Data from the past decade and a half revealed that many people, at least in the United States and Western Europe, have used the internet as a means to seek and acquire sex partners, both for short-term and potentially long-term relationships. Early survey research and 1 meta-analysis of men who have sex with men (MSM) suggested that those who sought sex partners on the internet engaged in riskier behaviors (eg, multiple sex partners) than those who did not.1,2 One later 2006–2008 clinic-based survey has shown fewer differences between internet users and non-users in risky behaviors and infection rates, although this clinic-based survey has limited generalizability.3 Intervention services have also been distributed through the same medium, including one of the major components of sexually transmitted disease (STD) prevention programs: partner services. In this editorial, we address a study in which an STD clinic implemented and evaluated the effects of an online partner notification program.4 The results have led us to write about the role of the intervention, as well as the role of the clinic.
If people can find partners online, many of them should be able to either put a disease intervention specialist (DIS) in touch with those partners through the same medium or send an online notification message themselves. In fact, DIS have used email and other electronic methods5 to contact partners of persons infected with syphilis or HIV, whether the infection occurred with a partner met over the internet.6,7 However capable DIS may be, there are insufficient numbers of them to provide partner services to all infected people, and, in the current fiscal climate, that fact is not likely to change soon. With the index patient as the alternative medium through which partner services can be offered, it makes sense to explore how the internet might contribute to partner services intervention.
With a few exceptions,2,8 the majority of the literature on online sex partner seeking has either focused on MSM or found that MSM make up a disproportionate fraction of people seeking sex on the internet. A substantial proportion of this subset of MSM has relatively large numbers of partners and poor-quality contact information for them. Consequently, initial efforts to establish internet partner notification programs focused upon MSM. While internet sexuality information services first adopted this approach when it created inSPOT, a website dedicated to facilitating internet partner notification, it now aims to be inclusive of all audiences, regardless of sexual orientation.9
In this issue, Rietmeijer et al. describe the promotion of inSPOT and uptake of its services among STD clinic clients, a predominantly heterosexual population in Denver.4 Promotion of inSPOT was achieved through 4 activities that were “feasible in the ‘real-world’ setting [given] the resource constraints of a typical STD clinic”: (1) distribution of cards advertising inSPOT to index cases, (2) clinic posters and flyers, (3) a link to inSPOT on the STD clinic website, and (4) newspaper and radio advertisements. Evaluation was straightforward: distribution of pre- and post-surveys assessing recognition and use of the website, and an analysis of website statistics. The study thus provides an example for how the promotion of inSPOT can be embedded in routine operations and how an affordable and meaningful evaluation can be conducted within a given STD clinic setting.
Sadly, the quality of implementation and evaluation is not a guarantee of efficacy. Despite promotion efforts, this evaluation found recognition and use of inSPOT was too low (<6%) to contribute meaningfully to STD prevention efforts in the clinic. Given the resource restrictions plaguing STD clinics and health departments, it is unlikely that future promotional activities of inSPOT services will surpass the efforts described in this study. Furthermore, the majority of clinic survey respondents (90%) indicated that they would notify sex partners in-person if they were (hypothetically) diagnosed with an STD; 5% indicated that they would use email or the internet. These findings cohere with other recent studies in which predominantly heterosexual samples acknowledge that internet-based systems may be useful but prefer face-to-face or telephone conversations for patient-based notification and referral.10
We suspect that the apparent ill-fit of inSPOT to the clinic is not fundamentally about whether the clinic clientele comprises heterosexuals, or MSM, gay-identified or otherwise. The key variables may instead lie in the technical proficiency of the clinic population or even the nature of the relationships. Given the extent to which communications technology has permeated modern culture, simple lack of proficiency is unlikely to be the difference between 5% uptake and 75% uptake, although technological apathy and uncertainty might play a larger role. About relationships, transient consensual sexual encounters among partners whose expectations for future contact are low or undefined may lend themselves to a brief and even relatively impersonal notification through a popular and accessible medium (eg, email or instant messaging). More established relationships, as alluded to in Rietmeijer et al.,4 perhaps require more personalized and interactive contact. This broad categorization of relationships may be correlated with sexual orientation or gender, which would then be markers for notification preferences. Orientation and gender should not be mistaken, however, for the causes of the preference. For example, although MSM appear amenable to internet-based notification,11 1 survey showed that a majority of MSM sampled preferred to notify partners face to face.12 As one thinks of calibrating the use of a program like inSPOT for greatest efficiency and cost-effectiveness among the range of partner notification interventions, the focal issue is presumably to select implementation sites in which infection is diagnosed among people who are technologically adept and inclined and who seek casual sexual encounters. Whether this hypothesis is correct, prevention programs will benefit from additional research that measures levels and correlates of acceptance for website-facilitated partner notification.
As for the role of the clinic, this study4 implicitly speaks to the difficulties and value of delivering partner services. As noted above, the current burden of STD morbidity precludes offering DIS partner services to many patients. The gap between service availability and need has been a motivator for the development of patient-based partner notification innovations. As public health enters a rapidly and broadly changing health care environment, especially with a focus on individually oriented preventive care strategies (eg, increasing enrollment in community health centers), it is important to remember that STD clinics provide services for the public good, such as disrupting infectious disease transmission networks through partner services. If trained investigators are not available to perform the function, providers should be able to counsel infected patients on notification approaches, assure patient and partner safety, and equip them with tools such as referral cards, contact numbers and, in some cases, expedited partner therapy (all of which are available in the Denver clinic). There is no reason to oppose increased individually focused preventive care and every reason to integrate STD clinics into emerging health systems, including any necessary revisions to clinic missions as broad sources of sexual health expertise. While we are not the first to surmise on this topic,13 we want to highlight our belief that the value of sexual health specialty settings should not be underestimated.
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