participant match related to race and gender, as well as study site were considered as covariates.

RESULTS

Concordance between recall and daily reports on penile-vaginal sex was moderately strong (Spearman's r (rs)=0.62; p<0.001). Comparison for reports for condom-unprotected penile-vaginal sex resulted in a correlation coefficient of 0.61 (p<0.001), also indicating moderately strong agreement between the two methods. Two generalised logit models were conducted to explain lack of strong concordance in penile-vaginal sex acts and condom-unprotected penile-vaginal sex. The odds of a female reporting higher frequency of sex in daily reports compared with recall were more than two times that of a male. Every five person increase in the number of lifetime sexual partners was associated with five times the odds of a discrepancy in reporting methods. Age was also significantly associated with unequal daily versus recall sex frequency reporting.

CONCLUSIONS

Shifting focus to methodological considerations of technological reports can help ensure better investment of resources into sexual health research due to greater understanding of the methodological properties of data collection methods.

Patterns and Predictors of Compliance in a Prospective Diary Study of Substance Use and Sexual Behavior in a Sample of Young Men Who Have Sex With Men

Behavioral diaries are used for observing health-related behaviors prospectively. Little is known about patterns and predictors of diary compliance to better understand differential attrition. An analytic sample of 241 young men who have sex with men (YMSM) from a 2-month diary study of substance use and sexual behavior were randomized to complete daily or weekly timeline followback diaries. Latent class growth analyses were used to analyze data. Weekly and daily diary groups produced similar compliance patterns: high, low, and declining compliance groups. Black YMSM were more likely to be in the declining compared with the high compliance group. YMSM who were randomly assigned to receive automated feedback about risk behaviors did not differ in compliance rate compared with those who did not. Risk behavior engagement did not predict compliance in the daily condition, but some substances predicted compliance in the weekly condition. Implications for observational and behavior change methods are discussed.

Opportunities and Challenges of Digital Technology for HIV Treatment and Prevention

Novel eHealth interventions are creating exciting opportunities for health promotion along the continuum of HIV care and prevention. Reviews of recent work indicate the use of multiple platforms (e.g., smartphones, social media), with trends toward individualized approaches and real-time assessments. However, the field needs more rigorous investigations to provide evidence of long-term impact on clinical indicators and should expand its targets beyond men who have sex with men and medication adherence. Challenges to the field include working within restricted funding timelines and disseminating eHealth interventions to those most in need.

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

This study delivered a daily diary to 67 HIV-infected men who have sex with men (MSM) between 16 and 24 years old for 66 days to measure HIV-risk behaviors and other psychosocial variables via two diary modalities: internet (accessible via any web-enabled device) and voice (accessible via telephone). Participants were randomized to complete one diary modality for 33 days before switching to the second modality for 33 days. The study was implemented in three urban HIV health care centers in the United States where participants were receiving services. Through diary data and qualitative interview data, we examined the feasibility and acceptability of the dairies and identified barriers and facilitators of dairy compliance. Results show high participant retention in the daily diary (93.4 %) and high compliance for the number of dairies completed (72.4 %). Internet diaries were preferred by 92 % of participants and completed at a significantly higher rate (77.5 %) than voice diaries (67.7 %). Facilitators included opportunities for self-reflection and cathartic sharing, monetary compensation, relationships with study staff, and daily reminders. Barriers included being busy or not having privacy at the time of reminders, forgetting, and falling asleep. Participants also described barriers and facilitators unique to each modality. Overall, both modalities were feasible and acceptable for use with our sample of HIV-infected MSM.