Deploying Visual Narrative on the Mobile App Stage in a Posttest HIV Counseling Tool for Central American Militaries

Background: For HIV-negative individuals, posttest counseling is a critical period in which to increase risk perceptions and decrease risk behaviors. In Latin America, where resources for testing are limited and the stigma surrounding HIV and risk behaviors is high, health providers and counselors may skip crucial risk behavioral screening (e.g., questions about unprotected anal sex) during posttest counseling.

Program background: To address this issue, in 2014–2015 with funding by the U.S. Naval Health Research Center's Department of Defense HIV/AIDS Prevention Program, RTI International piloted the development of a self-administered posttest counseling interface for Voluntary Counseling and Testing (VCT) centers in the armed forces of the Dominican Republic and Belize. The tablet-based interface aids in posttest communication about risk factors and behaviors associated with contracting HIV. Through Computer Assisted Personal Interviewing on tablet devices, patients are walked through two gender-based interventions designed using CDC guidelines on the provision of posttest counseling. Approximately 28 comic military images were developed to accompany the questions and corresponding information screens provided to respondents based upon their responses. Visuals help explain terminology and various aspects of HIV prevention, including risk behaviors and preventive measures. Many members of the military population in the region are young and exposed to western media, so it was thought that casting characters in comic art would be more appealing and help reduce stigma. A visual narrative was developed around two virtual comic characters, Bob and Britney, to guide users through the risk assessments, including demonstrations of risk behavior, and to encourage safe behaviors.

Evaluation Methods and Results: A 3-month pilot study was conducted at two military sites in the Dominican Republic and two military sites in Belize that measured the ability of the interface to enhance the impact of the behavior change messages provided. Automated HIV testing and counseling (HTC) was offered to all personnel attending a VCT facility and who tested negative for HIV infection, a total of 128 clients. Participants were administered a behavioral questionnaire immediately before, during, immediately after, and 3-months following the HTC session based upon their gender. Respondents ranged in age from 18 to 66, and the majority (66%) were male and from the Dominican Republic (68%). At 3-months following automated posttest counseling, reductions in sexual risk behaviors were observed in both genders. Both male and female participants showed decreases in inconsistent condom use during vaginal sex. We observed a 16.5% reduction in inconsistent condom use during vaginal sex among men, a common risk behavior reported in comparable military populations. We observed an overall 22% increase in knowledge of water-based lubricants. Visuals eliminated confusion about the survey questions (as there had been in the past). The positive response to the visuals lead to updating the artwork in companion flipcharts.

Conclusions: As military healthcare systems in low prevalence regions seek to continue streamlining prevention services, automated HTC platforms may be one viable method for achieving reductions in HIV risk behavior for HIV-negative patients. 

Implications for research and/or practice: Future research should compare automated HTC platforms to HTC that is delivered as part of normal HIV testing services.