HIV G.E.T (Gaming, Engaging and Testing) Project

Lead Research Organisation: Liverpool School of Tropical Medicine
Department Name: Liverpool School of Tropical Medicine

Abstract

HIV is a significant health issue in the Philippines. In May 2015 the Philippines Department of Health (PDOH) Aids Registry reported 22,684 people living with HIV/AIDS. 86% of the HIV+ population are men who have sex with men (MSM) of which 36% engage in heterosexual activities with women. There are two major issues with the current diagnosis system. According to observations by the PDOH, high risk groups, tend not to come forward for testing, and the two week time period between testing and diagnosis in the current system leads to few returns for treatment and care. This and several other factors are leading to the Philippines having the fastest growing HIV epidemic in the world. There is a clear need to address the current diagnosis system and run targeted interventions.
As adolescents make up a high proportion of the hard to reach high risk group, this project seeks to: improve treatment seeking behaviour and compliance through a digital gaming intervention; and improve access to testing and speed of diagnosis through rapid diagnostic tests (RDTs).
The study will be undertaken in Metro Manila which has HIV prevalence of 5.3-6.7%. Two intervention clinics in the Metro Manila area and 4 control clinics will be included. A step wedge study design will be followed for game evaluation. The current laboratory-based ELISA and western blot testing algorithm for HIV testing and counselling (HTC), will be replaced by a Rapid Diagnostic Algorithm (RDA) intervention. This will be rolled out for 24 months in 2 intervention clinics and the game introduced after 12 months in a stepped process to provide three arms of evaluation for the two interventions: current practices, RDA only and RDA in combination with gaming intervention.
The pilot study will indicate whether the numbers of people seeking HIV services at intervention clinics, compared to control facilities have increased. It will also generate a better understanding of motivational factors for seeking diagnosis, especially from the at risk groups. This will provide valuable information for possible expansion of interventions nationally.
The UK-based research team will provide expertise and guidance, ensuring the transfer of skills and knowledge to the Philippines to plan, strengthen capacity within the HIV health system, roll out, monitor and evaluate the value of the two proposed interventions.

Technical Summary

According to PDOH (2015), 748 individuals were newly diagnosed, since last years report, to be HIV Ab seropositive, a 51% increase in cases compared to May 2014. Among the newly diagnosed cases, 96% were male with a median age of 28 years old (range: 16-69 yrs. old), 28% were youth (15-24 years old), and 37% came from National Capital Region (Metro Manila area). In addition, 86% of the sexually transmitted HIV cases were MSM, 7% were Overseas Filipino Workers, and 11% were engaging in transactional sex.
HIV rapid tests are simple to perform with two or more tests providing confirmed results in 30 minutes or less in a serial or a parallel algorithm. A parallel algorithm will be used for the study. The WHO pre-qualifies rapid test kits with a diverse and standardized set of specimens collected globally, requiring test kits to have a minimum sensitivity >99% and specificity >98%. Quality-assured rapid testing has facilitated the movement from laboratory-based testing to other settings, and it has been highlighted that with good training, performance of non-laboratory workers is similar to laboratory staff. HIV testing strategies that rely on rapid testing are widely used in outreach settings with MSM in concentrated epidemic settings. They have been shown to improve the uptake of testing, increase dramatically the proportion of those receiving their results, and improve linkage rates to care and treatment programmes.
The approach to game development and analysis will be conducted trough customised tried and tested frameworks for evaluating games for health. Development of the digital game will be completed in the Unity3d version 4.x engine, or an equally standard, industry-grade middleware package to allow for customisation by other software developers and alleviate concerns over the longevity of development partners.

Planned Impact

The study will generate an evidence-base to support the roll out of an RDA in the Philippines. The advantage of rapid diagnostics and counselling at clinics and the introduction of a targeted advocacy game will be communicated. Peer reviewed papers will provide a case study to support further dissemination of the game and use of an RDA in health facilities across the Philippines.
Dr. Jose Gerard B. Belimac (Philippines, PDOH) is the designated National Program Manager for HIV and AIDS, STI in PDOH and is a Co-Investigator on the project. Dr Belimac is responsible for technical coordination of partners, direction setting, evidence-based policies/guidelines and standards development for the health sector response to HIV spanning from prevention, health promotion, diagnosis, treatment and the key populations for HIV and AIDS. This will allow for a direct line of communication between project team members and the PDOH to ensure national processes are addressed and by-in from the PDOH is gained at project inception.
Mid-term workshops with PDOH and University of the Philippines (UP) stakeholders, will be held to demonstrate the game and to discuss and plan future collaborations.
During the project the roll out and marketing of the game will be controlled to avoid contamination between the control and intervention groups. Upon completion of the study the online gaming market will be utilised to provide free country-wide access to the game. Monitoring of use, after general game release will be possible.
If this initial game is successful we will develop capacity in the UP and PDOH, to enable them to undertake simple customisation to make the gaming platform applicable to a variety of public health challenges.
The game will be jointly-owned, through the legal transfer of the software source code, to the PDOH and UP.
Workshops will be held with the PDOH, HIV stakeholders and the wider public health community to communicate the results of the pilot and how the results should be taken forward to improve health within the Philippines. Social networking sites and local media deemed appropriate will be utilised to disseminate project information and results.

Publications

10 25 50
 
Title Mobile Game Development Concept Art 
Description Game character concepts produced by the game development team lead artist. 
Type Of Art Artwork 
Year Produced 2016 
Impact Feedback from target users on character design to develop game art that is contextually appropriate and taps into an existing market to facilitate game uptake. 
URL https://drive.google.com/open?id=0B7Z3jBTNUcJZbEJjMFJyZzlVWW8
 
Description Policy brief for implementation of HIV self-testing
Geographic Reach National 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Description Technical input into rHIVda documentation
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
 
Description HPRU Funding for A Game Changer for Public Health Promotion Workshop
Amount £420 (GBP)
Organisation NIHR Health Protection Research Unit 
Sector Public
Country United Kingdom
Start 10/2017 
End 03/2018
 
Title Custom Unity Game Analytics 
Description An adaptation of Unity Analytics has been utilised to track game uptake and use to assess demand for the game among key populations. A combination of industry standard and custom metrics enables researchers to track game use by gender, age, sexuality and geographical location of players. i.e. we can monitor how many daily active users report as adolescent men who have sex with men. 
Type Of Material Improvements to research infrastructure 
Year Produced 2018 
Provided To Others? Yes  
Impact Game analytics are used to identify bugs or sticking points in the game i.e. a difficult level. A number of stats in the game can be edited live via Google Sheets to change the difficulty, changes will appear across all devices without the need to release and update or incur additional development costs. Enabling researchers to make evidence based adjustments to the games difficulty curve and improve retention. The analytics provide a unique and efficient way to assess demand and make improvements to the game design. Lessons learnt during the development and use of the analytics will be communicated via relevant research networks to support future games for health research. Key findings from this study centre around challenges in ensuring users are informed about the data that is being collected and how it is being used. 
 
Title Recruitment Method for Self Report Survey 
Description An online and face to face survey targeted towards the MSM population was conducted as part of the formative research stage of the project. The online survey was advertised on 3 social apps for MSM; Grindr, Planet Romeo and GROWLr. The advert included a link to the survey and a short description. Adverts were also run in local newspapers. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact The targeted promotion for the survey attracted 705 responses. All of which completed the survey, only 49 did not meet the criteria. Coupled with the face to face survey, which captured 243 responses that met the criteria, the project achieved an astounding response rate for the survey. Initial analysis of the demographic data indicates that the population from the online and face to face survey differed significantly. The online survey demonstrated significantly higher numbers of MSM that are not open about their sexuality and a key at-risk group. 
 
Title Battle in the Blood Development: FGD Transcripts & Video Recordings 
Description A database of qualitative data from focus group discussions and user-testing sessions collected throughout the development of Battle in the Blood. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact Initial analysis of qualitative data was used to improve the usability of the game and clarity of key health messages. A protocol was developed to enable rapid translation of qualitative data into prioritised game changes within the constrained development period. Perceptions of the game and understanding of health messages was shown to improve at each development phase. Use of this data enabled researchers to develop an engaging game, attuned to the sociocultural beliefs and practices of its target users that was effective in communicating the predetermined health messages. Further analysis will be conducted to conclude on the acceptability of the game among target users. 
 
Title Battle in the Blood Pilot: Baseline Clinic Use at Study Sites 
Description Database includes monthly aggregated data on clinic use, metrics include: total number of clients tested, total number of reactive and non-reactive clients, total number of reactive clients that completed baseline evaluation within 3 months of the test, total number of reactive clients enrolled onto treatment within 3 months of the test. All data fields are broken down by age, gender and sexuality. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact Data will be used to monitor any changes in HIV testing and treatment services in the 12 months pre- and post-game launch. Baseline data has provided evidence of significant dropout of reactive clients between receipt of results and enrolment on to treatment at 3 clinics. Analysis of the data will be regularly shared with the clinics to help them assess impact of clinic based interventions among key populations. 2019 update: Descriptive analysis of the clinic data has been shared with the clinics. 
 
Title Battle in the Blood Pilot: Game Analytics 
Description Data on game uptake, use and retention is collected via Unity Analytics, Google Play and App Store. The data also includes responses to in game demographic, knowledge and attitude based questions. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact Analysis of the game data will be used to assess demand for the game among key populations in the Philippines. Responses to in-game questions will provide evidence of the game's ability to communicate health messages. Game analytics are used to identify bugs or sticking points in the game i.e. a difficult level. A number of stats in the game can be edited live via Google Sheets to change the difficulty, changes will appear across all devices without the need to release and update or incur additional development costs. Enabling researchers to make evidence based changes to the game and improve retention. 2019 update: Game analytics have demonstrated demand for the game, as of the 01/12/2018, 3,325 unique device installs were recorded globally, with a vast majority in the Philippines. Geographical data reported significantly higher uptake in the regions of Manila and Davao. Game use was concentrated around urban areas. Since its launch, Battle in the Blood has achieved an average of 33 daily active users. Game analytics also aided the identification of an access issue affecting Android devices. The issue was caused by changes made to app permissions managed by the Google Play Store and was therefore out of our control. An update to the game was launched in November 2018 to fix the access issue. Since the update was launched installs of Battle in the Blood increased by 511.54% on Google Play compared to the previous reporting period. (21/10/18 to 18/11/18 compared with 21/09/18 to 20/10/18) In November 2018, Battle in the Blood also reached #1 on the Google Play trending educational apps list in the Philippines. 
 
Title Battle in the Blood Pilot: Game Use by HIV Testing and Treatment Service Users 
Description Database includes responses from a short registration survey delivered at 4 study sites. Metrics include; total number of clients that are aware of Battle in the Blood, total number of clients that have played Battle in the Blood and total number of clients that report Battle in the Blood played a role in their decision to attend the clinic. Data will be collected over a 12-month period. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact Data will give an indication of whether anyone playing the game is also using HTC services. Data will provide justification for further exploration into the games effect. To date, the data has already identified a significant number of clients at a study site in Davao that have played the game, attended the clinic for HIV testing and reported that the game played a role in their attendance. Researchers will now work with clinic staff and review the game analytics to uncover the cause. 2019 update: data will be used to embellish qualitative findings around the community health worker effect on uptake and impact of the game among target users. 
 
Title Formative Research: KII & FGD Transcripts 
Description A collection of qualitative data established from the following activities: Key informant interviews with HIV testing and counselling (HTC) service users and non-users. Focus group discussions with HTC service providers. Focus group discussion for game design and delivery approach with target users. 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact Analysis of this data has informed: The questions and response options in the self-report survey. The objective, design, content and delivery method of the serious game. The selection of speakers and topics for the capacity building seminar with clinic counsellors. 
 
Title Formative research: Clinic Service Report 
Description A collection of clinic mapping reports with observations under key domains and client flow. To date 3 sets of site visits have been conducted by project researchers, the first by the UP research team and the remaining 2 by LSTM researchers. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact The clinic mapping has identified a need to produce materials to support the standardisation of counselling in clinics. Additionally, data collection and handling should be standardised across clinics and data generated used more to assess and improve clinic performance. Significant variations in the application of the rapid diagnostic algorithm for HIV were observed. Observations from the clinic mapping were used to develop realistic scenarios for the game design. 2018 Update: A patient flow chart was produced and put up in the study clinics to ensure clinic staff understood and followed correct procedure. 
 
Title Formative research: Self-Report Survey Dataset 
Description Data was collected using two methods: 1) Face to face during outreach HIV screening events. Participants were invited to complete the survey in a private room by counsellors from Klinika Bernardo or LoveYourself PH. Participants entered their responses by themselves using a tablet, research assistants were on hand if the participants had any questions. Participants were offered a free drink as an incentive. 2) Participants accessed the online survey via targeted advertisements and completed it completely independently. No incentives were offered. All data was collected using the Bristol Online Survey tool. Data was exported into encrypted excel sheets for further analysis. 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact Analysis of this data has informed the objective, design and content of the mobile game. Recruitment method used generated a significantly high response rate and will be used to advise recruitment strategies for similar projects. 
 
Title HIV Self-testing Formative Research: KII and FGD Transcripts 
Description A collection of qualitative data from a series of stakeholder interviews and focus group discussion with potential end users as part of an explorative study on HIV self-testing in the Philippines. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact HIV self-testing was overwhelmingly regarded as a strategy that has the potential to increase testing uptake among key populations including MSM and transgender women in the Philippines. Reservations centred upon regulation and legal aspects were identified. Data from this study will be used to illustrate the potential, demand and acceptance of HIV self-testing and will help identify appropriate regulatory pathways should the Philippines consider this testing strategy. 2019 update: Journal article titled - "It would be easier, you can do it anywhere, anytime". Is the Philippines ready for HIV self-testing? - submitted to Journal of the International Aids Society and is awaiting review. Findings were also adapted into a 2-page policy brief which was shared with Filipino stakeholders during the AIDS 2018 pre-conference workshops. 
 
Description Davao Social Hygiene Clinic 
Organisation Davao City Health Office
PI Contribution LSTM research team aims to use data collected through the project to inform on targeted interventions to improve quality and uptake of HIV testing and counselling (HTC) services. The research team brings with it expertise in diagnostic implementation research and directly supports researchers in the Philippines in data collection and HTC systems analysis. To date the research team has: Consulted on clinic mapping guidelines. Conducted clinic site visits. Conducted short interviews with staff to facilitate an understanding of clinic procedure and challenges. Improved clinic data management. Davao Social Hygiene clinic replaced Manila Social Hygiene Clinic and expanded the projects geographical reach to the south of the Philippines. 2019 update: Initial findings from the study have been fed back to senior clinic staff and Davao City Council.
Collaborator Contribution The clinic provides project researchers access to clinic data, facilities and staff. To date, the clinic: Hosted and informed researchers during site visits. Distributed a short survey to all clients at registration post-game launch, to assess how many clients are aware of and have played Battle in the Blood over a 12-month period. Clinic counsellors' play tested Battle in the Blood during a focus group discussion and provided input into the messaging in the game. Data gathered at the clinic will support the design and evaluation of interventions deployed by the project. 2019 update: Data collection at the clinics has been completed. Clinic staff continue to promote and use Battle in the Blood as part of their counselling and community engagement activities.
Impact In collaboration with the research team at the University of the Philippines, College of Medicine (UP) the following outcomes/ outputs have been achieved and are detailed in the relevant sections: Improved data collection at HTC clinics. Battle in the Blood Pilot: Baseline Clinic Use at Study Sites. Battle in the Blood Pilot: Game Use by HIV Testing and Treatment Service Users.
Start Year 2017
 
Description Game Developers 
Organisation EM Studios
Country United Kingdom 
Sector Private 
PI Contribution Researchers at LSTM work directly with the game development team at EM Studios to support the game design. All game related activities are co-ordinated by the ETCH unit with researchers from the University of the Philippines (UP) regularly consulted. To date the research team has: Co-ordinated the production of a game design document and development schedule. Produced a detailed game specification. Co-ordinated and facilitated workshops with potential end users to assess their perceptions and use of mobile games and gain feedback on initial design approaches for the game. Established a development schedule with key deliverables. Conduct weekly meeting to discuss development progress. 2018 Update: LSTM researchers successfully co-ordinated the development of Battle in the Blood. In partnership with UP, repeated user-testing sessions were conducted to inform the game design. The ETCH unit was responsible for communicating feedback from user-testing sessions to EM Studios. All changes and bug fixes resulting from this feedback were discussed and prioritised. The ETCH unit developed a specification for the game analytics to ensure they were ethical and in line with research activities.
Collaborator Contribution The game is still in early stages of development. To date EM Studios have: Produced a game design document based on the detailed game specification and direct input from ETCH and UP. Produced and released a technical prototype of the game demonstrating the underlying game mechanics. Produced concept art. Produced wireframes for the game's interface. Conducted research into the Philippines commercial gaming market to support the game design. 2018 Update: The game (Battle in the Blood) is currently being piloted and distributed via the Google Play and AppStore. EM Studios built Battle in the Blood to a high standard on budget and on time. Features of the game are described under the Medical Products, Interventions and Clinical Trials section of the report. The lead coder was responsible for setting up the collection and storage of all game data within the Unity Game Engine. A custom-built data visualisation tool was also developed to support researchers in monitoring game use and assessing demand for the game among key populations. EM Studios manage the app store distribution of the game on behalf of UP, UP own the app store account. They continue to support the game by making any necessary fixes to the game and releasing updated builds. The developers are currently considering ways the game can be optimised for use on very low-end budget smartphones.
Impact Serious Mobile Game - Early Development. Mobile Game Development Character Concepts. Royal Society Summer Science Exhibition. Custom Unity Game Analytics. Battle in the Blood - Game Analytics. Battle in the Blood - Support Tool for Medical Intervention. Certificate of Recognition for Innovation in Apps for Health: International Society for Neglected Tropical Diseases
Start Year 2016
 
Description HIV Self Testing Africa (STAR) Consortium 
Organisation London School of Hygiene and Tropical Medicine (LSHTM)
Country United Kingdom 
Sector Academic/University 
PI Contribution Miriam Taegtmeyer and Russ Dacombe have been conducting work under STAR, the results of which have fed into our future strategy and methods. To date they have lead a study on the visual stability of late reads of oral fluid self-tests and suitability in external quality assurance. Conducted Key Informant Interviews with policy makers and regulators on HIV self-testing in 3 African countries. Initiated the development of regulatory pathways for the introduction of HIV self-testing. Provided comments on the Technical Specification Series for submission to the WHO Prequalification Diagnostic Assessment document on HIV testing. The ETCH Unit has held initial discussion with implementers on the development and use of games to support uptake and use of HIV self-tests.
Collaborator Contribution Invited researchers into the qualitative research network for capacity development in the implementation challenges for testing scale-up and stigmatisation in key populations. Informed on methods for multi-level research on preferences of self-testing among different communities. Informed on research for the distribution of HIV self-testing kits in STAR countries. This research has included economic assessments, measuring linkage to care and uptake of testing in different distribution models.
Impact ETCH Blog
Start Year 2017
 
Description HIV Self Testing Africa (STAR) Consortium 
Organisation Population Services International
Country United States 
Sector Charity/Non Profit 
PI Contribution Miriam Taegtmeyer and Russ Dacombe have been conducting work under STAR, the results of which have fed into our future strategy and methods. To date they have lead a study on the visual stability of late reads of oral fluid self-tests and suitability in external quality assurance. Conducted Key Informant Interviews with policy makers and regulators on HIV self-testing in 3 African countries. Initiated the development of regulatory pathways for the introduction of HIV self-testing. Provided comments on the Technical Specification Series for submission to the WHO Prequalification Diagnostic Assessment document on HIV testing. The ETCH Unit has held initial discussion with implementers on the development and use of games to support uptake and use of HIV self-tests.
Collaborator Contribution Invited researchers into the qualitative research network for capacity development in the implementation challenges for testing scale-up and stigmatisation in key populations. Informed on methods for multi-level research on preferences of self-testing among different communities. Informed on research for the distribution of HIV self-testing kits in STAR countries. This research has included economic assessments, measuring linkage to care and uptake of testing in different distribution models.
Impact ETCH Blog
Start Year 2017
 
Description Manila Social Hygiene 
Organisation Manila Social Hygiene Clinic and Treatment Hub
Country Philippines 
Sector Hospitals 
PI Contribution LSTM research team aims to use data collected by partners to inform on targeted interventions to improve quality and uptake of HIV testing and counselling (HTC) services. The research team contributed in diagnostic implementation research and directly supports researchers in the Philippines in data collection and HTC systems analysis. To date the research team has: Consulted on clinic mapping guidelines. Consulted on topic guides for focus group discussions (FGD) with service providers. Conducted clinic site visits. Conducted short interviews with staff. Conducted qualitative analysis of FGD transcripts.
Collaborator Contribution The clinics provide project researchers access to clinic data, facilities and staff: Clinic staff have attended focus group discussions. Hosted and informed researchers during site visits. Counsellors and peer educators have attended a capacity building seminar. The collaboration with the clinic ceased in 2016 due to concerns over the continued sustainability of counselling services. The clinic will be replaced with Davao Social Hygiene Clinic.
Impact In collaboration with the research team at the University of the Philippines, College of Medicine (UP) the following outcomes/ outputs have been achieved and are detailed in the relevant sections: Capacity Building Seminar for Clinic Counsellors - multi-disciplinary: clinical epidemiology, dermatology, microbiology, game development. Formative Research: KII & FGD Transcripts. Formative Research: Clinic Service Report.
Start Year 2016
 
Description NGO Social Hygiene Clinics 
Organisation LoveYourself Inc
Country Philippines 
Sector Private 
PI Contribution LSTM research team aims to use data collected by partners to inform on targeted interventions to improve quality and uptake of HIV testing and counselling (HTC) services. The research team has contributed to the diagnostic implementation research and directly supports researchers in the Philippines in data collection and HTC systems analysis. To date the research team has: Consulted on clinic mapping guidelines. Consulted on topic guides for focus group discussions (FGD) with service providers. Conducted site visits at LoveYourself Uni and LoveYourself Anglo HIV testing and counselling facilities. Conducted short interviews with staff. Conducted qualitative analysis of FGD transcripts. 2019 update: Initial findings from the study have been fed back to senior staff at Loveyourself Uni and Anglo.
Collaborator Contribution The clinics provide project researchers access to clinic data, facilities and staff: Clinic staff have attended focus group discussions. Hosted and informed researchers during site visits. Counsellors and peer educators have attended a capacity building seminar. Data gathered at the clinic will support the design and evaluation of interventions deployed by the project. 2018 update: Clinic staff are distributing a short survey to all clients at registration post-game launch, to assess how many clients are aware of and have played Battle in the Blood over a 12-month period. 2019 update: Data collection at the clinics is complete. Clinic counsellors continue to promote and use Battle in the Blood as part of their counselling and community engagement activities.
Impact In collaboration with the research team at the University of the Philippines, College of Medicine (UP) the following outcomes/ outputs have been achieved and are detailed in the relevant sections: Capacity Building Seminar for Clinic Counsellors - multi-disciplinary: clinical epidemiology, dermatology, microbiology, game development. Improved data collection at HTC clinics. Formative Research: KII & FGD Transcripts. Formative Research: Clinic Service Report. Battle in the Blood Pilot: Baseline Clinic Use at Study Sites. Battle in the Blood Pilot: Game Use by HIV Testing and Treatment Service Users. Philippines 'It's time to test differently' Workshop AIDS 2018.
Start Year 2016
 
Description Quezon City Government Health Department 
Organisation Klinika Bernardo
Country Philippines 
Sector Hospitals 
PI Contribution LSTM research team aims to use data collected by partners to inform on targeted interventions to improve quality and uptake of HIV testing and counselling (HTC) services. The research team has contributed in diagnostic implementation research and directly supports researchers in the Philippines in data collection and HTC systems analysis. To date the research team has: Consulted on clinic mapping guidelines. Consulted on topic guides for focus group discussions (FGD) with service providers. Conducted clinic site visits. Conducted short interviews with staff. Conducted qualitative analysis of FGD transcripts. 2019 update: Initial findings from the study have been fed back to the clinic and Quezon City Council.
Collaborator Contribution The clinic provides project researchers access to clinic data, facilities and staff. Clinic staff have attended focus group discussions. Hosted and informed researchers during site visits. Counsellors and peer educators have attended a capacity building seminar. Data gathered at the clinic will support the design and evaluation of interventions deployed by the project. 2018 Update: Distributing a short survey to all clients at registration post-game launch, to assess how many clients are aware of and have played Battle in the Blood over a 12-month period. 2019 update: Data collection activities ceased in June 2018. Due to extraneous circumstances, the clinic was unable to continue supporting project activities. Researchers are in discussion over how this will affect the analysis. Clinic counsellors continue to promote and use Battle in the Blood as part of their counselling and community engagement activities.
Impact In collaboration with the research team at the University of the Philippines, College of Medicine (UP) the following outcomes/ outputs have been achieved and are detailed in the relevant sections: Capacity Building Seminar for Clinic Counsellors - multi-disciplinary: clinical epidemiology, dermatology, microbiology, game development. Improved data collection at HTC clinics. Formative Research: KII & FGD Transcripts. Formative Research: Clinic Service Report. Battle in the Blood Pilot: Baseline Clinic Use at Study Sites. Battle in the Blood Pilot: Game Use by HIV Testing and Treatment Service Users.
Start Year 2016
 
Description UP- LSTM Multidisciplinary Research Group 
Organisation University of Philippines Manila
Department College of Medicine
Country Philippines 
Sector Academic/University 
PI Contribution Researchers within LSTM's Department of International Public Health provide expertise in clinical and counselling services for HIV. To date the research team have: Consulted on the data collection tools to identify enablers and barriers to testing. Consulted on HTC clinic service mapping guides. Conducted site visits to support HTC clinic service mapping activities. Established lines of communication with NRL, Australia - currently consulting on rHIVda - for information sharing. Supporting the development of the gaming intervention are members of Engaging Tools for Communication in Health (ETCH). ETCH is a research unit within LSTM that brings together subject matter experts, stakeholders and professional game developers to support the design, development and evaluation of public health games. To date this unit has: Identified and established a contract with a game development company - EM Studios. Consulted on the data collection tools to identify enablers and barriers to testing that could contribute to the game design. Supported the analysis of the formative research on enablers and barriers to testing. Co-ordinated the production of a game design document and development schedule. Presented to Philippine stakeholders on the concept of serious gaming for public health purposes and the project's development approach. Co-ordinated and facilitated workshops with potential end users to assess their perceptions and use of mobile games and gain feedback on initial design approaches for the game. 2018 Update: LSTM researchers successfully co-ordinated the development of Battle in the Blood. In partnership with UP a total of 9 focus group discussions with target users and stakeholders were conducted throughout the development process, feedback from each session was used to assess the acceptability of the game and cognitive understanding of key health messages. Improvements were made to the game using information gathered from the focus group discussions and user-testing sessions. LSTM staff we're in-country from October to December 2017 to facilitate the focus group discussions and support the launch of the game onto the Google Play and Apple App Store on the 1st of December 2017. Activities included; supporting data collection for the project, participating in Filipino TV and print media interviews to promote the game and project, supporting the 4-day World AIDS Day Gaming competition and meeting with local Government officials to promote the game. LSTM researchers continue to improve the game by monitoring uptake and game use. Game analytics have been used to re-balance the difficulty of certain levels in the game and identify bugs and sticking points. LSTM staff are co-ordinating the analysis of data collected to determine the feasibility (demand, acceptability, practicality and limited efficacy) of the game. In addition to the development and feasibility study for the game, LSTM staff have supported research into the Philippine's readiness for HIV self-testing. Findings from this research will be communicated to relevant stakeholders. To date: Miriam Taegtmeyer has delivered a seminar, hosted at UP, and discussed key benefits and challenges in implementing HIV self-testing in the Philippines with stakeholders from Government and primary health care facilities as well as university students. A policy brief has been drafted and will be shared with relevant stakeholders. LSTM has maintained a close relationship with in-country partners and continue to support staff though the sharing of qualitative research skills. 2019 Update: The UP-LSTM multi-disciplinary team completed the final round of qualitative data collection in November 2018, involving 25 interviews with Battle in the Blood users. LSTM are co-ordinating write-up and publication of findings. Target journals include the Journal of Internet Medical Research, Serious Gaming Sister Journal and the Journal of the International AIDS Society. Two articles have been drafted and will be submitted Feb 2019. Analysis is underway for a further two articles. All members of the UP - LSTM Multi-Disciplinary Research Group will be involved in authoring these papers.
Collaborator Contribution UP-LSTM are working closely together. UPs primary role during this time was to: Co-ordinate the data collection for the formative research. Hire and train research assistants. Establish agreements with HTC clinics, local and national government. Responsibilities across all project activities are shared between the two institutes. 2018 Update: With support from LSTM, UP researchers led several user-testing sessions and focus group discussions with target users and stakeholders during the game development. Research assistants in the Philippines we're responsible for recruiting participants, transcribing and translating data for analysis. UP researchers consulted on the game design and contributed to the analysis of information gathered throughout the development process. UP led the marketing campaign for the game and established numerous interviews with TV, online and print media outlets and government officials as part of the launch. UP continues to manage data collection activities at the clinics. Summer 2017, UP hosted a MSc student from LSTM and provided substantial support for the data collection in their study. The student conducted a qualitative study with stakeholders (policymakers, men who have sex with men and transgender women) to explore perceptions of HIV self-testing. Key findings from the study were used to inform a policy brief. 2019 Update: UP researchers are leading the dissemination of initial study findings and key learnings to local stakeholders. They are in the process of obtaining resources to conduct additional marketing activities to expand Battle in the Blood's reach in the Philippines. UP researchers have begun discussions with the Philippines Council for Health Research and Development on the prospect of using mobile gaming technology to address challenges in dengue.
Impact Serious Mobile Game - Early Development. Formative research: Enablers and Barriers to HTC Use. Capacity Building Seminar for Clinic Counsellors - multi-disciplinary: clinical epidemiology, dermatology, microbiology, game development. Improved data collection at HTC clinics. ETCH Blog. Mobile Game Development Character Concepts. Royal Society Summer Science Exhibition. Recruitment Method for Self-Report Survey. Formative research: Self-Report Survey Dataset. Formative Research: KII & FGD Transcripts. Formative Research: Clinic Service Report. Battle in the Blood Development: FGD Transcripts & Video Recordings. Battle in the Blood Pilot: Game Analytics. Battle in the Blood Pilot: Baseline Clinic Use at Study Sites. Battle in the Blood Pilot: Game Use by HIV Testing and Treatment Service Users. HIV Self-testing Formative Research: KII and FGD Transcripts. Policy brief for implementation of HIV self-testing. Battle in the Blood - Support Tool for Medical Intervention. Guesting CNN Philippines. Guesting Good Morning Kuya. Guesting NWSRM5Live. Panel show guesting: The Bottom Line. Privilege Speech: Davao Local Government. Guesting Net 25 Pambansang Almusal. Guesting ABS-CBN Bandila. 4-day World AIDS Day Event in Davao: Gaming Competition. Battle in the Blood: Press Events and Press Release. HIV GET Facebook Page. Philippines 'It's time to test differently' Workshop AIDS 2018.
Start Year 2016
 
Description WHO 
Organisation World Health Organization (WHO)
Department WHO Western Pacific Region: WPRO
Country Philippines 
Sector Public 
PI Contribution Provided comments on rHIvda documentation. Contributions made through Miriam Taegtmeyer's membership to the WHO HIV testing counselling subcommittee. 2018 Update: LSTM and UP staff met with a representative from WPRO to discuss findings from a qualitative study on stakeholder perceptions of HIV self-testing. WPRO representatives were also informants for the study. LSTM researchers have drafted a policy brief on the implementation of HIV self-testing in the Philippines.
Collaborator Contribution Have facilitated communication lines with the WHO collaborating centre who are supporting the national reference lab with the Philippines RDA pilot. Provided links to informants in the WHO country and regional office. Provided a collaborative repository of status and evidence of HIV self-testing (http://hivst.org/ ).
Impact Technical input into rHIVda documentation. Policy brief for implementation of HIV self-testing.
Start Year 2016
 
Title Battle in the Blood 
Description Licensing agreement between LSTM and University of the Philippines (UP). LSTM has granted a non-exclusive, worldwide, in perpetuity license to UP to enable UP or its agents to publish and distribute Battle in the Blood and to produce any new versions, extensions or sequels to the game. While a formal agreement was not established until 2019, Battle in the Blood was published by the University of the Philippines throughout the 12-month pilot (Dec 2017 - 2018). 
IP Reference  
Protection Copyrighted (e.g. software)
Year Protection Granted 2019
Licensed Yes
Impact Initial study findings indicate that promoting Battle in the Blood as a game made by Filipino scientists and naming the University of the Philippines as the publisher had a positive influence on community acceptance and adoption of the game.
 
Title Mobile Game 
Description Technical services agreement regarding copyright and license between LSTM and EM Studio (professional game development company). Developer has granted a non-exclusive, worldwide, in perpetuity license to LSTM for all items prepared under the agreement to enable LSTM or its agents to publish and distribute the project and to produce any new versions, extensions or sequels to the project. 
IP Reference  
Protection Copyrighted (e.g. software)
Year Protection Granted 2016
Licensed No
Impact Commencement of game development
 
Title Battle in the Blood 
Description Dubbed "Battle in the Blood (#BitB)," the app is a unique puzzle and turn-based combat mobile game. The game aims to influence social norms, knowledge and attitude surrounding HIV/AIDs and challenge the belief that you can no longer live a long and fulfilling life after a positive diagnosis. It contrasts this by demonstrating the risk to your health by delaying or refusing testing and treatment services. Health messages are communicated across 90 unique levels and 10 animated stories. Players can earn power-ups to help them defeat levels by answering in-game questions. The game also features an extensive menu which includes a global leader board, information on each of the icons in the game and links to relevant information on HIV testing and treatment services. Using an iterative development process, informed through qualitative research with end users, the game took 10 months to develop from the technical prototype. The pilot game is freely available for download on the Google Play and App store. The game development was funded by the Newton Agham Programme. 
Type Support Tool - For Medical Intervention
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2018
Development Status Under active development/distribution
Impact The approach used for the development of Battle in the Blood was successful in improving key features of the game and can be applied to any game for health, provided the learning objectives and target audience for the game have been specified. This approach can also be used to optimise Battle in the Blood for use in different contexts. 2019 update: Research conducted through the project has demonstrated that Battle in the Blood is accepted by target users and has a positive influence over knowledge and attitudes towards HIV services and people living with HIV in the Philippines. A qualitative exploratory study has identified cases in which the game has triggered positive health seeking behaviours. Factors that have contributed to the game's performance have been identified and will be used to develop validated strategies for the roll out and sustainability of games for health in lower- and middle-income countries. 
URL https://etch.lstmed.ac.uk/games/battle-in-the-blood-bitb
 
Title Mobile Game 
Description A game design document (GDD) has been collaboratively produced by ETCH (LSTM), University of the Philippines and EM Studios. The GDD is a living document providing a detailed roadmap for the development of a purpose-built mobile game to encourage members of the at-risk population of the Philippines to access HIV testing and treatment services. A collection of artwork and interface mock-ups have been produced and reviewed internally and externally with target users. A technical prototype of the game will be submitted by EM Studio to the research team and reviewed at the end of February 2017. 
Type Support Tool - For Medical Intervention
Current Stage Of Development Initial development
Year Development Stage Completed 2017
Development Status Under active development/distribution
Impact Building capacity within the University of the Philippines to coordinate the design and development of a health advocacy game. 
URL https://drive.google.com/open?id=1bkdHpTAfNr0xUXKjGX2qOqk4WU4ENlRsetoH75m-ySo
 
Description 4-day World AIDS Day Event in Davao: Gaming Competition 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact A 4-day competition was held during the national World AIDS Day event in Davao. 60 competitors from 3 districts played Battle in the Blood with the finals held on the last day of the event. Audience members also competed for prizes by downloading and playing the game.
The competition was held to celebrate the global launch of Battle in the Blood on the Google Play and App Store. Over 500 individuals downloaded and played the game during the competition, 92% from the Philippines.
Year(s) Of Engagement Activity 2017
URL http://www.sunstar.com.ph/davao/local-news/2017/11/29/hiv-aids-game-app-launching-dec-1-577282
 
Description A Game Changer for Public Health Promotion: ISNTD Festival 2018 Workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The workshop demonstrated the use of mobile gaming as a two-way method of health communication. Workshop objectives included;
To understand the design and development process for games for health;
to understand how game analytics can be utilised to obtain data from key populations and assess the uptake and use of the intervention;
to explore the use of digital games to address health challenges in resource poor settings and neglected tropical diseases (NTDs).
Participants had a range of backgrounds, some with experience in games for health development and evaluation and some completely new to the concept. Consultation on game analytical tools was offered in kind to one of the participants after the workshop.
Year(s) Of Engagement Activity 2018
URL https://youtu.be/XkzKU8XK4To
 
Description Battle in the Blood Demo: Building Bridges Through HIV Testing Networking Zone AIDS 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact LSTM and UP researchers we're invited by WHO to demonstrate Battle in the Blood at the Building Bridges Through HIV Testing networking zone. Visitors at the Global Village were able to play test the game and speak with researchers to learn about the HIV GET Tested project. Two game competitions and question and answer sessions were held at the zone. The team joined representatives from UNAIDS, UNITAID and PSI to engage visitors at the AIDS 2018 Global Village.
Year(s) Of Engagement Activity 2018
URL https://etch.lstmed.ac.uk/news-events/news/meet-the-bitb-contestants-from-aids-2018
 
Description Battle in the Blood Promotional Exhibitions 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Throughout the 12 month pilot, UP and LSTM researchers have run a series of promotional exhibition booths for the game, visitors are awarded a prize for downloading the game. Visitors had the opportunity to speak with researchers about the project. Events include but aree not limited to the: eSports and Gaming Summit, Manila 2018; HIV/AIDS Colloquium by SOAS University of London, Manila 2018; 14th National Biotechnology Week, Pasay City 2018; 17th National Health Research Forum for Action, Manila 2018; PNHRS 12th National Conference, Baguio City 2018; BPO Beauty Queen Pageant, Manila 2018; White Beach Holy Week Festival, Puerto Galera 2018; Gamecon.ph Manila 2018; Health Symposium and Game Challenges University of the Philippines, Manila campus 2018.
In addition to this TV, print and radio channels were used to promote the game and the events.
Year(s) Of Engagement Activity 2018
 
Description Battle in the Blood: Press Events and Press Release 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact 3 press events were conducted in Manila and Davao with multimedia journalists and project researchers to raise awareness of project activities and promote the launch of the Battle in the Blood. A press release for the project was developed and shared with numerous print and online platforms. A complete list of news articles can be provided upon request.
Year(s) Of Engagement Activity 2017
 
Description Capacity Building Seminar for Clinic Cousellors 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Full day capacity building seminar with counsellors from project study clinics and additional sites across Manila, Philippines.
The objectives of the seminar were to:
Improve understanding of the HIV virus at a more technical level.
Inform on dermatological signs of HIV.
Inform on project activities and the development process for the serious game.
Presentation topics and speakers were selected following initial analysis of the focus group discussions with service providers. Clinic counsellors felt they could provide better support and counselling to certain clients if they could communicate risks associated with HIV at a more technical level. Equally, counsellors stated during discussions a desire to better understand the design process and purpose of the serious game.
The seminar facilitated questions and conversations between counsellors and subject matter experts. Feedback forms were completed at the end of the seminar for assessment.
Year(s) Of Engagement Activity 2016
URL https://www.youtube.com/watch?v=vmH5XM4t-K0
 
Description ETCH Website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact The ETCH website is a micro-site within the LSTM website and promotes the games for health research conducted at the school. Charlotte Hemingway, a member of HIV GET is responsible for managing the content on the website and regularly posts news articles associated with HIV GET.
Year(s) Of Engagement Activity 2017,2018,2019
URL https://etch.lstmed.ac.uk/projects/hiv-get-tested
 
Description Guesting ABS-CBN Bandila 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact Dr Emmanuel Baja and Charlotte Hemingway (LSTM) featured on a late-night news show to promote the project and launch of Battle in the Blood. During the interview researchers discussed the purpose of the project and how Battle in the Blood was developed. A demo of the game was given.
Year(s) Of Engagement Activity 2017
URL https://www.facebook.com/fatty.hemingway/videos/10154845029850303/
 
Description Guesting CNN Philippines 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact Dr Emmanuel Baja, project PI was interviewed on CNN Philippine's morning news show to promote the launch of the mobile gaming app Battle in the Blood. A short demo of the game was given.
Follow link to online copy of the interview.
Year(s) Of Engagement Activity 2017
URL https://www.facebook.com/CNNPhilippines/videos/2079886362251252/?hc_ref=ARRLiyG1TduP-g6EFH5Qo_UFArwE...
 
Description Guesting Good Morning Kuya 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact Dr Emmanuel Baja, Dr Jody Dalmacion (UP Manila) and Charlotte Hemingway (LSTM) were featured guests on a popular breakfast talk show in the Philippines. During the show researchers discussed the purpose of the project and how Battle in the Blood was developed. A demo of the game was given.
Follow link for video of the full show - skip to 1:37:00 for the interview.
Year(s) Of Engagement Activity 2017
URL https://www.untvweb.com/full_video/good-morning-kuya-november-24-2017/
 
Description Guesting NWSRM5Live 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact Dr Emmanuel Baja, Dr Jody Dalmacion (UP Manila) and Charlotte Hemingway (LSTM) were guests on an online feature show for World AIDS Day 2017. During the show researchers discussed the purpose of the project and how Battle in the Blood was developed. A demo of the game was given.
The show was broadcast via their Facebook channel and received over 13K views.
Year(s) Of Engagement Activity 2017
URL https://www.facebook.com/News5Features/videos/1782027715142996/
 
Description Guesting Net 25 Pambansang Almusal 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact Dr Emmanuel Baja and Charlotte Hemingway (LSTM) were guests on a breakfast news show. During the show researchers discussed the purpose of the project and how Battle in the Blood was developed. A demo of the game was given.
Year(s) Of Engagement Activity 2017
URL https://www.facebook.com/jhm.villafuerte/videos/10215432039900382/
 
Description HIV GET Facebook Page 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact The HIV GET Facebook page regularly posts information on HIV testing and treatment services and promotional material for the game. The page is also used to support recruitment for research activities by posting adverts.
The page is maintained by research assistants in the Philippines. LSTM staff have administrative access to the page and contribute to the content.
As of the 1st of February 2018, the page has 1,037 followers. Posts on the page reached over 82,000 Facebook users in January 2018. Users send any queries or concerns they have regarding HIV testing and treatment services or the game through posts or the private messaging service. Research assistants maintain a 100% response rate to messages.
Year(s) Of Engagement Activity 2017,2018
URL https://www.facebook.com/HIVGET/
 
Description Panel show guesting: The Bottom Line 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact Dr Emmanuel Baja represented the project during a panel show discussion on the rapidly emerging HIV epidemic in the Philippines and the activities taking place to increase uptake of testing and access to treatment.
Year(s) Of Engagement Activity 2017
URL https://www.facebook.com/TheBottomlinePH/videos/2011432898900741/
 
Description Philippines 'It's time to test differently' Workshop AIDS 2018 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Facilitated a pre-conference workshop 'It's time to test differently: Finding the right mix with differentiated HIV testing' at AIDS 2018 with delegates from the Philippines. The country team was made up of representatives from the Philippines Department of Health, Loveyourself, I-REACT, Pedal for HIV and UP College of Medicine. The workshop was facilitated by Miriam Taegtmeyer and Virginia Macdonald from the Key Populations and Innovative Prevention Unit, HIV Department, World Health Organisation.
Year(s) Of Engagement Activity 2018
 
Description Privilege Speech: Davao Local Government 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Dr Emmanuel Baja (UP manila) presented the project and Battle in the Blood at the 18th City Council of Davao to Vice Mayor Paolo Duterte and members of the Sangguniang Panglunsod ng Davao. The full Philippine's project team and Charlotte Hemingway (LSTM) were also in attendance.
Dr Emmanuel Baja, Dr Jody Dalmacion and Charlotte Hemingway also attended a local government media event to promote the launch of the game at the World AIDS Day event in Davao.
Year(s) Of Engagement Activity 2017
 
Description Royal Society Summer Science Exhibition 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Members of the ETCH research unit supported the coordination and design of LSTM's exhibition for the Royal Society Summer Science Exhibition.
ResistanceSim Bioassay Simulator, a mini game designed by ETCH and developed by EM studios was one of 4 interactive components of the exhibit. ETCH researchers volunteered as exhibitors and spoke to both the media and the public on the use of games for public health purposes.
Year(s) Of Engagement Activity 2016
URL http://www.lstmed.ac.uk/news-events/news/lstm-at-the-royal-society-summer-science-exhibition-2016-0