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Technology, including mobile technologies and social media, offers powerful tools to reach, engage, and retain youth and young adults in HIV prevention and care interventions both in the United States and globally. In this report we focus on HIV, technology, and youth, presenting a synthesis of recently published (Jan 2014-May 2015) observational and experimental studies relevant for understanding and intervening on HIV risk, prevention and care. We present findings from a selection of the 66 relevant citations identified, highlighting studies that demonstrate a novel approach to technology interventions among youth in regard to content, delivery, target population or public health impact.
We discuss current trends globally and in the US in how youth are using technology, as well as emergent research issues in this field – including the need for new theories for developing technology-based HIV interventions and new metrics of engagement, exposure, and evaluation. IntroductionWorldwide, nearly a third of all new HIV infections occur among youth ages 15 to 24 years. Adolescents and young adults are often situated within a confluence of behavioral and developmental transitions that create higher risk contexts for HIV acquisition and suboptimal care. These transitions include onset of sexual activity and substance use, shifting roles with family and peers, adoption of adult roles and responsibilities, and exposure to systemic barriers to health care services (-). As a result, compared to older populations, youth are less likely to know their HIV status, be retained in care, and achieve viral suppression (, ).
Youth also experience greater AIDS-related mortality than older cohorts.Over 50% of the world’s population is estimated to own mobile phones and 42% use the Internet. However, across the globe, technology ownership and use among youth is higher.
In the United States (US) in 2014, overall technology usage (including Internet and mobile phone use) among youth age 12 to 29 years was over 90%. Similarly, social media use is high among both younger (12-17 year olds: 81%) and older youth (18-29 year olds: 89%). Internet access and social media use among youth living in low- and middle-income countries is increasing, but has not achieved the same market saturation as in high-income countries. For example, in recent samples, reports of mobile phone ownership range from 47% among urban Ugandan youth to 90% among youth in Cape Town, South Africa.Researchers have sought to understand the role of technology in youth’s lives and to use it for HIV prevention and care purposes (, ). As the most avid and often earliest adopters of new technology, youth have a multifaceted relationship with technology.
Technology provides powerful means through which to spread information, educate, and support youth (-). These same tools may also link youth to services, facilitate social support and community mobilization , and promote risk reduction norms. However, technology may also facilitate youth’s exposure to behavioral (e.g., non-disclosure of HIV status to partners met online) or social (e.g., stigma, prejudice, bullying) risk factors.
Content shared among youth on social networking sites and perceptions of peers’ behaviors may also affect offline sexual risk intentions and behaviors (-). Furthermore, the intersection between legal age and technology use has developmental implications for HIV research. For example, the same behavior—online exchange of sexually explicit images or “sexting”— between a 13 and 24 year old person can be prosecuted as a crime, whereas it would be acceptable between two 21 year old adults.In this report we focus on HIV, technology, and youth, presenting a synthesis of recent observational and experimental studies relevant for understanding and intervening on HIV risk, prevention, and care.
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We discuss current trends globally and in the US, as well as emergent issues in this field – including the need for new theories for developing technology-based HIV interventions and new metrics of engagement, exposure, and evaluation. MethodsWe sought to identify articles for this synthesis that were published in English between January 1, 2014 and May 1, 2015. Our target population was “youth” – defined broadly as ages 13 to 29. Studies with broader samples that stratified results by age were also eligible. Studies needed to include a primary focus on one or more of the following technologies: mobile phone (SMS/texting, application “app”), computer/tablet (stand-alone programs, web-based programs), or social media (e.g. Facebook, Twitter, Instagram).
The following types of studies were reviewed: interventions (formative, usability, pilots, trials), observational studies, and reviews.Search strategies and disposition of citations are presented in. After reviewing the full text publications, 66 relevant records were identified, including 24 records from intervention studies. All intervention studies identified are presented in. In the body of this paper we highlight a subset of the 66 identified records that significantly extended prior work and/or presented novel methods or findings most pertinent to the field of technology for HIV prevention and care among youth. Author (Year)LocationTechnologyPopulation(Sample Size)Study designLength of interventionBehavioraltheoryResultsStudies conducted outside of the U.S.Rana et al(2015)Kampala,UgandaMobile phone- SMSYLHIV, age 14-24(n=39)4 focus groups to assessacceptability of RemindingAdolescents to Adhere (RATA),SMS for adherence and socialsupportInformation,Motivation,Behavioral Skillsmodel90% could write, read, and send texts; 72% own a cell phone(41% share a phone), 97% thought RATA would help withadherence. Some concern over accidental disclosure of HIV statusand sustainability of the program due to acclamation or boredomwith messages.Lopez et al.(2014)ColombiaMobile phone- appYouth, age 18-29(n=58)I: Users send sexual healthquestions and receivepersonalized physicianresponsesC: none6 months, FU month 6NRHigh loss to follow-up: 54.7% (127/232) completed FU; Low appuse: 54.3% (69/127) did not use app; 41% of remaining sample(24/58) used app only once.
No significant changes in sexual andreproductive health. Among retained app users (n=58): 92%valued access to a mobile-based teleconsultation tool on sexualhealth, 69.7% said app was easy to use.Villegas et al.(2014).Villegas et al.(2015)ChileWebChileanwomen, age18-24(n=40)I: STI/HIV preventionintervention (I-STIPI) (adaptedMano a Mano-Mujer and SEPA)4 weekly 40-50 min. Modules(STI/HIV information, partnercommunication, domesticviolence, substance abuse)C: none4 weeks, FU week 4Information-Motivation-Behavioral SkillsmodelSignificant improvement: STI/HIV knowledge (p. Use of technology and sexual riskRecent studies have examined youth’s online sexual behaviors, use of technology to facilitate off-line sexual encounters, and sexual risks associated with these activities. Research suggests a relationship between online social networking and sexual risk behaviors among youth, though causality has not been established (, -).
For example, among 1831 Los Angeles high school students, ages 12 to 18, youth who accessed the Internet by cell phone were more likely to be sexually active, to have been approached online for sex, and to have had sex with a partner met through the Internet. Compared to heterosexual students, bisexual students were more likely to be solicited online for sex while gay, lesbian, and questioning students were more likely to report seeking partners online and engaging in unprotected sex at last sexual encounter with a partner met online.Research on the online sexual behavior of sexting among youth is rapidly increasing. “Sexting” combines the words “sex and texting” to describe sending sexually suggestive/explicit photos or messages via an electronic device such as a mobile phone. Between 9 and 48% of US youth report sexting (, ). Recent work conducted among middle school students (age 10-14) (, ), high school students (age 15-18) (, ), and young adults (age 18-24) (, ) indicates that sexting occurs concurrently with other sexual behaviors. A national online survey of 5078 youth (ages 13 to 18) of different sexual orientations found that 18% had sexual conversations online and 7% shared sexual photographs online in the last year.
Lesbian, gay and bisexual youth (including queer, questioning, and those with other identities) were more likely than their heterosexual peers to have sexual conversations and post sexual pictures online. Of the 22% of adolescents who were sexually active, 10% had met a recent sexual partner online.
As the majority of studies have been cross sectional (see Temple et al. For an exception , the nature of the association between sexting and sexual risk behaviors has not been established. The majority of studies on sexting published in English have been conducted in the US, with notable exceptions from Peru and Italy. Current limitations in this literature include variation in the definitions of sexting, lack of longitudinal studies, and lack of studies that include both the sext senders and receivers.Another emerging body of research focuses on sexual risk and use of geosocial networking apps to find sex partners, in particular among YMSM (-). For example, among 146 randomly sampled YMSM, age 18 to 24, who reported having sex with partners met through Grindr, 20% had unprotected anal intercourse (UAI) with their most recent Grindr-met partner. Using Grindr for more than a year, posting sexualized photos and having more sexual partners met through Grindr in the past month were associated with reporting UAI. Among 379 MSM, age 19-73, in Washington, DC, 23.5% had sex with a partner met using geosocial networking apps in the past year; those under age 35 were more likely to report this behavior than those 35 or older (aOR 2.70, 95% CI 1.39, 5.22, p5 years older or younger), and hazardous alcohol use in the last year.
Mxit use was associated with multiple sex partners and hazardous alcohol use among males and females in the last year. Among an online sample of 1342 MSM in China (23.6% age 16 to 25), 40.6% of participants had used apps to find sex partners, a behavior associated with younger age, report of multiple recent sexual partners, and recent HIV testing; no difference was found in UAI. Acceptability of technology for sexual health promotionTwo recent US studies examined youth’s use of technology to find sexual health information. In semi-structured interviews with 81 African-American heterosexual youth, ages 15 to 17, less than half used the Internet to find sexual health information; those that reported this behavior often described it in the context of school assignments or finding information surreptitiously after clicking on advertisements on social networking sites. An online survey among 5542 youth age 13 to 18 found that 19% of heterosexual youth versus 78% of gay/lesbian/queer youth used the Internet to search for sexual health information, a difference primarily attributed to sexual minority youth reporting lack of credible offline information sources.Two studies examined young MSM (YMSM’s) interest in participating in technology-delivered HIV prevention interventions.
Among 6329 MSM ages 19 to 27 surveyed online, 49% of those who owned mobile phones were willing to receive text messages for HIV prevention. Important differences were noted by race/ethnicity (Black and Hispanic men more willing than White men), and education level and age (higher education and older age men less willing). In the Los Angeles area, among a sample of 195 MSM ages 18 to 24 who use Grindr, 70% expressed interest in a future smartphone HIV-prevention intervention and 71% in an online-based intervention.International settings also report high acceptability for technology use for sexual health. Among 620 Australian youth (age 16 to 29), 85% were comfortable getting sexual health information from websites, with somewhat lower levels for social media (Facebook, 52%; apps, 51%; SMS, 44%; Twitter, 36%). In Tanzania, among 60 surveyed youth (age 15 to 19), 92% agreed that health professionals should use Facebook to provide sexual health information, although there were some concerns about mixing the primarily social purpose of Facebook with this information. Similarly, 66% of 1107 youth age 16 to 24 in Cape Town expressed interest in online HIV prevention programming. Interest was higher for school-based programs (85%) and lower for SMS-based programs (55%).
HIV technology interventions for youth outside of the USWe identified four recent studies conducted outside of the US that describe the development or evaluation of technology-based HIV interventions for youth. Describe results from six focus groups conducted in Uganda with 39 youth (age 14 to 24) living with HIV to assess their opinion of the Reminding Adolescents to Adhere (RATA) SMS intervention. Ninety-seven percent thought RATA would help them with adherence (particularly the reminders and social support features); however, some concerns were expressed over accidental disclosure of HIV status and restrictions on using mobile phones at school and at home.Two studies (, ), both theoretically based on the Information, Motivation, Behavioral Skills model , used web-based formats to deliver HIV/STI prevention to youth. The Internet-based HIV/STI prevention intervention (I-STIPI) consisting of four online modules was evaluated for preliminary efficacy among 40 sexually active Chilean women (age 18 to 24) in a pre-posttest design. At four weeks, significant improvements were found in HIV/STI knowledge (p.
SMS-textingSMS texting is efficacious for encouraging HIV prevention, testing, care, and medication adherence (, ). A recent study by Sheoran et al.
Used texting to evaluate The Hookup, a weekly SMS intervention for adolescents age 13 to 24 in California that provides sexual and reproductive health information and linkage to local resources. All subscribers of The Hookup (N=2477) received a request to complete a four-question survey by SMS. A total of 832 (33.6%) subscribers responded to the initial question and 482 (19.5%) answered all four questions. Those that responded did so quickly (e.g.
Of the responses, 98% were received in the first 24 hours of the initial request) providing some evidence for feasibility of using SMS to gather response data from youth in a rapid, cost-effective manner. The low completion rate (19.5%) highlights the need to consider additional mechanisms to increase engagement. Web/mobile-optimized webThe majority of interventions identified utilized computers and/or websites—including those optimized for mobile phones.
We highlight the unique aspects of five interventions below.It’s Your Game (IYG)-Tech is a stand-alone, 13-lesson Internet-based sexual health life-skills curriculum for middle school youth. IYG-Tech was adapted from It’s Your Game Keep it Real, a middle school sexual health curriculum shown to delay sexual behavior (, ). IYG-Tech was evaluated as an intervention to delay sexual initiation using a randomized, two-arm nested design among 19 urban schools in Texas. The target population was English-speaking eighth-grade students (n=1374) followed into ninth grade. Findings indicated that IYG-Tech impacted some determinants of sexual behavior (e.g. STI and condom knowledge, attitudes about abstinence, condom use self-efficacy) but did not impact sexual behaviors or sexual initiation. Unique aspects: school-based sample of middle school youth (mean age 14.3), predominantly minority (74% Hispanic (English speaking) and 17% African American).Queer Sex Ed is an online, multimedia sexual health intervention consisting of five modules designed to promote comprehensive sexual health for lesbian, gay, bisexual and transgender (LGBT) youth, age 16-20.
The intervention is user-driven and was evaluated in a pre-post design with 202 youth. Follow-up at two weeks post intervention completion revealed extremely positive attitudes toward the intervention. Intervention effect sizes were small for sexual orientation (e.g., internalized homophobia) and relationship variables (e.g., communication skills) but moderate for safer sex (e.g., contraceptive knowledge) outcomes. Unique aspects: younger LGBT youth sample (mean age 17.9 years) and content focused on comprehensive sexual health promotion for LGBT youth.Outlaw et al. Demonstrated initial feasibility of an individually tailored computer-based two-session interactive motivational interviewing (MI) intervention for youth newly recommended to start antiretroviral therapy (ART). Intervention sessions lasted about one hour and took place one month apart.
Ten participants, ages 16 to 24, participated. The intervention consists of “conversations” with one of seven animated, two-dimensional characters. Tailoring is based on participants’ goal setting and ratings of the importance of and confidence for HIV medication adherence. Unique aspects: use of animated character software to deliver an online MI intervention and focus on HIV+ youth starting ART.Get Connected! Is a tailored web-based intervention designed to increase HIV/STI testing among YMSM (ages 15-24) in Southeast Michigan. Get Connected uses YMSM’s psychosocial data (i.e., age, race/ethnicity, sexual identity, relationship status, HIV/STI testing history and testing motivations, recent sexual behavior, sources of support, structural barriers, and values) to personalize imagery and content that each youth receives within the four web pages that make up the intervention.
In a pilot randomized controlled trial (RCT) (n=130) compared with a control condition consisting of a sortable web directory of HIV/STI testing providers (including contact and location information), those in the intervention arm perceived a higher credibility of the online content. Of the 104 participants who answered the 30-day follow-up assessment, 30 reported having tested for HIV/STIs, with the majority of these participants (n=22) in the intervention condition compared with the control condition (n=8). Unique aspects: use of community based participatory research to guide intervention development and use of multilevel comprehensive tailoring algorithm to motivate HIV/STI testing among YMSM.HealthMpowerment (HMP) is a mobile phone-optimized, Internet-delivered intervention developed through a multistage process based on iterative feedback from focus groups, individual interviews, and usability testing with the target population of Black YMSM and transgender women (TW) (age 18 to 30) (, ). The intervention provides information, resources, tailored feedback, game-based elements and a social networking platform to offer and receive social support. In a one-month pilot trial utilizing a pre-post design (n=15), statistically significant improvements were seen in social support (p =.012), social isolation (p =.050), and depressive symptoms (p =.045). An RCT is underway to test HMP against a control website consisting of HIV/STI information. Unique aspects: intervention focuses on Black YMSM/TW and includes social interactions and game based elements.
Social mediaInterventions delivered via social media can quickly reach large audiences through familiar platforms building on the trust and influence of social networks. A recent review on the use of social media to achieve positive health outcomes among adolescents and young adults concluded that while social media can be an effective way to reach this age group, most studies to date were preliminary, limited in methodologies, and mostly centered on evaluating how youth use social media and the resulting health implications.The IknowUshould2 was a campaign targeting youth age 13 to 24 (with a primary focus on those under 18 years of age) launched in Philadelphia to increase HIV/STI knowledge and testing. The campaign was primarily social-media based (website, Facebook, Twitter, Instagram, YouTube) but also included traditional media and in-person events.
During the first six months, the campaign’s Facebook page received approximately 6,000 visits and 1,500 unique individuals used the campaign’s webpage. At associated clinics, comparisons of pre- and post-campaign launch records reveals significant increases in HIV and syphilis testing rates among all youth and increases in the proportion of visits where 13 to 17 year olds were tested for any STI.MiCHAT is a live chat intervention for 18 to 29 year olds delivered on Facebook consisting of eight one-hour motivational interviewing and cognitive behavioral skills-based online sessions designed to reduce condomless anal sex and substance use among high risk YMSM. In a pre-posttest design among 41 participants with no control group, investigators found that participation in at least one session of the intervention (n= 31) was associated with reductions in days of drug use (5.52 vs.
3.30, p=0.073) and heavy alcohol use (10.7 vs. 8.52, p=0.082) in the past 30 days and instances of condomless anal sex (8.96 vs. 3.11, p=0.042), and condomless anal sex under the influence of substances (6.89 vs. Discussion: Emergent issues in the fieldThe proliferation of social media platforms has transformed Internet utilization and the ability to reach and interact with youth. In contrast to static websites where consumers were limited to passive viewing, new technologies allow co-creation of user-generated content within intervention forums and public virtual communities. As the field of technology and HIV continues to grow, we will need to be mindful of the rapidly changing technologies being used by adolescents and young adults. Our review suggests that technology-based studies with “youth” encompass a large developmental age range (13 to 30 years), with the majority focusing on young adulthood.
The varying developmental demands within this age group will require different research/intervention considerations based on developmental tasks and milestones (, ). Future research is warranted on developmentally appropriate tailoring, alongside comparisons of differing developmental periods. In addition, attention to ethical issues relevant to the development and implementation of technology-based interventions for youth such as obtaining online consent is critical (, ).Review findings caution against inferring temporal associations from observational studies of technology use and HIV risk among youth. Parallel to early research with computer-mediated technology (e.g. See review by Grov et al. ), care should be taken not to confound youth’s pervasive use of technology with their risk-taking behaviors; rather, we must carefully pinpoint the contexts in which technology use increases youth’s vulnerability to HIV risks.
For example, although much of the literature suggests that sexting is associated with sexual risk-taking, the causal mechanisms linking sexting and risk behaviors are unclear. It is possible that youth who are more likely to engage in risk behaviors offline are also engaging in sexting as foreplay with partners with whom they are already sexually involved.
Longitudinal studies are needed to test these hypotheses. Furthermore, the relation between sexting and sexual behavior may be connected to new relationship dynamics among youth who have grown up sharing their lives through online technologies.
In light of these trends, we must purposefully report the theoretical mechanisms that are being studied when we test the association between sexting and HIV risk, and contextualize our findings based on the study population’s age (adolescents versus young adults). Within existing HIV/STI interventions for youth, components may be needed that specifically address negative sexting-related consequences.In recent years a burgeoning number of technology-based interventions for HIV prevention and care have been published, with even more under development. As shown in prior reviews (, ), the majority of published studies continue to be reported from the US.
ConclusionWhile the speed of technology and availability of commercial resources often far outpaces what can be achieved in the public health research domain, many exciting opportunities remain. Although the majority of currently published studies have utilized website or SMS-based modalities, a growing number of researchers are exploring technologies that are particularly relevant for youth, including smartphone apps, social and sexual networking services, virtual reality, and gaming elements (e.g., gaming, rewards, competition). These technologies offer key functions that are particularly relevant within a youth HIV context, including anonymity, social support, provision of real-time assessment and feedback, and highly engaging features (, ). Contributor InformationLisa B.
Hightow-Weidman, Department of Medicine, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB#7030, Chapel Hill, NC 27599.Kathryn E. Allison S, Bauermeister JA, Bull S, Lightfoot M, Mustanski B, Shegog R, et al. The intersection of youth, technology, and new media with sexual health: moving the research agenda forward.
J Adolesc Health. 2012; 51(3):207–12.This article summarizes proceedings and key recommendations from a March 2011 joint meeting of the Internet Sexuality Information Services, National Institute of Mental Health, and the Ford Foundation. The meeting aimed to address the state and possibilities of using new forms of technology for sexual health promotion research. Muessig KE, Nekkanti M, Bauermeister J, Bull S, Hightow-Weidman LB.
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A systematic review of recent smartphone, Internet and Web 2.0 interventions to address the HIV continuum of care. Current HIV/AIDS Reports. 2015; 12(1):173–90.This article presents a detailed systematic review of mHealth interventions to address the continuum of HIV care (from 1/1/2013 to 9/1/2014). This paper provides information on 23 published intervention studies and 32 funded projects underway. Overall trends include use of new tools including social networking sites, provision of real-time assessment and feedback, gamification and virtual reality. Peskin MF, Shegog R, Markham CM, Thiel M, Baumler ER, Addy RC, et al.
Efficacy of It's Your Game-Tech: A Computer-Based Sexual Health Education Program for Middle School Youth. Journal of Adolescent Health. 2015; 56(5):515–21.This article presents a nested randomized control trial of It’s Your Game-Tech in 19 urban schools in Texas.
The study is notable for its rigorous design, use of Social Cognitive Theory and the Theory of Triadic Influence, school-based sample of middle school youth (mean age 14.3), and predominantly minority population (74% Hispanic (English speaking) and 17% African American). Study outcomes were promising for impacting determinants of sexual behavior, but not for the primary outcome of delayed sexual initiation. Mustanski B, Greene GJ, Ryan D, Whitton SW. Feasibility, Acceptability, and Initial Efficacy of an Online Sexual Health Promotion Program for LGBT Youth: The Queer Sex Ed Intervention.
Journal of Sex Research. 2015; 52(2):220–30.This study presents a pre-post evaluation of Queer Sex Ed online, multimedia intervention for sexual health. The study is notable for its focus on a younger LGBT youth sample (mean age 17.9 years), inclusion of content focused on comprehensive sexual health promotion for LGBT youth, and user-driven design. Grov C, Breslow AS, Newcomb ME, Rosenberger JG, Bauermeister JA. Gay and bisexual men's use of the Internet: research from the 1990s through 2013. Journal of Sex Research. 2014; 51(4):390–409.This article presents a thorough historical review of the role and evolution of the Internet and sex (and HIV research/intervention) for MSM.
The review is divided and presented chronologically into the following periods: 1990s, 2000–2004, 2005–2009, and 2010–2014 – with this last period focused on the mobile web and social media.
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