Welcome! You’ve got syphilis!

computer card

Imagine finding that in your e-mail in box. If sex educator Deb Levine, and Dr. Jeffrey D. Klausner have their way, that will be increasingly likely to happen. Levine and Klausner have created an innovative campaign to make it easier to find the partners of people with sexually transmitted diseases. Levine, Klausner and colleagues have recently published a scientific paper detailing their experience with e-mail notification for sexually transmitted diseases (STDs).

Mandated state reporting of STDs has existed for decades. Mandated reporting was instituted because STDs are easily transmitted, often produce no symptoms in those who are infected, and can cause long term health problems when undiagnosed. The mandated reporting puts the state in charge of making sure that partners are notified and come in for treatment. Doctors are required to report all cases of certain STDs that they diagnose.

The e-mail innovation is a response to rising rates of casual sex, when partners may know nothing more than a first name and e-mail address of a sexual contact. According to MSNBC:

The service is the creation of Deb Levine, a sex educator and author of a book called The Joy of Cybersex, and of Dr. Jeffrey D. Klausner, director of STD Prevention and Control Services for the San Francisco Department of Public Health.

“In 2001 I noticed a big rise in the number of syphilis cases among gay men,” recalls Klausner. “In 1998 it was about five cases. By 2001 we had 150 cases.”

Klausner set out to discover why the rate jumped and learned that men had begun meeting each other online for casual encounters. Those encounters may be anonymous, but usually involve an exchange of e-mails. “That turned on a light for me and I realized we needed to do something online.”

He tracked down Levine … and the two created ISIS, a non-profit community organization to put sexual health information online. One of their first projects was the e-mail notification system.

The service is called inSPOT:

More than 750 people visit the inSPOT site daily. Since 2004, the service has sent more than 49,500 e-cards. Syphilis and gonorrhea cases have each accounted for approximately 15 percent of the total cards sent, followed by chlamydia at 11.6 percent and HIV at 9.3 percent. More than half a dozen other diseases account for the rest, including crabs and scabies; hepatitis A, B and C and trichomoniasis, a parasitic STD.

How does it work? In October, the online journal PLOS Medicine published the paper inSPOT: The First Online Partner Notification System Using Electronic Postcards, detailing the system and the results.

On the rationale for the system:

In the United States there are 19 million new sexually transmitted disease (STD) cases diagnosed each year, including 900,000 reported cases of chlamydia, 330,000 reported cases of gonorrhea, and 55,400 estimated new HIV infections per year. Notifying sexual partners of their potential exposure to an STD has been a mainstay of disease prevention and control since the 1930s…

Traditionally, partner notification has been done in person, by phone, or by mail, with the assistance of a public health investigator. The high number of cases … makes partner notification for all named partners impractical in many jurisdictions. Particularly among gay men and other men who have sex with men (G/MSM), who tend to have higher numbers of partners, online notification may be an effective strategy to increase partner notification.

E-mail notification is sent by the infected person, because he or she often has nothing other than an e-mail address to identify the partner, and therefore cannot identify the partner for state reporting efforts:

… inSPOT is very simple. The two sections are Tell Them and Get Checked. In Tell Them, users follow this path:

·         Choose one of six e-cards,

·         Type in recipients’ e-mail addresses (up to six),

·         Select an STD from a pull-down menu,

·         Type in own e-mail address or send anonymously,

·         Type in an optional personal message.

When an e-card is clicked on by the recipient, users are linked to a page with disease-specific information.

The Get Checked section is divided into STD information, a map of local testing sites, and links to online resources. To ensure the privacy of the user, no database to store e-mail addresses or information about e-card senders or recipients exists.

Since its 2004 launch in San Francisco, inSPOT has been replicated in three countries, ten cities, and nine states…

How well does inSPOT work? The authors are extremely enthusiastic, but, in truth, the results are quite modest:

…[W]e analyzed rates at which e-card recipients clicked a link embedded in the card that connected to STD test site information. Annual “click-through” rates ranged from 20.4% in Los Angeles to 48.2% in Idaho, with an average across all sites of 26.8% in 2006 and 28.5% in 2007. During the period that inSPOT has been active, from December 2005 through February 2008, 29,137 people accessed STD testing information as a result of receiving an e-card…

Only one quarter to one half of recipients clicked through to the information about getting tested for the disease to which they were exposed. There is no information about what proportion actually got tested. Accessing the information does not mean that the recipient got tested, and not clicking through to the information does not preclude the possibility that the recipient sought testing through a private doctor. However, when you consider that none of the recipients could have been notified any other way, even small testing rates are encouraging.

The inSPOT notification system is a high tech response to a distinctly high tech modern problem. The internet has created an unprecedented opportunity for soliciting casual sexual encounters. This has contributed to an increase in sexually transmitted diseases, and an increasingly inability to identify sexual contacts of an infected person. It is fitting that the technology used to fuel the increase is also being used to limit its negative impact.

Some think that the inSPOT e-mails are already outmoded. E-mail is increasingly a tool of older people; teens and young adults have moved on to text messaging. According to Mary McFarlane, a behavioral scientist with the Division of STD Prevention at the Centers for Disease Control and Prevention in Atlanta:

“More and more people are going with mobile phone technology” to facilitate casual hookups she says. “I think it is very important that we in public health pay attention to these innovations and provide health information in those places.”

No doubt a text messaging service is on its way. In the near future, people may retrieve their text messages to find:

Wlcm! Yv gt syphilis!

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