Engaging Black or African American and Hispanic or Latino Men Who Have Sex With Men for HIV Testing and Prevention Services Through Technology: Protocol for the iSTAMP Comparative Effectiveness Trial

Background Gay, bisexual, and other men who have sex with men (MSM), particularly Black or African American MSM (BMSM) and Hispanic or Latino MSM (HLMSM), continue to be disproportionately affected by the HIV epidemic in the United States. Previous HIV self-testing programs have yielded high testing rates, although these studies predominantly enrolled White, non-Hispanic MSM. Mobile health tools can support HIV prevention, testing, and treatment. This protocol details an implementation study of mailing free HIV self-tests (HIVSTs) nested within a randomized controlled trial designed to assess the benefit of a mobile phone app for increasing the uptake of HIV prevention and other social services. Objective This study was a comparative effectiveness trial of innovative recruitment and testing promotion strategies intended to effectively reach cisgender BMSM and HLMSM. We evaluated the use of a mobile app for increasing access to care. Methods Study development began with individual and group consultations that elicited feedback from 3 core groups: HIV care practitioners and researchers, HIV service organization leaders from study states, and BMSM and HLMSM living in the study states. Upon completion of the formative qualitative work, participants from 11 states, based on the observed areas of highest rate of new HIV diagnoses among Black and Hispanic MSM, were recruited through social networking websites and smartphone apps. After eligibility was verified, participants consented and were randomized to the intervention arm (access to the Know@Home mobile app) or the control arm (referral to web resources). We provided all participants with HIVSTs. The evaluation of the efficacy of a mobile phone app to support linkage to posttest prevention services that included sexually transmitted infection testing, pre-exposure prophylaxis initiation, antiretroviral treatment, and acquisition of condoms and compatible lubricants has been planned. Data on these outcomes were obtained from several sources, including HIVST-reporting surveys, the 4-month follow-up survey, laboratory analyses of dried blood spot cards returned by the participant, and data obtained from the state health department surveillance systems. Where possible, relevant subgroup analyses were performed. Results During the formative development phase, 9 consultations were conducted: 6 in-depth individual discussions and 3 group consultations. From February 2020 through February 2021, we enrolled 2093 MSM in the randomized controlled trial from 11 states, 1149 BMSM and 944 HLMSM. Conclusions This study was designed and implemented to evaluate the effectiveness of recruitment strategies to reach BMSM and HMSM and of a mobile app with regard to linkage to HIV prevention or treatment services. Data were also obtained to allow for the analyses of cost and cost-effectiveness related to study enrollment, HIV testing uptake, identification of previously undiagnosed HIV, sexually transmitted infection testing and treatment, and linkage to HIV prevention or treatment services. Trial Registration ClinicalTrials.gov (NCT04219878); https://clinicaltrials.gov/ct2/show/NCT04219878 International Registered Report Identifier (IRRID) DERR1-10.2196/43414

1 U01 PS005181-01 3 ZPS1 GCA (27) SULLIVAN, P 3 ensure study integrity; insufficient budget considerations in the evaluation plan; very few details about where Black and Latino MSM will be referred to for local HIV-related services and an insufficient description of the types of services such as additional HIV testing, partner services, pre-exposure prophylaxis (PrEP), and other related services; no evidence of prior arrangements with known HIV care providers / clinics, and reporting of linkage to care based on self-report; and the stipulation that participants must have access to a private computer with internet access, which may be difficult in lower socioeconomic status (SES) minority men. Protection of human subjects is adequately addressed. Inclusion is acceptable in terms of gender, minority groups, and children. There are no animal welfare or biohazard issues. There is some concern with respect to the budget in that the timeframe for the formative and implementation periods, and steps in the logic model, do not align with the budget over the proposed four years of the project. Overall, this is an excellent application that is very strong with only some minor weaknesses.

DESCRIPTION (provided by applicant):
Men who have sex with men (MSM) are a key risk group in the United States and are disproportionately impacted in terms of HIV prevalence. The disparities experienced by MSM, and especially by Black and Hispanic MSM, are explicitly recognized in the National HIV AIDS Strategy, which calls for reducing disparities experienced by MSM, especially MSM of color. HIV testing is a key component of combination HIV prevention packages. Testing allows men to be aware of their HIV infection status and serves as a stepping stone to additional HIV prevention services, such as pre-exposure prophylaxis. Increasing testing rates among Black and Hispanic MSM is a key component to reducing disparities among these groups. We propose a comparative effectiveness study to assess the effects of two innovative strategies that combine online recruitment and testing promotion strategies to increase HIV testing in Black and Hispanic/Latino MSM. The two innovative strategies will be compared to a traditional recruiting strategy and comparison condition involving providing information about HIV testing and testing locations. The recruitment methods will be a social networking and dating app targeted to MSM (Grindr) and advertisements on gay-related websites; these recruiting strategies will be compared to a non-innovative strategy of targeted Facebook advertising. Innovative testing promotion strategies will be an app-based HIV prevention portal (HealthMindr) and a mobile-optimized website (healthMpowerment). Our primary aims are to conduct formative research to develop culturally appropriate innovative recruiting and testing promotion strategies, conduct a comparative effectiveness study to assess the effectiveness of each strategy in black and Hispanic MSM, and to develop a translation and dissemination plan to support uptake of the resulting intervention strategies in state and local health departments and community-based organizations.
PUBLIC HEALTH RELEVANCE: Black and Hispanic MSM are the most heavily impacted risk groups in the US HIV epidemic, but past studies have illustrated challenges with recruiting these men to uptake routine HIV testing. We propose a comparative effectiveness study to evaluate the relative performance of two strategies -each based on an innovative, established internet-based platform -to promote HIV testing among Black and Hispanic MSM.

CRITIQUE 1
Significance: 1 Investigator(s): 2 Innovation: 1 Approach: 2 Environment: 2 Overall Impact: This is a new application with a seasoned and outstanding Principal Investigator who has over 20 years of experience in HIV prevention and epidemiology work with MSM, along with a 1 U01 PS005181-01 4 ZPS1 GCA (27) SULLIVAN, P 4 competent and seasoned research team of co-investigators and other colleagues. The application proposes a project with the major goals of developing formative research for culturally-sound recruitment and HIV testing promotion strategies for Black and Latino MSM (BLMSM), assessing the effects of two innovative strategies that combine online recruitment and testing promotion strategies to increase HIV testing in Black and Latino MSM, using Grindr (mobile app) and ads on gay websites versus Facebook ads (for recruitment) plus HealthMindr (an HIV prevention app) and healthMpowerment (a mobile-optimized site) for promotion of HIV testing. The investigators will also be outlining ways in which health departments and CBOs may adopt these strategies to improve their services to these communities. This is a highly significant area because BLMSM have been disproportionately affected by HIV/AIDS since the beginning of the epidemic and testing efforts must increase to significantly reduce HIV rates in these communities. It is a highly innovative application because it will integrate the use of modern technologies and methods for reaching BLSMSM in the most effective ways, including mobile apps to increase engagement in HIV testing and telemedicine counseling, along with customized referrals for men who have seropositive results. The primary outcome is to have participants test for HIV within one month of enrollment, with calculations conducted separately for Black MSM and Latino MSM.

Strengths
 This study application is very well written and organized. Innovation of using multiple recruitment strategies with BLMSM and evaluating the feasibility of each one is key to the success of this project.  Dr. Sullivan and his team have the experience and expertise to fully design, implement, and evaluate this study.
 There was a lot of evidence provided to ensure a successful completion of the proposed study.

Weaknesses
 The application had a few minor areas that needed improvement, including inadequate specific expertise in research with Latino MSM, very little description of measures to ensure study integrity, and very few details about where BLMSM will be referred to for local HIV-related services.

Significance:
The project addresses the fact that Black and Latino MSM (BLSMSM) communities in the US have been disproportionately represented in the modern HIV epidemic with increasing rates of new HIV diagnoses and less likelihood of awareness of HIV infection compared to their non-BLMSM counterparts. This is occurring despite the evidence showing that BLSMSM and White MSM have similar rates of recent testing for HIV.
The project, if successfully completed, will contribute much needed knowledge to assist health service providers and clinicians to provide innovative and culturally-relevant services to BLMSM, related to HIV testing and follow-up treatment (for those who test positive).
Successful completion of the aims will provide evidence needed to significantly improve recruitment strategies to find BLMSM in highly affected areas of the United States, engage them in HIV testing efforts, and link participants with HIV to the medical and support services they need. The innovations in recruitment and the technology proposed by the investigators, by using mobile apps/sites, like Grindr, Facebook, and gay-related sites, will reach more BLMSM and, because of the comparative nature of the study, will provide much needed information on the most effective and cost-efficient ways to reach BLMSM in culturally-respective ways.

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The investigators report recent unpublished data they developed showing how risk of new HIV infections is mainly concentrated in the US South and coastal areas. In addition, they stated and provided evidence to show that the areas of highest impact are different for Black and Latino MSM. Thus, the investigators will focus their study on improving HIV testing among Black MSM in NC, SC, GA, AL, MS, FL, and LA, as well as among Latino MSM in CA, NV, MS, LA, TX, NY, and FL.
The application contained well-written, specific, and concise reporting of HIV testing and prevention services for BLMSM as well as HIV treatment services (see Table 1 and its corresponding narrative). The investigators stress that efforts in reaching BLMSM cannot focus solely on engaging them to adopt PrEP; recruitment into testing services will link them to needed services including PrEP as well as medical services for HIV positives and referrals to partner services. The investigators presented this information within the text of the application as well as in tabular form. As shown in Table 1, on page 166, they showed how there are "opportunities for improvement" for linking BLMSM to testing and linkage to care services.

Strengths
 The investigators provided more than enough evidence to substantiate the public health significance of conducting this effectiveness study.

Weaknesses
 There are no weaknesses to report for this section.

Investigator(s):
Over 50 years of collective experience is represented on this research team. Dr. Sullivan has assembled an exemplary group of colleagues and other collaborators to carry out this important project. He is joined by colleagues at Emory who have experience in HIV epidemiology as well as RCTs of HIV prevention interventions (e.g., Drs. Rosenberg and Wall). In addition, experts in Black or Latino MSM HIV prevention (e.g., Greg Millett, Latesha Elorpe, Kenneth Mayer) and collaborators at the University of Michigan and the University of North Carolina have been included to further add credibility and necessary expertise for implementing this project.
The members of the research team have each documented their achievements and accomplishments in their biosketches which are well detailed and exemplify expertise in the field.
Dr. Sullivan is the PI of this proposed project. There are six (6) co-investigators and multiple consultants. The research team members definitely show that they have complementary and integrated expertise in HIV prevention, treatment, medical and support services, as well as epidemiological research. This is described in detail in section 4.2 (and Figure 3) of the application.
All project personnel are well qualified to conduct work on this project. Considering the multi-site nature of the recruitment and testing aspects of this project, the percentages of time presented in the application seem adequate. In addition, the PI, the Co-I's, and the consultants/collaborators all have experience in multicultural and/or structural approaches to HIV prevention and/or treatment. They also show, according to their biosketches, successful acquisition of grant funding and completion of research studies with high public health impact and relevance to the work proposed in this application.
Dr. Sullivan has very recent experience in research with young Black MSM (1R01DA038196) and with racial disparities in HIV care (1R01AI112723). His colleagues have excellent track records in conducting formative research in HIV prevention with YMSM, Black MSM, and other MSM populations and disenfranchised communities.
Dr. Sullivan has an excellent track record in web-based and app-based recruitment for MSM in general. His specific expertise is not in conducting research with adult BLMSM populations; however, he has complemented his expertise with that of others who have worked with the BLMSM populations (i.e., Greg Millett, Latesha Elorpse, among others).
The research team has shown that, collectively, it has the expertise to conduct online HIV-related research with MSM in general, specifically YMSM and Black MSM. Work specifically with Latino MSM is shown only through collaboration with Dr. Hightow-Weidman; otherwise, no other specific expertise in Latino MSM research is shown in the application, despite the details provided in Table 2. Most of the reported work with Latino MSM seems to be conducted as part of other research among MSM.
Based on the multiple publications and grants reported and referred to in the application, Dr. Sullivan and his assembled team of researchers and collaborators have the ability to collect, manage, and analyze data in a timely manner.
The research team also seems to have recent experience in obtaining the required data security systems and certifications meeting federal FISMA requirements.

Strengths
 The research team has a substantial amount of experience with formative research and recruitment work with MSM populations, especially Black MSM.

Weaknesses
 However, the team only has minimal experience working specifically with Latino MSM populations.
Innovation: Dr. Sullivan and his research team propose a study that will challenge current web-based recruitment and linkage to services paradigms in five ways, as stated in the application. Among those approaches stated are 1) comparing two recruitment strategies for BLMSM against a more common (comparison) strategy (i.e., Facebook ads) as well as 2) offering telemedicine for counseling participants in both intervention arms within a comparative effectiveness study.
Though some aspects of the study have been used before by the researchers and in HIV prevention research, the combination of the approaches (i.e., using web-based apps) and the context in which the research is being conducted (i.e., multi-site, with BLMSM) is novel in the field of HIV prevention and linkage to care research.
The investigators are proposing that they will be using Social Cognitive Theory and the IOM Integrated Model as theoretical bases for the study; thus, results of the study will refine and improve the applicability of these theories, especially as they apply to the online behavior of BLMSM communities related to HIV testing and prevention.
The application describes a detailed plan for recruiting BLMSM using Grindr and gay websites (vs. Facebook ads). Each of the 8 consultants on the project will be tapped to provide expertise on how to develop these recruitment strategies in the most effective ways.
Dr. Sullivan is basing the proposed work on prior research conducted by him and his research colleagues; however, this is not duplication of current or prior research. As documented in section 4.3.6, the investigators plan to provide information and referrals to services in a cost-effective manner.
The research team states in section 4.3.1 that "there is sufficient evidence from [their] work and others' that simply recruiting men and either recommending that they test for HIV or offering HIV test kits is not sufficient to produce optimal uptake of testing, especially for MSM of color." With this in mind, they provide a rationale for identifying and developing innovative strategies to increase testing among BLMSM. In addition, as they mentioned in Section 3, the need for internet based approaches is needed for "reaching large numbers of men at limited marginal costs" (p. 167).

Strengths
 The proposed study has two innovative recruitment strategies being tested against "standard" Facebook ad recruitment.
 Online recruitment and HIV testing promotion (via telemedicine) in several areas of the US strengthens the innovation aspect of the study as well the public health significance.

Weaknesses
 There are no weaknesses to report for this section.
Approach: The strategies explained in the application are sound and well thought out. The methodology and analyses also seem appropriate for this project. The use of 8 consultants at multiple sites across the country may seem less community-driven than a project of this kind should integrate; however, because cost-effectiveness is a key component of this project, the use of multiple consultants is appropriate. Also, they plan to obtain a sample of 60 BLMSM to do online focus groups to gather feedback on the HIV testing promotion strategies of the study. Because the app and web-based strategies have already been normed successfully with MSM, the proposed project seems to utilize approaches that will be potentially successful in recruiting BLMSM from multiple sites across the US.
The researchers have presented a detailed discussion of possible problems and alternatives as well as benchmarks to measure success in the project.
The investigators have outlined a well-detailed plan on how to conduct this effectiveness study as well as how to manage the riskiest aspects of the study. They mentioned in section 4.4 how they successfully managed the development of HealthMindr and healthMpowerment over the past several years, including issues related to advancements in technology.
The study team plans to recruit and enroll a total sample of up to 3600 BLMSM. They provided details on human subjects protection (HSP) for every aspect of the study, including online focus group discussions with 60 BLMSM as well as the participants in the RCT. They also discussed HSP for participants ages 18-21, including special considerations made for this age group. Section 4.5 presents a well-written logic model including several inputs, outputs, and outcomes of the study organized by study year.
The investigators describe their plans for recruiting 1800 Black MSM and 1800 Latino MSM for the study, which meets the required total, as described on page 6 of the FOA.
They also describe in much detail how they plan to address all four goals of the FOA. It was very helpful to review plans to develop and evaluate their web-based recruitment strategies for BLMSM in 1 U01 PS005181-01 8 ZPS1 GCA (27) SULLIVAN, P 8 both English and Spanish, utilizing Spanish-speaking staff on the team (through its collaboration with the University of Michigan) for culturally-relevant Spanish translations of their apps and recruitment materials.
The PI and his team describe how they will engage the target population in these recruitment strategies with their online focus groups discussions (FGDs), with 60 men via 10 FGDs.
The investigators, in section 4.3.3., provide details for implementing the strategies and to pilot test the recruitment, enrollment, and data collection aspects of the study.
They also fully describe how they will consent, screen, and enroll participants using SurveyGizmo and keep the data on a HIPAA-compliant server at Emory University.
The research plan, study design, and power analyses are well-planned, detailed, and adequate. Their power analysis calculations assume a 40% uptake of testing within one month of study enrollment in the comparison arm while detecting 10% increase in testing in the intervention arms for each group (Black MSM and Latino MSM).
They also mention, in section 4.3.5, how they plan to examine test result outcomes, linkage to care, and linkage to additional services, and implement referral to HIV testing, PrEP, nPEP, health insurance, mental health services, and other related services.
The investigators also describe how they plan to recruit and follow-up with participants, based on the PI's and colleagues' past experiences in conducting research studies with similar populations.
As stated in section 4.3.5, the investigators will conduct a pilot study to test recruitment, data collection, and enrollment systems. This includes the Spanish-translated versions of materials for Grindr, HealthMindr, healthMpowerment, and the Facebook ads (comparison intervention).
The application mentions that Dr. Wall (one of the Co-I's) will be "responsible for measuring cost of recruitment strategies and cost-effectiveness analyses" (p. 168 and p. 180); in addition, in section 4.3.6, Dr. Sullivan and his team state that they will utilize "standard methods of cost analyses, as recommended by the US Panel on Cost-effectiveness in Health and Medicine." The investigators state that participants with positive test results will receive help for linkage to care with setting up appointments "at the provider of their choosing, using a list of providers in the study states who provide HIV care from [their] AIDSVu.org national resources and the American Academy of HIV Medicine provider locator" (section 4.3.3.13).
Regardless of the arm of the study that participants are in, each participant will be administered a baseline survey requesting information on "HIV testing history, HIV testing knowledge and beliefs, current HIV testing strategies, last HIV test and results, intentions/plans to test for HIV in the future, use of other HIV prevention services, and sexual risk and preventive behaviors" (p. 176).
The investigators mention that they will collect follow-up data from participants in the RCT approximately four months after enrollment with a $25 incentive to assess completion of HIV testing within one month of enrollment. Anyone who returns proof of HIV testing will receive an additional $10 incentive via Amazon gift credits (p. 177). The investigators also describe how HIV testing will be tracked by recording the participant's reported HIV test result as well as tracking referrals and linkages (p. 177-179).
All data collection activities, including assessment of recruitment costs, were described. The investigators were very succinct yet detailed in discussing a study design with enough flexibility for making a few modifications, if necessary, to successfully and ethically complete the study (see section 4.4). In addition, a detailed logic model and realistic timeline was provided. The proposed activity was scalable (see section 4.5). Even though a well-developed logic model was provided, no specific evaluation questions or items were provided related to budget, except for brief mentions of "budget" in Table 4.
There did not seem to be specific information relating to collecting process evaluation data to assess contextual factors that may relate to changes in outcomes, as described in the FOA, nor the use of Evaluation Standards for judging the quality of the study.
The research plan in this application provides details regarding the collection of outcome data as described in the FOA (e.g., number of Black and Hispanic/Latino MSM tested for HIV within one month of enrollment and provide the result of the test). It is summarized very well in Table 4 (p. 181).
The research team expects 128,925 BMSM and 522,531 HLMSM to be active on any one of the recruitment platforms in the states they are recruiting from; thus, the efforts described in the application have potential to reach a large proportion of the population.
The application includes an adequate plan for verifying results of HIV RDT and locally conducted HIV testing, as described in section 4.3.3. In addition, there is a description of how results will be provided to participants for tests conducted at the CDC and local labs.
The investigators describe in detail why the proposed study design, including sample size, power, and effect size, will guide them to successful completion of the study. The quality of the proposed research plan, study design, and power analyses adequately address the research objectives of the FOA (see section 4.3). As mentioned before, the investigators propose an adequate sample size calculation (of 600 men in each arm of the study).
The investigators briefly but adequately describe retention strategies based on previous virtual and local cohort studies to achieve retention rates of at least 70% (see section 4.3.3.6).
Quality assurance will be led by Dr. Jones (Co-I) (see section 4.3.4.6). In addition, Ms. Luisi, a data manager for the project will assist with QA (p. 125). However, the investigators did not explain in detail measures that ensure integrity of online systems, enrollment of study participants, delivery of home testing materials, and retention of study participants.

Strengths
 The approaches described were well written, with adequate details that provided evidence for the potential of a successful research project.

Weaknesses
 Description of measures to ensure integrity of certain aspects of the study (i.e., enrollment, home testing delivery) and process evaluation data collection were not provided in an adequate manner.

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 Only passing mentions about budget considerations were included in the evaluation plan.

Environment:
Dr. Sullivan and his research team have the scientific expertise and are in environments conducive to the completion of successful research studies. Among all the institutions represented by the study team members (e.g., Emory, UNC, UM, among others mentioned), there is more than adequate support and related resources reported to implement and complete the study.
The collaborations being established in the study will help ensure the completion of the study, especially because of its multi-site arrangement throughout several states.
The investigators report that they will have access to adequate numbers of Black and Latino MSM by virtue of the collaborators and consultants located in the several states they will be recruiting from. In addition, Spanish-speaking staff will help reach Spanish-speaking Latinos for potential recruitment into the study.
The application, in the budget justification section and other areas, provides detailed descriptions of duties and responsibilities of project personnel; a summary of personnel duties is summarized in Figure  3 (p. 168).
The plans put forth in the application for programming online systems, data management, data security, and data analyses is adequately described and the data security systems are sufficient to protect participants' data and confidentiality, as evidenced by the research team's past and current study implementation experiences (see section 4.3.4).
The application includes a detailed total budget with staffing plans and activities for each project year.
The research team, however, did not perform an adequate job in describing the local services for referring study participants for additional HIV testing, partner services, PrEP, and other related services.

Strengths
 More than 50 years of collective experience exist among the main members of the research team.
 The collaborations and institutional/community environments will provide a forum for a potentially successful study.

Weaknesses
 There were very few details about the agencies BLMSM will be referred to for local HIV-related services.

Vertebrate Animals:
Not Applicable (No Animals) Overall Impact: This is a new application with an outstanding Principal Investigator with the major goal to evaluate the performance of two internet-based strategies to promote HIV testing among Black and Hispanic MSM. The first step will be a formative phase to assess the two internet-based strategies and refining two existing web-based tools through theater testing and qualitative interviews. The two strategies will include a testing promotion component, HealthMindr, a mobile phone app and healthMpowerment, an HIV education interactive web app. Next, they will conduct a comparative effectiveness study of the two internet-based strategies in comparison to recruitment through Facebook. The primary outcome is testing for HIV within the first month of enrollment. Finally, they will conduct a secondary outcomes analysis. This is a highly significant area because young Black and Latino MSM are disproportionately affected by HIV and innovative ways to increase testing, condom uptake and prevention strategies to engage these key populations are needed. This is a highly innovative application because they will use a hybrid comparative effectiveness design which allows for the possibility that different post-recruitment modalities of testing promotion are better for men recruited through different internet-based formats; they will test two app based strategies HealthMindr based on Social Cognitive Theory and healthMpowerment based on the IOM's Integrated Model of Behavior Theory; and the two prevention platforms will potentially be able to reach a large audience for a relatively small cost. Strengths  Use of Social Cognitive Theory which will focus on the importance of self-regulation in learning via the HealthMindr.
 Use of Integrated Model of Behavior Theory, which has been widely used as a tool to design and evaluate health behavior change interventions via healthMpowerment.  This is an extremely seasoned study team with a successful independent and collaborative experience well suited to complete this project.

Weaknesses
 Requires participants to have access to a private computer with Internet access. This may be difficult in lower SES minority men.
 Not sure if simply translating the two established apps into Spanish will be enough to be culturally effective. Weaknesses  None noted.

Innovation: Strengths
 The investigators will integrate a telemedicine component, which to date has not been used in a comparative effectiveness study, in both strategies to ensure proper self-administration of OraQuick or self-collection of DBS specimens  By using existing knowledge of internet based recruitment, it focuses on HIV testing uptake and linkage to HIV care or prevention services by using and improving on existing online modalities.
 The study is comparing two strategies on two different theoretical bases: Social Cognitive Theory and Integrated Model of Behavior theory.

Weaknesses
 None noted.

Approach: Strengths
 The investigators will capitalize on preliminary data on HealthMindr and healthMpowerment developed by the PI and Co-PI (Sullivan and Stephenson).
 The investigators will translate both apps into Spanish.

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 As smart phones are ubiquitous in the US, with use greatest in youth and young adults, this study has the potential to reach its targeted population at a relatively low cost. Overall Impact: This is a new application from a very good Principal Investigator with three goals. The first is to conduct a formative phase to assess two innovative, culturally-appropriate and sensitive, internet based strategies to recruit BMSM and HLMSM to HIV testing. This will include translation into Spanish, expert review, and engagement of men in research communities to refine existing web-based tools (healthMpowerment and HealthMindr) through theater testing and qualitative interviews. The second goal is to conduct a comparative effectiveness study of two innovative strategies with a third, non-innovative comparison strategy to promote uptake of HIV testing by Black and Hispanic/Latino MSM. 3,600 MSM will be enrolled attaining at least 70% retention over 4 months, with a primary outcome of HIV testing within 1 month of enrollment. The third goal is to conduct secondary analyses of outcomes of relevance to the HIV prevention and care cascades, including linkage to HIV care or prevention services and costs per person tested for HIV, diagnosed with HIV, linked to medical care, linked to prevention or social services. This is a significant area because HIV risks and infections are continuing vectors of the AIDS epidemic with potential to renew the outbreak of HIV in the general public. It is a highly innovative application because HIV testing has not been done before in this way with these high-risk populations.