Internet-based site-specific interventions for syphilis prevention among gay and bisexual men

Effect of a Popular Web Drama Video Series on HIV and Other Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in Singapore: Community-Based, Pragmatic, Randomized Controlled Trial

Background

Gay, bisexual, and other men who have sex with men (GBMSM) are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBMSM are increasing worldwide, they remain suboptimal in a variety of settings. While many studies have attempted to evaluate the efficacy of a variety of community-based campaigns, including peer and reminder-based interventions on HIV/STI testing, however few have attempted to do so for a web drama series.

Objective

This study evaluates the effectiveness of a popular web drama video series developed by a community-based organization in Singapore for GBMSM on HIV and other STI testing behaviors.

Methods

The study is a pragmatic, randomized controlled trial to evaluate a popular web drama video series developed by a community-based organization in Singapore for GBMSM. A total of 300 HIV-negative, GBMSM men in Singapore aged 18 to 29 years old were recruited and block-randomized into the intervention (n=150) and control arms (n=150). Primary outcomes included changes in self-reported intention to test for, actual testing for, and regularity of testing for HIV, syphilis, chlamydia or gonorrhea, while secondary outcomes include changes in a variety of other knowledge-based and psychosocial measures at the end of the study period.

Results

Overall, 83.3% (125/150) of participants in the intervention arm completed the proof of completion survey, compared to 88.7% (133/150) in the control arm. We found improvements in self-reporting as a regular (at least yearly) tester for HIV (15.9% difference, 95% CI, 3.2% to 28.6%; P=.02), as well as chlamydia or gonorrhea (15.5% difference, 95% CI, 4.2% to 26.9%; P=.009), indicating that the intervention had positively impacted these outcomes compared to the control condition. We also found improvements in participants’ intentions to test for HIV (16.6% difference, 95% CI, 4.3% to 28.9%; P=.009), syphilis (14.8% difference, 95% CI, 3.2% to 26.4%; P=.01), as well as chlamydia or gonorrhea (15.4% difference, 95% CI, 4.2% to 26.6%; P=.008), in the next 3 months, indicating that the intervention was effective in positively impacting intention for HIV and other STI testing among participants.

Conclusions

There are clear benefits for promoting intentions to test regularly and prospectively on a broad scale through this intervention. This intervention also has potential to reach GBMSM who may not have access to conventional HIV and other STI prevention messaging, which have typically been implemented at sex-on-premises venues, bars, clubs, and in sexual health settings frequented by GBMSM. When coupled with community or population-wide structural interventions, the overall impact on testing will likely be significant.

Trial Registration

ClinicalTrials.gov NCT04021953; https://clinicaltrials.gov/ct2/show/NCT04021953

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2019-033855

Effect of a web drama video series on HIV and other sexually transmitted infection testing among gay, bisexual and queer men: study protocol for a community-based, pragmatic randomised controlled trial in Singapore: the People Like Us (PLU) Evaluation Study

INTRODUCTION

Gay, bisexual and queer (GBQ) men are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBQ men are increasing worldwide, they remain suboptimal in a variety of settings.

METHODS AND ANALYSIS

The study is a pragmatic randomised controlled trial designed to evaluate an online video series developed by a community-based organisation in Singapore for GBQ men. A total of 300 HIV-negative GBQ men in Singapore aged 18-29 years old will be recruited for this study. Participants will subsequently be randomised into the intervention arm (n=150) and the control arm (n=150). The intervention arm (n=150) will be assigned the intervention along with sexual health information via a pamphlet, while the control group (n=150) will be assigned only the sexual health information via a pamphlet. Participants should also not have watched the video prior to their participation in this study, which will be ascertained through a questionnaire. Primary outcomes for this evaluation are changes in self-reported intention to test for, actual testing for and regularity of testing for HIV, syphilis, chlamydia and gonorrhoea at the 3 and 6 months after intervention. Secondary outcomes include changes in self-reported risk perception for HIV and other STIs, knowledge of HIV, knowledge of risks associated with acquiring STIs, knowledge of HIV pre-exposure prophylaxis, consistent condom use for anal sex with casual partners, incidence of STIs, connectedness to the lesbian, gay, bisexual and transgender community, self-concealment of sexual orientation, perceived homophobia, internalised homophobia, HIV testing self-efficacy and HIV testing social norms.

ETHICS AND DISSEMINATION

The study has been approved by the National University of Singapore Institutional Review Board (S-19-059) and registered at ClinicalTrials.gov. The results will be published in peer-reviewed academic journals and disseminated to community-based organisations and policymakers.

TRIAL REGISTRATION NUMBER

NCT04021953.

Context-Appropriate Interventions to Prevent Syphilis: A Narrative Review

BACKGROUND

The success of an intervention to prevent syphilis will depend on the context and the goal of the intervention. To help programs choose interventions, we reviewed major changes in context and types of interventions that may be effective.

METHODS

We reviewed the literature on the changing context of syphilis in the United States and interventions to prevent syphilis, focusing on articles that included evidence of effectiveness.

RESULTS

Populations acquiring syphilis are constantly changing. Currently, incidence is very high among men who have sex with men (MSM). Among adults, late disease caused by syphilis has become rare. Congenital syphilis incidence has been low but is increasing, and morbidity and mortality remain high when babies are infected. Congenital syphilis now causes more deaths than syphilis among adults.Routine screening of MSM can identify and treat infections before they progress to disease (secondary prevention). Screening rates are highest when done as part of routine standing orders. Partner notification effectiveness has decreased, partly because many partners are anonymous. Most congenital syphilis can be prevented by screening pregnant women; it has been eliminated in areas where intense primary prevention efforts eliminated syphilis among women.

CONCLUSIONS

So far, no program has stopped the increasing rates of infection among MSM, but secondary prevention efforts have prevented most disability. Congenital syphilis is increasing, and can be decreased by screening pregnant women and stopped by intensive efforts to prevent infection among women.

Providing Online-Based Sexual Health Outreach to Gay, Bisexual, and Queer Men in Ontario, Canada: Qualitative Interviews with Multisectoral Frontline Service Providers and Managers

The Internet is a common tool for gay, bisexual, and other men who have sex with men (MSM) to find sexual partners and sexual health information. Given persistently high human immunodeficiency virus (HIV) infection rates among MSM, it is important to examine the role of online outreach for MSM as part of HIV prevention and care. We provide an overview of the unique perspectives of online sexual health outreach, delivered through AIDS Service Organizations (ASOs) through sociosexual Internet sites and mobile applications. Data were drawn from the qualitative arm of the community-based Cruising Counts study conducted across Ontario from December 2013 to January 2014. ASO online outreach providers and managers (n = 22) were recruited to complete a 1-h in-person/telephone interview to explore in-depth their experiences with, and perspectives on, delivering online outreach services for MSM in Ontario. Thematic analyses were conducted inductively using NVivo 10. Service providers suggested a high demand for online outreach services for MSM. Strengths and advantages of online outreach over face-to-face outreach included anonymity, instant access to services, peer model, and accessing hard-to-reach populations of MSM. Barriers included consistent quality of service, collaborations between companies that own online technologies and outreach service agencies, budgetary and staff capacity issues, and uncertainty of best practices and evaluation parameters for online outreach. Findings from these interviews can inform service providers, policy makers, and researchers on how online sexual health outreach can play a greater role in HIV prevention by better acknowledging and addressing the opportunities and barriers experienced by service providers working with MSM communities online.

Expanding syphilis testing: a scoping review of syphilis testing interventions among key populations

INTRODUCTION

Syphilis is an important sexually transmitted infection (STI). Despite inexpensive and effective treatment, few key populations receive syphilis testing. Innovative strategies are needed to increase syphilis testing among key populations. Areas covered: This scoping review focused on strategies to increase syphilis testing in key populations (men who have sex with men (MSM), sex workers, people who use drugs, transgender people, and incarcerated individuals). Expert commentary: We identified many promising syphilis testing strategies, particularly among MSM. These innovations are separated into diagnostic, clinic-based, and non-clinic based strategies. In terms of diagnostics, self-testing, dried blood spots, and point-of-care testing can decentralize syphilis testing. Effective syphilis self-testing pilots suggest the need for further attention and research. In terms of clinic-based strategies, modifying default clinical procedures can nudge physicians to more frequently recommend syphilis testing. In terms of non-clinic based strategies, venue-based screening (e.g. in correctional facilities, drug rehabilitation centres) and mobile testing units have been successfully implemented in a variety of settings. Integration of syphilis with HIV testing may facilitate implementation in settings where individuals have increased sexual risk. There is a strong need for further syphilis testing research and programs.

Health Communication and Social Marketing Campaigns for Sexually Transmitted Disease Prevention and Control: What Is the Evidence of their Effectiveness?

BACKGROUND

Despite the ubiquity of sex in the media, a culture of silence surrounds sexual health in the United States, serving as a barrier to sexually transmitted disease (STD) prevention, testing, and treatment. Campaigns can increase STD-related knowledge, communication, and protective behaviors. This review assesses the effectiveness of STD prevention and testing campaigns in the United States to inform the field on their use as a strategy for affecting behavior change.

METHODS

A comprehensive literature search was conducted to identify original research articles, published between 2000 and 2014, which report on US media campaigns promoting community- or population-level STD testing or prevention behaviors and are evaluated for impact on one or more behavioral outcomes. Titles and abstracts were independently reviewed by 2 researchers.

RESULTS

The review yielded 26 articles representing 16 unique STD testing and/or prevention campaigns. Most campaigns were developed using formative research and social marketing or behavioral theory. Most campaigns (68.75%) used posttest-only or pretest-posttest designs without comparison groups for evaluation; only 5 campaigns used control groups, and these proved challenging (i.e., achieving necessary exposure and avoiding contamination). Nearly all campaigns found differences between exposed and unexposed individuals on one or more key behavioral outcomes. Several campaigns found dose-response relationships. Among evaluations with uncontaminated control groups whose campaigns achieved sufficient exposure, sustained campaign effects were observed among targeted populations.

CONCLUSIONS

Current findings suggest that campaigns can impact targeted STD-related behaviors and add to the evidence that greater exposure is associated with greater behavior change.

Risk Factors Associated with Incident Syphilis in a Cohort of High-Risk Men in Peru

BACKGROUND

Syphilis is concentrated among high-risk groups, but the epidemiology of syphilis reinfection is poorly understood. We characterized factors associated with syphilis incidence, including reinfection, in a high-risk cohort in Peru.

METHODS

Participants in the NIMH CPOL trial were assessed at baseline and 2 annual visits with HIV/STI testing and behavioral surveys. Participants diagnosed with syphilis also attended 4- and 9-month visits. All participants underwent syphilis testing with RPR screening and TPPA confirmation. Antibiotic treatment was provided according to CDC guidelines. Reinfection was defined as a 4-fold titer increase or recurrence of seroreactivity after successful treatment with subsequent negative RPR titers. The longitudinal analysis used a Possion generalized estimating equations model with backward selection of variables in the final model (criteria P <0.02).

RESULTS

Of 2,709 participants, 191 (7.05%) were RPR-reactive (median 1:8, range 1:1-1:1024) with TPPA confirmation. There were 119 total cases of incident syphilis, which included both reinfection and first-time incident cases. In the bivariate analysis, the oldest 2 quartiles of age (incidence ratio (IR) 3.84; P <0.001 and IR 8.15; P <0.001) and being MSM/TW (IR 6.48; P <0.001) were associated with higher risk of incident syphilis infection. Of the sexual risk behaviors, older age of sexual debut (IR 12.53; P <0.001), not being in a stable partnership (IR 1.56, P = 0.035), higher number of sex partners (IR 3.01; P <0.001), unprotected sex in the past 3 months (IR 0.56; P = 0.003), HIV infection at baseline (IR 3.98; P <0.001) and incident HIV infection during the study period (IR 6.26; P = 0.003) were all associated with incident syphilis. In the multivariable analysis, older age group (adjusted incidence ratio (aIR) 6.18; P <0.001), men reporting having sex with a man (aIR 4.63; P <0.001), and incident HIV infection (aIR 4.48; P = 0.008) were significantly associated.

CONCLUSIONS

We report a high rate of syphilis reinfection among high-risk men who have evidence of previous syphilis infection. Our findings highlight the close relationship between HIV incidence with both incident syphilis and syphilis reinfection. Further studies on syphilis reinfection are needed to understand patterns of syphilis reinfection and new strategies beyond periodic testing of high-risk individuals based on HIV status are needed.

Reaching Suburban Men Who Have Sex With Men for STD and HIV Services Through Online Social Networking Outreach: A Public Health Approach

BACKGROUND

Technology-enabled approaches may reach suburban and rural men who have sex with men (MSM) who lack physical venues, where they live for sexually transmitted disease (STD)/HIV prevention efforts. We evaluated using Grindr, an all-male social networking platform, for STD/HIV prevention services to MSM by a suburban Public Health department.

METHODS

Phase 1 (October 2012-March 2013) focused on acceptability of prevention messages by MSM on Grindr and phase 2 (October 2013-March 2014) Grindr use for implementing testing and linkage-to-care. We compared the number of Public Health encounters with MSM before and after initiation of Grindr use and the proportion of users who remained engaged with Public Health staff after being told they were interacting with a health educator.

RESULTS

For a 6-month period before Grindr outreach, Public Health had 60 contacts with MSM. Contacts increased to 305 MSM in phase 1, of which 168/213 (79%) remained engaged. In phase 2, among 903 MSM contacts, 69% remained engaged. Asian and Hispanic MSM were more likely to remain engaged with outreach staff; white men were more likely to be not engaged. No significant difference in age between engaged and nonengaged MSM was seen.

CONCLUSIONS

Grindr outreach by Public Health in a suburban county seems acceptable to MSM and leads to a 14-fold increase in MSM reached for counseling and education compared with a traditional outreach period. Further evaluation of technology-enabled approaches for STD/HIV prevention in suburban and rural MSM is warranted.

A case-control study evaluating the role of internet meet-up sites and mobile telephone applications in influencing a syphilis outbreak: Multnomah County, Oregon, USA 2014

OBJECTIVES

Early syphilis in Multnomah County, Oregon, USA, increased 16-fold during 2007-2013. Cases predominantly occurred among men who have sex with men (MSM); 55% were HIV coinfected. We conducted a case-control study to evaluate the association between meeting sex partners online and early syphilis.

METHODS

Cases subjects (cases) were Multnomah County resident, English speaking, MSM, aged ≥18 years with laboratory-confirmed early syphilis reported 1 January to 31 December 2013. We recruited two MSM controls subjects (controls) per case, frequency matched by HIV status and age. Participants completed self-administered questionnaires. We performed multivariable logistic regression.

RESULTS

Seventy per cent (40/57) of cases and 42% (50/119) of controls met partners online (p<0.001). Cases more frequently met partners online (adjusted OR (aOR)=3.0; 95% CI 1.2 to 6.7), controlling for presumptive confounders. Cases reported more partners than controls (medians 5, 2; p<0.001). When including number of partners, aOR decreased to 1.4 (95% CI 0.5 to 3.9).

CONCLUSIONS

Early syphilis was associated with meeting partners online. We believe this association may be related to number of sex partners acting as an intermediate variable between use of online resources to meet sex partners and early syphilis. Online meet-up sites might represent areas for public health interventions targeting at-risk individuals.

Setting the scene: locations for meeting sex partners among behaviorally bisexual men in Vientiane, Laos, and opportunities for health promotion

Behaviorally bisexual men (BBM) in Vientiane, Laos report high-risk sexual behaviors. We explore settings for meeting sex partners and associated risk behaviors among BBM in Laos. BBM and their sexual partners were recruited in Vientiane Capital using modified snowball sampling (2010). Settings for usually meeting sex partners and associations with risk behaviors were assessed. Among 88 BBM, the most common settings for men meeting male, kathoey, and female sex partners were private residences (48%, 37%, 51%, respectively) and hospitality settings (39%, 31%, 40%, respectively). Hospitality settings were more commonly reported by heterosexual-identifying BBM, and private residences more commonly reported by bisexual/homosexual-identifying BBM. Inconsistent condom use was high across partners and settings. Meeting partners in hospitality settings was associated with reporting a high number of female sex partners and frequently drinking alcohol before sex. Our results suggest that targeted health promotion initiatives in bars, clubs, and beer-shops could reach a high proportion of high-risk bisexual men, particularly heterosexual-identifying BBM.

Gay and bisexual men's use of the Internet: research from the 1990s through 2013

We document the historical and cultural shifts in how gay and bisexual men have used the Internet for sexuality between the 1990s and 2013-including shifting technology as well as research methods to study gay and bisexual men online. Gay and bisexual men have rapidly taken to using the Internet for sexual purposes: for health information seeking, finding sex partners, dating, cybersex, and pornography. Men have adapted to the ever-evolving technological advances that have been made in connecting users to the Internet-from logging on via dial-up modem on a desktop computer to geo-social-sexual networking via handheld devices. In kind, researchers have adapted to the Internet to study gay and bisexual men. Studies have carefully considered the ethics, feasibility, and acceptability of using the Internet to conduct research and interventions. Much of this work has been grounded in models of disease prevention, largely as a result of the ongoing HIV/AIDS epidemic. The need to reduce HIV in this population has been a driving force to develop innovative research and Internet-based intervention methodologies. The Internet, and specifically mobile technology, is an environment gay and bisexual men are using for sexual purposes. These innovative technologies represent powerful resources for researchers to study and provide outreach.

Sex, drugs (methamphetamines), and the Internet: increasing syphilis among men who have sex with men in California, 2004-2008

OBJECTIVES

We examined primary and secondary syphilis cases among men who have sex with men (MSM) in California, and the association of methamphetamine use and Internet use to meet sex partners (Internet use) with number of sex partners.

METHODS

We analyzed California surveillance data for MSM who were diagnosed with syphilis between 2004 and 2008, to assess differences in the mean number of sex partners by methamphetamine use and mutually exclusive groups of patients reporting Internet use (Internet users).

RESULTS

Large proportions of patients reported methamphetamine use (19.2%) and Internet use (36.4%). From 2006 through 2008, Adam4Adam was the most frequently reported Web site statewide, despite temporal and regional differences in Web site usage. Methamphetamine users reported more sex partners (mean = 11.7) than nonmethamphetamine users (mean = 5.6; P < .001). Internet users reported more sex partners (mean = 9.8) than non-Internet users (mean = 5.0; P < .001). Multivariable analysis of variance confirmed an independent association of methamphetamine and Internet use with increased numbers of sex partners.

CONCLUSIONS

Higher numbers of partners among MSM syphilis patients were associated with methamphetamine and Internet use. Collaboration between currently stand-alone interventions targeting methamphetamine users and Internet users may offer potential advances in sexually transmitted disease control efforts.

Knowledge, attitudes, and practices regarding syphilis screening among men who have sex with men in San Francisco

BACKGROUND

Syphilis screening for men who have sex with men (MSM) in San Francisco (SF) is recommended every 3 to 6 months. We surveyed MSM in SF to determine the prevalence and factors associated with complying with that recommendation, identify screening barriers, and investigate whether identifying low perceived syphilis risk as a reason for not testing correlated with syphilis risk factors.

METHODS

We conducted a cross-sectional survey as part of the National HIV Behavioral Surveillance System. We used logistic regression to analyze factors associated with complying with the SF-specific screening recommendation and with identifying low perceived risk as a reason for not testing. We analyzed data on screening barriers descriptively.

RESULTS

Among 441 MSM, 37.5% (95% confidence interval [CI], 31.5%-43.6%) complied with the recommendation. Compliance was associated with human immunodeficiency virus infection (odds ratio [OR], 3.6; 95% CI, 1.7-7.8), more than 10 male sex partners (OR, 4.3; 95% CI, 1.6-12.0), having unprotected anal sex with a casual partner (OR, 4.2; 95% CI, 2.0-8.9), and knowing the recommendation (OR, 4.1; 95% CI, 2.1-8.2). Low perceived risk, time constraints, and not knowing that one should get screened were identified as reasons for not testing by 61.7%, 18.9%, and 18.8%, respectively. Identifying low perceived risk as a reason for not testing was associated with having more than 10 sex partners (OR, 0.2; 95% CI, 0.1-0.5).

CONCLUSIONS

Attempts to improve compliance with the syphilis screening recommendation should include education regarding recommended screening frequency and syphilis risk factors and interventions to increase screening convenience.

Craigslist exposed: the Internet-mediated hookup

This research examines how people advertise themselves on Craigslist. The authors develop a framework that highlights 13 resources that heterosexual and homosexual men and women offer in Craigslist advertisements. The results reveal that many heterosexual advertisers offer and seek similar resources on Craigslist, whereas gay men primarily use Craigslist to seek and offer sex. About one-fourth of homosexual advertisers are in committed relationships. The authors build on this finding by exploring the extent to which married men use Craigslist for "hookups." The authors show the extent to which married men solicit responses to 6 different advertisements for sexual encounters that range from safe to high risk.

Epidemiologic characteristics of an ongoing syphilis epidemic among men who have sex with men, San Francisco

BACKGROUND

Since 2001, San Francisco has experienced a sustained syphilis epidemic that has been nearly exclusively limited to men who have sex with men. We examined the characteristics associated with changes in the syphilis epidemic in San Francisco.

METHODS

All primary and secondary (P&S) syphilis cases reported to the San Francisco Department of Public Health between 2001 and 2011 were examined using joinpoint analysis to identify periods within the broader epidemic. Characteristics of the index cases were compared across the periods using χ(2) statistics and t tests.

RESULTS

Three distinct periods were identified, an acute increase, decline, and then period of resurgence. In the most recent period of resurgence, compared with earlier periods, patients with P&S syphilis were more likely to have a prior syphilis infection, were older, were more likely to meet partners online, and were more likely to have a partner from outside San Francisco.

CONCLUSIONS

In an analysis of 11 years of P&S syphilis data, several factors were associated with declines or resurgences. Innovative prevention measures are needed to reduce syphilis morbidity among men who have sex with men.

A virtual community: concerns of patients with pulmonary hypertension

Pulmonary Hypertension (PH) is a complex disorder characterized by elevated pressures in the pulmonary artery that cause right heart failure and eventually leads to death. Treatment regimens can be complex and mortality is high. The purpose of this study was to determine how people with PH are using an online Discussion Board. Qualitative descriptive methodology was used to analyze a convenience sample of self-identified patients with PH. Internet posts to an online Discussion Board from January 1, 2010 to December 31, 2010 were analyzed for common themes. Five hundred forty-nine individuals with PH posted to the Discussion Board. Four themes emerged: Uncertainty and Concern, Guidance and Validation, Support, and Refocusing Life. People with PH are using the Internet to answer questions about PH and seeking support. Future research needs to be conducted to further explore the needs and concerns of people with PH to provide tailored interventions.

Online advertising to reach and recruit Latino smokers to an internet cessation program: impact and costs

BACKGROUND

Tobacco cessation among Latinos is a public health priority in the United States, particularly given the relatively high growth of this population segment. Although a substantial percentage of American Latinos use the Internet, they have not engaged in Web-based cessation programs as readily as other racial/ethnic subgroups. A lack of culturally specific advertising efforts may partly explain this disparity.

OBJECTIVE

Phase I of this study focused on the development of four Spanish-language online banner advertisements to promote a free Spanish-language smoking cessation website (es.BecomeAnEX.org). Phase II examined the relative effectiveness of the four banner ads in reaching and recruiting Latino smokers to the cessation website.

METHODS

In Phase I, 200 Spanish-speaking Latino smokers completed an online survey to indicate their preference for Spanish-language banner ads that incorporated either the cultural value of family (familismo) or fatalism (fatalismo). Ads included variations on message framing (gain vs loss) and depth of cultural targeting (surface vs deep). In Phase II, a Latin square design evaluated the effectiveness of the four preferred ads from Phase I. Ads were systematically rotated across four popular Latino websites (MySpace Latino, MSN Latino, MiGente, and Yahoo! en Español) over four months from August to November 2009. Tracking software recorded ad clicks and registrants on the cessation website. Negative binomial regression and general linear modeling examined the main and interacting effects of message framing and depth of cultural targeting for four outcomes: number of clicks, click-through rate, number of registrants, and cost per registrant.

RESULTS

In Phase I, smokers preferred the four ads featuring familismo. In Phase II, 24,829,007 impressions were placed, yielding 24,822 clicks, an overall click-through rate of 0.10%, and 500 registrants (2.77% conversion rate). Advertising costs totaled US $104,669.49, resulting in an overall cost per click of US $4.22 and cost per registrant of US $209.34. Website placement predicted all four outcomes (all P values < .01). Yahoo! en Español yielded the highest click-through rate (0.167%) and number of registrants (n = 267). The message framing and cultural targeting interaction was not significant. Contrary to hypotheses, loss-framed ads yielded a higher click-through rate than gain-framed ads (point estimate = 1.08, 95% CI 1.03 1.14, P = 0.004), and surface-targeted ads outperformed deep-targeted ads for clicks (point estimate = 1.20, 95% CI 1.13 1.28, P < .001), click-through rate (point estimate = 1.22, 95% CI 1.16 1.29, P < .001), and number of registrants (point estimate = 2.73, 95% CI 2.14 3.48, P < .001).

CONCLUSIONS

Online advertising can be an effective and cost-efficient strategy to reach and engage Spanish-speaking Latino smokers in an evidence-based Internet cessation program. Cultural targeting and smoking-relevant images may be important factors for banner ad design. Online advertising holds potential for Web-based cessation program implementation and research.

Online sex-seeking behaviors among men who have sex with men: implications for investigation and intervention

To investigate factors associated with online sex-seeking behaviors among men who have sex with men (MSM) in Beijing, China. MSM participants were recruited from two cohort studies with multiple enrollment methods from November 2006 to February 2007 and from March to June 2008, respectively. Data collected included demographics and sexual behaviors. Of the 901 participants, 68.1% were single; 69.3% were non-Beijing residents; 94.4% considered themselves to be homosexual; 65.2% received college or higher levels of education; the median age was 26 years; 73.0% sought male sex partners via the Internet in the past 3 months; 66.2% had ≥2 sex partners. Younger age, higher levels of education and having had ≥2 male sex partners in the past 3 months were independently associated with seeking sex partners on the Internet. These findings indicate that Internet-based intervention programs could encourage younger high-risk MSM to use condoms and reduce their numbers of sexual partners.

African American adolescents meeting sex partners online: closing the digital research divide in STI/HIV prevention

Minority adolescents are affected disproportionately by HIV and STIs, and the Internet is a popular venue to meet sex partners. Little is known about the risks of this behavior for minority adolescents. The majority of studies that have examined sexual risk behavior online or STI/HIV prevention programs online have been among adult MSM. In this study, data from 1,045 African American youth found that 6% met sex partners online and in chat rooms. Odds ratios, adjusting for gender, found this behavior was associated with alcohol (AOR = 2.33, 95% CI [1.1, 4.7]) and drug use (AOR = 3.45, 95% CI [1.9, 6.1]), unprotected vaginal (AOR = 4.71, 95% CI [1.9, 8.4]) and anal sex (AOR = 4.77, 95% CI [1.3,17.1]) in the last 90 days, more lifetime vaginal (AOR = 3.65, 95% CI [2.0, 6.8]) and anal sex (AOR = 2.74, 95% CI [1.5, 4.8]), greater sexual sensation seeking (AOR = 2.92, 95% CI [1.5, 5.7]) and greater depression (AOR = 2.06, 95% CI [1.2, 3.6]. A final multiple logistic regression analyses found that male gender (AOR = 3.13, 95% CI [1.7, 5.8]), drug use at last sex (AOR = 2.41, 95% CI [1.3, 4.5]), lifetime history of vaginal (AOR = 2.90, 95% CI [1.5, 5.5]) and anal sex (AOR = 2.09, 95% CI [1.2, 3.6]), and cocaine use (AOR = 8.53, 95% CI [2.7, 27.3]) were independently associated with having sex with a partner met online. Meeting sex partners online is associated with a variety of risks among African American youth; however, the Internet may be an opportunity for intervention.

HealthMpowerment.org: feasibility and acceptability of delivering an internet intervention to young Black men who have sex with men

Young Black men who have sex with men (BMSM) are disproportionately affected by HIV/AIDS in the USA and continue to experience rapidly increasing HIV incidence. We designed a tailored, theory-based interactive HIV/STI prevention website for young BMSM, called HealthMpowerment.org (HMP) and conducted a small pilot trial comparing HMP to currently available HIV/STI websites. We present findings demonstrating feasibility and acceptability of delivering the intervention to the target population of young BMSM. Retention rates were 90% and 78% at one- and three-month follow-ups, respectively. Evaluation immediately after the intervention's completion revealed that participants who used the HMP website reported high levels of user satisfaction and interest and low levels of website difficulty and frustration. At the end of the intervention, there was a trend in increased behavioral intentions to use condoms and engage in preparatory condom use behaviors in the intervention group compared to the control group (p=0.10). We observed a reduction in mean scores on the CES-D scale among those in the intervention group that was not seen in the control group at the one-month follow-up, though this was not statistically significant. Feedback from exit interviews with study participants suggested that HMP is relevant to the prevention needs of young BMSM. Overall, the findings support the acceptability and feasibility of delivering this prevention program to a group that has few interventions despite bearing a significant burden of the epidemic. Future trials, combining Internet and mobile phone technologies, are planned to test HMP among larger and more diverse populations of young BMSM.

HIV disclosure and subsequent sexual behaviors among men who have sex with men who meet online

To assess HIV disclosure discussions and related sexual behaviors among men who have sex with men (MSM) who meet sex partners online, 28 qualitative interviews with Seattle-area MSM were analyzed using grounded theory methods and themes and behavior patterns were identified. MSM found a greater ease in communicating and could prescreen partners through the Internet. However, no consistent relationship was found between HIV disclosure and subsequent behaviors: some were safer based on disclosure while perceived HIV status led others to risky behaviors. Interventions need to promote accurate disclosure while acknowledging its limitations and the need for men to self-protect.

Use of the Internet for the surveillance and prevention of sexually transmitted diseases

The Internet is a relatively new tool in the surveillance and prevention of sexually transmitted infections, and this review examines its global use in this regard. Much use has been made in the form of information collection and dissemination; targeted population engagement through chat rooms, partner notification and other mechanisms; and the provision of testing services and other products. Internet users may need education concerning reputable websites, and public health practitioners need proficiency in the use of social media and marketing.

[Attitudes toward online HIV/sexually-transmitted infection prevention programs and Internet user profiles among men who have sex with men]

OBJECTIVES

To describe the attitudes of men who have sex with men (MSM) toward online HIV/sexually-transmitted infection (STI) prevention programs and to identify and characterize user profiles with regard to their attitudes toward online prevention programs.

METHOD

A survey in gay venues or via the internet was completed by 2,044 participants from Madrid, Barcelona, Bilbao and San Sebastián (Spain). The survey explored socio-demographic variables, sexual behavior and other risk behaviors associated with HIV infection, as well as attitudes toward online prevention programs. The statistical analysis included factor analysis and non-hierarchical cluster analysis.

RESULTS

Most MSM had positive attitudes towards online HIV/STI prevention programs. Factor analysis revealed two factors: online prevention aimed at interaction and online prevention aimed at information. Based on these factors, three user profiles were identified: users oriented toward informative and interactive online prevention (53.5%), users oriented toward interactive online prevention (25.9%) and users were not oriented toward online prevention (20.7%). On characterizing these profiles, we observed a significant presence of men who were not interested in online prevention among those with a lower educational level, bisexual men and HIV-positive men. Conversely, those most receptive to online prevention were men self-identified as gay, those with a bachelors degree, those who had been tested for HIV and those who were HIV-negative.

CONCLUSION

The internet can facilitate sexual health promotion among MSM. Characterization of user profiles offers the possibility of segmenting prevention programs and of combining online and offline strategies.

A systematic examination of the use of online social networking sites for sexual health promotion

BACKGROUND

In recent years social networking sites (SNSs) have grown rapidly in popularity. The popularity of these sites, along with their interactive functions, offer a novel environment in which to deliver health promotion messages. The aim of this paper is to examine the extent to which SNSs are currently being used for sexual health promotion and describe the breadth of these activities.

METHODS

We conducted a systematic search of published scientific literature, electronic sources (general and scientific search engines, blogs) and SNSs (Facebook, MySpace) to identify existing sexual health promotion activities using SNSs. Health promotion activities were eligible for inclusion if they related to sexual health or behaviour, utilised one or more SNSs, and involved some element of health promotion. Information regarding the source and type of health promotion activity, target population and site activity were extracted.

RESULTS

178 sexual health promotion activities met the inclusion criteria and were included in the review; only one activity was identified through a traditional systematic search of the published scientific literature. Activities most commonly used one SNS, were conducted by not-for-profit organisations, targeted young people and involved information delivery. Facebook was the most commonly used SNS (used by 71% of all health promotion activities identified), followed by MySpace and Twitter. Seventy nine percent of activities on MySpace were considered inactive as there had been no online posts within the past month, compared to 22% of activities using Facebook and 14% of activities using Twitter. The number of end-users and posts in the last seven days varied greatly between health promotion activities.

CONCLUSIONS

SNSs are being used for sexual health promotion, although the extent to which they are utilised varies greatly, and the vast majority of activities are unreported in the scientific literature. Future studies should examine the key factors for success among those activities attracting a large and active user base, and how success might be measured, in order to guide the development of future health promotion activities in this emerging setting.

HIV prevention and care in the digital age

OBJECTIVES

To describe the technologic advances in the digital media, including computers, mobile phones, and the Internet, that have greatly expanded opportunities to deliver evidence-based HIV education, prevention, and treatment programs.

METHODS

This article examines the use of digital media in the United States and its potential role in HIV prevention and care.

RESULTS

Although the "digital divide" is shrinking, access varies by age, race/ethnicity, and education. The Internet is an important medium for delivering universal and targeted HIV education and prevention, especially for men who have sex with men, who report going online to seek health information online and for social and sexual networking. Online and off-line behavioral interventions using digital media range from computerized multimedia interventions that take into account individual behaviors to brief untailored video interventions. Numerous Web sites facilitate access to care by providing a variety of services, including location of and linkage to HIV testing and treatment sites. HIV treatment and adherence programs that use online medical records text messaging, paging, and tablet computer-based counseling tools are also being developed.

CONCLUSIONS

HIV prevention and care programs using digital media have great potential to cost-effectively meet the complex needs of diverse and often underserved populations living with or at high risk of HIV.

Evaluation of an innovative internet-based partner notification program for early syphilis case management, Washington, DC, January 2007-June 2008

BACKGROUND

The Internet has become a common venue for meeting sex partners and planning participation in risky sexual behavior. In this article, we evaluate the first 18 months of the Washington, DC, Department of Health Internet-based Partner Notification (IPN) program for early syphilis infections, using the standard Centers for Disease Control and Prevention (CDC) Disease Investigation Specialist (DIS) disposition codes, as well as Washington, DC, Department of Health's IPN-specific outcomes for pseudonymous partners.

METHODS

We analyzed DIS disposition codes and IPN-specific outcomes from all early syphilis investigations initiated January 2007-June 2008. Internet partners were defined as sex partners for whom syphilis exposure notification was initiated by e-mail because no other locating information existed. If the e-mails resulted in additional locating information, we used the standard CDC disposition codes. Alternatively, the following IPN-specific outcomes were used: Informed of Syphilis Exposure, Informed of General STD Exposure, Not Informed or Unable to Confirm Receipt of General STD Exposure.

RESULTS

From the 361 early syphilis patients, a total of 888 sex partners were investigated, of which 381 (43%) were via IPN. IPN led to an 8% increase in the overall number of syphilis patients with at least one treated sex partner, 26% more sex partners being medically examined and treated if necessary, and 83% more sex partners notified of their STD exposure.

CONCLUSIONS

IPN augmented traditional syphilis case management and aided in the location, notification, testing, and treatment of partners. Conversely, without IPN, these 381 partners would not have been investigated.

HealthMpowerment.org: development of a theory-based HIV/STI website for young black MSM

Black men who have sex with men (BMSM) are disproportionately affected by the HIV epidemic, yet few prevention interventions have been developed specifically for them. Recent studies suggest that the Internet is a promising intervention delivery avenue. We describe results from our formative work in developing a theory-based online HIV/STI prevention intervention for young BMSM including focus groups, semistructured interviews, and usability testing. The Intervention, HealthMpowerment.org , was created based on the Institute of Medicine's integrated model of behavior change with extensive input from young BMSM. Key interactive Web site features include live chats, quizzes, personalized health and "hook-up/sex" journals, and decision support tools for assessing risk behaviors. Creating an interactive HIV/sexually transmitted infection web site for BMSM was a complex process requiring many adjustments based on iterative feedback throughout all development stages. Preliminary satisfaction, content acceptability, and usability findings support the use of the Internet to deliver risk reduction messages to young BMSM.

The intersection between HIV and syphilis in men who have sex with men: some fresh perspectives

Syphilis is increasing in men who have sex with men and disproportionately affects HIV-infected men. Here we review the epidemiology, diagnostic techniques, treatment guidelines, follow-up procedures and control of syphilis. The difference in these factors in HIV-infected men and uninfected men and evidence for this is reviewed. We explain that HIV-infected men are at higher risk of syphilis acquisition as a result of different behavioral factors. Thus, some control strategies may be different for HIV-infected men owing to these factors and also because HIV-infected men are more closely linked with medical care. There is no strong evidence to suggest there should be any differences in diagnostic techniques, treatment guidelines or follow-up procedures between HIV-infected and uninfected men.

Developing a Text Messaging Risk Reduction Intervention for Methamphetamine-Using MSM: Research Note

Men who have sex with men (MSM) who use methamphetamine experience high risks for HIV infection due to sexual transmission behaviors often engaged in when under the influence of methamphetamine. Methamphetamine-using MSM use various forms of information technology (IT) communication such as instant messaging, social networking sites, and websites to facilitate a sexual and/or drug “hook up.” Given the acceptability of IT communication in their daily lives, an IT intervention represents an appropriate strategy to reach and intervene with out-of-treatment, methamphetamine-using MSM. The aim of this study was to conduct formative work to develop a text messaging intervention to reduce methamphetamine use and high-risk sexual behaviors among out-of-treatment MSM, which involved conducting focus groups, community partners’ meetings, and a pre-test intervention. These activities culminated in the development of a two-week, text-messaging intervention that delivered real-time electronic correspondence based on the behavioral change theories of Social Support Theory, Health Belief Model, and Social Cognitive Theory. The focus groups, community meetings, and pre-test were used to identify the IT communication device, the text messages that best support risk reduction and healthier behavioral choices, and logo, flyer and website development. The input and feedback from the target population and community partners were critical to the successful development of a culturally appropriate intervention. The knowledge gleaned from the formative work of this study will be vitally helpful in designing future IT studies.

Increased HIV disclosure three months after an online video intervention for men who have sex with men (MSM)

A behavioral intervention for men who have sex with men (MSM) was created for online delivery. The nine-minute video drama "The Morning After" (www.hivbigdeal.org) was designed to promote critical thinking about HIV risk. MSM were recruited for the evaluation through banner ads on a subscription-based gay sexual meeting web site. Participants viewed the intervention online and completed online behavioral questionnaires at enrollment and three month follow-up. Each participant served as his own control. No participant incentives were provided. Follow-up was completed by 522 (54%) of 971 eligible men. Men completing follow-up were similar to those who did not by age and prevalence of unprotected anal intercourse (UAI) but reported more lifetime sex partners. They also differed somewhat by race, education, and HIV testing. In the three months after the intervention, men were significantly more likely to disclose HIV status to partners (odds ratio [OR] = 3.37, p<0.001) and less likely to report a casual partner or UAI in their most recent sexual encounter than at baseline. Of 120 men HIV tested during follow-up, 17 (14%) reported being HIV seropositive. These findings show that MSM at high risk for HIV will participate in a brief online video intervention designed to engage critical thinking and that significant, self-reported increases in HIV disclosure and decreases in risk behavior occurred three months after MSM viewed the video.

Sexual risk behaviors and HIV infection among men who have sex with men who use the internet in Beijing and Urumqi, China

OBJECTIVES

To assess HIV and syphilis infections among men who have sex with men who use the internet (MSMUI) and their risk behaviors.

METHODS

In 2007, 429 MSMUI were recruited via the internet in Beijing and Urumqi, China. A questionnaire was administered, and a blood specimen was collected and tested for HIV and syphilis.

RESULTS

Median age of participants was 25 years. Median number of lifetime sexual partners was 10. 90.7% ever had sex with a cyber friend. Rates of condom use in the last oral, insertive, and receptive anal sex were 9.1%, 66.3%, and 60.4%, respectively. Infection rates of HIV, syphilis, and HIV/syphilis coinfection were 4.8%, 11.4%, and 1.7%, respectively. Factors associated with HIV infection were being < or =24 years [odds ratio (OR) = 2.85, 95% confidence interval (CI): 1.05 to 7.75], syphilis positive (OR = 4.78, 95% CI: 1.68 to 13.58), used non-water-based liquid as lubricant (OR = 8.03, 95% CI: 1.03 to 62.52), and having bleeding gums or oral ulcers during condom-free oral sex (OR = 3.17, 95% CI: 1.13 to 8.88).

CONCLUSIONS

MSMUI engage in high-risk sexual behaviors and have a high prevalence of HIV and syphilis infections. The internet is the predominant venue for the majority of MSMUI to find sexual partners. It is urgent to implement effective intervention programs targeting this group.

PowerON: the use of instant message counseling and the Internet to facilitate HIV/STD education and prevention

OBJECTIVE

In recent years, Internet-based or online counseling has emerged as an effective way to assess psychological disorders and discuss destructive behaviors with individuals or groups of individuals. This study explores the application of online counseling to HIV/STD risk-taking behavior among men who have sex with men (MSM).

METHODS

PowerON, an organization that provides sexual health information to MSM exclusively online, used instant message technology to counsel MSM in real time through computer-mediated means. A sample of 279 transcripts of instant message exchanges between PowerON counselors and Gay.com users were recorded and qualitatively analyzed.

RESULTS

Approximately 43% of the instant message sessions discussed information about HIV/STD testing. Risk-taking behaviors were addressed in 39% of the sessions. Information about HIV/STDs and general counseling were given in 23% and 18% of the counseling sessions, respectively.

CONCLUSION

The data showed these instant message sessions to be a potentially feasible forum for HIV/STD counseling.

PRACTICE IMPLICATIONS

Information ordinarily disseminated at health clinics could be successfully distributed through the Internet to MSM.

Syphilis: continuing public health and diagnostic challenges

As the "great imitator" of disease, syphilis, caused by the bacterium Treponema pallidum, continues to be a conceptually elusive condition that is surrounded by diagnostic ambiguity and clinical misunderstanding. Concurrent HIV infection adds further difficulty by introducing the oldest and most confusing medical conundrum into the socially and biologically complex situation of treating patients with a virus we are still only learning to manage. Syphilis continues to be a challenge to the health of men who have sex with men and people of color as infection rates continue to increase within these substantial subgroups living with HIV. As the resurgence of syphilis continues, a clear understanding of diagnostic testing, disease-staging paradigms, and treatment strategies are necessary for optimal management of the HIV co-infected patient.

Online advertising as a public health and recruitment tool: comparison of different media campaigns to increase demand for smoking cessation interventions

BACKGROUND

To improve the overall impact (reach x efficacy) of cessation treatments and to reduce the population prevalence of smoking, innovative strategies are needed that increase consumer demand for and use of cessation treatments. Given that 12 million people search for smoking cessation information each year, online advertising may represent a cost-efficient approach to reach and recruit online smokers to treatment. Online ads can be implemented in many forms, and surveys consistently show that consumers are receptive. Few studies have examined the potential of online advertising to recruit smokers to cessation treatments.

OBJECTIVE

The aims of the study were to (1) demonstrate the feasibility of online advertising as a strategy to increase consumer demand for cessation treatments, (2) illustrate the tools that can be used to track and evaluate the impact of online advertising on treatment utilization, and (3) highlight some of the methodological challenges and future directions for researchers.

METHODS

An observational design was used to examine the impact of online advertising compared to traditional recruitment approaches (billboards, television and radio ads, outdoor advertising, direct mail, and physician detailing) on several dependent variables: (1) number of individuals who enrolled in Web- or telephone-based cessation treatment, (2) the demographic, smoking, and treatment utilization characteristics of smokers recruited to treatment, and (3) the cost to enroll smokers. Several creative approaches to online ads (banner ads, paid search) were tested on national and local websites and search engines. The comparison group was comprised of individuals who registered for Web-based cessation treatment in response to traditional advertising during the same time period.

RESULTS

A total of 130,214 individuals responded to advertising during the study period: 23,923 (18.4%) responded to traditional recruitment approaches and 106,291 (81.6%) to online ads. Of those who clicked on an online ad, 9655 (9.1%) registered for cessation treatment: 6.8% (n = 7268) for Web only, 1.1% (n = 1119) for phone only, and 1.2% (n = 1268) for Web and phone. Compared to traditional recruitment approaches, online ads recruited a higher percentage of males, young adults, racial/ethnic minorities, those with a high school education or less, and dependent smokers. Cost-effectiveness analyses compare favorably to traditional recruitment strategies, with costs as low as US $5-$8 per enrolled smoker.

CONCLUSIONS

Developing and evaluating new ways to increase consumer demand for evidence-based cessation services is critical to cost-efficiently reduce population smoking prevalence. Results suggest that online advertising is a promising approach to recruit smokers to Web- and telephone-based cessation interventions. The enrollment rate of 9.1% exceeds most studies of traditional recruitment approaches. The powerful targeting capabilities of online advertising present new opportunities to reach subgroups of smokers who may not respond to other forms of advertising. Online advertising also provides unique evaluation opportunities and challenges to determine rigorously its impact and value.

Internet and email use among STD clinic patients

BACKGROUND

Little data exist on Internet and email use among STD clinic patients for research and clinical care communication.

METHODS

An anonymous cross-sectional survey of STD clinic patients aged >/=18 years in Seattle, WA, March 13 to 22, 2006.

RESULTS

Of 489 study period patients, 251 (51%) completed the questionnaire. Participants had a median age of 30 (range 18-66) years and were 69% male, 56% white, 19% black, 9% Hispanic, and 7% Asian/Pacific Islander. Of all participants, 75% had some postsecondary education but half reported an annual income of <US$15,000. Of 251 participants, 200 (80%) reported using the Internet from a private location at least once a week, 190 (76%) had their own email that they check at least 3 times a week, and 144 (57%) were willing to receive an email reminding them to come back for a follow-up appointment if diagnosed with an STD. Men who have sex with men were more likely than women and heterosexual men to be regular Internet and email users (92% vs. 70%, P = 0.001) and to have met a sex partner over the Internet during the past year (69% vs. 11%, P <0.001). Higher educational level and income, but not age or gender, were also associated with Internet and email use, as was racial/ethnic background (86% of whites, 48% of blacks, 73% of Hispanics, 100% of Asians/Pacific Islanders, and 57% of others, P <0.001).

CONCLUSIONS

Internet and email use are common and acceptable to many STD clinic patients for research and clinical purposes.

Improving recruitment and retention for an online randomized controlled trial: experience from the Youthnet study

The objective of the study was to present recruitment and retention findings for an Internet based HIV prevention trial evaluated using a randomized controlled design among 15-25-year-olds accessing a website on the Internet. We used a combination of automated electronic and personalized approaches to increase and diversify recruitment, verify participant eligibility and increase retention. We posted 3.5 million banner advertisements, 9354 individuals clicked on the advertisement, 8950 completed an eligibility screener and 3298 a baseline survey; we flagged 675 of these as suspicious and enrolled 2623 individuals. Of these, 2082 (79%) completed a follow-up at one-month and 1398 (53%) completed a two-month follow-up. This retention rate is the highest we have seen for an Internet-based HIV-prevention trial. Our procedures can be replicated in other trials. We stress the importance of using a combination of automated and personalized techniques to increase enrollment, verify eligibility and promote retention.

Frequent and systematic unprotected anal intercourse among men using the Internet to meet other men for sexual purposes in France: results from the "Gay Net Barometer 2006" survey

For men who have sex with men (MSM), the Internet has imposed itself in the past decade as the place to be to meet other men with similar interests for sex or just to surf in search of excitement. This is a biennial study on the MSM in France. Between December 2005 and February 2006, 15,085 MSM completed an online questionnaire on their social and sexual uses of the Internet. Participants in the "The Gay Net Barometer 2006" study responded to questions related to their sexual and sexual risk behaviours. One third of respondents reported at least one event of unprotected anal intercourse while 11.1% reported frequent or systematic unprotected anal intercourse. These sexual risk behaviours were associated with various sociodemographic and sexual variables in addition to the recruitment website. The study suggests Internet users are not a homogeneous group and intervention targeting of them should be based on an in-depth understanding of the sexual cultures operating within websites.

Sexual risk taking among young internet-using men who have sex with men

OBJECTIVES

We examined the characteristics of young Internet-using men who have sex with men (MSM) and risks associated with seeking sex online, offline, or through both strategies.

METHODS

Data were obtained from MSM aged 18 to 24 years who completed a 45-minute online survey regarding sex and Internet use in the preceding 3 months.

RESULTS

Significantly more Internet-using MSM who had met sexual partners both online and offline (43%) reported unprotected anal intercourse than did those who had met sexual partners exclusively online (29%) or offline (34%). MSM who met sexual partners exclusively offline reported the fewest partners but the greatest proportion of partnerships involving unprotected anal intercourse (49%). Meeting sexual partners both online and offline (odds ratio [OR]=3.38-58.42) and being drunk (OR=1.57) or high (OR=2.24) increased the odds of having more sexual partners. The same factors increased the odds of having unprotected anal intercourse (online and offline sexual partners, OR=1.60; being drunk, OR=1.43; being high, OR=1.61).

CONCLUSIONS

Risky sexual behavior was prevalent among all of the study subgroups. Our findings suggest that online sex seeking is associated with greater numbers of sexual partners but neither promotes nor discourages unprotected anal intercourse. Regardless of where sexual partners met, being drunk and high were significant risks for unprotected anal intercourse.

Moderating effects of age on the alcohol and sexual risk taking association: an online daily diary study of men who have sex with men

Men who have sex with men (MSM) account for the majority of HIV/AIDS diagnoses and data suggest infection rates are rising. Identification of factors that increase the risk of infection is key to the development of effective prevention programs. Previous research has been inconsistent regarding the link between alcohol consumption and sexual risk taking among MSM. Daily reports of alcohol consumption and sexual behavior were completed for up to 30 days by 143 HIV negative MSM recruited online. This resulted in 2,887 daily reports of number of sex partners and 549 episodes of sex. Independent variables included age, number of standard drinks consumed, and partner type. Outcome variables included sex with a partner, a composite sexual risk variable, and unprotected anal intercourse (UAI). Alcohol consumption significantly increased the odds of having sex and had a significant positive association with the sexual risk composite variable. Age was a significant moderator of the association between alcohol consumption and sexual risk taking, with the effects of alcohol increasing with age. For example, at the 75%tile of age (37 years old), the odds of UAI increase from approximately 0.2 to 0.35 as the number of alcoholic drinks increases from zero to seven. Partner type did not have significant effects. Daily reports of alcohol consumption had a significant within-person association with sexual risk behaviors, particularly among older MSM. Findings highlight the importance of measuring individual differences as moderators of the association between alcohol and risky sexual behavior.

Men Who Have Sex With Men and Recruit Bareback Sex Partners on the Internet: Implications for STI and HIV Prevention and Client Education

Men who have sex with men (MSM) frequently use Internet-based Web sites to recruit sex partners. Although many MSM users of such sites advocate for safe sex practices in their personal profiles, some users actively recruit sexual partners who wish to participate in anal sexual intercourse without the use of condoms, also known as “bareback” sex. Participating in this sexual practice places both sexual partners at higher risk of HIV transmission. In addition, data indicate this behavior is associated with other high-risk activities such as drug use and communication of other sexually transmitted infections. This article summarizes the literature assessing this phenomenon on the Internet. Specific recommendations are provided for clinicians, health educators, and researchers.

Syphilis in the United States: an update for clinicians with an emphasis on HIV coinfection

Diagnosis and treatment of syphilis are challenging because of its variable clinical presentation and course and the lack of definitive tests of cure after treatment. This review of the most recent literature on the epidemiology, clinical manifestations, current diagnosis, and treatment of syphilis is focused toward clinicians who treat patients with this disease. Syphilis coinfection with human immunodeficiency virus is emphasized because it is increasingly common in the United States and affects the initial presentation, disease course, diagnosis, and treatment of syphilis. Of particular consequence is the effect of human immunodeficiency virus on the clinical diagnosis, prevalence, and course of neurosyphilis, one of the most serious consequences of syphilis infection.

Partner notification for sexually transmitted diseases in Peru: knowledge, attitudes, and practices in a high-risk community

OBJECTIVES

Notification and treatment of sex partners after diagnosis of a sexually transmitted disease (STD) is essential to reduce reinfection and further transmission.

GOAL

The goal of this study was to determine the prevalence of partner notification and subsequent health-seeking behavior in a high-risk population in Lima, Peru.

STUDY DESIGN

STD-infected participants of an HIV/STD prevention trial completed a questionnaire concerning partner notification.

RESULTS

Of the 502 STD-positive subjects, 287 completed the survey. Among survey participants, 65% informed their primary partner and 10.5% informed casual or anonymous partners. Reasons for failure to notify varied by partner type and included not understanding the importance of partner notification, embarrassment, fear of rejection, and inability to locate the partner. When notified, approximately one third of all partners sought medical attention.

CONCLUSIONS

Partner notification in Peru is limited by relationship dynamics, social stigma, and limited contact information. Interventions could emphasize the importance of notification, improvement of communication skills, and introduce contact tracing programs (including Internet-based systems) and expedited partner therapy.

Tip of the Iceberg: young men who have sex with men, the Internet, and HIV risk

OBJECTIVES

We examined the prevalence of Internet use for meeting sexual partners (Internet partners) and HIV risk behaviors associated with this use among young men who have sex with men (aged 16-24 years).

METHODS

A sample of 270 young men who have sex with men completed a computer-assisted survey. We used bivariate chi(2) analyses and hierarchical logistic regression to assess factors associated with Internet-facilitated sexual encounters.

RESULTS

Using the Internet to meet sexual partners was common; 48% of our sample had sexual relations with a partner they met online. Of these, only 53% used condoms consistently, and 47% reported having sexual partners older (>4 years) than themselves. Regression analyses showed increased age, White race/ethnicity, history of unprotected anal intercourse, multiple anal intercourse partners, and engaging in sexual activity at a sex club or a bathhouse were associated with meeting sexual partners through the Internet. Only history of unprotected anal intercourse was associated with risky sexual behaviors with Internet partners (P<0.025).

CONCLUSIONS

Young men who have sex with men and who seek partners online also engage in other behaviors that place them at risk for HIV and other sexually transmitted infections.

The resurgence of syphilis among men who have sex with men

PURPOSE OF REVIEW

To identify recent progress and emerging problems in addressing syphilis among men who have sex with men.

RECENT FINDINGS

A resurgence of syphilis has occurred among men who have sex with men in many developed countries. Infection has been associated with HIV coinfection, multiple partners, and recreational drug use. Unlike HIV, oral sex appears to be a common route of syphilis transmission. Many prevention approaches have shown, at best, modest success. Variable clinical presentation and potentially inconclusive lab tests make diagnosis confusing.

SUMMARY

As the infection remains relatively rare, clinicians treating men who have sex with men should maintain a high index of suspicion for syphilis lesions, and should screen their sexually active patients for latent disease. Debates about syphilis control and treatment continue. The clinical manifestations, serologic responses, efficacy of treatment, and complications of syphilis have always been complicated. HIV coinfection adds to the confusion.

The effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men: a systematic review

This article presents the results of a systematic review of the effectiveness and economic efficiency of individual-, group-, and community-level behavioral interventions intended to reduce the risk of acquiring sexually transmitted HIV in adult men who have sex with men (MSM). These results form the basis for recommendations by the Task Force on Community Preventive Services on the use of these interventions. Sexual risk behavior and condom use were the outcomes used to assess effectiveness. Intervention effectiveness on biological outcomes could not be assessed because too few studies of adequate quality have been published. The evidence found in our review shows that individual-level, group-level, and community-level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse (range 27% to 43% decrease) and increasing the odds of condom use for the group-level approach (by 81%). The Task Force concluded that the findings are applicable to MSM aged 20 years or older, across a range of settings and populations, assuming that interventions are appropriately adapted to the needs and characteristics of the MSM population of interest. Based on findings from economic evaluation studies, the Task Force also concluded that group- and community-level HIV behavioral interventions for adult MSM are not only cost effective but also result in actual cost savings. Additional information about other effects, barriers to implementation, and research gaps is provided in this paper. The recommendations based on these systematic reviews are expected to serve the needs of researchers, planners, and other public health decision makers.

Syphilis and HIV infection: an update

The striking increase in the prevalence of concordant human immunodeficiency virus (HIV) infection and syphilis observed by clinicians and public health officers over the past decade has renewed interest in the subject. Although the effect of HIV infection on the natural history of syphilis has been known for a long time, it was not until recently that several studies documented that syphilis may also impact the course of HIV infection. Despite an improved understanding of the interaction of these 2 conditions, many controversies still exist. In this article, we focus on the most recent literature describing the epidemiology, clinical manifestations, and treatment of syphilis in the context of HIV infection.