February 20, 2004
LACDHS reviewed disease intervention specialist (DIS) interview records to identify cases of online partner notification. Subsequent interviews with DIS personnel were conducted to determine the degree of partner follow-up and testing.
Case 2. In January 2003, an LAC resident aged 31 years sought medical attention at an emergency department after noticing a rash on his body. He received a diagnosis of scabies and was administered treatment; most of the rash resolved. However, a palmar/plantar rash persisted, and the patient tested positive for syphilis on March 3. In March, LACDHS interviewed the patient, who reported that he met 16 male sex partners over the Internet during his infectious period. He was asked to send his contacts an e-mail message about his infection. Subsequently, he provided LACDHS with 16 e-mail addresses and copies of 13 e-mail messages that he had sent to his sex partners, notifying them of their exposure to syphilis and the health department's efforts to contact them. Seven of the 13 persons replied and made arrangements to be tested for syphilis.
As the cases described in this report indicate, the Internet presents new challenges and opportunities for STD and HIV prevention and control. Using the Internet to meet sex partners can be a sexual risk-taking behavior.3, 5 Persons seeking testing at a municipal HIV-counseling and -testing site who sought Internet sex partners reported a high level of sexual risk-taking behavior; compared with non-Internet sex seekers, Internet sex seekers were more likely to be MSM and to have more previous STDs, more partners, more anal sex, and more sexual exposure to partners known to be HIV-positive.3 In a case involving seven persons with syphilis who met through an Internet chat room, the local health department worked with a marketing firm to enter the Internet chat room and send electronic messages to hundreds of users about the syphilis cluster.5 As a result, the local health department was able to notify and evaluate approximately 40% of named sex partners. A case-control study demonstrated a statistically significant association between Internet use and acquisition of syphilis in this population.5
The cases described in this report indicate that public health departments can use the same technology that facilitates dissemination of STDs to prevent and control STDs. In addition, case 2 indicates that involvement of the index patient in partner notification via e-mail can improve partner response rates. In a separate evaluation of instant messaging (i.e., messages sent to a person logged into a chat room), nearly 50% of all persons contacted via this method by the health department responded and were evaluated for syphilis (K. Myers, LACDHS, personal communication, 2003).
Further study is needed to determine the most effective method of using the Internet as a means of partner notification and evaluation. However, personalized messages, messages sent from an e-mail provider or within an Internet service provider (ISP), and message headers referencing a health matter might be more likely to be read than general messages that are not personalized or do not reference a specific health matter (K. Myers, LACDHS, personal communication, 2003). The same confidentiality rules apply to messages sent online as to those sent via telephone or mail; for this reason, discreet, urgent messages are most effective. Although online referral makes ensuring the confidentiality of the contact more difficult, it is an efficient method for establishing initial contact with an otherwise inaccessible person and allows subsequent communication to occur.
Public health authorities should develop strategies to use the Internet to reduce transmission of STDs. Suggested practices for online partner notification have been published.2 Other strategies include 1) providing health education and prevention messages on Web sites that are frequently visited by MSM via pop-up ads and links to Web sites offering information on STD-testing sites, STDs, and partner referral; 2) making health educators available in chat rooms to answer health-related questions; and 3) offering online test-result reporting, which might increase testing for HIV and STDs by preserving anonymity and decreasing the lag period from test to result.
R.M. Pioquinto, E.A. Tupas, and P.R. Kerndt, M.D. are with the STD Program, Los Angeles County Department of Health Services, California. M.M. Taylor, M.D. is with the Division of STD Prevention. S.D. Holmberg, M.D. is with the Division of HIV Prevention, National Center for HIV, STD, and TB Prevention. P.A. Patel, M.D. is EIS Officer, CDC.