AIDS and Behavior https://doi.org/10.1007/s10461-023-04165-2 ORIGINAL PAPER Response Rate, Acceptability and Effectiveness of an Intervention Offering HIV/STI Testing Via Apps Among Gay, Bisexual, and Other Men Who Have Sex With Men in Barcelona, Spain, from 2016 to 2020 Miguel Alarcón Gutiérrez1,2,3 · David Palma Díaz2,4,5 · Mireia Alberny Iglesias6 · Rafael Ruiz Riera7 · Rafael Guayta-Escolies8 · Patricia García de Olalla2,5,9 · Cristina Rius Gibert2,5,9 Accepted: 7 September 2023 © The Author(s) 2023 Abstract We evaluated the response rate, acceptability, and effectiveness of a preventive programme offering rapid HIV and other STI testing, as well as sexual counselling to gay, bisexual, and other men who have sex with men (GBMSM) via dating apps over a 4-year period. The programme was carried out in 9 out of the 10 districts in the city of Barcelona, Spain. The response rate was defined as the proportion of people responding to the message sent, acceptability as the propor- tion of those responding favourably, and effectiveness as the proportion of users requesting a test. We performed uni- variate analysis and multivariate logistic regression in relation with the response rate, acceptability and effectiveness. A total of 5,254 messages were send to different users. The response rate was 33.1% (n = 1,741), acceptability was 86.2% (n = 1,500), and effectiveness was 10.1% (n = 532). The factors associated with user response were recent connection to the app (aOR = 1.85; CI:1.39–2.46) and the presence of a profile photograph (aOR = 1.34; CI:1.11–1.64). Acceptability was associated with recent connection to the app (aOR = 1.98; CI:1.09–3.58). Effectiveness was associated with lower reported age (aOR = 0.98; CI:0.97–0.99), contact before 14:00 (aOR = 2.47; CI: 1.77–3.46), and recent connection to the app (aOR = 4.89; CI:1.98–12.08). Effectiveness was also greater in districts that were more disadvantaged or had fewer sexual health services. This study demonstrates that the use of these apps is an acceptable and effective method of pre- vention and sexual health promotion in GBMSM in this setting and identifies the associated factors that could guide such interventions. Keywords Men who have sex with men · HIV testing · STI testing · Health promotion · Dating apps 5 Miguel Alarcón Gutiérrez Centro de Investigación Biomédica en Red de Epidemiología migo.miguel@gmail.com y Salud Pública (CIBERESP), Madrid, Spain 6 1 Health Department, Catalan Institute of Health, Generalitat Department of Paediatrics, Obstetrics and Gynaecology and de Catalunya, Barcelona, Spain Preventive Medicine, Universitat Autònoma de Barcelona, 7 Barcelona, Spain Direcció Estratègica d’Atenció Primària i Comunitària, 2 Health Department, Generalitat de Catalunya, Barcelona, Epidemiology service, Agència de Salut Pública de Spain Barcelona, Barcelona, Spain 8 3 Projects and Research Directorate, Council of Pharmacists Centre of Epidemiological Studies of HIV/AIDS and STI of Colleges of Catalonia, Barcelona, Spain Catalonia (CEEISCAT), Health Department, Generalitat de 9 Catalunya, Badalona, Spain Institut de Recerca de l’Hospital de la Santa Creu i Sant Pau, 4 Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain Department of International Health, Care and Public Health Research Institute – CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands 13 AIDS and Behavior Introduction efficacy of this strategy in a more socially and geographi- cally diverse group of GBMSM in the city. The aim of this In the last 40 years, gay, bisexual, and other men who have study was to assess the response rate, acceptability, and sex with men (GBMSM) have been found to have multifac- effectiveness of a programme offering rapid HIV, syphilis, torial vulnerability, increasing their morbidity and mortality and hepatitis C testing via apps for GBMSM in different due to HIV and the incidence of other sexually transmit- areas of the city of Barcelona, Spain, over a 4-year period. ted infections (STI) [1–4]. Consequently, The World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) have characterised this group as Methods a collective that benefits from specific risk-reduction inter- ventions [5]. Intervention and Variables GBMSM have been pioneers in the use of new tech- nologies for sexual purposes [6]. Among them, geosocial We conducted a descriptive study in the city of Barcelona networking applications (GSN apps, or dating apps) for between January 2016 and February 2020. GBMSM were smartphones are widely used in this population [7, 8]. GSN contacted through the Grindr, Wapo, and PlanetRomeo apps. apps use the global positioning system (GPS) to facilitate The research team sent messages through the profiles of personal encounters according to geographical proximity. users who were connected between 9:00 and 19:00 h, from Several researchers have described the use of mobile Monday to Friday. The message, in the form of an image technologies to facilitate access to prevention and sexual (Fig. 1), offered free and confidential rapid HIV, syphilis, health promotion messages among key populations, such as and hepatitis testing. Users expressing a willingness to be GBMSM (mHealth) [9]. Among these, the use of GSN apps tested could choose to attend the testing site immediately or has been reported to be an effective way to reach these pop- could schedule an appointment for another time. The pro- ulations, with good acceptance and effectiveness in spread- gramme also offered online counselling on sexual health, ing preventive messages, offering screening services, and covering mainly issues of sexual risk practices and informa- acting as a link to the health system [9–12]. tion on the risk of drug use. The massive use of GSN apps has been reported to be a To increase the coverage area, the intervention was con- factor associated with the rapid spread of STIs, including ducted in primary care centres in 9 of the 10 districts of HIV infection [11]. The prevalence of risky sexual behav- the city (Fig. 1). For each contact made, we recorded self- iours has been reported to be higher among GBMSM using reported age in years, the time of the intervention (before these apps than among GBMSM not using these apps. These 14 h, between 14 and 17 h, and after 17 h), the time of the behaviours include unprotected sex, drug use to maintain user’s last connection (as the apps show this information sexual relations (chemsex), and having multiple sexual on users’ profiles in different timings: we considered in partners [11, 13–16]. Explanations for this increased risk the last hour or more than 1 h ago), the presence of a user include the desired gratifications motivating these encoun- photograph (with or without a photo), the app used (Grindr, ters (physical, social, psychosocial) and the proximity and Planet Romeo, Wapo) and the district of the centre send- immediacy of encounters arranged through these apps [17, ing the message (Ciudat vella, Eixample, Sants-Montjuic, 18]. Prior research has reported that attraction to online Sarrià-Sant Gervasi, Gràcia, Horta-Guinardó, Nou Barris, encounters can be particularly enhanced among GBMSM Sant Andreu, Sant Martí). The socioeconomic conditions of due to the safety and anonymity of this setting versus greater the various districts varied and we distinguished between discrimination and stigma that may be present in offline or high- or very high-income areas (Sarrià-Sant Gervasi, Les public settings [11]. Corts), medium-income areas (Ciutat vella, Eixample, In 2016, our research team conducted a 3-month pilot Sants-Montjuic, Gràcia) and low-income areas (Horta-Gui- intervention to determine the response rate and acceptabil- nardó, Nou Barris, Sant Andreu, Sant Martí) [20]. The rapid ity of a programme offering HIV, syphilis, and hepatitis C tests used were Determine™ HIV-1/2 for HIV, Determine™ testing through GSN apps for GBMSM in the city of Barce- Syphilis TP for syphilis and OraQuick™ HCV for hepatitis lona, Spain. The intervention was performed through com- C. Users who tested positive were referred for confirmation, mercially available apps, such as Grindr, Wapo and Planet treatment and follow-up. In addition, we registered if the Romeo, and showed a high response rate and acceptance researcher’s profile was blocked by the app administrator. [12]. However, the pilot intervention was conducted in a Profile blocking is usually due to complaints by users of very small geographical area of the city, thus failing to cap- the app. ture area- and housing-related social inequalities [19]. Find- While the programme was ongoing, we also designed ings in the pilot programme led to new questions about the a protocol for app-based interventions (Appendix 1). The 13 AIDS and Behavior Fig. 1 Sent message to app users and map of the city of Barcelona with intervention points among different districts face-to-face intervention included a pre-test counselling ses- am interested, how can I do it?”. Negative responses exam- sion covering sexual risk situations that evaluated risk and ples are: “Why are you telling me this? Do I look like an could lead to the recommendation of post-exposure prophy- irresponsible person?”. Indifferent responses were those we laxis (PEP), direct viral load or repeat testing after window were unable to categorise as positive or negative, such as: period, based on international recommendations [21–23]. In “Hello”, “Who are you?”. Effectiveness was defined as the addition, STI vaccination was carried out according to local proportion of users who underwent testing among the users guidelines (hepatitis A and B, and human papilloma virus). whom the message was sent. To identify users when they responded, the type of response, intention to get tested and Intervention in Retail Pharmacies attending the testing site, we created an anonymous record with a unique identifier for each contacted user. A programme using a similar method was performed in retail Calculations, and subsequent analysis, were performed pharmacies in different locations of the city, where a profile separately among the interventions conducted in retail phar- was created in Grindr® and messages were sent to nearby macies and elsewhere since the method of contact and set- users. To do this, pharmacy staff were trained and were ting differed. given an abbreviated protocol (Appendix 2). The follow- ing data were recorded: number of days the programme was Statistical Analysis active, the number of messages sent, number of responses obtained, the number of people visiting the pharmacy to To achieve an acceptability of 70%—as estimated by previ- request a test, and the number of times the pharmacy pro- ous studies reporting this measure, [24, 25]—the required file was blocked by the app administrator. If the profile was number of responses needed to obtain a 95% confidence blocked three times, the intervention was discontinued. level and a precision of 0.05 units would be 1259. The sample size was calculated using the GRANMO calculation Outcome Definitions program, version 7.12. A descriptive univariate analysis was conducted and The response rate was defined as the proportion of users main variables were reported for response rate, acceptability responding to the message sent, among all the users who and effectiveness. Proportions and 95% confidence intervals were sent a message. Acceptability was defined as the (CI) were calculated for categorical variables and medians proportion of users responding favourably, among users and interquartile ranges (IQR) were calculated for quan- responding to the message. Favourable responses were titative variables. A bivariate analysis was performed for defined as those considered “positive”, or which gener- response rate, acceptability and effectiveness, using the chi- ated some type of engagement, versus rejection, indifferent square test for categorical variables and the Mann-Whitney response, or non-response. Examples of positive responses U test for quantitative variables. Statistical significance was are (translated to English): “Thank you! All those (tests) I set at < 0.05. have made it two weeks ago, but I’ll take it into account”, “I 13 AIDS and Behavior To determine the factors associated, a multivariate analy- recently undergone testing and were consequently unsuit- sis was performed through logistic regression, and the final able for the testing intervention. A total of 532 users model was selected according to Akaike information criteria attended a centre to undergo a test, representing an effec- (AIC) among all possible models [26]. For the model selec- tiveness of 10.1% (n = 532/5,254). In the 532 tested users, tion, we included the variables that had a significance of 499 HIV tests, 403 syphilis tests, and 393 hepatitis C tests > 95% in the bivariate analysis, age due to its epidemiologi- were performed. Among these tests, HIV infection was con- cal relevance, and district due to the study objectives. The firmed in 1.8% (n = 9/499), syphilis in 2.2% (n = 9/403) and data are expressed as adjusted odds ratios (aOR) and CI. hepatitis C in 0.3% (n = 1/393). In all, 3.2% (n = 169/5,254) The analysis was performed with the Stata 15® programme. of users responded that they would like to resolve doubts about their sexual health through the app. A flowchart of the intervention with the main outcomes is shown in Fig. 2. Results The researcher’s profile was blocked once in Grindr® app but was restored after contact was made with the app A message was sent to 5,254 users, and responses were administrator. obtained from 33.1% (n = 1,741). Of these, 86.2% The main characteristics of the intervention are shown (n = 1,500) were favourable. Among these users, 415 had in Table 1. Nearly half (46.2%) of the messages were sent Fig. 2 Flow chart of the main out- comes of an HIV/STI prevention programme through geolocation apps in Barcelona, Spain. *Indif- ferent answers were those did not qualify as positive or negative 13 AIDS and Behavior between 14:00 and 17:00. The most widely used app was presence of a profile photograph (aOR = 1.34; CI:1.11– Grindr (52.2%) and the district showing the highest number 1.64), and the intervention being conducted in the districts of responses was Gràcia (25.9%). of Ciutat Vella (aOR = 2.12; CI: 1.64–2.74), Sant Ger- Among the persons contacted, the median age given in vasi (aOR = 1.68; CI: 1.10–2.59), Gràcia (aOR = 2.50; CI: user profiles was 32 (IQR: 26–38) years, and 91% were 1.93–3.24), Horta-Guinardó (aOR = 1.88; CI: 1.39–2.54), recently connected when the message was sent (at the same Nou Barris (aOR = 1.74; CI: 1.10–2.73), and Sant Andreu time or during the last hour). (aOR = 2.22; CI:1.40–3.51). Response to the Intervention Acceptability of the Intervention In the bivariate analysis, the factors associated with a After bivariate analysis, the only factor associated with greater response to the intervention were more recent user greater acceptability was the time of the user’s most recent connection (33.5% of responses; p < 0.001), the presence of online connection (86.2% of acceptability; p = 0.030). No a photograph in the user profile (33.4%; p < 0.001), and the significant differences were found among the remaining districts where the intervention was performed (p < 0.001), factors (Table 1). After multivariate adjustment, greater with effectiveness being highest in Gràcia (38.5%), Nou acceptability was significantly associated with recent user Barris (37.6%), Sant Andreu (37.1%), and Ciutat Vella connection to the app (aOR = 1.98; CI:1.09–3.58) and (34.9%) (Table 1). In the multivariate analysis, response performance of the intervention in the district of Gràcia was significantly associated with recent online connection (aOR = 0.38; CI:0.16–0.91). to the app among users (aOR = 1.85; CI:1.39–2.46), the Effectiveness of the Intervention Table 1 Univariate analysis of the main variables of the prevention programme through geolocation apps in Barcelona, Spain After bivariate analysis, greater effectiveness was associ- Variable N % ated with younger age reported in users’ profiles (median Total sent messages 5,254 30 years old; p = 0.003); the time when the message was Time of the intervention sent, before 14:00 (12.3% effectiveness) or after 17:00 < 14:00 1,374 26.1% (9.5%) (p < 0.001); the time of the user’s most recent con- 14:00 to 17:00 2,427 46.2% nection (6.9%; p = 0.002); and the district where the inter- 17:00 or later 1,453 27.7% vention was performed (p < 0.001), with effectiveness Application used being highest in Sant Martí (19.2%), Gràcia (18.0%) and Planet Romeo 765 14.6% Grindr 2,745 52.2% Sant Andreu (14.6%) and lowest in Ciutat Vella (3.4%) Wapo 1,666 31.7% (Table 1). After multivariate adjustment, greater effec- Scruff 51 1.0% tiveness was significantly associated with younger age Missing 27 0.5% (aOR = 0.98; CI:0.97–0.99), sending of messages before District of the intervention 14:00 (aOR = 2.47; CI: 1.77–3.46), recent user connection Ciudat vella 1,591 30.3% to the app (aOR = 4.89; CI:1.98–12.08) and performance Eixample 510 9.7% of the intervention in Gràcia (aOR = 3.18; CI:2.07–5.42), Sants-Montjuic 580 11.0% Sant Andreu (aOR = 5.08; CI:2.59–11.17), and Sant Martí Sant Gervasi 172 3.3% (aOR = 5.83; CI:3.09–12.42). Gracia 1,361 25.9% Horta-Guinardó 559 10.6% Retail Pharmacies Nou Barris 202 3.9% Sant Andreu 140 2.7% Sant Martí 134 2.6% Of 37 pharmacies available in the city of Barcelona, the Age (Median [IQR]) 32 [26– intervention was conducted in 7, and complete data was pro- 38] vided by 3. In the latter, the intervention lasted for a mean of Time of connection 35 days, 434 messages were sent, and the response rate was Connected in the last hour 4,782 91.0% 18.2% (n = 79). Finally, 12 people were tested, represent- More than 1 h ago 332 6.3% ing an effectiveness of 2.76% (n = 12/434). In the remaining Missing 140 2.7% 4 pharmacies, the profile was blocked by the app adminis- Profile photograph trators and no interventions could be made. Consequently, With photo 785 14.9% interventions in retail pharmacies were cancelled due to the Without photo 4,438 84.5% lack of feasibility. Missing 31 0.6% 13 13 Table 2 Factors associated with the level of response, acceptability, and effectiveness of the prevention programme through geolocation apps in Barcelona, Spain. Bivariate and multivariate analyses Response Acceptability Effectiveness Variables Yes No p-valuea aORb Yes No p-valuea aORb Yes No p-valuea aORb Age (median[IQR]) 32 [27–39] 32 [26–39] 0.312 1.00 [0.99–1.01] 32 [27–39] 31 [26–40] 0.373 1.01 [0.99–1.03] 30 [25–35] 32 [26–39] 0.003 0.98 [0.97–0.99] Time of intervention < 14:00 31.40% 68.60% 0.293 87.70% 12.20% 0.433 12.30% 87.70% < 0.001 2.47 [1.77–3.46] 14:00 to 17:00 33.60% 66.40% 86.20% 13.80% 6.10% 93.90% 1 17:00 or later 33.90% 66.10% 84.80% 15.20% 9.50% 90.50% 1.12 [0.80–1.55] Time of connection Connected in the last hour 33.50% 66.50% < 0.001 1.87 [1.41–2.48] 86.20% 13.80% 0.030 1.98 [1.09–3.58] 6.90% 93.10% 0.002 4.89 [1.98–12.08] More than 1 h ago 24.10% 75.90% 1 77.50% 22.50% 2.50% 97.50% Profile photograph With photo 34.40% 65.60% < 0.001 1.34 [1.11–1.64] 86.30% 13.70% 0.470 7.10% 92.90% 0.247 Without photo 26.20% 73.80% 1 84.50% 15.50% 8.30% 91.70% District of the intervention Ciutat Vella 34.90% 65.10% < 0.001 2.12 [1.64–2.74] 85.60% 14.40% 0.071 0.45 [0.19–1.08] 3.40% 96.60% < 0.001 0.76 [0.46–1.37] Eixample 24.90% 75.10% 1.23 [0.89–1.70] 89.80% 10.20% 0.65 [0.22–1.91] 4.20% 95.80% 0.93 [0.47–2.01] Sants-Montjuic 23.10% 76.90% 1 92.50% 7.50% 1 5.60% 94.40% 1 Sant Gervasi 29.70% 70.40% 1.68 [1.10–2.59] 92.20% 7.80% 0.73 [0.22–1.91] 8.40% 91.60% 1.56 [0.64–4.33] Gràcia 38.50% 61.50% 2.50 [1.93–3.24] 83.00% 17.00% 0.38 [0.16–0.91] 18.00% 82.00% 3.18 [2.07–5.42] Horta-Guinardó 33.10% 66.90% 1.88 [1.39–2.54] 84.90% 15.10% 0.43 [0.16–1.13] 4.90% 95.10% 1.36 [0.73–2.83] Nou Barris 37.60% 62.40% 1.74 [1.10–2.73] 88.20% 11.80% 0.39 [0.12–1.35] 6.60% 93.40% 1.83 [0.79–4.81] Sant Andreu 37.10% 62.90% 2.22 [1.40–3.51] 92.30% 7.70% 0.91 [0.21–3.95] 14.60% 85.40% 5.08 [2.59–11.17] Sant Martí 27.60% 72.40% 1.58 [0.97–2.56] 89.20% 10.80% 0.69 [0.16–3.05] 19.20% 80.80% 5.83 [3.09–12.42] a = U Mann-Whitney test for numerical variables and Chi-square test for categorical variables b = Adjusted Odd Ratios IQR = Interquartile Range AIDS and Behavior AIDS and Behavior Discussion participate in studies in exchange for remuneration, such as the rate obtained in the study by Holloway et al., which was This study demonstrates that the preventive intervention 12.8% [24]. Due to the geographical scope of these apps and performed through GSN apps obtained a high response rate lower concentration of GBMSM users, these interventions and good acceptability and effectiveness among users con- could be even more effective in rural areas, where a larger tacted over a 4-year period. Moreover, this is the first study territory could be covered. of this kind of intervention to determine the factors associ- ated with specific indicators, as response rate, acceptability Retail Pharmacies and effectiveness, providing essential knowledge for the design of future interventions. The intervention carried out by retail pharmacies obtained a The high response rate shows the viability of implement- low response rate and effectiveness. Moreover, because of ing programmes using these apps as a sexual health strategy continual blocking by app administrators, this type of inter- among their users in this setting. Previous studies similar to vention is not feasible in this context. These results could be our own have reported user response rates of up to 26.5%, influenced by two factors. First, the presence of the phar- but in the context of study recruitment [27]. Strategies macy in the app could be seen as a threat to privacy among measuring response rates often occur within the context of users embarrassed to ask for a test in person or who felt developing new platforms, unlike this intervention, which that the staff might be judgmental. Second, the pharmacy created personal profiles in already existing apps [8, 28, could be perceived as a for-profit organization attempting 29]. In this regard, we believe that these profiles facilitate to sell a product, thus increasing income by selling tests, an enhanced response as they are created in spaces already even though the price of testing was lower than usual in known to users and do not require them to perform actions pharmacies. different from their daily acts or to use device storage. On the other hand, because these types of intervention are new, Factors Associated with Response Rate, they may generate distrust among users who might be reluc- Acceptability and Effectiveness tant to reveal confidential information on their sexual health. These factors, the already known spaces and distrust of new The effectiveness of the intervention was associated with elements, may create a disposition in users, and these match younger user age. This finding could be related to familiar- to the concepts of control and subjective norms described ity or normalization of the use of apps for multiple tasks within the theory of planned behaviour, which describes an in the youngest populations [8, 34]. However, we believe individual´s intention to participate in a behaviour in a spe- that, with the greater incorporation of technologies in all age cific time and place [30]. ranges, this variable may become less important in future. The high acceptability of unsolicited messages in a set- Effectiveness was also associated with the timing of ting strongly linked to sexuality suggests the need for users message sending and was higher with messages sent before to have a reference point for sexual health in these contexts 14:00. This could be a local factor that could differ in other [31, 32]. Although spaces for information on sexual health contexts. Therefore, it would be advisable to adapt the tim- are provided in some apps, such as Grindr, there are no ing of message sending in any future programmes when they options for cybereducation, or online sexual health coun- are underway. That means it is necessary to adapt preventive selling delivered by trained peers or health care workers programs to specific contextual characteristics, conducting in commercial GSN apps. Other studies exploring recep- simultaneous evaluation and implementation in order to tiveness to possible interventions among app users have improve outcomes, as has been reported previously [35]. reported an effectiveness of up to 70% [24]. Therefore, One of the factors most strongly associated with the smartphone app-based prevention has been described in this response rate, acceptability and effectiveness was recent use context and could be replicated in other contexts, such as of apps by users. Given that most testing in this intervention other cities or rural areas, since the characteristics of users occurred within 48 h of message sending, a possible expla- of these apps have been reported to be similar in other parts nation for this association could be the emphasis on imme- of the world [8, 33]. diacy within GSN apps. These apps are typically used by The effectiveness achieved in this study is a positive seeking instant encounters who are more likely to quickly element and suggests the possibility of replicating the pro- transition to a different location [36]. gramme in other settings. We found no similar data about Despite being a local factor, the districts where the inter- effectiveness in other programmes with these characteris- vention was conducted generate valuable information on the tics. We were only able to compare our data with those of geospatial characteristics of an app-based intervention, as some studies reporting the recruitment rate of app users to well as on the particular contexts of the territorial diversity 13 AIDS and Behavior of the city. In Barcelona, economic indicators have been intervention (between 8:00 and 19:00 h), as some app users created by districts, revealing significant inequalities [20]. connect at other times and may have different characteristics. Thus, it can be deduced that the districts with the highest GSN app-based interventions may have technical limita- response rate and greatest effectiveness, apart from the dis- tions, such as the radius of visibility or the number of users trict of Gràcia, have a lower socioeconomic level and fewer who can be reached, as well as the limitations related to available services offering testing and prevention targeting acceptability among users. Their use poses ethical dilemmas vulnerable populations [37]. This indicates that this type of related to the mechanisms for obtaining data by users due to intervention is even more useful in disadvantaged areas and the absence of consent in app-based interventions. One of those with less access to sexual health services, as may be the limitations specific to using a virtual setting is the inabil- the case in rural areas where this type of intervention has ity to guarantee the confidentiality of the data obtained, been reported to be acceptable to GBMSM [33]. The dis- which is owned by a private company [40]. Likewise, user trict of Gràcia, which has a higher socioeconomic level and recruitment should encompass individual variability within greater availability of STI screening services, had a higher the GBMSM collective, which could be reflected in the response rate and greater effectiveness. This finding may be various platforms. This variety of apps is related to the dis- due to its over-representation in the given that most of the tinct goals among the users of each app and their different messages were sent from our centre in this district. In addi- sociodemographic characteristics, generating differences in tion, among the centers included in this study, the center in the response rate, acceptance and effectiveness of interven- Gracia was that which remained operational for the longest tions [41]. time within the study period, making it easily recognizable Among the strengths of the study is the standardised use of to nearby users. indicators, as response rate, acceptability and effectiveness, Moreover, this intervention was able to provide preven- over a prolonged period, allowing greater representativeness tive services and sexual health counselling to a substantial of the local reality. The geographical representativeness of number of persons through the in-app chat feature. This the city and the large number of users contacted enhanced activity, previously described as “reaching out online”, has the ability of this study to analyse the topic investigated. been shown to be effective as an alternative to peer counsel- Moreover, the app-based intervention allowed counselling ling in leisure venues and centres dedicated to sexual health and education strategies to be performed in real time, mak- counselling [38]. ing it a highly opportune tool for prevention and screening. A substantial number of attended persons tested posi- The performance of this intervention indirectly prompted tive for STI, indicating the opportuneness of this type of the creation of a space dedicated to the sexual health of key intervention in places concentrating the population at risk collectives directed by the epidemiological surveillance ser- for STI. In 2010, the ECDC defined interventions as highly vice of the city. This opportunity allowed links to be forged effective if more than 1% of persons tested had a positive with other community and healthcare services, transforming result [39]. the intervention into one of the sexual health services in the area. We believe that these interventions and secondary inte- Limitations and Strengths gration processes strengthen the response of these services to future sexual health needs. One of the limitations of this study is its cross-sectional design, which cannot demonstrate causality, only associa- Recommendations for App-Based Interventions tions. GSN app-based recruitment could fail to reach the GBMSM population not using these platforms, although Factors that could be related to the success of the interven- these individuals were not included in the aim of this study. tion are the geographical proximity of researchers and users, Moreover, offering rapid HIV and syphilis testing might the possibility of testing shortly after the first contact and not appeal to persons already diagnosed with HIV, users its rapid results, the absence of a charge for the service, its of HIV pre-exposure prophylaxis, and those with prior performance as a community service rather than as a clini- syphilis infection, which should be taken into account when cal procedure, the provision of sexual counselling, confi- evaluating future interventions. The response rates, accept- dentiality, the direct approach to users, and the personal and ability and effectiveness reported here refer to a specific friendly attitude of the intervenor. These factors have been area the city of Barcelona, where there is strong aware- identified as the preferred attributes in STI testing services ness of LGBT + sensitivities and needs, and consequently among GBMSM [42]. Moreover, elements can be drawn levels could be lower in areas with less receptiveness or from m-Health studies, such as apps designed for preven- greater homophobia. Another limitation is the timing of the tion and sexual health promotion. These have been effective 13 AIDS and Behavior Stockholm. ; 2020. Available from: https://www.ecdc.europa.eu/ with elements such as adaptation to user behaviours or the sites/default/files/documents/gonorrhoea-annual-epidemiologi- gamification of the design [43–45]. cal-report-2018.pdf. Some app-based interventions have raised ethical ques- 4. MacGregor L, Kohli M, Looker KJ, Hickson F, Weatherburn P, tions, mainly concerning confidentiality and the use of data Schmidt AJ et al. Chemsex and diagnoses of syphilis, gonorrhoea and chlamydia among men who have sex with men in the UK: a and metadata for research. These considerations should be multivariable prediction model using causal inference methodol- borne in mind before an activity of this type is conducted, ogy. Sex Transm Infect England; 2021;054629. whether for research or intervention purposes [40]. 5. Joint United Nations Programme on HIV/AIDS (UNAIDS). IN DANGER: UNAIDS Global AIDS Update 2022 [Internet]. Authors’ Contributions All authors contributed to the study conception Geneva. ; 2022. Available from: https://www.unaids.org/en/ and design. Material preparation and data collection were performed resources/documents/2022/in-danger-global-aids-update. by Miguel Alarcón Gutiérrez and David Palma Díaz. Analysis was per- 6. Grov C, Breslow AS, Newcomb ME, Rosenberger JG, Bauer- formed by Miguel Alarcón Gutiérrez. The first draft of the manuscript meister JA. Gay and bisexual men’s use of the internet: research was written by Miguel Alarcón Gutiérrez, David Palma Díaz y Patricia from the 1990s through 2013. J Sex Res. 2014;51:390–409. García de Olalla. All authors commented on previous versions of the 7. Alarcón-Gutiérrez M, Palma Díaz D, Arando Lasagabaster M, manuscript. All authors read and approved the final manuscript. De García P. Prevalence of dating app usage in Gay, Bisexual, and other men who have sex with men (GBMSM). Enf Emerg. 2022;21:73–80. Funding This study was funded by the Health Research Fund (FIS) PI 8. Castro Á, Barrada JR. Dating apps and their sociodemographic 16/02025 of the Instituto de Salud Carlos III of the Ministry of Science and psychosocial correlates: a systematic review. Int J Environ and Innovation, Government of Spain. Res Public Health. 2020;17:1–25. Open Access Funding provided by Universitat Autonoma de Barce- 9. Nelson KM, Perry NS, Horvath KJ, Smith LR. A systematic lona. review of mHealth interventions for HIV prevention and treat- ment among gay, bisexual, and other men who have sex with Declarations men. Transl Behav Med [Internet]. Oxford University Press; 2020 [cited 2022 Aug 1];10:1211. Available from: /pmc/articles/ Competing Interests The authors have no relevant financial or non- PMC7549406/. financial interests to disclose. 10. Choi EPH, Wong JYH, Fong DYT. An Emerging Risk Fac- tor of Sexual Abuse: The Use of Smartphone Dating Applica- tions: https://doi-org.are.uab.cat/101177/1079063216672168 Ethics Approval The study was approved by the research ethics [Internet]. SAGE PublicationsSage CA: Los Angeles, CA; committee of Parc de Salut Mar Nº 2016/6984/I. All data were ano- 2016 [cited 2022 May 24];30:343–66. Available from: https:// nymised. Information was treated in accordance with the data storage journals-sagepub-com.are.uab.cat/doi/10.1177/107906321667 procedures stipulated in Organic Law 3/2018 on personal data protec- 2168?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref. tion and guarantee of digital rights. org&rfr_dat=cr_pub++0pubmed. 11. Choi EPH, Chow EPF, Wan EYF, Wong WCW, Wong JYH, Fong Open Access This article is licensed under a Creative Commons DYT. The safe use of dating applications among men who have Attribution 4.0 International License, which permits use, sharing, sex with men: a study protocol for a randomised controlled trial adaptation, distribution and reproduction in any medium or format, to evaluate an interactive web-based intervention to reduce risky as long as you give appropriate credit to the original author(s) and the sexual behaviours. BMC Public Health BMC Public Health. source, provide a link to the Creative Commons licence, and indicate 2020;20:1–7. if changes were made. The images or other third party material in this 12. Alarcón Gutiérrez M, Fernández Quevedo M, Martín Valle S, article are included in the article’s Creative Commons licence, unless Jacques-Aviñó C, Díez David E, Caylà JA, et al. Acceptability indicated otherwise in a credit line to the material. If material is not and effectiveness of using mobile applications to promote HIV included in the article’s Creative Commons licence and your intended and other STI testing among men who have sex with men in Bar- use is not permitted by statutory regulation or exceeds the permitted celona, Spain. Sex Transm Infect. 2018;94:443–8. use, you will need to obtain permission directly from the copyright 13. Chow EPF, Cornelisse VJ, Read TRH, Hocking JS, Walker S, holder. To view a copy of this licence, visit http://creativecommons. Chen MY et al. 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