The document discusses HIV prevention for adolescents and young adults. It begins by discussing theoretical approaches to HIV transmission and the importance of social factors. It then summarizes statistics showing the increased burden of HIV among young men who have sex with men in the US. The remainder of the document discusses using technology and tailored digital interventions for HIV prevention in this high-risk group. It describes a study testing an online and mobile tool called "Get Connected" that provides tailored HIV/STI testing information and connects users to local testing sites. The tool was found to be acceptable to users and showed potential for increasing HIV/STI testing rates among young men who have sex with men.

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. 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. 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. 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. 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. DIAGNOSES OF HIV INFECTION AMONG MEN WHO
HAVE SEX WITH MEN, BY AGE AT DIAGNOSIS,
2010 –2014: UNITED STATES AND 6 DEPENDENT
AREAS

7. DIAGNOSES OF HIV INFECTION (AGES 13-24)
BY RACE/ETHNICITY, 2010–2014

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. HOW CAN TECHNOLOGY ADDRESS THE NEED?

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. 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. 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. 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. Message Library
Barriers Motives Support Knowledge
= Untailored
message
+ + +
ONE SIZE (DOES NOT) FIT ALL…

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. Information needs
Degree of uncertainty
Relationship strengths
Decision Making
Emotional states
Message
Library
User
Values
red
blue
aqua, gray
orange
green
Tailored
Message

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. 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. 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. “CONNECT-YM: DEVELOPING A HIV/STI TESTING NAVIGATION TOOL FOR YMSM”
(CENTERS FOR DISEASE CONTROL AND PREVENTION; PI: BAUERMEISTER)

21. ARE ALL HIV/STI SITES CREATED EQUAL?

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. CHECKLIST

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. 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. 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. 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. “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. “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. 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. 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. 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. 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

40. VISIT RESOURCE

41. Randomization
Baseline
Tailored Content +
Test Locator
Site Feedback
30 day
Follow-Up
Baseline Test Locator Site Feedback
30 day
Follow-up
STUDY DESIGN

42. 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

43. 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

44. 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

45. 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)

46. 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

47. 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

48. MOBILE REDESIGN

49. MOCK TESTING SITE REPORT

50. FUTURE DIRECTIONS

51. 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

52. 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

53. 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

54. OTHER ONGOING PROJECTS
myDEx (R34-MH-101997-
01A1)

55. 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

57. iCON+ (U01MD011274-01)

58. • 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.

60. WE’RE HIRING!

61. The content is solely the responsibility of the author and does not necessarily represent the official views of funding
agencies.
ACKNOWLEDGMENTS

62. CONTACT INFORMATION
For more information:
José A. Bauermeister, MPH, PhD
bjose@upenn.edu
www.pennpstar.org