APPROXIMATELY 45 MILLION American households are using the Internet for a wide array of activities, including e-mail, online shopping, and finding information on numerous topics. By 2004, this number is projected to double, representing up to 170 million users. 1 The use of the Internet is particularly widespread among adolescents and young adults, the group at highest risk for sexually transmitted infections (STIs). In a recent survey by the Kaiser Family Foundation of men and women aged 15–24 years, 90% of respondents had online experience. 2 We and others have reported on the use of the Internet to seek and find sex partners. 3–8 For example, in a study among clients visiting an HIV counseling and testing site, we found that Internet sex-seekers were more likely to be men who have sex with men (MSM), to have higher rates of STIs, to report more partners, and to report sex with partners who were HIV-infected than were clients who did not seek sex on the Internet. 4 Elford et al 6 also found that seeking sex on the Internet was associated with recent STI and high-risk sexual behavior among HIV-positive and HIV-negative MSM in London. In a study in San Francisco, MSM with Internet sex partners were found to be younger, more likely to report having sex with an HIV-positive person in the past year, and more likely to report having casual partners in the past year than MSM who did not have online partners. 8 Demonstrating that Internet risk behaviors may actually translate into enhanced STI transmission, Klausner et al 9 recently described a syphilis outbreak among gay men in San Francisco that was associated with meeting sex partners through the Internet.
To date, research on the Internet as an HIV/STI risk environment has focused on subjects observed online, 3 recruited in HIV counseling and testing sites 4 or in venues frequented by MSM. 6 Less is known about use of the Internet by persons who visit STI clinics. In this article we report on a survey we recently conducted among clients of the Denver Metro Health (STI) Clinic (DMHC). In addition to Internet-related sex-seeking risk behaviors, we were also interested in the potential benefits of the Internet for finding information about STI in this population, as well as the relationship between sex-seeking and information-seeking behaviors, as this information may suggest means by which the Internet can be used for STI-prevention efforts in the future.
The DMHC is the largest STI clinic in the Rocky Mountain region, logging approximately 12,000 patient visits for a new problem per year. Between September 2000 and May 2001, a brief survey was conducted among English-speaking persons who accessed DMHC for a new problem. The survey instrument comprised 10 items, soliciting information on access to the Internet, use of the Internet for sex-seeking purposes, sex partners found via the Internet, and Internet use to find information on STI (see Appendix). The questionnaire was inserted into the patient chart by clerical staff and administered either by clinic personnel during admission (before examination by a clinician) or by the clinician after the medical/STI history was recorded.
Survey data were entered into a data file and linked by the patient identification number to demographic, risk, and clinical information contained in the computerized patient record. Only those survey forms for which a successful link could be established were used in this analysis.
All analyses were conducted with version 8 of the SAS statistical software package (SAS Institute, Cary, NC). We used the chi-square test for categorical data in the univariate analysis and multiple logistic regression analysis with backward elimination in the multivariate analysis. In the analyses we distinguished three risk categories: women, MSM (defined as men who reported having a male sex partner in the previous 12 months), and men who have sex with women (MSW, defined as men who had sex with a woman in the previous 12 months but denied having sex with a man in this period). Men who had sex with both men and women in this interval were included in the MSM group. The group of women having sex with women was too small to study separately. The study was approved by the Colorado Multiple Institute Review Board.
Between September 2000 and May 2001, a total of 4741 surveys were completed that could be successfully linked to the DMHC database, representing 55.9% of eligible clients (n = 8485) during the study period. Many unlinkable questionnaires were found to be incomplete due to clinician error or oversight, while some questionnaires were completed but were missing a valid patient identification code. Actual refusal was low (1.7%). Respondents and nonrespondents (including incomplete or unlinkable questionnaires and refusals) were nearly identical in terms of demographic characteristics (Table 1). However, respondents were significantly more likely to have reported more than one partner and/or a new sex partner in the previous 4 months than were nonrespondents, but the proportional differences were small. Moreover, condom use as well as prevalence of gonorrhea and chlamydia were not significantly different between the groups, suggesting that the surveyed sample was reasonably representative of the total STI clinic population during the survey period.
Of the total survey sample, 2159/4741 (45.5%) reported access to the Internet. Of these, 73.1% accessed the Internet at home, 11.5% at work, 5.6% at a library, 5.6% at a friend's house, and 4.1% at another site. Whites (64.0%) had significantly more Internet access than other racial/ethnic groups, as did MSM (63.3%), those with a new partner in the previous 4 months (48.9%), those with multiple partners in the past 4 months (48.0%), and those consistently using condoms (55.4%). Less access was reported by those who were older than 40 years (39.2%) or had chlamydia diagnosed (40.2%) at the survey visit (Table 1).
Of those with access to the Internet, 138 (6.4%) reported to have gone on-line with the specific purpose of finding a sex partner. Table 2 summarizes the univariate characteristics of the sex-seeking group, and the multivariate analysis of factors associated with Internet sex-seeking is presented in Table 3. In the multivariate model, MSM (28.6%) and MSW (4.4%) were significantly more likely to report Internet sex-seeking than were women (1.3%;P < 0.001). Blacks were less likely then whites to use the Internet for sex-seeking (1.7 versus 8.2%;P < 0.01), while those reporting more than one partner in the previous 4 months were more likely to seek sex than were those with one or no partner (11.0% versus 2.1%;P < 0.001). Those reporting a new partner in the previous 4 months were also more likely to seek sex than those not reporting a new partner (11.1% versus 3.9%;P < 0.001). Factors not retained in the model included age, condom use, and a diagnosis of gonorrhea or chlamydia at the time of the visit.
Sex With Online Partners
Among persons with Internet access, 146 (6.8%) reported to have had sex with one or more partners they had found on-line. The average number of lifetime Internet partners was 3 (range, 1–100). The majority (54.1%) stated that the last time they had sex with an Internet partner was less than 3 months ago, while for 19.2% it was more than 1 year ago. Condom use at last sex with an Internet partner was reported by 55.5%. Characteristics of persons with Internet sex partners were very similar to those seeking sex (see Table 2), but the results of logistic regression were different (Table 3). As for sex-seekers, MSM were more likely (30.1%) than MSW (3.7%) or women (3.1%) to have Internet sex partners (P < 0.001), and those reporting a new partner in the previous 4 months were more likely to report an Internet sex partner (10.4%) than those without a new partner (2.3%;P < 0.001). However, race/ethnicity and having multiple partners in the previous 4 months were not retained in the logistic regression model. Upon further analysis, it appeared that persons reporting online sex partners were not all sex-seekers. In fact, 45/146 (30.1%) of persons with online sex partners denied Internet sex-seeking. Compared to the 101 sex-seekers who reported Internet sex partners, this group was more likely to comprise women (31% versus 7.9%) and MSW (40.0% versus 24.7%) rather than MSM (28.9% versus 67.3%;P < 0.0001), blacks (24.4% versus 3.9%;P < 0.001), persons younger than 30 years (75.6% versus 47.5%;P < 0.05), and persons with one or no partner in the previous month (37.8% versus 14.9%;P < 0.05).
Online STI Information–Seeking
Of clients with Internet access, 604/2159 (28.0%) had used the Internet to find information on STI. In the multivariate model, MSM (42.4%) were more likely than MSW (26.8%) and women (24.5%) to seek STI/HIV information (P < 0.001). Whites (32.4%) were more likely to seek information than blacks (21.4%), and those using condoms consistently were also more likely to seek STI information online than were those using condoms never or sometimes (33.9% versus 27.0%;P < 0.05). Table 4 summarizes online STI/HIV information–seeking data as related to specific STI and risk group. Of persons seeking STI information, most (65.1%) were looking for general STI information, followed by information specific to HIV (36.3%). Similar proportions were looking for information about genital herpes (25.7%), chlamydia (22.4%), human papillomavirus (21.7%), and gonorrhea (19.9%); fewer people were interested in syphilis (16.1%). Women were significantly more likely to seek information on genital herpes (32.6%) than were MSM (13.2%) and MSW (26.4%;P < 0.01). MSM were more likely to be seeking HIV-related information (57.0%) than were MSW (29.5%) and women (34.9%;P < 0.001).
Finally, we analyzed the relationship between online sex-seeking and STI information–seeking. Of online seekers, 75/138 (54.4%) also sought STI information, compared with 529/2021 (26.2%) of those who did not seek sex (P < 0.0001).
In our survey of clients of a large urban STI clinic, we found that access to the Internet was quite high. While access was highest among whites (64.0%), considerable proportions of blacks (42.2%) and Hispanics (24.6%) also reported Internet access. As the costs of personal computing and use of online resources are decreasing and larger segments of the population are being educated about the usefulness of the Internet for daily activities, the proportion of STI clinic clients with Internet access is likely to increase in the future. From an STI epidemiology and prevention perspective, the Internet can be seen as potentially having risks as well as benefits, both of which we attempted to evaluate in our survey. Consistent with previous studies, 3–8 we found that MSM were significantly more likely to access the Internet, both in general and for sex-seeking. Still, close to 45% of persons either seeking sex on-line or reporting sex with an Internet sex partner were MSW or women. It is interesting that 30% of persons who reported online sex partners had not accessed the Internet with the specific purpose of finding a sex partner. This pattern appeared to be more common among women, MSW, and persons with fewer sex partners. We speculate that this group comprises persons who may have accessed the Internet to find companionship or romantic involvement with a person without the primary purpose of having sex but that a sexual relationship evolved subsequently.
In absolute terms, Internet sex-seeking and having sex with Internet partners are not (yet) very common behaviors, even among persons who may be considered to be at high risk for STI by virtue of the fact that they attend an STI clinic. In contrast, seeking information on STI appears to be much more common in this population: 28% of persons who have access to the Internet reported this behavior. The group of STI information–seekers showed significant overlap with the sex-seeking group in our study, suggesting that STI information–seeking is not limited to the low-risk “worried well” and that Internet-based prevention interventions may reach at-risk populations. Since adolescents and young adults are at particular risk for STIs, such interventions should be focused on this segment of the population. The previously mentioned report form the Kaiser Family Foundation provides further support of this approach. Among the 90% who reported access to the Internet in this random-dial telephone survey, 44% had sought information online about pregnancy, birth control, HIV/AIDS, or other STIs. Among those who had used the Internet to find health information, 39% said they had changed their behavior as a result of information they received online. 2 A number of recently published reports further support the potential use and feasibility of Internet-based STI/HIV-prevention interventions. 10,11
There are a number of limitations to our study. First, the study population comprised a convenient, albeit reasonably representative, sample of one urban STI clinic. Also, the study excluded persons speaking only Spanish, who make up approximately 20% of our STI clinic population. Results of this survey can therefore not be generalized to other populations, where Internet access and sex-seeking patterns may be different. Second, as with many other surveys of a sensitive nature, Internet sex-seeking behaviors may have been underreported by survey participants. Finally, for many people, use of the Internet is a relative novelty, and many participants in our study who did not have access to the Internet at the time of their interview may have gained access in the meantime. The results of this study may therefore be rapidly outdated, as more people are coming on-line every day. As the overall use of the Internet increases, so may the proportion of STI clinic clients who become aware of the possibility of using the Internet for sex-seeking and may consequently go on-line for this purpose. To investigate these possible trends, we intend to repeat this survey in the future.
In summary, it appears that the Internet is becoming increasingly popular among STI clinic patients. Our findings indicate that a considerable proportion of these clients are accessing the Internet for STI information, suggesting that the Internet may become an important STI/HIV-prevention venue. Research into the feasibility, acceptability, and effectiveness of Web-based STI/HIV-prevention interventions should therefore be encouraged.
1. The Strategis Group. Internet service providers: financial benchmarks and market potential. Washington, DC: The Strategis Group, 2000.
2. The Kaiser Family Foundation. Generation Rx.com: how young people use the Internet for health information. Menlo Park, California: The Henry J. Kaiser Family Foundation, 2001.
3. Bull SS, McFarlane M. Soliciting sex on the Internet: what are the risks for sexually transmitted diseases and HIV? Sex Transm Dis 2000; 27: 545–550.
4. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases [see comments]. JAMA 2000; 284: 443–446.
5. Bull SS, McFarlane M, Rietmeijer C. HIV and sexually transmitted infection risk behaviors among men seeking sex with men on-line. Am J Public Health 2001; 91: 988–989.
6. Elford J, Bolding G, Sherr L. Seeking sex on the Internet and sexual risk behaviour among gay men using London gyms. AIDS 2001; 15: 1409–1415.
7. Rietmeijer CA, Bull SS, McFarlane M. Sex and the Internet. AIDS 2001; 15: 1433–1434.
8. Kim A, Kent C, McFarland W, Klausner J. Cruising on the Internet highway. J Acquir Immune Defic Syndr Hum Retrovirol 2001; 28: 89–93.
9. Klausner JD, Wolf W, Fischer-Ponce L, Zolt I, Katz MH. Tracing a syphilis outbreak through cyberspace [see comments]. JAMA 2000; 284: 447–449.
10. Bull S, McFarlane M, King D. Barriers to STD/HIV prevention on the Internet. Health Educ Res 2001; 16: 661–670.
11. Klausner J. Websites and STD services. Sex Transm Dis 1999; 26: 548.
Appendix: Internet Survey Instrument
- Do you have access to the Internet? (Is there anyplace you can go to use a computer if you want to get on the Internet?)
- How do you access the Internet most frequently?
- Have you ever logged on to the Internet to find information about STI or HIV?
- Please tell us what type of information you were trying to find.
- Have you ever logged on to the Internet with the intention of seeking a sex partner?
- Have you ever had sex with someone you met over the Internet?
- How many sex partners have you ever met over the Internet?
- When was the last time you had sex with someone you met over the Internet?
- Think about the last time you had vaginal, anal, or oral sex with someone you met over the Internet. Was a condom used?
- Of the sex partners you have met over the Internet in the past 12 months, how many were male and how many were female?