Digital interventions to prevent HIV and other STIs
Digital interventions to decrease sexually transmitted infections (STIs) provide participants with health information and assistance with decision making, behavior change, and emotional support. These interactive programs incorporate contributions from users to produce tailored material and feedback that is personally relevant1. Programs may be delivered on computers or mobile devices such as smartphones, may be accessible offline or web-based, and may be available through apps, other digital platforms such social media, or computer software2.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Reduced risky sexual behavior
Increased HIV and STI knowledge
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Delayed initiation of sex
Increased condom use
What does the research say about effectiveness?
There is strong evidence that digital interventions decrease risky sexual behavior3, 4, 5, 6 and increase knowledge about HIV and other sexually transmitted infections (STIs) among adults and adolescents1, 3, 4, 6, 7, 8.
Digital interventions can also increase testing for HIV and other STIs5, especially among young people9. These inventions can increase condom use3, 10, especially among young women9, and decrease the number of sexual partners4, 10. Digital interventions, including text message and internet-based interventions, can improve antiretroviral therapy (ART) adherence in people living with HIV and increase clinic attendance5.
Among adolescents, digital interventions may also delay initiation of sex and increase pregnancy prevention knowledge7, however, additional evidence is needed to confirm these effects.
Digital interventions that are tailored to individual users tend to be most successful1, 3, 8, 10; those teaching behavioral skills may increase effectiveness among men who have sex with men (MSM) and may be especially effective in young people2. Provision of individualized feedback, promotion of active learning, anonymity, and repeatability are also frequent components of effective digital interventions1. In some cases digital interventions adapted from in person interventions can provide results similar to the original intervention11, but in other cases adaptation may not work, such as an unsuccessful attempt to condense a lengthy group intervention into a two-hour computer program12.
Digital interventions have been shown to be effective among MSM4 and Black and Hispanic women3 and may be as effective in adolescent substance users as interventions delivered by a prevention specialist11. There are gaps in evidence for young MSM who are transgender, have low incomes or are HIV positive13 and for other at-risk groups such as young women after pregnancy, youth in institutional care, young people experiencing sexual and domestic violence, young people with learning difficulties, and LGBT youth6.
Digital interventions can be easily disseminated and can be relatively inexpensive1.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by intervention design.
Digital interventions to reduce HIV and other STIs have the potential to decrease disparities in HIV and STI incidence, if they are designed for those most at risk of HIV and STI infection. Inequalities by sexuality, gender, race, geographical location, and economic status persist in HIV diagnosis and care18. In 2021, 70% of new HIV infections where among men who have sex with men (MSM)19 and in 2019, 29% of new HIV infections were among Hispanic individuals20, most of them among MSM21, and 41% were in Black individuals22. New HIV infections disproportionately affect Black MSM (who account for 26% of new HIV cases)23, Black heterosexual women, and Black transgender women24. Chlamydia, gonorrhea, and syphilis also disproportionally affect racial and sexual minority groups. In 2021, almost a third of new infections were in Black individuals, MSM were diagnosed with around a third of gonorrhea cases and almost half of syphilis infections, and among women STI rates were highest for Black, American Indian and Alaska Native, and Native Hawaiian/Pacific Islander individuals25.
Culturally tailored interventions can increase condom use, decrease risky sexual behavior, and increase knowledge among Black and Hispanic women3. However, impacts among Black men were more mixed. A computer-based intervention designed for Black MSM did not change users’ engagement in risky sexual behavior26, while an online intervention for young Black MSM and mobile optimized reduced risky sexual behavior in the short term27. Another online intervention, this one for Black bisexual men, found it reduced risky sexual behavior with male partners, but not with female partners28.
Overall, digital interventions can reduce risky sexual behaviors, increase testing, and increase use of condoms among MSM4. Among young MSM interventions can, in some circumstances, reduce risky sexual behavior and increase condom use and knowledge, but more research is needed on subgroup effects and particularly those from vulnerable groups, such as those who are transgender, have low incomes or are HIV positive, are unclear, with limited or no available research13. A brief online group intervention reduced risky sexual behavior in HIV positive gay and bisexual men29. Few interventions are specifically for LGBT youth6, adolescent girls or women30.
What is the relevant historical background?
Sexually transmitted infections (STIs) have carried stigma for centuries, shaped by negative views of poverty, women, and sex31. STIs are associated with promiscuity and deviant behavior for women, while STIs in men are treated merely as a medical condition32. Stigma has continued to shape how STIs are studied, diagnosed, and treated. The racist and unethical Tuskegee Syphilis Study, administered by the federal government, intentionally withheld syphilis treatment from Black men for decades without their knowledge, to study the natural course of the disease, ultimately sowing widespread mistrust of health systems and medical research33.
When the AIDS epidemic began, federal response was slow to acknowledge and respond to it, in part because it primarily affected gay men in a time when many states still criminalized homosexuality. While the first case of HIV/AIDS in the U.S. was reported in 198134, 35, major federal funding wasn’t allocated until 198535. HIV criminalization laws were passed in many states criminalizing behavior such as non-disclosure, exposure, and/or transmission of HIV, or increasing sentence length for crimes based on someone’s HIV status36, long before pharmaceuticals were available to treat or prevent transmission37. Today, HIV criminalization unjustly applies criminal law to nonmalicious behavior by people living with HIV and the laws are disproportionately applied to people from groups who have been marginalized38, While 13 states have repealed or modernized their HIV criminalization laws, 34 states still have HIV/STI/communicable disease criminalization laws in place in 2023. Such laws can carry penalties up to life in prison36.
Most digital interventions created for men who have sex with men (MSM) have been designed for more general audiences, while relatively few have been aimed at Black or rural MSM4, 39
State and federal funding are important to address the rising incidence of STIs, however, historical trends show that funding has stagnated40.
Equity Considerations
- Who could benefit from digital interventions to reduce HIV and other STIs in your community? Are there groups in your community who might be better reached on their mobile phones or computers?
- Who can you partner with to communicate about digital interventions for HIV and other STIs in your community? Who has experience in communication and community outreach?
- How does stigma, and other systematic barriers, prevent people from accessing sexual health care and STI testing services in your community? What additional strategies can be implemented to overcome those barriers?
Implementation Examples
As of August 2023, the CDC’s Compendium of Evidence-based Interventions and Best Practices for HIV Prevention contains 46 interventions which are computer/technology-based; digital or mobile health, apps or media; or social media/internet/web-based14. Examples include Keep It Up! 2.0, Positive Choices, and Care+. Keep It Up! 2.0, which is an online, interactive intervention for young men who have sex with men and includes booster sessions at 3 and 6 months15. Positive Choices and Care+ are computer-based interventions for HIV positive patients that tailor their feedback16, 17.
Implementation Resources
‡ Resources with a focus on equity.
CDC Compendium - Centers for Disease Control and Prevention (CDC). Compendium of evidence-based interventions and best practices for HIV prevention.
Footnotes
* Journal subscription may be required for access.
1 Cochrane-Bailey 2010 - Bailey J, Murray E, Rait G, et al. Interactive computer-based interventions for sexual health promotion. Cochrane Database of Systematic Reviews. 2010;(9):CD006483.
2 Long 2016 - Long L, Abraham C, Paquette R, et al. Brief interventions to prevent sexually transmitted infections suitable for in-service use: A systematic review. Preventive Medicine. 2016;91:364-382.
3 Chandler 2022 - Chandler R, Guillaume D, Parker A, Wells J, Hernandez ND. Developing culturally tailored mHealth tools to address sexual and reproductive health outcomes among Black and Latina women: A systematic review. Health Promotion Practice. 2022;23(4):619-630.
4 Nguyen 2019 - Nguyen LH, Tran BX, Rocha LEC, et al. A systematic review of eHealth interventions addressing HIV/STI prevention among men who have sex with men. AIDS and Behavior. 2019;23:2253-2272.
5 Daher 2017 - Daher J, Vijh R, Linthwaite B, et al. Do digital innovations for HIV and sexually transmitted infections work? Results from a systematic review (1996-2017). BMJ Open. 2017;7:e017604.
6 Bailey 2015a - Bailey J, Mann S, Wayal S, et al. Sexual health promotion for young people delivered via digital media: A scoping review. Public Health Research. 2015;3(13):1-120.
7 Guse 2012 - Guse K, Levine D, Martins S, et al. Interventions using new digital media to improve adolescent sexual health: A systematic review. Journal of Adolescent Health. 2012;51(6):535-543.
8 Noar 2010 - Noar SM, Pierce LB, Black HG. Can computer-mediated interventions change theoretical mediators of safer sex? A meta-analysis. Human Communication Research. 2010;36(3):261-297.
9 Swanton 2015 - Swanton R, Allom V, Mullan B. A meta-analysis of the effect of new-media interventions on sexual-health behaviours. Sexually Transmitted Infections. 2015;91(1):14-20.
10 Noar 2009 - Noar SM, Black HG, Pierce LB. Efficacy of computer technology-based HIV prevention interventions: a meta-analysis. AIDS. 2009;23(1):107-115.
11 Marsch 2015 - Marsch LA, Guarino H, Grabinski MJ, et al. Comparative effectiveness of web-based vs. educator-delivered HIV prevention for adolescent substance users: A randomized, controlled trial. Journal of Substance Abuse Treatment. 2015;59:30-37.
12 Klein 2017b - Klein CH, Kuhn T, Altamirano M, Lomonaco C. C-SAFE: A computer-delivered sexual health promotion program for Latinas. Health Promotion Practice. 2017;18(4):516-525.
13 Knight 2017 - Knight R, Karamouzian M, Salway T, Gilbert M, Shoveller J. Online interventions to address HIV and other sexually transmitted and blood-borne infections among young gay, bisexual and other men who have sex with men: A systematic review. Journal of the International AIDS Society. 2017;20(3):e25017.
14 CDC Compendium - Centers for Disease Control and Prevention (CDC). Compendium of evidence-based interventions and best practices for HIV prevention.
15 CDC Compendium-Keep It Up! - Centers for Disease Control and Prevention (CDC). Compendium of evidence-based interventions and best practices for HIV prevention: Keep it up! 2.0.
16 CDC Compendium-Positive choice - Centers for Disease Control and Prevention (CDC). Compendium of evidence-based interventions and best practices for HIV prevention: Positive choice interactive video doctor.
17 CDC Compendium-Care - Centers for Disease Control and Prevention (CDC). Compendium of evidence-based interventions and best practices for HIV prevention: CARE+.
18 Taggart 2021 - Taggart T, Ritchwood TD, Nyhan K, Ransome Y. Messaging matters: Achieving equity in the HIV response through public health communication. Lancet HIV. 2021;8(6):e376-e386.
19 CDC-HIV incidence - Centers for Disease Control and Prevention (CDC). HIV Incidence.
20 CDC-Hispanic/Latino HIV Incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and Hispanic/Latino People: HIV Incidence.
21 CDC-Hispanic/Latino MSM HIV incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and Hispanic/ Latino Gay and Bisexual Men: HIV Incidence.
22 CDC-African American HIV Incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and African American People: HIV Incidence.
23 CDC-African American MSM HIV Incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and African American Gay and Bisexual Men: HIV Incidence.
24 CDC-HIV and black discrimination - Centers for Disease Control and Prevention (CDC). HIV and Black/African American people in the U.S.
25 CDC-STI Surveillance - Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Surveillance.
26 Klein 2017a - Klein CH, Kuhn T, Huxley D, et al. Preliminary findings of a technology-delivered sexual health promotion program for Black men who have sex with men: Quasi-experimental outcome study. JMIR Public Health and Surveillance. 2017;3(4):e78.
27 Hightow-Weidman 2019 - Hightow-Weidman LB, LeGrand S, Muessig KE, et al. A randomized trial of an online risk reduction intervention for young Black MSM. AIDS and Behavior. 2019;23:1166-1177.
28 Fernandez 2016 - Fernandez MI, Hosek SG, Hotton AL, et al. A randomized controlled trial of POWER: An internet-based HIV prevention intervention for Black bisexual men. AIDS and Behavior. 2016;20:1951-1960.
29 Cruess 2018 - Cruess DG, Burnham KE, Finitsis DJ, et al. A randomized clinical trial of a brief internet-based group intervention to reduce sexual transmission risk behavior among HIV-positive gay and bisexual men. Annals of Behavioral Medicine. 2018;52(2):116-129.
30 Blackstock 2015 - Blackstock OJ, Patel VV, Cunningham CO. Use of technology for HIV prevention among adolescent and adult women in the United States. Current HIV/AIDS Reports. 2015;12:489-499.
31 McGough 2005 - McGough LG. HIV/AIDS stigma: Historical perspectives on sexually transmitted diseases. Virtual Mentor: Ethics Journal of the American Medical Association. 2005;7(10):710-715.
32 East 2012 - East L, Jackson D, O’Brien L, Peters K. Stigma and stereotypes: Women and sexually transmitted infections. Collegian. 2012;19(1):15-21.
33 Tobin 2022 - Tobin MJ. Fiftieth anniversary of uncovering the Tuskegee syphilis study: The story and timeless lessons. American Journal of Respiratory and Critical Care Medicine. 2022;205(10):1145-1158.
34 HIV.gov - HIV.gov. HIV and AIDS timeline.
35 Bennington-Castro 2020 - Bennington-Castro J. How AIDS remained an unspoken—but deadly—epidemic for years. History. 2020.
36 CDC HIV-Exposure - Centers for Disease Control and Prevention (CDC). (2023, December 19). HIV and STD criminalization laws. Retrieved October 17, 2024.
37 CDC HIV-Criminalization - Centers for Disease Control and Prevention (CDC). (2023, December 18). HIV criminalization and ending the HIV epidemic. Retrieved September 18, 2024.
38 Bernard 2022 - Bernard, E. J., Symington, A., & Beaumont, S. (2022). Punishing vulnerability through HIV criminalization. American Journal of Public Health, 112(S4), S395–S397.
39 Klein 2016 - Klein C, Lomonaco C. Real talk: Developing a computer-delivered sexual health program for Black men who have sex with men. AIDS Education and Prevention. 2016;28(6):455-471.
40 NCSD-STD Funding - National Coalition of STD Directors (NCSD). As STD funding stagnates, rates rise to all-time highs.
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