In This toGether: Testing a population-based text messaging-based HIV prevention program for young adults across Uganda - To harness the potential of text messaging to deliver research-driven HIV preventive information during a critical age period, we developed and pilot tested In This toGether (ITG; R34MH109296), an HIV prevention program developed specifically for, and with ongoing feedback from, 18-22 year-olds across Uganda. ITG is one of the first comprehensive, text messaging-based HIV prevention programs developed and tested nationally in any sub-Saharan African country. Findings from the R34 suggest that, despite the small sample size (n=150) and the inclusion of youth across the HIV behavioral risk spectrum, ITG is associated with higher rates of condom-protected sex (aIRR = 1.68, p<.001) and odds of HIV testing (aOR = 2.41, p = 0.03). Here, we propose to build upon this promising R34 pilot by conducting a well-powered efficacy trial. Reach will be expanded by translating the intervention into 3 additional languages. Specifically, we aim to: Primary Aim: Measure the 12-month efficacy of ITG on HIV preventive behaviors for Ugandan youth 18-22 years of age in a national RCT (n=750). We will conduct a 17-month RCT, thereby extending our R34 work by increasing our observation period by 12 months and by having a fully powered sample size. Primary Aim 1 a: Test whether ITG is more effective in HIV prevention when compared to control conditions. Our main outcome measures will be: (i) the rate of condom-protected sex acts and (ii) HIV testing. Secondary outcomes will be (iii) STI testing and (iv) the odds of PrEP uptake among those eligible. Primary Aim 1 b: Using a fractional factorial-based MOST design, we will identify the impact that intervention components have on behavior change. Participants who are in the intervention will be further randomized to one of four arms predicated on having or not having the three interactive features: 1) Level Up quiz questions; 2) milestone-driven Badges (e.g., carrying condoms); and 3) access to on-demand advice. Secondary Aim: Assess RCT outcomes by factors associated with HIV acquisition: Sex, urban/rural setting, and education. People who are women, live in urban areas, and have lower educational attainment face higher HIV risk. We will further extend our R34 by examining here intervention impact for important subgroups. Findings will inform potential future targeting and also adaptations of ITG. Exploratory Aim: Measure the feasibility and acceptability of photo-verification of HIV testing. The national reach of ITG results in a stronger public health potential than a localized intervention because youth from varied backgrounds - particularly those outside of Kampala and without access to local healthcare resources - can be engaged and affected. It also makes verification of HIV testing difficult because the gathering of clinic data is complex even for local, let alone, national cohorts. As such, we will pilot a photo verification procedure that Dr. Bogart innovated with a different population in a different region. The Ministry of Health will guide us on sustainability should the findings of this R01 warrant.
