Using EMA to developmentally tailor an intervention to support on-demand PrEP among YMSM

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Project Abstract Adolescent and young adult men who have sex with men (YMSM) bear a heavy burden of HIV in the United States (US). Despite the availability of highly effective daily oral HIV pre-exposure prophylaxis (PrEP), uptake and adherence to PrEP among YMSM remains low. The challenge of taking a daily pill, as well as concerns regarding side effects of the medication, have been identified as reasons for lower than expected uptake of PrEP among youth, and particularly YMSM of color. On-demand, or event-driven, PrEP has been shown to be effective among adult MSM but, to date, has not been examined among YMSM. Data from the extant literature support that YMSM with and without experience with PrEP show interest in exploring different dosing strategies. This interest may translate into greater uptake of PrEP, particularly among those who have expressed unwillingness to try a daily regimen or have not been successful adhering to a daily regimen. While preliminary evidence from adolescent treatment studies suggests that intermittent regimens may be feasible for youth, their ongoing executive function development, coupled with heightened responsiveness to socioemotional contexts, has implications for decision making around sexual behavior and preventative health care. In addition, traits common in adolescents – including impulsivity and sensation seeking - have demonstrated significant and meaningful associations with behaviors that place YMSM at risk for HIV. For these reasons, variable “on demand” strategies may be challenging for youth who are still developing cognitively, and, require developmentally appropriate interventions to maximize their success. While studies of on-demand PrEP strategies have shown that adult MSM have difficulties accurately predicting when sex will occur, this has not been explored among YMSM. The proposed study fills these important gaps in understanding to guide future on-demand PrEP interventions with YMSM. This study will provide insights into potential developmental barriers to on-demand PrEP among YMSM and lay the groundwork for an innovative intervention approach to address them through the completion of three specific aims. Specific Aims 1 and 2 will provide a greater understanding of developmental and cognitive facilitators and barriers to on-demand PrEP. To accomplish these aims, a sample of 120 youth (age 16-24 years) will be recruited and complete a daily electronic diary for 8 weeks to record their predictions of, and actual engagement in, sexual encounters. Surveys conducted at baseline and study completion will measure developmental and sociocultural factors likely to impact prediction of risk (e.g. executive function, impulsivity, planning), and potential intervention approaches (e.g. gist vs. verbatim messages, reward sensitivity). Focus groups conducted in Aim 3 will help to translate findings from Aims 1 and 2 into a just-in-time intervention to increase YMSM's ability to plan for sexual activity and incorporate PrEP dosing based on accurate risk perception. Youth Advisory Board meetings will take place to provide feedback on intervention design.