Evaluation of Online Partner Notification Services Like inSPOT Requires Starting With the Client, Not the Clinic

To the Editor:

Two recent publications in Sexually Transmitted Diseases have evaluated uptake of the Web-based partner notification (PN) service inSPOT. Rietmeijer et al describe low awareness (6%) and usage (2%/1% had sent/received an e-card) of inSPOT among 481 clients sampled from a predominantly heterosexual STD clinic population exposed to various promotional messages during the course of 6 months.¹ Kerani et al randomized 75 men who have sex with men diagnosed with gonorrhea or chlamydia to one of 4 study arms—traditional PN, inSPOT, PDPT (patient-delivered partner therapy), or inSPOT/PDPT combined—and found that only 1 of the 27 clients assigned to an inSPOT arm used the service.² Authors of both studies conclude that few clients are interested in inSPOT and thus caution against its use as a PN tool.

These studies yield important information about the overall appeal of inSPOT, suggesting that broad promotion of the service is unlikely to result in high uptake; however, by using a clinic-based sampling frame, their results do not resolve the question, for whom are online PN services most beneficial? As an alternative hypothesis, we offer that inSPOT is not an intervention to be applied to all clients diagnosed with an STD but rather a supplemental tool to existing PN services, and one likely suited to a particular client who chooses to self-notify partners. Even if clients who opt to use inSPOT are few, they may nonetheless be of interest if they have numerous sex partners and would not otherwise encourage those partners to get tested. Clients with multiple partners indeed have been shown to be more likely to have only electronic contact information for their partners³ and less likely to follow through with PN.⁴ Determining the best way to support PN for these clients—whether through services like inSPOT or through other means—is critical.

In the light of this reconsideration of the scope and purpose of inSPOT, we contend that evaluation of the service should start with the client who uses it rather than an entire clinic population. Clients who are inclined to use inSPOT may not enroll in a randomized controlled trial, particularly if they are disinclined to discuss PN to begin with (notably only 19% of those eligible ultimately enrolled in the Kerani trial). These individuals may be missed, both by traditional PN services and by clinic-based research, perhaps for similar reasons (e.g., an aversion to engage with public health or STD clinic providers at the time of diagnosis). Therefore, we propose a study design complementary to that of Rietmeijer and Kerani, which directly samples clients who elect to use inSPOT as their preferred PN method, as well as those who have received an e-card. This approach could be efficiently achieved through a Web-based survey—thereby reaching a sample of clients amenable to online services—that better characterizes clients successfully using inSPOT and measures whether those who receive an electronic notification follow through with testing. Both questions are of keen importance to the inSPOT debate and remain unanswered by research published to date.

Travis S. Hottes, MSc

Mark Gilbert, MD, MHSc

British Columbia Centre for Disease Control

Vancouver, British Columbia, Canada