2. Internet based HIV Prevention for rural MSM: Issues & Preliminary Efficacy Anne Bowen, PhD U. Wyoming

4.  Rural Culture  Few HIV Prevention Programs  MSM (including IDU)

5.  Affordable  Anonymous  Accessible

6.  5 year NIH/NIMH Funded Grant  GOAL: Develop and Implement an INTERNET based HIV prevention for Rural MSM  Years 1 & 2: Assessment Study Qualitative and Quantitative Assessment of rural MSM risk  Years 3-5: PROJECT HOPE Develop and Pilot an Internet delivered HIV Prevention

7.  Recruiting  Screening  “Frauds” or multiple submitters  Participant Retention  Interventions  Intervention Outcomes

9. Individual Face to Face Internet Chat Rooms  Public and Private Mass Recruiting (Ads) Magazines, Newspapers Internet Ads (big boxes, banners)

10.  Types of sites Match.com: Monthly Fees Lavalife.com: “Pay for Play” – free profiles, messages cost  Specialty sites VeggieDate.com SingleswithScruples.com MuslimSingles.com, ChristianSingles.com Ashleymadison.com “When Monogamy becomes Monotony”  Streams within sites Dating Relationship X-rated intimate encounters

11.  Expensive ($10,000/month)  Many exposures and “clicks”, lower follow-through  Banner Messages Generic or Message framing Ethnicity Money

12.  GOAL: Increase minority recruitment  Variables Ethnic specific – pictures and messages Message Framing  Gain & “Safe”  Sun screen, bicycle helmets  Loss Message & “Risk”  Mammograms, HIV Interventions

13. Wyoming Rural AIDS Prevention Projects © 2001-2005, All rights reserved

15. WRAPP HOPE N720100 % Caucasian96.572 Hispanic013 African Am.21.0 Native Am.06 Asian or API1.48

16. Finding Qualified Participants

17.  Passive Consent  Distraction questions  Non-Qualified Age Sexual identity or behavior  Qualified Rural vs. Urban Pay/no pay

18.  Multiple bulleted pages  “Tell me more”  Terms of Participation Page  Accept Username Password  Valid Email  Other contact information (voluntary)

23. “Frauds”

24.  Automatic: IP, machine information  User supplied Required:  Valid e-mail  Username, password Optional:  Name, phone, second e-mail  Friend’s name, friend phone, friend’s e-mail

26.  Check Computer generated matches  If yes – Explore Route to Urban (No pay) lock if seems to be a duplicate  If no or not duplicate Activate

27. YesYes YesYes YesYes YesYes YesYes YesYes YesYes

29. N=431% Identical IP Address66 Password54 Phone45 Email29 Username11 Last Name5

31. Label # Tries N%IDInfrequent2-410481.3 IP, PW, UN, e-mail, Phone Persistent5-91712.7 Repeater10-2354.0 IP, PW, Phone Hackers45-6732.4 IP, reverse phone

32. Reimbursement History Q1 % Yes Q2 Q3 Q4 Infrequent21171412 Persistent24201918 Repeater28211615 Hackers54473831

34.  Previous studies say “it’s a must”  WRAPP: Urban vs. Rural  How do we do it? Cash  Mail cash/check  PayPal Gift certificates  Companies  Permissions  Large or small quantities

35.  Amounts Money vs. other? Money “required” More money, more “fraud”  Different ways to pay Same amount Increasing amounts

36.  Method E-mail Phone, letters  Messages Simple Enhanced Bonuses

37. E-mail reminder None 1 st 2 nd 3 rd Complete Number Completed 334/57778/24399/16530/66 % Complete 58%32%60%46%94% First Intervention & Q2, only

39. Information Motivation Behavioral Skills HIV Prevention BEHAVIOR Fisher & Fisher

40.  Knowledge (Information) Living with HIV HIV Prevention  Life Goals and Sexual Partners (Motivation) New Partners Casual Partners  Contexts of Risk (Behavior) Bar Internet

41. Wyoming Rural AIDS Prevention Projects © 2001-2005, All rights reserved

44. SCREENER & CONSENT INTERVENTION 2 INTERVENTION 3 INTERVENTION 1 Q1 Q4 Q3 Q2

45.  Completers vs. Drop-outs No Differences:  Age, Sexual Orientation, Ethnicity, Religion  Education, Student or Work status, Income  Completers: # Sex partners last 30d (Zero, One, > 2) One significant difference  More of the non-students were monogamous

46.  HIV Knowledge  Self-efficacy Mechanical Emotional Refusal  Outcome Expectancies Negative Fell Safer  Willingness to engage in safer sex practices  Behavior (Q1 & Q4 only) # sex partners Frequency of anal sex Frequency of condom use

47.  One Intervention Knowledge Intervention:  Knowledge, SE- mech All Interventions:  OE-safe, SE-emot., & SE-refusal  Three Interventions INTERVENTION ORDER didn’t matter ALL outcome variables changed significantly

49. Number of sex partners at Q1 Main Effect of time Paired Comparisons Zero p<.001 1 p<.001 >=2 p<.001Eta 2 Knowledge+++.30 Outcome Expectancy Safe +++.12 Negative - +++.04 Self-efficacy Mech. +++.31 Emot. +++.23 Refusal +++.22

50. # Sex partners at Q1 ME Time Paired ComparisonsZero1>=2Eta 2 Limit sex partners to one per month +++.04 Condoms with new partners, always +++.06 Oral sex until monog. and text neg. +++.09 Condom until monog. and test neg. ++++.09

51. Number of sex partners at Q1 Zero1>=2 Number Sex Partners 0 1.0 0 1.0 1 1.7 5.3 3.9 Frequency of anal sex Na.80.69.59.56 Condom use for anal sex Na.41.63.49.70

53. Subset of Interv. completers, Sent E-mail requesting F-U Pre-Intervention Questionnaire (N=211) Q5 -1 mo N=55 Post-Intervention Questionnaire (N=211) Q5 -9 mo N=14 Complete interventions

54.  Non-Random Sample  E-mailed Q4 completers, asked of do a follow-up  Q5 Follow-up - voluntary 55 at 1 month 14 at 9 months

55. Q4 Only (n = 211) % Q5 (n = 69) % Age - 18-244932 Sexual Identity Gay Bisexual 78 22 **97 3 Ethnicity (Caucasian)7375 Single7371 Residency (<20,000)5648 Employment5159 Full Time Student29*36

56. Pre-test, Post-test, Follow-up

57. Outcome Variables  HIV Knowledge  Willingness to engage in safer sex practices  Self-efficacy ( Mechanical, Emotional, Refusal )  Outcome Expectancies ( Negative, Safer)  Risk Behavior # sex partners Frequency of anal sex Frequency of condom use

58. Q1 M Q4 M Q5 M Knowledge 1 mo. 9 mo. 9.22 9.11 9.64 <<<11.96 11.85 12.29 >11.69 11.71 Willingness 1 mo. 9 mo. 4.84 4.78 4.93 <5.08 5.11 4.95 NS5.13 5.14

59. Q1 M Q4 M Q5 M Mechanical 1 mo 9 mo. 3.97 3.93 4.13 <<<5.10 5.08 5.15 NS5.13 5.16 5.03 Emotional 1 mo. 9 mo. 4.22 4.11 4.63 <<<5.01 4.96 5.21 NS5.05 5.09 4.91 Refusal 1 mo. 9 mo. 4.26 4.16 4.63 <<<5.06 4.99 5.32 NS5.04 5.02 5.12

60. Q1 M Q4 M Q5 M Safety 1 mo. 9 mo. 4.72 4.66 7.99 << 5.14 5.09 5.33 NS5.15 5.09 5.51 Negative 1 mo. 9 mo. 3.11 3.27 2.46 >2.76 2.87 2.34 <3.07 3.11 2.91

61. BehaviorN Q1 M Q5 M 30d/# sex partners Anal Sex Index Condom use Index 69 48 a 3.36.69 b.52 c NS >> 3.81.63 b.72 c a Excludes participants reporting no sex partners at baseline. b Frequency of anal sex divided by number of sex partners. If no anal sex, index = 0. c Frequency of condom use divided by frequency of anal sex. If no anal sex, index = 1.0.

62. The Good, The Bad, The Future

63.  Banner Ads Effectively recruit Tailored Messages increase minority recruitment  “Fraud” accounts Numerous resubmissions Programming and verification

64.  3 Interventions > 1  Sign. Improvement  Behavior Change # sexual partners decreased for those with > 2 Freq. anal sex reduced for MSM with 1 SP Condom use for anal sex increased

65. Recruiting “Fraud” Reimbursement Retention: Long-term Maintenance

66.  Upgrade Audio Animation Cultural Relevance Translation  Long term follow-up  Translational Studies Clinic use Popular Opinion Leader

67. QUESTIONS? abowen@uwyo.edu Interventions available at: http://www.wrapphome.net/

68. Project Publications Bowen, A. M., Williams, M. L., Daniel, C. M., & Clayton, S. (2008). Feasibility, acceptability, and preliminary efficacy of Internet HIV prevention research: Targeting rural MSM. J. Behavioral Medicine., Online First Bowen, A. M., Daniel, C. M., Williams, M. L., & Baird, G. L. (2008). Identifying multiple submission in Internet research: Preserving data integrity. AIDS and Behavior, Online First. Clayton, S., *Daniel, C. & Bowen, A. (2008). The Internet: The New Frontier in HIV Prevention. In (Edgar, T., Noar, S. M., & Freimuth, V. S. Eds.) Communication perspectives on HIV/AIDS for the 21 st century. New York: Lawrence Erlbaum Associates Bowen, A. M., Horvath, K., & Williams, M. L. (2007). A randomized control trial of Internet- delivered HIV prevention targeting rural MSM. Health Education Research, 22(1), pp. 120-127. Horvath, K. J., Bowen, A. M., & Williams, M. L. (2006). Virtual and physical venues as contexts for HIV risk among rural MSM. Health Psychology, 25(2), pp. 237-242. Bowen, A. M. (2005). Internet sexuality research with rural MSM: Can we recruit and retain them? Journal of Sex Research, vol. 42(4), pp. 317-323. Williams, M., A. Bowen, and K. Horvath (2005). The social/sexual environment of gay men residing in a rural frontier state: Implications for the development of HIV prevention programs. Journal of Rural Health, 21(1), 48-55. Bowen, A. M., Williams, M. L., & Horvath, K. (2004). Using the Internet to recruit rural MSM for HIV risk assessment: Sampling issues. AIDS and Behavior, 8(3), pp.311-319.