A social media based peer-delivered HIV prevention intervention for men who have sex with men in Mumbai, India: a randomized trial comparing two messaging approaches Viraj V. Patel, MD, MPH S Rawat, A Dange, C Lelutiu-Weinberger, R Poojary, K Kamath, M Bisht, SA Golub July 22, 2016

Disclosures Funding  Global Health Center, Albert Einstein College of Medicine, Bronx, New York City, USA  National Institute of Mental Health, National Institutes of Health, USA 1K23MH (PI: Patel)  I have no other conflicts or disclosures

Acknowledgments Humsafar Trust, Mumbai, India  Shruta Rawat  Alpana Dange  Kam Gade  Rohan Pujari  Mayank Bisht  Vivek Anand Albert Einstein College of Medicine Bronx, New York, USA  Julia Arnsten  Einstein Global Health Center Hunter College, City University of New York City, USA  Sarit Golub  Corina Lelutiu

Background: HIV in Indian MSM MSM in India have a high HIV prevalence  4.5%-14% (MSM) vs. 0.4% (general) Interventions for MSM often face restrictions and are limited in reach due stigma and marginalization  Sec 377 of Indian Penal Code  Challenges in identifying MSM in physical spaces New strategies with broader reach to engage MSM in India are urgently needed

Social & Mobile Technologies  Large increase in internet connectivity  Rapid rise in mobile, including smartphones with increased affordability  Shifts in how people socialize, date, connect  MSM increasingly use online social networking technologies (e.g. Facebook, dating apps)  Unprecedented opportunity to engage hard-to-reach populations

But… How do we reach and engage hard-to-reach populations in virtual spaces? What strategies or interventions are effective for changing health behaviors in online settings?

Objectives To determine the feasibility and acceptability of CHALO! - a theory guided online intervention to increase consistent condom use and HIV testing in MSM in Mumbai, India To explore the comparative effectiveness of two types of message frames to increase HIV testing and condom use: – Appro ach highlights benefits of engaging in a behavior – Avoidance emphasizes a negative outcome to be avoided

Setting – Mumbai, India

CHALO Intervention Overview Theoretical basesInformation-Motivation-Behavioral Skills (Fisher & Fisher) Intervention Elements -2 messaging strategies promoting HIV testing and consistent condom use – using the IMB framework -Avoidance -Approach Target PopulationHIV negative, sexually active MSM over 18 living in Mumbai, recruited from Facebook & MSM dating platforms Delivery MethodsFacebook private groups, Whatsapp, or (participant selected) Deliverers4 Trained peers (2 per arm) Unit of Delivery15 messages in each arm, delivered over 12 weeks

Message Development  10 HST staff developed messages  Targeted HIV testing & condom use using I-M-B domains  Used Avoidance or Approach frames  Developed simultaneously in Hindi & English  Messages ranked by 30 additional Humsafar staff  15 highest ranked messages for each frames selected & refined for testing

Examples of Messaging Approach Whether you ride from the front seat or back seat, you both need a helmet. Use a condom either way. Keep yourself and your partner healthy! Avoidance It doesn't matter you sleep with only 4 or 5. It only takes one. Not using condoms puts you at risk for HIV. Avoid HIV by using condoms!

Intervention Flow Users sent messages via Whatsapp, Private Facebook Group, or Messages had embedded links to an informational website Website had more information on using condoms, and where and how to access HIV testing, and accessing services at Humsafar Trust, including contact information

Outcomes Assessed Feasibility -% Retained Acceptability: -% Willing to participate again Preliminary Efficacy: ( by arm and pooled ) A. Having a HIV test in past 6 months OR intention to test in next 1 month B. Condom Use (Always vs. Other)

Recruitment: Planet Romeo, Grindr, Facebook Clicked link, screening and baseline survey n=1084 Approach n=122 Retained n=112 (92%) Completed follow-up Survey at 12 weeks n=68 Avoidance n=122 Retained n=108 (89%) Completed follow-up survey at 12 weeks n=62 Study Flow 670 lived outside Mumbai 110 not MSM 60 did not complete screen Retention Measured by: - read receipts -Whatsapp read indicator -Facebook viewer metrics

Participant Characteristics Approach (n=122) % Avoidance (n=122) % Age %65% %25% 42 and above 9%10% Sexual Orientation Gay 72%71% Bisexual 25%26% Heterosexual 3% Level of Outness No one 22%24% Some people 60%58% Most people 18% Monthly Income 3,000-9,000 24%22% 9,001-15,000 7%9% > 15,001 (US $250) 70% Has a Main Partner 51%49% Male partners in past year M(SD) 3.1 (3.2)4.5 (6.4) Approach (n=122) % Avoidance (n=122) % Access Smartphone 54%57% Home Computer 35%29% Have never visited Humsafar (CBO) 45%50%

Acceptability & Feasibility Acceptability 86% (n=106) completing endline assessment liked or strongly liked CHALO and would be willing to continue participation. Feasibility -90% Retained -53% completed follow-up assessment

Results – by condition HIV test in past 6 months OR intention to test in next 1 month

Results – Condom Use

Results – Pooled Analysis: 1 p=0.045 p=0.01 All Participants Never Tested

Limitations All data were self-report Potential contamination between arms

Summary CHALO was feasible and highly acceptable We found preliminary evidence for using online outreach approaches to increase HIV testing Avoidance framed messages appeared to be slightly more effective in this pilot study CHALO was not effective in changing condom use

Implications –This first study of an online HIV intervention in India demonstrates preliminary evidence for increasing HIV testing in an urban online sample of MSM –A better understanding of for whom do different types of messaging strategies and frames work better for can help inform tailored interventions –We need to explore other prevention modalities (e.g. PrEP) in addition to condom use

Thank You Questions?

No differences between those for whom it worked and did not work in: Age Income Identity Outness Whether or not they had a main partner Number of male partners Whether or not they used condoms at the last sexual encounter Frequency of condom use for anal sex Frequency of HIV testing Intentions to test