Engaging Seronegative Youth to Optimize HIV Prevention Continuum
Condition: HIV; Mental Health; Substance Use; STI
MeSH terms: Substance-Related Disorders
Study type: Interventional

Summary: 
      The focus of this study (Engaging Seronegative Youth to Optimize HIV Prevention Continuum) -
      will be to stop HIV-related risk acts and to encourage youth at high risk for HIV to adopt
      antiretroviral medications as treatment and prevention (either pre exposure prophylaxis
      (PrEP) or post exposure prophylaxis) among gay, bisexual and transgender and/or homeless
      youth with contact with the criminal justice system in the HIV epicenters of Los Angeles and
      New Orleans. A cohort of 1500 youth at the highest risk of seroconverting over 24 months will
      be identified. The goal will be to optimize the HIV Prevention Continuum over 24 months. The
      proposed randomized controlled trial (RCT) aims to compare youth outcomes when randomized to
      one of four automated and person-mediated social media delivered intervention conditions: 1)
      Automated Messaging and Monitoring Intervention (AMMI) only (n=900) consisting of daily
      motivational, instructional, and referral text-messaging (SMS), and brief, weekly SMS
      monitoring surveys of outcomes; 2) Peer Support through social media plus AMMI (n=200) via
      private online discussion boards; 3) Coaching plus AMMI (n=200) to provide service linkages,
      eligibility support, appointment coordination and follow-up, communication with healthcare
      providers, and brief motivational and strengths-based counseling for linkage and retention to
      prevention, mental health, and substance abuse services; and, 4) Coaching plus Peer Support
      and AMMI (n=200).
    

Detailed description: 
      Despite dramatic improvements in the biomedical treatments for both preventing and treating
      HIV infection, American adolescents are increasingly likely to become infected, are not using
      ARV for prevention or treatment, and are not learning they are HIV seropositive when they
      have become infected. America's HIV epidemic among youth has more than doubled in the last 15
      years and now represents 26% of the epidemic. These youth are not found in every community -
      geography is destiny in HIV prevention (www.AIDSVu.com). YLH are concentrated along I-95 on
      the East Coast, in Southern cities, and West Coast. Given the distribution of emerging
      infections, we have chosen two HIV epicenters, Los Angeles (LA) and New Orleans, to test a
      strategy to identify, link to care, and intervene to prevent HIV. Even in those two areas,
      adolescent HIV will not be found in every neighborhood. In LA, six neighborhoods account for
      80% of HIV cases in the County - reflecting the concentration of HIV within neighborhoods and
      settings. In each epicenter, the youth at highest risk of infection will be gay, bisexual,
      and transgendered youth (GBTY), especially those who are Black and Latino. Homeless youth
      will also be at highest risk: the last HIV seroprevalence study showed a 5.3% rate among
      homeless youth. Youth who are incarcerated are at higher risk of being in risk setting and
      will be targeted for recruitment to this study. Having a sexual orientation as GBTY is highly
      stigmatizing and youth are developmentally challenged about who, when, how, and what to
      disclose their sexual orientation of HIV status to their families and their peers.
      Unfortunately 42% of GBTY's parents eject their children when children disclose being GBTY
      resulting in 40% of homeless youth being GBTY. Homeless GBTY had a seroprevalence of 24.8% in
      1989.

      The sites that typically serve GBTY and High Risk Youth (HRY) (gay-identified CBO and
      homeless shelters) in HIV epicenters only provide HIV testing to about 10% of youth
      currently. To effectively stop HIV among youth, a more integrated strategy that tests for HIV
      and STIs repeatedly, links youth to care, and helps youth access all HIV prevention
      strategies, including Pre Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP), is
      needed. The proposed research will test such a strategy.

      To eliminate HIV among youth, scalable, efficacious, and cost-effective strategies are needed
      to optimize the HIV Prevention Continuum of repeat testing, linkage to biomedical and
      behavioral prevention, and retention and adherence over time to PrEP, PEP, condom use and
      reduced number of partners. The HIV Prevention Continuum is a framework for guiding
      prevention efforts.

      Advances in mobile and social media technologies have created opportunities to engage and
      intervene with large numbers of youth at relatively low costs, technologies that permeate
      their daily routines. This study will use two primary technology platforms: text-messaging
      and social media. Text-messaging, email, internet and social media use are nearly universal
      among youth, including homeless youth. Rates of mobile phone, smartphone, and internet usage
      increase with age, and nearly 90% of young adolescents (age 13-17) having a mobile phone.
      Texting is particularly important for adolescents; 90% of those with phones text, typically
      receiving and sending 30 texts each day. Similarly, over 90% of adolescents under age 18 go
      online daily, more than half several times a day, which is facilitated the three quarters
      with smartphones that are crossing the digital divide. African-American and Latino youth have
      higher rates of smartphone and internet use than White. All of these rates increase for
      adolescents 18 and over. Ownership, access, and use rates are similar for homeless youth,
      although with less frequency and some inconsistency. Much of this online activity is driven
      by social media, particularly via smartphones, with over 70% of adolescents under 18, for
      example, using Facebook and other applications (about half also use Instagram and Snapchat).

      The interventions proposed in this study will use text-messaging and social media to engage
      "youth where they're at" in the digital environment as preferences and functions change.
      Importantly, mobile phones continue to receive text-messages even when data plans run out of
      credit to use apps' and mobile-web browsers or send text-messages. Therefore, the core
      component our technology strategy will be text-messaging in the Automated Messaging and
      Monitoring Intervention (AMMI) for all youth in the cohort. Social media will be used by Peer
      Supporters to engage and support their peers through online discussion boards while Coaches
      will engage through social media, text-messaging, and voice and video-chats (however most
      acceptable to individual youth), as well as in person contacts. Mobile and social media
      technology-based engagement, retention, prevention, and mobilization strategies are likely to
      be scalable. This study will test whether they are also efficacious and cost-effective.

      Upon study launch in April 2017, decisions were made with the funder to provide three-site
      STI testing at baseline and every follow-up assessment. In December 2018, the funder changed
      priorities and reduced support for STI testing to rectal testing only at baseline, 12- and
      24-month follow-up, unless the participant displays STI symptoms or requests testing at other
      follow-up assessments. The funder has also decided to terminate the intervention and
      follow-up assessments at 12 months, rather than 24 months, for youth who are at lower
      behavioral risk for HIV acquisition.
    

Intervention name(s): Automated Messaging & Monitoring; Peer Support; Coaching
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): Youth will receive messages 1-5 messages per day for 24 months. Message banks of about 750 text messages (70-120/domain) will focus on the HIV Prevention Continuum, with messages dedicated to healthcare, wellness, sexual health, drug use and medication reminders (e.g., for PrEP) for MSM and non-MSM. Youth will be able to choose the time that they receive daily texts. Text timing and the frequency of texts (e.g., if the youth "comes out") will be updated at 4-month intervals.
Youth will complete weekly monitoring surveys by text message. The survey will cover seven domains related to the HIV Prevention Continuum. In case of non-response, reminder messages will be sent to the youth. After three days of non-response, a follow-telephone call will occur.; Youth will be enrolled in online, private discussion groups.
Peer Support will be offered by fellow participants and/or Youth Advisory Board members that have been trained in basic information on HIV, STI, drug use, mental health, homelessness, and stigma; using social media to create wall posts and use chat functions; and, how to initiate conversations on sensitive topics. By posting and responding to messages, Peer Supporters will encourage and broadly guide conversation related to the HIV Prevention Continuum, and other relevant topics.
Coaches and Project Coordinators will be available to provide factual information (as needed), and remove inappropriate content.; Youth will have access to a dedicated Coach to assist with crisis support and problem-solving, linkage to HIV and related services (e.g., for substance use, mental health), and care coordination. Coaches will be accessible electronically (using social media, e-mail, text messaging) and by phone. In cases where virtual support has failed, Coaches will be available in-person (e.g., to accompany a participant to a doctor's appointment). We anticipate that Coaches will provide each youth with 10 hours of support, on average, per year.
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Prevention
Keywords: HIV; STI; Mental Health; Substance Use; Peer Support