Efficacy of a Just-in-Time Adaptive Intervention to Promote HIV Risk Reduction Behaviors Among Young Adults Experiencing Homelessness: Pilot Randomized Controlled Trial

Diane Santa Maria, Nikhil Padhye, Michael Businelle, Yijiong Yang, Jennifer Jones, Alexis Sims, Marguerita Lightfoot, Diane Santa Maria, Nikhil Padhye, Michael Businelle, Yijiong Yang, Jennifer Jones, Alexis Sims, Marguerita Lightfoot

Abstract

Background: People experiencing homelessness have higher rates of HIV than those who are stably housed. Mental health needs, substance use problems, and issues unique to homelessness such as lack of shelter and transiency need to be considered with regard to HIV prevention. To date, HIV prevention interventions for young adults experiencing homelessness have not specifically addressed modifiable real-time factors such as stress, sexual or drug use urge, or substance use, or been delivered at the time of heightened risk. Real-time, personalized HIV prevention messages may reduce HIV risk behaviors.

Objective: This pilot study tested the initial efficacy of an innovative, smartphone-based, just-in-time adaptive intervention that assessed predictors of HIV risk behaviors in real time and automatically provided behavioral feedback and goal attainment information.

Methods: A randomized attention control design was used among young adults experiencing homelessness, aged 18-25 years, recruited from shelters and drop-in centers in May 2019. Participants were randomized to either a control or an intervention group. The intervention (called MY-RID [Motivating Youth to Reduce Infection and Disconnection]) consisted of brief messages delivered via smartphone over 6 weeks in response to preidentified predictors that were assessed using ecological momentary assessments. Bayesian hierarchical regression models were used to assess intervention effects on sexual activity, drug use, alcohol use, and their corresponding urges.

Results: Participants (N=97) were predominantly youth (mean age 21.2, SD 2.1 years) who identified as heterosexual (n=51, 52%), male (n=56, 57%), and African American (n=56, 57%). Reports of sexual activity, drug use, alcohol use, stress, and all urges (ie, sexual, drug, alcohol) reduced over time in both groups. Daily drug use reduced by a factor of 13.8 times over 6 weeks in the intervention group relative to the control group (Multimedia Appendix 4). Lower urges for sex were found in the intervention group relative to the control group over the duration of the study. Finally, there was a statistically significant reduction in reports of feeling stressed the day before between the intervention and control conditions (P=.03).

Conclusions: Findings indicate promising intervention effects on drug use, stress, and urges for sex in a hard-to-reach, high-risk population. The MY-RID intervention should be further tested in a larger randomized controlled trial to further investigate its efficacy and impact on sexual risk behaviors.

Trial registration: ClinicalTrials.gov NCT03911024; https://ichgcp.net/clinical-trials-registry/NCT03911024.

Keywords: HIV; behavior; drug; drug use; ecological momentary assessments; efficacy; feasibility; homelessness; intervention; just-in-time adaptive interventions; mHealth; mobile phone; pilot; predictor; prevention; risk; smartphone; stress; youth.

Conflict of interest statement

Conflicts of Interest: MB is the primary inventor of the Insight mHealth platform, which was used to create the data collection and intervention components of the smartphone app used in this study. He receives royalties related to the use of Insight.

©Diane Santa Maria, Nikhil Padhye, Michael Businelle, Yijiong Yang, Jennifer Jones, Alexis Sims, Marguerita Lightfoot. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.07.2021.

Figures

Figure 1
Figure 1
Daily totals of participants who reported using drugs over the 6-week study period, shown separately for the control and intervention groups of the study.
Figure 2
Figure 2
Tipping-point display of the sensitivity analysis for drug use that is based on two nonignorable missingness mechanisms. Each 2.5-unit increment in the translation levels represents roughly one unreported drug use event per nonuser during the study period. The multipliers are inflation factors of the probability of drug use on nonresponse days among those with a record of drug usage. The numbers in each cell display the odds ratio (OR) of the intervention effect, that is, the interaction of group and time. The cells with a thick navy border have P<.05. The OR and P values represent a summary of results from the multiple imputation.

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