Table 6.

Key Challenges, Lessons Learned, and Recommendations for Future Researchers, Understanding New Infections Through Targeted Epidemiology, United States, 2017–2018

Challenge	Lessons Learned And Recommended Practices
Identifying venues for ongoing high-volume recruitment poses challenges	The leading mobile application and website companies that are most popular among sexual minority men have a large reach, but advertising multiple times leads to duplicate participants as well as advertising fatigue. Recommendations include limiting the number of advertisements per venue, spacing advertisements in the same venue by several weeks, and targeting fewer, higher-volume advertisement options versus a more evenly distributed and longer advertising program.
Marketing trends and advertising costs present a challenge for recruitment	Different types of advertisement within the same venue have differing effectiveness, and our work demonstrated that “inbox” style advertisements were more effective than pop-ups that could be easily and quickly dismissed. For social media where there is significant corporate advertising, costs per impression go up substantially around holidays and other high-volume shopping periods, and use of these should be limited during such times. Finally, due to high costs per eligible/enrolled participant, screening for multiple studies at the same time significantly enhances the value and diminishes overall costs of advertisements.
Avoiding duplicate and fraudulent enrollments is logistically challenging	Several studies have been published that document best practices for identifying fraudulent and duplicate participants. Strategies successfully used in the present study included nonincentivized screening, requiring completion of multiple steps before receiving compensation, and requiring verification by multiple means (i.e., completing links within study e-mails, responding to an automated text message, and receiving a package at a residential address).
Few devices available to conduct at-home sampling for lab-based HIV testing	There is a strong ethical imperative to inform research participants of their HIV status; thus, an FDA-approved clinical test is the preferred option even within the context of research. Few such devices exist and, as of the start of this study, none were FDA-approved for at-home sample collection. This requires a validation study to be conducted by a CLIA-approved clinical laboratory before use, which also makes finding a laboratory more difficult.
Compensation challenges to adequate recognition of participants’ time and effort while minimizing coercion and fraudulent enrollment	Compensation values participants’ time and efforts and thus should be set at an appropriate level that encourages completion of study tasks without being coercive or incentivizing multiple enrollments. Based on our experiences with enrollment and feedback received, future studies should include higher compensation (e.g., $50), splitting up payments (e.g., compensating for the survey and HIV test separately), but also incentivizing full completion by building in bonus structures. These strategies implemented over time in our study have proven fruitful.
Reducing participant burden	Self-report surveys, in particular, are a source of potential frustration at longer durations. The field would benefit strongly from the development of standardized, comprehensive, and brief survey measures that encompass a range of social, psychological, and behavioral factors that serve as barriers and facilitators to HIV prevention. Surveys should be limited to 30–45 minutes, on average, and should focus on limiting perceived redundancy, highlighting the importance of the data, and providing an explanation of why different questions are being asked (particularly if sensitive in nature).
Minimizing participant confusion	One of the largest difficulties in a remote study with a substantial sample size recruited in a brief period of time is effectively responding to participant e-mails and other communications. Beyond individual issues that warranted one-on-one communication, the largest reason for participant e-mails was confusion about where they were in the enrollment process, what they had and hadn’t completed, and when they would be compensated. To minimize this, 2 strategies implemented over time in our study have proven significantly helpful. First, using informational videos is a cost-effective way of explaining different procedures, and our participants indicated a preference for animated rather than live-action videos. Second, login-based home pages or study portals should be provided that allow a participant to see a breakdown of all activities, their completion status, and associated compensation (if relevant).
Preparing at-home test kits for shipment	Preparation of mailers with at-home test kits and supplemental material (e.g., a card with participant’s test kit identification, a card with important information) must be performed well in advance for rapid distribution. Over time, we discovered the importance of making small but important adjustments to the contents based on participant e-mails and common issues reported by the lab, including the modification of our information card to ensure proper procedures were followed. Additionally, rate changes over time for shipping led to the need to modify the postage of our return envelopes that had already been packed and sealed within the outgoing envelope. To minimize personnel effort and supply cost, sealing of mailers should be postponed until the date of shipment, and preprinted postage should only be applied for kits expected to be used within 6 months to avoid postage changes.

Abbreviations: CLIA, Clinical Laboratory Improvement Amendments; FDA, Food and Drug Administration; HIV, human immunodeficiency virus.