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The Epidemiology of Internet Sex Partnering and Intervention Use, California Jeffrey D. Klausner, MD, MPH Director, STD Prevention and Control Services San Francisco Department of Public Health Associate Clinical Professor of Medicine University of California, San Francisco
© 2006 ISIS, Inc. All rights reserved. 1 Disclosure • Dr. Klausner is an employee of the City & County of San Francisco • In the past 12 months Health Communication Strategies, a health marketing company supported by King Pharmaceuticals the manufacturer of penicillin G benzathine, has supported City & County education, research and training programs • Dr. Klausner has received consulting fees from MedReviews to speak with financial analysts from Rodman & Renshaw an Investment Bank • Dr. Klausner has received medical research grant funding from Gen­ Probe, Inc.
© 2006 ISIS, Inc. All rights reserved. 2 Tracing a syphilis outbreak through cyberspace Klausner et al JAMA 2000; 284:447­450 § Report of 7 cases of syphilis associated with the Internet use in Summer 1999 § Use of the Internet for disease control ­­ Combining traditional/ cyber­notification 40% of named partners interviewed 6 cases per index patient evaluated
Sexual network of syphilis cases associated with Internet use, San Francisco, 1999 1/1 4/99 6/1 8/99 A D 3 /11/99 7/7 /9 9 7/2 6/99 E * B * C 8 /2/99 F * G * 8/5/99 A = tested positive (case) = tested negative Bold = index case * = new case
= not tested © 2006 ISIS, Inc. All rights reserved. 4 •
Cruising on the Internet highway Kim AA, Kent C, McFarland W, Klausner JD. J Acquir Immune Defic Syndr 2001; 1: 28(1):89­93. • Survey of men attending STD clinic • 32% of gay men used Internet to meet partners • Men with Internet partners had more partners, less condom use, more substance use
© 2006 ISIS, Inc. All rights reserved. 6 Correlates of Internet use in MSM with Syphilis in Los Angeles Taylor M, Aynalem A, Smith L et al. . Sex Trans Dis 2004; 31(9):552­556. • Review of 1219 syphilis cases 2001­2003 • Increase in Internet 18% ® 26% • Internet users more likely to be white, have anal sex, anonymous sex, any drug use.
© 2006 ISIS, Inc. All rights reserved. 7 Percent of Interviewed Men who Have Sex with Men Primary & Secondary Syphilis Cases Reporting Meeting Partners by Venue, California, 2001–2005 40 Percent of MSM Cases . Internet 30 Bars/Clubs 20 Bathhouses 10 Sex Clubs 0 2001 2002 2003 2004 2005 Note: The difference between bathhouses and sex clubs is the presence of private rooms; sex clubs do not have private rooms. © 2006 ISIS, Inc. All rights reserved. 8 7/2006 Provisional Data ­ CA DHS STD Control Branch
Percent of Interviewed Gay Male Cases Reporting Meeting Internet Partners by Area, California, 2001–2006 Internet Use among MSM, Interviewed P&S Syphilis Cases, CA 2001-2006*
(excluding Northern CA and Central CA due to small numbers)
Internet 50.0
45.0
40.0
Bars/Clubs % Internet Users
35.0
30.0
Bathhouses 25.0
20.0
California Total
Bay Area, No SF (Area 3)
15.0
Long
Beach (Area 7) & East
Sex Clubs 10.0
San Diego (Area 8) & East
SF (Area 9)
5.0
LA (Area 10)
0.0
2001
2002
2003
2004
2005
2006
Note: The difference between bathhouses and sex clubs is the presence of private rooms; sex clubs do Year
not have private rooms. © 2006 ISIS, Inc. All rights reserved. 9 7/2006 Provisional Data ­ CA DHS STD Control Branch
Internet site mentions, syphilis cases, San Francisco 2001­2006* 600 m4m Men4now Manhunt Other M4Msexnow.com M4M4sex.com Craigslist Gay.Com AOL 500 400 300 200 100 0 2000 2001 2002 2003 2004 2005 2006* *First half, 2006
© 2006 ISIS, Inc. All rights reserved. 10 Internet site mentions, syphilis cases, California 2002­2006* 400
Use of Specific Sites among P&S Syphilis Cases Reporting Internet Use, CA 2002-2006*
(NOTE: reported usage of individual sites is NOT mutually exclusiv e)
Manhunt.com
Adam4Adam
350
Craiglist
AOL
300
Gay.com
# Cases
250
M4M
Men4Men
200
150
100
50
0
2002
2003
2004
2005
2006
Year
*First half, 2006
© 2006 ISIS, Inc. All rights reserved. 11 Internet site mentions, new HIV cases San Francisco City Clinic 2005­2006* 140 m4m Men4now Manhunt Other M4Msexnow.com M4M4sex.com Craigslist Gay.Com AOL 120 100 80 60 40 20 0 2005 2006* © 2006 ISIS, Inc. All rights reserved. *First half 2006 includes SFGH/COPC cases
12 Sex and the Internet Davis M, Hart G, Bolding G et al. Cult Health Sex 2006; 8(2):161­174 • Interviewed 128 gay men in London; 25% HIV+ – Identity management – Anonymity – Harm avoidance (abuse, discrimination, rejection) – Potential for risk mitigation—filtering, pre­ determination
© 2006 ISIS, Inc. All rights reserved. 13 Online access increases persons learning STD test results Test results
Month © 2006 ISIS, Inc. All rights reserved. 14 The Internet for STD/HIV Prevention & Sexual Health Promotion Deb Levine, M.A., Executive Director Internet Sexuality Information Services, Inc. November 15th, 2006
ISIS, Inc. • 501(c)3 organization founded in 2001 • Creating new & effective tools to reach people with critical sexual health information • Developing high­tech solutions for sexual education and HIV/STD prevention
© 2006 ISIS, Inc. All rights reserved. 16 Best Practices for Interventions • Needs assessment – focus groups, chat/IM interviews, community advisory boards • Include community in all aspects of program development • Extensive usability testing with target audience • Good on and offline social marketing • Evaluation plan
© 2006 ISIS, Inc. All rights reserved. 17 Model ISIS Programs All program developed in partnership with SF DPH • inSPOT: an anonymous peer­to­peer online STD partner notification program • SexINFO: a sexual health cell phone text messaging program for youth • STDTest.org: download lap slips & get test results online via unique ID
© 2006 ISIS, Inc. All rights reserved. 18 © 2006 ISIS, Inc. All rights reserved. 19
inSPOT: STD e­cards • Developed in response to the rise in syphilis among men who have sex with men in San Francisco • Focus groups of target population found: 1) Pre­AIDS vs. post­AIDS mentality towards STDs 2) Always tell partners about STDs, but not always hookups, f* buddies, etc. 3) Would tell “casual sex partners” if there were an easy, anonymous way
© 2006 ISIS, Inc. All rights reserved. 20 inSPOT • Launched in October, 2004 to national media acclaim • Simple mechanics and design: § Tell Them § Get Checked • Cards can be sent anonymously or from an email address to up to 6 people § Drop down menu of STDs § Personal message optional • No back­end database • Quickly gained community trust & support
© 2006 ISIS, Inc. All rights reserved. 21 Sample e­card
© 2006 ISIS, Inc. All rights reserved. 22 Current Site • Available in 6 cities, 4 states, one country • Being translated into Spanish • Content updated for all sexual orientations • E­prescriptions available in SF for gonorrhea and chlamydia treatment
© 2006 ISIS, Inc. All rights reserved. 23 Usage statistics • 750+ people visit the site each day • 30,000 ecards have been sent to 49,500 recipients from SF site • Every month, from 50­700 ecards are sent from each site in the portal (50= Indiana; 250 = San Francisco; 700 = Los Angeles) ­ 80% of ecards are sent anonymously ­ 80% of ecards include a personal message • >49% of people receiving ecards click­through for more info about STDs and testing sites
© 2006 ISIS, Inc. All rights reserved. 24 Impact? HIV High Estimate Low Estimate (Feb – Apr Avg.) (May–Jun Avg.) Annual e­cards sent* (projected) 1,776 879 New LAC HIV Cases, 2002­04** 1,598 – 1,897 1,598 – 1,897 Est. Annual Click­ throughs* 634 427 HIV partner contacts, 2005 (113 CBO­based + 395 DHS 505 505 126% 85% PCRS)*** inSPOTLA contacts as % of Current Contacts *Projected, based on May­June 2006 ** Reported cases. Source: HIV/AIDS Semi­Annual Surveillance Summary, Jan. 2006. General est. 1500­2000 cases per year. © 2006 ISIS, Inc. All rights 25 *** From 1,347 identified index patients. Source: LAC STDP, 2006
reserved. Impact? Syphilis High Estimate Low Estimate (Feb – Apr Avg.) (May–Jun Avg.) Annual e­cards sent (projected)* 1,400 764 2005 Early Syphilis Cases** 1,185 1,185 Est. Annual Click­ throughs* 500 372 Number of 2005 Field partner contacts (sy)*** 392 392 inSPOTLA contacts as % of Current Contacts 128% 95% *Projected, based on May­June 2006 © 2006 ISIS, Inc. All rights ** Provisional. Source: LAC STDP, 2006 reserved. *** From 793 case interviews. Source: LAC STDP, 2006
26 Online Surveys • Two week survey in April 2006 • Convenience sample • Links posted on inSPOT portal, City Clinic website, HookingUpOnline.org, and Yahoo! Health • Banner ads on Gay.com – SF only
© 2006 ISIS, Inc. All rights reserved. 27 Street Intercept Surveys Convenience sample of 833 gay and bisexual men interviewed between March and December 2005 • • • • 19% knew what inSPOT was 2% had received an e­card 4% had sent an e­card 73% said, if diagnosed with an STD, would consider sending an anonymous e­card
© 2006 ISIS, Inc. All rights reserved. 28 Online survey respondents N=317 • Mean age= 31 years, (18­55+) • 64% female; 36% male • 48% Caucasian; 26% African­American; 11% Latino; 15% other • 33% spend 10­20 hours/wk online • 14% spend more than 30 hours/wk
© 2006 ISIS, Inc. All rights reserved. 29 Online surveys • • • • 13% knew what inSPOT was 3% had sent an ecard 3% had received an ecard 65% of total respondents said they would consider sending an anonymous ecard if they were diagnosed with an STD in the future
© 2006 ISIS, Inc. All rights reserved. 30 Provider Surveys • 150 surveys mailed to HIV medical providers in San Francisco; 46 (31%) returned surveys § 26% had heard of inSPOT § 9% had referred patients to site • 84% would do so in the future § 74% agreed that palm­sized cards were best way to give patients the information
© 2006 ISIS, Inc. All rights reserved. 31 SexINFO – SexText.org • Sexual health text messaging project for youth age 12­24 in San Francisco • Developed in response to rise in gonorrhea and chlamydia among young African American women • Technology driven thru the web, delivered via cell phones • Focus groups of youth found that they consider text messages to be accessible, affordable and private
© 2006 ISIS, Inc. All rights reserved. 32 © 2006 ISIS, Inc. All rights reserved. 33
Usage Stats • Developed with Advisory Board of youth workers, clergy members, adolescent medicine professionals, & young people • 4500 unique inquiries in the first 25 weeks • Top 3 Inquiries 1. What 2 do if condom broke 2. 2 find out about STDs 3. What 2 do if u think ur pregnant
© 2006 ISIS, Inc. All rights reserved. 34 Awareness of Service • 322 surveys collected at 3 SF clinics • 11% of clinic patients knew of SexINFO • Patients from target audience MOST likely to know about service African­American, aged 12­18 Low income, live in target areas Least expensive cell phone provider
© 2006 ISIS, Inc. All rights reserved. 35 © 2006 ISIS, Inc. All rights reserved. 36
Technical Side • Personal identifying info is downloaded every 24 hours to local medical record system • Results are faxed from lab to DPH and input manually by data entry person into web database via unique ID • Identifying information is never associated on the Web with test results
© 2006 ISIS, Inc. All rights reserved. 37 Statistics • Average 2000 visitors per month • 620 blood draws to date • All reactive tests have been followed up by Health Department • Future: Private server, adding chlamydia and gonorrhea testing, adding interactive feature to determine necessary tests
© 2006 ISIS, Inc. All rights reserved. 38 Online vs. Overall Screening Rates STDtest.org Overall screening 6.25% tbd Reactive serologies Early 2.6% syphilis Primary & 1.9% Secondary 2.5% 1.9% © 2006 ISIS, Inc. All rights reserved. 39 Acknowledgements • Dr. Jeffrey Klausner, San Francisco Department of Public Health, Director of STD Prevention and Control • Gilbert Herdt, PhD, Director of NSRC and SFSU Human Sexuality Program • Mary McFarlane, PhD, Research Behavioral Scientist CDC Division of STD Prevention • Eric Whitney, Associate Director, ISIS • Richard Foxall, Board Member, ISIS
© 2006 ISIS, Inc. All rights reserved. 40 Contact Information Deb Levine, MA, Executive Director ISIS, Inc. 436 14 th Street, Suite 1511 Oakland, CA 94612 510­835­9400 510­835­9402 fax deb@isis­inc.org www.isis­inc.org
© 2006 ISIS, Inc. All rights reserved. 41