Findings:
The aim of this randomized trial of the effectiveness of a group, counselor-delivered, evidence-based intervention, named “Getting Off,” adapted into an individualized, self-directed computerized mobile app, was to reduce amphetamine use, sexual risk behaviors, and advance participants along the HIV prevention and care continua. Subjects were sexual minority men (SMM) who had used methamphetamine at least once in the past 365 days, and were randomized into one of two conditions:1) immediate delivery (ID) of the Getting Off app; or 2) delayed delivery (DD) of the same app. Participants were given 30 days to complete the 24 sessions. Findings were as follows: Compared to the DD condition, participants in the ID group had significantly fewer days of injection methamphetamine use, but not methamphetamine use by all routes, and lower likelihood of having either condomless anal intercourse (CAI), or CAI while high on methamphetamine, at 1-month assessment. When compared to baseline measures, by the 9-month follow-up time period, both ID and DD conditions showed significantly less frequent methamphetamine use by both all and injection routes, as well as less CAI and CAI while high on methamphetamine. Interestingly, compared to the DD condition, participants in the ID condition demonstrated greater total reductions in past-30-day methamphetamine use, and more rapid reductions in number of days injecting methamphetamine. These finding are consistent with previous research demonstrating that the most significant reductions in substance use occur in the first few weeks following treatment and that response to delayed treatment is more modest in comparison.           

Strengths and limitations:
The sample represented a diverse population of SMM and there were no significant differences in participant characteristics, methamphetamine use and sexual risk behaviors. Well over half of the sample were either African American/Black or Latine, populations disproportionately represented among people living with HIV. Over half the sample reported annual income at $15,000 and under. Although a strength, this characteristic may also limit findings since financial need may introduce self-selection bias. A monetary incentive was offered for completing all the administrative procedures and for each follow-up assessment. In addition, the large majority of the sample either had no insurance or used non-commercial insurance, and 30% reported unstable housing. The average DSM-5 score for methamphetamine use disorder was severe. This high level of use is significant since eligibility required use of methamphetamine only once in the past year. The use of a self-report measure for frequency of methamphetamine use introduces social desirability bias and problems with recall, although assessments were completed by a computer assisted platform. Findings may not be generalizable beyond the greater Los Angeles metropolitan area from which the participants were recruited. The “Getting Off” app was designed using local cultural references which may not translate well to other settings.                

Relevance:
Methamphetamine use disproportionately affects SMM, is associated with psychosocial and medical complications that can be devastating and is a major driver of the HIV epidemic among SMM. Approximately 1 in 3 new infections among SMM, and serious disruptions along the HIV prevention and care continua can be linked to methamphetamine use. Poor HIV medication adherence and consequent immune system dysregulation and unsuppressed viral load greatly increase risk of transmission. Unlike for alcohol, tobacco, and opioids, there are no effective medications for treatment of methamphetamine use. To date, behavioral treatment interventions have shown the most promise. Technology-facilitated treatment delivery offers significant advantages. SMM face many barriers to treatment access and retention: stigma, medical mistrust, and structural concerns such as housing and job instability. Smartphone apps are an ideal method for connecting with this population. Apps are already widely used for socializing, selecting sexual partners, procuring drugs and seeking sexual health information. Randomized trials of mobile health interventions have demonstrated notably high retention rates. The “Getting off” app can be used in various settings including outpatient clinic, residential facilities, and while on a waiting list for in-person treatment. The app may also serve as a trial treatment entry point for SMM in the precontemplative or contemplative phase of change. Lastly, these findings suggest that adaptation of other counselor-delivered behavioral interventions into app-based treatments may be feasible for other hard-to-reach populations. Future research should test the effects of expanded access to the app beyond the 30 days permitted in this trial.