Efficacy of an Interactive Life Simulation Gaming App on Improving HIV Testing Uptake Among Adolescents and Young Adults at Risk for HIV: Results of a Randomized Controlled Trial.

BACKGROUND: Adolescents and young adults account for a disproportionate number of new HIV diagnoses in the United States due to missed opportunities for education, testing, and prevention. OBJECTIVE: We tested the efficacy of an interactive life-simulation gaming intervention to provide HIV education and improve HIV testing uptake and preventive services among youths ages 13-24 years in the Washington, DC area. METHODS: We conducted a parallel randomized controlled trial testing the efficacy of an HIV-focused gaming intervention app to a control app in increasing HIV testing uptake. Participants were recruited via social media and peer referral. Eligible participants were randomized 1:1 by age (13-17 vs 18-24 years) and sexual orientation (lesbian, gay, bisexual, or "other" vs heterosexual). Participants accessed their assigned app for 3 months and completed baseline, 1-, 3-, and 6-month surveys. The primary outcome was self-reported HIV testing within 6 months after enrollment; secondary outcomes included intent to test for HIV, HIV knowledge, and intention to start pre-exposure prophylaxis (PrEP). Analyses were conducted as intent-to-treat and stratified by sexual orientation. RESULTS: From November 2023 to May 2024, we randomized 309 participants (intervention: n=156; control: n=153) with 80% and 88% retention at 6 months, respectively. Among the analyzed participants (intervention: n=150; control: n=149), the mean age was 20.7 (SD 1.84) years, 49% (145/299) were women, and 34% (103/299) were non-Hispanic White. Overall, 53% (158/299) self-reported as gay, lesbian, bisexual, or "other" sexual orientation. A total of 48% (144/299) had previously tested for HIV. Compared to the control app, game participants were 32% less likely to test for HIV within 6 months (relative risk 0.68, 95% CI 0.47-0.98). The two groups showed no statistically significant differences regarding their intention to get tested for HIV or to start PrEP. A significantly higher difference in mean HIV knowledge scores at 3 months (0.99, 95% CI 0.33-1.65; P<.01) and 6 months (0.81, 95% CI 0.14-1.48; P=.02) was observed in the game arm compared to the control arm. Additionally, heterosexual participants in the game arm had statistically significant increases in PrEP intention (0.53, 95% CI 0.05-1.00; P=.03) across all time points compared to controls. CONCLUSIONS: Our interactive gaming app was less effective than an information control app in increasing HIV testing and changing testing and prevention intentions among adolescents and young adults. In the game arm, we did observe increased HIV knowledge and increased PrEP intention among heterosexual adolescents and young adults. Few life-simulation apps integrating HIV testing and prevention features have been rigorously tested among adolescents and young adults. Our efficacy findings suggest that while these interventions are feasible and acceptable to adolescents and young adults, they require additional tailoring to improve their reach, use, and potential effectiveness in real-world settings.