Cyberspace and cellphones: New frontiers for HIV prevention with gay, bisexual and other men who have sex with men
In Canada, rates of HIV transmission among gay, bisexual and other men who have sex with men (MSM) remain steady and account for one half of all estimated new HIV infections each year. While rates of transmission seem generally stable, the ways that gay and bi men meet and socialize are constantly evolving. In this context service providers working in HIV prevention need to continually adapt their methods to meet the changing needs and realities of the populations they work with. This is particularly the case when it comes to technologies such as mobile phones and the Internet. These have quickly become a primary way for MSM – and younger MSM in particular – to meet other guys, find sex and seek sexual health information. In response, service providers are increasingly turning to eHealth interventions, delivered via the Internet and other technologies, to carry out HIV prevention efforts with MSM.
This article describes and summarizes a systematic literature review of research on eHealth HIV prevention interventions with MSM.
Changing means of communication and connection
Modern communication technologies like smartphones and the Internet are changing the way many people communicate, socialize and find information. This is especially true when it comes to gay, bisexual and other MSM meeting other guys, finding sex, and seeking sexual health information. This is well demonstrated by findings from the Sex Now Survey. In 2011 over 80% of young MSM reported using the Internet to find a sexual partner, and 75% used the Internet to find sexual health information.1
At the same time we know that in 2011 half of all new estimated HIV infections in Canada were in MSM, and that MSM are 71-times more likely to get HIV than men who do not have sex with men.2 This highlights the continuing need for effective interventions to support increases in HIV testing and treatment, and the adoption and consistent and correct use of HIV prevention interventions.
Acknowledging the growing role of the Internet in the lives of MSM, and the increasing relevance this may have for HIV prevention interventions, researchers at the Columbia University School of Nursing conducted a systematic literature review of research on Internet-based interventions with MSM. Overall, they found that outreach and education interventions that use technologies like chat rooms, social networking sites, text messages and interactive games can be effective tools to increase HIV testing, reduce use of crystal methamphetamine, and decrease behaviours more likely to lead to HIV transmission, such as condomless anal sex. Strategies such as the use of pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP) and viral load of HIV-positive partners, were not measured in assessments of risk, likely because at the time of the studies their effectiveness had not yet been as clearly demonstrated, and thus present exciting opportunities for continued innovation and research.3
What are eHealth interventions and why are they relevant?
eHealth is a generic term used to describe health interventions that are delivered electronically.3 They can range from web-based tools like videos, games, chat rooms and social networking sites to text messaging (SMS) and e-mail. Research on this type of intervention has shown that it can be effective across a wide range of diseases and health behaviours such as treating alcohol use disorders4 and preventing obesity.5,6
HIV prevention outreach and education activities with MSM have historically been face-to-face and location-based. However, eHealth interventions are similarly showing a great deal of promise as being acceptable and even appealing to MSM because they are accessible from anywhere and can be used privately. This helps reduce the fear of being stigmatized for engaging with these kinds of interventions and makes them more acceptable to men who would not be reached through in-person strategies.7
Online interventions might even be more likely to reach MSM at higher risk of HIV than those conducted in person. Some studies have shown that gay men who find sex partners online are more likely to report engaging in behaviours with a higher risk of HIV transmission,8 have a lack of basic HIV knowledge, have questions about HIV testing, and generally feel that community resources do not fit their needs.9,10
Do eHealth interventions reduce the chances of MSM acquiring HIV?
To answer this question, the authors conducted a systematic review of the research evaluating these types of interventions.
To be included in this systematic review, studies had to:
- be interventions for changing behaviours;
- focus on HIV prevention or testing and not on HIV care;
- be published in English between January 2000 and April 2014;
- be quasi-experimental or a randomized-controlled trial (studies that had some kind of control/comparison group);
- measure behavioural outcomes; and
- focus on adult MSM.3
A total of 13 studies met these criteria and each one was assessed using an extensive quality-assessment tool.
Below is some key information on the studies included in the systematic review:
- The samples varied significantly in size from 52 participants to over 3,902.
- Most of the studies (69%) were conducted in the United States; other locations included Peru, Australia, Taiwan and Hong Kong.
- Most used a theoretical framework to guide development (for example, the Health Belief Model, Stages of Change, Social Cognition and Developmental Theory, and others).
- The length of the intervention period ranged from about 15 minutes11 to six months.9,12,13,14
- Measured outcomes (the intended behaviour changes) included indicators such as condom use, HIV testing rates and sexual risk behaviours
What types of interventions were shown to be effective?
The studies selected for inclusion in the review varied in the method used and site of intervention. None of the interventions were Canadian (and some were conducted as many as seven years ago) and therefore they may contain information that is not relevant in a Canadian context today.
These studies used online videos designed to convey information and show dramatic re-enactments of HIV-related situations (such as finding out a previous sexual partner was HIV positive). The enactments were followed by information or education or showed the participants a possible scenario for dealing with the situation.
One of the studies, conducted in Peru, looked at the effectiveness of a five-minute video designed to motivate the viewer to get an HIV test, and compared the outcomes with an intervention that used text-based information used in previous HIV testing campaigns. There were three different videos: one for non-gay identified MSM, one for gay-identified MSM and one for trans men. The video presented different reasons MSM had reported for not getting tested for HIV (for example, fear or lack of confidentiality) and modelled men overcoming these barriers. The video created for non-gay-identified MSM was shown to be particularly effective. In the video, a young man discovers that a guy he’d had sex with was HIV positive and, after shock and confusion, gets tested at a well-known HIV testing site where he receives a negative result and discusses the advantages of getting tested. Results showed that 62.5% of the men shown this video reported they intended to get tested for HIV within the next 30 days, compared to 15.4% of the men shown only the text information.15
Another study, from the U.S., compared outcomes for participants who watched one or both of two videos – a video drama (The Morning After)16 and a five-minute documentary video (Talking about HIV)17 – to those who viewed a prevention web page (HIVBigDeal.org), or received no intervention. When followed up after 60 days, the odds of reporting full HIV status disclosure to their last sexual partner was 32% higher among guys who had watched a video compared with those who received no intervention. The odds of condomless anal sex were 62% lower among HIV-positive guys who had watched one or both of the videos compared with before the intervention. The odds of condomless anal sex with serodiscordant partners were 47% lower among HIV-positive guys who had watched one or both of the videos compared with before the intervention.11
Education Modules and Games
These interventions involved a series of online interactive modules with videos, multiple-answer questions, self-assessment tools, and other exercises that aimed to increase awareness of HIV risk and provide the participants with opportunities for self-reflection and planning to engage in safer behaviours.
Sexpulse, an American study, created an extensive online site where participants were led through numerous interactive modules to build a personal “portrait of sexual health.” Each module was centred on a different aspect of sexual health. Examples include: a “hot sex” calculator, which calculated the odds of great sex while demonstrating decision-making in dating; a virtual gym where men could explore body image concerns; an online chat simulation where users were presented with ambiguous or evasive chat scenarios; and a “reflective journey,” which gave participants a chance to identify and graph the effects of past successes and disappointments. The men randomized to the Sexpulse intervention reported a 16% reduction in condomless anal sex in the three months after participation compared with the control group who received no intervention.18 No difference was seen after 12 months, which speaks to a general challenge in sustaining the impact of behavioural interventions regarding the challenge of having a lasting/sustained impact.
There were two other online module-based interventions. Keep It Up! was designed to be delivered to young MSM who had recently received an HIV-negative test result. The intervention involved three two-hour sessions done at least one day apart. Participants assigned to the intervention had a 44% lower rate of condomless anal sex acts at the 12-week follow-up compared with those who were not assigned to the intervention but accessed non-interactive online HIV and STI information.7
The Wyoming Rural AIDS Prevention Project was unique in that it aimed to reach MSM living in rural areas. It involved different modules containing computer-animated conversations between characters of different HIV statuses interspersed with questions for self-reflection. Men who participated in the study who had two or more current sexual partners reported a significant increase in condom use during anal sex (48% before the intervention and 72% after the intervention).19
Socially Optimized Learning in Virtual Environments (SOLVE) was a downloadable simulation game that immersed “high-risk” young adult MSM in virtual scenarios (such as a gay house party or possible group sex scene) and allowed them to make different choices and see possible outcomes. Participants who played the game reported more shame reduction after the intervention compared with MSM in the control condition who did not play the game. The authors predicted that reductions in shame would result in decreased condomless anal sex. However, while some decrease was found, the change was not statistically significant.20
Text messages (SMS) and E-mail messaging
These interventions used text messages (SMS) or e-mails with participants to change behaviours.
An Australian study involved clinicians sending text messages to patients who had previously come to a sexual health clinic to remind them to come back for follow-up testing. Among men who received SMS text reminders, 64% were retested within nine months compared with only 30% in the control group who did not receive text mesages.12
The Project Tech Support study sent one to two social-support and health-education text messages per day over two weeks to encourage HIV-negative guys to reduce methamphetamine use. The intervention was successful, with 49% of participants reporting methamphetamine abstinence compared with 13% at baseline. High-risk sexual behaviours were also reduced. Participants reported condomless anal sex with an average of 1.9 partners after the intervention, compared with 4.4 partners in the two months before the intervention.21 Reductions were reported for sexual encounters after methamphetamine use as well as generally.
Another intervention, from Hong Kong, involved sending biweekly e-mails to participants with information and discussion about HIV transmission, correct condom use, HIV testing, “relationships & love,” and the relationships between drugs and sex. This intervention, however, didn’t find any significant behaviour changes compared to the control group that only received educational information.14
This type of intervention uses participation in chat rooms to change behaviours.
CyBER/testing involved an outreach worker joining a gay chatroom from 9.00 a.m. to 5.00 p.m., Monday to Friday. Every 30 minutes the worker posted information about HIV testing as well as making himself available to answer questions.9 Self-reported testing rates increased from 44.5% before engaging in the intervention to nearly 60% after engaging in the intervention.3
This type of intervention uses social networking sites such as Facebook to change behaviours.
The HOPE study used 16 peer leaders, who volunteered to share information over Facebook with groups of study participants over 12 weeks. The researchers created four closed Facebook groups, two of which were focused on general health and two on HIV-specific health information. For each group, four peer leaders were recruited and trained to use messages, chats and wall posts to share information. Every four weeks, all participants were sent a message offering them a free HIV testing kit that allowed them to self-collect a blood sample and then send it to a lab for processing. Significantly more participants in the group who received HIV-specific information (44%) followed up and requested a test be sent to them compared with those in the control group who only received general health information (20%). Further, nine of the 25 intervention participants (36%) who requested the test took it and mailed it back for analysis compared with two of the 11 control participants (18%) who requested the test.22
Implications for frontline work
It is clear from this systematic review that eHealth interventions can be an effective way to promote behaviour change in MSM at high risk of getting HIV. This evidence provides an impetus to expand research on eHealth interventions in diverse social and geographic settings in Canada to see which methods are most effective in particular contexts. In view of the potential impact of eHealth interventions, this is a promising area for Canadian program evaluation research to demonstrate effectiveness and provide successful program models for adoption by service providers who are expanding their eHealth outreach activities. The Cruising Counts study of online and app-based sexual health outreach for MSM in Ontario is a notable example of current research being conducted in Canada.
Many service providers working with MSM will likely already be familiar with using online platforms like Grindr, Squirt and Manhunt as virtual sites for outreach and education and may find that the studies in the systematic review provide evidence that such interventions can be effective. eHealth interventions can be operationalized in a number of ways using a wide range of technologies (from SMS to virtual reality) to “meet guys where they are at.” These interventions present exciting opportunities for outreach workers and other service providers to build off of, and connect with, current and past prevention work to increase their impact.
The authors of the systematic review note that there is a pressing need for ongoing work to assess the use of eHealth strategies for HIV prevention in MSM. They especially highlight the need for studies that employ these interventions in longer and larger trials to evaluate whether these interventions have beneficial long-term effects.
The study authors used a scoring system developed by the U.S. Centers for Disease Control and Prevention (CDC) HIV/AIDS Prevention Research Branch.23,24 The system assesses interventions across seven different domains or characteristics. Each study was given a score based on its:
- Representativeness: How well the authors described the population they were working with.
- Bias and confounding: The study took into account factors like demographics, other possibly contributing interventions and compliance (percentage of the intervention a participant was involved with).
- Description of the intervention: The intervention was described well enough that it could be recreated.
- Outcomes and follow-up: Study authors clearly explained how they would evaluate the success of the intervention in achieving its goals, and the study population was well followed so that there was little loss of participants.
- Statistical analysis: Authors chose the appropriate methods to analyse results and described them clearly.
- Strength of evidence: Not only should the intervention have a measurable positive impact, but it was statistically significant (in other words, chance alone wouldn’t be able to explain the change in behavior of participants).
- Group equivalence: The researchers had one or more clearly defined control/comparison groups and properly explained how participants were sorted into respective groups.23,24
The quality of the 13 articles that were included in the systematic review varied, with quality scores ranging from 49.4% to 94.6% and none of the studies fulfilling all of the criteria.3
Systematic reviews are important tools for informing evidence-based programming. A systematic review is a critical summary of the available evidence on a specific topic. It uses a rigorous process to identify all the studies related to a specific research question. Relevant studies can then be assessed for quality and their results summarized to identify and present key findings and limitations. If studies within a systematic review contain numerical data, this data can be combined in strategic ways to calculate pooled estimates. Combining data to produce pooled estimates can provide a better overall picture of the topic being studied.
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