Parts of this chapter have been reproduced or adapted with permission from Meiksin et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes additions and minor changes to the original text.
Background
This review synthesises evidence on electronic health (e-health) interventions aiming to reduce the ‘syndemic’ of human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) and sexual risk, substance use (defined as use of alcohol and other legal and illegal drugs) and mental ill health among men who have sex with men (MSM). A syndemic refers to simultaneous, mutually reinforcing epidemics, in this case of sexual risk, substance use and mental ill health.
Description of the problem
Despite major advances in treatments and pharmacological prevention, MSM continue to experience the highest incidence of STIs and HIV of any population group in the UK, and report high levels of sexual risk behaviours.2,3 The lifetime cost of treatment per HIV infection in the UK is almost £380,000.4 Each case of other STIs is estimated to cost £1215 per infection.5 MSM also report high rates of alcohol6–8 and recreational drug use9–11 and high rates of common mental illnesses.12 MSM are twice as likely as other men to be depressed or anxious.13 According to the 2013 Annual Report of the Chief Medical Officer, mental health problems cost the UK economy an estimated £70–100 billion each year.14
Sexual risk, alcohol and drug use, and mental ill health are increasingly considered to constitute a ‘syndemic’, in that these outcomes commonly co-occur and mutually reinforce one another. There is consistent evidence that these outcomes intercorrelate strongly at the level of the individual and the sexual event.15–21 Drug use is both a symptom and cause of mental ill health, and both drug use and mental illness are associated with increased sexual risk behaviours.22 Nationally representative surveys suggest that almost half of MSM experience one or more of these outcomes.23 MSM who report using certain drugs – nitrite inhalants and various drugs commonly used during sex and at parties – are more likely to report sexual risk with multiple partners.24 Survey data indicate that MSM reporting substance use are more likely to report condomless anal intercourse (CAI) and HIV infection,25 MSM with higher levels of anxiety and depression are more likely to have potential alcohol dependency26 and MSM with depressive symptoms report more CAI.27 Therefore, public health strategies to address these outcomes together have the potential to achieve multiplicative effects because interventions may have impacts directly on each outcome, as well as via multipliers involving other outcomes acting as mediators.
Existing public health strategies have failed to adequately address these outcomes either separately or together.28,29 Common mental illnesses among MSM are underdiagnosed and undertreated, partly because of low rates of general practice registration.30 One study reported that, among MSM attending sexual health clinics in the UK, 42% of those with depressive symptoms were not diagnosed and 48% were not receiving treatment.31 Spending on HIV prevention for MSM is falling32 despite strong evidence, albeit primarily from non-UK studies, for effective interventions.33 Drug treatment services tend to focus predominantly on heroin and crack cocaine, rather than the drugs most commonly used by MSM. There is an urgent need for cost-effective new strategies to address these outcomes.
Description of the intervention
E-health interventions are those facilitated by electronic media and devices. Such interventions aim to promote healthy behaviours and mental health by increasing or maintaining motivation, setting and reviewing goals, providing feedback on behaviour, and challenging thought patterns that obstruct change. Behaviour change interventions typically draw on social learning theory and the transtheoretical model, while mental health interventions draw on mindfulness or cognitive–behavioural approaches. There is good evidence from systematic reviews focused on general or mixed populations that e-health interventions can reduce alcohol use34 and address common causes of mental ill health.35–41 Emerging evidence also suggests that e-health interventions might reduce drug use and sexual risk behaviour.42–45 Given the clustered and interacting nature of these problems among MSM, if e-health interventions were found to be effective in addressing these outcomes among MSM, then this might suggest the value of developing an e-health intervention that addresses these outcomes simultaneously and holistically. Such an approach might well have multiplicative, not merely additive, effects.
Rationale for the current study
We cannot assume that effects found for e-health interventions targeting general or mixed populations34–42,44–46 are applicable to MSM. Effect sizes may be greater for MSM because of MSM’s greater use of social media, including to meet sexual partners and obtain drugs.47 But effects may be limited by MSM’s risk being influenced by factors that e-health interventions cannot address, such as early and ongoing experience of homophobia48–50 and participation in social networks in which social norms support risk behaviour.51 Therefore, there is a need to assess the potential effects of e-health interventions on these outcomes among MSM.
A 2014 review by Schnall et al.43 examined e-health interventions to reduce HIV and other sexual risks among MSM (but did not examine alcohol or drug use or mental health), reporting that such interventions have the potential to be effective. This review had several important limitations such as a very narrow search, unreliable quality assessment and a lack of synthesis of effect estimates. These limitations explain why it was not able to provide a clear answer to the question of whether or not e-health interventions are effective in reducing sexual risk behaviour. A 2017 review by Daher et al.52 synthesised evidence on a range of e-health interventions addressing different aspects of the prevention and treatment of HIV/STIs, but did not address substance use or mental health. This review had broad inclusion criteria focused on ‘innovative’ interventions and all populations, not just MSM. Its very limited search strategy found only two studies pertinent to this review, and so can offer no clear indication of the impact of e-health interventions on sexual risk among MSM.53,54 A 2019 review by Nguyen et al.55 assessed e-health interventions targeting HIV/STI prevention among MSM, concluding that such interventions could achieve short-term behavioural impacts, but with only one intervention reporting an impact after 1 year. In this review, heterogeneity precluded meta-analysis, neither substance use nor mental health were addressed, the search was limited to four databases and interventions included those with a human component (e.g. chat room). Only one existing review has examined e-health interventions addressing mental ill health among gay and lesbian populations, but it did not synthesise empirical evidence on these, and so provides no guide as to their effectiveness.56 Furthermore, none of the above reviews synthesised the theories of change for how included interventions were intended to modify the health outcomes, nor synthesised evidence on factors affecting delivery or receipt.
The present systematic review aimed to address these gaps in order to determine the effectiveness of e-health interventions addressing these outcomes among MSM. It focused on interventions addressing HIV, STIs, sexual risk behaviour, alcohol and drug use, or mental health, aiming to synthesise evidence of effects on these outcomes. We were interested in studies of interventions that addressed outcomes in these different domains either in combination or separately. The former would indicate whether or not there is already good evidence for ‘holistic’ e-health interventions to address this syndemic of interclustered outcomes. The latter would provide some indication of the potential for developing and testing such a holistic intervention, particularly if no such holistic interventions have been evaluated to date. It also aimed to synthesise theories of change to understand how interventions are intended to work, evidence from process evaluations on what factors affect delivery and receipt to assess what factors might affect the transferability of such interventions, and evidence from economic evaluations to examine the cost-effectiveness of such interventions. This review thus aimed to provide the evidence required to determine the value of, and inform the development of, an e-health intervention holistically addressing the syndemic of HIV and STIs, sexual risk behaviour, alcohol and drug use and mental ill health among MSM.
This review also aimed to use a network meta-analytic approach to compare the effectiveness of interventions that had not, to date, been the subject of empirical comparisons. This approach has not been used in any previous reviews of e-health interventions among MSM and could transform our understanding of which intervention approaches and combinations are most effective. However, we were unable to undertake these models with the body of evidence included because pairwise comparisons did not form an interconnected network with similar populations and outcomes.
Review aims, questions and objectives
Review aims and questions
The aims of this review were to search systematically for, appraise the quality of and synthesise evidence to address the following research questions:
- Research question (RQ) 1. What approaches and theories of change do existing e-health interventions employ to prevent HIV, STIs, sexual risk behaviour, alcohol and drug use or common mental illness symptoms among MSM?
- RQ2. What factors relating to interventions, providers, participants or contexts promote or impede delivery or receipt of such interventions?
- RQ3. What are the effects of such interventions on HIV and STIs, sexual risk behaviour, alcohol and drug use, and depression and anxiety, overall and by intervention and client subgroup?
- RQ4. Are such interventions cost-effective in reducing these outcomes?
- RQ5. Does the existing evidence overall suggest that these outcomes can coherently, feasibly and effectively be addressed by a single, joined-up e-health intervention targeting UK MSM and, if so, what might such an intervention look like?
Review objectives
- To conduct electronic and other searches.
- To screen found references and reports for inclusion in the review.
- To extract data from, and assess the quality of, included studies.
- To develop a typology of interventions and synthesise theories of change and process evaluations.
- To consult with policy/practice and community stakeholders on the typology and theory of change/process synthesis.
- To synthesise outcome evaluation and cost-effectiveness data.
- To draw on these syntheses to draft a report addressing our research questions.
- To consult with policy/practice and community stakeholders on the draft report (to inform amendments and dissemination).
- To submit the final report to the National Institute for Health Research.