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Formative Research: Assessing Areas of Agreement and Disagreement between Internet Dating Site Managers, MSM, and Public Health Dan Wohlfeiler CA STD/HIV.

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Presentation on theme: "Formative Research: Assessing Areas of Agreement and Disagreement between Internet Dating Site Managers, MSM, and Public Health Dan Wohlfeiler CA STD/HIV."— Presentation transcript:

1 Formative Research: Assessing Areas of Agreement and Disagreement between Internet Dating Site Managers, MSM, and Public Health Dan Wohlfeiler CA STD/HIV Prevention Training Center March 29, 2009

2 What Ill cover Current challenges we all face How much intervening do our customers want? If they dont want interventions, what can we do? How do we decide what to do? Concept mapping survey to collect input from all stakeholders

3 Our Team STOP AIDS Project San Francisco Department of Public Health CA STD/HIV Prevention Training Center Concept Systems NCSD and NASTAD Funding generously provided by AMFAR (The Foundation for AIDS Research)

4 We all face challenges in helping reduce infections associated with meeting partners online Public health (CBOs and Health Departments) Website Owners and Managers Customers

5 Challenges facing Public Health Uncoordinated requests No consensus on what we should do when we can choose between strategies Undercutting each other Low budgets Low reach

6 Challenges facing Website Owners Different mission - sometimes in synch with public health, and sometimes not, but its not the same. Bombarded with sometimes contradictory requests Great knowledge about their sites, but less about public health interventions Hard to know which intervention to move ahead

7 Challenges facing Customers High risk of exposure/infection, particularly in high-prevalence areas Lack of access to tools that match diverse risk levels Lack of information about partners in a dont ask, dont tell environment Wide variation in intervention quality Many dont want an intervention – just want to find a new partner efficiently

8 Percentage of MSM using HIV- prevention services or programs during past 12 months, by venue – US NHBS, 2003-2005 Sanchez T, Finlayson T, Drake A, Behel S, Cribbin M, Dinenno E, Hall T, Kramer S, Lansky A; Centers for Disease Control and Prevention (CDC). Human immunodeficiency virus (HIV) risk, prevention, and testing behaviors--United States, National HIV Behavioral Surveillance System: men who have sex with men, November 2003-April 2005. MMWR Surveill Summ. 2006 Jul 7;55(6):1-16.

9 Can we pull customers to our sites? How much do youth prioritize the sites we create to promote sexual health?

10 How many people visited in December, 2007? Facebook32,097,588 CDC.Gov2,262,122 Manhunt398,201 Ashastd.org130,000* Teensource.org58,000* Siecus.org120,000* Hivtest.org28,228 Even if Compete is insensitive to low numbers, its not off by 1000-fold. *numbers provided by website managers

11 Alternatives: Go where they are. Improve links. Encourage internet sites to help provide environmental supports that men will benefit from, even if they dont think of them - or even if WE dont think of them - as interventions

12 Reasons cited for doing outreach online We can answer questions like How safe is oral sex? We can provide links to testing. We can provide links to other services. Many of these can be accomplished by googling or by providing links on the sites themselves.

13 Our goal To come up with interventions that customers want to participate in (or may benefit from even if they dont participate in them), that website owners want to implement, and that public health believes will work.

14 John Snows pump Source: The Broad Street Pump, Safe & Sound, Penguin, 1971 in English MP. Victorian Values -- The Life and Times of Dr. Edwin Lankester, 1990.

15 The internet IS a network, and a structure. So we can use networks to: Find partners who are at highest risk Spread messages efficiently AND Shape them so we can reduce transmission.

16 Syphilis Case Studies CASE 1 Health Department Clinic interviewed by 332 Volunteer, 30s, male, Pacific Islander, gay, HIV (-), ulcer, chancre, primary lesion, lesion/bump. Partners: 2-named. Venues: Drug use: none. Last syphilis test: 9/15/05. Employment: Retail, $30,000. CASE 2 Health Department Clinic interviewed by 212 True Screening, 30s, male, White, gay, HIV (-), body rash. Partners: 3-named, 7-refused to name, 10-other. Venues: Steamworks, sex on- site, 440 Castro,, Condom use: never for oral sex, rarely for anal insertive. Drug use: none. Last syphilis test: 10/8/02. Employment: Banking, $40,000.

17 In many venues, we dont know who is having sex with whom 10% high-risk

18 Serial Monogamy Exposure Flow Infected Partner After A is exposed to infected partner D, three are potentially infected.

19 Concurrency Flow Infected Partner Given the same time period: After A is exposed to infected partner D, five are potentially infected. Concurrency facilitates more transmission than serial monogamy.

20 Of those men with whom STOP AIDS contacts had anal sex … how many did they have serodiscordant unprotected anal sex with in the past 6 months? All first-time respondents January 1999 – December 2002 ( N=2,430) Number anal sex partners Number serodiscordant unprotected anal sex partners 0123 1 (n=1,088) 988100 2 (n=331)2605021 3 (n=230)18334103 4-5 (n=257)169352726 6-10 (n=247)142362544 11-20 (n=158)8313557 >20 (n=119)5855 51

21 * National HIV Behavioral Surveillance-MSM, Nov. 2003-Dec. 2004, n=1,574 ~108 men

22 Major Themes Emerging from Network Theory-into-Practice Meeting, 2003 Focus on concurrency Create areas where low risk individuals, if they choose to have unsafe sex, may face lower risk of encountering HIV or STDs Help people be better shoppers for partners in venues where high and medium-risk individuals mix –Baths –Internet sites


24 The internet may help pull high- risk men in one direction….

25 And low-risk men in another.

26 Maximize Disruption on Internet Remove/treat ONLY three actors –Network=159 members (50% drop)17 unconnected clusters

27 What SF focus groups said about this: Everybodys just a little bit away from everybody else…if youre not being careful, it can lead to a serious infection. Six degrees of separation Youre not only sleeping with him, but with everybody he has ever slept with


29 So where do we go from here? Lets get input from all stakeholders on different strategies: Customers Website Owners Public Health experts

30 Consumer input An outreach worker? Talk about a buzz kill. Like going to a fancy dinner party and having to sit next to a starving child. Some are more amenable to sorting by risk than by HIV status If Im partying, I dont want to hook up with someone whos not.

31 Categories of Interventions and examples Groupings: Sites or subsites for safe only, unprotected only, HIV+ Messages: Tips re healthy sex, automatic email at chosen intervals with testing reminders Links: Test sites, health/drug information Partner Notification: Public health, anonymous Education/motivation: Outreach, videos, counseling (1:1 or group)

32 Introduction to concept maps These maps can also allow all stakeholders to see how others rated interventions and strategies: –Website owners will rate by feasibility and willingness to implement; –Customers will rate by acceptability and willingness to participate; –Public health will rate by feasibility and estimated impact.

33 Sample Concept Map of Internet Interventions 3 1.414.13 1.15 4.18 Feasibility 2.71 3 7 8 14 34 52 56 60 62 94 95 116 Impact

34 Benefits of concept maps Identify areas of agreement and go zone Isolate areas which need more discussion Hold up a mirror to stakeholders as to how their perceptions compare to others perceptions Helps all stakeholders move forward with better understanding of all players perspectives.

35 Example of high impact/high feasibility (internet) Sites provide search functions to allow members to view profiles with specific risk preferences and HIV or STD status. Impact Feasibility

36 High feasibility / low impact HDs provide regularly updated data to internet site management for sharing with their members. Impact Feasibility

37 Low feasibility / high impact HDs provide regular and comprehensive training on internet partner notification for CBO outreach staff, DIS, and others. Impact Feasibility

38 Low feasibility / low impact Sites enforce laws regarding illegal activity taking place on their sites (e.g., distribution of illegal drugs) and terminate members found to be violating these laws. Impact Feasibility

39 Next steps Start assembling advisory group Get ideas from website owners and public health to add to survey Invite all participants to complete survey Analyze data by stakeholder and customer variables (risk/age/serostatus) Generate data and give to all stakeholders.

40 For more information …or discussion, or suggestions, or input, or debate…. 510 625 6026

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