Love, sex, and Choices- Soap Opera Video Episodes Streamed to Smartphones in a Randomized Controlled Trial to Reduce HIV Sex Risk in Young Urban African American/Black Women Rachel Jones, PhD, RN, FAAN, Northeastern University Donald R Hoover, PhD, MPH, Rutgers, University Lorraine Lacroix, MPH, Northeastern University

This research was supported by: National Institute of Nursing Research R01NR10860 National Library of Medicine G08 LM008349 Healthcare Foundation of New Jersey

HIV/AIDS in Women IN THE UNITED STATES

In 2009, the majority of diagnosed HIV infections among females aged 13 years or older were attributed to heterosexual contact for all age groups. However, the percentages attributed to heterosexual contact decreased as age group increased. An estimated 17.9% of diagnosed HIV infections among females aged 45 years and older were attributed to injection drug use, compared with 9.6% in females aged 13–19 years, 10.0% in females aged 20–24 years, 13.0% in women aged 25-34 years, and 15.9% in women aged 35-44 years. The following 40 states have had laws or regulations requiring confidential name-based HIV infection reporting since at least January 2006: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. The 5 U.S. dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands.   Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting. Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.

Formative Studies Women had unprotected sex with partners they believed engaged in HIV risk behaviors Jones, 2006; Jones & Gulick, 2009 Patterns of Unprotected Sex Among Women Importance of unprotected sex to win and hold onto a man and to show trust Jones & Oliver, 2007

Theoretical Framework TO Soap Opera Development Sex Scripts Power as Knowing Participation in Change ®

Framework Sex scripts: socially shared meanings about sex behavior (Simon & Gagnon, 1989) Power as Knowing Participation in Change® (Barrett, 2010) being aware of what one is chooses to do feeling the freedom to act intentionally being involved in creating the changes that one intends People participate in change, but not always in a knowing manner Jones, 2006; Jones & Oliver, 2007

Why soap operas ?

Entertainment-Education Soap Operas Singhal, Cody, Rogers, Santelli, 2004 Stories grounded in urban women’s own experiences Women identify with the heroines’ process of change Messages to reduce HIV risk are designed to fulfill familiar relationship needs

Pilot Study on Handheld Computers A Story about Toni, Mike, and Valerie 43 minute pilot video available at: www.womenspoweragainsthiv.com Jones, 2008; Jones & Oliver 2007

The intervention: Love, Sex, and Choices (LS&C) Twelve, 15-20 minute episodes; Written & scripted by study team, professional filmmaker(Alan Roth), and actors

Study Design and Expected Outcome 1:1 randomized controlled trial (RCT) Comparing LS&C to 12-week HIV prevention intervention of text messages Both groups used study-provided smartphones Jones & Lacroix, 2012 Expected Outcome Video intervention participants have less unprotected vaginal and anal sex with high risk partners at 3 months (T2) and at 6 months (T3) than the comparison text message group

Sex Risk Measured by VEE Unprotected anal and vaginal sex using the vaginal episode equivalent (VEE)* with high risk partners ∑ (#UV) i + 2 (#UA)i )= sex risk the sum of the # of unprotected vaginal sex acts + 2 x the number of unprotected anal sex acts, where i is the # of high risk partners in the past 3 months *Susser, Desvarieux, & Wittkowski (1998), Reporting sexual risk behavior for HIV: A practical risk index and a method for improving indices. American Journal of Public Health, 88, 671-674.

Participants and Settings 18 to 29 year old women Inclusion criteria: Had unprotected vaginal / anal sex with men they believed had sex with other women/men, and/or injected drugs -past 3 months Recruited in Newark, Jersey City, East Orange, & Irvington, NJ from: Public housing, STD Clinics, Community Center, Storefront, Food Pantry Screening, Baseline, and Post-Intervention Interviews conducted with Audio Computer Assisted Self-Interview (ACASI)

Interventions Sent weekly for 12 wks √ Study provided smartphones Video LS&C (n=117) Written messages (n=121) Sent weekly for 12 wks √ Study provided smartphones Sent weekly email to phone with link to open intervention F/u contact if missed weekly emails Can watch/read current & previous episodes /messages 24/7 Track Frequency Track viewing time Responds on the phone with reason for re-watching Responds on the phone with answers about content

Data Analysis Outcome = VEE with high risk partners at T2 (3 mo), and T3 (6 mo) Due to skewness (VEE +0.5) was log transformed Repeated measures mixed linear models that adjusted for baseline behavior were fit

Results

Results: Participant Flow 505 screened -295 eligible, consented, randomized -57 lost to f/u, most due to lost cell phones 238 completed T2 and T3 post-intervention interviews -117 in Video Group -121 in Text Group

Table 1. Baseline Equality of Video and Text Arms Variable Text (n=121) Video (n=117) Mean ± std-dev or % Age (years) 22.0 ± 3.4 22.1 ± 3.6 Age at first sexual intercourse (years) 14.4 ± 1.8 14.5 ± 2.2 Highest grade completed 12.2 ± 1.7 12.22 ± 1.7 African American/Black 90.1% 86.32% Employment outside home 36.4% 40.2% Study Site Community center Public Housing Food Pantry Storefront STD Clinics 14.1% 30.6% 19.0% 22.3% 18.8% 30.8% 10.3% 17.1% 23.1% Used Alcohol before /during sex 81.8% 75.2% Injected drugs 2.5 3.4 Any unprotected vaginal sex with a high risk partner 99.2% Any unprotected anal sex with a high risk partner 40.5% 47.9% Sexual Pressure Score 25.5 ± 15.3 29.7 ± 16.3 Sensation Seeking Score 13.6 ± 6.9 15.1 ± 7.5 High Risk Sex Scripts Score 5.1± 5.9 6.6 ± 7.4 Any Male partner had sex with other women 100% Any Male partner had sex with men 29.8% 41.9% Any Male partner injected drugs 25.6% 31.6% * Note- The intervention groups did not differ on any of these variables at p < 0.05 by exact test or Wicoxon test

Summary of Baseline Findings Almost half had unprotected anal sex in the prior 3 months with high risk partners. Half (n=121, 51%) had 3 or more partners A surprising number knew/ suspected their partners had sex with men –42 % Video vs 30% of Text arm, P =0.06. Over half the sample (56.7%) had first coitus at ≤ 14 years old.

Table 2. Pre and Post Intervention VEE Change Geometric Mean Of VEE Acts Point Estimate ± Standard Error Text Arm Video Arm At baseline1 21.32 ± 2.83 22.20 ± 3.01 Follow Up At T2 (3 months)1 6.55 ± 1.02 5.70 ± 0.84 At T3 (6 months) 1 5.93 ± 0.91 4.85 ± 0.73 P > 0.20 from Wilcoxon test for difference in VEE between Video Arm and Text Arm at each of the three time points BUT NOTE THE DRAMATIC DECLINE IN VEE FOR BOTH GROUPS FROM BASELINE TO T2 and T3. ALL DECLINES AT P < 0.001

Table 3 Associations of Variables with VEE behavior Change 1 Characteristic2 Association With Ratio of the Post to Pre intervention VEE Behavior3 Point Estimate ( ±SE) P Video (Vs Text). 0.81 ±0.13 0.21 Visit 3 (Vs Visit 2) 0.88 ±0.08 0.17 High Risk Sex Script/ Log Unit 0.87 0.10 Study Site4 Community center Public Housing Food Pantry Storefront STD clinics 1.48 2.10 1.73 1.74 Baseline ±0.39 ±0.48 ±0.50 ±0.45 NA .03 -OVERALL4 0.12 0.002 0.06 0.03 1. From Mixed Model Linear Regression on log transformed VEE at T2 and T3 with log baseline VEE as a covariate. Video Vs. Text and time points T2 Vs. T3 are forced into the model, otherwise only variables with P < 0.20 in Adjusted Models are included. Pre-intervention baseline VEE is included in all models. 2. NOTE – Age, Age at First Sex, Ethnicity, Work Outside of Home, Education, Sexual Pressure Score, Sensation Seeking Score, and Any Male Partner had sex with Men did not meet the P < 0.20 Selection criteria 3. From exponentiation of parameter estimates from mixed linear regression models with Log transformed VEE at post intervention Visits 2 and 3 as outcomes. 4. Overall P-value for study site association with post intervention behavior was 0.03 in the multivariate model

Summary of Main Findings Sex risk behavior declined by 19% more in the soap opera video group than the HIV prevention text group. Difference was not statistically significant (p=0.21). VEE risk behavior was ~12% lower at T3 (6 Mo) than T2 (3 Mo) in both groups, this difference between time points was not statistically significant (p = 0.17) Greater risk post-baseline reduction of VEE at STD clinic sites than in storefront or public housing.

Evaluation of Love, Sex, and Choices Videos By Participants Women were enthusiastic about the videos. All but 4 of 117 thought the stories were realistic All but 8 could relate to the characters 90 % thought their friends might like to watch All but one wanted the stories to continue

Evaluation of Smartphone by 117 Video Participants Using cell phone for the project was easy (n = 113, 96.6%) Using the cell phone maintained privacy (n =113, 96.6%) Wanted to continue watching with the phone (n =107, 91.4%) Jones & Lacroix (2012)

Discussion, Implications

High risk behavior at baseline Post-intervention sex risk VEE behavior was reduced (p < 0.001) in both groups. While reduction was 19% more in the video group, this difference was not statistically significant. Both groups received emails, calls, smartphones, high level of involvement /attention Greater VEE reduction at STD clinic sites than public housing or storefront: further study needed The stories held participants’ attention Participants identified with characters & stories and wanted to continue watching

Conclusion This is the first study to evaluate streaming weekly videos to smartphones to promote health. We believe that Love, Sex, and Choices was highly effective in reducing HIV risk behavior and the comparison group also received a viable HIV prevention intervention. A streamed video intervention can be widely distributed and accessed 24/7 Allows usage to be tracked, providing measures of treatment fidelity

Gratefully Acknowledge The National Institute of Nursing Research (NINR) supported this work (RO1-NRO10864). Technical support at Rutgers Newark Computing Services Alan Roth, filmmaker, Martinique L. Moore, Assistant Director The cast of Love, Sex and Choices; Starring: Toni:Yasmine Weaver, Diamond:Tationna Bosier, Valerie: Leeann Hellijas, Keyanna: Darnell Rhea Williams, Mike: Laurence Covington, Dante: Omar Golden, James: Jaylen Sansom Rutgers University College of Nursing and the Educational Opportunity Fund (EOF) research assistants whose dedication made this work possible: Yvesnallie Antoine, Magnolita Bonheur, Essence Burrows, Fernandine Charles, Lin Chen, Geraldine Dufort, Catherine Lora, Judeline Marcellus, Sandra Rios, Tatiana Saavedra, Griselda Sanchez, and Mireille Zuniga; Thank you to the site recruiters, and to: Carol Tyler, the late Kevin Burnett, Brenda Davis, MS, LCSW, and Grace Malley, at Jersey City Public Housing; Honorable Mayor Wayne Smith of Irvington Township; Dorothy Wojcik, Program Manager, Jersey City Preventive Medicine Clinic; Ms. Verna Sims, Director at Mary McLeod Bethune Life Center; Rochelle D. Williams-Evans, RN, MS, Director/Health Officer, East Orange Department of Health & Human Services; And with gratitude to the women who participated in this study.

Jones, R. & Lacroix, L.J. (2012). Using Smartphones to View Weekly Soap Opera Videos in a Randomized Controlled Trial to Reduce HIV Risk in Young Adult, Urban African American/Black Women. DOI 10.1007/s10461-012-0170-9 AIDS & Behavior, 16, 1341–1358.  Jones, R. (2012). Handheld computers to run ACASI to assess HIV risk and deliver tailored soap opera video feedback: Acceptability among young adult urban women. DOI: 10.1016/j.jana.2011.04.001 Journal of the Association of Nurses in AIDS Care, 23 (3). Jones, R. & Gulick, E. (2009).The Sexual Pressure Scale for Women-Revised. Research in Nursing and Health. 32, 71–85 Jones, R. (2008). Soap opera video on handheld computers to reduce urban women’s HIV risk. AIDS and Behavior, 12, 876–884 Jones, R. & Oliver, M. J. (2007). Young urban women’s patterns of unprotected sex with men engaging in HIV risk behaviors. AIDS and Behavior, 11 (6), 812-821. Jones, R. (2006). Reliability and validity of the Sexual Pressure Scale. Research in Nursing and Health, 29, 281-293.   Jones, R. (2006) Sex Scripts and power: A framework to explain urban women’s HIV sexual risk with male partners. Nursing Clinics of North America, 41, 425-436.  Jones, R. (2004). Relationships of sexual imposition, dyadic trust, and sensation seeking with sexual risk behaviors in young urban women. Research in Nursing and Health, 27, 185-197. Jones, R. (2003). Survey data collection using Audio Computer Assisted Self-Interview. Western Journal of Nursing Research, 25, 349-358.

Many Thanks to the XIX International AIDS Conference Rachel Jones, PhD, RN, FAAN ra.jones@neu.edu www.womenspoweragainsthiv.com