Reducing High-risk Behaviors for HIV Prevention

Jeffrey Wickersham, PhD, associate professor of medicine (infectious diseases), was inspired to work in HIV research because of what he was seeing across his community.

“I was bothered by seeing so many new infections and wanted to find solutions that were effective and that the community felt they had ownership of as well—that they had a stake in, that they had a role in designing and choosing,” said Wickersham.

So when he was offered the serendipitous opportunity to work as a postdoctoral fellow in the Yale School of Medicine (YSM) lab of Frederick Altice, MD, he took it. Wickersham arrived at YSM in 2009 and began to work with Malaysia’s incarcerated population and HIV prevention.

“The first case of HIV in Malaysia was detected in 1986, five or so years after the first cases emerged in the United States. It was almost entirely an injection drug use-driven epidemic for the first 10-15 years. When methadone became more accessible in Malaysia, those cases started to account for a smaller share of new diagnoses. And sexually-driven transmission of HIV exploded. Now nine out of 10 new cases are sexually transmitted, and just over half of those cases are occurring among gay and bisexual men or other men who have sex with men,” explained Wickersham.

He started making connections with the Universiti Malaya and the LGBTQ NGOs in the country. He saw a need for public health prevention research. He started his work to lower HIV transmission among gay and bisexual men in Southeast Asia. This focused on sexualized drug use, known as chemsex.

Previous research demonstrates that the use of drugs like methamphetamine, ecstasy, and GHB can lead to risk-taking behavior like multiple sexual partners, reduced condom use, and poor adherence to pre-exposure prophylaxis (PrEP) or medications that can prevent HIV infection.

Wickersham and his co-principal investigator Roman Shrestha, PhD, MPH, assistant professor at the University of Connecticut, designed a micro-randomized trial using a just-in-time adaptive intervention to determine whether using an app could reduce HIV-uninfected gay or bisexual men from engaging in high-risk behavior that would put them at risk for HIV transmission. They recently received an R01 grant from the National Institute of Drug Abuse for this work.

The app, called JomCare, will ask study participants twice a day about their substance cravings and their intention to engage in drug use. The researchers will randomize the participants to receive one of three types of interventions. Within 12 hours, the men will be assessed to see if they engaged in any kind of sexualized drug use activity and will undergo urine testing for stimulant drugs as an objective measure. Participants are followed for 90 days.

“Sexualized drug use is hard to intervene on. Unfortunately, there are no medication-based therapies like those that are available for opioid dependence, such as buprenorphine or naltrexone. There are no approved therapies for people experiencing dependence on these drugs,” explained Wickersham.

Through this study, the research team is trying to refine which prompts at which time and under which conditions are the most impactful in reducing risk-taking behaviors. The team will use that data with machine learning to predict under which conditions, which answers at which times of day, and which intervention prompts yield the greatest reduction in those risk behaviors.

Premananda Indic, PhD, associate professor in the Department of Electrical Engineering at UT Tyler, will lead the machine learning component of the study.

YSM’s James Dziura, MPH, PhD, professor of emergency medicine, of biostatistics, and of medicine (endocrinology) and Edward Boyer, MD, PhD, professor of emergency medicine at The Ohio State University, and Iskandar Azwa, MBChB, MRCP, associate professor of medicine at the Universiti Malaya in Kuala Lumpur, Malaysia, are also part of the research team.

Wickersham and team plan to continue these efforts in the future to focus specifically on HIV prevention.

Yale School of Medicine’s Department of Internal Medicine Section of Infectious Diseases engages in comprehensive and innovative patient care, research, and educational activities for a broad range of infectious diseases. Learn more at Infectious Diseases.