Integration of Electronic SBI(RT) Into an HIV Testing Program to Reduce Substance Use and HIV Risk Behavior Among MSM in Argentina

This proposed study consists of two stages. Stage 1: Development will consist of developing e-SBI, the adaptation of YMHP into MHP, training counselors to deliver MHP, and piloting e-SBI with 50 MSM coming to Nexo for HIV testing. During the Stage 2: RCT Pilot, we will randomize 200 MSM coming to Nexo for HIV testing at a 3:1 ratio (eSBI: Screening Assessments Only-SA) to assess the feasibility and acceptability of e-SBI among MSM coming to Nexo for HIV testing and establish and pilot the RCT process for a future trial. As a secondary aim, we will assess uptake, acceptability, and feasibility of delivering MHP to participants with moderate risk substance use and subsequent referrals to SATx among participants with high-risk substance use or dependence. Lastly, we will explore preliminary findings on substance use and sexual risk reduction outcomes.

3.3.4. Stage 1: Development. 3.3.4.1. Development of e-SBI. Development of e-SBI app will be guided by the User Centered Rapid Application Development process (UCRAD). UCRAD merges the streamlined, iterative Rapid Application Development (RAD) approach with the User Centered Design approach (UC) which engages intended users throughout the app development process. This integrated approach aims to develop successful apps with good functionality, simple features, and a usable interface. As such, intended users are given access to prototypes of the app, allowing them to provide feedback before the next iteration of the app. UCRAD uses a three-phase process, as follows: Pre-design and interface prototyping, System architecture and coding, Deployment.

3.3.4.1.A Pre-design and interface prototyping. To accomplish this phase of UCRAD will obtain feedback from the Community Advisory Board regarding the study screening instruments (see below) and preliminary plans for the e-SBI content. After incorporating their feedback, we will conduct two focus groups (FGs) with MSM (N=16) recruited from Nexo testing clients who are 18+ years of age. They will complete a substance use screener consisting of the Illicit drug use question on the NIDA-modified ASSIST brief screen and the AUDIT-C (a 3-item alcohol use screen). Those who indicate using illicit drugs at least monthly and/or receive a score ≥4 on the AUDIT C will be eligible to participate. After completing informed consent, they will each complete paper and pencil versions of the screening instruments planned for inclusion in e-SBI. The 90-minute audio-recorded FGs will: 1) explore participants' reaction to the screeners and their impact on risk perception and motivation to reduce PSU and risk behavior; 2) evoke content for the BI component to develop menus of options for reasons to change and potential approaches to reduce problem substance use (PSU) and sexual risk behavior from which e-SBI users can choose. Within 48 hours of completing the FG, we will initiate a rapid analysis of this data using a qualitative matrix onto which participants responses and recommendations will be entered to quickly organize and summarize FG findings. These findings will be used to build the prototype of the e-SBI.

3.3.4.1.B System architecture and coding. This Phase 2 iterative app development process will be conducted with waves of 6 MSM also recruited from Nexo testing clients, with the same inclusion criteria as in the FGs. They will be recruited during two-week intervals to maintain a steady pace of feedback and revisions. Participants will complete the intervention on the tablet. Then, they will complete a 7-item self-report acceptability assessment. Afterwards, participants will be debriefed during an audio-recorded interview to explore four main areas: 1) their responses to the acceptability assessment; 2) overall reactions to e-SBI; 3) emotional reactions as e-SBI progressed, including heightened risk awareness, concern, or motivation to reduce substance use and sexual risk behavior; and 4) recommendations for improving the ability of the e-SBI to engage MSM who high-risk drugs and/or alcohol use into treatment. Interview data will undergo the same matrix-based, rapid analysis process used for the FG to quickly inform the next revision of the intervention. This process will be repeated with waves of 6 participants until mean scores on each acceptability question are ≥4.0 (≤2.0 on annoying), which we expect within 3-4 cycles. Development of the e-SBI will be guided by Choice Theory which has been used extensively to inform goal choice interventions, including MI interventions to reduce substance use among MSM. Rather than pre-set outcome expectations (ie., abstinence), goal choice interventions highlight personal choice and goal setting to engage individuals to reduce drug and alcohol use. Goal choice interventions appear to be equally effective as those that are abstinence-based and allowing individuals to set their own treatment goals appears to increase success rates.

3.3.4.1.C. Deployment. The initial version of the e-SBI will be deployed with 50 MSM coming to Nexo for HIV testing, to be used while they await their HIV test. After undergoing informed consent, these individuals will complete the eSBI, a brief quantitative acceptability assessment, and then proceed to have their HIV test (to minimize participant distress). Afterwards, up to 25 of these participants will be randomly selected (5 with low-risk substance use, 20 with moderate or high-risk substance use) to undergo an audio-recorded IDI. These IDIs will be guided by the Theoretical Framework of Acceptability (TFA) which was derived from a review of the literature on acceptability, and views acceptability as "a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention." These IDIs will be transcribed and uploaded to Dedoose for analysis. Additionally, we will use findings from these IDIs to finetune wording for a TFA-based quantitative assessments of acceptability that we will incorporate into the assessment battery during the Stage 2 RCT.