Social Inequity and Structural Barriers to Completion of Ecological Momentary Assessments for Young Men Who Have Sex With Men and Trans Women Living With HIV in San Francisco

Abstract

Background Ecological momentary assessments (EMAs) administered via text messaging facilitate real-time data collection. With widespread cell phone access, EMAs are becoming more available to even the most disenfranchised communities, such as those living with HIV. However, structural barriers disproportionately burden young men who have sex with men (MSM) and trans women (TW) living with HIV and threaten participation in HIV research. Objective We aim to identify structural barriers to completing EMA text surveys nested within a digital HIV care intervention for young MSM and TW living with HIV in San Francisco. Methods A total of 10,800 EMA text messages were delivered daily over 90 days to 120 participants enrolled in the Health eNav intervention (2017-2018) at the San Francisco Department of Public Health. EMA surveys inquired about participants’ daily affect, sexual behaviors, substance use, and treatment adherence. Survey completion was calculated after 30, 60, and 90 days of follow-up. We described characteristics of nonstarters (those who provided less than four complete responses to the first seven EMA surveys) and analyzed structural correlates of days to first weeklong or more EMA survey noncompletion using multivariable Cox proportional hazards regression. Qualitative interviews were used to evaluate the acceptability of EMA surveys. Results Participants completed 4384 of 10,800 (40.59%) EMA surveys. Completion of 70% or more of EMA surveys was attained by 56 of 120 participants (46.7%) at 30 days of follow-up, 40/120 (33.3%) at 60 days of follow-up, and 30/120 (25.0%) by the end of the 90-day study period. Twenty-eight participants (23.3%) were identified as nonstarters, and were more likely to be recently incarcerated (prevalence ratio [PR] 2.3, 95% CI 1.3-4.4), forego basic needs for HIV medications (PR 2.4, 95% CI 1.3-4.5), and be diagnosed with HIV in the last year (PR 2.2, 95% CI 1.1-4.1). Adjusting for nonstarters, young MSM and TW living in temporary/transitional housing (adjusted hazard ratio [aHR] 1.8, 95% CI 1.1-3.0), foregoing HIV medications to afford basic needs (aHR 1.7, 95% CI 1.1-2.7), and having less than a college education (aHR 3.5, 95% CI 1.4-9.0) had greater hazard of weeklong or more EMA survey noncompletion. Overall, there was high acceptability of the EMA surveys. Conclusions Although access to and use of technology is increasingly ubiquitous, this analysis demonstrates persisting gaps in EMA completion by socioeconomic factors such as incarceration, education level, housing, and competing needs for young MSM and TW living with HIV in San Francisco. Moreover, those recently diagnosed with HIV were more likely to experience an immediate drop-off in completing EMA surveys. EMAs are feasible for individuals not experiencing social inequity and structural barriers. HIV prevention technologies addressing these barriers and leveraging similar methodolo...

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“…(64,65). Innovative approaches will also be needed to 1) account for disparities in access to technology (both digital devices and internet access), and 2) monitor the e cacy and safety of medication use if regular testing and viral load monitoring are limited (63,(66)(67)(68)(69)(70).…”

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“…There are numerous ways of providing remote interventions. Text messaging has been used frequently for motivational messages, reminders, and ecological momentary assessments [12][13][14]. Many text messaging platforms have been developed and evaluated for HIPAA-compliant communication with participants [15].…”

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“…Finally, future EMA studies would benefit from a thorough consideration of institutional and individual barriers to EMA survey completion in order to reduce missing responses. A previous analysis of Health eNav EMA data confirmed that housing instability, incarceration, competing needs, and educational constraints interfered with EMA completion for young MSM and TW, even though participants had continuous access to cellular devices [ 38 ]. While one recommendation to preemptively address participant nonresponse would be to invest in procedures that sustain retention over the follow-up period, structural barriers to such an investment (eg, systemic marginalization of the populations served or lack of grant funding) highlight the unrealistic nature of such a recommendation.…”

“…A number of previous studies have used EMAs to capture fine-grained variations in substance use [ 28 - 31 ] and, more recently, behaviors among people living with HIV [ 28 , 32 - 34 ]. A number of studies have shown that EMA is feasible and acceptable among MSM [ 34 - 37 ] and persons who use substances [ 28 , 29 ]; one study showed moderate compliance to EMA among young MSM and TW living with HIV [ 38 ].…”