Piloting an App-Based Just-in-Time Adaptive Ecological Momentary Intervention to Reduce Substance Use among HIV-Positive Sexual MinorityMen

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ABSTRACT In the United States (U.S.), sexual minority men (SMM) are disproportionately affected by HIV compared to the general population. For this population, intersectional sexual minority and HIV-related stress add to general life stressors to increase health risks. Research demonstrates a bidirectional association between psychosocial stress and physiological HIV progression, including CD4 decline and increased viral load. However, stress is not only associated with HIV progression, it is also linked to transmission risk behaviors (TRB), such as medication non-adherence and substance use. Substance use is a particularly important risk factor for HIV transmission. In addition to injection drug use risk, recreational use is associated with sexual TRB and increased risk for HIV among SMM. As such, interventions which target stress responses may be particularly useful for HIV risk reduction among substance using SMM (SUSMM) living with HIV (LWH). Positive affect and mindfulness-based interventions have shown promise in reducing stress across various populations living with chronic illness, including HIV. However, despite the fact SMM represent a majority of the U.S. HIV+ population and SUSMM in particular experience prominent, unique stressors, few studies have examined these interventions and their potential health benefits for SUSMM-LWH. This R34 application builds on our pilot work in the areas of positive affect induction and mindfulness as potential intervention approaches to improve HIV-related health outcomes among SMM-LWH. In our proof-of-concept pilot (n=22), we adapted an integrative positive affect and mindfulness intervention for mobile app delivery. Our pilot findings suggest the mobile app is an acceptable and feasible delivery platform for SMM-LWH. However, SUSMM-LWH experience unique stressors (e.g. substance use stigma), and experience additional barriers to intervention. While the in-person version of this intervention demonstrated efficacy in a randomized control trial with SUSMM-LWH, we have yet to assess acceptability and feasibility for delivering it via mobile app with this population. We propose to first pilot our existing app-based intervention with a sample of SUSMM-LWH to gather community feedback, which will be used to tailor the app design and intervention content for the target population. In Phase 2, we will pilot a factorial optimization trial to assess acceptability and feasibility of two additional features that may enhance our just-in-time-adaptive ecological momentary intervention (EMI) design and delivery: (1) random craving prompts throughout the day in addition to a fixed, once-daily survey and (2) a smart watch in addition to our phone-based EMI. Data from this formative pilot will inform the development of subsequent research grant application to conduct a larger factorial optimization trail to assess how each of these new features (and their combination) impact the effectiveness of our intervention. This will be followed by a subsequent randomized control trial to evaluate efficacy of our optimized intervention, which will have a powerful and sustained effect on substance use and other HIV-related outcomes for SUSMM-LWH.