Bias in online recruitment and retention of racial and ethnic minority men who have sex with men

Feasibility and Acceptability of a Motivational Interviewing-Based Telehealth Intervention for Bacterial Sexually Transmitted Infection Screening: Protocol for a Sequential Explanatory Mixed Methods Study

BACKGROUND

Gay, bisexual, and other men who have sex with men living with HIV (GBMSM-LWH) in the United States bear a heavy burden of bacterial sexually transmitted infections (STIs). Timely diagnosis and treatment are key to prevention. Only a few studies have combined home specimen self-collection for bacterial STI screening with live audio and video (AV) conferencing. None have focused on GBMSM-LWH or incorporated motivational interviewing (MI), a client-centered, strengths-based counseling approach that seeks to support individuals to create positive behavioral change.

OBJECTIVE

Our study seeks to investigate the feasibility and acceptability of an MI-based telehealth intervention that integrates home specimen self-collection from different anatomical sites of possible exposure and MI delivered via live AV conferencing to engage sexually active GBMSM-LWH in bacterial STI screening.

METHODS

Participants are being recruited from across the United States via advertising on mobile dating apps and social networking sites and via peer referral. Phase 1 involves piloting the delivery of an innovative telehealth intervention for bacterial STI screening to 75 GBMSM-LWH. Our intervention includes three components: (1) a pretest live AV conferencing session involving an MI-guided discussion to elicit awareness of bacterial STIs; fill any knowledge gaps; bolster the perceived importance of regularly testing for gonorrhea, chlamydia, and syphilis; and build self-efficacy for specimen self-collection; (2) home self-collection and return via mail of a urine sample (for gonorrhea and chlamydia testing), a throat swab (for gonorrhea and chlamydia testing), a rectal swab (for gonorrhea and chlamydia testing), and a finger-stick blood sample (for syphilis testing); and (3) a posttest live AV conferencing session involving an MI-guided discussion to prepare participants for receiving test results and formulate personalized action plans for seeking treatment (if warranted) and repeat testing. Descriptive statistics and progression ratios will be calculated, and potential variations in our intervention's feasibility and acceptability will be numerically summarized and graphically visualized. Phase 2 involves elucidating attitudes, facilitators, and barriers related to engaging in each intervention component via semistructured in-depth interviews with a purposive subsample of 20 participants who complete progressively smaller subsets of the pretest session, specimen return for bacterial STI testing, and the posttest session. Thematic analysis will be used to identify, analyze, and report patterns in the data. Quantitative and qualitative data will be integrated at the design, methods, interpretation, and reporting levels.

RESULTS

Study procedures were approved by the Institutional Review Board at the University of Michigan in September 2023. Participant recruitment began in April 2024.

CONCLUSIONS

Our study will advance multiple goals of the STI National Strategic Plan for the United States for 2021 to 2025, specifically those pertaining to preventing new STIs; accelerating progress in STI research, technology, and innovation; and reducing STI-related health disparities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06100250; https://www.clinicaltrials.gov/study/NCT06100250.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64433.

"I don't see myself represented:" Strategies and considerations for engaging gay male Native Hawaiian and Other Pacific Islander teens in research and HIV prevention services

Significant efforts have been applied to the development of sexual health programs for minority young gay males. Given the absence of research with Native Hawaiian and other Pacific Islander (NHOPI) gay teen males, this study was done to assess how to reach them. Interviews were conducted with 20 NHOPI gay males ages 19-24 as near peers that can inform reaching teens. Data was analyzed using the Reflexive Thematic Analysis method. Three themes were identified: (1) Culture is a crucial factor for recruitment and engagement-whether participants realized it or not; (2) Confidentiality is key in recruitment to provide a safe space for NHOPI gay teen male research participation; and (3) NHOPI gay teen males experience multiple identity conflicts that must be considered for recruitment and engagement initiatives. Online recruitment efforts are optimal and should reflect distinct NHOPI cultures. More research is needed when it comes to understanding the cultural acceptance and understanding of homosexuality in NHOPI communities and how to integrate cultural education into recruitment methods and interventions.

Optimizing Uptake of Long-Acting Injectable Pre-exposure Prophylaxis for HIV Prevention for Men Who Have Sex with Men

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool. Long-acting injectable PrEP (LAI-PrEP) offers another opportunity to reduce HIV. However, how at-risk individuals will consider LAI-PrEP over other modes of administration is unclear. We conducted a discrete choice experiment on preferences for PrEP among a sample of N = 688 gay, bisexual, and other men who have sex with men (GBMSM). We analyzed preferences for mode of administration, side-effects, monetary cost, and time cost using a conditional logit model and predicted preference for PrEP options. LAI-PrEP was preferred, despite mode of administration being the least important PrEP attribute. Side-effects were the most important attribute influencing preferences for PrEP (44% of decision); costs were second-most-important (35% of decision). PrEP with no side-effects was the most important preference, followed by monthly out-of-pocket costs of $0. Practitioners and policymakers looking to increase PrEP uptake should keep costs low, communicate clearly about PrEP side-effects, and allow the use of patient-preferred modes of PrEP administration, including LAI-PrEP.

Talking to My Partners About PrEP: Factors Associated with PrEP-Related Communication in a Longitudinal US Study of Sexual Minority Men Living with HIV

Treatment as prevention and pre-exposure prophylaxis (PrEP) have reduced HIV transmission among sexual minority men (SMM). However, little is known about PrEP-related communication in serodiscordant partnerships. In 2015-2016, 965 US SMM living with HIV (Mage = 39; 63% White, 19% Black, 18% Latinx) enrolled in a year-long longitudinal study with surveys every 3 months (2,850 surveys). Multilevel models explored factors associated with PrEP-related communication with HIV-negative partners. Most participants (77%) reported PrEP-related communication. Participants were more likely to discuss PrEP during periods with more sexual partners, AOR = 2.89, p < .001, and group sex, AOR = 1.99, p = .001. Those with more partners on average, β = 0.48, p < .001, and those engaging in other drug use more frequently, β = 0.11, p = .002, were more likely to discuss PrEP. PrEP-related communication was more common for men who disclosed their HIV status, β = 0.22, p < .001, and who had undetectable viral loads, β = 0.25, p = .007. Communication was also more common for those with higher incomes, β = 0.12, p = .02, and from larger cities, β = 0.07, p = .048, and less common for Black participants, β =  - 0.29, p = .003, and older participants, β =  - 0.18, p < .001. PrEP-related communication increased over the course of the study, AOR = 1.16, p= .02. PrEP can confer additional HIV prevention benefits within serodiscordant partnerships, and future research should continue to explore the role PrEP plays in these partnerships.

Considerations for partnering with Ryan White Case Managers to create equitable opportunities for people with HIV to participate in research

Many research studies focus on recruitment from one or few HIV clinics or internet-engaged populations, but this may result in inequitable representation of people with HIV (PWH), across the rural/urban/suburban continuum. Ryan White Case Managers (RWCM) meet regularly with PWH, potentially positioning them as partners in gathering research-related data from diverse groups of low-income, marginalized, PWH. Yet, data collection in partnership with RWCM, particularly over large geographic areas, has been under-explored. We partnered with RWCM and their organizations throughout Florida to administer a 10-item technology use and willingness survey to clients living with HIV; RWCMs provided process-oriented feedback. Among 382 approached RWCM, 71% completed human subjects and survey administration training; 48% gathered data on 10 predetermined survey administration days; and 68% administered at least one survey during the entire period for survey administration. Altogether, 1,268 client surveys were completed, 2.7% by rural participants. Stigma, privacy concerns, and disinterest reportedly inhibited client participation; competing obligations, policies, and narrow recruitment windows prevented some RWCM from offering the survey to clients. Research should further explore strategies and best practices to ensure equitable access to participate in research among PWH.

An assessment of the proportion of LGB+ persons in the Belgian population, their identification as sexual minority, mental health and experienced minority stress

BACKGROUND

Previous studies report vast mental health problems in sexual minority people. Representative national proportion estimates on self-identifying LGB+ persons are missing in Belgium. Lacking data collection regarding sexual orientation in either census or governmental survey data limits our understanding of the true population sizes of different sexual orientation groups and their respective health outcomes. This study assessed the proportion of LGB+ and heterosexual persons in Belgium, LGB+ persons' self-identification as sexual minority, mental health, and experienced minority stress.

METHOD

A representative sample of 4632 individuals drawn from the Belgian National Register completed measures of sexual orientation, subjective minority status, and its importance for their identity as well as a range of mental-health measures.

RESULTS

LGB+ participants made up 10.02% of the total sample and 52.59% of LGB+ participants self-identified as sexual minority. Most sexual minority participants considered sexual minority characteristics important for their identity. LGB+ persons reported significantly worse mental health than heterosexual persons. Sexual minority participants did not report high levels of minority stress, but those who considered minority characteristics key for their identity reported higher levels of minority stress. LGB+ participants who did not identify as minority reported fewer persons they trust.

CONCLUSIONS

The proportion of persons who identified as LGB+ was twice as large as the proportion of persons who identified as a minority based on their sexual orientation. LGB+ persons show poorer mental health compared to heterosexual persons. This difference was unrelated to minority stress, sociodemographic differences, minority identification, or the importance attached to minority characteristics.

A Relational Framework for Engaging Latino Sexual Minority Men in Sexual and Behavioral Health Research

Latino sexual minority men (LSMM) experience sexual and behavioral health disparities. Yet, LSMM are underrepresented in sexual and behavioral health research, creating scientific inequity. There is, therefore, a need to identify the barriers and facilitators to LSMM's participation in sexual and behavioral health research, which is the gap that the current study sought to fill. We interviewed LSMM (n = 28; age 18-40, 57% US born) and key informants (n = 10) regarding LSMM's barriers and facilitators to participating in sexual and behavioral health research and suggestions for increasing participation. The research team coded the data via thematic analysis. We found that relational factors are central to understanding LSMM's participation in sexual and behavioral health research. Some relational experiences (e.g., interpersonal stigma) interfered with participation, whereas others (e.g., altruistic desires to contribute to community well-being) facilitated participation. The findings are consolidated within a new relational framework for understanding LSMM's participation in sexual and behavioral health research. Study findings highlight the centrality of relational factors in influencing LSMM's participation in sexual and behavioral health research. Relational factors can be used to inform the development of culturally relevant recruitment strategies to improve representation of LSMM in sexual and behavioral health research. Implementing these recommendations may address scientific inequity, whereby LSMM are disproportionately impacted by sexual and behavioral health concerns yet underrepresented in related research.

Interpersonal Stigma, Mental Health, and Sexual Compulsivity Among an Online U.S. Sample of Men Who Have Sex with Men Living with HIV

This cross-sectional study sought to determine whether HIV-related interpersonal stigma was associated with the presence of sexual compulsivity (SC) in a national online sample of 936 men who have sex with men (MSM) living with HIV who reported recent suboptimal adherence to their antiretroviral therapy (ART) or virologic non-suppression. A modest association was found between perceptions of HIV-related interpersonal stigma and SC that was partially mediated by current mental health symptoms. White MSM were significantly more likely than Black MSM to report SC or HIV-related interpersonal stigma. Findings signal the need for therapeutic interventions that include behavioral and/or pharmacologic therapy to address overlapping intervention targets, including mental health, substance use, and sexual health. Future research should assess temporality of HIV-related interpersonal stigma and SC, as well as racial differences in relation to these constructs.

Transgender Women's Internet Survey and Testing: Protocol and Key Indicators Report

Purpose: There is a need for ongoing behavioral surveillance of human immunodeficiency virus (HIV)/sexually transmitted infection (STI) risk among transgender women, using assessments adapted to this population. We therefore developed and piloted the Transgender Women's Internet Survey and Testing (TWIST) study, a cross-sectional behavioral survey of transgender women in the United States coupled with remote biospecimen collection and testing. Methods: Participants age 15+ were recruited by using social media advertisements. Participants were eligible to take the survey if they reported male sex at birth, identified as female or as a transgender woman, resided in the United States, and reported ever having oral, vaginal, or anal sex. We examined a number of behavioral indicators by age, county population density, and medical gender affirmation treatment, using multivariable regression modeling. A sample of respondents was invited to receive a home biospecimen collection kit for HIV/STI testing. Results: The 401 participants were mainly non-Hispanic white and younger than 25 years. Self-reported HIV prevalence was 1.3% (5/401), and almost half (47.1%, 189/401) did not know their HIV status. Receiving medical gender affirmation was strongly associated with past-year HIV and STI testing, independent of general health care engagement. Of the 155 participants invited to receive home biospecimen collection kits, 48 (31.0%) consented and of those, 21 (43.8%) returned specimens for testing. Conclusion: This pilot study successfully reached its recruitment target and generated useful behavioral measures from an online sample of transgender women. We anticipate that online recruitment combined with self-collection of biospecimens will serve as an innovative and scalable strategy for ongoing monitoring of HIV/STI behavioral trends among U.S. transgender women.

Recruiting young women of color into a pilot RCT targeting sexual health: Lessons learned and implications for applied health technology research

Objective To evaluate different recruitment methods to enroll participants into a mHealth pilot RCT: banner ads on Facebook and OkCupid, and targeted electronic outreach (e.g., emails to community-based organizations and to professors at local colleges). Participants: Between October 2015 and May 2016, 114 college-aged Black and Latina women 18 to 24 participated in the study. Methods: Recruitment methods compared online banner ads on social media to targeted electronic outreach. Individual banner ad images were compared by impressions, clicks, and cost by enrolled participants. Results: More targeted electronic recruited participants enrolled than via banner advertisements. Banner ads with images of women yielded a higher click-through-rate and was more cost effective versus the logo alone. Conclusions: Recruiting young women of color may be facilitated through known and trusted adults, such as college professors, rather than through anonymous banner advertisements on social media.

Association between HIV PrEP indications and use in a national sexual network study of US men who have sex with men

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) is effective in preventing HIV transmission. United States Public Health Service (USPHS) clinical practice guidelines define biobehavioral indications for initiation. To assess guideline implementation, it is critical to quantify PrEP nonusers who are indicated and PrEP users who are not indicated. We sought to estimate current PrEP use among US men who have sex with men (MSM), characterize whether their PrEP use aligned with their current indications for PrEP, and assess whether the association between PrEP indications and PrEP use differed by demography or geography.

METHODS

Using data from a US web-based sexual network study of MSM between 2017 and 2019, we measured PrEP usage and assessed whether respondents met indications for PrEP. Log-binomial regression was used to estimate the relationship between PrEP indications and PrEP use, with adjustment for geography, age and race/ethnicity.

RESULTS

Of 3508 sexually active, HIV-negative MSM, 34% met indications for PrEP. The proportion with current PrEP use was 32% among MSM meeting indications and 11% among those without indications. Nearly 40% of those currently using PrEP did not meet indications for PrEP, and 68% of MSM with indications for PrEP were not currently using PrEP. After adjusting for geography and demographics, MSM with PrEP indications were about three times as likely to be currently using PrEP. This association varied slightly, but not significantly, by geographic region, age and race/ethnicity.

CONCLUSIONS

Indications for PrEP strongly predicted current PrEP use among US MSM. However, we identified substantial misalignment between indications and use in both directions (indicated MSM who were not benefitting from PrEP, and MSM taking PrEP while not presently being indicated). PrEP underuse by those at greatest risk for HIV acquisition may limit the projected impact of PrEP implementation, despite reported increases in PrEP provision. This calls for further implementation efforts to improve PrEP delivery to those most in need during periods of elevated sexual risk and to close the gap between indications and uptake.

Geosocial Networking Apps Use Among Sexual Minority Men in Ecuador: An Exploratory Study

Geosocial networking applications (GSN apps) have become important socialization contexts for sexual minority men (SMM). Despite their popularity, there is limited research carried out in Latin American countries and no single previous study done in Ecuador. To fill this gap, this exploratory study described and analyzed the relationships between the sociodemographic characteristics of SMM using GSN apps, their sought and fulfilled expectations, profile shared and sought characteristics, and the evaluation of their experiences as users including their perceptions of support, and discrimination. We used an online recruited sample of 303 participants enrolled between November 2019 and January 2020. Most respondents used Grindr and reported spending up to 3 h per day using apps. Most common sought expectations were getting distracted, meeting new friends, and meeting people for sexual encounters. The least met expectation was meeting someone to build a romantic relationship with. When asked about their profiles, participants reported sharing mainly their age, photographs, and sexual role. Participants also prioritized these characteristics when looking at others' profiles. When asked about their experiences, most reported having been discriminated against, weight being the main reason for it. Some participants also indicated having received emotional support from other users. Correlation analyses indicated significant but weak relationships among the variables. Results indicated a positive correlation between time as an active GSN app user and higher experiences of discrimination. Likewise, higher number of used apps related positively with levels of received support. These results provide information that could inform future research in the country and the region regarding GSN apps use among SMM, socialization practices, and modern dating tools.

Sexual Behaviors and HIV/STI Prevention Strategies Among Sexual Minority Men in Ecuador Who Use Geosocial Networking Apps

Around the world, geosocial networking apps have become widely popular among sexual minority men (SMM). This research analyzed the sexual behaviors and HIV and STI prevention strategies (HIV/STI testing, HIV/STI inquiry, and HIV/STI disclosure) of an online-recruited sample of 284 SMM living in Ecuador. Sexting and oral sex were the most common sexual behaviors among SMM in the sample. Most participants had low perceptions of HIV and STI risk; 85% reported being tested for HIV and 70% for STIs. Being older predicted higher odds of being tested for either HIV or STIs at least once. Being single also predicted HIV testing. Future interventions in the country should explore apps' utility as intervention tools to spread information about sexual health and HIV prevention strategies, such as condom use and event-driven PrEP. Apps can also facilitate connections to sexual health services, including programs for PrEP initiation and linkage to HIV treatment. They should also focus on promoting sexual harm reduction conversations among potential app-met sexual partners.

HIV and Sexually Transmitted Infection Epidemic Potential of Networks of Men Who Have Sex With Men in Two Cities

BACKGROUND

The speed with which a pathogen circulates in a sexual network is a function of network connectivity. Cross-sectional connectivity is a function of network features like momentary degree and assortative mixing. Temporal connectivity is driven by partner acquisition rates. The forward-reachable path (FRP) has been proposed as a summary measure of these two aspects of transmission potential. We use empirical data from San Francisco and Atlanta to estimate the generative parameters of the FRP and compare results to the HIV/sexually transmitted infection epidemics in each city.

METHODS

We used temporal exponential random graph models to estimate the generative parameters for each city's dynamic sexual network from survey data. We then simulated stochastic dynamic networks from the fitted models and calculated the FRP for each realization, overall, and stratified by partnership type and demographics.

RESULTS

The overall mean and median paths were higher in San Francisco than in Atlanta. The overall paths for each city were greater than the sum of the paths in each individual partnership network. In the casual partnership network, the mean path was highest in the youngest age group and lowest in the oldest age group, despite the fact that the youngest group had the lowest mean momentary degree and past-year partner counts.

CONCLUSIONS

The FRP by age group revealed the additional utility of the measure beyond the temporal and cross-sectional network connectivity measures. Other nonnetwork factors are still necessary to infer total epidemic potential for any specific pathogen.

Awareness, Utilization, and Preferences for Traditional and Contemporary HIV Prevention Strategies Among Facebook and Instagram-Using MSM in the United States

HIV prevention research among men who have sex with men (MSM) has traditionally focused on individual risk reduction strategies. Our study evaluated awareness, utilization, and preferences for 10 complementary HIV prevention strategies among 1,286 MSM recruited via Facebook and Instagram from June-August 2018. Ages ranged from 18-85 years, and the majority were non-Hispanic white (n = 1,019, 79.24%), college-educated (n = 819, 63.69%), gay-identifying (n = 1,074, 83.51%), and partnered (n = 808, 62.83%). Post-exposure prophylaxis was the least familiar option, and engaging in sexual activities other than anal sex was the most utilized option. Progressively older and bisexual-identifying MSM were less likely, but those with higher educational levels and easy access to local HIV resources were more likely to be aware of and to be utilizing a greater number of strategies. Additionally, Hispanic MSM were less likely to be aware of, and those in a “closed” relationship were less likely to be utilizing a greater number of strategies. In a subset of 775 multiple strategy users, pre-exposure prophylaxis, regularly testing for HIV, and limiting the number of sex partners emerged as the most preferred options. Combination intervention packages for MSM should be tailored to personal circumstances, including sexual orientation, relationship characteristics and access to local HIV resources.

Increased alcohol use during the COVID-19 pandemic: The effect of mental health and age in a cross-sectional sample of social media users in the U.S

The COVID-19 pandemic has triggered a public health crisis of unprecedented scale. Increased alcohol use has been extensively documented during other crises, particularly among persons with anxiety and depression. Despite COVID-19's differential impact by age, the association of age, mental health and alcohol use during the pandemic has not been explored. This study aimed to examine whether age modified the association of anxiety and depressive symptoms with alcohol use during the COVID-19 pandemic. Two online surveys were administered to U.S. adult social media users in March and April 2020. Generalized linear models were conducted in 2020 among 5850 respondents (52.9% female; 22.0% aged 18-39 years, 47.0% aged 40-59 years, and 31.0% aged ≥60 years) to examine if age modified the association of anxiety and depression symptomatology and alcohol use. Overall, 29% of respondents reported increased alcohol use. Adjusted odds ratios of reporting increased alcohol use were 1.41 (95% CI = 1.20-1.66) among respondents with anxiety symptoms and 1.64 (95% CI = 1.21-2.23) among those with depressive symptoms compared to those without such symptoms. Whereas respondents aged 18-39 years had the highest probability of reporting increased alcohol use, the probability of older persons (40-59 and ≥60 years) reporting increased drinking was much greater among those with symptoms of anxiety and depression, compared to those without symptoms. These findings warrant age-differentiated public health messaging on the risks of excessive alcohol use and scale-up of substance use services for middle-aged and older adults with symptoms of depression and anxiety.

A digital health research platform for community engagement, recruitment, and retention of sexual and gender minority adults in a national longitudinal cohort study--The PRIDE Study

OBJECTIVE

Sexual and gender minority (SGM) people are underrepresented in research. We sought to create a digital research platform to engage, recruit, and retain SGM people in a national, longitudinal, dynamic, cohort study (The PRIDE Study) of SGM health.

MATERIALS AND METHODS

We partnered with design and development firms and engaged SGM community members to build a secure, cloud-based, containerized, microservices-based, feature-rich, research platform. We created PRIDEnet, a national network of individuals and organizations that actively engaged SGM communities in all stages of health research. The PRIDE Study participants were recruited via in-person outreach, communications to PRIDEnet constituents, social media advertising, and word-of-mouth. Participants completed surveys to report demographic as well as physical, mental, and social health data.

RESULTS

We built a secure digital research platform with engaging functionality that engaged SGM people and recruited and retained 13 731 diverse individuals in 2 years. A sizeable sample of 3813 gender minority people (32.8% of cohort) were recruited despite representing only approximately 0.6% of the population. Participants engaged with the platform and completed comprehensive annual surveys- including questions about sensitive and stigmatizing topics- to create a data resource and join a cohort for ongoing SGM health research.

DISCUSSION

With an appealing digital platform, recruitment and engagement in online-only longitudinal cohort studies are possible. Participant engagement with meaningful, bidirectional relationships creates stakeholders and enables study cocreation. Research about effective tactics to engage, recruit, and maintain active participation from all communities is needed.

CONCLUSION

This digital research platform successfully recruited and engaged diverse SGM participants in The PRIDE Study. A similar approach may be successful in partnership with other underrepresented and vulnerable populations.

Online recruitment of youth for mHealth studies

BACKGROUND

Social networking sites and apps have emerged as an opportunity to engage in research young men who have sex with men (YMSM) at risk of HIV infection who may not be otherwise reached by in-person recruitment efforts. This paper highlights lessons learned, best practices and on-going recruitment challenges in the iTech network of the NIH Adolescent Trials Network for HIV Interventions.

METHODS

Recruitment was conducted for four randomized controlled trials (RCTs) of mHealth HIV prevention interventions for YMSM living in 10 US cities. Advertising was purchased on Facebook, Instagram, Snapchat, Twitter and Grindr. Users who clicked on banner ads were taken directly to a study-specific eligibility screener and if eligible, were asked to provide contact information for follow-up by respective study site staff. Ad and screening metrics (impressions, clicks, cost per click (CPC), click-through rate (CTR), number screened, number eligible, number who provided contact information and cost per eligible contact) were compared across platforms, studies and geographic areas (where available). Screening metrics were also calculated for in-person recruitment efforts.

RESULTS

Grindr and Snapchat ads produced the highest CTRs as compared to Facebook ads. However, these ads had the lowest proportions of users who initiated eligibility screeners and ultimately Facebook ads yielded the lowest cost per eligible contact across studies. Instagram ads yielded the highest proportions of eligible contacts who were racial/ethnic minorities and under the age of 18. Geographic variability in cost per eligible contact was observed for studies with identical eligibility criteria running concurrently in different regions, driven by both advertising costs and the screening and eligibility rates. Despite lower eligibility rates, the total numbers of eligible contacts were higher for online advertising campaigns, as compared to other recruitment efforts, for all studies except P3. Ads recruiting for P3 had the highest cost per eligible contact, likely due to this study having the most stringent eligibility criteria of the studies described.

CONCLUSIONS

We implemented a successful online advertising strategy to recruit YMSM at high risk for HIV infection into four RCTs of mHealth interventions. This report provides a framework for evaluation of data from future online recruitment efforts across platforms and geographic areas, regardless of inevitable changes in the digital marketing space.

Estimated Number of Men Who Have Sex With Men With Indications for HIV Pre-exposure Prophylaxis in a National Sexual Network Study

BACKGROUND

A 2015 CDC analysis estimated that 24.7% of sexually active men who have sex with men (MSM) had indications for HIV pre-exposure prophylaxis (PrEP) based on 2014 US Public Health Service (USPHS) clinical practice guidelines. Given that the USPHS revised these guidelines in 2017, updated estimates of the fraction of MSM indicated for PrEP overall and stratified by demographic factors and geography are needed to scale-up PrEP for MSM in the US.

METHODS

We conducted a national web-based study of 4904 MSM aged 15-65 who had ever had sex with another man between July 2017 and January 2019. We estimated the percentage of HIV-negative, sexually active MSM meeting USPHS indications for PrEP by demographic category.

RESULTS

Of 3511 sexually active, HIV-negative MSM, 34.0% (95% confidence interval: 32.4 to 35.6) met USPHS indications for PrEP, with percentages consistent across US census region and varying slightly by race/ethnicity (Black: 32.2%, White: 33.7%, Hispanic: 36.4%, Other: 33.6%). Among individuals meeting USPHS PrEP indications, 93.5% reported condomless anal intercourse in the prior 6 months. Among all survey respondents, PrEP eligibility was lowest among non-Hispanic black (18.4%) and younger respondents (15-17: 4.1%; 18-24: 18.1%).

CONCLUSIONS

Estimated percentages of MSM meeting indications for PrEP exceeded the previous CDC estimate across race/ethnicity, age, and census regions, with one-third of adult, sexually active, HIV-negative MSM exhibiting indications for PrEP. This study suggests, given current guidelines for PrEP indications, that a different fraction of eligible MSM could be receiving PrEP than previously estimated.

A Syndemic Model of Exchange Sex Among HIV-Positive Men Who Have Sex With Men

Exchange sex is a behavior associated with HIV transmission risk among men who have sex with men (MSM). Few studies have examined exchange sex among HIV-positive MSM. We utilize a syndemic framework to account for co-occurring psychosocial problems that suggest the presence of intertwining epidemics (i.e., syndemics), which have not been examined within the context of exchange sex among HIV-positive MSM. In 2015, MSM were recruited via online sexual networking Web site and app advertisements for Sex Positive!^[+], a video-based online intervention that aimed to improve health outcomes for men living with HIV. Participants completed surveys every three months for a year. Surveys covered demographics, drug use, exchange sex, intimate partner violence (IPV), and past 2-week depressive symptoms. We conducted three logistic regression models to assess syndemic factors associated with exchange sex in the past 3 months. Of the 722 HIV-positive MSM included in the sample, 59 (8%) reported exchange sex in the past 3 months at 12-month follow-up. HIV-positive MSM who had more syndemic factors had greater odds of exchange sex. Exchange sex was associated with being African-American/Black, age 18-29 years, past and present experiences with IPV, stimulant use, polysubstance use, and depressive symptoms. Exchange sex was associated with multiple psychosocial factors, indicating exchange sex may be part of a syndemic involving substance use, depression, HIV, and IPV. Interventions should address the social and behavioral circumstances that perpetuate environments that can foster multiple negative health outcomes.

State Policies and Healthcare Use Among Transgender People in the U.S

INTRODUCTION

The introduction and passing of restrictive and protective transgender-specific state policies have increased during the past decade. These policies are critical for the health of transgender and other gender diverse people; however, little is known about the relationship between these policies and healthcare use, and the role that race/ethnicity plays in this relationship.

METHODS

Analysis was conducted in 2018-2019 using multilevel modeling and data from the 2015 U.S. Trans Survey (conducted by the National Center for Transgender Equality among nearly 28,000 transgender and other gender diverse people across the U.S.) to explore associations between transgender-specific state policies and healthcare avoidance because of fear of mistreatment. State policies included those related to experiences of discrimination, health insurance coverage, and changing legal documents. Restrictive and protective policies were measured individually and as a composite index. The relationship between race/ethnicity and healthcare use was also examined to determine whether there were differences in the association between race/ethnicity and healthcare avoidance by state.

RESULTS

None of the individual policies were associated with healthcare use, but the composite index was significant, such that living in states with more protective policies was associated with reduced odds of avoiding health care because of fear of mistreatment. The relationship between race/ethnicity and health care also varied across states.

CONCLUSIONS

Findings suggest the importance of advocating for more protective transgender-specific policies to improve healthcare access for transgender and other gender diverse people in the U.S., particularly for transgender and other gender diverse people of color.

Methodological Challenges in Web-Based Trials: Update and Insights From the Relatives Education and Coping Toolkit Trial

RR2-10.1136/bmjopen-2017-016965.

The Adaptive Behavioral Components (ABC) Model for Planning Longitudinal Behavioral Technology-Based Health Interventions: A Theoretical Framework

A growing number of interventions incorporate digital and social technologies (eg, social media, mobile phone apps, and wearable devices) into their design for behavior change. However, because of a number of factors, including changing trends in the use of technology over time, results on the efficacy of these interventions have been mixed. An updated framework is needed to help researchers better plan behavioral technology interventions by anticipating the needed resources and potential changes in trends that may affect interventions over time. Focusing on the domain of health interventions as a use case, we present the Adaptive Behavioral Components (ABC) model for technology-based behavioral interventions. ABC is composed of five components: basic behavior change; intervention, or problem-focused characteristics; population, social, and behavioral characteristics; individual-level and personality characteristics; and technology characteristics. ABC was designed with the goals of (1) guiding high-level development for digital technology–based interventions; (2) helping interventionists consider, plan for, and adapt to potential barriers that may arise during longitudinal interventions; and (3) providing a framework to potentially help increase the consistency of findings among digital technology intervention studies. We describe the planning of an HIV prevention intervention as a case study for how to implement ABC into intervention design. Using the ABC model to plan future interventions might help to improve the design of and adherence to longitudinal behavior change intervention protocols; allow these interventions to adapt, anticipate, and prepare for changes that may arise over time; and help to potentially improve intervention behavior change outcomes. Additional research is needed on the influence of each of ABC’s components to help improve intervention design and implementation.

The CAN-DO-IT Model: a Process for Developing and Refining Online Recruitment in HIV/AIDS and Sexual Health Research

PURPOSE OF REVIEW

HIV/AIDS and sexual health research has increasingly relied on online recruitment in recent years. However, as potential online recruitment avenues (e.g., dating and sexual networking applications, websites, social media) have proliferated, navigating this process has become increasingly complex. This paper presents a practical model to guide researchers through online recruitment irrespective of platform.

RECENT FINDINGS

The CAN-DO-IT model reflects 7 iterative steps based on work by the authors and other investigators: conceptualize scope of recruitment campaign, acquire necessary expertise, navigate online platforms, develop advertisements, optimize recruitment-to-enrollment workflow, implement advertising campaign, and track performance of campaigns and respond accordingly. Online recruitment can accelerate HIV/AIDS research, yet relatively limited guidance exists to facilitate this process across platforms. The CAN-DO-IT model presents one approach to demystify online recruitment and reduce enrollment barriers.

Comparison of Social Media, Syndromic Surveillance, and Microbiologic Acute Respiratory Infection Data: Observational Study

Background

Internet data can be used to improve infectious disease models. However, the representativeness and individual-level validity of internet-derived measures are largely unexplored as this requires ground truth data for study.

Objective

This study sought to identify relationships between Web-based behaviors and/or conversation topics and health status using a ground truth, survey-based dataset.

Methods

This study leveraged a unique dataset of self-reported surveys, microbiological laboratory tests, and social media data from the same individuals toward understanding the validity of individual-level constructs pertaining to influenza-like illness in social media data. Logistic regression models were used to identify illness in Twitter posts using user posting behaviors and topic model features extracted from users’ tweets.

Results

Of 396 original study participants, only 81 met the inclusion criteria for this study. Of these participants’ tweets, we identified only two instances that were related to health and occurred within 2 weeks (before or after) of a survey indicating symptoms. It was not possible to predict when participants reported symptoms using features derived from topic models (area under the curve [AUC]=0.51; P=.38), though it was possible using behavior features, albeit with a very small effect size (AUC=0.53; P≤.001). Individual symptoms were also generally not predictable either. The study sample and a random sample from Twitter are predictably different on held-out data (AUC=0.67; P≤.001), meaning that the content posted by people who participated in this study was predictably different from that posted by random Twitter users. Individuals in the random sample and the GoViral sample used Twitter with similar frequencies (similar @ mentions, number of tweets, and number of retweets; AUC=0.50; P=.19).

Conclusions

To our knowledge, this is the first instance of an attempt to use a ground truth dataset to validate infectious disease observations in social media data. The lack of signal, the lack of predictability among behaviors or topics, and the demonstrated volunteer bias in the study population are important findings for the large and growing body of disease surveillance using internet-sourced data.

Association of co-occurring psychosocial health conditions and HIV infection among MSM in Malaysia: Implication of a syndemic effect

In Malaysia, the HIV epidemic is concentrated in a highly stigmatized population, men who have sex with men (MSM). The relationship of multiple psychosocial health conditions and HIV risks have not been investigated. This study aims to assess the association of multiple psychosocial factors with risky sexual behaviour and HIV infection among MSM. Data on demographic characteristics, psychosocial health conditions, condomless anal intercourse (CAI), HIV testing and HIV status were collected via an anonymous online survey. Multivariable logistic regression model was used to determine whether psychosocial health conditions among MSM have a syndemic association with HIV status. Between July 2017 and February 2018, 622 MSM completed the online survey. Overall, 54.3% of participants reported engaging in CAI in the past three months and 46.0% were found to have two or more psychosocial health conditions. Increasing numbers of psychosocial health conditions (1, 2, 3, 4 or more) were significantly associated with HIV infection compared to those without psychosocial health condition (odds ratio [OR] 3.39, 95% confidence interval [CI]: 1.41–8.14; OR 3.51, 95% CI: 1.43–8.61; OR 4.22, 95% CI: 1.68–10.96, and OR 7.58, 95% CI: 2.44–23.55, respectively). Comprehensive HIV prevention programs addressing mental health and substance use are needed for MSM in Malaysia.

Egocentric sexual networks of men who have sex with men in the United States: Results from the ARTnet study

In this paper, we present an overview and descriptive results from one of the first egocentric network studies of men who have sex with men (MSM) from across the United States: the ARTnet study. ARTnet was designed to support prevention research for human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) that are transmitted across partnership networks. ARTnet implemented a population-based egocentric network study design that sampled egos from the target population and asked them to report on the number, attributes, and timing of their sexual partnerships. Such data provide the foundation needed for parameterizing stochastic network models that are used for disease projection and intervention planning. ARTnet collected data online from 2017 to 2019, with a final sample of 4904 participants who reported on 16198 sexual partnerships. The aims of this paper were to characterize the joint distribution of three network parameters needed for modeling: degree distributions, assortative mixing, and partnership age, with heterogeneity by partnership type (main, casual and one-time), demography, and geography. Participants had an average of 1.19 currently active partnerships ("mean degree"), which was higher for casual partnerships (0.74) than main partnerships (0.45). The mean rate of one-time partnership acquisition was 0.16 per week (8.5 partners per year). Main partnerships lasted 272.5 weeks on average, while casual partnerships lasted 133.0 weeks. There was strong but heterogenous assortative mixing by race/ethnicity for all groups. The mean absolute age difference for all partnership types was 9.5 years, with main partners differing by 6.3 years compared to 10.8 years for casual partners. Our analysis suggests that MSM may be at sustained risk for HIV/STI acquisition and transmission through high network degree of sexual partnerships. The ARTnet network study provides a robust and reproducible foundation for understanding the dynamics of HIV/STI epidemiology among U.S. MSM and supporting the implementation science that seeks to address persistent challenges in HIV/STI prevention.

Correlates of Successful Enrollment of Same-Sex Male Couples Into a Web-Based HIV Prevention Research Study: Cross-Sectional Study

Background

The recognition of the role of primary partners in HIV transmission has led to a growth in dyadic-focused HIV prevention efforts. The increasing focus on male couples in HIV research has been paralleled by an increase in the development of interventions aimed at reducing HIV risk behaviors among male couples. The ability to accurately assess the efficacy of these interventions rests on the ability to successfully enroll couples into HIV prevention research.

Objective

This study aimed to explore factors associated with successful dyadic engagement in Web-based HIV prevention research using recruitment and enrollment data from a large sample of same-sex male couples recruited online from the United States.

Methods

Data came from a large convenience sample of same-sex male couples in the United States, who were recruited through social media venues for a Web-based, mixed method HIV prevention research study. The analysis examined the demographic factors associated with successful dyadic engagement in research, measured as both members of the dyad meeting eligibility criteria, consenting for the study, and completing all study processes.

Results

Advertisements generated 221,258 impressions, resulting in 4589 clicks. Of the 4589 clicks, 3826 individuals were assessed for eligibility, of which 1076 individuals (538/1913, 28.12% couples) met eligibility criteria and were included in the study. Of the remaining 2740 ineligible participants, 1293/3826 (33.80%) were unlinked because their partner did not screen for eligibility, 48/2740 (1.75%) had incomplete partner data because at least one partner did not finish the survey, 22/2740 (0.80%) were ineligible because of 1 partner not meeting the eligibility criteria. Furthermore, 492/3826 (12.86%) individuals were fraudulent. The likelihood of being in a matched couple varied significantly by race and ethnicity, region, and relationship type. Men from the Midwest were less likely to have a partner who did not complete the survey. Men with college education and those who labeled their relationships as husband or other (vs boyfriend) were more likely to have a partner who did not complete the survey.

Conclusions

The processes used allowed couples to independently progress through the stages necessary to enroll in the research study, while limiting opportunities for coercion, and resulted in a large sample with relative diversity in demographic characteristics. The results underscore the need for additional considerations when recruiting and enrolling, relative to improving the methods associated with these research processes.

Maximizing Response Rates to Ads for Free At-Home HIV Testing on a Men-for-Men Geosocial Sexual Networking App: Lessons Learned and Implications for Researchers and Providers

Internet-based recruitment can be effective in reaching large numbers of geographically diverse individuals. Geosocial sexual networking apps on smartphones have emerged as the modal way in which men who have sex with men (MSM) meet sex partners, and as venues for sexual health research. We report on the performance of three types of ads-text-only, text with male figure (no face), and text with male figure (with face)-used on a geosocial sexual networking app to advertise free at-home HIV testing and to enroll in an online study. We ran five 2-week-long ads on a popular MSM geosocial app between fall 2017 and spring 2018 (~2.19 million impressions). Ads were evaluated in terms of the click-through rate (CTR = advertisement clicks/advertisement impressions), conversion rates (CR = number of enrolled participants/ad-generated clicks), cost per enrolled participant, and demographic composition of survey respondents. We enrolled n = 4,023 individuals, n = 2,430 of whom completed HIV testing-$6.21 spent on advertising per participant enrolled and $10.29 spent for everyone who completed HIV testing. Cost per enrolled participant was associated with the content of the ad used-ads featuring male figures (with or without a face shown) were more cost efficient than ads featuring text alone. These ads also outperformed text-only ads across a range of metrics, including responsiveness among younger MSM as well as MSM of color. Advertising materials that combine text with images may have greater appeal among priority populations.

Changes in Sleep Quality and Associated Health Outcomes among Gay and Bisexual Men Living with HIV

Objectives/Background: Although gay, bisexual, and other men who have sex with men (GBMSM) bear a disproportionate burden of HIV in the U.S., they are underrepresented in HIV-related sleep research. This study sought to (a) investigate changes in self-reported sleep quality among a sample of GBMSM living with HIV during participation in an online sexual risk reduction intervention and (b) examine whether changes in sleep quality predicted later health outcomes.Method/Participants: Men (n = 505) completed measures of sleep quality, psychological distress, condom use self-efficacy, and antiretroviral therapy (ART) adherence. Analyses focused on data obtained from participants as part of the eligibility survey, baseline assessment, and the 9- and 12-month follow-up assessments.Results: Most participants did not report changes in their sleep quality (i.e., 50.1% maintained good sleep quality, 22.8% maintained poor sleep quality) between study screening and 9-month follow-up. Nevertheless, 17.0% indicated improved sleep quality and 10.1% indicated a negative change in sleep quality. Compared to those who maintained good sleep quality during the study, men whose sleep quality declined by 9 months reported significantly greater symptoms of depression and anxiety, as well as lower ART adherence and condom use self-efficacy at 12 months. Similarly, men who maintained poor sleep quality reported greater symptoms of depression and anxiety at 12 months. Men whose sleep quality improved reported better mental health than those with poor or worsening sleep quality.Conclusions: Findings suggest that optimizing sleep health should be prioritized in interventions aimed at improving overall well-being of GBMSM living with HIV.

Seeing Is Believing? Unique Capabilities of Internet-Only Studies as a Tool for Implementation Research on HIV Prevention for Men Who Have Sex With Men: A Review of Studies and Methodological Considerations

BACKGROUND

In 2014, Grov et al published a comprehensive review cataloguing both men who have sex with men's (MSM's) sexual behavior transitions in online environments from the 1990s through 2013, as well as researchers' efforts in tandem to use the internet to engage MSM into research, treatment, and prevention.

METHODS

In this article, we discuss historical events and research having occurred in the half decade since the Grov et al publication.

RESULTS

Notable transitions include MSM's expanded use of geosocial networking apps, as well as other forms of social media accessed primarily through mobile devices, as well as the addition of biomedical prevention strategies (eg, pre-exposure prophylaxis and undetectable = untransmittable) to the proverbial HIV prevention toolkit. In tandem, researchers have rapidly expanded their employment of internet-mediated methods for the recruitment and engagement of key populations for HIV research, treatment, and prevention. In this article, we discuss methodological considerations for using the internet to conduct HIV prevention research with MSM: (1) sources of recruitment (eg, geosocial apps, Facebook, crowdsourced online panels); (2) design (eg, cross sectional, longitudinal, diaries); (3) incentives (including disincentivizing fraudulent participants and/or spam bots); (4) confidentiality; and (5) representativeness.

CONCLUSION

We conclude by discussing future directions in HIV prevention research in light of forthcoming technologies such as fifth generation (5G) mobile networks, combined use of self-collected biological data alongside self-report, and the utility of metadata and metaresearch to document, evaluate, and inform best practices.

Evaluation of Sex Positive! A Video eHealth Intervention for Men Living with HIV

Sex Positive!^[+] is a two-arm, video-based web intervention aimed at reducing condomless anal sex (CAS) with partners of known and unknown serostatus that was delivered online to a racially and ethnically diverse sample of 830 gay, bisexual, and other men who have sex with men living with HIV. Men in each arm received 6 weekly videos after completing a baseline assessment and 4 weekly booster videos following a 6-month assessment. Follow-up assessments were conducted every 3 months for 1 year. At 3-month follow-up, men in the intervention arm reported significantly reduced risk of having unknown serodiscordant CAS partners than men in the control arm (RR 0.60, 95% CI 0.39-0.92), partially supporting study hypotheses. Aside from this finding, similar reductions in sexual risk behaviors were observed in both arms over the study period. There is much to be learned about video-based web interventions in terms of methodological development and intervention delivery, including frequency and duration of intervention components.

A Web-Based Study of HIV Prevention in the Era of Pre-Exposure Prophylaxis Among Vulnerable HIV-Negative Gay and Bisexual Men, Transmen, and Transwomen Who Have Sex With Men: Protocol for an Observational Cohort Study

Background

Gay, bisexual, and other men who have sex with men continue to bear a large burden of the HIV epidemic in the United States and are among the only populations with increasing incidence in recent years.

Objective

The Together 5000 (T5K) Study aimed to enroll a US-based, racially diverse sample of HIV-negative men, transmen, and transwomen who are not on pre-exposure prophylaxis (PrEP) into an observational cohort to inform the design, implementation, scale-up, and evaluation of HIV prevention programs.

Methods

We used internet-based strategies to enroll a large, racially diverse national sample of HIV-negative men, transmen, and transwomen aged 16 to 49 years at high risk of HIV acquisition via sexual networking apps. Study participants are contacted every 6 months (in between annual surveys) for a brief survey on HIV testing, HIV diagnosis, and PrEP use (ie, attempts to access, PrEP initiation, and PrEP discontinuation). Participants complete annual self-administered at-home HIV testing and Web-based surveys. Using baseline serologic data and self-reported HIV testing history, we reconstructed a cohort of persons who were HIV negative at 12 months before baseline to estimate HIV incidence leading up to cohort enrollment.

Results

The study sample included 8777 participants from all 50 US states, Puerto Rico, and Guam; 50.91% (4468/8777) were persons of color and 25.30% (2221/8777) were young individuals aged 16 to 24 years. Per eligibility criteria, all T5K participants reported having sex with >2 male partners in the 90 days before enrollment, self-reported not having been diagnosed with HIV, and were not actively taking PrEP. In addition, 79.39% (6968/8777) reported >2 insertive condomless anal sex (CAS) acts, 61.02% (5356/8777) reported >1 receptive CAS acts in the past 90 days. Furthermore, most (7525/8777, 85.74%) reported never having taken PrEP. In total, 70.25% (6166/8777) were sent a self-administered at-home HIV test kit and 82.29% (5074/6166) of those sent a kit returned a sample for testing. The HIV incidence rate during the 12-month period leading up to enrollment was estimated to be 2.41 (95% CI 2.02-2.90) per 100 person-years.

Conclusions

A large, national, and racially diverse fully Web-based cohort of HIV-negative men, transmen, and transwomen at high risk for HIV seroconversion has successfully been recruited into longitudinal follow-up. This cohort is at high risk for HIV acquisition and can provide important insights related to the real-world uptake, impact, and equity of HIV prevention interventions in the United States. Participants can be invited to participate in trials aimed at testing strategies to improve the uptake of and engagement in these interventions.

International Registered Report Identifier (IRRID)

RR1-10.2196/13715

Interaction Patterns of Men Who Have Sex With Men on a Geosocial Networking Mobile App in Seven United States Metropolitan Areas: Observational Study

BACKGROUND

The structure of the sexual networks and partnership characteristics of young black men who have sex with men (MSM) may be contributing to their high risk of contracting HIV in the United States. Assortative mixing, which refers to the tendency of individuals to have partners from one's own group, has been proposed as a potential explanation for disparities.

OBJECTIVE

The objective of this study was to identify the age- and race-related search patterns of users of a diverse geosocial networking mobile app in seven metropolitan areas in the United States to understand the disparities in sexually transmitted infection and HIV risk in MSM communities.

METHODS

Data were collected on user behavior between November 2015 and May 2016. Data pertaining to behavior on the app were collected for men who had searched for partners with at least one search parameter narrowed from defaults or used the app to send at least one private chat message and used the app at least once during the study period. Newman assortativity coefficient (R) was calculated from the study data to understand assortativity patterns of men by race. Pearson correlation coefficient was used to assess assortativity patterns by age. Heat maps were used to visualize the relationship between searcher's and candidate's characteristics by age band, race, or age band and race.

RESULTS

From November 2015 through May 2016, there were 2,989,737 searches in all seven metropolitan areas among 122,417 searchers. Assortativity by age was important for looking at the profiles of candidates with correlation coefficients ranging from 0.284 (Birmingham) to 0.523 (San Francisco). Men tended to look at the profiles of candidates that matched their race in a highly assortative manner with R ranging from 0.310 (Birmingham) to 0.566 (Los Angeles). For the initiation of chats, race appeared to be slightly assortative for some groups with R ranging from 0.023 (Birmingham) to 0.305 (Los Angeles). Asian searchers were most assortative in initiating chats with Asian candidates in Boston, Los Angeles, New York, and San Francisco. In Birmingham and Tampa, searchers from all races tended to initiate chats with black candidates.

CONCLUSIONS

Our results indicate that the age preferences of MSM are relatively consistent across cities, that is, younger MSM are more likely to be chatted with and have their profiles viewed compared with older MSM, but the patterns of racial mixing are more variable. Although some generalizations can be made regarding Web-based behaviors across all cities, city-specific usage patterns and trends should be analyzed to create targeted and localized interventions that may make the most difference in the lives of MSM in these areas.

HIV testing intervention development among men who have sex with men in the developed world

HIV testing is a 'gateway' technology, enabling access to treatment and HIV prevention. Biomedical approaches to prevention, such as pre-exposure prophylaxis and treatment as prevention, require accurate and regular HIV test results. HIV testing also represents a powerful 'teachable moment' for behavioural prevention. An increasing range of HIV tests and the emergence of self-managed diagnostic technologies (e.g. self-testing) means there is now considerable diversification of when, where and how results are available to those who test. These changes have profound implications for intervention development and, indeed, health service redesign. This paper highlights the need for better ways of conceptualising testing in order to capitalise on the health benefits that diverse HIV testing interventions will bring. A multidimensional framework is proposed to capture ongoing developments in HIV testing among men who have sex with men and focus on the intersection of: (1) the growing variety of HIV testing technologies and the associated diversification of their pathways into care; (2) psychosocial insights into the behavioural domain of HIV testing; and (3) better appreciation of population factors associated with heterogeneity and concomitant inequities. By considering these three aspects of HIV testing in parallel, it is possible to identify gaps, limitations and opportunities in future HIV testing-related interventions. Moreover, it is possible to explore and map how diverse interventions may work together having additive effects. Only a holistic and dynamic framework that captures the increasing complexity of HIV testing is fit for purpose to deliver the maximum public health benefit of HIV testing.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Methodological Considerations for Advancing Research on the Health and Wellbeing of Sexual and Gender Minority Youth

Continued research with sexual and gender minority (SGM) youth is essential both to understand health disparities and to develop interventions targeting those disparities, but conducting rigorous, ethical research with these populations remains a substantial challenge. In addition to considerations for research with adolescents in general, such as utilizing developmentally appropriate measures and obtaining parental permission, factors unique to SGM youth must be addressed at every step of the research process. Defining the study population is complex, as is recruiting a sample once it is defined. Measurement is another challenge, given the paucity of measures developed for or validated with SGM samples. Key constructs, such as sexual orientation, gender identity, and family acceptance, are not amenable to randomization and involving minor participants' parents poses ethical concerns given the precarious home and safety situations that can arise from employing typical study procedures with youth who have a stigmatized identity. In this article, we examine some of these unique methodological challenges. Informed by theoretical and empirical literature, practical experience, and an ongoing dialogue with SGM youth themselves, we present a guide to best practices for ethical, productive research with SGM youth. By discussing existing approaches to studying SGM youth and suggesting innovative ways to approach the questions that remain, we hope to assist the research community in addressing methodological gaps to advance research on SGM youth in relation to families and schools.

Online recruitment of a non-help-seeking sample for an internet intervention: Lessons learned in an alcohol-exposed pregnancy risk reduction study

BACKGROUND

Recruiting a hidden population, such as the population of women at risk for alcohol-exposed pregnancy (AEP) who binge drink and are at risk of an unintended pregnancy, is challenging as this population is not typically seeking help or part of an identifiable group. We sought to identify affordable and efficient methods of recruitment for hidden populations.

METHODS

Several popular online social media and advertising sites were identified. Cities with high rates of binge drinking among women were targeted. We placed advertisements and study notices using Facebook, Twitter, Craigslist, University postings, and ClinicalTrials.gov.

RESULTS

For this study, 75 women at risk for AEP were recruited from across the U.S. within 7 months. Online advertising for study participants on Craigslist resulted in enrollment of the majority 51 (68%) of the study participants. While Craigslist advertising could be tailored to specific locations with high rates of binge drinking among women, there were challenges to using Craigslist. These included automated deletion due to repeated postings and mention of sexual behavior or drinking, requiring increased efforts and resources by the study team. Several strategies were developed to optimize advertising on Craigslist. Approximately 100 h of staff time valued at $2500 was needed over the 7-month recruitment period.

DISCUSSION

Despite challenges, the target sample of women at risk for AEP was recruited in the 7 month recruitment period using online advertising methods. We recommend that researchers consider online classified advertisements when recruiting from non-help seeking populations. By taking advantage of national data to target specific risk factors, and by tailoring advertising efforts, it is possible to efficiently and affordably recruit a non-treatment seeking sample.

Randomised controlled trial of incentives to improve online survey completion among internet-using men who have sex with men

BACKGROUND

HIV prevention research often involves the use of online surveys as data collection instruments. Incomplete responses to these surveys can introduce bias. We aimed to develop and assess innovative methods to incentivise respondents to complete surveys.

METHODS

Adult men who have sex with men (MSM) living in the USA were recruited through banner advertisements on Facebook from 27 April 2015 to 6 May 2015 to participate in an online survey about HIV prevention and risk behaviours. Participants were randomised to one of four conditions: a monetary incentive; a series of altruistic messages highlighting the importance of participating in research; access to a dashboard comparing their responses with statistics from other participants after completion; and no incentive. Kaplan-Meier survival methods and univariate Cox proportional hazard models were used to evaluate survey dropout by incentive group and demographic variables of interest.

RESULTS

There were a total of 1178 participants randomised to the four treatment groups. The rate of survey dropout among participants in the altruistic (HR=0.68, 95% CI 0.49 to 0.93), monetary (HR=0.44, 95% CI 0.32 to 0.61) and dashboard (HR=0.78, 95% CI 0.58 to 1.06) groups was lower than the non-incentivised control group. Regardless of condition, survey dropout was also lower among MSM aged 28-34 (HR=0.67, 95% CI 0.50 to 0.90) compared with those aged 18-22 years old, and MSM who were white (HR=0.78, 95% CI 0.60 to 1.02) compared with non-white participants.

CONCLUSION

Monetary incentives and altruistic messaging can improve survey completion in online behavioural HIV prevention research among MSM.

TRIAL REGISTRATION NUMBER

NCT02139566.

Questionnaire Breakoff and Item Nonresponse in Web-Based Questionnaires: Multilevel Analysis of Person-Level and Item Design Factors in a Birth Cohort

BACKGROUND

Web-based questionnaires are increasingly used in epidemiologic studies, as traditional methods are facing a decrease in response rates and an increase in costs. However, few studies have investigated factors related to the level of completion of internet-based epidemiologic questionnaires.

OBJECTIVE

Our objective was to identify person-level characteristics and item design factors associated with breakoff (not finishing the questionnaire) and item nonresponse in a Web-based questionnaire.

METHODS

This study was a cross-sectional analysis of the baseline questionnaire, applied from 2005 to 2016, of the Italian NINFEA (Nascita e Infanzia: gli Effetti dell'Ambiente) birth cohort. The baseline questionnaire was administered to enrolled women, who could register at any time during pregnancy. We used logistic regression to analyze the influence of person-level factors on questionnaire breakoff, and a logistic multilevel model (first level: items of the questionnaire; second level: sections of the questionnaire; third level: study participants) to analyze the influence of person-level and item design factors on item nonresponse. Since the number of applicable items depended on the respondent's characteristics and breakoff, we used inverse probability weighting to deal with missing by design.

RESULTS

Of 5970 women, 519 (8.69%) did not finish the questionnaire. Older age (adjusted odds ratio 1.40, 95% CI 1.05-1.88), lower educational level (adjusted odds ratio [OR] 1.53, 95% CI 1.23-1.90), and earlier stage of pregnancy (adjusted OR 3.01, 95% CI 2.31-3.92) were positively associated with questionnaire breakoff. Of the 1,062,519 applicable items displayed for the participants, 22,831 were not responded to (overall prevalence of item nonresponse 2.15%). Item nonresponse was positively associated with older age (adjusted OR 1.25, 95% CI 1.14-1.38), being in the first trimester of pregnancy (adjusted OR 1.18, 95% CI 1.06-1.31), and lower educational level (adjusted OR 1.23, 95% CI 1.14-1.33). Dropdown menu items (adjusted OR 1.77, 95% CI 1.56-2.00) and items organized in grids (adjusted OR 1.69, 95% CI 1.49-1.91) were positively associated with item nonresponse.

CONCLUSIONS

It is important to use targeted strategies to keep participants motivated to respond. Item nonresponse in internet-based questionnaires is affected by person-level and item design factors. Some item types should be limited to reduce item nonresponse.

Attrition and HIV Risk Behaviors: A Comparison of Young Men Who Have Sex with Men Recruited from Online and Offline Venues for an Online HIV Prevention Program

In addition to offline venue-based and time-space sampling, recruitment of young men who have sex with men (YMSM) into HIV surveillance and prevention studies has expanded over time to include Internet-based approaches. Despite broadening recruitment strategies, enrolling racially and ethnically diverse YMSM who are disproportionately impacted by HIV continues to be challenging. Additionally, there is little literature on the impact of recruitment venue on participant characteristics and likelihood to enroll YMSM into online randomized control trials (RCT). This study used data from the multisite RCT, Keep It Up! 2.0, to examine the impact of recruitment venue on participant demographics, behavioral HIV risks, and enrollment. A total of 2984 participants were screened for eligibility from community-based organizations, Facebook, dating apps, and outreach events. There were significant differences by venue in age (χ2[3] = 54.38, p < .001), race/ethnicity (χ2[9] = 110.78, p < .001), sexual orientation (χ2[3] = 7.85, p < .05), relationship status (χ2[6] = 27.71, p < .001), and region of recruitment (χ2[6] = 1480.51, p < .001). There were no significant differences by venue in attrition during the enrollment process. The only difference in attrition was by race/ethnicity. Compared to White participants, eligible Black (OR: 0.35, p < .01) and Latino (OR: 0.46, p < .05) participants were significantly less likely to enroll in the intervention. There were also no significant differences by recruitment venue in sexual risk behaviors among enrolled participants. These findings suggest that recruitment into online HIV interventions from a variety of venues is feasible for diverse YMSM who are at similar risk for HIV infection.

National Trends in Sexual Behavior, Substance Use and HIV Testing Among United States Men Who have Sex with Men Recruited Online, 2013 Through 2017

The American Men's Internet Survey (AMIS) is conducted annually with 10,000 men age 15 + who have sex with men (MSM). Modeling was used with 39,863 AMIS surveys from 4 cycles between December 2013 to February 2017 to identify temporal trends in sexual behavior, substance use, and testing behavior (within 12 months preceding interview) stratified by participants' self-reported HIV status. HIV-negative/unknown status MSM had significant increases in condomless anal intercourse (CAI), marijuana use, use of other illicit substances, sexually transmitted infection (STI) diagnoses, and HIV or STI testing (testing only increased among MSM age 25 +). HIV-negative/unknown status MSM had significant decrease in CAI with an HIV-positive or unknown status partner. HIV-positive MSM had significant increases in CAI, methamphetamine use, and STI diagnoses/testing. Although encouraging, the few indicators of improvement in HIV/STI sexual health practices are not consistently seen across sub-groups of MSM and may be counteracted by growing proportions of MSM engaging in CAI and acquiring STIs.

Birth Cohort Variations Across Functional Knowledge of HIV Prevention Strategies, Perceived Risk, and HIV-Associated Behaviors Among Gay, Bisexual, and Other Men Who Have Sex With Men in the United States

Gay, bisexual, and other men who have sex with men (GBMSM) in the United States remain heavily impacted by HIV. The purpose of this study was to describe intergenerational differences in functional knowledge of HIV prevention strategies, perceived risk, recent condomless anal sex (CAS), and HIV testing behavior. Eight hundred sexually active GBMSM were recruited via Facebook from August to September 2015, and administered a Web-based survey which included 12 multiple-choice questions to elicit data regarding functional knowledge of different HIV prevention approaches (e.g., condom use, pre-exposure prophylaxis post-exposure prophylaxis, treatment as prevention, circumcision). Cumulative logit and multivariable logistic models were formulated to examine birth cohort variations across four analytic outcomes. Younger generations were significantly more knowledgeable, as were GBMSM with higher education. Non-Hispanic non-White GBMSM and those reporting a bisexual/other sexual orientation had lower functional knowledge. Younger generations were equally concerned about contracting HIV as their older counterparts. Perceived risk was significantly higher among non-Hispanic non-White and Hispanic GBMSM, but lower among those with higher education and those in a relationship. Finally, birth cohort variations with respect to engaging in CAS with ≥2 men in the past 3 months and testing for HIV in the past year were not markedly pronounced. Younger GBMSM might be more knowledgeable about HIV prevention strategies compared to their predecessors, but are equally concerned about contracting HIV. Researchers and practitioners should consider intergenerational and other demographic differences while designing multifaceted HIV prevention programs for GBMSM.

Reducing HIV Vulnerability Through a Multilevel Life Skills Intervention for Adolescent Men (The iREACH Project): Protocol for a Randomized Controlled Trial

Background

Few HIV interventions have demonstrated efficacy in reducing HIV risk among adolescent men who have sex with men (AMSM), and fewer still have recognized the unique needs of AMSM based on race/ethnicity or geographical setting. Recognizing that youths’ HIV vulnerability is intricately tied to their development and social context, delivering life skills training during adolescence might delay the onset or reduce the consequences of risk factors for HIV acquisition and equip AMSM with the skills to navigate HIV prevention. This protocol describes the development and testing of iREACH, an online multilevel life skills intervention for AMSM.

Objective

This randomized controlled trial (RCT) aims to test the efficacy of an online-delivered life skills intervention, iREACH, on cognitive and behavioral HIV-related outcomes for AMSM.

Methods

iREACH is a prospective RCT of approximately 600 cisgender adolescent males aged 13 to 18 years who report same-sex attractions. The intervention will be tested with a racial/ethnically diverse sample (≥50% racial/ethnic minority) of AMSM living in four regions in the United States: (1) Chicago to Detroit, (2) Washington, DC to Atlanta, (3) San Francisco to San Diego, and (4) Memphis to New Orleans.

Results

This project is currently recruiting participants. Recruitment began in March 2018.

Conclusions

iREACH represents a significant innovation in the development and testing of a tailored life skills-focused intervention for AMSM, and has the potential to fill a significant gap in HIV prevention intervention programming and research for AMSM.

Registered Report Identifier

RR1-10.2196/10174

Comparative Analysis of Recruitment Strategies in a Study of Men Who Have Sex with Men (MSM) in Metropolitan Detroit

HIV/AIDS-related research requires recruitment of representative samples of MSM; yet, we know little about the comparative yield, diversity and cost-benefit tradeoffs between different recruitment venues. We compared 11 recruitment venues used for nine HIV prevention-related focus groups with MSM in Metropolitan Detroit. Of the 64 participants, 24 were clients recruited via an HIV/AIDS-focused nonprofit, 20 from Grindr advertisements, 6 from university-student email lists, and 5 from flyers/palmcards. Significantly more African-American, low-income and HIV-positive participants were recruited via the nonprofit. The best cost-benefit tradeoffs were for organizational Facebook posts, email groups, personal networking, and nonprofit recruitment. Grindr increased the size of the sample, though at greater expense. Facebook and Scruff advertisements and gay bar outreach represented greater costs than benefits. Only 11.6% of Grindr respondents attended the focus groups. A mix of online and offline recruitment venues can generate a large and diverse sample of MSM, but venue performance is uneven.

MSM at Highest Risk for HIV Acquisition Express Greatest Interest and Preference for Injectable Antiretroviral PrEP Compared to Daily, Oral Medication

Men who have sex with men (MSM) account for nearly 70% of new HIV diagnoses, with young black MSM at the highest risk for infection in the United States. Pre-exposure prophylaxis (PrEP) can decrease HIV acquisition in at-risk individuals by over 90%. However, therapeutic efficacy requires a daily pill, posing adherence challenges. Experimental modalities, including injectable PrEP given once every 2 months, may improve adherence among those most in need. To assess interest in and preference for injectable PrEP, an online survey was mounted on two popular MSM sexual networking apps. Differences by age, race, and other characteristics were examined using multinomial logistic regressions. Of 4638 respondents, 73% expressed interest in injectable PrEP and 47% indicated they would prefer an injection (compared to 17% who prefer a daily pill and 36% who were unsure). Within this sample, interest in and preference for injectable PrEP was highest among MSM at highest risk for HIV infection (i.e., younger age groups, racial/ethnic minorities, those with risker sexual behavior). As a result, if proven effective in clinical trials, injectable PrEP has the potential to reduce social disparities in HIV transmission among MSM.

Multiple strategies to identify HIV-positive black men who have sex with men and transgender women in New York City: a cross-sectional analysis of recruitment results

INTRODUCTION

Black men who have sex with men and transgender women are at high risk for HIV infection, but are more likely to be unaware of their infection or not in care for diagnosed HIV compared to other races. Respondent driven sampling has been advanced as a method to reach stigmatized and hidden populations for HIV testing. We compared strategies to recruit black, substance-using men who have sex with men and transgender women to identify newly diagnosed HIV infection, or those previously diagnosed but not in care.

METHODS

The STAR (Seek, Test, and Retain) study (ClinicalTrials.gov NCT01790360) used several recruitment strategies to identify black, substance-using men who have sex with men and transgender women with undiagnosed HIV infection or with previously diagnosed HIV infection but who were not in HIV care. Respondent-driven sampling, community-based recruitment and online advertising were used to recruit participants. Incentivized peer referral was integrated into all recruitment strategies. Participants completed interviewer-administered questionnaires and HIV testing. Demographic and HIV risk-related characteristics and recruitment strategy were summarized and stratified by HIV status. Associations were tested using Pearson's chi-squared, Fisher's exact, and Wilcoxon rank sum tests. Factors associated with HIV-positive diagnosis at p < 0.1 were included in a multivariable logistic regression model.

RESULTS

From July 2012 through October 2015, the study enrolled 1929 participants; 96.3% men who have sex with men and 3.7% transgender women. Behavioural risk factors included recent condomless anal sex (55.6%) and recent substance use during sex (73.1%). HIV prevalence was 8.7%. In multivariable analysis, significant associations with HIV infection included being transgender; non-Hispanic black; gay/homosexual orientation; not homeless; and less likely to have insufficient income for necessities. Among recruitment strategies, respondent driven sampling was least effective in identifying HIV-positive participants.

CONCLUSIONS

Integrating multiple recruitment strategies yielded a large sample of black men who have sex with men and transgender women at substantial risk for HIV. Respondent-driven sampling was less effective than other strategies at identifying men who have sex with men and transgender women with HIV.

Mixed-Method Evaluation of Social Media-Based Tools and Traditional Strategies to Recruit High-Risk and Hard-to-Reach Populations into an HIV Prevention Intervention Study

Men who have sex with men and transgender women are hard-to-reach populations for research. Social media-based tools may overcome certain barriers in accessing these groups and are being tested in an ongoing study exploring HIV home-test kit use to reduce risk behavior. We analyzed pre-screening responses about how volunteers learned about the study (n = 896) and demographic data from eligible participants who came for an initial study visit (n = 216) to determine the strengths and weaknesses of recruitment strategies. Social media-based strategies resulted in the highest number of individuals screened (n = 444, 26% eligible). Dating sites/apps reached large numbers of eligible participants. White-Hispanics and African-Americans were more likely to be recruited through personal contacts; community events successfully reached Hispanic volunteers. Incorporating recruitment queries into pre-screening forms can help modify recruitment strategies for greater efficacy and efficiency. Findings suggest that recruitment strategies need to be tailored to reach specific target populations.

Comparing Self-Reported Demographic and Sexual Behavioral Factors Among Men Who Have Sex with Men Recruited Through Mechanical Turk, Qualtrics, and a HIV/STI Clinic-Based Sample: Implications for Researchers and Providers

Recruitment for HIV research among gay, bisexual, and other men who have sex with men (MSM) has increasingly moved to the online sphere. However, there are limited data comparing the characteristics of clinic-based respondents versus those recruited via online survey platforms. MSM were recruited from three sampling sites (STI clinic, MTurk, and Qualtrics) to participate in a survey from March 2015 to April 2016. Respondents were compared between each of the sampling sites on demographics, sexual history, substance use, and attention filter passage. Attention filter passage was high for the online sampling sites (MTurk = 93%; Qualtrics = 86%), but significantly lower for the clinic-based sampling site (72%). Clinic-based respondents were significantly more racially/ethnically diverse, reported lower income, and reported more unemployment than online respondents. Clinic-based respondents reported significantly more male sexual partners in the previous 3 months (M clinic-based = 6; MTurk = 3.6; Qualtrics = 4.5), a higher proportion of gonorrhea, chlamydia, and/or syphilis in the last year, and a greater proportion of methamphetamine use (clinic-based = 21%; MTurk = 5%), and inhaled nitrates use (clinic-based = 41%; MTurk = 11%). The clinic-based sample demonstrated more demographic diversity and a greater proportion of HIV risk behaviors when compared to the online samples, but also a relatively low attention filter passage rate. We recommend the use of attention filters across all modalities to assess response validity and urge caution with online survey engines as samples may differ demographically and behaviorally when compared to clinic-based respondents.