Young men who have sex with men (YMSM) are disproportionately impacted by HIV in the United States with evidence indicating that the majority of new HIV infections in YMSM occur in the context of serious romantic relationships. Additionally, YMSM note fatigue related to HIV prevention programming while expressing a desire for culturally relevant relationship education. In response to community appeals, we developed 2GETHER, a relationship education and HIV prevention program for young male couples, currently being evaluated in two large randomized trials. Using data from one of these trials, this talk will focus on the complexities involved in recruitment and retention of young male couples into clinical trials of behavioral interventions. 2GETHER Chicago is an ongoing large scale randomized controlled trial evaluating the efficacy of 2GETHER (current N=70). We are randomizing 200 dyads to receive 2GETHER (i.e., group-based and individual relationship coaching to young male couples) or an attention-matched control (i.e., positive affect enhancement for couples). Recruiting dyads occurs in various contexts, including: in-person clinic based engagement through electronic medical records and provider referral; paid advertising on social media (e.g., Facebook); unpaid/organic social media advertising (e.g., Reddit posts, Twitter retweets); in-person recruitment at local events (e.g. Pride month events, bar nights); and warm referrals from other sources (e.g., local social service agencies, prior study participants). Using data from consort diagrams (i.e., recruitment flowcharts), we have characterized barriers and facilitators of recruitment and retention by identifying points in the recruitment process with the highest rates of attrition, as well as eligibility screener completion to program enrollment ratios by recruitment source and strategy. To date, the most effective recruitment sources for young male couples are paid social media advertisements (i.e. Facebook, Instagram) and in-person clinic based recruitment. While social media advertisements resulted in the highest number of enrolled couples, in-person clinic-based recruitment resulted in the highest ratio of screener to enrollment (i.e., largest percentage of eventual enrolled couples). Preliminary analyses and process data reveal various points at which attrition is highest, including the requirement of a couple validation screening (i.e., a second eligibility screener to remove “fake” couples) and in scheduling couples for the first intervention session. However, once couples complete their first session, retention at follow-up to date is extremely high (i.e., over 95% at 3- and 6-month follow up), indicating that enrolled couples are highly invested. Streamlining the recruitment process has resulted in lower attrition over time, including more automated screening options, frequent contact with participants prior to enrollment, tailoring retention messages to participant motivations (e.g., desire to build a healthy relationship, monetary compensation), and offering flexible dates/times for intervention sessions. While recruiting couples into intervention studies poses additional complexities, we have identified various strategies for minimizing these challenges. Given the benefits to practicing relationship and HIV prevention skills in vivo with a partner, addressing these complexities in recruitment is worth the added effort. Relationship education is an innovative and high-impact platform for addressing the health needs of YMSM.

Background: In recent years, there has been a steady advancement in sexual and gender minority (SGM) measure inclusion on state and federal surveillance instruments. The Behavioral Risk Factor Surveillance System is the most robust of the federal surveillance instruments, as it collects the largest number of cases when aggregated nationwide. But because each state has determination on the final form of their BRFSS survey, it is complicated to monitor the changing status of SGM measure inclusion. Methods: We reviewed BRFSS items utilized by States and Territories to assess GI, SOI, and SSB since 1995 to identify 1) the extent of questions assessing these concepts, and 2) the history of the wording of these questions and response options. Results: 44 of the 50 states, the District of Columbia, and the territory of Guam have assessed GI, SOI, and/or SSB in at least one year since 1995. Connecticut was the first state to assess SSB in 1995; Vermont was the first state to assess SOI and GI in 2000. Assessment of SSB has declined, with Texas being the last state to assess SSB in 2013. The introduction of a standard optional Sexual Orientation and Gender Identity (SOGI) module in 2014 led to a large increase in the number of states and territories assessing GI and SOI, as well as enhanced ease of use for researchers. Despite the availability of a standard module, numerous states continue to field GI and SOI items as state-added items. These state-added items are difficult to access and often use terminology inconsistent with the standard module, making incorporation into multi-state analyses challenging. 32-35 states have included items assessing GI and SOI in each year since 2014, covering over two-thirds of the US population. However, the haphazard coverage of states using the standard SOGI module makes nation-level inference from these data challenging. Furthermore, the unvalidated nature of the GI item raises concerns in the context of assessments of health disparities. Discussion: The standard SOGI module should be incorporated into the demographics section of the core interview. Methods to assess the validity of these items, especially the GI item, are needed. Call-back methodology may be the most efficient approach to assessing these items. However, concerns about item validity should not discourage states from implementing the SOGI module on an optional basis. An overall analysis of BRFSS SGM measure inclusion demonstrates this is quickly becoming the standard on the largest surveillance system in the country, paving the way for other surveys to follow suit.

Background: Human papillomavirus (HPV) is a common sexually transmitted infection that can cause genital warts and anal, penile, and oropharyngeal cancer. Men who have sex with men (MSM) are at particularly high risk for HPV and HPV-related cancers. The HPV vaccine is recommended for MSM through age 26, but few are vaccinated. txt2protect (t2p) is a text message based intervention aiming to encourage young MSM (YMSM) to receive the vaccine. This poster explores potential differences by demographics and other participant characteristics in the acceptability of txt2protect. Methods: Between January and September 2018, 148 YMSM ages 18 – 25 living in the Chicagoland area were recruited primarily through online ads and participant registries. Participants receive text messages promoting sexual health for 9 months. During the first three weeks (Phase 1), participants receive daily messages emphasizing the importance of HPV vaccination (i.e. intervention arm) and general HIV/STI prevention and healthy relationships (i.e. control arm). Tarnowski and Simonian’s Acceptability Rating Profile was adapted to assess acceptability of Phase 1 messages. Participants responded to two open-ended questions about t2p (likes and dislikes) and 12 items using a 5-point Likert scale (strongly disagree to strongly agree). Factor analysis was used to find meaningful patterns among these questions and create a smaller set of items. Group differences were identified by one way ANOVAs and Kruskal-Wallis H tests. Results: Overall, participants rated the acceptability of t2p highly (means of 4 out of 5). Items from the acceptability profile loaded onto three factors (eigenvalues > 1). A ‘positive feedback’ score was created using the means of seven variables (e.g. “t2p provided helpful information on HPV vaccination”) and a ‘negative feedback’ score using the means of three variables (e.g. “t2p sent too many text messages”). Only two variables loaded onto the third factor and were excluded from further analysis as it is recommended that factors include three or more variables. There were differences in positive participant feedback by relationship status (χ2(2)=8.084, p=0.018), race/ethnicity (χ2(3)=3.860, p=0.011), and phone type (χ2(1)=7.559, p=0.007). Participants differed in giving negative feedback by relationship status (χ2(2) = 10.794, p=0.005), student status (χ2(1) = 5.479 p=0.019), and phone type (χ2(1) = 10.337, p=0.002). Participants casually dating had higher positive feedback scores than those not dating anyone or in serious relationships. Participants not dating anyone had the highest negative feedback score. White participants had lower positive feedback scores than Asian, Black, and Latino participants. Current students had a higher negative feedback score than non-students. Finally, iPhone users had higher negative feedback scores than Android users. Discussion: Phase 1 messages are highly acceptable to participants. There are, however, some demographic differences in how acceptable participants find the program. This data can be used to shape future versions of t2p and similar programs to better meet the needs of particular groups (e.g. White YMSM, students, men not dating). There may also be programmatic features (e.g. how messages are displayed on different phones) that should be considered in future implementations of text message based programs.

E-Health HIV prevention interventions have been demonstrated in rigorous evaluation studies to be efficacious in mitigating risk factors and promoting protective behaviors among young men who have sex with men (YMSM) who are disproportionately impacted by the disease in the US. However, to curb HIV incidence and change the course of the epidemic, public health researchers need not only to develop effective interventions but also to ensure widespread implementation of those interventions using implementation science.
To help bridge the gap between pure efficacy and implementation studies and accelerate the translation to public health practice, there has been a growing trend toward using hybrid effectiveness–implementation designs. These types of designs simultaneously examine both effectiveness and implementation outcomes, with an increasing focus on the latter as one moves from type I to type III. However, little guidance exists on how to conduct a hybrid type III trial, particularly in diverse community-based prevention settings and with added technological complexity.
Keep It Up! is an online, multimedia HIV prevention intervention previously shown to be effective at reducing sexual risk behavior and STI incidence among YMSM aged 18–29. In an ongoing hybrid type III trial, we are comparing direct-to-consumer delivery of the program against a community-based organization delivery approach. Outcomes include constructs from the RE-AIM model as well as public health impact, a measure of reach x efficacy that is calculated using individual-level demographics, behavior change, and STI incidence. In preparing for the trial, we have encountered numerous questions around how to implement the study as pragmatically as possible. A continual subject of debate is how to differentiate aspects of the study required for research purposes and those specific to the service implementation of the program.
This presentation will describe the processes used and decisions made by the Keep It Up! study team to address the challenges of studying the implementation of an eHealth intervention in the real-world while collecting sufficient data from YMSM users and implementers and meeting standards for research and data safety. Discussions will cover recruitment, screening and enrollment, technology, navigating institutional review boards, retention, incentives, data collection, and data safety. By reporting on our lessons learned from our preparation year of the study, we hope to provide guidance for others who may use hybrid study designs in the future.

Background: The HIV epidemic has severely impacted transgender women in the U.S. According to the Centers for Disease Control and Prevention, transgender persons have the highest HIV incidence of any risk group. Despite these disparities, the U.S. National HIV/AIDS Strategy notes that HIV prevention efforts specifically targeting transgender populations have been minimal, leaving a dearth of evidence-based programs that address the unique needs of transgender women. This project fills this critical gap in prevention by developing and establishing the efficacy of a multimedia interactive sex-positive mobile app-delivered HIV/STI prevention and sexual health promotion intervention designed for use by transgender women. The objective of this study is to describe the development and translation of formative research into a theory-based HIV prevention mobile app that demonstrated high acceptability and increases in knowledge and attitudes. 
Methods: We conducted four focus groups and 20 in-depth interviews with a regionally and racially diverse sample of transgender women in order to identify overarching content framing strategies, themes and content for app activities, and format and functionality preferences. Using an intervention mapping approach to ensure content is behaviorally-anchored and strategies are theoretically based, we developed a curriculum outline for the intervention, determined the correct number, timing, length, and format for these activities, discussed preliminary decisions with the Expert Panel of transgender women, and made modifications as necessary to create a final content outline. Every prototype activity was created through an iterative process with the Expert Panel of transgender women who reviewed mockup wireframes and storyboards and made suggestions for changes.
Results: Our intervention curriculum is focused around four domains: sexual health harm reduction, identity affirmation, structural realities, and community connection. Guided by the formative research and expert panel, three prototype activities were created that builds on the theoretical perspectives of social support, gender affirmation, social cognitive theory, and resilience. Create Your Own Vision (Board) encourages transgender women to situate their well-being and sexual health within the social determinants of health/structural factors that emerged as the dominant theme of the focus groups and interviews. Is PrEP Right for Me or My Partners presents a basic overview of PrEP and guides participants through a benefits and risks assessment and addresses formative research findings about the confusion surrounding PrEP. In response to the need for helping transgender women find culturally competent and welcoming services, the Interactive Resource Map displays providers/organizations in five service categories and user ratings and user reviews. 
Conclusion: This app represents an important effort by members of transgender women community to reduce HIV inequities. This process offers a systematic approach to intervention development that may yield more successful and effective interventions that address community identified needs and priorities.

A large body of research among lesbian women in Western countries has demonstrated that minority stigma significantly contributes to these women’s disproportionately higher rates of substance abuse and mental health problems than their heterosexual counterparts. By contrast, no similar research has been undertaken among women with same-sex attraction (WSSA) in mainland China, partially due to the lack of stigma measurement culturally valid to this minority group. While recognizing this absence itself as one concrete expression of minority stigma, this study devoted itself to the development of stigma measurement with cultural validity through investigating the nature, genesis, and pathways of minority stigma among Chinese WSSA. A qualitative, grounded theory approach was taken to this study to identify culturally specific components of perceived and internalized stigma firmly anchored in the experiences and perspectives of Chinese WSSA. Between August 2017 to July 2018, a total of 28 Chinese WSSA participated in one-time, 100-minute long, in-depth telephone interviews. A semi-structured questionnaire used in the interview was developed based on (1) the commonly used minority stigma scales in the US and Europe, (2) opinions of people who are gay activists and/or researchers of LGBT health in mainland China, and (3) the first author’s long-term observation of and volunteer service for this sexual minority group. Data analysis proceeded using a constant-comparative method. A model was generated to show major components of minority stigma and relationships among these components. Findings from this study suggest that minority stigma operates to negatively affect the health of Chinese WSSA through a dual and interwoven process that denies the existence of same-sex attraction among women while reifies such non-existent status by hounding these non-heterosexual women into heterosexual marriage. The long-run system of patrilineal kinship and its core Confucian value of filial piety (a virtue of respect for one's parents, elders, and ancestors), complicated by modernized gender ideology and birth-control policies, have produced family conflicts, in particular, between traditional parents and their sexual minority daughter over their daughter’s marital decision. The struggling to balance same-sex attraction and parents’ expectation to marry a man and produce grandchildren has served as the proximal source of minority stress for Chinese WSSA. Therefore, stigma measurements for Chinese WSSA need to focus on these women’s relationship with their parents over their marital decision. Findings also highlighted the importance to address the cultural validity of stigma measurement. It will not work to simply apply minority stigma instruments developed among lesbian women in Western countries to WSSA in mainland China. Rather, these instruments need to be subject to a specifically Chinese reformulation in terms of mainland China’s unique social and cultural systems dictated initially by Confucianism and, later, by Communism. This study is among the first to explore minority stigma among WSSA in mainland China. Its findings lay the groundwork for the design of stigma measurements specific to a rarely studied minority group---Chinese women with same-sex attraction, in a rarely studied locale--- mainland China.

The purpose of the proposed talk is to (1) present recently collected data across a series of studies conducted by the research team that focuses on the topic of dating violence (DV) among sexual minority youth (i.e., LGBQ+ youth) and (2) how this data is currently being leveraged to develop an online DV prevention initiative for queer youth. Data presented will document that although the vast majority of DV research has focused exclusively on heterosexual youth, research also suggests that DV occurs at high rates among LGBQ+ youth. This increased risk for DV among LGBQ+ youth can be explained by experiences of minority stress, including identity concealment (i.e., hiding one’s sexual orientation from others) and internalized homonegativity (i.e., feeling ashamed of one’s sexual orientation). Whereas minority stress increases risk for DV perpetration and victimization, having a sense of community (e.g., sense of belonging, emotional connectedness) with other LGBQ+ individuals reduces risk for DV perpetration. Thus, prevention programming that targets these two modifiable risk and protective factors, in conjunction with other known programming components to reduce DV (e.g., healthy communication skills) could ultimately reduce rates of DV among LGBQ+ youth. To date, there is no DV prevention programming specifically developed for LGBQ+ youth that focuses on enhancing sense of community and reducing minority stress in conjunction with other programming components known to reduce DV (e.g., bystander intervention training). Moreover, preliminary research conducted by our research team found that an in-person bystander-focused prevention program for high school youth was effective at reducing stalking and sexual harassment for heterosexual youth but the program was not effective for LGBQ+ youth. Although more macro-level initiatives are critically needed that seek to eliminate minority stress at structural levels, it is also urgent that programming initiatives exist that seek to promote resilience in LGBQ+ youth to reduce their risk for DV and other deleterious health behaviors. Thus, we are in the process of developing a new online DV prevention initiative for LGBQ+ youth (15 to 18 years), preliminarily entitled Radicalizing Respect and Relationships (R3). The R3 Prevention Initiative (R3-PI) will be theoretically grounded, follow all of the best practices for effective health behavior prevention, and is expected to include eight, 30 minute modules intended for delivery as an online synchronous program. Plans for a stage 1a and 1b evaluation are underway, which will be shared in the presentation along with more information on the R3-PI session content, intervention development procedures, and so forth. Ultimately, the proposed project has the potential to for high public health impact because we will develop the first ever DV prevention initiative specifically for LGBQ+ youth that given the online-delivery format has the potential to reach a sizeable portion of LGBQ+ youth across the U.S. including youth in rural and remote areas where rates of minority stress are highest and sense of community are lowest.

Our study developed from a need for early intervention and prevention efforts to address the high rates of new HIV infection among adolescent males who have sex with males (AMSM) and transgender youth, particularly minority youth. More research on this population is needed; however, there are immense challenges to conducting high quality surveys on a geographically dispersed population of AMSM and transgender youth including a lack of disclosure to others about their sexual identity and its still-developing nature. The data for this paper come from the Survey of Today’s Adolescent Relationships and Transitions (START), conducted on behalf of the Centers for Disease Control and Prevention’s Division of Adolescent and School Health. Social media advertisements were used to recruit this hard-to-reach population employing a variety of techniques to capture their attention in an environment with many competing advertisements, posts, and pictures. A combination of video and static image ads were posted to Facebook, Instagram, and Snapchat. The ads were designed to appeal to specific subgroups within the population of interest – AMSM, transgender, and the “questioning” general teen population. Moreover, several experimental treatments were embedded in the study to assess any effects from the overall design. For example, we tested the effect of eligibility language with some ads containing text about survey eligibility and other ads without. The purpose of this paper is to assess the effectiveness of using social media advertisements to recruit a national sample of AMSM (13 to 18 y/o) and transgender youth (13 to 24 y/o) for a web survey. We begin with a discussion of the varied forms of recruitment advertisements used to reach our target population. We then discuss the resulting diversity of the sample recruited and their reported sexual activity and HIV prevalence. Ads were posted intermittently between January and April 2018. In all, there were 24,980 ad clicks with a final sample consisting of 1,541 completes from AMSM and 1,567 completes from transgender youth. Nearly 70% of completes were drawn from video ads (as opposed to static image ads) but a full 92% of invalid cases and 75% of cases that clicked the ad but did not start the survey also came from video ads. In terms of ad targeting, despite the fact that certain ads were designed to target Black and Latino youth, it was an ad featuring a white feminine adolescent that performed best among Black and Latino youth. We also found that ad sharing can be useful to reach social media networks of subpopulations of interest. For instance, a specific ad share that we monitored resulted in 583 completes, all from transgender respondents. Overall, although social media recruitment can be efficient in recruiting this population, resulting data quality and coverage continue to be areas that require attention. We will continue to evaluate the START data and compare our recruited sample with those obtained from national probability surveys (e.g., YRBS, NSFG).

Background: There is robust international data showing lesbian, bisexual and queer (LBQ) women smoke at higher rates than their heterosexual peers. As part of a program of work funded by Cancer Institute NSW, Australia and in collaboration with a community health promotion organisation (ACON Health), our study sought to understand the significance of smoking for LBQ women. Methods: We conducted 6 focus groups with 28 LBQ women smokers and ex-smokers in urban and regional settings in Australia. We report here on perceptions of mass-media anti-smoking campaigns. Results: Mainstream messaging failed to connect with participants for three reasons. First, messaging and imagery were simply un-relatable; not as expected because LBQ women were invisible but because participants saw old men, unhealthy people, no one ‘like them’. Women, when featured, quit smoking to fulfil family responsibilities. Second, LBQ women talked about resisting what they saw as an attempt to control them (often through scare tactics); they didn’t believe government messaging reflected a genuine care for them as LBQ women. Finally, women reacted negatively to the shame, guilt and stigma implicit in the campaigns they could recall. We’ll look briefly at what participants thought would resonate for women like them, and then demonstrate how this was articulated by the Smoke Free Still Fierce smoking cessation community campaign developed by ACON Health. Discussion: Tackling persistent disparities in smoking rates means designing campaigns that engage LBQ women. That includes mass-media campaigns that do not exclude or worse, are counter-productive, as well as creating targeted campaigns.

Background: Although transgender individuals may also identify as heterosexual/straight, these sexual and gender minorities are often only described as a lesbian, gay, bisexual, or transgender (LGBT) aggregate group. For example, Su and colleagues reported that 46.2% (n=42/91) of transgender individuals had a high level of self-acceptance of LGBT identity compared to 55.1% (n=371/676) of non-transgender sexual minorities (i.e., lesbian, gay, bisexual). The fact that this difference did not reach statistical significant (p=0.107) suggests that a better understanding of transgender individuals’ sexual orientation is warranted. Methods: In our study, we used data from the 2017 Behavioral Risk Factor Surveillance System (BRFSS) survey to describe transgender individuals’ sexual orientation. Frequencies are reported on the unweighted data. Proportions with 95% confidence intervals were calculated for the weighted data using Stata/SE 15.1. Results: Of 197,061 adults who completed the 2017 BRFSS survey, < 1% (n=789) identified as transgender (male-to-female, female-to-male, or gender nonconforming). More than half of the transgender 2017 BRFSS survey respondents identified as straight (59.5%; 95% CI: 52.6-66.0). About one third identified as lesbian, gay, or bisexual (32.0%; 95% CI: 25.9-38.7). Only a few identified as other sexual orientation (8.6%; 95% CI: 4.8-14.7). Conclusion: While some researchers have combined sexual orientation and gender identity, our study findings suggest that gender identity and sexual orientation should be measured as independent variables. It is more appropriate to assess transgender individuals’ sexual orientation separately as straight, lesbian, gay, bisexual, or other as their lived experiences may differ from that of non-transgender sexual minorities (i.e., lesbian, gay, bisexual). Only using an LGBT identity to characterize the transgender individuals will likely miss important nuances unique to transgender individuals who identify as straight. As researchers further our understanding of how to address the healthcare needs of transgender individuals, it is critically important that we allow this sexual and gender minority population to have an identified voice in how to address their healthcare needs.