From the *Denver Public Health Department and Departments of Medicine and Preventive Medicine, University of Colorado, School of Medicine, Denver, Colorado; and †Centers for Disease Control and Prevention, Atlanta, Georgia.
Supported by the Internet and STD Center of Excellence; CDC Cooperative Agreement U50/CCU300860; APTR TS-1400.
Correspondence: Cornelis A. Rietmeijer, MD, MSPH, Denver Public Health Department, 605 Bannock Street, Denver, CO 80204. E-mail: firstname.lastname@example.org.
Received for publication May 2, 2008, and accepted May 16, 2008.
The Internet as a place to find sex partners and thus as a potential risk factor in the acquisition of sexually transmitted infections (STI) was first described at the beginning of the new millennium.1,2 Similar to offline outreach interventions, the congregation of at-risk populations on the Internet was quickly recognized as a potential “venue” for STI and HIV prevention. During the past decade, a multitude of online interventions have been launched, some of which included rather basic adaptations of offline interventions, whereas others have used the full interactive potential of the Internet in very innovative ways. An inventory of such interventions was recently published, but is becoming rapidly outdated because new interventions are coming online on a regular basis.3
Although the field of online STI/HIV prevention is promising and exciting, there are a number of challenges that must be overcome before interventions using new communication technologies (including mobile telephones and instant messaging) can be recommended and implemented on a large scale. First, most of what is known about these interventions from the literature and presentations at conferences is descriptive and a “proof of concept” at best. Larger scale evaluation studies are relatively rare. Thus, the article published by Koekenbier et al. in this issue of Sexually Transmitted Diseases4 is to be applauded. This article reports on an online intervention in which syphilis testing was offered to men who have sex with men (MSM) in the Amsterdam area. The website, during part of the study promoted by banner advertisements on gay Internet sites, invited visitors to download and print a laboratory form that could be brought to a testing site where blood was drawn for syphilis testing. Results were made available online within a week of testing. Evaluation findings of the intervention indicate that the investigators were able to attract high-risk MSM for testing; the proportion of men testing positive for syphilis using the online service was higher than among men visiting the Amsterdam STI clinic. However, the article also points to an important limitation that it shares with many other online interventions. During the time frame studied, the online service added just five new cases of infectious syphilis to the 249 cases diagnosed at the STD clinic (2.0%), thus calling into question the potential public health impact of the intervention and whether, at the end of the day, the intervention will be cost-effective. One could argue that most of the costs related to Internet-based interventions are incurred at the start-up and that, once the intervention site is “up”, it can be sustained with minimal additional financial support, effectively reducing the marginal cost for each additional test and each additional new case of syphilis diagnosed. Thus, even though the effectiveness of the intervention may be limited, it could still be cost-effective. However, if the use of the site requires ongoing maintenance and advertising through (costly) banner ads, the costs may be higher and the intervention less efficient.
Ultimately, the success of Internet-based STD interventions, like their offline counterparts, will be determined by how they will be scaled-up and disseminated.
There are two properties of the Internet that should be explored further to advance the utility of this prevention tool. First, one of the great advantages of the Internet is that everyone with access can visit a single, centralized website. Unlike offline interventions, online prevention services need not be replicated endlessly. Even adaptation to local circumstances can be accomplished in a centralized way. Thus, resources can be pooled to provide the necessary financial support to create attractive, professional Internet-based prevention programs and promote them adequately.
Second, the Internet is increasingly accessible by all populations, including those at risk for STIs. The challenge is to attract at-risk individuals to these services and make use of them. One way of achieving this is for us as providers to further develop and integrate Internet-based services as part of our prevention repertoire and to educate our clients and patients about the availability of these services. In other words, we need no to normalize the Internet environment as a place for STI prevention services. People exist in multiple venues, including bricks-and-mortar buildings, cell-phones, online social networks, game-based virtual worlds, and chat rooms. All of these venues have the potential to convey health information, as do e-mail, didactic web pages, and traditional media. Health-care providers and systems of health management need to incorporate blended-media approaches to effectively reach clients in a variety of venues. Messages and services should be designed with multiple platforms and venues in mind, rather than adapting one concept to fit all media. In addition, the development of new partnerships between health professionals and the communications-technology industry will synergize talents across these fields. Finally, simple tools for health-behavior self-management should be developed to allow individuals to actively participate in their own wellness. The more people encounter relevant opportunities for health and wellness in the venues where they shop, study, socialize, and seek sex, the better our chances of improving sexual health in the population.
1. Klausner JD, Wolf W, Fischer-Ponce L, Zolt I, Katz MH. Tracing a syphilis outbreak through cyberspace.[comment]. JAMA 2000; 284:447–449.
2. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. JAMA 2000; 284:443–446.
3. Rietmeijer C, Shamos SJ. HIV and sexually transmitted infection prevention online: current state and future prospects. Sex Res Social Policy 2007; 4:65–73.
4. Koekenbier R, Davidovich U, Van Leent E, Thiesbrummel H, Fennema H. Online-mediated syphilis testing: feasibility, efficacy and usage. Sex Transm Dis 2008; 35:764–769.