A novel online HIV prevention programme with spicy soap operas and interactive games – like a rising thermometer of sexual risk – reduced sexually transmitted infections in gay young men by 40%, reports a Northwestern Medicine study. “That is a huge effect,” said lead author Brian Mustanski, director of The Institute for Sexual and Minority Health and Wellbeing at Northwestern University Feinberg School of Medicine. “We were expecting it be 20%.”
This is the first online HIV prevention programme to show effects on a biological outcome. It is targeted to young men ages 18 to 29 who have sex with men, who have the highest rate of HIV infections in the US. The results show the effectiveness of an online programme to promote safe sex in this highest risk group.
These young men represent 2% of young people in the US but account for almost 70% of HIV diagnoses, according to the Centres for Disease Control and Prevention (CDC). Their rate of new HIV diagnoses is 44 times higher than that of other men. “The numbers are alarming,” Mustanski said. “The CDC estimates that without an intervention half of young black gay men and a quarter of Latino gay men will get HIV at some point in their lives.”
Prior studies using eHealth HIV prevention programmes used self-reports to determine their effectiveness. “People can sometimes forget or may not always tell the truth. A biological outcome is often considered more trustworthy,” Mustanski said.
Mustanski and colleagues developed the programme called Keep it Up! The study included 901 participants primarily from the Atlanta, Chicago and New York City study sites. Participants who used Keep It Up! had a 40% lower incidence of sexually transmitted disease – specifically chlamydia and gonorrhoea – compared with the control group at 12 months.
Instead of the typical HIV prevention approach, which provides facts about how HIV is transmitted and how to use a condom, Keep It Up! focuses on the lives of young gay men and weaves HIV prevention information into their typical experiences. Each of the programme’s modules targets a particular setting that is relevant to the men such as dating and starting new relationships. One is about going to a bar and using drugs and alcohol.
In that episode, men learned the benefits of avoiding substance use in sexual situations and how to reduce their risk when they do use substances (making sure to bring a condom with them, so they don’t need to navigate obtaining and deciding to use a condom while intoxicated).
In one of the interactive games, men could look at different sexual behaviours and rate them on a “thermometer of risk.” Then the game tells them if they got it right. “The game let them see ‘what are things I can do that are pleasurable but wouldn’t put me at risk?'” Mustanski said.
A soap opera tracks a group of young men who make assumptions about their partners. “One guy assumes the guy he is dating is monogamous, but he never talked to the guy about it. In fact, his partner was dating a few people,” Mustanski said.
“We know that the majority of HIV transmissions in young gay/bisexual guys occur in a serious relationship, so it is important for them to have explicit discussions about whether their relationship is open or closed and that both partners get tested for HIV and share their status,” Mustanski said.
Another man in the video assumes his partner is HIV negative while the partner assumes he is positive. “It shows you can’t assume it’s your partner’s job to disclose their HIV status. It’s really important to have everyone take responsibility for those conversations,” Mustanski said. The video emphasises the importance of regular HIV testing and skills negotiating condom use.
Participants said they learned a lot from the games and soap opera. One commented, “I didn’t really think about my own behaviour until I watched the soap opera. When I saw those characters, I was judging them, but then I realised I was doing the same (risky) thing.”
“It motivated me to get tested,” another man wrote about participating in the programme. “I had waited two years because I was afraid of the result, so without Keep It Up I would still be in the dark. Also, I liked that the content dealt with real-world situations like meeting at clubs or online.”
PrEP was US Food and Drug Administration approved as an HIV prevention medication around the start of the trial, so the team moved quickly to add content on PrEP into the booster sessions of the intervention. That content was designed so it could be easily updated as new information emerged about PrEP.
Mustanski emphasised, “The core principals of how we motivated risk reduction are equally applicable to PrEP. eHealth interventions need to be updatable as new developments occur in the HIV prevention landscape.”
Study participants had received a HIV-negative test during screening. They had not been in a monogamous relationship for at least six months prior to recruitment and reported at least one or more acts of condom-less anal sex during that period. Participants completed online questionnaires and performed testing for urethral and rectal gonorrhoea and chlamydia upon enrolment as well as 12 months post intervention.
Mustanski hopes to get a grant for a trial to implement and disseminate the programme in 50 US counties. “It’s not enough just to put it on a website. We want to find the most cost-effective way to get this out in the community and how to reach the people with the highest risk,” he said.
In 2015, the US National HIV/Aids strategy called for a 15% reduction in HIV incidence among young gay men who have sex with men. Only two of 59 current HIV-related evidence-based interventions target them. HIV prevention programmes for gay young men should not be simple modifications of those developed for heterosexual youth, because gay young men have different challenges related to their sexual orientation, such as feeling isolated or not having supportive networks.
The study was supported by a grant from the National Institute on Drug Abuse and National Institute of Mental Health.
Introduction: HIV diagnoses among young men who have sex with men are increasing, but few effective HIV prevention interventions exist for this population. An RCT was conducted of the online Keep It Up! intervention to determine if it significantly reduced condomless anal sex and sexually transmitted infections compared with an HIV knowledge condition.
Study design: From May 2013 to March 2017, a total of 901 participants were enrolled in a double-blinded RCT of Keep It Up! with 1-year follow-up. After completing baseline surveys and sexually transmitted infection testing, participants were randomized by an eHealth platform to the intervention or control condition.
Setting/participants: HIV-negative men who have sex with men reporting condomless anal sex, aged 18–29 years, were recruited through advertising and from HIV testing sites and outreach in Atlanta, Georgia; Chicago, Illinois; and New York, New York.
Intervention: Multimedia was used to address HIV knowledge and motivate safer behaviors. The control condition reflected existing online HIV information.
Main outcome measures: Primary outcomes were incident gonorrhea or chlamydia at 12-month follow-up and self-reported condomless anal sex with casual partners at 3-, 6-, and 12-month follow-up.
Results: In 2017, data were analyzed from 445 (49%) participants randomized to the intervention and 456 (51%) to the control. Participants were primarily racial/ethnic minorities (63%). Sexually transmitted infections at Month 12 was 40% lower for intervention participants (risk ratio=0.60, 95% CI=0.38, 0.95, p=0.01). For the primary behavioral outcome, both arms showed reductions over time with 44% of control and 37% of intervention participants reporting condomless anal sex at Month 12 (prevalence ratio=0.83, 95% CI=0.70, 0.99, p=0.04).
Conclusions: The Keep It Up! intervention resulted in significantly lower sexually transmitted infection incidence and a small but significant decrease in condomless anal sex 12 months post-intervention relative to an online HIV knowledge condition. In addition, this study demonstrated the feasibility and acceptability of at-home sexually transmitted infection testing as part of an eHealth intervention.
Brian Mustanski, Jeffrey T Parsons, Patrick S Sullivan, Krystal Madkins, Eli Rosenberg, Gregory Swann