Published on in Vol 14 (2025)

This is a member publication of Florida State University

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/63114, first published .
Adolescent Youth Survey on HIV Prevention and Sexual Health Education in Alabama: Protocol for a Web-Based Survey With Fraud Protection Study

Adolescent Youth Survey on HIV Prevention and Sexual Health Education in Alabama: Protocol for a Web-Based Survey With Fraud Protection Study

Adolescent Youth Survey on HIV Prevention and Sexual Health Education in Alabama: Protocol for a Web-Based Survey With Fraud Protection Study

Protocol

1Institute on Digital Health and Innovation, College of Nursing, Florida State University, Tallahassee, FL, United States

2Birmingham AIDS Outreach, Birmingham, AL, United States

Corresponding Author:

Henna Budhwani, MPH, PhD

Institute on Digital Health and Innovation, College of Nursing

Florida State University

Innovation Park, Research Building B

2010 Levy Ave, RM B3400

Tallahassee, FL, 32310

United States

Phone: 1 8506443296

Email: hbudhwani@fsu.edu


Background: In Alabama, the undiagnosed HIV rate is over 20%; youth and young adults, particularly those who identify as sexual and gender minority individuals, are at elevated risk for HIV acquisition and are the only demographic group in the United States with rising rates of new infections. Adolescence is a period marked by exploration, risk taking, and learning, making comprehensive sexual health education a high-priority prevention strategy for HIV and sexually transmitted infections. However, in Alabama, school-based sexual health and HIV prevention education is strictly regulated and does not address the unique needs of sexual and gender minority teenagers.

Objective: To understand knowledge gaps related to sexual health, HIV prevention, and pre-exposure prophylaxis (PrEP), we conducted the Alabama Youth Survey with individuals aged 14-17 years. In the survey, we also evaluated young sexual and gender minority individuals’ preferences related to prevention modalities and trusted sources of health information.

Methods: Between September 2023 and March 2024, we conducted a web-based survey with 14- to 17-year-olds who are assigned male at birth, are sexually attracted to male youth, and lived in Alabama. Half of the study’s participants were recruited through community partners, the Magic City Acceptance Academy and Magic City Acceptance Center. The other half were recruited on the web via social media. A 7-step fraud and bot detection protocol was implemented and applied to web-based recruitment to reduce the likelihood of collecting false information. Once data are ready, we will compute frequencies for each measure and construct summary scores of scales, such as HIV and PrEP knowledge, to determine internal consistency. Using multivariable logistic regression, we will examine associations between personal characteristics of survey respondents and key constructs using SPSS 29 (IBM Corp) or SAS 9.4 (SAS Institute).

Results: Analyses are ongoing (N=206) and will conclude in June 2025. Preliminary results include a sample mean age of 16.21 (SD 0.88) years; about a quarter identified as transgender or gender nonconforming, with 6% stating their gender as a transgender woman. A total of 30% self-reported their race as African American or Black; 12% were Hispanic or Latinx. More than half reported being sexually active in the past 6 months. Primary data analyses will be completed in mid-2025. If findings are promising, results will be used as preliminary data to support the development of an intervention to address knowledge gaps and prevention preferences.

Conclusions: If the study is successful, it will yield information on HIV knowledge, PrEP awareness, PrEP preferences, and related outcomes among sexual and gender minority teenagers in Alabama, an underserved, hard-to-reach, but also high-priority population for public health efforts to Ending the HIV Epidemic.

International Registered Report Identifier (IRRID): DERR1-10.2196/63114

JMIR Res Protoc 2025;14:e63114

doi:10.2196/63114

Keywords



Background

In Alabama, the undiagnosed HIV rate is over 20%; youth and young adults, particularly those who identify as sexual and gender minority individuals, are at elevated risk for HIV acquisition and are the only demographic group in the United States with rising rates of new infections [Fast facts: HIV in the US by age. Centers for Disease Control and Prevention. URL: https://www.cdc.gov/hiv/data-research/facts-stats/age.html? [accessed 2025-01-08] 1,Allan-Blitz LT, Mena LA, Mayer KH. The ongoing HIV epidemic in American youth: challenges and opportunities. Mhealth. 2021;7:33. [FREE Full text] [CrossRef] [Medline]2]. Adolescence is a period marked by exploration, risk taking, and learning [Budhwani H, Naar S. Training providers in motivational interviewing to promote behavior change. Pediatr Clin North Am. 2022;69(4):779-794. [FREE Full text] [CrossRef] [Medline]3], making comprehensive sexual health education, typically delivered in school systems, a high-priority prevention strategy for HIV and sexually transmitted infections [Goldfarb ES, Lieberman LD. Three decades of research: the case for comprehensive sex education. J Adolesc Health. 2021;68(1):13-27. [FREE Full text] [CrossRef] [Medline]4,Budhwani H, Maragh-Bass AC, Tolley EE, Comello MLG, Stoner MCD, Adams Larsen M, et al. Tough talks COVID-19 digital health intervention for vaccine hesitancy among black young adults: protocol for a hybrid type 1 effectiveness implementation randomized controlled trial. JMIR Res Protoc. 2023;12:e41240. [FREE Full text] [CrossRef] [Medline]5]. However, in Alabama, school-based sexual health education is strictly regulated [Alabama code title 16. Education § 16-40A-2 section 16-40A-2 minimum contents to be included in sex education program or curriculum. FindLaw. URL: https://codes.findlaw.com/al/title-16-education/al-code-sect-16-40a-2/ [accessed 2025-01-08] 6]; school-based sexual health education must adopt an abstinence orientation, and HIV prevention is typically discussed within the context of heterosexual marriage [Selma AIR. Centers for Disease Control and Prevention. 2020. URL: https://npin.cdc.gov/organization/selma-air [accessed 2025-01-14] 7,HIV prevention and education. Birmingham AIDS Outreach (BAO). URL: https://www.birminghamaidsoutreach.org/hivpreventioneducation [accessed 2025-01-08] 8]. In response to these structural limitations, community-based organizations have developed their own sexual health and HIV prevention education programs [Budhwani H, Kiszla BM, Outlaw AY, Oster RA, Mugavero MJ, Johnson MO, et al. Adapting a motivational interviewing intervention to improve HIV prevention among young, black, sexual minority men in Alabama: protocol for the development of the kings digital health intervention. JMIR Res Protoc. 2022;11(7):e36655. [FREE Full text] [CrossRef] [Medline]9]. However, their content is typically delivered inconsistently, relies on funding availability, and is offered only to youth engaged in services. In 2019, pre-exposure prophylaxis (PrEP) was established as safe and effective in preventing HIV among adolescent-aged men who have sex with men (MSM), and the US Food and Drug Administration approved PrEP for individuals weighing at least 77 pounds (~34.9 kg), thereby making it available to adolescents [Guidelines on long-acting injectable cabotegravir for HIV prevention. World Health Organization. 2022. URL: https://www.who.int/publications/i/item/ [accessed 2025-01-08] 10,Beymer MR, Holloway IW, Pulsipher C, Landovitz RJ. Current and future PrEP medications and modalities: on-demand, injectables, and topicals. Curr HIV/AIDS Rep. 2019;16(4):349-358. [FREE Full text] [CrossRef] [Medline]11]. Nevertheless, prescribing PrEP to adolescents remains under ideal levels [Taggart T, Liang Y, Pina P, Albritton T. Awareness of and willingness to use PrEP among Black and Latinx adolescents residing in higher prevalence areas in the United States. PLoS One. 2020;15(7):e0234821. [FREE Full text] [CrossRef] [Medline]12]. Potentially, due to the lack of comprehensive HIV prevention and sexual health education in Alabama schools, there are high rates of HIV among sexual and gender minority youth and low rates of PrEP uptake. This leads to unanswered questions about what adolescents know or do not know about HIV and sexually transmitted infections (STIs) and about characteristics of their psychosocial profile, which may influence the acceptance of PrEP. Furthermore, new PrEP modalities are being developed, and clinicians and researchers alike are interested in learning about what PrEP options may be more acceptable to adolescents.

While the National Institutes of Health–funded Adolescent Medicine Trials Network for HIV/AIDS Interventions and HIV Prevention Trials Network have supported studies that assess PrEP preferences among sexual and gender minority adolescents and young adults [Valente PK, Bauermeister JA, Lin WY, Da Silva DT, Hightow-Weidman L, Drab R, et al. Preferences across pre-exposure prophylaxis modalities among young men who have sex with men in the United States: a latent class analysis study. AIDS Patient Care STDS. 2022;36(11):431-442. [FREE Full text] [CrossRef] [Medline]13,Biello KB, Valente PK, da Silva DT, Lin W, Drab R, Hightow-Weidman L, et al. Who prefers what? Correlates of preferences for next-generation HIV prevention products among a national U.S. sample of young men who have sex with men. J Int AIDS Soc. 2023;26 Suppl 2(Suppl 2):e26096. [FREE Full text] [CrossRef] [Medline]14], the age range usually begins at 15 or 16 years, with few studies enrolling as young as 14 years, even though sexual debut is thought to be younger in MSM as compared to the public [Outlaw AY, Phillips 2nd G, Hightow-Weidman LB, Fields SD, Hidalgo J, Halpern-Felsher B, et al. Age of MSM sexual debut and risk factors: results from a multisite study of racial/ethnic minority YMSM living with HIV. AIDS Patient Care STDS. 2011;25 Suppl 1:S23-S29. [CrossRef] [Medline]15]. There also continues to be a need to examine PrEP preferences of sexual and gender minority adolescents in the southern United States, where stigma related to HIV, sexual orientation, and gender identity is high and resources are limited [Budhwani H, Mills L, Marefka LEB, Eady S, Nghiem VT, Simpson T. Preliminary study on HIV status disclosure to perinatal infected children: retrospective analysis of administrative records from a pediatric HIV clinic in the southern United States. BMC Res Notes. 2020;13(1):253. [FREE Full text] [CrossRef] [Medline]16,Stringer KL, Turan B, McCormick L, Durojaiye M, Nyblade L, Kempf MC, et al. HIV-related stigma among healthcare providers in the deep south. AIDS Behav. 2016;20(1):115-125. [FREE Full text] [CrossRef] [Medline]17]. Some research on adolescent knowledge and preferences related to HIV prevention has been conducted in the region [Hill SV, Johnson J, Rahman F, Dauria EF, Mugavero M, Matthews LT, et al. Exploring adults as support persons for improved pre-exposure prophylaxis for HIV use among select adolescents and young adults in the Deep South. PLoS One. 2021;16(3):e0248858. [FREE Full text] [CrossRef] [Medline]18,Pratt MC, Hill SV, Elopre L, Simpson T, Lanzi R, Matthews LT. PrEP prescription for black adolescent girls and young women in Alabama: findings from a survey of healthcare providers. J Int Assoc Provid AIDS Care. 2022;21:23259582221127936. [FREE Full text] [CrossRef] [Medline]19]; however, studies more often occur with adolescents’ support persons, including guardians and providers, rather than the adolescents themselves and occur in clinical settings. Web-based surveys offer adolescents a comfortable and confidential way to share their essential opinions without feeling judged, especially since they heavily rely on digital technologies to build their social networks, receive social support, and obtain health information [Budhwani H, Maragh-Bass AC, Tolley EE, Comello MLG, Stoner MCD, Adams Larsen M, et al. Tough talks COVID-19 digital health intervention for vaccine hesitancy among black young adults: protocol for a hybrid type 1 effectiveness implementation randomized controlled trial. JMIR Res Protoc. 2023;12:e41240. [FREE Full text] [CrossRef] [Medline]5,Hightow-Weidman LB, Muessig KE, Bauermeister J, Zhang C, LeGrand S. Youth, technology, and HIV: recent advances and future directions. Curr HIV/AIDS Rep. 2015;12(4):500-515. [FREE Full text] [CrossRef] [Medline]20-Pingel ES, Thomas L, Harmell C, Bauermeister J. Creating comprehensive, youth centered, culturally appropriate sex education: what do young gay, bisexual and questioning men want? Sex Res Social Policy. 2013;10(4):293-301. [FREE Full text] [CrossRef] [Medline]22]. Engaging sexual and gender minority adolescents in research to understand their HIV and STI prevention is critical to reducing rates of HIV transmission but is challenging to do, making this protocol a high public health priority project.

While increasing PrEP uptake among young sexual and gender minorities is urgently warranted [Hosek SG, Rudy B, Landovitz R, Kapogiannis B, Siberry G, Rutledge B, et al. An HIV preexposure prophylaxis demonstration project and safety study for young MSM. J Acquir Immune Defic Syndr. 2017;74(1):21-29. [FREE Full text] [CrossRef] [Medline]23], and federal and local agencies are supporting behavioral interventions to reach this group [What is ‘ending the HIV epidemic: a plan for America’? HIV.gov. URL: https://www.hiv.gov/ending-hiv-epidemic [accessed 2025-01-08] 24], adolescent sexual and gender minority individuals will not engage in HIV biomedical prevention if (1) they do not know about PrEP, (2) PrEP options are not acceptable for their developmental period, or (3) they do not understand their risk [Owens C, Moran K, Mongrella M, Moskowitz DA, Mustanski B, Macapagal K. "It's very inconvenient for me": a mixed-method study assessing barriers and facilitators of adolescent sexual minority males attending PrEP follow-up appointments. AIDS Behav. 2022;26(1):21-34. [FREE Full text] [CrossRef] [Medline]25-Stocks JB, Calvetti S, Rosso MT, Slay L, Kipke M, Puentes M, et al. Evaluating the feasibility and acceptability of a digital pre-exposure prophylaxis navigation and activation intervention for racially and ethnically diverse sexual and gender minority youth (PrEPresent): protocol for a pilot randomized controlled trial. JMIR Res Protoc. 2023;12:e50866. [FREE Full text] [CrossRef] [Medline]27]. There is an unmet need to deliver tailored HIV prevention for diverse sexual and gender minority youth, built upon adolescents’ existing knowledge and preferences [Cantos VD, Hagen K, Duarte AP, Escobar C, Batina I, Orozco H, et al. Development of a mobile app to increase the uptake of HIV pre-exposure prophylaxis among latino sexual minority men: qualitative needs assessment. JMIR Form Res. 2023;7:e43844. [FREE Full text] [CrossRef] [Medline]28,Zapata JP, Hirshfield S, Nelson K, Horvath K, John SA. Preferred characteristics for mHealth interventions among young sexual minoritized men to support HIV testing and PrEP decision-making: focus group study. JMIR Form Res. 2023;7:e51103. [FREE Full text] [CrossRef] [Medline]29]. To understand existing knowledge gaps and specifically address them via intervention, we conducted the Alabama Youth Survey to evaluate 14- to 17-year-old sexual and gender minority individuals’ preferences and knowledge related to HIV prevention, PrEP, and STIs. The aim of this study was to elucidate knowledge, beliefs, and preferences related to HIV and STI prevention from sexual and gender minority adolescents in Alabama through a web-based survey to inform future intervention development. Because this study is exploratory, no hypotheses are proposed.

Objectives

In this study, we aim to elucidate knowledge, beliefs, and preferences related to HIV and STI knowledge and prevention among sexual and gender minority adolescents in Alabama through a web-based survey to inform future intervention development. If this study yields informative results, we will develop or adapt digital health intervention modules [Budhwani H, Kiszla BM, Hightow-Weidman LB. Adapting digital health interventions for the evolving HIV landscape: examples to support prevention and treatment research. Curr Opin HIV AIDS. 2022;17(2):112-118. [FREE Full text] [CrossRef] [Medline]30,Green L. Confident, capable and world changing: teenagers and digital citizenship. Commun Res Pract. 2020;6(1):6-19. [CrossRef]31], a preferred and effective modality for reaching youth to address PrEP uptake while considering preferences and levels of knowledge.


Ethical Considerations

All study materials and procedures were reviewed and approved by the University of Alabama at Birmingham Institutional Review Board (IRB; IRB-300009255) and the Florida State University IRB (STUDY00003480). Informed assent was collected digitally from all study participants before data collection. Potential participants were informed of the purpose of the survey and anonymity, confidentiality, and voluntary principles before responding. We received parental waivers from both reviewing IRBs due to the precarious situation of many sexual and gender minority youth in Alabama. Still, an information sheet for parents was made available. Participation in the study was voluntary. Study data have been deidentified and stored on a secure server. Study participants received an incentive of a US $35 digital gift card.

Eligibility Criteria

All potential participants completed a web-based screening survey via Qualtrics to verify their eligibility. To be eligible for the study, potential participants must have been 14-17 years old, assigned male at birth, report sexual attraction to men, and live in Alabama. MSM, transgender women, and genderqueer individuals were eligible if they met the aforementioned criteria.

Recruitment

We partnered with three local agencies for this study. The Magic City Acceptance Academy is the only trauma-informed charter school for LGBTQIA+ (lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual) individuals in the US Deep South. Magic City Acceptance Academy recruitment was supplemented by recruitment from the Magic City Acceptance Center [Fifolt M, Gurley DK, White D. Demonstrating resilience in the face of adversity: an embedded phenomenological case study of the Magic City Acceptance Academy. J LGBT Youth. 2024;21(4):699-715. [FREE Full text] [CrossRef]32,Fifolt M, Gurley K, White DM. How the magic city acceptance academy‘s school environment creates conditions to promote community. J Educ Stud Placed Risk. 2024. [FREE Full text] [CrossRef]33]. While both agencies are independent, they have ties to leadership and are connected to Birmingham AIDS Outreach [HIV prevention and education. Birmingham AIDS Outreach (BAO). URL: https://www.birminghamaidsoutreach.org/hivpreventioneducation [accessed 2025-01-08] 8,Kay ES, Musgrove K. From HIV to Coronavirus: AIDS service organizations adaptative responses to COVID-19, Birmingham, Alabama. AIDS Behav. 2020;24(9):2461-2462. [FREE Full text] [CrossRef] [Medline]34]. About half of our sample was recruited in person from these sites. The other half was recruited on the web via social media through targeted advertisements on Facebook, Instagram, and Snapchat. Adolescents could access the survey via QR codes linked to an eligibility screener. Eligible individuals were automatically redirected to the Alabama Youth Survey.

Bot Detection and Data Protection

Fraudulent data and fake responses are commonplace in web-based surveys, especially when a monetary incentive is provided. Examples of data fraud include bad actors, such as eligible individuals who submit surveys multiple times for multiple incentives, ineligible individuals who lie to meet eligibility criteria, and programmed bots. Since half of our sample was recruited on the web, we used extensive screening protocols, including (1) requiring the answering of youth-focused qualitative questions that require a typed response that would indicate residence, such as “What’s your favorite local restaurant?” and “What’s your favorite television show?” during screening [Outlaw AY, Phillips 2nd G, Hightow-Weidman LB, Fields SD, Hidalgo J, Halpern-Felsher B, et al. Age of MSM sexual debut and risk factors: results from a multisite study of racial/ethnic minority YMSM living with HIV. AIDS Patient Care STDS. 2011;25 Suppl 1:S23-S29. [CrossRef] [Medline]15]; (2) embedding multiple reCAPTCHAs throughout with review of Qualtrics bot detection; (3) requiring a US-based IP address; (4) locking surveys to disallow multiple submissions from the same IP address or device; (5) requiring all eligible respondents to provide an in-state phone number, which was then pinged for SMS text messaging verification before sharing the survey link—while many people have out-of-state area codes, this is much less likely for 14- to 17-year-old adolescents; (6) checking that all linked surveys were completed sequentially; and (7) using Zoom (Zoom Video Communications)–based verification audits when data seemed suspicious. Suspicious activities or indicators included but were not limited to submitting more than two surveys back to back, surveys received from the same small town in Alabama, and using an AOL or Yahoo (Yahoo Inc) email address. We also changed the survey links weekly to avoid improper circulation. These procedures were completed for all participants who were recruited on the web to ensure data integrity.

Adolescent Youth Survey

The Adolescent Youth Survey was developed and implemented following the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) checklist [Eysenbach G. Correction: improving the quality of web surveys: the checklist for reporting results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2012;14(1):e8. [FREE Full text] [CrossRef]35]. The web-based survey was programmed in Qualtrics to collect data on HIV knowledge, perceived HIV risk, actual HIV risk, PrEP knowledge, preferences related to PrEP modalities, stigmas, and characteristics that are known to be related to HIV prevention among sexual and gender minority individuals. Some constructs were explicitly developed for this study, such as PrEP modality preference, while in other cases, we used validated scales. The measures are shown in Table 1 below. The question order was not randomized. Questions were adaptive, and questions that were not applicable were not presented. For example, if a participant was not sexually active, questions about using protection during sexual intercourse were not presented. Respondents were allowed to go “back” in the survey. However, they could not adjust their responses after pressing the final submit. We aimed to recruit 200 participants and were able to recruit a total of 206 participants between September 2023 and March 2024 via a convenience sample that was shared by those recruited via the Magic City Acceptance Academy, the Magic City Acceptance Center, and the web.

Table 1. Measures collected
ConstructDescription or examplesQuestions, n
DemographicsAge, gender, sex, race, ethnicity, sexual orientation, residence in Alabama, parental education, and income10
HIV risk and preventionSexually active [Sexual risk behavior - male. PhenX Toolkit. URL: https://www.phenxtoolkit.org/protocols/view/101701 [accessed 2024-05-30] 36,Pre-exposure prophylaxis (PrEP) screening for substantial risk and eligibility. Amazon AWS. 2019. URL: https:/​/icap-aws-bucket.​s3.amazonaws.com/​icapcolumbiau/​wp-content/​uploads/​1_PrEP_Screening_for_Substantial_Risk_and_Eligibility_final_3.​4.​2019.​pdf [accessed 2025-01-08] 37], injectable substance use, on PrEPa, and previous STIb diagnosis [Self-report of human immunodeficiency virus (HIV) testing. PhenX Toolkit. URL: https://www.phenxtoolkit.org/protocols/view/570201 [accessed 2024-05-30] 38]10
HIV knowledgeHIV-KQ-18c [Carey MP, Schroder KEE. Development and psychometric evaluation of the brief HIV Knowledge Questionnaire. AIDS Educ Prev. 2002;14(2):172-182. [FREE Full text] [CrossRef] [Medline]39]18
STI knowledgeSTI Knowledge Scale [Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav. 2007;11(4):557-574. [FREE Full text] [CrossRef] [Medline]40]27
Medication experience and preferencesOral pills, shots, suppositories, patches, etc13
PrEP familiaritySeen commercials, types of PrEP, and PrEP brands6
PrEP awarenessPrEP-COLd Scale [Mueses-Marín HF, Alvarado-Llano B, Torres-Isasiga J, Camargo-Plazas P, Bolívar-Rocha MC, Galindo-Orrego X, et al. Scales to assess knowledge, motivation, and self-efficacy for HIV PrEP in Colombian MSM: PrEP-COL study. AIDS Res Treat. 2021;2021:4789971. [FREE Full text] [CrossRef] [Medline]41]10
PrEP preferencesPrEP modalities, PrEP delivery locations, etc20
Trusted sourcesTypes of information sources and people24
StigmaIHP-Re [Herek GM, Gillis JR, Cogan JC. Internalized stigma among sexual minority adults: insights from a social psychological perspective. J Couns Psychol. 2009;56(1):32-43. [CrossRef]42] and Everyday Discrimination Scale [Williams DR, Yu Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: socio-economic status, stress and discrimination. J Health Psychol. 1997;2(3):335-351. [FREE Full text] [CrossRef] [Medline]43]14
DepressionPHQ-8f [Kroenke K, Strine TW, Spitzer RL, Williams JBW, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009;114(1-3):163-173. [CrossRef] [Medline]44]8
ResilienceMOS Social Support Survey [Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705-714. [CrossRef] [Medline]45], GSEg [Schwarzer R, Jerusalem M. Generalized self-efficacy scale. In: Measures in Health Psychology: A User’s Portfolio. Causal and Control Beliefs. Windsor, England. NFER-NELSON; 1995:35-37.46]29

aPrEP: pre-exposure prophylaxis.

bSTI: sexually transmitted infection.

cHIV-KQ-18: HIV knowledge questionnaire.

dPrEP-COL: PrEP Columbia Scale

eIHP-R: Revised Internalized Homophobia Scale.

fPHQ-8: Personal Health Questionnaire Depression Scale.

gGSE: General Self-Efficacy Scale.

Pilot Testing

Study team members aged 20-24 years pilot-tested the survey multiple times to assess its completion time. It was determined to be about 20-25 minutes, depending on how slowly one reads the questions and the time to consider response options. We then pilot-tested the survey with the first 10 respondents and found similar completion metrics, with no complaints or concerns reported.

Data Storage and Analysis

Encrypted data are saved on a Florida State University server with password protection. The database and associated data structures were developed before survey distribution and were not adjusted during the protocol. We asked participants to voluntarily provide emails and cell phone numbers to facilitate the provision of incentives. These personal data were only known to the incentive processors and were kept separate from survey responses. During data collection, we examined data quality weekly (eg, missing data, assessment of distributional assumptions, and identification of outliers) and will do so before statistical analysis is conducted. As a pilot study, missing scale data will not be estimated. Once data are ready, we will compute frequencies for each measure and for each scale to assess variability and internal reliability. We will construct summary scores of scales, such as HIV and PrEP knowledge, to determine if these have adequate internal consistency (Cronbach α≥0.70) [Tavakol M, Dennick R. Making sense of Cronbach's alpha. Int J Med Educ. 2011;2:53-55. [FREE Full text] [CrossRef] [Medline]47]. Using multivariable logistic regression, we will examine associations between the personal characteristics of survey respondents and key constructs. We will use SPSS 29 (IBM Corp) or SAS 9.4 (SAS Institute) for quantitative analyses.


While this study was approved in 2021, data collection began in September 2023 and concluded in March 2024. Since the survey was open, the system could not record the number of unique visitors; thus, a formal response rate cannot be calculated. Data analysis is underway and will conclude in June 2025. The sample included 206 participants aged 14-17 years with a mean age of 16.21 (SD 0.88) years; about a quarter identified as transgender or gender nonconforming, with 6% explicitly stating their gender as a transgender woman. A total of 30% self-reported their race as African American or Black; 12% were Hispanic or Latinx. About half of them reported being sexually active in the past 6 months.


Principal Findings

In this study, we aim to elucidate knowledge, beliefs, and preferences related to HIV and STI prevention among sexual and gender minority adolescents in Alabama through a web-based survey to inform future intervention development. If this study yields informative results, data could inform the adaptation or creation of a sexual health and HIV prevention intervention for sexual and gender minority adolescents who live in southern states, where school-based sexual health education may be unavailable or strictly limited.

While hypotheses were not proposed, based on preliminary analyses and the extant literature, we anticipate finding low levels of knowledge and high levels of poor mental health outcomes. Little is known about PrEP modality preference in this population, so we cannot anticipate findings related to this topic. Findings will provide intervention targets (eg, PrEP education) and the needed dose; very low knowledge will necessitate more significant emphasis on PrEP education. When recruiting on the web, we encountered an enormous amount of fraud and ultimately needed to implement SMS text messaging verification, wherein eligible participants would only be routed to the survey after their unique phone number, with in-state area code, was verified. Even after verification, since Google phone numbers can be created, we audited suspicious submissions, such as surveys that were completed too quickly. A total of 10% of web-recruited submissions were audited via a Zoom call with a trained study coordinator. The web-based survey and fraud detection strategies were feasible; however, completing this survey with data protection and scientific integrity was much more costly and time-intensive than expected. For future web-based survey studies, we recommend implementing SMS text messaging verification at study onset with a random audit of 20% of records. Audits should include a video call (preferred) or a voice call (acceptable). Email verification, while simple, was not reliable, likely due to the ease of creating email accounts.

As noted in the Introduction, little is known about 14- to 17-year-olds’ knowledge, beliefs, and preferences related to HIV and STI prevention in the United States; thus, comparison to other studies is challenging. Recent research on these topics has been conducted in global settings with mixed findings [Obeagu EI, Obeagu GU, Ede MO, Odo EO, Buhari HA. Translation of HIV/AIDS knowledge into behavior change among secondary school adolescents in Uganda: a review. Medicine (Baltimore). 2023;102(49):e36599. [CrossRef] [Medline]48-Badru T, Mwaisaka J, Khamofu H, Agbakwuru C, Adedokun O, Pandey SR, et al. HIV comprehensive knowledge and prevalence among young adolescents in Nigeria: evidence from Akwa Ibom AIDS indicator survey, 2017. BMC Public Health. 2020;20(1):45. [FREE Full text] [CrossRef] [Medline]50]. A unique feature of our survey study is the assessment of PrEP modality preference, including options currently in clinical trials or may be available outside of the United States. Findings on modality preference have the potential to inform clinical care and how providers offer PrEP to sexual and gender minority adolescents.

While the study team was meticulous in bot detection and other fraud measures, some participants did not receive face-to-face interaction, and thus, those recruited on the web may be different from participants recruited from our local community partners. Second, the study may be susceptible to desirability bias, especially from participants recruited via in-person venues. While our sample is large for sexual and gender minority adolescents, a larger sample would increase generalizability. Some domains would have been valuable to assess, such as living circumstances and previous experiences with adverse life events; however, in pilot testing, adolescents felt the survey could not be lengthened.

Conclusions

If the study is successful, we will yield information on HIV knowledge, PrEP awareness, PrEP preferences, and related outcomes among sexual and gender minority teenagers in Alabama, an underserved, hard-to-reach, but also high-priority population for public health efforts to Ending the HIV Epidemic. Data can inform the development of a culturally appropriate (for southern contexts, to be adolescent-friendly) and modular HIV prevention intervention, targeting behavior change related to HIV prevention for sexual and gender minority adolescents, that can be seamlessly integrated into amenable community settings in the southern United States.

Acknowledgments

We thank Dr. Patton Furman, Principal of the Magic City Acceptance Academy, and Amanda Keller and Lauren Jacobs, leadership at the Magic City Acceptance Center, for their support with recruitment. This study was supported by a research grant from Merck Sharp & Dohme LLC Investigator-Initiated Studies Program (MISP) under award 60819. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme LLC.

Data Availability

Data are available upon reasonable request through this study’s lead author (HB).

Authors' Contributions

HB is the principal investigator and lead author of the study and is involved in all aspects of the study from conceptualization and funding acquisition to writing. IY is the lead statistician and led the formal analysis. JB led data collection efforts with the support of CLB and AJ. JB, CLB, and AJ were involved with project administration and writing the original draft.

Conflicts of Interest

None declared.

  1. Fast facts: HIV in the US by age. Centers for Disease Control and Prevention. URL: https://www.cdc.gov/hiv/data-research/facts-stats/age.html? [accessed 2025-01-08]
  2. Allan-Blitz LT, Mena LA, Mayer KH. The ongoing HIV epidemic in American youth: challenges and opportunities. Mhealth. 2021;7:33. [FREE Full text] [CrossRef] [Medline]
  3. Budhwani H, Naar S. Training providers in motivational interviewing to promote behavior change. Pediatr Clin North Am. 2022;69(4):779-794. [FREE Full text] [CrossRef] [Medline]
  4. Goldfarb ES, Lieberman LD. Three decades of research: the case for comprehensive sex education. J Adolesc Health. 2021;68(1):13-27. [FREE Full text] [CrossRef] [Medline]
  5. Budhwani H, Maragh-Bass AC, Tolley EE, Comello MLG, Stoner MCD, Adams Larsen M, et al. Tough talks COVID-19 digital health intervention for vaccine hesitancy among black young adults: protocol for a hybrid type 1 effectiveness implementation randomized controlled trial. JMIR Res Protoc. 2023;12:e41240. [FREE Full text] [CrossRef] [Medline]
  6. Alabama code title 16. Education § 16-40A-2 section 16-40A-2 minimum contents to be included in sex education program or curriculum. FindLaw. URL: https://codes.findlaw.com/al/title-16-education/al-code-sect-16-40a-2/ [accessed 2025-01-08]
  7. Selma AIR. Centers for Disease Control and Prevention. 2020. URL: https://npin.cdc.gov/organization/selma-air [accessed 2025-01-14]
  8. HIV prevention and education. Birmingham AIDS Outreach (BAO). URL: https://www.birminghamaidsoutreach.org/hivpreventioneducation [accessed 2025-01-08]
  9. Budhwani H, Kiszla BM, Outlaw AY, Oster RA, Mugavero MJ, Johnson MO, et al. Adapting a motivational interviewing intervention to improve HIV prevention among young, black, sexual minority men in Alabama: protocol for the development of the kings digital health intervention. JMIR Res Protoc. 2022;11(7):e36655. [FREE Full text] [CrossRef] [Medline]
  10. Guidelines on long-acting injectable cabotegravir for HIV prevention. World Health Organization. 2022. URL: https://www.who.int/publications/i/item/ [accessed 2025-01-08]
  11. Beymer MR, Holloway IW, Pulsipher C, Landovitz RJ. Current and future PrEP medications and modalities: on-demand, injectables, and topicals. Curr HIV/AIDS Rep. 2019;16(4):349-358. [FREE Full text] [CrossRef] [Medline]
  12. Taggart T, Liang Y, Pina P, Albritton T. Awareness of and willingness to use PrEP among Black and Latinx adolescents residing in higher prevalence areas in the United States. PLoS One. 2020;15(7):e0234821. [FREE Full text] [CrossRef] [Medline]
  13. Valente PK, Bauermeister JA, Lin WY, Da Silva DT, Hightow-Weidman L, Drab R, et al. Preferences across pre-exposure prophylaxis modalities among young men who have sex with men in the United States: a latent class analysis study. AIDS Patient Care STDS. 2022;36(11):431-442. [FREE Full text] [CrossRef] [Medline]
  14. Biello KB, Valente PK, da Silva DT, Lin W, Drab R, Hightow-Weidman L, et al. Who prefers what? Correlates of preferences for next-generation HIV prevention products among a national U.S. sample of young men who have sex with men. J Int AIDS Soc. 2023;26 Suppl 2(Suppl 2):e26096. [FREE Full text] [CrossRef] [Medline]
  15. Outlaw AY, Phillips 2nd G, Hightow-Weidman LB, Fields SD, Hidalgo J, Halpern-Felsher B, et al. Age of MSM sexual debut and risk factors: results from a multisite study of racial/ethnic minority YMSM living with HIV. AIDS Patient Care STDS. 2011;25 Suppl 1:S23-S29. [CrossRef] [Medline]
  16. Budhwani H, Mills L, Marefka LEB, Eady S, Nghiem VT, Simpson T. Preliminary study on HIV status disclosure to perinatal infected children: retrospective analysis of administrative records from a pediatric HIV clinic in the southern United States. BMC Res Notes. 2020;13(1):253. [FREE Full text] [CrossRef] [Medline]
  17. Stringer KL, Turan B, McCormick L, Durojaiye M, Nyblade L, Kempf MC, et al. HIV-related stigma among healthcare providers in the deep south. AIDS Behav. 2016;20(1):115-125. [FREE Full text] [CrossRef] [Medline]
  18. Hill SV, Johnson J, Rahman F, Dauria EF, Mugavero M, Matthews LT, et al. Exploring adults as support persons for improved pre-exposure prophylaxis for HIV use among select adolescents and young adults in the Deep South. PLoS One. 2021;16(3):e0248858. [FREE Full text] [CrossRef] [Medline]
  19. Pratt MC, Hill SV, Elopre L, Simpson T, Lanzi R, Matthews LT. PrEP prescription for black adolescent girls and young women in Alabama: findings from a survey of healthcare providers. J Int Assoc Provid AIDS Care. 2022;21:23259582221127936. [FREE Full text] [CrossRef] [Medline]
  20. Hightow-Weidman LB, Muessig KE, Bauermeister J, Zhang C, LeGrand S. Youth, technology, and HIV: recent advances and future directions. Curr HIV/AIDS Rep. 2015;12(4):500-515. [FREE Full text] [CrossRef] [Medline]
  21. Allison S, Bauermeister JA, Bull S, Lightfoot M, Mustanski B, Shegog R, et al. The intersection of youth, technology, and new media with sexual health: moving the research agenda forward. J Adolesc Health. 2012;51(3):207-212. [FREE Full text] [CrossRef] [Medline]
  22. Pingel ES, Thomas L, Harmell C, Bauermeister J. Creating comprehensive, youth centered, culturally appropriate sex education: what do young gay, bisexual and questioning men want? Sex Res Social Policy. 2013;10(4):293-301. [FREE Full text] [CrossRef] [Medline]
  23. Hosek SG, Rudy B, Landovitz R, Kapogiannis B, Siberry G, Rutledge B, et al. An HIV preexposure prophylaxis demonstration project and safety study for young MSM. J Acquir Immune Defic Syndr. 2017;74(1):21-29. [FREE Full text] [CrossRef] [Medline]
  24. What is ‘ending the HIV epidemic: a plan for America’? HIV.gov. URL: https://www.hiv.gov/ending-hiv-epidemic [accessed 2025-01-08]
  25. Owens C, Moran K, Mongrella M, Moskowitz DA, Mustanski B, Macapagal K. "It's very inconvenient for me": a mixed-method study assessing barriers and facilitators of adolescent sexual minority males attending PrEP follow-up appointments. AIDS Behav. 2022;26(1):21-34. [FREE Full text] [CrossRef] [Medline]
  26. Mocorro I, Sandhu PJ, Rowniak S, Leonard A. Initiation of HIV pre-exposure prophylaxis in adolescents and young adults: barriers and opportunities. J Am Assoc Nurse Pract. 2020;33(9):700-708. [CrossRef] [Medline]
  27. Stocks JB, Calvetti S, Rosso MT, Slay L, Kipke M, Puentes M, et al. Evaluating the feasibility and acceptability of a digital pre-exposure prophylaxis navigation and activation intervention for racially and ethnically diverse sexual and gender minority youth (PrEPresent): protocol for a pilot randomized controlled trial. JMIR Res Protoc. 2023;12:e50866. [FREE Full text] [CrossRef] [Medline]
  28. Cantos VD, Hagen K, Duarte AP, Escobar C, Batina I, Orozco H, et al. Development of a mobile app to increase the uptake of HIV pre-exposure prophylaxis among latino sexual minority men: qualitative needs assessment. JMIR Form Res. 2023;7:e43844. [FREE Full text] [CrossRef] [Medline]
  29. Zapata JP, Hirshfield S, Nelson K, Horvath K, John SA. Preferred characteristics for mHealth interventions among young sexual minoritized men to support HIV testing and PrEP decision-making: focus group study. JMIR Form Res. 2023;7:e51103. [FREE Full text] [CrossRef] [Medline]
  30. Budhwani H, Kiszla BM, Hightow-Weidman LB. Adapting digital health interventions for the evolving HIV landscape: examples to support prevention and treatment research. Curr Opin HIV AIDS. 2022;17(2):112-118. [FREE Full text] [CrossRef] [Medline]
  31. Green L. Confident, capable and world changing: teenagers and digital citizenship. Commun Res Pract. 2020;6(1):6-19. [CrossRef]
  32. Fifolt M, Gurley DK, White D. Demonstrating resilience in the face of adversity: an embedded phenomenological case study of the Magic City Acceptance Academy. J LGBT Youth. 2024;21(4):699-715. [FREE Full text] [CrossRef]
  33. Fifolt M, Gurley K, White DM. How the magic city acceptance academy‘s school environment creates conditions to promote community. J Educ Stud Placed Risk. 2024. [FREE Full text] [CrossRef]
  34. Kay ES, Musgrove K. From HIV to Coronavirus: AIDS service organizations adaptative responses to COVID-19, Birmingham, Alabama. AIDS Behav. 2020;24(9):2461-2462. [FREE Full text] [CrossRef] [Medline]
  35. Eysenbach G. Correction: improving the quality of web surveys: the checklist for reporting results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2012;14(1):e8. [FREE Full text] [CrossRef]
  36. Sexual risk behavior - male. PhenX Toolkit. URL: https://www.phenxtoolkit.org/protocols/view/101701 [accessed 2024-05-30]
  37. Pre-exposure prophylaxis (PrEP) screening for substantial risk and eligibility. Amazon AWS. 2019. URL: https:/​/icap-aws-bucket.​s3.amazonaws.com/​icapcolumbiau/​wp-content/​uploads/​1_PrEP_Screening_for_Substantial_Risk_and_Eligibility_final_3.​4.​2019.​pdf [accessed 2025-01-08]
  38. Self-report of human immunodeficiency virus (HIV) testing. PhenX Toolkit. URL: https://www.phenxtoolkit.org/protocols/view/570201 [accessed 2024-05-30]
  39. Carey MP, Schroder KEE. Development and psychometric evaluation of the brief HIV Knowledge Questionnaire. AIDS Educ Prev. 2002;14(2):172-182. [FREE Full text] [CrossRef] [Medline]
  40. Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav. 2007;11(4):557-574. [FREE Full text] [CrossRef] [Medline]
  41. Mueses-Marín HF, Alvarado-Llano B, Torres-Isasiga J, Camargo-Plazas P, Bolívar-Rocha MC, Galindo-Orrego X, et al. Scales to assess knowledge, motivation, and self-efficacy for HIV PrEP in Colombian MSM: PrEP-COL study. AIDS Res Treat. 2021;2021:4789971. [FREE Full text] [CrossRef] [Medline]
  42. Herek GM, Gillis JR, Cogan JC. Internalized stigma among sexual minority adults: insights from a social psychological perspective. J Couns Psychol. 2009;56(1):32-43. [CrossRef]
  43. Williams DR, Yu Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: socio-economic status, stress and discrimination. J Health Psychol. 1997;2(3):335-351. [FREE Full text] [CrossRef] [Medline]
  44. Kroenke K, Strine TW, Spitzer RL, Williams JBW, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009;114(1-3):163-173. [CrossRef] [Medline]
  45. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705-714. [CrossRef] [Medline]
  46. Schwarzer R, Jerusalem M. Generalized self-efficacy scale. In: Measures in Health Psychology: A User’s Portfolio. Causal and Control Beliefs. Windsor, England. NFER-NELSON; 1995:35-37.
  47. Tavakol M, Dennick R. Making sense of Cronbach's alpha. Int J Med Educ. 2011;2:53-55. [FREE Full text] [CrossRef] [Medline]
  48. Obeagu EI, Obeagu GU, Ede MO, Odo EO, Buhari HA. Translation of HIV/AIDS knowledge into behavior change among secondary school adolescents in Uganda: a review. Medicine (Baltimore). 2023;102(49):e36599. [CrossRef] [Medline]
  49. Chory A, Gillette E, Callen G, Wachira J, Sam-Agudu NA, Bond K, et al. Gender differences in HIV knowledge among adolescents and young people in low-and middle-income countries: a systematic review. Front Reprod Health. 2023;5:1154395. [FREE Full text] [CrossRef] [Medline]
  50. Badru T, Mwaisaka J, Khamofu H, Agbakwuru C, Adedokun O, Pandey SR, et al. HIV comprehensive knowledge and prevalence among young adolescents in Nigeria: evidence from Akwa Ibom AIDS indicator survey, 2017. BMC Public Health. 2020;20(1):45. [FREE Full text] [CrossRef] [Medline]


IRB: institutional review board
LGBTQIA+: lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual
MSM: men who have sex with men
PrEP: pre-exposure prophylaxis
STI: sexually transmitted infection


Edited by A Schwartz; submitted 10.06.24; peer-reviewed by K Kidd, N Gleason; comments to author 09.10.24; revised version received 17.10.24; accepted 18.12.24; published 29.01.25.

Copyright

©Henna Budhwani, Ibrahim Yigit, Josh Bruce, Christyenne Lily Bond, Andrea Johnson. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 29.01.2025.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.