Efficacy of a Mobile Serious Game (SwaziYolo) for Increasing HIV Risk Perception: Randomized Controlled Trial (Preprint)

BACKGROUND Eswatini has one of the highest HIV prevalence rates worldwide (24.8% among people aged ≥15 years), with unprotected heterosexual transmission accounting for more than 90% of new HIV infections in the country. Low HIV risk perception is known to influence risk behavior. Mobile phone technology is growing rapidly, offering opportunities for technology-driven interventions to improve HIV risk perception and prevention. OBJECTIVE We aimed to design and test a serious game to increase HIV risk perception and intention to engage in protective HIV behaviors among young people in Eswatini. METHODS Our team developed SwaziYolo, a smartphone-based, interactive, educational story game that places the player in the role of a young adult looking for love in Eswatini’s capital city. We conducted the Serious Games HIV Prevention Trial (SGPrev-Trial), a 4-week, 2-arm, unblinded, 1:1 randomized controlled trial of SwaziYolo among people aged between 18 and 29 years in Eswatini. The primary outcome was HIV risk perception using a 10-item and subset 8-item Perceived Risk of HIV Infection Scale (PRHS). We used modified intention-to-treat and per-protocol difference-in-difference (DID) estimation to compare the change between groups in the mean PHRS scores before and after intervention. RESULTS Of the 380 participants in the study, 122 (64.2%) in the control group and 119 (62.6%) in the intervention group completed the follow-up, and 95 (79.8%) played the game. In the modified intention-to-treat analyses, no significant differences between groups were observed for the 8-item PRHS (DID: mean 1.1, SD 0.72; P=.13) and the 10-item PRHS (DID: mean 1.3, SD 0.80; P=.12) scores. In the per-protocol analyses, HIV risk perception increased significantly among participants who played the game (8-item DID: mean 1.6, SD 0.74; P=.04 and 10-item DID: mean 1.8, SD 0.83; P=.03). Nearly all (94/95, 98.9%) participants strongly agreed or agreed that they would recommend SwaziYolo to their peers. CONCLUSIONS SwaziYolo was acceptable and increased HIV risk perception among young people in Eswatini who self-selected to play the game. More research is needed to improve and evaluate the SwaziYolo intervention. CLINICALTRIAL UMIN Clinical Trial Registry UMIN000021781; center6.umin.ac.jp