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Creating Digital Bridges to HIV Prevention: Online interventions for adolescents and young adults

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Jose Bauermeister presented on the use of technologies for HIV prevention at the March 13th, 2017 meeting of the Philadelphia HIV Integrated Planning Council.

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Creating Digital Bridges to HIV Prevention: Online interventions for adolescents and young adults

  1. 1. CREATING DIGITAL BRIDGES TO HIV PREVENTION: ONLINE INTERVENTIONS FOR ADOLESCENTS AND YOUNG ADULTS José A. Bauermeister, MPH, PhD Penn Presidential Associate Professor University of Pennsylvania
  2. 2. THEORETICAL APPROACHES “…[HIV infection is] first and foremost a consequence of behavior. It is not who you are but what you do that determine(s) whether or not you expose yourself to HIV, the virus that causes AIDS.” (NIMH Task Force, 1991) Not quite… “[The Task Force] failed to note that ‘who you are’—not in terms of individual identity, but in terms of social location within a context of social oppressive factors—determines to a great extent what you can and cannot do”. (Díaz & Ayala, 2002)
  3. 3. HIV/AIDS: A NATIONAL PRIORITY  1.25 million HIV/AIDS cases in the US  1/4 people HIV-infected are unaware of their serostatus  Increased burden of MSM who are:  Under the age of 35  Belong to a racial/ethnic minority group
  4. 4. DIAGNOSES OF HIV INFECTION AMONG MALE ADULTS AND ADOLESCENTS, BY TRANSMISSION CATEGORY, 2010–2014: UNITED STATES AND 6 DEPENDENT AREAS CDC. Diagnoses of HIV infection in the United States and dependent areas, 2014. HIV Surveillance Report 2015;26. Subpopulations representing 2% or less of HIV diagnoses are not reflected in this chart. Abbreviation: MSM=men who have sex with men.
  5. 5. DIAGNOSES OF HIV INFECTION, 2014 CDC. Diagnoses of HIV infection in the United States and dependent areas, 2014. HIV Surveillance Report 2015;26. Subpopulations representing 2% or less of HIV diagnoses are not reflected in this chart. Abbreviation: MSM=men who have sex with men.
  6. 6. DIAGNOSES OF HIV INFECTION AMONG MEN WHO HAVE SEX WITH MEN, BY AGE AT DIAGNOSIS, 2010 –2014: UNITED STATES AND 6 DEPENDENT AREAS
  7. 7. DIAGNOSES OF HIV INFECTION (AGES 13-24) BY RACE/ETHNICITY, 2010–2014
  8. 8. Low Reach High Reach High Efficacy Low Efficacy Good One-on-One Counseling One Size Fits All Interventions Individually Tailored Interventions Bad One-on-One Counseling BEHAVIORAL INTERVENTIONS
  9. 9. HOW CAN TECHNOLOGY ADDRESS THE NEED?
  10. 10. HIV & TECHNOLOGY  Approach  Gen 1: Real or Virtual  Gen 2: Virtual and Real  Gen 3: Augmented Reality  Technology  Computer-based  Web-based  Mobile supported Muessig, K., Nekkanti, M., Bauermeister, J.A., Bull, S., & Hightow-Weidman, L. (2015). A systematic review of recent smartphone, internet and web 2.0 interventions to address the HIV continuum of care. Current HIV/AIDS Reports, 12(1), 173-190. Grov, C., Breslow, A.S., Newcomb, M., Rosenberger, J., & Bauermeister, J.A. (2014). Gay and bisexual men’s use of the Internet: Research from the 1990s through 2013. Journal of Sex Research: Annual Review of Sex Research Special Issue,
  11. 11. Muessig, K., Nekkanti, M., Bauermeister, J.A., Bull, S., & Hightow-Weidman, L. (2015). A systematic review of recent smartphone, internet and web 2.0 interventions to address the HIV continuum of care. Current HIV/AIDS Reports, 12(1), 173-190.
  12. 12. Muessig, K., Nekkanti, M., Bauermeister, J.A., Bull, S., & Hightow-Weidman, L. (2015). A systematic review of recent smartphone, internet and web 2.0 interventions to address the HIV continuum of care. Current HIV/AIDS Reports, 12(1), 173-190.
  13. 13. SOCIAL MEDIA INTERVENTIONS  44 studies published on HIV prevention/care through social media (2005- 2015)  17 were intervention studies  76.5% of studies used Facebook  5.9% used a geospatial social network app  Populations  MSM (n = 9, 52.9%), youth (n = 5, 29.4%), and patients of sexual health clinics (n = 2, 11.8%).  Behavior Change (Prevention: n =15, 88.2%; Care: n=2))  HIV testing (n = 5, 29.4%),  Raise online awareness (n = 4, 23.6%), and  Increase condom use (n = 3, 17.6%). Garett, R., Smith, J., & Young, S.D. (2016). A review of social media technologies across the global HIV care continuum. Current Opinion in Psychology, 9, 56-66.
  14. 14. Message Library Barriers Motives Support Knowledge = Untailored message + + + ONE SIZE (DOES NOT) FIT ALL…
  15. 15. MAXIMIZING THE POWER OF TECHNOLOGY 1. Assessment of individual characteristics relevant to the behavior, 2. Algorithms that use the assessment data to generate intervention messages relevant to the specific needs of the user, 3. Feedback protocol that delivers these messages to the user in a clear, vivid format.
  16. 16. Information needs Degree of uncertainty Relationship strengths Decision Making Emotional states Message Library User Values red blue aqua, gray orange green Tailored Message
  17. 17. META-ANALYSES AND REVIEWS OF TAILORED INTERVENTIONS  Significant positive impact on health outcomes:  Breast cancer  Diet, exercise, physical activity  Alcohol abuse  Smoking cessation  Obesity  Diabetes  Mental health  Asthma/COPD  Menopause/HRT  HIV/STI testing  Condom use Populations Settings Channel Adolescents Smokers Caregivers Low literacy Low income Hypertensive pts Heart Failure pts Parents Asthma pts Pts in recovery Adults Primary Care Settings Grocery Stores Classrooms Worksites In the Home Stand-alone Computer Web-based Telephone
  18. 18. Noar SM, Benac CN, Harris MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull. 2007;133(4):673–693. doi:10.1037/0033- 2909.133.4.673. EFFECT SIZES BY TAILORING FACTORS COMBOS
  19. 19. SOCIOECOLOGICAL APPROACH  Relationships (not disease-related outcomes) may aid to elucidate new HIV/STI prevention opportunities  Acknowledgement of YMSM’s lives as ecologically complex  Developmentally  Interpersonally  Socio-spatially  Develop theoretical models and interventions that aid in documenting and improving those realities.  Development of interdisciplinary and multisectoral partnerships are crucial in sexuality and technology-related health research.
  20. 20. “CONNECT-YM: DEVELOPING A HIV/STI TESTING NAVIGATION TOOL FOR YMSM” (CENTERS FOR DISEASE CONTROL AND PREVENTION; PI: BAUERMEISTER)
  21. 21. ARE ALL HIV/STI SITES CREATED EQUAL?
  22. 22. SECRET SHOPPERS  2 secret shoppers visited 46 sites at different dates/times.  7 sites excluded:  “Satellite” sites  Non-operational sites  Forced testing  Demanding ID  Co-pay > $60 Bauermeister, J.A., Pingel, E., Jadwin-Cakmak, L., Meanley, S., Alapati, D., Moore, M., Lowther, M., Wade, R. & Harper, G.W. (2015). The use of mystery shopping for quality assurance evaluations of HIV/STI testing sites offering services to young gay and bisexual men. AIDS & Behavior, 19(10), 1919-1927.
  23. 23. CHECKLIST
  24. 24. TESTING EXPERIENCES Total (N=46) HIV-Only (N=13) Comprehensive Testing (N=33) N (%) N (%) N (%) p Counseling Session The provider explored my motivation for testing. 40 (87.0%) 12 (92.3%) 28 (84.8%) 0.50 The provider offered to help me set action steps to meet new safer sex goals. 20 (43.5%) 10 (76.9%) 10 (30.3%) 0.01 The provider offered me risk reduction options. 33 (71.7%) 11(47.8%) 22 (66.7%) 0.22 The provider’s recommendations were valuable. 40 (87.0%) 11(47.8%) 25 (75.8%) 0.38 Safer Sex Education Provider made sure I knew how to use a condom. 12 (26.1%) 7 (53.8%) 5 (15.2%) 0.01 Provider helped me identify a condom that works for me. 11(23.9%) 7 (53.8%) 4 (12.1%) 0.01 Provider helped me identify a lube that works for me. 9 (19.6%) 13 (100%) 2 (6.1%) 0.01
  25. 25. VIGNETTE 1: BEST PRACTICES “Ideal site. Totally one of the best testing experiences. When I said that I was concerned that I was exposed to HIV, the tester was supportive. Explained – to me and told me that it would be worth to test. Extremely compassionate and courteous. Discussed a variety of topics including PREP, sex with HIV positive individuals, oral sex and HIV.” “Overall, this was a great experience and one of the best I’ve had testing for Connect. The provider was extremely kind, nonjudgmental, and gave off a calm aura. She didn’t outwardly judge my encounters w/ anonymous partners. Also it was a decently quick interaction compared to some of the hour waits I’ve had at other testing locals. Would recommend this site.”
  26. 26. VIGNETTE 2: PROTOCOL DEVIATION “After beginning the HIV test, the provider left me alone in the room while the test was running, and left the test device uncovered while she was gone. I was able to see my results the entire time (it was clear after 5 minutes while the total run time is 15 minutes). This is highly discouraged according to the training procedures that I have been exposed to. The provider may have assumed that I didn’t know what I was looking at, as she did not go over any information about the testing device and what a positive/negative/invalid reading looks like.”
  27. 27. VIGNETTE 3: POOR CARE “Initially, the nurse practitioner appeared friendly and well- meaning. She told me about the different options and testing procedures that were available to me. […]When I refused to do the penile swab she replied: “Our clients do not have the option to pick and choose which test they can or can’t do. It is all or none here; if you do not do the penile swab then I cannot offer you any other tests.”
  28. 28. “When I still refused, she replied that this was a simple painless procedure and that it would take a few seconds. She seemed almost disappointed that she had not intimidated me into doing the penile swab.Then she did the HIV rapid test and did not explain anonymity or confidentiality. She asked me to wait outside, and did not do any more counseling for me.“ “She seemed really disappointed that my results were not what she expected. She said, “With your history, I was certain you would be positive. But you seem to be negative. I am going to give you some condoms. Use them every time for sex.”
  29. 29. “Overall, this was the worst testing site, where my autonomy were taken away and I was denied services because I refused to toe the line.This is a site that should be avoided for its unethical approaches and for being unapproachable to clients.This is definitely a site that should be avoided in its entirety.”
  30. 30. GET CONNECTED  Adaptation of the Project Connect Health Systems Intervention for adolescent heterosexual populations.  Acknowledged need to circumvent/address structural barriers affecting the reach and service efforts geared towards YMSM’s HIV/STI prevention and care.  Developed through a CBPR approach and informed by existing mixed- methods data focused on YMSM in Southeast Michigan. Bauermeister, J.A., Pingel, E., Jadwin-Cakmak, L., Harper, G.W., Horvath, K., Weiss, G. & Dittus, P. (2015). Acceptability and preliminary efficacy of a tailored online HIV/STI testing intervention for young men who have sex with men: The Get Connected! Program. AIDS & Behavior, 19(10), 1860-1874. PMCID: PMC4522230
  31. 31. WHAT IS THE CONTENT TAILORED ON?  Age  Race/ethnicity  Sexual identity  Relationship status  HIV/STI test history  Testing barriers/fears  Structural struggles  Sources of support  Core values Age Values Race/ Ethnicity
  32. 32. LINKING SHOPPER SCORES TO SITE SELECTION ALGORITHMS  Raters’ scores  Site is youth friendly  Site is LGBTQ inclusive  Provider is LGBT friendly  Provider is sex positive  Goal setting  Ideal/best practices  Confidentiality  Assessed IPV  Explored motivations  Pressure to Adopt RR  Structural characteristics  Days/hours  Walk-ins  Location  Close to bus route  Phone appointment  Walk-in appointment  Session speed (In & Out)  Testing services offered  Provides sliding scale fee  Requires insurance  Accepts insurance
  33. 33. A CASE STUDY  19 years old  Black  Single  Never tested for HIV or STIs  Barriers:  Cost  Fear it will hurt  Doesn’t seem urgent  Values:  Sexy  Strong  Successful
  34. 34. VISIT RESOURCE
  35. 35. Randomization Baseline Tailored Content + Test Locator Site Feedback 30 day Follow-Up Baseline Test Locator Site Feedback 30 day Follow-up STUDY DESIGN
  36. 36. EVALUATION OF GET CONNECTED Contacted • 444 individuals contacted over 4 month period • 62 were not interested Screened • 382 individuals screened • 180 eligible and invited (2:1 design; YMSM ages 15- 24) • 50: 14 stopped at consent; 36 never entered Consente d • 130 completed study • 104 completed 30-day follow-up
  37. 37. SAMPLE CHARACTERISTICS (N=130)  Age: 21.12 years (SD=2.23)  102 (83.8%) identify as gay  Race/Ethnicity  White: 84 (64.6%)  Black: 26 (20.0%)  Latino: 15 (11.5%)  Middle Eastern: 11 (8.5%)  API: 9 (6.9%)  Other: 2(1.5%)  92% completed HS  73% reported working  Relationship Status: 45.6%  Prior Incarceration: 10%  HIV  Prior test was HIV-: 70.8%  Median time: 6mo.  Never tested: 26.2%  HIV positive: 3.0%  STIs  Prior STI testing: 62%  60.5% reported prior STI  Median time: 5.5 months
  38. 38. FEASIBILITY & ACCEPTABILITY Tailored Intervention (n=86) Test Locator (n=44) t value Cohen’s d Overall, I am very satisfied with Get Connected a 6.16 (1.08) 6.00 (.77) .97 .18 Using Get Connected is very frustrating a 2.09 (1.27) 2.19 (1.44) -.40 -.07 I would recommend Get Connected to my friends a 6.00 (1.21) 5.74 (.99) 1.21 .22 Get Connected is easy to use a 6.29 (.96) 6.24 (1.01) .28 .06 Get Connected provided me accurate information a 6.35 (.88) 5.74 (1.15) 2.99** .55 How likely would you be to continue using Get Connected if it were available? b 5.77 (1.30) 5.79 (.93) -.06 -.06 a Items are scored on a 1-7 scale (1=Strongly Disagree; 7=Strongly Agree). b Item is scored on a 1-7 scale (1=Very Unlikely;7=Very Likely). **p<.01
  39. 39. TESTING BEHAVIOR  Have you visited an HIV or STI provider in the past 30 days?  Yes  Get Connected: 22 (73.3%)  TL: 8 (26.7%)  No  Get Connected: 46 (62.2%)  TL: 28 (37.8%)  A new HIV case diagnosed and 2 medically diagnosed STIs: one case of Chlamydia and a diagnosis of Herpes/HSV. TL+Tailoring Test Locator Yes No Differences in proportion are clinically meaningful (Cohen’s d = .34)
  40. 40. MOVING FORWARD  Testing efficacy of GC among YMSM in three different cities  Run intervention for one year, with surveys at 1, 3, 6, 9, and 12 months  Add information about PrEP, optimize for mobile use
  41. 41. STUDY SCHEMA Screener Randomization Baseline Baseline C3C2 C4 C5 I2 I4I3 I5 3 Months 9 Months6 Months 12 Months I1 C1 1 Month Get Connected! AIDSVu Test Locator Mystery Shopper Site Visits (Baseline site performance evaluation) Participants across Intervention Conditions Visit Sites Sites Receive Quarterly Report Participants across Intervention Conditions Visit Sites Sites Receive Quarterly Report Participants across Intervention Conditions Visit Sites Sites Receive Quarterly Report In-depth interviews with agencies regarding Site Quarterly Reports
  42. 42. MOBILE REDESIGN
  43. 43. MOCK TESTING SITE REPORT
  44. 44. FUTURE DIRECTIONS
  45. 45. INNOVATIONS AND NEW OPPORTUNITIES  Approach  Gen 1: Real or virtual  Gen 2: Virtual and real  Gen 3: Augmented reality  Gen 4: Digitized reality  Technology  Computer-based  Web-based  Mobile supported  Biosensor enhanced
  46. 46. SPECIFIC NEEDS ADDRESSED OVER THE USERS’ LIFE Awareness Contemplatio n Preparation Action Adherence • Provide education • Show that positive factors outweigh negative ones • Find ways to motivate • Reinforce positive beliefs • Provide skills • Address concerns & barriers • Check motives • Provide specific skills • Offer coping strategies • Provide support • Reinforce success • Remind of positive outcomes • Remind of positive outcomes achieved • Build relapse skills
  47. 47. FUTURE DIRECTIONS  Technology-driven solutions must acknowledge dynamic changes  Employ theoretically-driven frameworks  Identify and leverage data from a digitized society  Promote youth empowerment  Facilitate real-time linkage and access to care  The future is adaptive  Design, function and content must be youth-centered  Technology solution must connect to real-time needs  Analyses of data will require multidisciplinary teams
  48. 48. OTHER ONGOING PROJECTS myDEx (R34-MH-101997- 01A1)
  49. 49. MYDEX  Agile development of a youth-driven curriculum delivered as a WebApp  Pilot RCT of Single HIV- YMSM (N=180) with recent CAI experience seeking partners online  50% Racial/Ethnic Minority  2:1 Randomization (2 Intervention; 1 Control)  Intervention:  6 sessions focused on tailored risk reduction content regarding partner seeking behaviors, relationship desires, sex, PrEP and condom use, and HIV/STI testing  Comparison:  6 static CDC HIV prevention information sessions
  50. 50. iCON+ (U01MD011274-01)
  51. 51. • Users may navigate 16 domains of content. • Content tailored to users’ characteristics: • Age • Sexual Orientation • Gender Identity • Region • Education Status • HIV Status • HIV/STI Testing History • Residential instability • Goals are set and linked to resources.
  52. 52. WE’RE HIRING!
  53. 53. The content is solely the responsibility of the author and does not necessarily represent the official views of funding agencies. ACKNOWLEDGMENTS
  54. 54. CONTACT INFORMATION For more information: José A. Bauermeister, MPH, PhD bjose@upenn.edu www.pennpstar.org

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