Men who have sex with men (MSM) and transgender women are disproportionately affected by HIV in Guatemala, yet little is known about their experiences with diagnosis, linkage to care, and retention. We conducted qualitative interviews with 26 MSM and transgender women living with HIV in Guatemala City. HIV diagnosis experiences changed over time with increasing asymptomatic testing at non-governmental organizations. Fear of the physical and social impacts of HIV delayed testing, acceptance of diagnosis, and linkage to HIV care. These fears were driven by layered stigma and discrimination due to non-normative gender expressions and/or sexual orientation. Retention-specific determinants included HIV clinic dynamics and limited employment opportunities. There is an urgent need to improve support systems for early testing and linkage to care and to expand employment opportunities. Stigma and discrimination must be addressed at the family, clinic and contextual levels to reduce fear of diagnosis and improve access to care.

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BACKGROUND HIV status disclosure is an important decision with barriers specific to young men who have sex with men (YMSM), who have the highest rates of new HIV infections in the US. Behavioral and social determinants of the difficulty to disclose can include fear of rejection, stigma, loss of financial stability, and a lack of communication skills. Once able to disclose, a person may have increased access to social support, improved medication adherence, and informed risk reduction conversations. Despite the known challenges and advantages of disclosure, there are few effective tools supporting this behavior. OBJECTIVE To address this gap in disclosure interventions, Tough Talks™ App, an mHealth intervention using artificially intelligent (AI)-facilitated role-playing scenarios, was developed for YMSM. Here we report stages of developing the integrated app and the results of the usability testing. METHODS Building on the results of a successful phase 1, we subsequently developed an enhanced interactive dialogue feature for YMSM to practice disclosing their HIV status and placed this feature within the context of an integrated app. We assessed the new iteration for acceptability and relevance in a usability study with 8 YMSM with HIV in North Carolina. Participants completed a pre-survey, app modules, and a semi-structured qualitative interview. RESULTS Tough Talks™ App content and activities were based on Social Cognitive Theory and Disclosure Process Model framework and expanded into a 4-module curriculum. The AI-facilitated scenarios and associated utterance database were refined from a crowdsourced comic book contest. In usability testing, YMSM reported high satisfaction with Tough Talks™ App, with 93% of activities receiving positive ratings. Participants found the AI-facilitated scenarios and activities to be representative and relevant to their lived experiences, though, they noted difficulty having nuanced disclosure conversations with the AI. CONCLUSIONS Tough Talks™ App was an engaging and practical intervention for self-disclosure among YMSM living with HIV. Facilitating informed disclosure decisions has the potential to impact engagement in sexual risk behaviors and HIV care. More information is needed about the ideal environment, technical support, and clinical connection for an mHealth disclosure intervention. Tough Talks™ App is being tested as a scalable intervention in a multi-site, randomized control trial to address outstanding questions on accessibility and effect on viral suppression. CLINICALTRIAL NCT03414372