An interactive online programme, tailored to real-life contexts of ethnically diverse young American men who have sex with men (MSM), resulted in a substantial drop in sexually transmitted infections (STIs) and a fall in condomless anal sex, according to the results of a randomised trial reported in the American Journal of Preventive Medicine.
The Keep It Up! programme “represents a scalable and cost-effective way to deliver behavioural prevention,” the researchers say.
Keep It Up! is an interactive online HIV prevention intervention tailored to ethnically diverse MSM, aged 18 to 29. It uses videos, interactive animations and games to provide information, motivate and teach safer behaviours and instil self-efficacy for prevention strategies.
Each of the nine modules is based on a particular setting or situation that is relevant to men’s lives, such as hooking up online; assumptions about HIV status and monogamy in relationships; the impact of alcohol, drugs and sexual arousal on condom use; power dynamics in a relationship with an older man; and regular HIV testing.
The intervention was informed by principles of e-learning, the information-motivation-behaviour skills model of HIV risk behaviour change and qualitative interviews with young MSM.
Participants can complete the programme in around two hours. Most of the material can be viewed over three days soon after enrolment, with two modules completed after three months and six months respectively. The intervention could be completed on computers and tablets, but not phones, due to technical requirements.
In this study, participants were told that they would be randomly allocated to one of two online HIV prevention programmes. Half were allocated to Keep It Up! whereas those in the control group received an online programme that conveyed factual information through static text and images. The control programme had the same number of modules as the main intervention, but used a didactic approach and was not tailored to the contexts of young men’s lives. Participants and researchers were blinded to which arm participants had been allocated to.
Most of the 901 participants were recruited at a range of testing services and community organisations in New York, Chicago and Atlanta, whereas just over a quarter were recruited through online advertising. To be eligible, participants had to have recently had condomless anal sex and to test HIV negative at baseline (participants recruited online were sent a self-test and had to upload a photo of their test stick to confirm their HIV-negative status). To test for gonorrhoea and chlamydia, participants provided urine samples and rectal swabs they had taken themselves.
Just over half the participants were either black or Hispanic; 86% described themselves as gay with most others being bisexual; and all were aged 18 to 29. Comparing the two study arms at baseline, there were some differences in the participants’ characteristics, including a greater number of men in the intervention arm who only had high school education (16% compared to 9%) and more STIs at baseline (18% compared to 11%).
Outcomes were assessed after one year. The study’s primary biomedical outcome was infection with gonorrhoea or chlamydia. In the control group, 11% had infections at baseline, rising to 14% at 12 months. In the intervention group receiving Keep It Up!, 18% had infections at baseline, dropping to 9% one year later (risk ratio 0.60, 95% confidence interval 0.38-0.95).
There were no statistically significant differences in outcomes according to different demographic groups.
A further analysis considered within-person changes in STIs. In members of the control group, there was a 55% increase in infections over the year, compared to a 51% reduction in the intervention group.
The study’s primary behavioural outcome was condomless anal sex with a casual partner in the previous three months. This fell in both arms, but to a greater extent in those receiving the intervention. In the control group, this was reported by 69% at baseline and 44% at 12 months. In the intervention group, it was reported by 68% and 37% respectively.
The study was not powered to detect a difference in new HIV diagnoses, but the numbers reported in each arm were the same at 2%.
Most participants remained engaged with the study (financial incentives totalling around $200 may have helped), with 80% of those who enrolled at a physical location being retained after one year, rising to 88% of those recruited online.
“It is notable that a relatively brief eHealth intervention demonstrated such strong effects on objective STI outcomes,” Brian Mustanski and colleagues write. They also note that whereas both STI incidence and self-reported sexual behaviour have limitations as study outcomes, the fact that both were significantly reduced suggests a real effect of the intervention.
The programme’s focus on contextual factors that drive sexual health among young men who have sex with men, the diverse range of intervention components (such as interviews, scripted videos and interactive elements) and the developmental tailoring to the unique issues facing the target audience are likely to have contributed to the intervention efficacy, the researchers believe.
Mustanski B et al. Biomedical and Behavioral Outcomes of Keep It Up!: An eHealth HIV Prevention Program RCT. American Journal of Preventive Medicine, online ahead of print, June 2018. (Full text freely available.)