Plant, Aaron MPH; Rotblatt, Harlan BA; Montoya, Jorge A. PhD; Rudy, Ellen T. PhD; Kerndt, Peter R. MD, MPH
In the last decade, the Internet has increasingly been used for public health purposes. In particular, a wide range of Internet interventions have been developed and evaluated for sexually transmitted disease (STD) and HIV prevention and management, with efficacy often on par with offline interventions.1 These include effective behavioral interventions for HIV prevention,2,3 HIV testing,4 and STD testing.5 Simply using the Internet to locate health information has been associated with active coping behaviors and treatment adherence for people living with HIV/AIDS.6
One of the promising Web-based interventions for HIV and STDs is Internet partner notification. Partner notification has been a widely utilized element of STD control for decades, with the goal of getting partners of infected patients tested and treated in a timely manner to prevent further spread of infection.7 Several studies have found Internet partner notification to be an effective complement to traditional partner notification in STDs, most notably among men who have sex with men (MSM).8–10 For instance, an evaluation of one health department's efforts found that Internet partner notification increased the number of sex partners notified of syphilis exposure by 83% and the number of sex partners examined by 26%.11
Unique among Internet partner notification efforts is inSPOT (http://www.inspot.org). Developed by Internet Sexuality Information Services, Inc. (ISIS.) in San Francisco in 2004, inSPOT was the first self-contained partner notification Web site to allow patients diagnosed with an STD to notify their partners through electronic postcards (e-cards). In December 2005, inSPOTLA was launched with funding and support from the Los Angeles County Department of Public Health Sexually Transmitted Disease Program and AIDS Healthcare Foundation. In addition to San Francisco and Los Angeles, there are now numerous jurisdictions across the United States as well as internationally that pay start-up and yearly maintenance fees to have inSPOT service in their area. Although inSPOTLA is available for anyone to use, in Los Angeles, the primary target is MSM due to their relatively large number of sex partners met online.12
One of the main benefits of inSPOTLA is that it is both simple and efficient to use. Users of inSPOTLA can choose from 6 different e-cards, which vary in tone from serious to humorous. Users then select their STD from a pull-down menu of 10 different diseases. An e-card can be sent to up to 6 partners at once, can be sent anonymously or not, and can include a personal note from the sender. E-card recipients receive an email from email@example.com.
From the very inception of the program, Web site data indicated an impressive level of use. From the launch of inSPOTLA through 2009, the Web site received over 440,000 visits, with 48,263 e-cards sent to 79,980 recipients. This includes 5635 e-cards sent for syphilis and 6348 for HIV. The launch of inSPOTLA involved a 3-month marketing campaign, as well as a press event, which resulted in widespread newspaper and television coverage. The number of e-cards sent decreased steadily after launch from an average of 826 sent per month in 2006 to 284 per month in 2009, likely due to the diminishing effects of the initial press coverage and marketing campaign.
Despite the overall high number of visits to the Web site and e-cards sent, the anonymous and limited nature of these Web site statistics severely restricts our knowledge of how inSPOTLA is actually used. For example, the Web site data are only able to show the number of e-cards sent, which STD was specified, the number of recipients, if the e-card was sent anonymously, and if the recipient clicked on the e-card he or she received. Users are asked to voluntarily disclose their zip code, but this was the only demographic data collected by the Web site before 2010. Most importantly, the Web site data cannot be used to determine how many of the nearly 50,000 e-cards sent using inSPOTLA through 2009 were sent for the intended purpose of the program, notifying sex partners of a potential STD exposure in Los Angeles County.
Several studies attempting to measure the effectiveness of inSPOT have been carried out previously. A 2005 street-intercept survey in San Francisco found 19% inSPOT awareness among MSM interviewed, with 4% having sent an e-card and 2% having received an e-card.13 A study from 2008 found no evidence for the effectiveness of inSPOT among a primarily heterosexual clinic population in Denver, where patients overwhelmingly preferred notifying partners in person.14 Finally, in a randomized controlled trial conducted from 2007 to 2009 in Washington State, only 1 of 27 (4%) MSM STD patients assigned to the inSPOT arm of the study sent an e-card.15 The goal of our evaluation was to assess inSPOTLA awareness and use for partner notification among Los Angeles County MSM, as well as to measure the impact of a 2008 advertising campaign.
MATERIALS AND METHODS
Data relevant to inSPOTLA were gathered from a high-volume sexual health clinic that primarily serves MSM in Los Angeles from 2007 through 2009. More than 85% of clinic clients identify as gay or bisexual. This clinic ranks first in diagnosing syphilis and gonorrhea in Los Angeles County compared with any other public or private clinics. The clinic diagnoses approximately 10% of syphilis cases (all MSM) and approximately 7% of gonorrhea cases (96% MSM) in Los Angeles County (Los Angeles County STD Program, unpublished data, 2009). The “reason for visiting” was collected from all patients who came to the clinic for STD/HIV testing. Clinic staff was trained to ask patients who came in because of a partner contact if they had received an inSPOTLA e-card.
Four items relevant to inSPOTLA were added to a baseline, and follow-up survey intended to evaluate a new syphilis social marketing campaign for MSM in Los Angeles County. To assess aided awareness and use of inSPOTLA, participants were asked: (1) if they had heard of inSPOTLA; (2) whether they had ever sent an inSPOTLA e-card; (3) whether they had ever received an inSPOTLA e-card; and if so, (4) if they got an HIV or STD test because of receiving the e-card. Other relevant data collected in these surveys included sexual risk behavior, HIV status, and STD infection in the past 6 months.
A time-location sample methodology was used for both the baseline and follow-up surveys. This method is often used for sampling hard-to-reach populations, such as MSM.16 The sampling frame consisted of 163 venues where substantial numbers of MSM in Los Angeles County congregate, along with the days and times when they could likely be encountered. Time/locations were randomly selected (without replacement) and put into a schedule, 1 week at a time. At least 3 trained interviewers were sent to each selected venue for a 4-hour time period. Interviewers entered participant responses into a personal digital assistant (PDA). Questions about sexual risk were completed by participants on the PDA. Interviews occurred at a total of 20 venues for the baseline survey and 21 venues for the follow-up survey.
Participants were eligible if they were male and had male or male-to-female transgender sex partners, lived in Los Angeles County, and were between 18 and 60 years of age. The baseline survey was conducted in May 2007, and the follow-up survey was conducted in August 2009. A 5-dollar incentive was offered to participants.
In 2008, the Los Angeles County Sexually Transmitted Disease Program implemented an advertising campaign to promote inSPOTLA in an effort to reverse the apparent downward trend in use. Advertisements in both English and Spanish were placed in local gay magazines and in the bathrooms of Los Angeles restaurants and nightclubs popular with MSM from June through November 2008. This advertising period occurred between the baseline and follow-up survey.
Data analysis for time-location samples may involve weighting data to account for a participant's probability of being sampled.16 However, we found no association between frequency of venue attendance and awareness or use of inSPOTLA. Therefore, the data were not weighted.17 χ2 and Fisher's exact tests were used to determine whether there was a statistically significant difference between awareness and use of inSPOTLA before and after the advertising campaign and whether MSM who were aware of inSPOTLA were at higher risk for STD infection compared with those who were not aware. All data were analyzed using SPSS version 11.0.1 (SPSS, Inc. Chicago, IL). The study protocol was reviewed by the Los Angeles County Department of Public Health institutional review board and granted exempt status, as it was deemed routine public health program evaluation.
From 2007 through 2009, a total of 29,857 patients attended the clinic to address a new STD problem or issue. Of these, 1287 (4.3%) came in due to a partner contact. Of the partner contacts, 2 (0.2%) reported coming into the clinic because of receiving an e-card from inSPOTLA.
In all, 707 individuals were approached and asked to participate in the study, with 300 agreeing to participate (42.4%). Of these, 97 were ineligible to participate, reducing the sample size to 203. Age of respondents ranged from 21 to 60 years with a median of 38. The majority of respondents were white (52.7%), followed by Latino/Hispanic (24.4%), black (13.9%), Asian/Pacific Islander (6.0%), and other race/ethnicity (3.0%). Approximately 86% of participants were MSM exclusively; 13.8% were men who have sex with men and women. Less than 1% reported male-to-female transgender partners. Participants stated residence in 70 different Los Angeles County zip codes. Ten (4.9%) of the interviews were conducted in Spanish.
Four participants (2.0%) reported one or more STD infections in the last 6 months, including one case each of syphilis, chlamydia, gonorrhea, genital herpes, and hepatitis C; 10.3% of the sample reported being HIV positive. Awareness of inSPOTLA was 15.8%, with 1 individual (0.5%) reporting ever using inSPOTLA to notify someone of a possible exposure to an STD. No respondent had ever received an inSPOTLA e-card (Table 1). Of the 4 men reporting an STD in the last 6 months, none had used inSPOTLA.
A total of 627 individuals were approached and asked to participate in the study, with 379 agreeing to participate (60.4%). Of these, 73 were ineligible to participate, reducing the sample size to 306. Age of respondents ranged from 18 to 60 years, with a median of 36. The majority of respondents were white (48.0%), followed by Latino/Hispanic (30.4%), black (12.7%), Asian/Pacific Islander (5.9%), and other race/ethnicity (2.9%). Nearly 92% of participants were MSM exclusively; 7.8% were men who have sex with men and women, and less than 1% reported male-to-female transgender partners. Participants stated residence in 99 different Los Angeles County zip codes. Twenty-four (7.8%) interviews were conducted in Spanish.
Thirty-four participants (11.1%) reported one or more STD infections in the last 6 months, including 14 chlamydia cases, 21 gonorrhea cases, 5 syphilis cases, and 3 genital herpes cases; 13.7% of the sample reported being HIV positive. Awareness of inSPOTLA was 14.4%, with 4 individuals (1.3%) reporting ever using inSPOTLA to notify someone of a possible exposure to an STD. Three (1.0%) respondents had received an inSPOTLA e-card, and all 3 reported getting an STD or HIV test because of receiving the e-card (Table 1). Two respondents had both sent and received an e-card. Therefore, the service was used by a total of 5 (1.6%) MSM. Of the 34 men reporting an STD in the last 6 months, 1 had used inSPOTLA.
There was no significant difference in awareness for inSPOTLA between the baseline and follow-up survey. The number of participants who reported ever sending an e-card increased from 1 at baseline to 4 at follow-up, and the number of participants who reported ever receiving an e-card increased from 0 to 3. However, these usage changes were not statistically significant.
In the baseline sample, MSM who were aware of inSPOTLA were no more likely to be HIV positive, have had a recent STD infection, to have met partners on the Internet or a commercial sex venue, or to have had 3 or more sex partners in the last 3 months than MSM who were not aware of inSPOTLA (Table 2). In the follow-up sample, MSM who were aware of inSPOTLA were significantly more likely to be HIV positive and to have met one or more partners on the Internet in the last 3 months.
We used 2 distinct methods to evaluate the effectiveness of inSPOTLA. This included 2 cross-sectional community surveys of MSM in Los Angeles County intended to measure inSPOTLA awareness and use for partner notification. These surveys revealed that aided awareness of inSPOTLA was relatively low, with approximately 15% of MSM in both the baseline and follow-up survey able to recall the program. Similar to earlier studies,13–15 these data also demonstrated that inSPOTLA is not commonly used by MSM in Los Angeles. Less than 1% of respondents reported sending an e-card and less than 1% reported receiving an e-card between the 2 community surveys. Furthermore, only 1 of the 38 men reporting an STD in the last 6 months was an inSPOTLA user. However, it is promising that the 3 individuals in the follow-up survey who received an e-card all sought HIV or STD testing as a result.
In addition to gathering survey data, we also attempted to measure the impact of inSPOTLA in a real-world setting. Data collected from a highly used MSM sexual health clinic, whose client population was a primary target for our advertising campaign, also found negligible use, with only 2 of over 29,000 patients visit surveys over 3 years stating that inSPOTLA was the reason for their clinic visit. Given the volume of MSM using this clinic, we would expect this number to be much higher if MSM in Los Angeles County were regularly using inSPOTLA for partner notification.
We also investigated whether MSM with a recent STD infection were aware of inSPOTLA. A total of 38 (7.5%) study participants across both samples reported an STD infection in the previous 6 months, however, in neither survey was this associated with an increased awareness of inSPOTLA. Furthermore, we investigated whether inSPOTLA awareness was associated with HIV status and certain risk factors for STD infection. We found no correlation in the baseline survey. In the follow-up survey, HIV-positive MSM and those reporting Internet partners in the last 3 months were significantly more likely to be aware of inSPOTLA. These results suggest that we were somewhat more successful at reaching an appropriate target audience by the follow-up survey, perhaps as a result of the inSPOTLA advertising campaign.
However, other than this possible outcome, our evaluation indicated that the advertising campaign had no effect. Despite a fairly substantial investment and a steady presence in local gay magazines and restaurants in gay neighborhoods in Los Angeles in the second half of 2008, there was no significant change in awareness or use of inSPOTLA after the campaign. A more robust and sustained marketing effort might have been able to achieve a better outcome. However, due to budget considerations as well as the lack of apparent impact of the advertising campaign, our current efforts have shifted to promoting inSPOTLA directly to patients at the time of their STD diagnosis through their health providers. Specifically, this includes distribution of palm cards, posters, and increased focus on provider education and training.
The disappointing results of our evaluation stand in stark contrast to the high levels of traffic received by the Web site. The nearly 50,000 e-cards sent to almost 80,000 recipients from 2005 through 2009 would seem to suggest that inSPOTLA greatly augmented partner notification in Los Angeles County. However, Web site statistics cannot determine with any certainty the number of STD-infected individuals who used inSPOTLA to notify partners, or the number of partners who sought testing and treatment after receiving an e-card. Furthermore, although users are asked to enter their zip code, many fail to supply this information or enter a fictitious zip code, making it difficult to estimate how many users even reside in Los Angeles County. Clearly, a certain number of e-cards are sent as pranks, although this number is also impossible to quantify using Web site statistics. For example, 28% of e-cards sent from 2005 through 2009 specified “crabs and scabies” as the STD, despite the fact that Los Angeles County has not experienced a large outbreak of these parasites. It is likely that the program's extensive press coverage exposed inSPOTLA to individuals outside of our target audience and resulted in use for the purpose of pranks or simply testing out the service. Whatever the case, the findings of our evaluation indicate that Web site data are insufficient to gauge the effectiveness of inSPOT.
Several limitations of this study should be considered. Because the surveys used time-location samples, MSM who do not attend these venues or who attend rarely may not be represented, resulting in a possible sampling bias. Furthermore, the increase in the number of reported STD infections in the last 6 months from baseline to follow-up could reflect a difference in the characteristics of the 2 samples. However, Los Angeles County surveillance data show a general increase in case finding for chlamydia, gonorrhea, and syphilis among MSM during the study period,18,19 likely due to several major provider initiatives for rectal and pharyngeal screening for chlamydia and gonorrhea, as well as a large-scale syphilis social marketing campaign for MSM.20 This could account for some of the rise in reported STDs in the follow-up survey. In addition, the rigor of the time-location sampling methodology should lend credibility to our findings. Using this method, we were able to systematically recruit 2 samples that were both diverse in terms of age and race/ethnicity from numerous venues across Los Angeles County. Another source of sampling bias could have been the relatively low participation rate, primarily in the baseline survey. Additionally, the fact that the surveys relied on self-report from participants in a face-to-face interview could have resulted in recall or social desirability bias, yet the latter should have been mitigated to some degree by having respondents complete sexual risk questions themselves on a PDA. The low usage numbers for inSPOTLA could be partially explained by the fact that only 38 respondents across both surveys reported an STD in the last 6 months. However, only one of these men reported using inSPOTLA, and this negligible level of use is consistent with findings from the clinic data. Moreover, the survey did not measure STD infections that were older than 6 months. Many additional participants would likely have experienced an STD since the program became available in 2005, and therefore represent potential users. A limitation of the clinic data could be that some counselors failed to elicit or accurately record the reason for visit, but it is unlikely that this could account for the extremely limited number of times inSPOTLA was mentioned as the reason for visit in recorded data from nearly 30,000 clinic visits. Finally, determining the effectiveness of the advertising campaign relied on an ecologic comparison, which cannot be used to demonstrate a causal relationship.
Despite the findings of our evaluation, we believe inSPOTLA may hold some potential to augment traditional partner notification and help to interrupt the chain of STD infection in Los Angeles County. If even a few individuals use the service for partner notification each month, the relatively modest yearly maintenance fees would be offset, and the project would likely be cost-effective relative to traditional partner notification. However, in our case, we found that the expense of a general advertising strategy, even when directed at a population with a high prevalence of STDs and large numbers of Internet partners, may not be justifiable. Other strategies, such as using health providers to promote inSPOTLA, may be more effective. One area of concern is that current data from our public health investigation staff, as well as from an ongoing study of MSM in Los Angeles County, indicate that MSM now rarely have the e-mail addresses of sex partners, but often have cell phone numbers. Adding anonymous text message notification functionality21 to inSPOT could make it usable to a higher proportion of our target population and keep the program relevant as technology use changes. Finally, we believe, it is imperative that evaluations of inSPOT be conducted in other jurisdictions to determine how it can best be used for local populations at risk for STD infection and to measure the effectiveness of the program as a whole.
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