Effectiveness and implementation of text messaging to improve HIV testing in sexual and gender minority adolescents

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Project Summary Adolescent sexual minority males, transgender girls, and gender diverse teens (ASMM/TGD; ages 13-18) are disproportionately affected by HIV, accounting for 79% of new infections among this age group. Although CDC and USPTF recommend HIV screening among teens, testing rates among ASMM/TGD are very low (1 in 4 ASMM; <1 in 10 TGD). Increasing HIV testing in ASMM/TGD is critical in mitigating transmission rates and in linkage to care for those who test positive. Despite this alarming public health issue, few developmentally tailored HIV prevention interventions exist for ASMM/TGD, and to date, no CDC best-evidence interventions for this group are focused on increasing HIV testing as a primary outcome. G2G was a 6-week text message-based HIV risk behavior reduction program originally designed for ASMM. Active treatment arm content focused on providing HIV prevention information, increasing HIV prevention motivation, and increasing HIV prevention self- efficacy relative to an information-only healthy lifestyle control arm. The G2G pilot RCT showed adolescents in the active treatment arm were >3x more likely to report being tested for HIV at follow-up versus those in the control arm, even though only a minority of messages focused on testing. We propose to update G2G with the latest HIV prevention and testing science, make content inclusive of TGD, and test its effectiveness on the outcome of validated HIV testing (e.g., photo of test result). Moreover, widespread adoption of digital HIV prevention programs has lagged due to lack of attention to implementation throughout software development, intervention design, and testing. For instance, who should implement digital HIV prevention/testing interventions for teens (e.g., direct-to-consumer, clinics) remains an open question, and involving potential implementers in the development process can ensure intervention success; best practices for updating content and technology for digital HIV prevention/testing programs to prevent their obsolescence are lacking; and there is a lack of consensus on how best to reach SGM adolescents for such programs. We propose a Hybrid Type 1 trial that will establish G2G effectiveness and identify best practices for implementing digital HIV prevention/testing for teens via three specific aims. In Aim 1 we will collaborate with a youth advisory council to add content reflecting our increased emphasis on HIV testing and update gender inclusivity and cultural relevance of existing content. With prospective implementers’ input, we will also modernize the G2G software platform with an eye toward implementation. In Aim 2 we will test G2G effectiveness on HIV testing in a nationwide randomized controlled trial with 360 ASMM/TGD aged 13-18. Finally, Aim 3 will convene a experts in ASMM/TGD youth research and service provision to identify and achieve consensus in processes of, requirements for, and barriers/facilitators to reaching and engaging ASMM/TGD for HIV testing/prevention. The goal of Aim 3 is to inform, develop, and disseminate concrete tools to ensure HIV prevention programs reach ASMM/TGD. The panel will also recommend potential implementation models and adaptations needed to scale up G2G in real world settings.