CURSO DE LICENCIATURA EM ENFERMAGEM

CAROLINA MARQUES SIMÃO GERALDES DOS SANTOS

MARIA JOÃO MOURÃO NOGUEIRA

VANESSA MARIA GONÇALVES DE ALMEIDA

AS REDES SOCIAIS E A SAÚDE SEXUAL E REPRODUTIVA DA

POPULAÇÃO LGBTQ+

Coimbra, 2023
 CURSO DE LICENCIATURA EM ENFERMAGEM

CAROLINA MARQUES SIMÃO GERALDES DOS SANTOS

MARIA JOÃO MOURÃO NOGUEIRA

VANESSA MARIA GONÇALVES DE ALMEIDA

AS REDES SOCIAIS E A LITERACIA EM SAÚDE SEXUAL E

REPRODUTIVA DA POPULAÇÃO LGBTQ+

Este trabalho foi realizado no âmbito da unidade

curricular opcional de Enfermagem Clínica –
Intervenção de Enfermagem Comunitária em Grupos
Vulneráveis, sob orientação pedagógica da Professora
Aliete Cunha.

Coimbra, 2023
ABREVIATURAS E SIGLAS

ACES - Agrupamentos de Centros de Saúde

IPSS - Instituições Particulares

IST - infeções sexualmente transmissíveis

LGBTI - lésbicas, gay, bissexuais, trans e intersexo

UCC - Unidades de Cuidados na Comunidade

UCCFM - Unidade de Cuidados na Comunidade Farol do Mondego

LISTA DE TABELAS

Tabela 1 - Proposta de intervenção ................................................................................. 19

SUMÁRIO

INTRODUÇÃO ............................................................................................................. 11

1. CARACTERIZAÇÃO DA UCC.............................................................................. 13

2. SÍNTESE TEMÁTICA ............................................................................................. 15

3. PROPOSTA DE INTERVENÇÃO ......................................................................... 19

SÍNTESE CONCLUSIVA ............................................................................................ 23

REFERÊNCIAS BIBLIOGRÁFICAS ........................................................................ 25

ANEXOS E APÊNDICES

APENDICE I – PRISMA da busca bibliográfica

APENDICE II - Plano de Educação para a saúde

APENDICE III – Análise crítica de um artigo: Carolina Marques Simão Geraldes dos
Santos

APENDICE IV – Análise crítica de um artigo: Maria João Mourão Nogueira

APENDICE V – Análise crítica de um artigo: Vanessa Maria Gonçalves de Almeida

APENDICE VI – Declaração de Autoria

INTRODUÇÃO

Este trabalho foi realizado no âmbito da Unidade Curricular de Intervenção de

Enfermagem Comunitária em Grupos Vulneráveis, do 8º semestre, sob a orientação da
Professora Aliete Oliveira, sendo proposto a apresentação de uma proposta de intervenção
em contexto de grupos e situação de vulnerabilidade, baseada na literatura existente,
intervenção essa que poderemos realizar em ensino clínico. O Ensino Clínico será
realizado na Unidade de Cuidados na Comunidade Farol do Mondego (UCCFM).

As Unidades de Cuidados na Comunidade (UCC) surgem no âmbito da reforma dos

Cuidados de Saúde Primários, onde se reconfigurou os Centros de Saúde em
Agrupamentos de Centros de Saúde (ACES), implementando várias tipologias de
unidades funcionais. Esta reforma teve como objetivo reforçar os recursos na área dos
cuidados de saúde primários, resultando em ganhos em saúde mais eficientes e eficazes
(Ordem dos Enfermeiros, 2018).

Desta forma as UCC, de acordo com o Despacho n.º 10143/2009 de 16 de abril, são
unidades que prestam “cuidados de saúde e apoio psicológico e social, de âmbito
domiciliário e comunitário, às pessoas, famílias e grupos mais vulneráveis em situação
de maior risco ou dependência física e funcional”. Na sua área de atuação integram-se a
educação para a saúde, integração em redes de apoio à família e implementação de
unidades móveis de intervenção.

A UCCFM, na qual se integra a proposta de intervenção apresentada neste documento,

disponibiliza os seus serviços aos residentes da área geográfica do concelho da Figueira
da Foz (UCCFM, 2019).

Sendo que as UCC prestam cuidados aos grupos mais vulneráveis e em situação de maior
risco, consideramos pertinente que a população alvo da nossa intervenção seja a
população LGBTI, sigla que se refere a pessoas lésbicas, gay, bissexuais, trans e
intersexo. É importante referir que existem variações desta sigla sendo muitas vezes
utilizada a sigla LGBTIQ+, sendo que a letra Q significa Queer e o sinal “+” representa
todas as pessoas e grupos que não se enquadram na normativa heterossexual e cis-género
nem nas letras mencionadas (Safe.To.Be, s.d.).
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Segundo Craig et al. (2019), algumas das minorias socias, nomeadamente a comunidade
LGBTQ+, carecem frequentemente de suporte na exploração da sua identidade e os riscos
psicossociais associados. Quando o ambiente envolvente apresenta desafios e fatores
stressantes ao seu bem-estar, muitos destes indivíduos recorrem a plataformas de
tecnologias como motores de busca de informação e apoio. A utilização de plataformas
online, com o propósito da promoção da literacia em saúde, têm-se demonstrado cada vez
mais comum e com uma maior procura comparativamente aos meios tradicionais de saúde
(Tacco et al. 2018).

Desta forma, ao longo deste trabalho iremos abordar especificamente a relação entre a
utilização das redes sociais e a literacia em saúde sexual e reprodutiva na comunidade
LGBTQ+. Para tal, para a realização deste trabalho, procuramos responder à questão de
investigação “Qual a efetividade das redes sociais na literacia em saúde da população
LGBTQ+?”, planificando uma intervenção que responda às necessidades identificadas da
população alvo.

Relativamente à metodologia, iniciamos por formular a questão de investigação

supramencionada. De seguida, recorremos à plataforma de pesquisa EBSCO selecionando
as bases de dados CINHAL e MedLine, utilizando os descritores de busca “Interventions,
Internet”, “lgbt or lesbian or gay or homosexual or bisexual or trangender or queer”,
“Health promotion”, “Sexual Health” . A pesquisa foi realizada com recurso a
operadores booleanos, obtendo 649 artigos publicados entre 2019 e 2023 e apenas em
idioma inglês.

O desenvolvimento deste trabalho está dividido em quatro capítulos sendo eles a

caracterização da UCC, síntese temática, proposta de intervenção e síntese conclusiva.
No primeiro faremos uma breve caracterização da UCCFM; na síntese temática
abordaremos os principais conceitos desta temática, bem como os resultados da nossa
pesquisa que fundamentam a nossa intervenção e respondem à questão de investigação;
e no terceiro apresentaremos a proposta de intervenção.

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1. CARACTERIZAÇÃO DA UCC

A UCCFM faz parte do ACES do Baixo Mondego e é constituída por cinco enfermeiros
e dois técnicos superiores. Os serviços são disponibilizados aos residentes (incluindo os
temporários) na área geográfica do concelho da Figueira da Foz (UCCFM, 2019), que de
acordo com acordo com o Bilhete de Identidade dos Cuidados de Saúde Primários (s.d.),
abrange 63 159 utentes.

Como missão, a UCCFM tem a prestação de cuidados em comunidade e para a

comunidade, que garantam a acessibilidade, equidade, personalização e continuidade,
atuando fundamentalmente na educação para a saúde e na integração de redes de apoio à
família (UCCFM, 2019). A prestação de cuidados por esta UCC é fundamental para
melhorar a qualidade e acesso aos cuidados de saúde por populações em contexto de
vulnerabilidade.

Com esta missão, a Unidade dedica-se à promoção e prevenção da saúde de modo a

capacitar a comunidade para a adoção de estilos de vida saudáveis, intervindo a vários
níveis da comunidade como escolas, instituições particulares de solidariedade social
(IPSS), juntas de freguesias, comunidades de risco, recreativos e outros.

De acordo com o Regulamento Interno, os enfermeiros prestam cuidados no âmbito da

promoção, prevenção, tratamento e reabilitação de acordo com o contexto e os
diagnósticos de enfermagem identificados, sendo responsáveis pelas intervenções
autónomas de enfermagem e respetiva avaliação (UCCFM, 2019).

Deste modo, enquadrando-se a população LGBTQ+ num grupo vulnerável, e sendo esta
a área de atuação das UCC, consideramos relevante abordar a efetividade das redes
sociais na literacia em saúde sexual e reprodutiva da população LGBTQ+, apresentando
uma intervenção de educação em saúde nesta área.

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14
2. SÍNTESE TEMÁTICA

Antes de mais é importante compreender o que são grupos em contexto de vulnerabilidade

e em que medida é que a população LGBTQ+ se insere neste.

No contexto da saúde o termo “vulnerabilidade” está associado ao reconhecimento de que

certos indivíduos podem estar particularmente suscetíveis ao risco e a prejuízos da sua
saúde devido a desvantagens sociais, sendo que este conceito não é visto como uma
característica intrínseca da pessoa (Ferreira, Santos, Ribeiro, Fracon & Wong, 2021).
Desta forma, populações ou grupos em situações de vulnerabilidade são aqueles que se
encontram mais suscetíveis a prejuízos na sua saúde por não terem recursos sociais,
materiais ou pessoais para conseguir lidar com os riscos que podem causar esses
prejuízos. Estas populações demonstram uma maior dificuldade no acesso a cuidados de
saúde equitativos e um maior risco de uma qualidade de vida condicionada. Desta forma,
é fundamental que as instituições prestem cuidados adaptados e acessíveis às populações
em contexto de vulnerabilidade, cujas necessidades são mais complexas e particulares
que a população em geral, promovendo assim a equidade e facilitando o acesso destas
populações aos cuidados de saúde primários (Smithman, Descôteaux, Dionne Richardm
Breton, Khanassov, Haggerty, 2020).

Congruentemente, a população LGBTQ+ está particularmente suscetível a exclusão

social, estigmatização e discriminação, inclusive nos contextos de saúde. Estes fatores
dificultam o acesso aos cuidados de saúde e têm um impacto negativo na saúde destes
(Mendes, 2022).

De acordo com a WHO (2015), a discriminação e desigualdade têm um papel

determinante no facto de a pessoa conseguir ou não atingir e manter a sua saúde sexual e
reprodutiva. Esta é fundamental tanto para a saúde física e emocional, e bem estar dos
indivíduos, famílias, casais, como para o desenvolvimento socioeconómico dos países e
comunidades.

A saúde sexual e reprodutiva engloba tanto aspetos como o acesso à contraceção e aborto,
o acesso a meios de prevenção de infeções sexualmente transmissíveis (IST), como

15
também de poder viver experiências sexuais seguras e prazerosas sem qualquer forma de
coerção, violência ou discriminação (WHO, 2015).

Um dos aspetos indispensáveis para a promoção da saúde sexual e reprodutiva inclui a

educação em saúde, acessível e compreensível para todos. A literacia em saúde sexual e
reprodutiva proporciona às pessoas conhecimento, empoderando-as para fazerem
escolhas informadas relativamente à sua saúde sexual (por exemplo, como se protegerem
das infeções sexualmente transmissíveis (IST), rastreios de saúde recomendados e
disponíveis e quais os recursos de saúde disponíveis) e também encorajando-as a
denunciarem violência e abuso sexual ou a inspirar outros que partilham das mesmas
vivências a procurar ajuda (WHO, 2015).

A população LGBTQ+ tem um risco acrescido de problemas de saúde do foro sexual e

reprodutivo, devendo-se isto não só ao facto das suas particularidades e diferenças de
comportamento individual, como também ao estigma sociocultural e à forma como os
cuidados prestados pelos profissionais de saúde estão desenhados (direcionados à
população heterossexual). Tudo isto resulta em barreiras ao acesso e obtenção de cuidados
de saúde seguros e inclusivos (Mendes, 2022).

Os contextos de saúde, nomeadamente aqueles onde se realiza o planeamento familiar e

outros aspetos relacionados à saude sexual e reprodutiva, seguem maioritariamente uma
perspetiva heteronormativa, resultando num sentimento de exclusão por parte dos utentes
desta comunidade. Além disso, verifica-se uma inadequação da educação sexual nas
escolas que é muitas vezes escassa e não tem conteúdos relacionados às particularidades
da população. Em consequência, para a procura de informação relativa a esta temática, os
indivíduos optam por recorrer a comunidades online, parceiros e amigos ao invés dos
serviços de saúde (Mendes, 2022).

A falta de confiança nos serviços de saúde e o facto destes não serem inclusivos traz
diversas consequências ao nível da saúde da população LGBTQ+. Em Portugal, o número
de casos de IST a serem notificados aumentou consideravelmente, nomeadamente entre
pessoas LGB. Verificou-se um maior aumento das notificações de sífilis e gonorreia nas
pessoas LGB comparativamente à população heterossexual. O mesmo se verifica
relativamente ao VIH/SIDA onde, tem havido um aumento exponencial do número de
casos a serem notificados. Outro aspeto relevante refere-se ao uso inconsistente de
contracetivos e atitudes preventivas onde é evidente que, nomeadamente as mulheres de

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minorias sexuais, não estão conscientes para os verdadeiros riscos, optando por não
utilizar métodos contracetivos e atitudes preventivas como rastreios de saúde (Mendes,
2022).

Abordando agora o papel da internet e redes sociais na literacia em saúde sexual e

reprodutiva, tem se revelando que a população jovem LGBTQ+ usa a internet para
procurar informações relativas a género, sexualidade, relações e saúde (física, mental e
sexual) (Mclnroy, McCloskey, Craig & Eaton, 2019).

Os resultados da análise secundária feita por Mclnroy, McCloskey, Craig & Eaton (2019)
de um inquérito online dirigido a esta população jovem (14 a 29 anos), revelaram que
63.2% dos participantes reportaram aceder a informação sobre saúde sexual online,
verificando-se que há uma maior proporção de indivíduos que procura esta informação
online comparativamente a offline. No geral, os resultados demonstraram que a
população jovem é mais ativa online e sente-se mais segura e apoiada em recursos e
comunidades online, sendo mais provável que utilizem este meio comparativamente aos
recursos offline.

Ademais, alguns estudos sugerem que homens gays e bissexuais optam mais vezes pelas
novas tecnologias do que a população em geral. (Grov et all., 2013). Posto isto, Cruess et
al. (2018) realizaram um estudo com base em intervenções online, através de estratégias
informativas, motivacionais e comportamentais, com o objetivo de reduzir o risco de HIV
na população alvo de homens gays e bissexuais. No atual contexto da epidemia de HIV
múltiplas estratégias de prevenção têm sido apresentadas como alternativas para
populações mais suscetíveis. A amostra do estudo consistiu num grupo de homens e
bissexuais que vivem com a doença e que encontram parceiros sexuais online. As sessões
consistiram na discussão de informações relacionadas à saúde e segurança na Internet,
bem como apresentação e discussão de cenários para aumentar a motivação e fornecer as
habilidades comportamentais necessárias para reduzir o comportamento sexual de risco.
Após a conclusão das sessões, os autores verificaram que as intervenções tiveram
resultados positivos na redução de comportamentos específicos de risco de transmissão
de HIV, tais como: mais assiduidade na prática de limitar encontros sexuais sem
preservativos a parceiros que se acredita serem do mesmo tipo sorológico. Assim, os
autores concluem que a utilização de redes socias, e outras formas de ligação online, pode
ajudar a promover e manter benefícios significativos.

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O estudo de Wang, Tang, Wu, Nong, & Li (2020), encontra-se direcionado à promoção
do autoteste oral do Vírus da imunodeficiência humana (VIH) em homens que fazem sexo
com homens (HSH), através das redes sociais. Primordialmente, foram recrutados 510
participantes para a realização deste estudo e, as informações recolhidas permitiram
realizar uma distinção entre os mesmos, sendo que, os homens recrutados através do uso
da Internet, realizavam menos testes ou já tinham realizado testagem oral para o VIH,
uma vez que procuraram conhecimentos sobre o vírus em si, assim como a sua prevenção
ou programas de intervenção. Os dados foram recolhidos através de questionários aos
participantes, autoteste oral de VIH e testes sanguíneos de confirmação de VIH em
clínicas com o apoio e o acompanhamento de profissionais de saúde. Os resultados da
literatura analisada revelam que a promoção online da realização do autoteste oral de
VIH, aumenta o início e a repetição da despistagem do vírus. Este estudo abordou o
autoteste oral de VIH, para promover e capacitar estes homens a realizar de forma
autónoma e no conforto da sua privacidade, tornando-se mais apelativo e mais eficaz na
prevenção da infeção do VIH. Conclui-se assim, que as redes sociais enquanto
plataformas de meio comunicativo, são eficazes na promoção da despistagem, sendo
relatada uma atitude positiva em relação ao autoteste oral de VIH e entre os homens
utilizadores da internet, dada a facilidade em obter o teste e informações em como o
realizar.

Apesar de não ser inteiramente online, o estudo de Ybarra, Goodenow, Rosario, Saewyc
& Prescott (2020) utiliza de igual forma os meios digitais para promover a saúde sexual
e reprodutiva. O programa “Gil2Girl”, direcionado a raparigas adolescentes cisgénero
LGB+, envia mensagens de texto motivacionais e informativas acerca da prevenção da
gravidez, acerca dos aspetos de uma relação saudável, uma linha de mensagens que
permite às participantes entrar em contacto e pedir mais informações e permitem
interação dois para dois para que se possam encorajar e apoiar umas às outras. Os
resultados revelaram que este programa está associado a uma maior taxa de uso de
preservativos e uma maior probabilidade de utilizar outros métodos de contraceção,
sugerindo que este poderá estar associado a vários comportamentos de prevenção da
gravidez.

Tendo em conta o apresentado, consideramos relevante propor uma intervenção

direcionada ao aumento da literacia em saúde sexual e reprodutiva da população
LGBTQ+, através das redes sociais.
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 3. PROPOSTA DE INTERVENÇÃO

Tabela 1 - Proposta de intervenção

ESCOLA SUPERIOR D ENFERMAGEM DE COIMBRA, CURSO LICENCIATURA EM ENFERMAGEM,
4ºANO, 8ºSEMESTRE
TÍTULO DO PROJETO: Conecta-te
NOME DA UCC: UCC Farol do Mondego
ESTUDANTES: Carolina Santos, Maria João Nogueira, Vanessa Almeida
Contexto de De acordo com o Bilhete de Identidade dos Cuidados de Saúde Primários (s.d.), a
intervenção UCCFM abrange 63 159 utentes. Uma vez que esta intervenção é realizada online (redes
sociais) pode abranger outros contextos sociodemográficos, embora o nosso foco seja a
população LGBTQ+ residente no concelho da Figueira da Foz.

Foco de Foco: promoção da literacia em saúde sexual e reprodutiva

intervenção e População-alvo: comunidade LGBTQ+
população-alvo
Justificação da A Estratégia de Saúde para as Pessoas Lésbicas, Gays, Bissexuais, Trans e Intersexo
criação do projeto (LGBTI), lançada no dia 1 de julho de 2019, decorre atualmente e apenas foi lançada a
primeira etapa que é dedica à promoção da saúde das pessoas trans e intersexo. Através
desta estratégia é definida pelo Ministério da Saúde uma linha global de intervenção
como resposta às necessidades de saúde desta população (DSPDPS Núcleo sobre Género
e Equidade em Saúde, 2019).
Enquadramento

Como referido ao longo deste trabalho, a população LGBTQ+ demonstra uma maior
dificuldade no acesso a cuidados de saúde equitativos, contribuindo para a carência de
conhecimento e para a insatisfação das necessidades desta comunidade.
Tendo a saúde sexual e reprodutiva um grande impacto no bem estar da pessoa,
consideramos fundamental atuar na literacia em saúde sexual e reprodutiva,
proporcionando uma ferramenta de fonte fiável e empoderando as pessoas para poderem
tomar decisões conscientes e seguras, melhorando a sua qualidade de vida.

Comportamentos Com este trabalho pretendemos aumentar a literacia em saúde sexual e reprodutiva, de
e contextos a modo a diminuir comportamentos sexuais de risco.
serem
modificados
Fatores  Falta de literacia em saúde sexual e reprodutiva.
predisponentes  Estigma sociocultural.
desses  Inadequação da educação sexual nas escolas e dos cuidados prestados pelos
comportamentos profissionais de saúde.
 Idade.
 Educação familiar.

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 Fatores  Acesso às redes sociais (uma vez que facilitam cenários propícios a
facilitadores comportamentos de risco).
desses  Uso de drogas.
comportamentos  Falta de apoio do agregado familiar.
 Estado de humor.
 Falta de confiança nos cuidados de saúde primários e receio de recorrer aos mesmos.
Fatores de reforço  Influência por parte dos parceiros.
desses  Influência social.
comportamentos  Acesso a informação não fidedigna.
O que agiliza a  O fácil acesso à internet e redes sociais, bem como aos recursos necessários.
criação do  Literatura disponível.
projeto?
Há possibilidade Os profissionais de saúde têm um papel importantíssimo na promoção da literacia em
de expansão do saúde através das sessões de educação para a saúde, tornando-se ativos na prevenção de
papel dos comportamentos de risco.
profissionais de Além disso, é fundamental que estes estejam preparados e possuam o conhecimento
saúde? necessário acerca das particularidades desta comunidade, de forma a poder prestar os
melhores cuidados.
Consideramos importante que os profissionais de saúde tenham um papel ativo nesta
temática.
Descrição da O projeto “Conecta-te” consiste na criação de uma página de Instagram (rede social)
intervenção a com diversos posts informativos acerca de: Locais de rastreio das infeções sexualmente
desenvolver no transmissíveis, rastreios disponíveis e aconselhados, desmistificação de preconceitos
Ensino Clínico relacionados à saúde sexual e reprodutiva, métodos contracetivos e prevenção de IST.
fundamentada na Além disso também estará disponível a interação entre profissional de saúde e pessoa
evidência através de mensagens diretas e caixas de perguntas.
A nossa intervenção é direcionada para plataformas digitais, nomeadamente instagram,
pois esta app encontra-se disponível vinte e quatro horas por dia, sem restrições ou
limitações físicas e representa uma forma bastante eficaz para atingir o público-alvo
desejado. Sendo que as plataformas digitais não substituem o enfermeiro nem invalidam
o mesmo, consideramos as mesmas como um recurso a ser utilizado pelos profissionais
Intervenção

mas sempre salvaguardando a importância de frequentar as instituições e recursos de

saúde físicos existentes.
Em que medida Dada a literatura analisada concluímos que as redes sociais podem ser eficazes na
vai melhorar as transmissão de informação fidedigna (informação transmitida e filtrada por profissionais
condições de de saúde). Além disso, de acordo com a mesma, a população em questão recorre
saúde da frequentemente a informação sobre saúde sexual e reprodutiva online.
população-alvo? A literacia em saúde tem um papel fundamental no empoderamento das pessoas,
permitindo-as fazer escolhas informadas e conscientes (WHO, 2015). Desta forma, ao
informá-las, através de um meio facilmente acessível, pensamos que será possível
diminuir certos comportamentos de risco desta comunidade.
Estratégias de Análise dos dados estatísticos fornecidos pela rede social (número de visualizações,
avaliação de interações com os posts, interações com outros usuários e com os profissionais de saúde,
resultados interações sociodemográficas).
Questionários acerca de aspetos a melhorar na página e conteúdos desejados.

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 Habilidade de Conhecimentos relativos acerca dos meios de contraceção existentes e informação
competências a acerca da sua utilização, recursos de saúde disponíveis na comunidade.
desenvolver pelos Conhecimento relativamente às IST, vias de transmissão, e sensibilização para o risco.
participantes Conhecimento relativo a outras doenças do aparelho reprodutor.
Parceiros e a sua Profissionais de saúde da UCCFM e Docentes da Escola Superior de Enfermagem de
função Coimbra.
Diretrizes e Regulamento interno da UCCFM, programa que consta do Plano de Ação “Projetos
quadro Comunitários de Parceria”.
regulamentar A Estratégia de Saúde para as Pessoas Lésbicas, Gays, Bissexuais, Trans e Intersexo
(LGBTI), 1 de julho de 2019.
Programa Nacional de Prevenção e Controlo do VIH SIDA, Direção Geral da Saúde.
Estratégia Nacional para a Igualdade e não discriminação, 2018.
Lei no38/2018 - Direito à autodeterminação da identidade de género e expressão de
género e à proteção das características sexuais de cada pessoa. Diário da República

Recursos a alocar Recursos humanos – profissionais de saúde.

Internet e dispositivos móveis.
Powerpoint e Canva.

Benefícios da Conhecimentos adquiridos acerca dos métodos de contraceção e correta forma de uso,
intervenção recursos de saúde disponíveis na comunidade, patologias do aparelho reprodutivo
Diminuição de comportamentos de risco e aumento da adesão aos serviços de saúde.
Custos do projeto de Recursos humanos – profissionais de saúde.
intervenção Internet e dispositivos móveis.
Powerpoint e Canva.

21
22
SÍNTESE CONCLUSIVA

Em conclusão, é fundamental atuar junto das populações em situação de vulnerabilidade,

nomeadamente a comunidade LGBTQ+, promovendo a equidade e dando resposta às
necessidades específicas destas. De forma a reduzir os riscos a que estas estão sujeitas,
não apenas devido a características intrínsecas como também aos fatores
socioeconómicos, é dever do enfermeiro prestar cuidados adaptados às necessidades
específicas desta população.Uma das formas é através da promoção da literacia em saúde,
consciencializando a população e empoderando a mesma a desempenhar um papel ativo
na identificação e prevenção destes comportamentos.

Escolhemos este público alvo uma vez que vários estudos encontram-se direcionados
maioritariamente para uma população heterosexual/cis-genero, havendo assim uma maior
necessidade de abordar temáticas relacionadas a grupos em situação de vulnerabilidade.
Além disso, através da pesquisa bibliográfica foi possível verificar que existe uma falta
de confiança nos cuidados de saúde e uma inadequação da educação sexual nas escolas,
pelo que a população acaba por recorrer a outros recursos para obter informações acerca
da saúde sexual e reprodutiva.

O projeto Conecta-te procura empoderar / informar a comunidade LGBTQ+, e transitá-

los de espectadores passivos para espectadores ativos, desempenhando um papel
importante na promoção e prevenção de comportamentos de riscos, melhorando a sua
saúde.

Com o aumento da utilização da internet pelos jovens é fundamental esclarecer e informar

os profissionais de saúde da mais recente evidência científica, de modo a aumentar
qualidade dos cuidados de enfermagem e tornar a prática mais adequada e segura, tanto
para os utentes como para os enfermeiros. Neste sentido, como profissionais de saúde é
possível crescer com o florescer das novas tecnologias, uma vez que as aplicações digitais
insurgem-se como uma proposta educacional capaz de propagar informações em
diferentes contextos. O uso de plataformas digitais e a prática de enfermagem não são
exclusivas e devem ser então mutuamente inclusivas.

23
24
REFERÊNCIAS BIBLIOGRÁFICAS

Breton, M., Descôteaux, S., Dionne, E., Haggerty, J., Khanassov, V., Richard, L.
& Smithman, M. (2020). Typology of organizational innovation components: building
blocks to improve access to primary healthcare for vulnerable populations. International
Journal for Equity in Health, 19(174). https://doi.org/10.1186/s12939-020-01263-8

Despacho n.º 10143/2009, de 16 de abril. Diário da República n.º74/2009, Série

II. Ministério da Saúde-Gabinete do Secretário de Estado da Saúde.
https://dre.pt/dre/detalhe/despacho/10143-2009-2216310

DSPDPS Núcleo sobre Género e Equidade em Saúde. 2019. Estratégia de Saúde

para as pessoas Lésbicas, Gays, Bissexuais, Trans e Intersexo – LGBTI.
https://www.portugal.gov.pt/pt/gc21/comunicacao/comunicado?i=apresentacao-da-
estrategia-de-saude-para-as-pessoas-lesbicas-gays-bissexuais-trans-e-intersexo

Grov, C., Ventuneac, A., Rendina, H., Jimenez, R., Parsons, J. (2013). Perceived
Importance of Five Different Health Issues for Gay and Bisexual Men: Implications for
New Directions in Health Education and Prevention. Mens Health 7(4), 274–284.
https://doi.org/10.1177/1557988312463419

Ferreira, J., Fracon, B., Ribeiro, L., Santos, L. & Wong, S. (2021). Vulnerability
and Primary Health Care: An Integrative Literature Review. Journal of Primary Care &
Community Health 12, 1–13. https://doi.org/10.1177/21501327211049705

Haidar, O., Lamarche, P., Levesque, J. & Pampalon, R. (2018). The Influence of
Individuals' Vulnerabilities and Their Interactions on the Assessment of a Primary Care
Experience. International Journal of Social Determinants of Health and Health Services,
48(4), 1-22. https://doi.org/10.1177/0020731418768186

Mclnroy, L., McCloskey, R., Craig, S., Eaton, A. (2019). LGBTQ+ Youths’
Community Engagement and Resource Seeking Online versus Offline. Journal of
Technology in Human Services, 37(4), 315-333.
https://doi.org/10.1080/15228835.2019.1617823
 Mendes, R. (2022). A Saúde da Comunidade LGBTQ+: Especificidades e
Disparidades nos Cuidados de Saúde. [Master’s thesis, Universidade Beira Interior].
Repositório Digital da UBI.
https://ubibliorum.ubi.pt/bitstream/10400.6/12885/1/8989_19328.pdf

Ordem dos Enfermeiros. (2018). Parecer nº 12/2018.

https://www.ordemenfermeiros.pt/media/6031/parecer-mceemc-n%C2%BA-12-
2018_enquadramento-do-eemc-nas-unidades-de-cuidados-na-comunidade.pdf

Safe.To.Be. (s.d). Terminologia. https://safetobe.eu/pt/fact-checking/

Tacco, F. M. D. S., Sanchez, O. P., Connolly, R., & Compeau, D. R. (2018). An

examination of the antecedents of trust in Facebook online health communities. In
Proceedings of European Conference on Information Systems (p. 150). Portsmouth,
United Kingdom.

UCCFM. (2019). Regulamento Interno. https://bicsp.min-

saude.pt/pt/biufs/2/20020/2061351/QUEM%20SOMOS/RI%20%20-2019.pdf

Wang, X., Tang, Z., Wu, Z., Nong, Q., & Li, Y. (2020). Promoting oral HIV self-
testing via the internet among men who have sex with men in China: a feasibility
assessment. HIV Medicine, 21(5), 322–333. https://doi.org/10.1111/hiv.12830

WHO. 2015. Sexual health, human rights and the law.

https://apps.who.int/iris/bitstream/handle/10665/175556/9789241564984_eng.pd
f

Ybarra, M., Goodenow, C., Rosario, M., Saewyc, E., Prescott, T. (2020). An
mHealth Intervention for Pregnancy Precention for LGB Teens: An RCT. Pediatrics
147(3), 1-12. https://doi.org/10.1542/peds.2020-013607
APENDICES
 APENDICE I

PRISMA da busca bibliográfica

Identification of studies via databases and registers

Records removed before

screening:
Identification

Records identified from:

Duplicate records removed (n
Databases (n = 2)
= 0)
Registers (n = 649)
Records marked as ineligible
Pubmed (n= 371)
by automation tools (n = 0)
CINHAL (n= 278)
Records removed for other
reasons (n = 0)

Records screened Records excluded**

(n =322) (n = 327)

Reports sought for retrieval Reports not retrieved

(n =282 ) (n = )
Screening

Reports assessed for eligibility Reports excluded:

(n =40) Systematic reviews / Scoping
reviews (n =28 )
Full text not available (n = 4 )
Lingua (n = 5 )
etc.

Studies included in review

Included

(n = 3)
Reports of included studies
(n = )

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020
statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71

For more information, visit: http://www.prisma-statement.org/

 APENDICE II

Plano de Educação para a saúde

Objetivos Conteúdos Estratégias Avaliação

específicos/Resultados
esperados Métodos Recursos

-Pretende-se que no período - O que é a profilaxia pré- -Método -Internet e -Análise dos dados
inicial de 6 meses do projeto, exposição e pós- expositivo: plataformas estatísticos fornecidos
se verifique um aumento exposição do VIH; publicação de online pela rede social (número
mínimo de 30% de posts e (instagram e de visualizações,
seguidores mensais. -Métodos contracetivos conteúdo canva); interações com os posts,
existentes e a sua digital interações com outros
-Dispositivos
-Pretende-se que no período utilização; (instagram e usuários e com os
móveis;
inicial de 6 meses do projeto, canva). profissionais de saúde,
se verifique o mínimo de 600 -Informar sobre os -Recursos interações
visualizações dos stories recursos de saúde físicos -Método humanos: sociodemográficas).
pelo público-alvo. disponíveis na localidade interrogativo: estudantes e
da população alvo; interação com
profissionais -Questionários de
-Pretende-se que após 1 do as
de saúde; qualidade, onde os
projeto, se verifique um -Contextualizar os riscos, publicações, utilizadores expressam
vias das ISTs na caixas de -Inquéritos.
aumento de até 50% no pontos a melhorar e que
número de likes das comunidade LGBTQ+ opinião e
conteúdos gostariam que
publicações na página questionários
fossem abordados.
online. -Informar sobre online.
características do
aparelho sexual e
reprodutivo.

- Informar acerca de
outras patologias do
aparelho sexual e
reprodutivo.

-Aconselhamento de
medidas
comportamentais
preventivas.
APENDICE III – Análise crítica de um artigo: Carolina Marques Simão Geraldes dos
Santos
 Trabalho individual de síntese crítica de um artigo científico
Carolina Marques Simão Geraldes dos Santos – a21901262

Artigo: An mHealth Intervention for Pregnancy Prevention for LGB Teens: An RCT
Autores: Michele Ybarra, Carol Goodenow, Margaret Rosario, Elizabeth Saewyc, Tonya
Prescott
Yes No Unclear NA
1. Was true randomization used for assignment of participants to treatment groups?

“Participants were randomly assigned to the Girl2Girl intervention (n=473) or the

attention-matched control group (n=475) at a 1-to-1 randomization allocation ratio.
The random allocation was stratified by (1) sexual experience and (2) sexual identity”.

Foi utilizado o método minimização (aparece referenciado para “The random

□ □ x □
allocation was stratified by (1) sexual experience and (2) sexual identity”.) que é um
método de amostragem estratificada.
No entanto não é referido o procedimento utilizado para distribuir as subpopulações a
cada grupo, apenas que foi de forma randomizada, não sendo claro.

2. Was allocation to treatment groups concealed?

A informação sobre a alocação dos grupos não é aprofundada não se sabendo como é □ □ x □
que foi feita a mesma. Não faz referência a ocultação da alocação.

3. Were treatment groups similar at the baseline?

“Intervention and control participants were equivalent on their baseline
characteristics except for age, which was borderline statistically significantly
x □ □ □
different”.

4. Were participants blind to treatment assignment?

“Participants, but not researchers, were blind to arm allocation”.
“The control arm (…). To help blind this arm, 2 days of pregnancy prevention content
x □ □ □
readily available online were included”.

5. Were those delivering treatment blind to treatment assignment? □ □ □ x

6. Were outcomes assessors blind to treatment assignment? □ □ □ x
7. Were treatment groups treated identically other than the intervention of
interest?
“The control arm received a similar intensity and duration of messaging as the
intervention”. Não há outras exposições ou intervenções que ocorrem em simultâneo
x □ □ □
com a causa.

1
© JBI, 2020. All rights reserved. JBI grants use of these
tools for research purposes only. All other enquiries
should be sent to jbisynthesis@adelaide.edu.au.
 Trabalho individual de síntese crítica de um artigo científico
Carolina Marques Simão Geraldes dos Santos – a21901262

8. Was follow up complete and if not, were differences between groups in terms of
their follow up adequately described and analyzed?

Segundo a check-list não é suficiente saber o número de participantes e a proporção

dos mesmos que não concluíram o follow-up. No artigo não foi descrito as razões □ x □ □
pelas quais tal não aconteceu em cada um dos grupos nem analisadas. O artigo
apenas apresenta o número de participantes em cada grupo que não concluiu follow-
up. “As shown in Fig 1, 59 of 948 participants either actively terminated their
involvement in the RCT or were lost to follow-up”.

9. Were participants analyzed in the groups to which they were randomized?

x □ □ □
“Analyses were intention to treat”.

10. Were outcomes measured in the same way for treatment groups?

Ambos os grupos responderam ao mesmo questionário online, questionário esse que x □ □ □

foi aplicado tanto no início como no fim da intervenção para avaliação. Assim, foi
utilizado o mesmo instrumento para ambos os grupos.

11. Were outcomes measured in a reliable way?

Não existem detalhes sobre a confiabilidade inter-avaliador e intra-avaliador. Foram

□ □ x □
quatro avaliadores, todos com formação superior.

12. Was appropriate statistical analysis used?

“Logistic regression was used to quantify the relative odds of dichotomous

measures.”. x □ □ □
O teste paramétrico utilizado foi a regressão logística sendo esta adequada para
relações de causa efeito.

13. Was the trial design appropriate, and any deviations from the standard RCT
design (individual randomization, parallel groups) accounted for in the conduct
and analysis of the trial?

O desenho do estudo é apropriado. Este estudo permite responder ao objetivo deste

x □ □ □
estudo, verificando se a intervenção em causa alterou os comportamentos do grupo
experimenta. Não foram utilizadas variações do estudo controlado randomizado.

Overall appraisal: Include x Exclude □ Seek further info □

Comments: Este referencial da JBI permite-me avaliar a qualidade metodológica de um estudo com
base nos 13 itens apresentados. Considerei que apenas 11 destes eram aplicáveis ao estudo a ser
analisado. Os grupos eram comparáveis no início do estudo sendo possível atribuir o efeito à causa de
forma mais fidedigna, os participantes não conheciam a sua alocação pelo que elimina risco de
resultados alterados, não houve exposição a outras intervenções pelos grupos, os resultados foram
avaliados da mesma forma em ambos os grupos sendo possível compará-los e a análise estatística e o
desenho do estudo são adequados.
2
© JBI, 2020. All rights reserved. JBI grants use of these
tools for research purposes only. All other enquiries
should be sent to jbisynthesis@adelaide.edu.au.
 An mHealth Intervention for Pregnancy
Prevention for LGB Teens: An RCT
Michele Ybarra, MPH, PhD,a Carol Goodenow, PhD,b Margaret Rosario, PhD,c Elizabeth Saewyc, PhD, RN,d Tonya Prescott, BAa

BACKGROUND: Although lesbian, gay, bisexual and other sexual minority (LGB1) girls are more abstract
likely than heterosexual girls to be pregnant during adolescence, relevant pregnancy
prevention programming is lacking.
METHODS:A national randomized controlled trial was conducted with 948 14- to 18-year-old
cisgender LGB1 girls assigned to either Girl2Girl or an attention-matched control group.
Participants were recruited on social media between January 2017 and January 2018 and
enrolled over the telephone. Between 5 and 10 text messages were sent daily for 7 weeks.
Both experimental arms ended with a 1-week booster delivered 12 weeks subsequently.
RESULTS: Atotal of 799 (84%) participants completed the intervention end survey. Participants
were, on average, 16.1 years of age (SD: 1.2 years). Forty-three percent were minority race;
24% were Hispanic ethnicity. Fifteen percent lived in a rural area and 29% came from a low-
income household. Girl2Girl was associated with significantly higher rates of condom-
protected sex (adjusted odds ratio [aOR] = 1.48, P , .001), current use of birth control other
than condoms (aOR = 1.60, P = .02), and intentions to use birth control among those not
currently on birth control (aOR = 1.93, P = .001). Differences in pregnancy were clinically but
not statistically significant (aOR = 0.43, P = .23). Abstinence (aOR = 0.82, P = .34), intentions to
be abstinent (aOR = 0.95, P = .77), and intentions to use condoms (aOR = 1.09, P = .59) were
similar by study arm.
Girl2Girl appears to be associated with increases in pregnancy preventive
CONCLUSIONS:
behaviors for LGB1 girls, at least in the short-term. Comprehensive text messaging–based
interventions could be used more widely to promote adolescent sexual health behaviors
across the United States.

a
Center for Innovative Public Health Research, San Clemente, California; bIndependent Consultant, Northborough, WHAT’S KNOWN ON THIS SUBJECT: Although sexual
Massachusetts; cCity College and Graduate Center, The City University of New York, New York, New York; and minority girls are more likely than heterosexual girls
d
School of Nursing, University of British Columbia, Vancouver, Canada to be pregnant as a teenagers, pregnancy prevention
Dr Ybarra made substantial contribution to conception and design, acquisition of data, and analysis programs tailored to the lived experiences of these
and interpretation of data and drafted the article; Ms Prescott made substantial contribution to the girls are lacking.
acquisition of data and revised the manuscript critically for important intellectual content; Drs
WHAT THIS STUDY ADDS: Girl2Girl positively impacts
Saewyc, Rosario, and Goodenow made substantial contribution to analysis and interpretation of
data, provided consultation on the study design, and revised the manuscript critically for important
condom use and uptake of other types of
intellectual content; and all authors approved the final manuscript as submitted and agree to be contraception for sexual minority girls, at least in the
accountable for all aspects of the work. short-term. Findings further suggest that intensive
programming delivered over a long period is
This trial has been registered at www.clinicaltrials.gov (identifier NCT03029962).
acceptable to sexual minority girls.
Deidentified individual participant data will not be made available.
DOI: https://doi.org/10.1542/peds.2020-013607 To cite: Ybarra M, Goodenow C, Rosario M, et al. An
mHealth Intervention for Pregnancy Prevention for LGB
Accepted for publication Nov 13, 2020
Teens: An RCT. Pediatrics. 2021;147(3):e2020013607

PEDIATRICS Volume 147, number 3, March 2021:e2020013607 ARTICLE

Downloaded from http://publications.aap.org/pediatrics/article-pdf/147/3/e2020013607/1082495/peds_2020013607.pdf
by guest
 Although adolescent pregnancy rates
in the United States have decreased
over the past 40 years, just under
200 000 girls, 15 to 19 years old,
became pregnant in 2017.1 Cisgender
sexual minority girls, who comprise
an estimated 10% to 15% of female
youth,2 face differential risk: It may
seem counterintuitive given
assumptions that cisgender lesbian,
gay, bisexual, and other sexual
minority (LGB1) girls are only having
sex with other girls, but researchers
consistently find that they are
significantly more likely to get
pregnant than heterosexual girls.3–5
Cisgender LGB1 girls also are more
likely than their heterosexual female
peers to have sex at a younger
age,2,4,6,7 report more lifetime and
recent numbers of female or male
sexual partners,2,4,6,8 and are less
likely to use barrier methods to
prevent sexually transmitted
infections or pregnancy.2,7,9
Access to school-based sex education
varies widely across the United
States10: 19 states require an
abstinence-only perspective and 39
require that abstinence is presented
as an option; only 20 states require
contraception to be included in the
sexual education curriculum. Despite
the heightened risks of pregnancy
and sexually transmitted infections
that cisgender LGB1 girls face, sex
education that addresses these
disparities is often scarce or
inadequate.11,12 Indeed, although 11
states and the District of Columbia
require LGBT1 inclusive sex
education, an additional 7 require
that homosexuality be presented
negatively and/or that
heterosexuality be presented as the
only acceptable sexual identity.
To address the lack of sexual health
programming for many sexual
minority adolescents, we developed
and tested Girl2Girl, a text messaging-
based pregnancy prevention program
tailored to the unique needs of
sexually experienced and
inexperienced cisgender LGB1
2 YBARRA et al
Downloaded from http://publications.aap.org/pediatrics/article-pdf/147/3/e2020013607/1082495/peds_2020013607.pdf
by guest
adolescent girls. In this study, we
report the preliminary outcomes of
the randomized controlled trial (RCT)
at intervention end, 5 months after
program enrollment. Information
about the iterative, user-centered
intervention development, which
included 269 cisgender LGB1 girls
from across the country, is available
elsewhere.13 Findings from the
current investigation will contribute
to the growing literature examining
behavioral outcomes associated with
text messaging-delivered behavior
change content, particularly that
which targets complex behaviors,
such as pregnancy prevention.
METHODS
Girls were recruited and enrolled
between January 23, 2017, and
January 12, 2018. After completing
the baseline survey, they were
randomized and began the 5-month
program. Most participants completed
the intervention or control program
and their survey by May 31, 2018.
Advarra Institutional Review Board,
an Office of Human Research
Protections–approved institutional
review board, reviewed and approved
the research protocol. We were
granted a waiver of parental
permission so that girls would not
have to put themselves in
a potentially unsafe situation by
disclosing their sexual identity to
their parents to obtain permission to
participate in the study. The waiver
also prevented sampling bias that
would have occurred by including
only girls who were out to their
parents.
Participants
Girls were recruited across the United
States. To be eligible for the study,
participants were (1) aged 14 to 18
years, (2) cisgender female (ie,
assigned female sex at birth and
endorsed a female gender identity),
(3) sexual minority (eg, lesbian,
bisexual), (4) in high school or the
equivalent (including those who did
not finish or dropped out), (5) English
speaking, (6) exclusive users of a cell
phone (ie, they do not share the
phone with someone else) with an
unlimited text messaging plan, (7)
users of text messaging for at least 6
months, (8) intending to have the
same cell number for the next year,
and (9) able to provide informed
assent for those ,18 years of age and
consent for those 18 years of age,
including an acceptable score on the
“capacity to consent” and self-safety
assessment.14 Exclusion criteria
included knowing another girl
enrolled in the RCT and having
participated in a previous
intervention development activity.
Description of the Intervention and
Control Group Content
Girl2Girl is a 20-week, text
messaging–based teenage pregnancy
prevention program. For the first 7
weeks, participants are sent between
4 and 12 messages per day. They then
enter a 12 week “latency” period
when they receive ∼1 to 2 messages
per week. Finally, participants receive
4 to 12 messages daily for a review
week. This “booster” delivers
messages that reiterate the main
concepts discussed in the first 7
weeks of the program.
Intervention content is guided by the
information, motivation, behavioral
skills model15,16 and focuses on
pregnancy prevention information
(eg, how one gets pregnant),
motivations (eg, reasons to initiate
birth control), and behavioral skills
(eg, how to use barriers). Additional
content describes topics and
scenarios that are relevant to sexual
decision-making for sexual minority
girls (eg, aspects of a healthy
relationships).17,18 Content is tailored
on the basis of participants’ self-
reported sexual experience (ever
versus never had sex) and sexual
identity (lesbian or gay versus all
others, except for girls who identified
as queer; in this case, their sexual
attractions determined which content
 they received). Content was not information about sex, relationships, Girl2Girl participants also were paired
further tailored to the individual. and the LGBT1 community19,20; (3) with another participant, their “text
“leveling up” by answering a text buddy.”19,20 As part of the program
As described elsewhere,13 most
message question correctly about content, buddies received messages
program messages are
unidirectional (see Table 1). the week’s content; and (4) being that encouraged them to provide
Bidirectional, interactive awarded “badges,” which was a gif social support to one other and
components included (1) links to sent over text, for achieving practice skills taught in the program.
brief online videos in the messages behavioral skills they were Intervention participants accepted
that aimed to reinforce behavioral presented in the program (eg, a Buddy Code of Conduct, which
skills; (2) G2Genie, an on-demand getting barriers; talking to a health outlined acceptable and unacceptable
advice text line that provided provider about contraception). behavior. Buddy messages were

TABLE 1 Example Girl2Girl Program Messages That are Unidirectional and Bidirectional
Example Intervention Test Message
Unidirectional messages by domain
Teenage pregnancy prevention I get that you’re into girls, not guys. Here’s the thing: LGB1 girls are 2–4 times MORE likely to get pregnant than hetero
information girls. Totally unexpected, huh?a
About 1 in 20 teen girls are on an intrauterine device (IUD) or an implant. They can be great: They last 3–10 years so
you get it put in and forget about it.
Being on your period doesn’t protect you because sperm can live in your vagina for up to 5 days. So your period can
be over, but sperm are still swimming around.
Teenage pregnancy prevention There are a lot of reasons why LGB1 girls are more likely to get pregnant. Some assume they’re never going to have
motivation sex that involved a penis so they don’t have condoms.
Maybe surprisingly, women in committed relationships with women can have high STD rates. In fact, 13% to 30% of
women having sex with women have HPV (source: bit.ly/1SMlxH6)
A girl told me: “Most people won’t look bad at you for buying condoms or going to a gyno to get birth control. No
shame. It’s only natural.” Too right!
Some women say the female condom has more sensation than a male condom. And it rubs against your clitoris during
sex - bonus!
Dental dams/condoms prevent STDs and pregnancy but a backup never hurts - like having a car charger in case your
phone goes dead. And that’s birth control!
Teenage pregnancy prevention It’s fast and simple: Unroll the male condom. Cut off the tip of the condom. Cut down the length of the tube. Unfold to
behavioral skills a square. Done!
Unsure how to ask about birth control? Tell the provider you have questions about it and they’ll take it from there.
Don’t worry - they talk to teens every day.
No need to wait for a crisis. Go online to see where the nearest store is. Too far to get to? Buy the morning after pill
online so you have it if you need it.
Socio-cultural factors Dating violence can also happen. 2 in 5 LGB1 girls have been victims. 1 in 3 were violent themselves. It’s not ok to use
hurtful words or physical force.
If you or someone you know is assaulted, *please* get help. RAINN is amazing - they have an online chat (ohl.rainn.org/
online) and a hotline: 800-656-4673.
It’s common for us to question our sexual attractions and identity. Or for these to change over time. It’s OK to take time
to explore and discover who you are.
Bidirectional messages by domain
Level-up Initial message: I’m not sure where the last 2 weeks went, but here we are! This is for Level 2. True or False: You need
your parents’ permission for the morning after pill.
Correct response from participant: Yessss! You are absolutely right. You can get emergency contraception at many
drug stores or online and you don’t need your parent’s ok. Hellllooo Level 2!
Incorrect response form participant: Good news! You can get emergency contraception at many drug stores or online
and you don’t need your parent’s ok.
G2Genie Texting the keyword “condom” to G2Genie: If condoms (aka cut up to be dental dams) are too expensive, go to a clinic
and get them for free. The icondom app can help you find free stuff too. The Internet is magical!
Badges Initial message: Great! So, what’s your dental dam/condom status at the moment? Do you have one in your possession
(like in your bedroom, school bag, etc)? Let me know (yes/no).
Participant says yes: Nice! You earned your Go Getter Girl Badge!
Participant says no: It might seem really hard to get dental dams/condoms: they’re expensive, they can be
embarrassing to buy, and maybe you don’t know where to get them. What stops you: Parents, Cost, IDK where to go,
Embarrassed, Not having sex, Not having sex w/a guy, Waiting to have sex, In a relationship, No transport, Other.
“No” participant responds she is not having sex with a guy: I totally get that you’re not having sex with a guy but
practicing now to buy condoms now just makes it easier to them if you need them later on.
a This message is written specifically for lesbian or same-sex attracted girls.

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 routed through the study server so
that participants’ phone numbers
were not disclosed to buddies. Buddy
conversations were monitored by
research staff from 6 AM to 10 PM PST
to ensure harmful messages were not
being sent.
The control arm received a similar
intensity and duration of messaging as
the intervention. Content addressed
topics relevant to adolescents,
including diet, exercise, and how to
deal with bullying. To help blind this
arm, 2 days of pregnancy prevention
content readily available online were
included. Interactive components (eg,
Text Buddy) were not available to this
group.
Recruitment and Retention
Procedures
Participants were recruited through
online advertisements on Facebook
and Instagram. The ads were targeted
to users who indicated on their
profile that they were female,
between 14 and 18 years of age, and
“interested in females” or “interested
in males and females.” Youth who
clicked on the advertisement were
directed to the online screener form.
Potentially eligible youth were
contacted in order of receipt of
screeners while also considering
preset demographic targets to ensure
sample diversity. For example, once
the targeted number of non-Hispanic
white girls was enrolled, additional
demographically similar candidates
were not contacted. Enrollment
occurred over the phone with
research staff. Once eligibility was
confirmed and informed assent and
consent were obtained, participants
were emailed a unique link to the
baseline survey. Girls were
randomized to a study arm after they
completed the survey.
Randomization
Participants were randomly assigned
to the Girl2Girl intervention (n = 473)
or the attention-matched control
group (n = 475) at a 1-to-1
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randomization allocation ratio. The
random allocation was stratified by
(1) sexual experience and (2) sexual
identity.21 Participants, but not
researchers, were blind to arm
allocation.
Power
Effect size estimates for samples that
include both sexually experienced
and inexperienced LGB1 youth are
ill-defined because, as noted above,
pregnancy programs for LGB1
adolescent women are lacking. To
inform our power estimates about
sexual abstinence, we used data from
the authors’ Girl2Girl “recruitment
pilot” study. Among the 257 14- to
18-year-old sexual minority girls
surveyed, 22% had never had penile-
vaginal sex (M.Y., unpublished data).
A power estimate for condom use was
based on data from the authors’ Teen
Health and Technology survey.22
Eleven percent of LGB1 girls 14 to 18
years old reported having penile-
vaginal or penile-anal sex without
a condom in the past 3 months (M.Y.,
unpublished data). On the basis of
these prevalence estimates and
assuming 80% power and statistical
significance set at P = .05, the
minimum detectable odds ratio we
could detect with a sample size of 420
girls in each experimental group (n =
840) were 0.49 for condomless sex
and 1.66 for abstinence.23–27
Recruitment was more successful
than anticipated, with 948
participants recruited and
randomized.
Incentive
Participants received between $5 and
$35 for completing the survey at
intervention end; incentives varied on
the basis of the mode and length of
the survey they completed (see Data
Collection below). Youth were not
incentivized to complete the baseline
survey.
Data Collection
Baseline surveys were collected
online. We initially intended to collect
intervention end data via text
messaging. When funding
uncertainties arose, we shifted to an
online data collection format. As such,
299 participants completed the
intervention end survey via text
message and 500 completed it online.
Survey mode was balanced by
experimental arm: 62% of control
and 63% of intervention participants
completed the survey online (P = .71).
Program participation length varied
for intervention participants on the
basis of their responsiveness to
programmatic activities. For example,
those who did not respond to a level-
up question or badge message were
sent multiple reminders before the
program content resumed. Thus,
some had an intervention experience
that was longer than 20 weeks.
Measures
Main outcomes included (1) condom-
protected penile-vaginal sex in the
past 3 months, (2) current use of
contraception other than condoms,
(3) abstinence from penile-vaginal
sex in the past 3 months, and (4)
pregnancy since program enrollment.
Secondary outcomes included
behavioral intentions in the next year
to (5) use condoms and (6) other
forms of contraception and (7) be
abstinent. Outcome measures were
adapted from those recommended by
the Office of Adolescent Health.28
Because of the 160-character
limitation in text messages, questions
in the text messaging–based
intervention end survey varied from
the online version. Wording of
outcome measures is shown in Table
2.
Statistical Analyses
Participants who did not complete the
intervention end survey were
excluded from the analyses. Missing
data also occurred within the
intervention end survey when
participants declined to answer an
outcome measure. Intentions to use
condoms (5%), intentions to have
 TABLE 2 Girl2Girl2 RCT Outcome Measures
Measure Online Survey Text (Baseline and Intervention Text Messaging Survey Text (Intervention Outcomes Computation
End) End)
Abstinence in the past In the past 3 months, how many times have Since the beginning of the G2G program Those who answered 0 were coded as being
3 mo you had sex when a human penis went into on [date], how many times have you abstinent. Those who reported 1 or more
your vagina? had sex when a human penis (not times at baseline were coded as being
a toy) went in your vagina? recently sexually active.
No. condom-protected You said you had sex when a human penis And of the [3] times you had sex when Responses were treated as a count.
sex acts in the past (not a toy) went into your vagina [insert a human penis went in your vagina
3 mo number] in the past 3 months. How many since G2G started, how many times did
times did you use a female or male you use female or male condoms?
condom?
Currently using birth Youth were asked 6 separate questions about Are you on birth control? I mean the pill, Current use of birth control was indicated if
control whether they were currently using any shot (Depo-Provera), ring (NuvaRing), online survey respondents answered yes
types of the following methods of birth patch (Xulane), an IUD (like Paragard), to any of the 6 types of birth control
control: (1) birth control pills, (2) the shot or implant (like Implanon). queried, or text message survey
(like Depo-Provera), (3) the patch (like respondents answered yes to the single
Xulane), (4) the ring (like NuvaRing), (5) item.
IUD (like Skyla, Mirena, or Paragard), and
implants (like Implanon or Nexplanon).
Response options were no, yes, I don’t
know what this is, and do not want to
answer. Those who initially said they did
not know about the type of birth control
were directed to a pictorial representation
and a more detailed description.
Pregnancy since RCT As far as you know, have you been pregnant, As far as you know, since Girl2Girl started Those who said yes were coded as having
enrollment even if no child was born, ever/since on [date] have you been pregnant even been pregnant.
Girl2Girl started on [insert start date]? if no child was born?
Intentions to use “If I have sex where a human penis (not a toy) In the next 3 months, if you have sex when Those who said “somewhat true” or very
condoms in the goes into my vagina in the next year, I plan a human penis goes into your vagina, true” online or “Prob” or “Def’ via text
futurea to use or have my partner use a female or do you plan to use female or male were coded as having intentions to use
male condom.” Response options were on condoms? Def not, Prob not, Prob, Def, condoms.
a 5-point Likert scale ranging from very or IDK.
untrue to very true.
Intentions to use birth “In the next year, do you plan to use these “In the next 3 months, do you plan to use Those who said “Yes, probably” or “Yes,
control other than methods of birth control?” The 6 types of birth control (the pill, shot, ring, patch, definitely” to the online survey or “Prob”
condoms in the birth control described above. Response IUD, implant)? Def not, Prob not, Prob, or “Def” via text messaging, and said
futureb options were on a 4-point Liker scale Def, IDK, or not sure what this is.” they were not currently on birth control,
ranging from no, definitely not to yes, were coded as having intentions to use
definitely. birth control.
Intentions to be “In the next year, do you think you might have “And in the next 3 months, do you think Those who responded “Yes, probably” or
abstinent in the the following types of sex with a guy, or you might have sex when a human Yes, definitely” online, of “Prob” or “Def”
future someone with a penis regardless of their penis (not a toy) goes into your vagina? via text were coded as having an
gender presentation?” The specific item Def not, Prob not, Prob, Def, IDK.” intention to be abstinent.
was: “Sex with a human penis (not a toy)
that goes into your vagina.” Response
options were on a 4-point Likert scale
ranging from “no, definitely not” to “yes,
definitely.”
Two hundred and ninety-nine participants completed the intervention end survey via text message and 500, online. Online survey questions were based on those recommended by the
Office of Adolescent Health. Messages were adapted by the authors for text messaging. IDK, I don’t know.
a In the text messaging–based survey, this question was asked of everyone except those who said “definitely not” to the question about intentions to have penile-vaginal sex. It was asked

of everyone in the online survey.

b In the text messaging survey, this question was asked only of those who were not currently on birth control. In the online survey, it was asked of everyone.

penile-vaginal sex (4%), and protected sex; no intention to use the enrollment call. A small number
intentions to use birth control (4%) condoms). As a sensitivity analyses, of youth (n = 10) self-reported
had the highest rates of decline to models also were estimated with these a cisgender identity over the
answer. To analyze a consistent youth eliminated from the analyses. telephone and a noncisgender
sample across outcome measures, identity in the baseline survey.
decline to answer was treated as Analyses were intention to treat; Because these answers were not
outcome failure (eg, no condom- gender identity was assessed during again assessed for eligibility, these

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 youth were included in the study
sample. One of these participants’
baseline surveys was deleted. Eight
completed both the baseline and
follow-up surveys and are included in
analyses.
Logistic regression was used to
quantify the relative odds of
dichotomous measures:
contraception, abstinence, and
behavioral intentions. Poisson
regression was used to quantify the
relative count of condom-protected
sex acts.
Differences in behaviors at baseline
were likely equally distributed
between treatment and control
groups because arm assignment was
random. Because statistically
significant differences in these
characteristics might occur by chance,
any baseline characteristics on which
the experimental arms were
imbalanced were included in
multivariate models. Multivariate
models also adjusted for the baseline
indicator of the outcome in question
(eg, condom-protected sex) and the
survey mode through which the
intervention end survey was
completed (ie, online versus text
messaging).
Analyses were performed twice: once
with all youth and once for youth who
reported penile-vaginal sex in the 90
days before baseline, hereafter
referred to as “sexually active girls.”
Girls who had sex for the first time
during the observation period were
not included in the latter group. The
former provided an estimate of the
intervention effect in the target
population as a whole, and the latter
provided an estimate among those at
greater risk for pregnancy. We also
examined behavioral intentions among
youth who had not had penile-vaginal
sex in the past 3 months at baseline
(ie, were “not sexually active”).
RESULTS
As shown in Fig 1, 59 of 948
participants either actively
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terminated their involvement in the
RCT or were lost to follow-up. The
remaining 94% received all program
messages, thereby completing the
program. Seven hundred and ninety-
nine (84%) completed the
intervention end survey and are
included in the current analyses. No
unintended harms were reported.
Intervention and control participants
were equivalent on their baseline
characteristics except for age, which
was borderline statistically
significantly different (P = .051; see
Table 3).
Behavioral Outcomes
At RCT end, 5 months
postenrollment, 22% of intervention
and 19% of control participants
reported penile-vaginal sex in the
past 3 months; 17% and 13%
reported at least 1 condom-protected
sex act; and 10% and 12% reported
at least 1 condomless protected sex
act, respectively. The number of
condom-protected sex acts ranged
FIGURE 1
CONSORT Diagram for Girl2Girl RCT.
between 0 and 70 for intervention
and 0 to 60 for control participants.
Among those who reported penile-
vaginal sex in the past 3 months at
baseline (ie, sexually active girls),
46% of intervention and 43% of
control participants reported at least
1 condom-protected sex act in the
past 3 months at intervention end;
32% and 49%, respectively, reported
at least 1 condomless protected sex
act over the same time period.
As shown in Table 4, the rate of
condom-protected sex acts in the past
3 months was significantly higher at
intervention end for those in the
intervention versus control group
(adjusted odds ratio [aOR] = 1.48, P ,
.001) after adjusting for survey mode,
age, and number of condom-
protected sex acts at baseline. The
magnitude of association was similar
when examined among sexually
active girls (aOR = 1.64, P , .001).
The intervention also was associated
with significantly lower rates of
condomless sex acts generally (aOR =
 TABLE 3 Comparison of Baseline Characteristics of Girl2Girl RCT Participants Among Those Who Completed the Intervention End Survey (n = 799)
Youth Characteristics Control (n Intervention P
= 410) (n = 389)
Age, mean (SD) 15.97 (1.2) 16.14 (1.2) .051
Hispanic ethnicity, n (%) .25
No 300 (73.2) 302 (77.6)
Yes 109 (26.6) 85 (21.9)
Decline to answer 1 (0.2) 2 (0.5)
Race, n (%) .47
White 226 (55.1) 232 (59.6)
Black or African American 61 (14.9) 57 (14.7)
Asian American 16 (3.9) 14 (3.6)
Native Hawaiian or Other Pacific Islander 3 (0.7) 2 (0.5)
American Indian or Alaska native 9 (2.2) 3 (0.8)
Multiracial 58 (14.2) 54 (13.9)
Some other race 26 (6.3) 23 (5.9)
Do not want to answer 11 (2.7) 4 (1.0)
Rural,a n (%) 70 (17.1) 51 (13.1) .12
Income,b n (%) .86
Lower than the average 122 (29.8) 110 (28.3)
Similar to the average 213 (52.0) 200 (51.4)
Higher than the average 61 (14.9) 62 (15.9)
Do not want to answer 14 (3.4) 17 (4.4)
Sexual identity,c n (%)
Gay 83 (20.2) 78 (20.1) .95
Lesbian 178 (43.4) 169 (43.4) .99
Bisexual 172 (42.0) 170 (43.7) .62
Pansexual 106 (25.9) 121 (31.1) .10
Heterosexual 3 (0.7) 2 (0.5) .70
Queer 89 (21.7) 77 (19.8) .51
Asexual 9 (2.2) 8 (2.1) .89
Questioning 50 (12.2) 43 (11.1) .62
Unsure 7 (1.7) 8 (2.1) .72
Do not want to answer 0 (0) (0) 0 —
Gender identity, n (%) .55
Cisgender female 406 (99.0) 385 (99.0)
Male to female transgenderd 1 (0.2) 0 (0.0)
Male to female transgenderd 0 (0.0) 1 (0.3)
Genderqueer or pangenderd 0 (0.0) 1 (0.3)
I am unsured 2 (0.5) 2 (0.5)
Other 1 (0.2) 0 (0.0)
Do not want to answer 0 (0) 0 (0)
Ever penile-vaginal sex, n (%) .99
No 279 (68.1) 263 (67.6)
Yes 130 (31.7) 125 (32.1)
Do not want to answer 1 (0.2) 1 (0.3)
Penile-vaginal sex in the past 3 mo, n (%) .75
No 342 (83.4) 319 (82.0)
Yes 67 (16.3) 68 (17.5)
Do not want to answer 1 (0.2) 2 (0.5)
No. condom-protected vaginal sex acts in the past 3 mo, mean (SD) 0.8 (5.7) 1.1 (4.9) .42
Do not want to answer 0 (0) 0 (0)
Currently on birth control, n (%) .45
Yes, to any 101 (24.6) 87 (22.4)
Birth control pills .82
No 339 (82.7) 324 (83.3)
Yes 71 (17.3) 65 (16.7)
I don’t know what this is 0 (0) 0 (0)
Do not want to answer 0 (0) 0 (0)
The shot .69
No 401 (97.8) 382 (98.2)
Yes 9 (2.2) 7 (1.8)
I don’t know what this is 0 (0) 0 (0)

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 TABLE 3 Continued
Youth Characteristics Control (n Intervention P
= 410) (n = 389)
Do not want to answer 0 (0) 0 (0)
The patch .62
No 405 (98.8) 385 (99.0)
Yes 4 (1.0) 2 (0.5)
I don’t know what this is 1 (0.2) 2 (0.5)
Do not want to answer 0 (0) 0 (0)
The ring .82
No 406 (99.0) 384 (98.7)
Yes 3 (0.7) 3 (0.8)
I don’t know what this is 1 (0.2) 2 (0.5)
Do not want to answer 0 (0) 0 (0)
IUD .15
No 400 (97.6) 384 (98.7)
Yes 7 (1.7) 1 (0.3)
I don’t know what this is 3 (0.7) 3 (0.8)
Do not want to answer 0 (0.0) 1 (0.3)
Implants .44
No 393 (95.9) 379 (97.4)
Yes 16 (3.9) 9 (2.3)
I don’t know what this is 1 (0.2) 1 (0.3)
Do not want to answer 0 (0) 0 (0)
Ever pregnant, n (%) .50
No 388 (94.6) 369 (94.9)
Yes 15 (3.7) 13 (3.3)
I don’t know 5 (1.2) 7 (1.8)
Do not want to answer 0.5% (2) 0.0% (0)
—, not applicable.
a Based on the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties.29
b Self-appraised.
c Multiple response.
d Gender identity was assessed during the enrollment call. A small number of youth self-reported a noncisgender identity in the baseline survey. Because these answers were not again

assessed for eligibility, they were included in the sample.

0.79, P = .007) and among sexually
active girls specifically (aOR = 0.65, P
, .001).
The relative odds of current use of
birth control other than condoms was
60% higher in the intervention versus
control group (aOR = 1.60, P = .02).
Differences were not significant
among sexually active girls, however
(aOR = 0.98, P = .97).
The relative odds of abstaining from
penile-vaginal sex in the past 3
months at intervention end were
statistically similar for intervention
and control participants generally
(aOR = 0.82, P = .34) and sexually
active girls specifically (aOR = 1.20, P
= .63).
The magnitude of the relative odds of
pregnancy between intervention and
control participants was clinically
meaningful but not statistically
significant in general (aOR = 0.43, P =
.23) or among sexually active girls
(aOR = 0.39, P = .21).
Behavioral Intentions
As shown in Table 4, the relative odds
of intending to use birth control
among girls who were not currently
on birth control were significantly
higher for those in the intervention
versus control group at intervention
end (aOR = 1.93, P = .001). This also
was true among sexually active girls
(aOR = 3.25, P = .052) and abstinent
girls (aOR = 1.87, P = .003). When
girls who intended to use birth
control were combined with girls
currently on birth control, the relative
odds of being in the intervention
group were significantly higher
among all girls (aOR = 2.08, P ,
.001), as well as among sexually
active (aOR = 3.02, 0.04) and
abstinent (aOR = 2.10, P , .001) girls
specifically (data not shown).
Intentions to use condoms (aOR =
1.09, P = .59) and intentions to be
abstinent did not differ by study arm
(aOR = 0.95, P = .77).
Sensitivity Analysis
Results were similar when youth who
declined to answer an outcome
question were dropped rather than
coded as failure. Data are available on
request.
DISCUSSION
To our knowledge, Girl2Girl is the
first pregnancy prevention program
developed for and tested among
sexual minority girls across the
United States and the first
comprehensive, technology-based
teenage pregnancy prevention
program for any group of youth. In

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 TABLE 4 Pregnancy Preventive Behavior and Intentions Outcomes at Girl2Girl RCT Intervention End (n = 799)
Pregnancy Preventive Behaviors and Intentions Control Intervention IRR/ 95% CI P IRR/ 95% CI P
(n = 410) (n = 389) OR aOR
No. condom-protected sex acts in the past 3 mo
All youth (n = 799) mean (SD) 1.2 (6.0) 1.4 (5.9) 1.21 1.07–1.37 .002 1.48 1.30–1.68 ,.001
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 4.7 (11.9) 5.3 (11.6) 1.13 0.97–1.31 .13 1.64 1.40–1.93 ,.001
mean (SD)
No. condomless sex acts in the past 3 moa
All youth (n = 799) mean (SD) 0.7 (2.3) 0.6 (2.1) 0.83 0.70–0.99 .04 0.79 0.66–0.94 .007
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 3.5 (4.4) 2.3 (3.8) 0.64 0.52–0.79 ,.001 0.65 0.53–0.80 ,.001
mean (SD)
Currently using birth control, n (%)
All youth (n = 799) 110 121 (31.1) 1.23 0.91–1.67 .18 1.60 1.08–2.37 .02
(26.8)
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 37 (55.2) 33 (48.5) 0.76 0.39–1.50 .44 0.98 0.41–2.34 .97
Abstaining from penile-vaginal sex in the past 3 mo, n (%)
All youth (n = 799) 330 301 (77.4) 0.83 0.59–1.17 .28 0.82 0.55–1.23 .34
(80.5)
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 22 (32.8) 26 (38.2) 1.27 0.62–2.57 .51 1.20 0.57–2.55 .63
Pregnancy since program enrollment, n (%)
All youth (n = 799) 8 (2.0) 3 (0.8) 0.39 0.10–1.48 .17 0.43 0.11–1.70 .23
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 7 (10.5) 3 (4.4) 0.40 0.10–1.60 .19 0.39 0.09–1.73 .21
Intentions to use condoms in the next year, n (%)
All youth (n = 799) 265 261 (67.1) 1.12 0.83–1.50 .46 1.09 0.79–1.52 .59
(64.6)
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 41 (61.2) 48 (70.6) 1.52 0.74–3.12 .25 1.54 0.72–3.30 .26
Youth who have not had sex (n = 661) 223 213 (66.8) 1.07 0.78–1.48 .67 1.04 0.72–1.51 .84
(65.2)
Intentions to use birth control in the next year,b n (%)
All youth (n = 568) 99 (33.0) 128 (47.8) 1.86 1.32–2.61 ,.001 1.93 1.31–2.84 .001
Youth who have had vaginal sex in the past 3 mo at baseline (n = 65) 15 (50.0) 27 (77.1) 3.37 1.16–9.79 .03 3.25 0.99–10.70 .052
Youth who have not had sex (n = 500) 83 (30.9) 101 (43.7) 1.74 1.21–2.51 .003 1.87 1.24–2.84 .003
Intentions to be abstinent in the next year, n (%)
All youth (n = 799) 178 157 (40.4) 0.88 0.67–1.17 .38 0.95 0.67–1.35 .77
(43.4)
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 9 (13.4) 7 (10.3) 0.74 0.26–2.12 .57 0.75 0.23–2.42 .63
Youth who have not had sex (n = 661) 169 150 (47.0) 0.91 0.67–1.23 .54 0.95 0.65–1.38 .79
(49.4)
Sample size for intentions does not equal 799 because 3 people who declined to answer about recent vaginal sex are not included in either category. Models adjusted for survey mode,
age, and baseline indicator of outcome of interest (eg, condom use). aIRR, adjusted incident rate ratio; aOR, adjusted odds ratio; IRR, incident rate ratio; OR, odds ratio.
a Because of outliers (range: 0–663, SD = 24.2), censored at 101 acts.
b Among those not currently on birth control.

this large-scale RCT, outcomes at
intervention end suggest that
Girl2Girl is associated with increased
rates of condom use and increased
odds of using other types of
contraception. The intervention also
appears to be associated with
increased intentions to use birth
control among girls not on birth
control. Although few pregnancies
were reported over the 5 months, the
intervention group had half the odds
of pregnancy versus the control
group; given this rare event, the effect
size was not statistically significant.
Taken together, these findings suggest
that Girl2Girl may be associated with
multiple pregnancy preventive
behaviors, at least in the short-term.
Girl2Girl does not appear to be
effective in promoting sexual
abstinence or a return to abstinence
among recently sexually active girls.
This may be in part because the
health promotion messages were
intentionally sex positive and focused
on healthy relationships and use of
barriers and testing, rather than
solely emphasizing abstinence. Also,
other researchers have documented
that abstinence-focused interventions
appear to have no effect on sexually
active girls.30,31 Future research
about sex-positive programs that
includes sexually experienced and
inexperienced youth might consider
adding an outcome that reflects self-
efficacy to consent to sex when it is
wanted and demur to sex when it is
not.
Limitations
Given the nature of the intervention,
findings may not be generalizable to
girls who do not use social media or
have cell phones with a limited
messaging plan. Moreover, social
media advertising was targeted to
girls whose profiles indicated they
were “interested in” other girls.
Therefore, girls who saw the ads were

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 “out” at least on their social media
profile. Findings may not be
generalizable to those who are not
out to others. Additionally, it is
impossible to determine if
a particular program message was
read. This is not unlike school-based
programs in which it is unknown
whether students are listening to the
intervention facilitator. Finally,
because of funding uncertainty,
surveys at intervention end were
collected either via text messaging or
online. Aside from potential mode
differences, questions were worded
slightly differently and, in some cases,
referred to different time frames (eg,
next 12 months versus next 3
months). To mitigate the potential
impact of this, we adjusted for survey
mode in multivariate models.
Balancing these limitations, it should
be noted that the national sample was
diverse in terms of race and ethnicity,
sexual identity, rural and urban
setting, and age. The intervention also
was novel in its intervention target
(ie, sexual minority girls), delivery
mechanism (ie, comprehensive text
messages), and scope (ie, across the
United States).
Implications
Reviews suggest that text
messaging–based interventions can
affect and sustain complex health
behavior changes across a variety of
behaviors, including HIV testing,
medication adherence, physical
activity, and smoking cessation.32–42
Results here provide reason for
optimism that this approach can be
effective with adolescent pregnancy
prevention as well.
The high program completion rate
suggests that sexual minority
adolescent girls are willing to receive
voluminous amounts of sexual health-
related text messages over
a relatively long period of time (ie, 5
months). Given the relative cost
efficiency and wide reach of text
messaging as a delivery mechanism
compared with more traditional
models such as facilitator-based
education,43 researchers may
consider using this modality to
address other adolescent behavior
change efforts as well.
Opportunities for future research are
noted. First, it is unknown whether
some or all components of the
intervention (eg, Text Buddy,
G2Genie, level-up questions)
meaningfully contributed to behavior
change. Understanding the relative
contributions of these features could
inform the future development of
technology-based interventions that
seek to include game-like program
components. Second, girls of various
sexual minority identities were
analyzed together. Subsequent
research may wish to examine
outcomes for lesbian and bisexual
girls separately given they differ in
their sexual behaviors with girls and
boys.17,44 Additionally, it would be
useful to explore the optimal length of
interventions such as this, as well as
the timing of the booster delivery.
Other important questions include
whether the behavioral changes are
sustained over time and if behavioral
changes are noted in an effectiveness
trial.
CONCLUSIONS
Sexual minority girls are
significantly more likely to be
pregnant during their teenage years
compared to heterosexual girls and
yet, limited teenage pregnancy
prevention programming is available
that is tailored to their needs.
Findings suggest that Girl2Girl is
associated with changes in teenage
pregnancy preventive behaviors and
behavioral intentions with both
sexual minority girls who are having
penile-vaginal sex and those who are
not, at least in the short-term. The
latter are key to a comprehensive
public health approach that gives all
girls the tools they need to make
healthy decisions if, and when, they
choose to have sex that could lead to
pregnancy.
ACKNOWLEDGMENTS
We thank the study participants and
research team, particularly Katrina
Nardo, Dr Myeshia Price-Feeney, and
Desiree Fehmie for their
contributions to the study.
ABBREVIATIONS
aOR: adjusted odds ratio
LGB1: lesbian, gay, bisexual and
other sexual minority
RCT: randomized controlled trial

Address correspondence to Michele Ybarra, MPH, PhD, Center for Innovative Public Health Research, 555 N. El Camino Real No. A347, San Clemente, CA 92672. E-mail:
michele@innovativepublichealth.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2021 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Research reported in this publication was supported by the Office of Population Affairs (TP2AH000035) and the National Institute of Child Health and
Human Development (R01HD095648). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Office of
Population Affairs and the National Institutes of Health. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

10 YBARRA et al
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 COMPANION ARTICLE: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/2020-029801.
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YBARRA et al
APENDICE IV – Análise crítica de um artigo: Maria João Mourão Nogueira
M ª João Mourão Nogueira

Trabalho individual de síntese crítica de um artigo científico de avaliação crítica de

artigos científicos da JBI.

JBI CRITICAL APPRAISAL CHECKLIST FOR COHORT STUDIES

Reviewer: Mª João Mourão Nogueira Date: 27 de fev. 2023

Author: X. Wang, Z. Tang, Z. Wu, Qnong and Y. Li. Year: 2020

Yes No Unclear Not

applicable
1. Were the two groups similar and recruited from the
same population?
“The required sample size was estimated using the formula:
where Za = 1.96 and d = 0.1

“Based on these assumptions, the baseline sample size required was

calculated to be 522 MSM.” and “Study eligibility criteria included being
biologically male, being ≥ 18 years old, currently living in Beijing or
Nanning, and having had at least one sexual contact with another man in
the past 12 months.”
x □ □ □
“recruited through online advertising posted in mobile phone applications,
instant messaging chat rooms, blogs, and other websites known to be
frequently used in the Chinese MSM community. MSM were also
recruited at CDC VCT clinics or by referral by study participants.” N= 521

2. Were the exposures measured similarly to assign people

to both exposed and unexposed groups?

“For the baseline study, participants received pre-test counselling and

signed a written informed consent form. They were each then given an oral
HIVST kit and self-administered the test on-site. Participants next x □ □ □
provided blood samples for confirmatory HIV testing and completed a
questionnaire. All subjects received post-test counselling.” N= 279

3. Was the exposure measured in a valid and reliable way?

“The questionnaire was based on one previously used in the MSM

population in Beijing but modified to meet the requirements of this study.

□ □ □
This modified questionnaire was piloted by five MSM and feedback from
this pilot was incorporated prior to its use in this study. The questionnaire
included questions intended to collect information on demographic and
behavioural characteristics, HIV testing history, willingness to use an oral
x
HIV test, and preferred testing method. Trained interviewers administered
questionnaires via face-to-face interviews in private rooms.”

4. We’re confounding factors identified?

“Education level; Proportion of male sex partners met online ever ; Sought
a male sex partner in a park or public toilet at least once a month in the
x □ □ □
past 1 year; Tested for HIV in the past 6 months ;Number of previous HIV
M ª João Mourão Nogueira

Trabalho individual de síntese crítica de um artigo científico de avaliação crítica de

artigos científicos da JBI.

tests ; Seeking HIV knowledge mainly via the internet; seeking

information about HIV intervention programmes such as testing mainly
via the internet”

5. Were strategies to deal with confounding factors

stated?
Não – estudo observacional
□ □ □ x
6. Were the groups/participants free of the outcome at
the start of the study (or at the moment of exposure)? □ □ □ x
7. Were the outcomes measured in a valid and reliable
way?

□ □ □
“At follow-up, the questionnaire was shortened to include only questions
about sexual behaviour characteristics, HIV testing history, willingness to
use an oral HIV test, and preferred testing method. Trained interviewers
x
administered questionnaires via face-to-face interviews in private rooms”

8. Was the follow up time reported and sufficient to be

long enough for outcomes to occur?
“3-12 months”
x □ □ □
9. Was follow up complete, and if not, were the reasons to
loss to follow up described and explored?
“There were no significant differences in any of the socio-demographic
characteristics between those who attended follow-up (n = 279) and those
who were lost to follow-up (n = 181; data not shown), or between those x □ □ □
recruited via the internet (n = 85) and those recruited via peer referral (n =
194; data not shown).”

10. Were strategies to address incomplete follow up

utilized?
“The v2 test was performed to assess whether there were any statistically
significant diferences in demographic characteristics between participants
who presented for follow-up and those who were lost to follow-up. All P-
x □ □ □
values are two-sided. P-values < 0.05 were considered statistically
significant.”

11. Was appropriate statistical analysis used?

“Study data were double-entered using EPIDATA3.1 (The Epidata

Association Odense, Odense, Denmark). Data analysis was performed in
x □ □ □
SPSS 17.0TM (SPSS Inc., Chicago, IL). “

Overall appraisal: Include x Exclude □ Seek further info □

Comments (Including reason for exclusion): Estudo de Cohort incluído/ selecionado dado o rigor na seleção das
amostras (critérios de seleção, questionários e testagem sanguínea de VIH adaptados ao estudo e aplicados por
M ª João Mourão Nogueira

Trabalho individual de síntese crítica de um artigo científico de avaliação crítica de

artigos científicos da JBI.

profissionais), a análise dos resultados (confounding factos identificados e analisados – p < 0.001) e dadas as estratégias de
para a abordagem dos participantes que não concluíram/ não integraram (inferior a 80% - 39.3% da amostra).
 14681293, 2020, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hiv.12830 by Cochrane Portugal, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DOI: 10.1111/hiv.12830
© 2019 British HIV Association HIV Medicine (2020), 21, 322--333
ORIGINAL RESEARCH

Promoting oral HIV self-testing via the internet among men

who have sex with men in China: a feasibility assessment
X Wang 1 Z Tang,2 Z Wu,1 Q Nong3 and Y Li4
1
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing,
China, 2Guangxi Center for Disease Control and Prevention, Nanning, China, 3The Eighth People’s Hospital of Nanning,
Nanning, China and 4Fengtai District Center for Disease Control and Prevention, Beijing, China

Objectives
The HIV prevalence among Chinese men who have sex with men (MSM) is high, while the HIV
testing rate is low. HIV self-testing (HIVST) is a promising means of scaling up HIV testing among
MSM in China, as the ability to test in private is appealing to many individuals. We evaluated the
feasibility of promoting oral HIVST via the internet in the MSM population.
Methods
From April 2013 to April 2014, MSM in two major cities in China were recruited for an
observational study with assessment at baseline and follow-up. Data were collected via
questionnaire, oral HIVST, and clinic-based HIV confirmatory testing.
Results
A total of 510 MSM were recruited at baseline and 279 (54.7%) returned for a clinic follow-up
visit. Compared to MSM recruited via peer referral, those recruited via the internet were better
educated, had a higher monthly income, sought and met male sex partners online more frequently,
had less often tested or orally tested for HIV before, and being more likely to seek HIV knowledge
or HIV intervention information online. The sensitivity of oral HIVST among MSM recruited via
the internet was 92.9%, and the specificity was 96.8%. A total of 19.0% of MSM sought both male
sex partners and HIV intervention programmes online. The associated factors were > 10 past male
sex partners and ever testing for HIV using an oral self-test kit. All MSM who were followed up
re-administered oral HIVST, yet fewer MSM recruited via the internet accepted blood retesting than
other MSM.
Conclusions
Promoting oral HIVST via the internet could be a feasible and promising approach to facilitate HIV
testing among MSM in China.
Keywords: China, HIV, internet, men who have sex with men, self-testing
Accepted 8 November 2019

Introduction facilitating HIV testing.[6] However, the limitations of

The prevalence of HIV infection has been increasing
among men who have sex with men (MSM) in China.[1,2]
National sentinel surveillance data showed that the HIV
prevalence among Chinese MSM had increased annually,
from 0.9% in 2003 to 7.7% in 2014.[3] The “test and
treat” strategy has been proved to be effective in prevent-
ing HIV infection.[4,5] Existing testing strategies, such as
voluntary counselling and testing (VCT), have been
Correspondence: Dr Xiaofang Wang, National Center for AIDS/STD Con-
trol and Prevention, Chinese Center for Disease Control and Prevention,
155 Changbai Road, Changping District, Beijing 102206, China.
Tel: +86 10 5890 0952; fax: +861058900385; e-mail: fangerwon@163.com
such strategies in terms of expanding testing have
become clear. Around 33.2% of MSM in China have
never been tested for HIV.[7,8]
Use of HIV self-testing (HIVST), which is strongly rec-
ommended by the World Health Organization (WHO) and
is conducted by individuals at home or in other private
venues without specialized training, is an alternative
strategy to facility-based testing that could address barri-
ers of discrimination and increase access to HIV test-
ing.[9,10] An oral self-test may be more efficient as a
point-of-care self-test compared to a blood sample test as
a consequence of its being noninvasive and painless, and
the testing kit being easily disposable.[11–14] Studies

322
 14681293, 2020, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hiv.12830 by Cochrane Portugal, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HIV self-testing among MSM 323

conducted in the USA,[15] Singapore[16] and Malawi[17]
found high acceptability of HIVST, and high accuracy of
oral HIVST.
MSM in China have high rates of internet usage.[6]
MSM engaging in higher risk sexual behaviours such as
condomless anal intercourse (CAI) are more likely to be
recruited online or use the internet to seek sex part-
ners.[18,19] The internet has been increasingly used as a
cost-effective method of delivering HIV interventions
such as testing.[20–22] Although not authorized in China,
HIVST kits are easily available online.
Several studies in China reported high willingness to
conduct oral HIVST; one of them reported the accuracy
of the test.[7,11,23] However, few studies have evaluated
the feasibility of promoting HIVST via the internet for
MSM. The aim of this study was to assess the acceptabil-
ity and accuracy of oral HIVST among Chinese MSM
recruited online and to evaluate the potential to facilitate
HIVST uptake via the internet.
male, (2) being ≥ 18 years old, (3) currently living in Bei-
jing or Nanning, and (4) having had at least one sexual
contact with another man in the past 12 months.
Baseline study
A schematic of the study design is depicted in Fig. 1. For
the baseline study, participants received pre-test coun-
selling and signed a written informed consent form. They
were each then given an oral HIVST kit and self-adminis-
tered the test on-site. Participants next provided blood
samples for confirmatory HIV testing and completed a
questionnaire. All subjects received post-test counselling.
After the baseline study had been completed, all partic-
ipants were notified of their confirmatory HIV test result
and received post-test counselling. Confirmed HIV-posi-
tive participants were referred to treatment. Confirmed
HIV-negative participants were requested to return for

Methods
Study setting and sample size
This observational study was conducted from April 2013
to April 2014 in Beijing, northern China, and in Nanning,
southern China. These locations were selected based on
their being large capital cities, in different regions, with
large MSM populations, and their having local Centers
for Disease Control and Prevention (CDC) workers who
have strong relationships with the MSM communities.
The HIV prevalences in MSM in Beijing and Nanning
were both estimated to be 6.7% based on 2012 sentinel
surveillance data.[6,24] The required sample size was esti-
mated using the formula:
 2
Za
n¼ ð1pÞp
d
where Za = 1.96 and d = 0.1. Thus, the number of HIV-
positive participants needed for an estimated sensitivity
(Se) of 90% was found to be 35. Based on these assump-
tions, the baseline sample size required was calculated to
be 522 MSM.

Study recruitment and participant screening

MSM were recruited through online advertising posted in
mobile phone applications, instant messaging chat rooms,
blogs, and other websites known to be frequently used in
the Chinese MSM community. MSM were also recruited
at CDC VCT clinics or by referral by study participants.
Study eligibility criteria included (1) being biologically Fig. 1 Schematic of the study design.

© 2019 British HIV Association HIV Medicine (2020), 21, 322--333


324 X Wang et al.
the one-time, follow-up study any time between 3 and 12
months after baseline.
Follow-up study
At follow-up, participants were again given pre-test coun-
selling, and could choose to perform an oral HIVST or
receive a blood HIV test or both. Participants again com-
pleted a questionnaire and received post-test counselling.
Oral HIV self-testing
TM
In this study, the Aware HIV-1/2 OMT kit (Calypte
Biomedical Corporation, Portland, OR, USA; manufac-
tured and distributed in China by Beijing Marr Bio-Phar-
maceutical Co., Ltd, Beijing, China) was used for HIVST
by participants. This test is a rapid, qualitative
immunochromatographic assay for the visual detection of
HIV-1 and HIV-2 antibodies in oral fluid. Users are
informed of the test result by visual inspection of a test
strip after approximately 20 min. Instructions for use
were provided in Mandarin Chinese. Participants con-
ducted the self-test following the directions in the
instructions. The same CDC researcher was present for
each test to provide help, if necessary. Participants
reported the result to the researcher, and then the
researcher also directly observed the result. If an invalid
test result was obtained, the participant was instructed to
conduct one more test.
Confirmatory HIV blood testing
Whole blood samples from all study participants were
sent to CDC laboratories very near to the study clinics on
the same day for centrifugal separation of serum. The
serum samples were stored for a maximum of 5 days at
80°C. Serum samples were then tested for HIV antibod-
ies using the standard protocol for HIV testing in China:
an enzyme-linked immunosorbent assay (ELISA) (Diag-
nostic Kit for Antibody to HIV 1 and/or 2 and HIV-1
Antigen; Bio-Rad, Marnes-la-Coquette, France) followed
by western blot (WB; HIV Blot 2.2 WB; MP Biomedicals
Asia Pacific Pte Ltd, Singapore) only for samples testing
HIV-positive by ELISA.
Baseline and follow-up questionnaires
The questionnaire was based on one previously used in
the MSM population in Beijing[25] but modified to meet
the requirements of this study. This modified question-
naire was piloted by five MSM and feedback from this
pilot was incorporated prior to its use in this study. At
© 2019 British HIV Association
14681293, 2020, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hiv.12830 by Cochrane Portugal, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
baseline, the questionnaire included questions intended to
collect information on demographic and behavioural
characteristics, HIV testing history, willingness to use an
oral HIV test, and preferred testing method. At follow-up,
the questionnaire was shortened to include only questions
about sexual behaviour characteristics, HIV testing his-
tory, willingness to use an oral HIV test, and preferred
testing method. Trained interviewers administered ques-
tionnaires via face-to-face interviews in private rooms.
Data analysis
Categorical variables are presented as number and per
cent, while continuous variables are presented as mean
and interquartile range (IQR). Factors associated with
seeking male sex partners and HIV intervention pro-
grammes via the internet were assessed using univariable
and multivariable analysis. Univariable logistic regression
was performed for all demographic, sexual behaviour,
testing behaviour, and sexual health characteristics as
independent variables. Variables with P-values < 0.05 in
univariable analysis were included in the multivariable
analysis. Unadjusted odds ratios (ORs), adjusted ORs
(AORs), and 95% confidence intervals (CIs) were calcu-
lated in univariable and multivariable analyses. Univari-
able Poisson regression was performed to assess risk
factors for HIV incidence. The v2 test was performed to
assess whether there were any statistically significant dif-
ferences in demographic characteristics between partici-
pants who presented for follow-up and those who were
lost to follow-up. All P-values are two-sided. P-val-
ues < 0.05 were considered statistically significant.
The usability of the oral HIVST was described by com-
paring oral test results with blood test results. Sensitivity
(Se) was defined as the proportion of true positives to the
sum of true positives and false negatives. Specificity (Sp)
was defined as the proportion of true negatives to the sum
of true negatives and false positives. Positive predictive
value (PPV) was defined as the proportion of true positives
to the sum of true positives and false positives. Negative
predictive value (NPV) was defined as the proportion of
true negatives to the sum of true negatives and false nega-
tives. Participants who refused confirmatory HIV blood
testing were excluded from these analyses.
Study data were double-entered using EPIDATA3.1 (The
Epidata Association Odense, Odense, Denmark). Data anal-
ysis was performed in SPSS 17.0TM (SPSS Inc., Chicago, IL).
Ethical approval
This study was reviewed and approved by the Institu-
tional Review Board of the Guangxi Center for Disease
HIV Medicine (2020), 21, 322--333

Control and Prevention. All participants completed writ-
ten informed consent forms prior to HIV testing in the
baseline study.
RESULTS
Characteristics of the baseline study cohort
A flow chart describing how the study cohort was devel-
oped is shown in Fig. 2. Among the 521 MSM screened,
510 MSM (97.7%) met the eligibility criteria. All 510
MSM chose to enroll in the study and thus comprised the
baseline study cohort.
Table 1 displays the demographic, sexual behaviour,
testing behaviour, and sexual health characteristics of
the baseline cohort of all the 510 MSM, the 140 MSM
recruited via the internet, and the 370 MSM recruited
via peer referral. Most participants were over the age of
25 years (62.4%), Han Chinese (76.7%), from a rural
hometown setting (75.3%) and not local residents of
Beijing or Nanning (70.8%). Roughly half of the partici-
pants had at least some college-level education (50.4%).
Most were never married (73.3%), were employed full-
time (71.4%), and reported no illicit drug use in the past
Fig. 2 Number of participants at baseline and follow-up.
© 2019 British HIV Association
14681293, 2020, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hiv.12830 by Cochrane Portugal, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HIV self-testing among MSM 325
6 months (69.6%). Approximately half of participants
self-identified as homosexual (53.5%) and one-third as
bisexual (34.5%), with the remaining participants either
self-identifying as heterosexual (0.8%) or uncertain
(11.2%).
In terms of sexual behaviour, a majority of partici-
pants reported a male–male sexual debut at before
25 years of age (76.1%), nearly half reported having had
more than 10 male sex partners in their lifetime
(42.6%), and most reported having had two or more
partners in the past 6 months (67.8%). A majority
reported having had regular sex partners in their life-
time (80.2%). In the previous 6 months, approximately
one-third of participants reported having had receptive
CAI (33.5%) and insertive CAI (33.9%). Nearly half of
participants reported having had sex with a female part-
ner in their lifetime (44.7%).
A majority of participants had previous experience
with HIV testing: 35.7% reported receiving testing more
than four times in their lifetime and 44.1% reported
receiving testing within the previous 6 months. When
asked how participants knew of their regular and nonreg-
ular male sex partners’ HIV serostatus, 23.5% of partici-
pants reported that they attended testing and received
results together with their regular partner, while only
5.7% reported this method for their nonregular partner.
More than one-third of participants used questioning or
visual inspection of their regular (38.6%) or nonregular
(34.1%) partners to determine their HIV serostatus. A
total of 18.0% participants did not know their regular
partners’ HIV serostatus and 41.4% did not know their
nonregular partners’ HIV serostatus.
Most participants had never used an oral HIVST kit
(76.5%), but most reported being willing to use such a kit
outside of the present study (78.6%). However, a majority
(58.6%) reported unwillingness to purchase an oral HIV
self-test kit in the 6 months after the study, assuming
that the cost was approximately CNY 50 (~US$8.00).
Most participants responded that their preferred testing
method was blood test (65.5%).
Compared to MSM recruited via peer referral, those
recruited via the internet were better educated
(P < 0.001), had a higher monthly income (P = 0.002),
had more illicit drug use in the past 6 months
(P = 0.004), had an earlier male–male sexual debut
(P = 0.007), sought and met male sex partners online
more frequently (P = 0.005 and P < 0.001, respectively),
had less frequently tested or orally tested for HIV before
(P < 0.001 and P < 0.001, respectively), and were more
likely to have sought HIV knowledge or HIV intervention
information via the internet (P < 0.001 and P < 0.001,
respectively).
HIV Medicine (2020), 21, 322--333
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326 X Wang et al.

Table 1 Characteristics of participants in the baseline cohort

MSM recruited MSM recruited

Baseline cohort via internet via peer referral OR
Characteristic (n = 510) (n = 140) (n = 370) P (95% CI)

Demographics
Age (years)
Median (IQR) 28 (23–36) 27 (23-32) 29 (24-38)
≤ 25 years [n (%)] 192 (37.6) 61 (43.6) 131 (35.4) 0.089 1.4 (0.9-2.1)
> 25 [n (%)] 318 (62.4) 79 (56.4) 239 (64.6) 1.0
Ethnicity [n (%)]
Han Chinese 391 (76.7) 100 (71.4) 291 (78.6) 0.086 0.7 (0.4-1.1)
Other 119 (23.3) 40 (28.6) 79 (21.4) 1.0
Hometown setting [n (%)]
Rural 384 (75.3) 98 (70.0) 286 (77.3) 0.089 0.7 (0.4-1.1)
Urban 126 (24.7) 42 (30.0) 84 (22.7) 1.0
Local residence [n (%)]
Yes 149 (29.2) 45 (32.1) 104 (28.1) 0.371 1.2 (0.8-1.8)
No 361 (70.8) 95 (67.9) 266 (71.9) 1.0
Education level [n (%)]
≥ College 257 (50.4) 98 (70.0) 159 (43.0) < 0.001 3.1 (2.0-4.7)
≤ High school 253 (49.6) 42 (30.0) 211 (57.0) 1.0
Marital status [n (%)]
Never married 377 (73.9) 113 (80.7) 264 (71.4) 0.032 1.7 (1.0-2.7)
Married, divorced or widowed 133 (26.1) 27 (19.3) 106 (28.6) 1.0
Employment status [n (%)]
Employed full-time 364 (71.4) 103 (73.6) 261 (70.5) 0.713 0.9 (0.6-1.5)
Employed part-time 33 (6.5) 3 (2.1) 30 (8.1) 0.022 0.2 (0.1-0.8)
Unemployed 113 (22.2) 34 (24.3) 79 (21.4) 1.0
Monthly income [n (%)]
< CNY 3000 289 (56.7) 64 (45.7) 225 (60.8) 0.002 0.5 (0.4-0.8)
≥ CNY 3000 221 (43.3) 76 (54.3) 145 (39.2) 1.0
Illicit drug use in the past 6 months [n (%)]
Yes 152 (29.8) 55 (39.3) 97 (26.2) 0.004 1.8 (1.2-2.7)
No 358 (70.2) 85 (60.7) 273 (73.8) 1.0
Self-reported sexual orientation [n (%)]
Homosexual 273 (53.5) 79 (56.4) 194 (52.4) 0.509 0.8 (0.4-1.5)
Bisexual 176 (34.5) 40 (28.6) 136 (36.8) 0.112 0.6 (0.3-1.1)
Heterosexual 4 (0.8) 2 (1.4) 2 (0.5) 0.505 2.0 (0.3-15.3)
Uncertain 57 (11.2) 19 (13.6) 38 (10.3) 1.0
Sexual behaviour [n (%)]
Age of male–male sexual debut
Median (IQR) 22 (19–25) 21 (18-24) 22 (19-26)
< 25 years [n (%)] 359 (70.4) 111 (79.3) 248 (67.0) 0.007 1.9 (1.2-3.0)
≥ 25 [n (%)] 151 (29.6) 29 (20.7) 122 (33.0) 1.0
Sought a male sex partner online at least once a month in the past 1 year [n (%)]
Yes 197 (38.6) 68 (48.6) 129 (34.9) 0.005 1.8 (1.2-2.6)
No 313 (61.4) 72 (51.4) 241 (65.1) 1.0
Proportion of male sex partners met online ever [n (%)]
> 75% 271 (53.1) 104 (74.3) 167 (45.1) < 0.001 14.6 (5.2-41.0)
≤ 75% 141 (27.6) 32 (22.9) 109 (29.5) < 0.001 6.9 (2.4-20.2)
None 98 (19.2) 4 (2.9) 94 (25.4) 1.0
Sought a male sex partner in a park or public toilet at least once a month in the past 1 year [n (%)]
Yes 77 (15.1) 4 (2.9) 73 (19.7) < 0.001 0.1 (0.04-0.3)
No 433 (84.9) 136 (97.1) 297 (80.3) 1.0
Number of past male sex partners
Median (IQR) 10 (4–20) 10 (4-30) 10 (4-20)
> 10 [n (%)] 212 (41.6) 64 (45.7) 148 (40.0) 0.243 1.3 (0.9-1.9)
≤ 10 [n (%)] 298 (58.4) 76 (54.3) 222 (60.0) 1.0
Ever had a regular male sex partner [n (%)]
Yes 409 (80.2) 119 (85.0) 290 (78.4) 0.094 1.6 (0.9-2.6)
No 101 (19.8) 21 (15.0) 80 (21.6) 1.0
Role during anal intercourse in the past 6 months [n (%)]
Both 220 (43.1) 55 (39.3) 165 (44.6) 0.085 0.5 (0.2-1.1)
Insertive 145 (28.4) 40 (28.6) 105 (28.4) 0.166 0.5 (0.2-1.3)
Receptive 121 (23.7) 35 (25.0) 86 (23.2) 0.221 0.6 (0.2-1.4)
No anal intercourse 24 (4.7) 10 (7.1) 14 (3.8) 1.0

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HIV self-testing among MSM 327

Table 1 (Continued)

MSM recruited MSM recruited

Baseline cohort via internet via peer referral OR
Characteristic (n = 510) (n = 140) (n = 370) P (95% CI)

Number of male sex partners in the past 6 months

Median (IQR) 2 (1–4) 2 (1–4) 2 (1–4)
≥ 2 [n (%)] 346 (67.8) 96 (68.6) 250 (67.6) 0.829 1.0 (0.7-1.6)
< 2 [n (%)] 164 (32.2) 44 (31.4) 120 (32.4) 1.0
Had group sex in the past 6 months [n (%)]
Yes 45 (8.8) 11 (7.9) 34 (9.2) 0.636 0.8 (0.4-1.7)
No 465 (91.2) 129 (92.1) 336 (90.8) 1.0
Had condomless receptive anal intercourse with a male partner in the past 6 months [n (%)]
Yes 171 (33.5) 50 (35.7) 121 (32.7) 0.893 1.0 (0.6-1.5)
No (always used condoms) 155 (30.4) 35 (25.0) 120 (32.4) 0.130 0.7 (0.4-1.1)
No (no receptive anal intercourse) 184 (36.1) 55 (39.3) 129 (34.9) 1.0
Had condomless insertive anal intercourse with a male partner in the past 6 months [n (%)]
Yes 173 (33.9) 48 (34.3) 125 (33.8) 0.448 0.8 (0.5-1.3)
No (always used condoms) 172 (33.7) 40 (28.6) 132 (35.7) 0.090 0.7 (0.4-1.1)
No (no insertive anal intercourse) 165 (32.4) 52 (37.1) 113 (30.5) 1.0
Had condomless receptive anal intercourse with a regular male partner in the past 6 months [n (%)]
Yes 116 (22.7) 34 (24.3) 82 (22.2) 0.803 1.1 (0.7-1.7)
No (always used condoms) 109 (21.4) 26 (18.6) 83 (22.4) 0.399 0.8 (0.5-1.3)
No (no receptive anal intercourse/no regular male partner) 285 (55.9) 80 (57.1) 205 (55.4) 1.0
Had condomless insertive anal intercourse with a regular male partner in the past 6 months [n (%)]
Yes 125 (24.5) 35 (25.0) 90 (24.3) 0.822 0.9 (0.6-1.5)
No (always used condoms) 117 (22.9) 27 (19.3) 90 (24.3) 0.223 0.7 (0.4-1.2)
No (no insertive anal intercourse/no regular male partner) 268 (52.5) 78 (55.7) 190 (51.4) 1.0
Had condomless receptive anal intercourse with a nonregular male partner in the past 6 months [n (%)]
Yes 87 (17.1) 26 (18.6) 61 (16.5) 0.736 1.1 (0.6-1.9)
No (always used condoms) 134 (26.3) 33 (23.6) 101 (27.3) 0.464 0.8 (0.5-1.3)
No (no receptive anal intercourse/no nonregular male partner) 289 (56.7) 81 (57.9) 208 (56.2) 1.0
Had condomless insertive anal intercourse with a nonregular male partner in the past 6 months [n (%)]
Yes 84 (16.5) 22 (15.7) 62 (16.8) 0.779 0.9 (0.5-1.6)
No (always used condoms) 163 (32.0) 45 (32.1) 118 (31.9) 0.973 1.0 (0.6-1.5)
No (no insertive anal intercourse/no nonregular male partner) 263 (51.6) 73 (52.1) 190 (51.4) 1.0
Ever had sex with a female partner [n (%)]
Yes 227 (44.5) 54 (38.6) 173 (46.8) 0.097 0.7 (0.5-1.1)
No 283 (55.5) 86 (61.4) 197 (53.2) 1.0
Had sex with a female partner in the past 6 months [n (%)]
Yes 95 (18.6) 23 (16.4) 72 (19.5) 0.251 0.7 (0.4-1.2)
No 132 (25.9) 31 (22.1) 101 (27.3) 0.147 0.7 (0.4-1.1)
Never had sex with a female partner 283 (55.5) 86 (61.4) 197 (53.2) 1.0
Relationship with main female sex partners [n (%)]
Wife 114 (22.4) 22 (15.7) 92 (24.9) 0.026 0.5 (0.3-0.9)
Other 113 (22.2) 32 (22.9) 81 (21.9) 0.684 0.9 (0.6-1.5)
No female sex partner 283 (55.5) 86 (61.4) 197 (53.2) 1.0
Testing behaviour
Number of previous HIV tests
Median (IQR) 3 (1–6) 2 (1-4) 3 (1-6)
≤ 4 [n (%)] 328 (64.3) 109 (77.9) 219 (59.2) < 0.001 2.4 (1.5-3.8)
> 4 [n (%)] 182 (35.7) 31 (22.1) 151 (40.8) 1.0
Tested for HIV in the past 6 months [n (%)]
Yes 219 (42.9) 41 (29.3) 178 (48.1) <0.001 0.4 (0.3-0.7)
No 291 (57.1) 99 (70.7) 192 (51.9) 1.0
Source of knowledge of regular male sex partner’s HIV serostatus [n (%)]
Attended testing and received results together with their partner 120 (23.5) 28 (20.0) 92 (24.9) 0.651 1.2 (0.6-2.2)
Questioned or visually inspected their partner 197 (38.6) 59 (42.1) 138 (37.3) 0.093 1.6 (0.9-2.9)
Did not know partner’s serostatus 92 (18.0) 32 (22.9) 60 (16.2) 0.031 2.0 (1.1-3.9)
Did not have a regular sex partner 101 (19.8) 21 (15.0) 80 (21.6) 1.0
Source of knowledge of nonregular male sex partner’s HIV serostatus [n (%)]
Attended testing and received results together with their partner 29 (5.7) 2 (1.4) 27 (7.3) 0.030 0.2 (0.04-0.9)
Questioned or visually inspected their partner 174 (34.1) 41 (29.3) 133 (35.9) 0.409 0.8 (0.4-1.4)
Did not know their partner’s serostatus 211 (41.4) 70 (50.0) 141 (38.1) 0.378 1.3 (0.7-2.2)
Did not have a nonregular sex partner 96 (18.8) 27 (19.3) 69 (18.6) 1.0

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328 X Wang et al.

Table 1 (Continued)

MSM recruited MSM recruited

Baseline cohort via internet via peer referral OR
Characteristic (n = 510) (n = 140) (n = 370) P (95% CI)

Ever tested for HIV using an oral HIV self-test kit (prior to this study) [n (%)]
Yes 120 (23.5) 12 (8.6) 108 (29.2) < 0.001 0.2 (0.1-0.4)
No 390 (76.5) 128 (91.4) 262 (70.8) 1.0
Willing to use an oral self-test kit (outside of this study) [n (%)]
Yes 401 (78.6) 109 (77.9) 292 (78.9) 0.794 0.9 (0.6-1.5)
No 109 (21.4) 31 (22.1) 78 (22.1) 1.0
Willing to purchase an oral self-test kit (in the next 6 months) [n (%)]
Yes 102 (20.0) 32 (22.9) 70 (18.9) 0.642 1.2 (0.6-2.1)
No 299 (58.6) 77 (55.0) 222 (60.0) 0.586 0.9 (0.5-1.4)
Not willing to use an oral self-test kit 109 (21.4) 31 (22.1) 78 (21.1) 1.0
Preferred HIV testing method [n (%)]
Blood test 334 (65.5) 93 (66.4) 241 (65.1) 0.784 1.1 (0.7-1.6)
Oral test 176 (34.5) 47 (33.6) 129 (34.9) 1.0
Reason for blood test being preferred HIV testing method [n (%)]
Being accurate (preferred blood laboratory testing) 274 (53.7) 75 (53.6) 199 (53.8) 0.876 1.0 (0.7-1.6)
Being accurate and quick (preferred blood rapid testing) 60 (11.8) 18 (12.9) 42 (11.4) 0.662 1.2 (0.6-2.2)
None (preferred oral test) 176 (34.5) 47 (33.6) 129 (34.9) 1.0
Health-seeking behaviour
Seeking HIV knowledge mainly via the internet [n (%)]
Yes 214 (42.0) 83 (59.3) 131 (35.4) < 0.001 2.7 (1.8-4.0)
No 296 (58.0) 57 (40.7) 239 (64.6) 1.0
Seeking information about HIV intervention programmes such as testing mainly via the internet [n (%)]
Yes 217 (42.5) 115 (82.1) 102 (27.6) < 0.001 12.1 (7.4-19.7)
No 293 (57.5) 25 (17.9) 268 (72.4) 1.0

CI, confidence interval; IQR, interquartile range; MSM, men who have sex with men; OR, odds ratio.

testing, while seven (1.4%) of them declined to do so. A

Factors associated with seeking male sex partners
online
Factors associated with seeking a male sex partner online
at least once a month are described in Table 2. Signifi-
cant independent factors in the multivariable model were
> 75% of male sex partners having been met online ever
(AOR 2.5; 95% CI 1.3-5.1), having > 10 past male sex
partners (AOR 2.2; 95% CI 1.4-3.5), and having had
receptive CAI with a male partner in the past 6 months
(AOR 1.6; 95% CI 1.0-2.6).
Factors associated with both seeking male sex
partners and seeking HIV intervention programmes
online
Table 3 describes factors associated with both seeking a
male sex partner online at least once a month and seek-
ing HIV intervention programmes mainly via the internet.
Significant independent predictors in the multivariable
model were having > 10 past male sex partners (AOR 2.9;
95% CI 1.5–5.6) and having ever tested for HIV using an
oral self-test kit (AOR 2.9; 95% CI 1.5–5.6).
All 510 participants in the baseline cohort self-admin-
istered an oral HIVST kit and 503 of them (98.6%) addi-
tionally provided a blood sample for confirmatory HIV
total of 50 participants (of 510; 9.9%) were confirmed to
be HIV-positive at baseline (positive self-test result and
positive blood test result: n = 43). A total of 460 partici-
pants (of 510; 90.2%) were found to be HIV-negative at
baseline (negative self-test result and negative blood test
result: n = 453; negative self-test result only: n = 7)
(Fig. 2 and Table 4). There was no significant difference
in HIV infection rate between MSM recruited via the
internet (14/139) and other MSM (36/364; data not
shown).
A total of 279 of the 460 HIV-negative MSM (60.7%)
in the baseline cohort attended follow-up at any time
between 3 and 12 months after baseline. There were no
significant differences in any of the socio-demographic
characteristics between those who attended follow-up
(n = 279) and those who were lost to follow-up (n = 181;
data not shown), or between those recruited via the inter-
net (n = 85) and those recruited via peer referral
(n = 194; data not shown).
All 279 MSM who attended follow-up re-administered
an oral HIVST, but only 47.3% of them (132 of 279)
accepted blood re-testing at the follow-up clinic visit.
Fewer MSM recruited via the internet accepted blood re-
testing at the follow-up visit (36.5%; 31/85) than other
MSM (52.1%; 101/194; P = 0.016). At follow-up, nine of

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 14681293, 2020, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hiv.12830 by Cochrane Portugal, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HIV self-testing among MSM 329

Table 2 Factors associated with seeking a male sex partner online at least once a month among men who have sex with men (MSM) in Bei-
jing and Nanning, China

Unadjusted Adjusted
Factor n/total (%) OR (95% CI)* P-value† OR (95% CI)* P-value†

Education level
≥ College 112/257 (43.6) 1.5 (1.1-2.2) 0.021 1.4 (0.8-2.3) 0.231
≤ High school 85/253 (33.6) 1.0 1.0
Illicit drug use in the past 6 months
Yes 71/152 (46.7) 1.6 (1.1–2.3) 0.015 1.1 (0.7-1.9) 0.668
No 126/358 (35.2) 1.0 1.0
Proportion of male sex partners met online ever
> 75% 20/98 (20.4) 3.4 (2.0-5.9) < 0.001 2.5 (1.3-5.1) 0.009
≤ 75% 51/141 (36.2) 2.2 (1.2-4.0) 0.010 1.4 (0.7-3.0) 0.378
None 126/271 (46.5) 1.0 1.0
Sought a male sex partner in a park or public toilet at least once a month in the past 1 year
Yes 22/77 (28.6) 0.6 (0.3-1.0) 0.051 1.1 (0.5-2.5) 0.819
No 175/433 (40.4) 1.0 1.0
Number of past male sex partners
> 10 99/212 (46.7) 1.8 (1.2-2.6) 0.002 2.2 (1.4-3.5) 0.001
≤ 10 98/298 (32.9) 1.0 1.0
Number of past male sex partners in the past 6 months
>2 150/346 (43.4) 1.9 (1.3-2.8) 0.002 1.7 (0.9-3.2) 0.077
≤2 47/164 (28.7) 1.0 1.0
Had group sex in the past 6 months
Yes 24/45 (53.3) 1.9 (1.0-3.5) 0.036 1.9 (0.8-4.1) 0.127
No 173/465 (37.2) 1.0 1.0
Had receptive CAI with a male partner in the past 6 months
Yes 79/171 (46.2) 1.8 (1.1–2. 7) 0.015 1.6 (1.0-2.6) 0.036
No 51/155 (47.5) 1.0 1.0
Had receptive CAI with a nonregular male partner in the past 6 months
Yes 43/87 (49.4) 1.7 (1.1–2.7) 0.024 0.9 (0.5-1.8) 0.775
No 154/423 (36.4) 1.0 1.0
Seeking HIV knowledge mainly via the internet
Yes 96/214 (44.9) 1.6 (1.1–2.3) 0.014 0.8 (0.5-1.4) 0.486
No 101/296 (34.1) 1.0 1.0
Seeking information about HIV intervention programmes such as testing mainly via the internet
Yes 97/217 (44.7) 1.6 (1.1–2.2) 0.016 1.3 (0.7-2.2) 0.353
No 100/293 (34.1) 1.0 1.0

OR, odds ratio; CAI, condomless anal intercourse; CI, confidence interval.
*Univariable logistic regression was performed with all characteristics as independent variables. Only variables with P-values < 0.05 in univariable anal-
ysis are shown in the table and were included in the multivariable analysis.
†
All P-values are two-sided. Comparisons with P-values < 0.05 were considered statistically significant.

the 279 MSM (3.2%) were newly diagnosed as HIV-posi-
tive, and the HIV infection rate was 6.9/100 person-years.
All nine newly diagnosed individuals performed an oral
self-test and received confirmatory blood testing. Risk
factors for new HIV infection included number of male
sex partners in the past 6 months being ≥ 2 [relative risk
(RR) 19.0; 95% CI 1.1–326.4] and being willing to test for
HIV with an oral self-test kit in the following 3 months
(RR 19.0; 95% CI 1.1–326.4).
Performance of oral HIV self-testing
As shown in Table 4, baseline oral HIV self-test results
matched confirmatory HIV blood test results for the
majority of participants. Specificity was similarly high at
98.2% (445/453) at baseline, 97.6% (120/123) at follow-
up, 96.8% (121/125) among MSM recruited via the
internet, and 98.8% (324/328) among those recruited via
peer referral. Sensitivity was lower, 86% (43/50), 77.8%
(7/9), 92.9% (13/14), and 83.3% (30/36), respectively. The
PPVs were 84.3% (43/51), 70% (7/10), 76.5% (13/17), and
88.2% (30/34); the NPVs were 98.5% (445/452), 98.4%
(120/122), 99.2% (121/122), and 98.2% (324/330), respec-
tively.
DISCUSSION
The high HIV incidence in our study demonstrates that
MSM in the two cities are at high risk of HIV infection
and that innovative testing strategies are urgently needed.
The risk factor for HIV infection of having past multiple
male sex partners was associated with seeking both male
sex partners and HIV interventions online. This suggests
that an online HIV intervention targeting MSM could

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330 X Wang et al.

Table 3 Factors associated with both seeking a male sex partner online at least once a month and seeking HIV intervention programmes
mainly via the internet among men who have sex with men (MSM) in Beijing and Nanning, China

Unadjusted Adjusted
Factor n/total (%) OR (95% CI)* P-value† OR (95% CI)* P-value†

Age
≤ 25 years 65/257 (25.3) 2.3 (1.5–3.7) < 0.001 1.4 (0.7–2.7) 0.305
> 25 years 32/253 (12.6) 1.0 1.0
Monthly income
< CNY 3000 42/ 289 (14.5) 0.5 (0.3-0.8) 0.003 0.7 (0.4-1.4) 0.314
≥ CNY 3000 55/ 221 (24.9) 1.0 1.0
Illicit drug use in the past 6 months
Yes 37/152 (24.3) 1.6 (1.0-2.5) 0.047 0.8 (0.4-1.6) 0.609
No 60/358 (16.8) 1.0 1.0
Proportion of male sex partners met online ever
> 75% 70/ 271 (25.8) 2.7 (1.7–4.4) < 0.001 1.9 (1.0–3.8) 0.058
≤ 75%, ≥ 0 27/ 239 (11.3) 1.0 1.0
Sought a male sex partner in a park or public toilet at least once a month in the past 1 year
Yes 3/77 (3.9) 0.1 (0.05-0.4) 0.001 0.3 (0.1-1.5) 0.150
No 94/433 (21.7) 1.0 1.0
Number of past male sex partners
> 10 52/212 (24.5) 1.8 (1.2-2.9) 0.008 2.9 (1.5-5.6) 0.001
≤ 10 45/298 (15.1) 1.0 1.0
Ever had a regular male sex partner
Yes 85/409 (20.8) 1.9 (1.0-3.7) 0.044 1.0 (0.4-2.5) 0.952
No 12/101 (11.9) 1.0 1.0
Had receptive CAI with a male partner in the past 6 months
Yes 39/171 (22.8) 1.9 (1.1–3.4) 0.033 1.5 (0.8–2.8) 0.210
No 21/155 (13.5) 1.0 1.0
Had insertive CAI with a regular male partner in the past 6 months
Yes 33/125 (26.4) 1.8 (1.1-2.9) 0.016 1.5 (0.7-3.1) 0.311
No 64/385 (16.6) 1.0 1.0
Ever tested for HIV using an oral HIV self-test kit (prior to this study)
Yes 10/120 (8.3) 0.3 (0.2–0.6) 0.001 0.4 (0.1–0.9) 0.033
No 87/390 (22.3) 1.0 1.0

OR, odds ratio; CAI, condomless anal intercourse; CI, confidence interval.
*Univariable logistic regression was performed with all characteristics as independent variables. Only variables with P-values < 0.05 in univariable anal-
ysis are shown in the table and were included in the multivariable analysis.
†
All P-values are two-sided. Comparisons with P-values < 0.05 were considered statistically significant.

reach those at high risk of HIV infection. The other risk
factor of being willing to test for HIV with an oral self-test
kit showed that there is a demand for oral HIVST from
MSM at high risk of HIV infection. These two risk factors,
combined with the association between never having
tested for HIV with an oral self-test kit and seeking male
sex partners and HIV interventions online, indicate that
online oral HIVST promotion could be accessible and
acceptable to MSM at high risk of HIV infection.
Similar to other studies in Chinese MSM, in this study
MSM recruited via the internet, compared to other MSM,
had a higher income, were more likely to use illicit drugs,
had previously tested for HIV less frequently, and were
likely to seek male sex partners and HIV knowledge or
HIV intervention programmes online.[26,27] These find-
ings also suggest that online interventions could reach
internet-using MSM at high risk of HIV infection in
China. This was previously demonstrated in a study tar-
geting MSM recruited online in China.[28]
Our study showed that oral HIVST had comparatively
high accuracy. The sensitivity of the kit was higher than
that found in the other relevant study in China; the
specificity was slightly lower.[23] Accuracy could influ-
ence the acceptability of the oral HIVST among MSM.[7]
Oral HIVST performed by MSM recruited via the internet
had higher accuracy than that performed by other MSM.
This supports the conclusion that the internet is a poten-
tially effective route for oral HIVST promotion. No other
studies have reported the accuracy of HIVST performed
by internet-using MSM.
The proportion of MSM who were willing to conduct
the oral HIVST in future in our study is close to that
reported in other studies in China.[7,11] Willingness to
purchase or conduct oral HIVST was similar between the
MSM recruited online and other MSM in our study. How-
ever, the proportion of the MSM who had conducted oral
HIVST was much lower among those recruited online
than among other MSM. This suggests that there is great

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 14681293, 2020, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hiv.12830 by Cochrane Portugal, Wiley Online Library on [27/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HIV self-testing among MSM 331

Table 4 Two-by-two table comparing results of self-administered oral HIV test to results of confirmatory HIV blood test at baseline and at
follow-up

Results of confirmatory Results of confirmatory

Results of confirmatory Results of confirmatory HIV blood test HIV blood test
HIV blood test HIV blood test (MSM recruited via the internet (MSM recruited via peer referral
(at baseline) (at follow-up) at baseline) at baseline)
Results of self-administered
oral HIV test +  Total +  Total +  Total +  Total

+ 43 8 51 7 3 10 13 4 17 30 4 34
 7 445 452 2 120 122 1 121 122 6 324 330
Total 50 453 503 9 123 132 14 125 139 36 328 364

scope for promoting oral HIVST among internet-using
MSM who have not conducted HIVST but are willing to
do so. A study reported that 31% of internet-using Chi-
nese MSM tested for HIV used HIVST as their first HIV
test.[27] Studies in the USA demonstrated that internet-
using MSM, especially those who had never tested for
HIV or who had CAI, preferred oral HIVST to any other
testing strategies, such as VCT.[29] Our study also
demonstrated that MSM recruited online preferred oral
HIVST to testing at a clinic. Among the MSM who partic-
ipated in follow-up in our study, 2.1 times as many indi-
viduals used oral HIVST as underwent blood re-testing.
As demonstrated in online studies in 2306 MSM in Aus-
tralia and 1189 MSM in China, HIVST enables more fre-
quent HIV testing among MSM.[28,30,31] An online
study in China reported that 34.7% of MSM who had
conducted HIVST had obtained HIVST kits via the inter-
net.[28] A systematic review and meta-analysis reported
that social media as an internet-based platform is effec-
tive in promoting HIV testing among MSM, and 16% of
MSM requested an HIVST kit via social media.[32] The
studies suggest that online oral HIVST promotion is a
promising means of facilitating first-time and frequent
repeat HIV testing among internet-using MSM at high
risk of HIV infection.
Having received relevant information and users’ atti-
tudes to oral HIVST were the determinants of usage and
acceptability.[33] Our study demonstrated a positive
attitude to oral HIVST among internet-using MSM.
However, challenges for online oral HIVST promotion
exist.[34] A meta-analysis demonstrated that an oral
HIV test may yield some false positive results or low
PPV in low-prevalence populations.[35] As HIV preva-
lence among MSM is currently higher than in any other
key population in China, this is not a major problem in
this case. A study targeting internet-using MSM in
China reported that only 44% of MSM performing
HIVST confirmed their self-test results.[27] To maximize
the impact of HIVST on the HIV epidemic, effective
approaches should be identified to link those self-
testing positive to confirmatory testing and treatment.
Internet channels used for online HIVST promotion may
also be used to facilitate HIV risk behaviours among
MSM.[36] To offset this likely negative effect, it is nec-
essary to find effective and efficient ways to make full
use of the internet to promote HIVST. Lastly, further
research should be conducted to increase the accuracy
of HIVST.
Limitations
Oral HIVST in our study was mainly performed in a
supervised context and we provided on-site post-test
counselling and referral to care immediately, and hence
data are lacking on linkage to care following a positive
HIV test. We failed to obtain data on HIVST among MSM
who were active online and viewed our advertisements,
but decided not to attend the clinic for testing. This
should be explored in future studies. Also, the sample of
participants in our study were recruited using certain
strategies from two big cities, and hence the results can-
not be generalized to all MSM.
Conclusions
The findings suggest that online oral HIVST promotion
shows promise for scaling up first time and repeat HIV
testing among MSM at high risk of HIV infection in
China. Future studies should be conducted among inter-
net-using MSM to further evaluate the effect of prevent-
ing HIV infection, and explore effective measures to
promote HIVST via various online channels.
Acknowledgements
The authors thank all study participants. The authors also
thank Jennifer M. McGoogan for her valuable edits to the
Methods.
Conflicts of interest: The authors declare that they have
no conflicts of interest.

© 2019 British HIV Association HIV Medicine (2020), 21, 322--333


332 X Wang et al.
Financial disclosure: This study was supported by
Guangxi Provincial Center for Disease Control and
Prevention. The funding institution had no role in study
design, data analysis, or drafting of the manuscript.
Author contributions
XW designed the study. XW, ZT, QN, and YL implemented
the study. QN and YL were responsible for study site coor-
dination. XW conducted primary data analysis and created
the original draft of the manuscript. ZW reviewed and
revised the manuscript. All authors reviewed and approved
the final submitted version of the report. XW had full
access to all the data in the study and had final responsi-
bility for the decision to submit for publication.
Disclaimer
The views expressed here belong to the authors alone and
do not necessarily reflect the views of their affiliated
institutions.
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APÊNDICE V- Análise Crítica De Um Artigo: Vanessa Maria Gonçalves De Almeida
 “Trabalho individual de síntese crítica de um artigo científico”
Aluna: Vanessa Maria Gonçalves de Almeida, a21901189

JBI CRITICAL APPRAISAL CHECKLIST FOR

RANDOMIZED CONTROLLED TRIALS
Reviewer Vanessa Maria Gonçalves de Almeida
Author: Dean Cruess, Kaylee Burnham, David Finitsis, Brett Goshe, Lauren Strainge, Moira Kalichman, Tamar
Grebler, Chauncey Cherry e Seth Kalichman Year: 2018

Yes No Unclear NA
1. Was true randomization used for assignment of participants to treatment
groups? X □ □ □
2. Was allocation to treatment groups concealed?
x □ □ □
3. Were treatment groups similar at the baseline?
X □ □ □
4. Were participants blind to treatment assignment?
X □ □
5. Were those delivering treatment blind to treatment assignment?
□ X □ □
6. Were outcomes assessors blind to treatment assignment?
□ □ X □
7. Were treatment groups treated identically other than the intervention of
interest? X □ □ □
8. Was follow up complete and if not, were differences between groups in
terms of their follow up adequately described and analyzed? X □ □ □
9. Were participants analyzed in the groups to which they were randomized?
X □ □ □
10. Were outcomes measured in the same way for treatment groups?
□ □ x □
11. Were outcomes measured in a reliable way?
□ □ x □
12. Was appropriate statistical analysis used?
□ □ □ x
13. Was the trial design appropriate, and any deviations from the standard RCT
design (individual randomization, parallel groups) accounted for in the
conduct and analysis of the trial?
x □ □ □

Overall appraisal: Include X Exclude □ Seek further info □

Comments (Including reason for exclusion)

© JBI, 2020. All rights reserved. JBI grants use of these Critical Appraisal Checklist for Randomized Controlled Trials - 2
tools for research purposes only. All other enquiries
should be sent to jbisynthesis@adelaide.edu.au.
 “Trabalho individual de síntese crítica de um artigo científico”
Aluna: Vanessa Maria Gonçalves de Almeida, a21901189

EXPLANATION FOR THE CRITICAL APPRAISAL TOOL

FOR RCTS WITH INDIVIDUAL PARTICIPANTS IN
PARALLEL GROUPS

1. Was true randomization used for assignment of participants to treatment groups?

“Once the baseline survey was completed, participants were randomized using a computer-generated
randomization program to either the HINTS intervention or to a time-matched control condition.”

2. Was allocation to groups concealed?

“participants were randomized using a computer-generated randomization program”

3. Were treatment groups similar at the baseline?

“There were no significant differences in demographic or psychosocial characteristics at baseline, except for
self-identified sexual orientation with more men identifying as bisexual in the HINTS group than the control
group”

4. Were participants blind to treatment assignment?

“Participants were blind to randomization status.”

5. Were those delivering treatment blind to treatment assignment?

“Group facilitators were trained together on delivery of the HINTS and control interventions.” Os
intervenientes e gestores das sessões foram treinados a planear ambos os grupos de intervenção e de
control, pelo que sabiam a diferenciação entre os grupos.

6. Were outcomes assessors blind to treatment assignment?

“Group sessions were recorded and reviewed by the principal investigator, a licensed psychologist and the
project manager, a licensed social worker, to monitor intervention fidelity.”
Os resultados das sessões de ambos os grupos, de controlo e de intervenção, eram monitorizados pela
mesma equipa, existindo diferenciação entre os grupos.

7. Were treatment groups treated identically other than the intervention of interest?

“The Healthy Living comparison condition followed the same format as HINTS”. Não existem outras
diferenças entre os grupos em termos de intervenções, exceto a manipulada, pelo que o efeito
pode ser atribuído diretamente à causa potencial.

8. Was follow up complete and if not, were differences between groups in terms of their follow
up adequately described and analyzed?
© JBI, 2020. All rights reserved. JBI grants use of these Critical Appraisal Checklist for Randomized Controlled Trials - 3
tools for research purposes only. All other enquiries
should be sent to jbisynthesis@adelaide.edu.au.
 “Trabalho individual de síntese crítica de um artigo científico”
Aluna: Vanessa Maria Gonçalves de Almeida, a21901189

“There was no significant difference for group attendance between conditions (…)”.” Retention rate was
approximately 84%, with 140 of 167 participants (70 in each condition) available at 6-month follow-up. No
significant differences in attrition were observed between groups.” O projeto, verificou uma reduzida taxa
de desistência dos partipante, pelo que conseguiram concluir o estudo pelos métodos previamente
estabelecidos.

9. Were participants analyzed in the groups to which they were randomized?

“ANCOVA analyses controlling for baseline data, showed no significant change between groups”. Os
investigadores utilizaram o programa ANCOVA de forma a avaliar as variáveis dos respetivos grupos.

10. Were outcomes measured in the same way for treatment groups?

“ANCOVA analyses controlling for baseline data, showed no significant change between groups”.

Os investigadores usaram os mesmo métodos na análise dos resultados nos diferentes grupos.

11. Were outcomes measured in a reliable way?

Os resultados foram obtidos através de questionários aos participantes, sem a utilização de escalas
ou outro método de recolha de dados. Este método pode não ser totalmente viável uma vez que os
participantes podem decider esconder informação de forma deliberada.

12. Was appropriate statistical analysis used?

Os invetsigadores não recorrem assiduamente a uma análise estatística uma vez que os resultados
foram obtidos através de respostas diretas dos participantes e não por dados analíticos.

13. Was the trial design appropriate for the topic, and any deviations from the standard RCT
design accounted for in the conduct and analysis?

O desenho do estudo foi apropriado, pois os autores conseguiram alcançar o objetivo previamente
defenido. Os participantes relataram um elevado grau de satisfação e apresentou-se uma baixa taxa
de desistência dos participantes.

© JBI, 2020. All rights reserved. JBI grants use of these Critical Appraisal Checklist for Randomized Controlled Trials - 4
tools for research purposes only. All other enquiries
should be sent to jbisynthesis@adelaide.edu.au.
ann. behav. med. (2018) 52:116–129
DOI: 10.1093/abm/kax031
REGULAR ARTICLE
A Randomized Clinical Trial of a Brief Internet-based Group
Intervention to Reduce Sexual Transmission Risk Behavior Among
HIV-Positive Gay and Bisexual Men
Dean G. Cruess, PhD1,2 • Kaylee E. Burnham, MA1,2 • David J. Finitsis, MA1,2 • Brett M. Goshe, MA1,2 •
Lauren Strainge, MA1 • Moira Kalichman, MSW2 • Tamar Grebler, BA2 • Chauncey Cherry, PhD2 •
Seth C. Kalichman, PhD1,2
Published online: 29 November 2017
© The Society of Behavioral Medicine 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
Abstract
Background HIV disproportionately affects sexual
minority men, and developing strategies to reduce trans-
mission risk is a public health priority.
Purpose The goal was to empirically test a newly devel-
oped, Information, Motivation, Behavioral skills (IMB)
theoretically derived, online HIV sexual risk reduction
intervention (called HINTS) among a sample of sexual
minority men living with HIV.
Methods Participants were 167 men randomized to
either the four-session online HINTS intervention or to
a time-matched, online control condition. Participants
were assessed at baseline and at 6-month follow-up for
demographic, medical and psychosocial factors, and sex-
ual risk behavior. Analyses examined group differences in
incidence rates of condomless anal sex (CAS) at follow-up
with all male sex partners and by partner serostatus, either
seroconcordant or serodiscordant for HIV infection.
Results Men assigned to the HINTS intervention reported
decreased CAS with serodiscordant partners, a behavior
that confers high risk of HIV transmission, compared to
Dean G. Cruess
dean.cruess@uconn.edu
1
Department of Psychological Sciences, University of
Connecticut, 406 Babbidge Road, Unit 1020, Storrs, CT
06269-1020
2
Institute for Collaboration on Health, Intervention and
Policy, University of Connecticut, 2006 Hillside Road, Storrs,
CT 06268
the control group. Men assigned to the HINTS interven-
tion also reported increased CAS with seroconcordant
partners, a behavior indicative of serosorting. Although
the IMB model did not appear to mediate these interven-
tion effects, some IMB components were associated with
behavioral outcomes at 6-month follow-up.
Conclusions A new group-based sexual risk reduction
intervention conducted exclusively online was successful
in reducing HIV transmission risk behavior in a sample
of gay and bisexual men living with HIV. Future work
should consider utilizing this intervention with other
groups living with HIV, perhaps in combination with
biomedical HIV prevention strategies.
Keywords HIV • Gay and bisexual men • Sexual risk •
Intervention
Introduction
The number of new HIV infections in the USA has
remained stable at around 50,000 cases per year (Centers
for Disease Control and Prevention [CDC] [1, 2]).
However, men who have sex with men (MSM) are dis-
proportionately affected by HIV infection in the USA.
MSM, the majority of whom identify as gay or bisex-
ual, comprise less than 5% of the U.S.  population, yet
account for over 75% of new male HIV infections each
year [2]. At the same time, since the advent of highly
active antiretroviral therapy, MSM with HIV infection in
the USA are now living longer, healthier lives. With the
ann. behav. med. (2018) 52:116–129117
number of new infections at a plateau and fewer HIV-
associated deaths reported (World Health Organization
[WHO] [3]), innovations in HIV prevention strategies are
greatly needed to reduce HIV transmission.
The use of secondary HIV prevention strategies is a
national public health priority. Although the CDC rec-
ommends abstinence from anal sex as the most effective
way to prevent HIV transmission [4], a large majority of
MSM with HIV do not report the intention to abstain
from sex entirely, and even fewer follow through on such
intentions [5]. As a result, secondary prevention strat-
egies for MSM have tended to adopt a risk reduction
approach. Two commonly endorsed behavioral strat-
egies to reduce transmission risk among MSM include
serosorting practices and condom use. These transmis-
sion risk reduction behavioral strategies remain vital for
MSM with HIV infection even with the advent of new
biomedical HIV prevention strategies, including pharma-
cological treatment as prevention (TasP) or pre-exposure
prophylaxis (PrEP), for MSM without HIV infection [6,
7].
Serosorting refers to the practice of limiting condom-
less sexual encounters to partners believed to be of the
same serostatus, with the intention of reducing HIV
transmission risk [4]. Although there are other safety
concerns associated with serosorting behaviors [3, 8], it is
a commonly endorsed strategy in MSM with and without
HIV infection [9], and is recommended as a harm reduc-
tion strategy in certain circumstances [3]. Condom use is
another widely endorsed secondary prevention strategy
[5], which has been shown to substantially decrease the
risk of HIV transmission in MSM [10]. The efficacy of
condom use is well documented and long established
[11, 12], and consistent condom use is strongly recom-
mended by both the CDC [4] and the WHO [3] to reduce
HIV transmission risk in MSM. Despite the existence
of these risk reduction strategies, many MSM with HIV
infection continue to engage in sexual behaviors associ-
ated with a high risk of transmission (e.g., condomless
anal intercourse with serodiscordant partners) [13, 14].
Consequently, reducing risky sexual behaviors in this
population has been an important target for secondary
prevention efforts.
Meta-analytic evidence indicates that interventions
aimed at sexual risk reduction among individuals with
HIV infection can be successful, and that these efforts
are more effective when based on established health
behavior theories [15–17]. One model of HIV pre-
ventive behavior with strong empirical support is the
Information-Motivation-Behavioral Skills (IMB) model
[18, 19]. The IMB model suggests that HIV prevention
information, motivation, and behavioral skills are fun-
damental prerequisites to changes in sexual risk behav-
iors. Information concerning HIV risk-reduction and the
motivation to practice preventive measures are directly
relevant to behavioral change, and may also be expressed
indirectly through behavioral skills. Well-informed and
motivated individuals can apply successful behavioral
skills (e.g., condom negotiation) in order to initiate
and maintain risk reduction strategies (e.g., consistent
condom use). Studies using the IMB model to predict
sexual risk in MSM have reported somewhat mixed
findings [20–22], but the IMB model has received con-
siderable empirical support among individuals with HIV
infection [19, 23]. Furthermore, the IMB model has been
used to guide the development and implementation of
successful secondary prevention interventions targeting
sexual risk [24–27]. It is noteworthy that to date, these
interventions have relied on face-to-face delivery, and
few have capitalized on novel technological interfaces.
The Internet has changed the way many people live
their lives, especially with regards to connecting with
others. Some have suggested that gay and bisexual men
adopt new technologies at faster rates than the general
population [28]. There have been many social benefits
resulting from greater Internet usage, but its proliferation
has also been associated with increased sexually trans-
mitted infections and HIV transmission risk [29–31].
Several studies have documented the increased frequency
with which MSM seek sex partners online, and more re-
cently through mobile applications (apps), which are
now believed to be the leading modality by which men
meet other men for sex in the USA, even overtaking gay
bars [32–34]. Other studies have found increased rates
of condomless anal intercourse among MSM meeting
partners online [33, 35]. While the Internet has become
a means for people of all genders and sexual preferences
to connect with romantic and sexual partners, these find-
ings suggest that the Internet may offer a unique venue
for providing interventions to reduce HIV transmission
risk behavior among at-risk gay and bisexual men.
Research investigating web-based interventions
that specifically target sexual minority men has grown,
though it still remains a relatively small empirical base.
Recently, several online interventions delivered to young
MSM have been shown to be feasible and acceptable, and
have successfully enhanced HIV knowledge and moti-
vation to use condoms, as well as achieving reductions
in reported condomless sex acts [36–40]. Notably, many
of these interventions focused on primary HIV preven-
tion and did not include MSM living with HIV [41]. One
recent online secondary prevention study based on a
different model of health behavior (i.e., social cognitive
theory) implemented tailored risk reduction messages
regarding HIV status disclosure and condom usage and
found decreased rates of condomless sex as rates of dis-
closure increased [42]. However, there were no significant
differences between the intervention and control groups,
suggesting tailored messages provided minimal bene-
fit beyond that conferred by self-monitoring and risk
118
assessment. Considering the potential risks associated
with online partner seeking, empirical studies utilizing
online interfaces to target sexual transmission risk in men
living with HIV is an important area for intervention.
The purpose of the current study was to conduct a
field test of a newly developed, brief, exclusively online
sexual risk reduction intervention called the HIV Internet
Sex (HINTS) study. A  group-based intervention was
developed through formative research with men living
with HIV who had a history of risky sexual behavior
and online partner seeking. The IMB model served as a
theoretical framework for the intervention development.
Unlike some previous online interventions that utilized
the IMB model and targeted HIV-negative individuals [36,
40], HINTS was specifically designed for sexual minority
men living with HIV. Gay and bisexual men living with
HIV were randomized to either HINTS or a comparison
control condition, and our primary hypothesis was that
men assigned to HINTS would report increased sexual
risk reduction practices, such as reductions in condom-
less anal sex (CAS) with all male partners and especially
with HIV-negative or status unknown partners in the
6  months following the study, as compared to the men
assigned to the control group. Given that some prior sex-
ual risk reduction interventions among MSM living with
HIV have also reported increased serosorting behavior as
secondary outcome [43, 44], we also predicted that men
assigned to HINTS would show increased use of this risk
reduction strategy compared to men in the control group.
Finally, as an exploratory aim, we hypothesized that the
main theoretical components of the IMB model would
mediate the intervention effects on our primary sexual
risk reduction outcomes.
Methods
Participant Recruitment
Men were recruited for the HINTS study using on-
line and offline methods. Recruitment ads instructed
potential participants to call the HINTS screening phone
line. Study staff conducted a brief phone call with inter-
ested participants to assess eligibility. Inclusion criteria
included: (a) being at least 18  years old; (b) self-identi-
fying as gay or bisexual; (c) living with HIV/AIDS, (d)
reporting at least one instance of using the Internet to
meet a potential sex partner, and (e) reporting at least
one instance of CAS with a male partner. Filler ques-
tions were included in the screening assessment to limit
potential participants’ ability to detect eligibility criteria.
Eligible participants were then provided with informa-
tion about the study. If they agreed to participate, they
provided their email address to receive study-related
information.
ann. behav. med. (2018) 52:116–129
Procedure
Participants were emailed a unique link and password
to their online consent form. Once participants con-
sented to participate in the study, they were sent a link
to the baseline survey. Surveys were administered using
LimeSurvey [45], a free online open-source survey
service. Once the baseline survey was completed, par-
ticipants were randomized using a computer-generated
randomization program to either the HINTS interven-
tion or to a time-matched control condition. Participants
were blind to randomization status. Men also provided
their physical addresses in order to receive a free headset
to better participate in the online groups. Men were
assigned to an online group and emailed their four-ses-
sion group schedule. Group sessions were 45 min in dur-
ation and occurred in sequential order (Sessions 1–4).
Groups were scheduled twice per week over two consecu-
tive weeks, and participants were assigned to groups by
start time (e.g., 12 pm ET, 7 pm ET). In addition to their
group schedule, participants were emailed a reminder
the day before their scheduled group session to promote
attendance. Group interaction included a combination
of voice chat and typed chat with facilitators. Follow-up
measures were administered 6 months from the time of
participants’ baseline surveys and included the same
measures, as well as a satisfaction survey for the group
interventions. Our university’s Institutional Review
Board approved all study procedures. Fig. 1 displays par-
ticipant flow through the study from screening to follow
up. Our ClinicalTrials.gov number is NCT#02887508.
HINTS Intervention
Intervention content was developed using both form-
ative focus groups and individual interviews with gay
and bisexual men living with HIV in Atlanta, GA. In
each session, facilitators presented information, motiva-
tional skills, and behavioral strategies related to a spe-
cific topic relevant to online partner seeking and HIV
transmission risk reduction. Online interactive polls
were included throughout each session to assess partic-
ipants’ experiences and stimulate discussion. At the end
of each session, participants were given an assignment to
apply discussion topics to their own online experiences
between sessions, in order to promote continuity and
engagement.
Group facilitators included two clinical psychology
graduate students and two community-based counselors,
all of whom had specialized training for working with
populations affected by HIV. All facilitators were female.
Group facilitators were trained together on delivery of
the HINTS and control interventions. Group sessions
were recorded and reviewed by the principal investigator,
ann. behav. med. (2018) 52:116–129119
Fig. 1  Participant flow through enrollment, randomization, and follow-up.
a licensed psychologist and the project manager, a
licensed social worker, to monitor intervention fidelity.
Additionally, the study team met weekly for supervision
to discuss any pertinent issues regarding intervention
delivery.
In Session 1, group facilitators and group members
introduced themselves. The facilitators presented an
overview of the HINTS intervention, then discussed
the first HINTS topic: meeting people (including sexual
partners) via the Internet. Participants were asked about
their experiences of meeting others online and shared
instances in which they had encountered a deceptive
person or profile online. Facilitators also incorporated
relevant video clips during the session to promote dis-
cussion. The main goal of this session was to highlight
the possibility that potential sex partners might misrep-
resent their personal information (including serostatus)
online. The session ended with a brief review of the topic
and discussion, and an assignment to look for deceptive
information online to discuss during the next session
In Session 2, the facilitators reviewed the assignment
on deception from the previous session, and introduced
the topic of HIV serostatus disclosure with partners met
online. Participants discussed when and how to address
serostatus with potential sex partners, the pros and cons
of doing so, and how to manage possible rejections
following discussion of HIV status. The main goal of
this session was to enhance motivation and behavioral
strategies for engaging in a productive dialogue about
HIV serostatus. The session ended with an overview of
the day’s topics and an assignment to consider online
serostatus disclosure for the next session’s discussion.
Session 3 followed a similar format. Discussion began
with the assignment on serostatus disclosure from
the previous session. The facilitators then introduced
material regarding condom negotiation and condom use
with partners met online. Topics of discussion included
when to discuss condom use preferences with a potential
sex partner, how to make condom use more enjoyable
during sex, and how best to maintain sexual health. The
main goal of this session was to increase motivation and
discuss behavioral skills to effectively engage sex part-
ners in using condoms. The session concluded with a
brief review of the discussion topics and an assignment
regarding online condom negotiation to be shared in the
next session.
In Session 4, the group discussed their experiences
with the condom negotiation assignment from the pre-
vious session. Following this discussion, the facilitators
discussed safety when actually meeting potential sex
120
partners met online. Participants shared strategies for
maintaining safety when meeting an online acquaint-
ance in person, such as first meeting in a public and well-
lit area, letting a friend or family member know where
he would be meeting the person, and having an “escape
plan.” The goal of this session was to reinforce the top-
ics presented in earlier sessions and how to more safely
put them into practice in real-life settings. The session
ended with an overview of the entire HINTS program,
and participants were invited to provide feedback about
what they found most useful during the intervention.
Healthy Living Comparison Condition
The Healthy Living comparison condition followed the
same format as HINTS; facilitators presented infor-
mation, motivational skills, and behavioral skills strat-
egies, but sessions were tailored to address nonsexual
health-related topics relevant to individuals living with
HIV. Sessions were adapted from a similar control con-
dition implemented in previous studies, and addressed
the topics of (a) nutrition and healthy eating, (b) portion
control, (c) exercise and staying active, (d) stress reduc-
tion to maintain health [46]. As with the HINTS sessions,
videos and poll questions were integrated to stimulate
discussion during the groups. All control sessions were
time-matched with the intervention group sessions.
Measures
Demographic Information
Demographic characteristics including age, sexual iden-
tity, sexual orientation, marital status, education level,
and income were collected from all participants at
baseline.
Psychosocial Variables
Depressive symptoms were assessed using the 20-item
Center for Epidemiological Studies of Depression Scale
(CES-D; [47]). Participants endorsed how often they
experienced each symptom characteristic of depression
in the past week on a scale: 0 (no days), 1 (1–2 days), 2
(3–4 days), and 3 (5–7 days). Total scores range from 0 to
60, and a score of 16 indicates a potential clinical level of
depression (baseline α = .931).
The Alcohol Use Disorders Identification Test
(AUDIT; [48]) was used to assess alcohol use and related
problems. The AUDIT includes 10 items that assess fre-
quency of drinking, alcohol dependency, and problems
caused by alcohol use. The AUDIT was designed for use
in primary care settings to identify individuals at risk for
alcohol-related problems. Scores on the AUDIT range
ann. behav. med. (2018) 52:116–129
from 0 to 40, and a score of 8 or higher is indicative of
at-risk drinking. Reliability of the AUDIT in the present
sample was acceptable (baseline α = .861).
Information, Motivation, and Behavioral Skills
The IMB measures employed have been used by our
research team in prior studies. Knowledge pertinent to
the HINTS intervention was assessed using four ques-
tions tailored to session content. Participants responded
yes, no, or don’t know to each of the following: (a) Can
finding out the HIV status of a potential sex partner met
online have health benefits? (b) Does trusting people met
online pose risks to a person’s health and safety? (c) Can
using condoms help prevent STDs that could compli-
cate one’s health? (d) When deciding to meet someone
met online in person, should a person offer to meet in
a public place during the daytime? Internal consistency
between these Yes/No items at 6-month follow-up was
low (KR20 = .360).
Motivation was assessed using 10 questions assess-
ing participants’ intention/willingness to practice risk
reduction skills (e.g., condom use, serostatus disclosure,
strategic positioning, viral load tracking) when meeting
sex partner online. Participants responded to each ques-
tion using a scale from 0 (Definitely will not do) to 5
(Definitely will do). A  composite score was calculated
by averaging participants’ responses across questions
(6-month follow-up α = .833).
Behavioral skills were assessed using a series of
vignettes with content specific to meeting sex partners
online. Story content included feeling lonely and logging
onto a men’s dating site and chatting with someone who
clearly wants to hook up; or going out feeling buzzed
after a few drinks and instant messaging with someone
who wants to meet for sex. Participants were asked to
vividly imagine each story and rate their confidence in
their ability to engage safety skills using a scale from 0
(Cannot do at all) to 10 (Certain can do). A composite
score was calculated by averaging responses across ques-
tions (6-month follow-up α = .977).
Sexual Behavior
At baseline and 6-month follow-up, participants self-re-
ported their total number of male sex partners during the
past 6 months and how many of those partners they met
online. Participants reported male sex partner serostatus
(HIV-positive vs. HIV-negative/unknown) and the number
of times they had CAS with partners in each serostatus
category. CAS with partners living with HIV (serocon-
cordant) was measured to assess extent of serosorting as
an outcome measure, while CAS with partners without
HIV or whose HIV-status was unknown (serodiscordant)
ann. behav. med. (2018) 52:116–129121
was measured to assess HIV transmission risk behavior
as an outcome measure. This method of dichotomizing
sexual behavior by partner serostatus followed conven-
tions set by previous research on sexual risk behavior [49,
50]. An open response format was used to control for re-
sponse bias and allowed participants to freely enter their
number of sex partners and occasions of CAS. Survey
software tracked participant responses and prompted par-
ticipants with their previous entries for subsequent ques-
tions regarding the number of times they engaged in CAS.
This method of assessing sexual behavior has been used
successfully in several prior studies [51–53].
Data Analyses
Baseline characteristics, including demographic, health,
psychosocial, and sexual behavior variables for the inter-
vention and control groups were compared to assess the
success of randomization. Primary study analyses were
analyzed among participants who completed 6-month
follow-up surveys (N = 140, 84% of randomized sample).
Missing data was minimal (6%) at follow-up. Standard
power analyses confirmed sufficient sample size to test
our main hypotheses. All analyses were carried out using
SPSS, version 21.0.
Analyses were conducted to compare IMB and sex-
ual behavior variables from baseline to 6-month fol-
low-up between groups. ANCOVAs were used to examine
changes in the IMB variables over time. Primary outcomes
consisted of sexual risk behavior (i.e., CAS) reported at
6-month follow-up. Incidence of CAS was operational-
ized as count data, which tend to exhibit a strong posi-
tive skew and over dispersion [54]. As a result, a negative
binomial distribution was applied to analyze CAS with (a)
all male sex partners and then (b) seronegative/unknown
male sex partners and (c) seropositive male sex partners.
Multivariate analyses were conducted analyzing effects of
study condition (intervention vs. control), and controlling
for baseline sexual behavior, and a priori psychosocial
covariates (e.g., age, depression, alcohol use). Results
from the multivariate models are reported as exponen-
tiated beta coefficients representing incident rate ratios
(IRRs) with 95% confidence intervals for each predictor.
The exponentiated beta coefficients serve as a measure of
effect size in negative binomial distribution analyses.
As an exploratory aim, we also examined the effects
of the theoretical variables (IMB measures) on sexual
behavior outcomes to identify potential mediators of
primary study effects and also associations with study
outcomes at follow-up. Multivariate analyses, including
bootstrapping to assess indirect effects, were conducted
including our measures of information, motivation, and
behavioral skills to examine whether intervention effects
on sexual behavior were explained by these theoretical
variables. We also analyzed associations between the IMB
constructs and sexual behavior at 6-month follow-up
controlling for baseline sexual behavior in these analyses.
Results
Participant Characteristics
Recruitment commenced in May 2012, with the 6-month
follow-up assessments concluding by January 2014.
Table  1 presents sample characteristics at baseline for
both the intervention and control groups. There were no
significant differences in demographic or psychosocial
characteristics at baseline, except for self-identified sexual
orientation with more men identifying as bisexual in the
HINTS group than the control group (p = .046). There
were no significant differences in years since diagnosis,
HIV medication usage, CD4 cell counts, or viral load
status between the groups. Two participants identified as
transgender gay men and were included in the analyses.
A  total of 167 gay/bisexual men living with HIV were
randomized to either the HINTS intervention (n = 85) or
to the Healthy Living control condition (n = 82).
Study Participation, Retention, and Satisfaction
Participants in the HINTS conditions attended an aver-
age of 2.2 (SD = 1.8) out of four sessions. Participants
in the Healthy Living control conditions attended an
average of 2.7 sessions (SD  =  1.6). There was no sig-
nificant difference for group attendance between con-
ditions, F(1,165)  =  3.16, p  =  .077. The modal number
of sessions attended by both groups was four sessions.
Retention rate was approximately 84%, with 140 of 167
participants (70 in each condition) available at 6-month
follow-up. No significant differences in attrition were
observed between groups.
Participants were asked to rate their satisfaction using
the following scale: 0) Unsatisfied; 1) Somewhat unsat-
isfied; 2) Somewhat satisfied; 3) Satisfied. Overall, par-
ticipants in the HINTS intervention reported a mean
satisfaction of 2.72 (SD = 0.7), while participants in the
control condition reported a mean satisfaction of 2.57
(SD = 0.9). At 6-month follow-up, 97% of participants
in the HINTS intervention and 84% in the control condi-
tion agreed that study participation was worth their time.
Main Effects Analyses
Descriptive statistics for the IMB variables and the sexual
behavior outcomes at baseline and 6-month follow-up are
presented in Table  2. ANCOVA analyses controlling for
baseline data, showed no significant change between groups
in the IMB variables at 6-month follow-up (all p’s > .05).
122 ann. behav. med. (2018) 52:116–129

Table 1  Demographic, health, psychosocial, and sexual behavior characteristics for the entire sample at baseline

Total sample Intervention Control group p value for differences

(N = 167) group (n = 85) (n = 82) by condition

Mean (SD) or percentage

Age 44.7 (10.8) 43.7 (11.4) 45.7 (10.1) .230
Race/ethnicity .548
 White 58% 55% 60%
  Black/African American 25% 25% 24%
 Hispanic/Latino 14% 14% 13%
  Asian/Pacific Islander 2% 4% 0%
  Biracial/Mixed Ethnicity 2% 2% 2%
Male Gender Identification 99% 99% 99% 1.00
Transgender 1% 1% 1%
Sexual Orientation .046
  Gay or homosexual 92% 88% 96%
 Bisexual 8% 12% 4%
Married or living with a partner 20% 20% 21% .988
Education .613
  High school or less 17% 19% 16%
  Beyond high school 83% 81% 84%
Income .510
 $0–$10,000 18% 14% 22%
 $11,000–$20,000 23% 25% 21%
 $21,000–$30,000 16% 14% 18%
 $31,000–$40,000 14% 14% 13%
 $41,000–$50,000 7% 9% 4%
  Over $50,000 21% 21% 21%
Employment Status .845
 Unemployed 18% 19% 17%
 Working 42% 39% 45%
  Receiving disability 31% 33% 29%
 Student 5% 5% 6%
 Retired 4% 5% 2%
Health Characteristics
  Years since HIV Diagnosis 12.0 (9.4) 12.4 (9.7) 11.7 (9.1) .644
  Most recent CD4 cell count 644.8 (257.5) 643.7 (271.9) 646.1 (242.6) .958
  Currently taking HIV medications 93% 93% 94% .802
  Undetectable viral load (baseline) 74% 73% 76% .725
  Undetectable viral load (6 months) 75% 73% 80% .543
Psychosocial variables
  Depression (CES-D score) 17.0 (12.4) 18.4 (12.8) 15.6 (11.9) .148
  Problem drinking (AUDIT score) 5.7 (6.1) 5.4 (6.5) 5.9 (5.7) .633

CES-D Center for Epidemiological Studies of Depression Scale; SD standard deviation.

Participants in the HINTS intervention reported more male
sex partners at 6 months compared to the control condition,
controlling for baseline number of partners (IRR: 1.81;
95% CI: 1.23–2.68; p = .003). Participants in HINTS simi-
larly reported meeting more sex partners online at 6-month
follow-up (IRR: 2.72; 95% CI: 1.79–4.14; p < .001). While
no changes in CAS with all male partners were observed
between groups, we observed different patterns of CAS with
partners based on their serostatus between the HINTS and
control groups. Thus, the following main effects analyses
were conducted to explore these changes while controlling
for covariates and exploring for potential IMB mediators
assessed at 6-month follow-up. Results of the main effects
analyses are presented in Table 3 and are depicted in Fig. 2.
ann. behav. med. (2018) 52:116–129123

Table 2  Descriptive statistics of IMB and sexual behavior outcomes of the HINTS Intervention compared to the healthy living control
group at baseline and 6-month follow-up

HINTS intervention Control group

6-month 6-month
Baseline follow-up Baseline follow-up

Outcome M SD M SD M SD M SD p-value*

I: Knowledge 3.49 0.6 3.47 0.9 3.49 0.8 3.66 0.7 .540
M: Intentions 4.26 0.9 4.25 1.0 4.13 1.0 4.16 1.0 .805
Behavior: Efficacy 7.03 2.3 7.08 2.5 6.60 2.3 6.86 2.4 .742
Exp(B) (95% CI); p**
Number male sex partners 4.97 6.5 4.89 13.1 4.69 6.3 2.58 3.2 1.81 (1.23–2.68); p = .003
Sex partners met online 3.46 5.1 3.95 12.4 2.97 4.3 1.46 2.4 2.72 (1.79–4.14); p < .001
CAS – All partners 9.34 16.4 6.40 14.8 11.32 19.1 8.90 18.1 0.91 (0.63–1.30); p = .589
CAS – HIV-/unknown 3.70 6.33 1.54 4.1 5.31 11.2 3.58 13.3 0.33 (0.20–0.53); p < .001
CAS – HIV+ 7.17 16.0 4.86 13.4 8.02 17.3 5.32 12.0 1.61 (1.08–2.40); p = .020

CAS condomless anal sex; IMB Information, Motivation, Behavioral skills.

*Analysis of covariance results controlling for baseline levels.
**Negative binomial regression results, controlling for baseline levels reported as incident rate ratio.

Table 3  Results of the negative binomial models of the main effects of the intervention on sexual risk behavior (condomless anal sex) with
all sexual partners, and with sexual partners by serostatus

Sexual risk behavior outcome

at 6-month follow-up Model predictor B IRR CI95%lo CI95%hi p

Condomless anal CES-D −0.022 0.979 0.959 0.999 .038

sex – All partners Age −0.033 0.967 0.942 0.994 .015
AUDIT −0.043 0.958 0.913 1.005 .078
Condition −0.037 0.964 0.610 1.522 .874
Baseline risk behavior – All partners 0.030 1.030 1.014 1.047 <.001
Condomless anal CES-D −0.013 0.987 0.962 1.012 .304
sex - HIV-/unknown Age −0.014 0.987 0.953 1.021 .436
partners
AUDIT −0.008 0.992 0.936 1.050 .772
Condition −0.985 0.373 0.207 0.672 .001
Baseline risk behavior – HIV-/unknown 0.048 1.049 1.014 1.085 .006
partners
Condomless anal CES-D −0.011 0.989 0.967 1.011 .333
sex – HIV+ partners
Age −0.034 0.966 0.940 0.993 .014
AUDIT −0.039 0.962 0.911 1.014 .151
Condition 0.762 2.142 1.268 3.617 .004
Baseline risk behavior – HIV+ partners 0.042 1.043 1.022 1.064 <.001

CES-D Center for Epidemiological Studies of Depression Scale; IRR incident rate ratios.

Sexual Risk Behavior With all Male Sex Partners
Experimental condition (HINTS vs. Healthy Living con-
trol) was not a significant predictor of incidence of CAS
with all male sex partners regardless of serostatus (IRR:
0.964; 95% CI: 0.610–1.522; p = .874), when controlling
for age, depression, alcohol use, and sexual risk behavior
reported at baseline, indicating that receiving the HINTS
intervention did not significantly predict total frequency
of CAS with all male sexual partners.
Sexual Risk Behavior With Serodiscordant Male Sex
Partners
To assess for HIV transmission risk behavior as an
outcome, incidence of CAS with serodiscordant
124
Fig. 2  Marginal mean incidence of condomless anal sex at 6-month follow-up by experimental condition across (A) all male sex partners
and (B) by sex partner serostatus. HINTS HIV Internet Sex Study (experimental condition).
(HIV-negative/serostatus unknown) sex partners reported
at 6-month follow-up was examined. Participants in the
HINTS intervention reported significantly reduced sex-
ual risk behavior with serodiscordant partners at fol-
low-up (IRR: 0.373; 95% CI: 0.207–0.672; p  =  .001),
when controlling for age, depression, alcohol use, and
baseline sexual risk behavior. Men who participated in
the HINTS intervention were 62.7% less likely to engage
in CAS with a serodiscordant partner at follow-up than
men assigned to the control condition.
Sexual Risk Behavior With Seroconcordant Male Sex
Partners
Finally, incidence of CAS with seroconcordant sex part-
ners reported at 6-month follow-up was examined. This
outcome is consistent with serosorting behavior, which
was hypothesized to increase following intervention.
Participation in the HINTS intervention was signifi-
cantly associated with increased incidence of CAS with
sex partners living with HIV at follow-up (IRR: 2.142;
95% CI: 1.268–3.617; p = .004). Men who participated in
the HINTS intervention were more than twice as likely
to engage in CAS with seroconcordant partners com-
pared to men assigned to the control condition.
Theoretical IMB Analyses
Because the IMB variables did not significantly change
during the intervention as noted above, conditions were
not met for potential mediation effects of these theoreti-
cal constructs on our sexual behavior outcomes. Further,
ann. behav. med. (2018) 52:116–129
using formal mediation analyses with 1,000 boot-
strap samples, we did not see evidence for any indirect
effects of the IMB constructs on CAS for all partners
(Information: B[SE] = −0.28 [0.77], 95% CI: −1.40–0.53;
Motivation: B [SE]  =  −0.08 [0.55], 95% CI: −1.43–
0.98; Behavioral Skills: B [SE]  =  −0.07 [0.45], 95% CI:
−1.23–0.68), for HIV-/unknown partners (Information:
B [SE]  =  0.06 [0.30], 95% CI: −0.41–0.53; Motivation:
B [SE]  =  −0.02 [0.36], 95% CI: −0.87–0.68; Behavioral
Skills: B [SE] = −0.08 [0.34], 95% CI: −0.93–0.53), and
for HIV+ partners (Information: B [SE] = −0.40 [0.40],
95% CI: −1.49–0.10; Motivation: B [SE] = −0.03 [0.25],
95% CI: −0.59–0.56; Behavioral Skills: B [SE]  =  0.06
[0.32], 95% CI: −0.58–0.83).
We then examined the association of the information,
motivation, and behavioral skills variables at 6-month
follow-up with the primary study outcomes (CAS with
all male sex partners, CAS with serodiscordant partners,
and CAS with seroconcordant partners). Table 4 presents
the results of these analyses. Motivation (IRR: 0.485;
95% CI: 0.292–0.803; p  =  .005) and behavioral skills
(IRR: 0.749; 95% CI: 0.607–0.926; p = .007) at 6 months
were significantly associated with decreases in incidence
of CAS with serodiscordant partners. Motivation at
6 months was also significantly associated with increases
in CAS with seroconcordant partners (IRR: 0.634; 95%
CI: 0.419–0.960; p = .031).
Discussion
The goal of this study was to empirically test a newly
developed online HIV sexual risk reduction intervention
ann. behav. med. (2018) 52:116–129125

Table 4  Results of the negative binomial models of the mediating effects of IMB variables on sexual risk behavior (condomless anal sex)
with all sexual partners, and with sexual partners by serostatus

Sexual risk behavior

outcome at 6-month follow-up Model predictor B IRR CI95%lo CI95%hi p

Condomless anal CES-D −0.039 0.962 0.940 0.984 .001

sex – All partners Age −0.040 0.961 0.932 0.991 .011
AUDIT −0.040 0.961 0.913 1.011 .126
Condition 0.323 1.382 0.825 2.315 .219
Baseline risk behavior – 0.019 1.019 1.003 1.035 .019
All partners
Information 0.193 1.213 0.773 1.903 .401
Motivation −0.337 0.714 0.480 1.064 .098
Behavioral Skills −0.127 0.880 0.759 1.021 .092
Condomless anal CESD −0.021 0.979 0.951 1.009 .166
sex - HIV-/unknown Age −0.026 0.975 0.930 1.022 .286
partners
AUDIT −0.063 0.939 0.872 1.012 .098
Condition −0.397 0.672 0.330 1.369 .274
Baseline risk behavior – 0.036 1.037 0.997 1.076 .068
HIV-/unknown partners
Information 0.053 1.054 0.624 1.781 .843
Motivation −0.725 0.485 0.292 0.803 .005
Behavioral Skills −0.289 0.749 0.607 0.926 .007
Condomless anal CESD −0.013 0.987 0.963 1.011 .279
sex – HIV+ partners
Age −0.053 0.949 0.920 0.978 .001
AUDIT −0.020 0.980 0.923 1.040 .502
Condition 0.922 2.514 1.444 4.376 .001
Baseline risk behavior – 0.040 1.041 1.020 1.061 <.001
HIV+ partners
Information 0.214 1.239 0.751 2.043 .401
Motivation −0.455 0.634 0.419 0.960 .031
Behavioral Skills 0.163 1.177 0.991 1.396 .063

(called HINTS) among a sample of gay and bisex-
ual men living with HIV who meet sex partners online.
HINTS is a four-session, group-based behavioral inter-
vention delivered exclusively online and developed using
the IMB model of health behavior change [18, 19].
HINTS differs from previous online sexual risk reduc-
tion interventions in that it targets MSM living with HIV
across a range of ages, is based on the IMB model of
health behavior change, and includes information per-
tinent to online partner seeking. Sessions consisted of
health and Internet safety-related information, as well
as presentation and discussion of scenarios to enhance
motivation and provide the behavioral skills necessary
to reduce sexual risk behavior. A  total of 167 men (85
assigned to HINTS and 82 assigned to a Healthy Living
control condition) participated in the study. Condomless
anal sex (CAS) with male partners was assessed at base-
line (preintervention) and at 6-month follow-up. We also
assessed IMB variables as potential mediators of inter-
vention effects on sexual risk behavior.
Although the HINTS intervention did not have a sig-
nificant impact on frequency of CAS when examining
sexual risk behavior across all male partners, there were
significant intervention effects when tested separately by
partner serostatus. Men assigned to the HINTS inter-
vention were significantly less likely to engage in CAS
with male partners who were either HIV-negative or
whose HIV serostatus was unknown, as compared to
men assigned to the Healthy Living control condition.
For men living with HIV, CAS with serodiscordant part-
ners confers the greatest risk of HIV transmission [13,
14]. The reduced frequency of this behavior among men
who received the HINTS intervention indicates signifi-
cant alterations in sexual transmission risk behavior, a
finding with important clinical and public health impli-
cations. Motivation and behavioral skills assessed at
6 months were related to the decreased incidence of CAS
with serodiscordant partners. Thus, it appears that hav-
ing a greater level of motivation for reducing sexual risk
and the important skills for enacting safer sex practices is
126
associated with decreased HIV transmission risk behav-
ior. However, these IMB variables did not change due to
the HINTS intervention and cannot explain the change
in CAS based on HINTS group participation. These
IMB findings relate to other previous work linking the
components of the IMB model to health behavioral out-
comes [20–23].
Information did not have a significant impact in our
model, perhaps due to the low reliability of our measure
or, more likely, due to the established knowledge base
of our sample. In fact, it is quite possible that meth-
odological issues (e.g., reliability, validity) related to all
three of our IMB outcome measures may have led to not
observing a change in the IMB components as a result
of the HINTS intervention. We utilized the IMB the-
oretical model for developing the HINTS intervention
content during in-person interviews and face-to-face
focus groups, but perhaps did not adapt existing meas-
ures used in our prior work adequately for online use.
Thus, the existing measures simply may not have been
sensitive enough to assess what participants were really
getting from the HINTS intervention that led to the
reductions in sexual risk behavior. Future work should
look to tailor measures specifically to intervention con-
tent administered online.
Men assigned to HINTS also showed greater fre-
quency of CAS with partners living with HIV at fol-
low-up compared to men assigned to the Healthy Living
control condition. This result suggests that men who
received the HINTS intervention engaged in serosorting
behavior with greater frequency than men in the control
condition. Serosorting is a commonly endorsed strat-
egy in MSM with and without HIV infection because
it is perceived to reduce HIV transmission [9], and
serosorting frequency has been shown to increase dur-
ing some behavioral risk reduction interventions [38,
39]. Motivation level at 6  months was also related to
increased incidence of CAS with seroconcordant part-
ners. It appears that having a greater level of motiva-
tion for reducing sexual risk is associated with increased
serosorting behavior, but again since motivation level did
not significantly change due to the HINTS intervention,
it cannot explain the increases in serosorting behavior.
Regardless, participation in the HINTS intervention
promoted serosorting behavior among the participants,
perhaps reducing subsequent HIV transmission risk.
Although serosorting can help reduce HIV transmis-
sion risk compared to CAS with serodiscordant part-
ners [55], it is important to note that it is also associated
with a number of significant health risks, including
increased risk for contracting bacterial and viral sexu-
ally transmitted infections, and risk of “superinfection”
with multiple strains of HIV [55–59]. These health risks,
and the potential for increased stigma that may result
from serosorting, highlight the limitations of the current
ann. behav. med. (2018) 52:116–129
findings and the need for future studies to address the
unique risks associated with distinct sexual behaviors. In
addition, recent evidence suggests that serosorting may
be most relevant for MSM with undetectable viral loads
[60]. Incorporating conversations around viral load
status into sexual decision-making (e.g., viral-sorting)
would also be an important aspect of sexual risk reduc-
tion to explore in the future.
Some additional limitations are worth noting. The
sample was drawn primarily from the East Coast and
the Midwest due to logistical difficulties associated with
running groups in different time zones. However, the
study effectively engaged participants from both urban
and rural areas, and the exclusively online nature of the
intervention allowed sexual minority men in underserved
areas to participate. Participants’ sexual behavior data
must be interpreted with some caution, as it was collected
online via self-report, which may have resulted in biased
reporting. However, this strategy has been successfully
used in previous work, and prompts were incorporated
to help ensure valid data collection. Use of biomedical
prevention strategies (e.g., TasP or PrEP) by partici-
pants’ partners was not evaluated in this study, and will
be important to account for in the future. HIV treatment
is a critical component of recent primary and secondary
prevention efforts, and should be incorporated into the
development of future risk reduction strategies. Recent
recommendations now call for the use of combined
bio-behavioral prevention interventions [7], and the brief,
online HINTS intervention seems uniquely poised for
this role. This study also examined only gay and bisexual
men, and therefore cannot be generalized to all MSM,
women, transgender individuals, or other people living
with HIV. Since our HINTS intervention was specifically
developed using input from gay and bisexual men living
with HIV and was designed to address transmission risk
factors relevant to this group, it is unclear how effective it
would be in other populations affected by HIV infection.
Although sexual minority men represent the group with
the greatest incidence of HIV transmission in the USA,
it will be important to assess secondary transmission risk
among women and other key groups in future work.
Conclusion
Our novel, theoretically driven, brief group intervention
called HINTS was successful in reducing specific HIV
transmission risk behaviors, as well as increasing serosort-
ing behavior in a sample of gay and bisexual men who
meet their sex partners online. Some components of the
IMB model were related to observed changes in sexual
risk behavior, but did not explain the main intervention
effects. Although these effects were evident at 6-month
follow-up, it will be important to examine the durability
ann. behav. med. (2018) 52:116–129127
of the HIV risk reduction and serosorting behaviors
over longer periods of time in future work. Use of so-
cial media and other forms of Internet-based technology
(such as mobile apps) to follow individuals over longer
intervals may help to promote and maintain these sig-
nificant benefits. Given that the HINTS intervention is
brief and readily accessible online, its future use is war-
ranted in combination with biomedical strategies.
Funding:  This study was funded by an NIMH research grant
(R34MH087120). This research was also partially supported by an
NIMH training grant (T32MH074387).
Compliance with Ethical Standards
Disclosure of Potential Conflicts of Interest
Conflict of Interest:  D.G.C.  and S.C.K.  have received research
grants from NIMH. All other authors declare that they have no
conflict of interest.
Research involving Human Participants and/or Animals
Ethical approval:  All procedures performed in studies involving
human participants were in accordance with the ethical standards
of the institutional and/or national research committee and with
the 1964 Helsinki declaration and its later amendments or compar-
able ethical standards.
Informed consent:  Informed consent was obtained from all indi-
vidual participants included in the study.
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AP NDICE VI - Declara o de Autoria

DECLARA O DE AUTORIA DO TRABALHO APRESENTADO

Declaro que o presente trabalho, no mbito da Unidade Curricular Interven o de

Enfermagem Comunit ria em Grupos Vulneráveis da autoria de:

Carolina Marques Simão Geraldes dos Santos

Vanessa Maria Gonçalves de Almeida

Maria João Mourão Nogueira