Virtual Prevention: Fighting HIV Online
April 15, 2008
by David Evans
source: POZ
http://www.poz.com/articles/hiv_prevention_internet_401_14435.shtml
Describing the state of HIV prevention at a large, international AIDS
conference recently, Ronald Stall, PhD, of the University of Pittsburgh
School of Public Health, said, "Is HIV prevention working among gay men
in the United States? I think to put it in the most polite terms, the
best thing we can say is not as well as anyone would like."
A set of key statistics published by the Centers for Disease Control and
Prevention (CDC) on their website in March of 2008 states it more
plainly: The number of HIV-positive gay and bisexual men has increased
steadily between 2001 and 2005.
The problem has been well documented in various metropolitan areas.
According to the New York City Department of Health and Mental Hygiene,
between 2001 and 2006, HIV diagnoses increased by 32 percent among gay
and bisexual men aged 30 or younger in the city. And in a five-city CDC
study conducted between June 2004 and April 2005, 40 percent of 462 gay
and bisexual men tested for HIV were confirmed to be positive for the
virus-62 percent of them didn't even know they were infected, and a
whopping 8 percent were likely infected within six months prior to
testing.
So, what is causing the spike in new HIV diagnoses? Experts point to
several possibilities from "cultural amnesia around the epidemic" to the
age-old misperception of invincibility among youth to increased drug and
alcohol use to a lack of sufficient fear of a disease that has been
rendered "manageable" -and survivable-with treatment. Others point out
that in some cities younger gay men aren't getting tested as often. And
since researchers think that the majority of transmissions in the U.S.
happen during the first weeks and months after infection, when people
still think that they're HIV negative, less frequent testing means
people remain unaware of their status and pass on HIV to others. All of
these factors undoubtedly leave young people more susceptible to
contracting HIV.
But there's another factor-the Internet. While its impact on
relationships, dating and sex is still new and largely uncharted, most
will agree that it has drastically altered the way people, particularly
those looking for sex, connect. The Internet makes meeting people more
efficient. A single person can meet hundreds of people within a matter
of minutes in cyberspace-to do the same thing in the real world takes a
lot more time. Meeting online allows people to skip the stages of
getting acquainted, cutting straight to a sexual encounter without the
preamble that could provide the time and/or information that would
perhaps lead to a more considered decision. It may not be coincidental
that as the number of Internet-based dating and sex websites has
increased, so has the numbers of new HIV infections.
Simon Rosser, PhD, a researcher from the University of Minnesota, who
spoke after Stall at the 15th Conference on Retroviruses and
Opportunistic Infections (CROI) this past February in Boston, believes
that the rise of the Internet as a place to easily and efficiently find
sex partners is intimately connected with the increased numbers of gay
men who are becoming HIV positive. He likened the Internet's impact on
sex (rendering it more casual) to the drastic change that occurred in
attitudes about air travel. While airplanes were once thought to be the
realm of exotic thrill seekers, they are now commonly used by everyone
from grandmas to babies. "If the Internet has a similar effect on sex,
we have to ask is casual sex about to get a lot more common and even
more casual?" he asked.
While it has yet to be proven that the Internet is a direct cause of
increased HIV infections, the Web has undoubtedly created an arena that
presents new challenges for those looking to do prevention outreach
work. And some worry that the surge in online traffic will soon leave
many more traditional venues for hooking up-like parks, baths and
bars-empty. In an article in Xtra West, Terry Trussler, the research
director of Vancouver's Community Based Research Centre, explained that
the proportion of men who spend more than 50 percent of their free time
with the gay community-where traditional prevention efforts are focused
and where young men can learn about safer-sex norms-decreased from 62 to
42 percent, and said, "[For] many gay men who are 20 now, their first
sexual encounter will have happened through connections made through
their computer."
Rosser, speaking at the conference, concurred, pointing out that while
the gay community has grown considerably online, the traditional gay
infrastructure is eroding, and since online hookups are so much more
efficient than bars or bathhouse hookups, gay men are having more sex
with more people than before. More sex means that occasional slipups or
decisions to forgo condoms with a special guy are also more likely to
occur.
Acknowledging the potential link between a rise in online connections
and the spread of HIV, prevention experts are beginning to examine what
can and should be done to prevent HIV online-perhaps even in those very
settings that seem to contribute to behaviors that can lead to HIV. One
challenge is that most of the groups in the U.S. responsible for doing
HIV prevention work, and the government agencies that fund them, have a
limited presence in cyberspace. Critics of current off-line prevention
efforts point out that even if we could deliver new web-based prevention
tools tomorrow, they will have limited efficacy unless we find ways to
integrate them into the activities that gay and bisexual men already
enjoy doing, such as participating in social-networking sites, shopping
online and using the Internet to learn about non-health topics.
This shift in the way we meet and date online is leading several
ingenious pioneers to try to capitalize on the Internet's potential to
stretch the boundaries of traditional HIV prevention thinking. It's too
early to tell whether they'll succeed in changing behavior and reducing
new infections, or even whether they'll be able to convince their fellow
prevention workers to join them on the Web. But recent statistics point
to a critical need to find a mechanism that will reach those who are
looking for love-and everything else-online. And such a mechanism should
have enough sophistication, fun and sexiness to compete with other
things that men are also doing online, such as checking e-mail,
downloading music and updating their Facebook.com profile.
Disturbing Trends
Stall's conclusion that HIV prevention wasn't working well for gay and
bisexual men was based on his careful scrutiny of all the available data
he could find on HIV incidence, which estimates how many new infections
occur each year. He and his colleagues found that by the most
conservative estimate, 2.39 percent of gay and bisexual men in the U.S.
were becoming infected annually between 1995 and 2005. Stall then
calculated what would happen to a group of men who were 20 years old in
1995 and had a 2.39 percent HIV incidence rate. He found that by 2005,
when the men had turned 30, nearly a quarter of them were likely to be
infected with HIV, and that by 2015, when the men would turn 40, over 40
percent would be HIV positive.
If we consider this hypothetical group of twentysomethings, HIV wasn't
the only thing that began to affect them in 1995. By then the most
technologically advanced were regularly using the Internet for e-mail
and to find information. By the end of the century, gay chat rooms were
the rage, and more sophisticated websites devoted to personal ads for
sex and dating were beginning to show up all over the Web.
Epidemiologists began to see the influence of the Internet around 2000,
when rising syphilis rates among HIV-positive men were often traced back
to online chat rooms and websites where people could meet and hook up.
Early evidence also suggested that HIV transmission was being
facilitated online. Rosser says researchers like him began to ask, "Is
there something magical about the Internet? Is it attracting men of
higher risk? What's going on?"
Professor Jonathan Elford, of City University London, in England, says
the Internet has "opened up opportunities for conducting research, which
didn't exist 10 years ago," and that "What we do find, is that men who
are recruited through the Internet are more likely to report high levels
of risk."
Rosser's own research suggests that HIV-negative men are not necessarily
taking more risks with people they meet online than they would, say,
with someone they met at a bar or bathhouse, but that because hooking up
online is so much more efficient, they are having more sex. "In the old
days, let's say I might score five times a week; now I can score 50
times a week, and we don't think it's just increased it a little bit,
it's increased it a lot," he says.
While increased HIV risks and new diagnoses may cause some to
automatically assume that HIV-positive men are knowingly having sex with
unconcerned and irresponsible HIV-negative men, experts say this is a
rare phenomenon. In fact, the vast majority of people with HIV, once
they've been diagnosed, cease having unprotected sex with partners who
say they are HIV negative or don't know their status. Rather, new HIV
cases appear to happen in clusters, among men who assume they are HIV
negative, all of them in the early-infection stage with very high viral
loads. Since young gay men are having sex more often with more people,
but getting tested for HIV less often, taking higher risks or slipping
up on safer-sex commitments turns into a numbers game that more and more
men are losing.
What's more, "The Internet has now taken over as the No. 1 venue for
meeting sexual partners for men at high risk," says Rosser. He's
reported data from the Minneapolis St. Paul area that showed 52 percent
of single gay and bisexual men surveyed met sex partners online,
compared with 47 percent who met partners at a bar or club, and just 11
percent who met partners at either a bathhouse or a sex club.
Rosser also feels that the Internet isn't just affecting HIV
transmission among gay and bisexual men; it may also be affecting the
physical brick-and-mortar gay community. He has reported that with the
exceptions of gay Meccas like San Francisco or New York, "gay
neighborhoods and gay infrastructure, for instance gay bars, all appear
to be in decline."
Elford doesn't feel that the Internet is replacing physical venues in
the gay community as much as adding to them. He says, "Most of the men
who said they used the Internet also went to bars and clubs.... That's
what we found in London, and there's some evidence that the same is
probably true in bigger U.S. cities."
We Need New Tools and New Messages
Though experts may disagree about the effect that the Internet has had
on real-world gay environments, most agree that the majority of gay and
bisexual men probably have spent at least some of their time cruising
for sex partners online and that HIV prevention interventions should
increasingly be focused there.
Researchers have been quick to move some aspects of their research
online, such as surveys and behavioral surveillance, but few have moved
beyond what currently constitutes the majority of online HIV prevention
efforts, which are mostly limited to written HIV prevention information,
prevention workers who cruise chat rooms or post ads on craigslist.com,
profiles on Facebook and MySpace and e-mail notifications to the sex
partners of people who've tested positive for a sexually transmitted
infection (STI) like HIV or syphilis.
Joshua Tager, senior digital editor for Out and The Advocate magazines
in New York City, says that he worries that even if prevention experts
do manage to build new online tools, they may fail to work if they
follow the model of existing off-line prevention efforts, which rarely
adhere to the kinds of guidelines that gay businesses do if they want to
be successful-namely that their products need to be sexy and enjoyable.
Rosser, himself one of those prevention experts, agrees, saying, "One of
the problems [with existing prevention programs] is that we made them
more clinical and we had idiots like me develop more professional-type
seminars and we sort of left the community out of it, and we actually
left sex out of it." In short, the newer prevention tools are going to
have to go far beyond a simple message of "use a condom every time" if
they are going to match up with the kind of subtle risk assessment
strategies that gay and bisexual men are already using. And they're
going to have to be entertaining and sexy to get their point across.
Stall and others point out that many HIV-positive men are already using
a strategy called serosorting, whereby they choose to have sex only with
other HIV-positive men or at least only have unprotected anal sex with
these men, as a way to keep from passing HIV on to HIV-negative men.
This strategy isn't perfect, as the flurry of syphilis cases among
HIV-positive men around the globe indicates, but it does mean that
HIV-positive men are not putting their HIV-negative partners at risk.
While serosorting may be great for HIV-positive men who wish to
bareback, its effectiveness for HIV-negative men who'd also like to try
condom-free sex is questionable.
"If someone in their ad says that they're HIV positive, and another
person responds who says that they're HIV positive, chances are they
really are HIV positive. But if two men say that they're HIV negative,
that depends on when they've had their last test, and what they've done
since their last test. It's much less reliable," explains Elford.
Another risk-reduction strategy that some gay and bisexual men are
trying out is called strategic positioning, whereby HIV-negative men
have unprotected anal sex with partners who are HIV positive or whose
HIV status is unknown, but only as the insertive partner. As Michael
Ross, PhD, from the University of Texas School of Public Health in
Houston, observes, however, "You know strategic is a word that George
Bush uses all the time in reference to the war in Iraq, but just because
we say that something is strategic doesn't mean that it makes a lot of
sense."
Yet another factor causing gay and bisexual men to weigh the pros and
cons of condoms, is a Swiss proclamation made earlier this year that
stated that for straight monogamous couples, where one is HIV-negative
and the other HIV-positive, HIV transmission was impossible provided
that the HIV-positive partner was taking antiretroviral drugs, had an
undetectable viral load for at least six months, and didn't have any
other STIs.
Brave New World
New online prevention tools, therefore, need to be both technologically
innovative and offer sophisticated and comprehensive
sexual-risk-assessment strategies. But Tager feels they need to go even
further. He says, "If you think about most HIV prevention workshops,
they're always these stand-alone activities that someone has to make
time and effort to attend. Rarely, if ever, are they incorporated into
the kinds of activities that most gay men find enjoyable. I wish that
people doing prevention would ask for the help of [experts in the field
of gay website development] in devising new prevention efforts. I think
we've got a lot to offer."
Fortunately, the handful of people conducting research about what will
constitute the most effective online prevention tools have taken Tager's
message to heart. A Dutch group led by Gerjo Kok, PhD, from the
department of experimental psychology at Maastricht University in the
Netherlands, in what Ross calls "pretty much the gold standard for
interventions at this point in time," has built a virtual gay cruise
ship to help men navigate and learn about sexual decision making. Men
get to choose from one of four attractive animated male pursers, guiding
them through the cruise ship and helping them think through a number of
sexual decision-making scenarios arising from encounters with other
animated ship passengers.
Most men who participated in the gay-cruise prevention website liked it.
In their evaluations, 86 percent said it was enjoyable, 53 percent said
it helped them to know more about their sex life, and 61 percent said
they became more conscious about dating and sex.
You'd think, given this kind of response, that there'd already be an
online gay-cruise prevention tool available worldwide. But the release
of such a tool has been held up because there's a problem. Though Kok
and others proved that you can engage and retain large numbers of gay
men to complete an online intervention, they also recognized that it is
remarkably difficult to find those same men three or six months later to
follow up and see if their behavior changed as a result of the
intervention. Thus, as innovative as the gay-cruise prevention tool may
be, the researchers were unable to effectively track whether or not it
caused the men who experienced it to ultimately take fewer HIV risks.
Rosser is leading another team at the vanguard of online HIV prevention.
It's developed an online interactive health and sexuality environment
called SexPulse that is being rigorously evaluated. SexPulse is in its
third of 12 months of follow-up; involving about 600 gay men, though
early results are promising, the project is not yet ready for primetime
as, like with the online cruise ship, its longer-term effectiveness is
still unproven.
"What we're trying to do with SexPulse is to come up with engaging, fun
ways that guys can learn about their sexuality.... I mean there's a real
gay sensibility that is wonderful and relevant to the online experience
[of SexPulse] that we don't see in other [prevention] tools. For
instance we have modules on how to chat online, how to get the
information you need in order to make an informed decision, and one
about body image," explains Rosser. But as excited as Rosser and his
multidisciplinary team are, they are also proceeding cautiously. He
says, "We're trying to be realistic and modest and study it well, and so
maybe if version 1 won't work, maybe version 5 will."
Rosser also points out that his group is just one of several others
around the U.S. doing this kind of work. He praises Anne Bowen, PhD, at
the University of Wyoming, for her work on the Internet with rural men,
and Sheana Bull, PhD, at the University of Colorado, who is building STI
interventions that are based on the principles of social-networking
sites like Facebook or Twitter, where the users generate their own
content.
Rosser, who has been doing HIV prevention work for 25 years, describes
the work he and his team are doing with a zest and enthusiasm
reminiscent of a person fresh out of graduate school. He credits the
interdisciplinary nature of the work, saying, "You know the NIH came out
with a big report round about 2000, and they said that major scientific
advances of the 21st century are unlikely to occur by Simon Rosser
sitting in his office thinking up a brilliant thought. Rather, they said
that the major scientific advances are likely to occur in
multidisciplinary teams where people from very different backgrounds are
coming together and working together to solve a common problem."
As exciting and hopeful as these new interventions sound, they aren't
cheap, and as Sheana Bull points out, we still don't know for sure if
they work. Nevertheless, she says, "My call is more to my own colleagues
to stay ahead of innovations or at least try to anticipate things that
are coming out and being prepared to do quick evaluations to get
strategies out there to communities. Because they can take them and run
with them more quickly and do more adaptations than we can in the
academic setting."
Perhaps the most beneficial aspect of building online prevention tools
is that once something is proven effective, there's no need to wait
months and years and spend many thousands or millions of dollars ramping
it up and rolling it out. Of SexPulse, Rosser says, "If version 5 works,
then we can just hit the switch and everybody in the world has access.
So the days of having to show demonstrated and effective programs and
then scaling [them] up for everybody to repeat it-well we don't need to
repeat it, because it's the World Wide Web."
* All responses are from a POZ/AIDSmeds survey conducted in April 2008.
