Over a fifth (22%) of all new HIV infections in the United States occur among persons aged 13‑24 years, with most of these diagnoses occurring among gay and bisexual males (81%) [1]. While the epidemic of HIV in the United States has leveled off for many age groups, the annual number of new HIV diagnoses among young men who have sex with men (YMSM; 13-24 years old) remains high. Though it fell by 18% between 2008 and 2014, in 2015, YMSM accounted for 92% of new infections among people aged 13‑24 years and 27% of all new infections among MSM [2].

Advances in HIV prevention tools can effectively reduce new HIV infections among youth. Antiretroviral therapy (ART) is a powerful tool and can be used among HIV‑negative youth to reduce susceptibility to infection (pre-exposure prophylaxis, PrEP) or among youth living with HIV infection (in the form of treatment as prevention) to reduce infectiousness [3-6]. The effectiveness of ART for reducing HIV transmission requires successes at multiple steps of the HIV prevention and care continuum (HIV testing, PrEP or ART treatment initiation, and treatment adherence), which may prove challenging for youth due to individual, structural, and societal barriers [7-10]. Comprehensive, evidence-based behavioral, psychosocial, and structural interventions are needed to optimize PrEP and treatment as prevention among youth.

HIV testing is the critical first component to facilitate entry into HIV prevention and care. Individuals who are aware of their infection can begin treatment, thus reducing the likelihood of onward transmission and improving clinical outcomes [11]. Those individuals testing negative can engage in interventions to prevent HIV acquisition, such as behavioral counseling and PrEP initiation. Due to the high HIV incidence among YMSM, routine HIV testing is particularly important and represents an ongoing prevention activity that requires strategies for continued engagement [12]. Access to and uptake of HIV testing is suboptimal, even among YMSM who report behaviors that place them at high risk for infection [13,14]. Data from the 2015 Youth Risk Behavior Surveillance System, which collects data from high school students (9th-12th grade), found that among sexually debuted YMSM, only 21% had ever been tested for HIV [1]. Further, at the end of 2013, an estimated 60,900 youth were living with HIV in the United States. Of these, 51% (31,300/60,900) were living with undiagnosed HIV, the highest rate of undiagnosed HIV in any age group [1].

Although PrEP has demonstrated high efficacy in clinical studies, uptake has been low among YMSM, especially YMSM of color [8,15,16]. There have been a number of challenges to increasing PrEP uptake in the United States, including low awareness of PrEP among youth and providers, only recent FDA approval of PrEP for those aged <18 years, concerns about potential side effects or safety, low risk perception, and PrEP stigma [17-19]. Efficacy of PrEP is highly correlated with adherence, and evidence suggests there may be worse adherence rates among younger populations and racial and ethnic minority populations [20-23].

For youth diagnosed with HIV, engagement in care and treatment with ART to achieve viral suppression are critical components for reaching the goals of improved individual health and prevention of onward transmission. In the United States, only approximately 44% of young people aged 13‑24 years diagnosed with HIV have achieved viral suppression [1]. One recent study of 1548 youths [24], conducted within the Adolescent Trials Network for HIV/AIDS Interventions (ATN), showed that only 7% of diagnosed adolescents and young adults achieved undetectable viral loads. Among participants with baseline biomedical data (N=733), 81.0% (594/733) were male, 72.0% (528/733) were black, and 70.0% (513/733) were gay or bisexual. This was substantially lower than the estimated 50% of persons achieving viral suppression for all age groups combined [24,25].

Thus, traditional approaches to continuum improvement for youth have been insufficient. Targeted interventions are urgently needed to improve the knowledge of undiagnosed HIV infection, access to and retention in prevention and care, medication adherence, and long-term viral load outcomes among youth at risk for or infected with HIV. Interventions delivered through mobile health (mHealth) technology represent a promising approach for improving outcomes among youth at risk for or infected with HIV. Mobile phones have nearly reached saturation among youth, making mobile technology a particularly promising tool to reach this population. As of 2015, 78% of those aged 18-29 years in the United States own a desktop or laptop computer and 98% report having a mobile phone of some kind, and 86% of these devices are smartphones [26]. Although white teens (91%) are more likely than black or Latino teens to report owning a desktop or laptop computer (~80% each), black teens are more likely to own a mobile phone (85%) and go online through a mobile device (100%) than white teens (71% ownership, 90% access) [27].

Although a number of apps related to HIV and other sexually transmitted infections (STIs) are available via commercial sites (Apple iTunes, Google Play), there are limited data to support the design of these apps or rigorous evaluations of their impact [28,29]. Of note, there are no current mHealth interventions targeting access to, uptake of, and adherence to PrEP. Further, youth face unique barriers to care at multiple levels including individual, social, and structural. Thus, technology (including app-based) interventions for youth must be specifically tailored based on their developmental stage and should include factors beyond individual-level behaviors and barriers to care. Additionally, once developed, these interventions must be rigorously evaluated and include the estimation of both overall cost and cost-effectiveness (compared with standard of care).

To effectively advance HIV prevention for youth, technology-based, youth-relevant interventions that maximize adaptability and sustainability need to be developed, heeding lessons learned from successes and failures of in-person interventions. A more efficient and potentially more scalable process for developing and testing these interventions would be to collate interventions that share common principles, design elements, data collection, and evaluation approaches. Moving forward, it is imperative that we build upon and enhance successful platforms to develop sustainable technology-based solutions that represent the highest standards of usability, affordability, accessibility, and large-scale dissemination.

The University of North Carolina (UNC)/Emory Center for Innovative Technology (iTech) is a National Institutes of Health cooperative agreement as part of the ATN (see Eunice Kennedy Shriver National Institute of Child Health and Human Development ATN overview, also submitted for this special issue). iTech aims to impact the HIV epidemic by conducting innovative, interdisciplinary research on technology-based interventions across the HIV prevention and care continuum for adolescents and young adults in the United States. The overall goals of iTech seek to decrease the impact of HIV on the lives of adolescents and young adults in the United States, particularly YMSM, by providing the following: (1) evaluation of novel approaches to identifying youth with undiagnosed HIV infection; 2) evaluation of multilevel, combination prevention approaches, particularly relevant to gender and sexual-minority youth facing co-occurring health risks (eg, substance use, mental illness, homelessness; 3) evaluation of uptake of and adherence to biomedical prevention modalities; and 4) evaluation of interventions designed to promote or optimize engagement in care and ART adherence in HIV-positive youth, to optimize viral load suppression.

Formative work has already begun on a number of the iTech trials detailed above. We expect the first RCTs to begin in mid-2018. iTech is anticipating preliminary findings from the first randomized control trials (LYNX and MyChoices) to be presented by early 2019. Additional preliminary findings from TechStep and P3 are expected mid to late 2020, with YouTHrive, Get Connected, and ePrEP presenting preliminary RCT findings by late 2021. We expect additional findings as we add new interventions focused within each of our four iTech objectives.

iTech brings together multidisciplinary experts in the fields of adolescent HIV treatment and prevention, development and evaluation of technology-based interventions, HIV surveillance and epidemiology, and intervention design and evaluation. Fostered by an MC that prioritizes communication and collaboration, this robust team will work collaboratively to respond to emerging issues and promote continued advancements in the field.

Technology-delivered interventions are well-suited for youth given their modality, the common use of technology in the population, the platform’s suitability to deliver tailored content specific to each user’s HIV or AIDS risk behaviors and context, and the platform’s unique capability to diffuse HIV or AIDS prevention programs to large numbers of youth residing in numerous geographic locations. Youth, including YMSM, are receptive to internet- and mobile phone-delivered interventions [29,70,71].

Using the internet to recruit, engage, and retain youth in interventions is not only possible but also necessary. Youth may lack the social capital or resources to access in-person interventions, may be dependent on adults for money or transportation, or may need permission to attend programs. These barriers are particularly problematic for YMSM who, due to anticipated or actual stigma, are unable or unwilling to talk to adults about their same-sex attractions, behavior, sexual identity, and need to receive prevention and care services [72-75]. Traditional face-to-face formats thus create difficulties for youth when they cannot easily access these interventions in their communities, are not able to attend the sessions when they are offered, and cannot choose to engage with the interventions’ content when most convenient. In addition, in a world where so much content is available online, there is an appeal (and perhaps even an expectation) to interventions that can be accessed online, in the privacy of one’s home, viewed alone or with friends, and when best suits the young person. However, while in-person interventions may be costlier, some youth may benefit from face-to-face interactions with culturally responsive providers. Thus, costing analyses are critically important with regard to technology-based interventions that are resource intensive to develop but have a great potential to be scalable and cost-effective, with high public health impact [76]. We have integrated sophisticated methodologies to translate findings into HIV prevention recommendations for youth in the United States.