Developing an artificial intelligence-based mHealth intervention to increase HIV testing in Malaysia

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Project Summary HIV testing jumpstarts entry into the HIV prevention and treatment cascade. HIV testing levels, however, are especially low in men who have sex with men (MSM), who increasingly contribute to heightened HIV transmission in the presence of high levels of stigma and discrimination. For high risk MSM, new guidelines recommend frequent HIV testing, ranging from every 3 to 6 months. Yet, HIV testing in MSM often occurs less frequently due to individual (e.g., heightened concerns about risk disclosure), clinic (e.g., confidentiality breaches, and discrimination from healthcare providers) and policy (criminalization of same-sex sexual behaviors) barriers. HIV prevalence in MSM in Malaysia has soared to 21.6% nationally, exceeding 40.9% in Kuala Lumpur. While surveillance surveys of MSM in Malaysia who meet criteria for PrEP suggest that ever tested is 70.3%, past- year tested is 40.9%, and only 9.5% were tested more than 1 time per year, despite extraordinary levels of self- reported risk. Once tested, however, MSM with HIV in Malaysia are likely to be treated with ART and achieve viral suppression, making HIV testing a central focus for HIV prevention and treatment. Innovative strategies that motivate and provide guidance for testing among MSM in Malaysia are therefore urgently needed. Intervening using Information-Motivation-Behavioral Skills (IBM) model is ideally suited to overcome barriers to recommended HIV testing in MSM. Moreover, in settings like Malaysia where the HIV epidemic has transitioned from primarily concentrated in PWID to a volatile epidemic in MSM, theory-guided behavioral change strategies that inform, motivate and provide pragmatic skills to more fully engage in recommended HIV testing are poised to accelerate the HIV prevention and care continuum. Given that there are many individual, clinic and policy barriers to HIV testing, mobile health (mHealth) interventions that reduce “in person” contact and offer a menu of behavioral skills is ideally suited to increase access to MSM in highly stigmatized settings and promote recommended HIV testing. Recent studies in the U.S., China, South Africa, and Peru show that mHealth interventions using smartphones and apps have the potential to increase HIV testing while maintaining MSM’s confidentiality. Such mHealth interventions are feasible and acceptable among MSM, including in Malaysia where most MSM find sexual partners using social-networking apps with similar interfaces and functionalities to the proposed intervention. Current mHealth strategies, however, are limited by their lack of automation and need for high-intensity and sustained human inputs, which restricts their scale-up. Artificial intelligence (AI) using machine learning (ML) may overcome such limitations, but has yet to be applied to mHealth-based HIV testing algorithms. We therefore aim to develop and pilot test an AI-chatbot (R21 phase). Findings from the R21 phase will inform a Type 1 Hybrid Implementation Science trial (R33 phase) to evaluate the efficacy and implementation outcomes of the AI-chatbot for HIV testing relative to treatment as usual.