After the participant has provided consent to participate, the research team member administers the baseline assessment to the participant. Before the onset of the pandemic, data were collected in-person using an interviewer-administered baseline and follow-up assessment. However, adapting to the pandemic, a research team member collects these data by phone call or videoconferencing. After the baseline assessment is completed, the research team member informs the participant that they will be placing the participant’s token of appreciation and a receipt for the participant to sign at her door. The participant is instructed to place the signed consent form and the used HIV test kit materials (for disposal offsite), as well as the signed receipt, at her door for the research team member to collect. The research team member, wearing gloves as well as a face covering and maintaining physical distancing, retrieves these materials.
Virtual ChiCAS Implementation
After baseline data are collected, participants are randomized into the intervention or delayed-intervention group using a block randomization scheme (block size=4) generated with SAS version 9.3. Prior to the pandemic, ChiCAS was implemented in person, as a group-level intervention with about 10 participants at a time. Subsequently, the intervention curriculum18 and key characteristics were slightly adapted for virtual implementation (Table 2). For example, we found that limiting the number of participants during virtual sessions to about six was more deliverable than 10 participants given the challenges associated with participating in discussions with large numbers of participants by videoconferencing. The core elements did not require adaptation.
[Table 2 About Here]
Because of the virtual nature of the intervention, the research team works with each participant regarding the logistics of participation. A research team member contacts each participant who has been randomized to the intervention group by phone or videoconferencing and again reminds her that the sessions will be conducted virtually using the videoconferencing app Zoom and that she will not go to a specific community-based venue to attend but instead will attend the session using her phone, tablet, or laptop computer (most participants use their phones to participate). The research team member also advises each participant to select a location where she plans to participate in the virtual session. In selecting a location, the research team member advises each participant to consider her comfort and most importantly, her privacy. Ideally, the location, whether inside or outside the home, should have minimal interruptions and the participant should be able to speak freely. The participant is reminded to have her charger close in case the battery charge on her phone or other device runs low during the session. Most participants have used their phones to “video chat” with others within their social networks via apps such as Facebook Messenger or FaceTime but have not attended a group-level educational session with other participants whom they had not met before. Thus, the research team member explains the virtual group-level implementation to each participant in advance, so she knows what to expect. The research team member also makes sure that the participant feels comfortable using the Zoom app to participate in the session, particularly if the participant has not used the Zoom app much previously. This explanation includes how to manage the gallery view options, change backgrounds, use the chat and mute/unmute features, and change one’s display name and preferred pronouns. If the participant does not already have the Zoom app installed on the phone or other device she plans to use during implementation, a research team member talks the participant through the process for installing the app and practices using the app with the participant.
The activities in the ChiCAS curriculum include role plays, games, and group discussions that are designed to be interactive and promote active participation. However, we anticipated that even the most interactive four-hour sessions might be too long for virtual implementation. Thus, some activities were either eliminated (e.g., meals during sessions and a night simulator box activity that allows participants to practice putting a condom on a penis model in the dark39) or made shorter (e.g., PowerPoint presentations and the graduation celebration). We also adapted the sessions and activities in other ways to be more conducive to virtual implementation, and creativity was needed to ensure that virtual intervention sessions remained interesting and engaging for participants.
The research team members who deliver the intervention (hereafter referred to as interventionists) use multiple strategies to create a friendly and welcoming atmosphere to maintain participant attention. At the beginning of the first session, for example, the interventionists use an adapted icebreaker titled “Find Someone Who…” In this activity, participants must find someone in the group who has certain characteristics or experiences such as someone who has a tattoo, prefers hairy men, met one’s boyfriend or partner online, or had a crush on a teacher while in school. The original intervention activity instructs participants to move around the room to find and meet other participants who have the characteristic or experience described in the activity. However, the virtual implementation required us to adapt this activity to be one in which an interventionist reads out each characteristic and participants use Zoom reactions to indicate that they share the described characteristic or experience. The interventionists spend time acknowledging reactions, encouraging laughter and dialogue for participants to feel comfortable and start connecting with one another.
In the virtual environment, interventionists cannot rely on body language (as they had been able to during in-person implementation) to gauge and promote engagement. Thus, they developed and use non-threatening ways to encourage participants to answer questions, ask questions, and make comments. For example, when interventionists want participant input, they “call on” each participant by name; every participant is given an opportunity to speak. Because participants expect to be called on, we have learned that participants feel less pressure than if they were called on sporadically; interventionists also explain to participants that they can say nothing when called on or indicate that they would prefer to say nothing. This process also limits the confusion and awkward moments that can arise during videoconferencing when two or more attendees try to speak at the same time.
Several other adjustments were made to translate in-person activities to the virtual context, including using the screen sharing feature on Zoom to project PowerPoint slides and videos and typing notes on a shared screen rather than writing on newsprint during group discussions. The Zoom breakout room feature is used for the role-play activities focused on communication with providers about PrEP and gender-affirming hormone therapy and condom negotiation with partners. Each participant is paired with a partner and then assigned to a breakout room, where they practice and perform their role plays, and the interventionists rotate throughout the breakout rooms to answer questions and provide feedback to participants. Participants enjoy the novelty of “traveling” to the breakout room and then rejoining the larger group after the activity to report back about their experiences; interventionists add lightheartedness and ease any technical difficulties that occur by describing participants as being “teleported” to their breakout rooms, assuring participants that they will be brought back “safe and sound” to the larger group, and joking that participants who arrive back to the Zoom main room later than others were probably given a “faulty parachute”. Participants also particularly enjoy the role play activities because these activities provide an opportunity to interact one-on-one with other participants, create bonds, and promote a sense of community. In the in-person implementation of our partnership’s interventions, we have seen the building of community among participants,35,40 and we were gratified that we were able to recreate this critical component of the ChiCAS intervention18 during virtual implementation.
In order to further facilitate engagement in activities, prior to implementation, a set of session-specific materials is delivered to each participant’s home by a research team member following physical distancing procedures similar to those used during screening and enrollment. These materials include a penis model and condoms for practicing correct condom use, brochures with information about STIs/HIV, cards with descriptions of characters for role plays, lists of local providers of PrEP and medically supervised hormone therapy, and handouts with copies of all PowerPoint slides used. In addition, a set of cards, each describing a different step in the process for accessing services and obtaining PrEP, are provided for an activity in which participants are instructed to put the steps in the correct order. During in-person implementation, participants were divided in to two teams that “raced” to see which team could put the cards in correct order first. During virtual implementation, however, participants are given time during the session to put their cards in order individually and then led by an interventionist, participants review the order together as a group.
The two intervention sessions are delivered on consecutive Sunday afternoons, which we have found is the time that is most convenient for the majority of participants’ schedules. After each session, a research team member goes to each participant’s home (again, following similar physical distancing procedures to those previously described) to deliver their tokens of appreciation, the materials to be used for the following session, and a t-shirt and tote bag with the ChiCAS logo. After the second (final) session, a research team member delivers a framed and personalized ChiCAS graduation certificate. A research team member contacts participants during the week between the first and second session to find out what they thought of the first session (including the virtual delivery platform) and ask them to confirm the name they would like on their certificates. Some participants request two certificates (e.g., one with the name that appears on their government identification card and the other with the name that they use). After attending the first session, participants have often begun to bond with the other participants, have seen that the information provided in the sessions is interesting and useful and the atmosphere is empowering and fun, and have built trust in the research team. They see that the intervention is “legitimate” and that the team has no “hidden agenda”, increasing the likelihood that participants will return for the second session.