A new online survey module to measure sexual partnership timing

1. A new online survey module to measure sexual partnership timing With results from a focus group of MSM Eli S Rosenberg, Patrick S Sullivan Sex::Tech February 26, 2010 Department of Epidemiology Rollins School of Public Health Emory University, Atlanta, GA

2. Background [1]: Concurrency by example You have unprotected sex with A, B, C A B C • Timeline of interventions? time • C is at risk from B and A • B is at risk from A • A is not at risk from others Serial monogamy Another situation: A B C time Concurrency • Now A also at risk from B and C.

3. Background [2]: Concurrency, defined Concurrency: “Overlapping sexual partnerships where sexual intercourse with one partner occurs between two acts of intercourse with another partner.” Consultation on Concurrent Sexual Partnerships UNAIDS. Nairobi, Kenya, 2009 A B C time ≈ A A B C

4. Background [3]: Concurrency as amplifier of transmission risk • Concurrency accelerates HIV/STI transmission • Modest changes in concurrency can greatly impact transmission • Common among heterosexual young adults: • Concurrent partner during most recent relationship: • ♂ 31%, ♀ 26% (1995 survey in Seattle) • More prevalent among blacks • Timeline of interventions?

5. Background [5]: Concurrency in MSM • Little information about MSM • NHBS MSM-2, San Francisco (Bohl et al 2009) • First study to specifically look at concurrency in MSM • Some evidence for more concurrency among black MSM • A 2-year cohort of 680 HIV- black and white MSM in Atlanta, evaluating HIV and STI incidence. • Timeline of interventions? • HIV/STI testing • Risk behavior assessment • Individual level • Partnership level (including timing / concurrency) • Community level • Need for CASI behavioral assessments

6. Challenge:Difficulties in Measuring Concurrency • Ideal = Sex diary of who and when • Concurrency can be inferred • Not practical for our study • Two common solutions: • List all partners within the previous X months and then ask: • 1. “Once you began sexual activity with Joe, with how many other people did you engage in sexual activity?”(direct, Manhart et al ‘02) • or • 2. Start / end dates for sex for each partner (indirect) • Poor agreement between methods 1 and 2 (Manhart et al ‘07) • Primarily due to date recall and order • Dates often at the month-only resolution = ambiguities • Need better and smarter methods if using CASI • Timeline of interventions?

7. Overcoming challenges [1]: A third option – interactive calendar Concurrency Need to clarify Pattern! Concurrency Need to clarify all 3 pairs

8. Overcoming challenges [2]: Intelligent CASI survey • Implemented all 3 concurrency methods in SurveyGizmo • SurveyGizmo • Usual question types • Fancy ones too: Tables of checkboxes, rating scales, etc. • Can dynamically change based on user response: • Survey text • Question behavior • Page navigation • Export data to SPSS, Excel, CSV • Accessibility options • Integration with Facebook, cell phones, etc. • Timeline of interventions? • Interactive controls • PHP scripting

9. Solution: Partnership timing module (country-themed bar in ATL)

10. Triggers how many dates to collect

15. Let’s be mischievous and put an end date before a start date …. First had sex on 1/1/2010

16. We are sent back to beginning of dates section and need to correct

19. We’ve programmed other logical checks too!

20. Concurrent or serial? Need to clarify!

22. What if I stopped having sex with Buck456 in January 2010? Need to clarify!

23. What if I had sex with Joe in December 2009? Obvious concurrency = do not need to clarify! Need to clarify!

24. Results [1]: Pilot testing and focus group, Dec. 2009 • Venue- and street outreach-based recruitment in Atlanta • Eligibility criteria: • Black or white non-Hispanic MSM • Not currently in a mutually monog. relationship • Atlanta resident • ≥ 18 years • > 1 partner in previous 6 mo. • 13 MSM took survey, 10 took part in focus group • 10 white, 3 black • median age of 30 years • median 4 partners in the previous 6 mo.

25. Results [2]: Pilot testing and focus group, Dec. 2009

26. Results [3]: Relevant focus group comments • Preference for calendar method • “The grid at the end with the calendar, that sorta recapped everything… it was easier to think like that… it was easier to recall than one person at a time, with a date“ • “… most of them I just remembered generally, but I did know who was before who, so I knew exactly that” • Acceptability of follow-up questions to resolve ambiguities • “I liked that at the end where it came back and said, … ‘sex with these 2 people in October. If so, did you stop with him before you started with him’. That was so much easier for me. “

27. Results [4]: Suggested changes • Place the partner calendar at the beginning • “I would collect all of the relative stuff [calendar] up-front like this … because in our heads we know who these people are” • Only ask for month + year, allowing date opt-in • “… it’s just hard for me to remember exact dates. I was pretty much estimating.” • “Do the month thing first and then say, ‘if you have anything more specific, that would help us’ ” • A number of other helpful suggestions for language and • format

28. Conclusions • Concurrency an important determinant of STI/HIV transmission • We designed an improved survey with partner calendar to overcome measurement limitations • SurveyGizmo + scripting language allows for online implementation • Pilot testing demonstrates acceptability and preference over extant methods • NHBS-MSM, cycle 1: November 2003 - April 2005 • 13,670 men interviewed • 15 MSAs • Venue-based time-space sampling • Eligibility criteria: • Male, age ≥ 18 years, current MSA resident, provide informed consent • Analysis criterion: • ≥ 1 male sex partner in previous year

29. Thank you! supported by NIH grant # 1R01MH085600

30. Background [4]: What about MSM? • Men who have sex with men (MSM) are the most heavily impacted group in the United States • In 2006, comprised: • 53% of all new infections, overall • 72% of all new infections, among men • Within MSM, heterogeneity of risk • NHBS, venue-attending MSM, 5 cities ’04 - ’05 (n = 1,767): • Timeline of interventions? • Individual risk factors do not explain disparity (Millett et al ’06, ‘07) • Concurrency and other network factors?

31. Overcoming challenges [3]: SurveyGizmo Overview • Timeline of interventions?

32. Background [1]: SurveyGizmo shots • Timeline of interventions?

33. Overcoming challenges [4]: SurveyGizmo Overview • Timeline of interventions?

34. Background [1]: SurveyGizmo shots • Timeline of interventions?

35. Background [1]: SurveyGizmo shots • Timeline of interventions?

36. Background [1]: SurveyGizmo shots • Timeline of interventions?

37. Overcoming challenges [5]: SurveyGizmo Overview Powerful PHP scripting language extends the ability of the survey to adapt, respond, and perform advanced calculations.