Transcript non-AIDS mortality following seroconversion in the HAART era
Sexual Health & the Internet
The role of Internet interventions current achievements and potential
Udi Davidovich, PhD ORP – Online Research & Prevention unit Amsterdam Public Health Service
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
% penetration in 2009 (June) NL,NO – 85% UK – 80%, US – 74% PT – 42%
(Ref:Nielsen/Net ratings, ITU) Rural Uganda – adolsc. 45% ever,
of whom 78% reg. Ybarra ML. Kiwanuka J. Emenyonu N. Bangsberg DR.
Internet use among Ugandan adolescents:implications for HIV intervention.
PLoS Medicine / Public Library of Science. 3(11):e433, 2006 Nov
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Sexual health & Internet Brilliant match
for Research & for Sexual Health Promotion
Scientific research, Prevention interventions & Screening/testing Services
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Interactivity Connectivity
all the time Increasingly everywhere Increasingly easier
with same set of rules as for sexual contact
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Sexual health & the internet, what more…
Anonymity Comfort: physical & mental
How does that help sexual-health related research and prevention
?
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Research
(qualitative) the case of online chat interviews with webcams
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Goal
Examine barriers to protective behavior against HIV and other STI among heterosexual youth aged 14-24 in the Netherlands.
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit Evaluation of the usability and acceptability N= 203 – Sex: – Age: 51% males 50% between 14-17 years, 50% between 18-24 years – Ethnicity: 40% Dutch, 32% Surinamese, 28% Dutch Antillean/ Aruban – Residence: 70% in urban, 30% in rural areas – Educational level: 37% low, 35% average, 28% high
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
The anonymity paradox & emotional ease
A: “It is anonymous but it is still personal cause you talk to someone ”.
A: “ehm, well if you have to talk for real you might lie cause you have to tell it to the persons face”.
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Non-compromising visual contact Q:
“ but you also see me here via the cam”?
A: “That’s different” Q: “Why”?
A: “you see each other but not in reality ”
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Comfort & emotional ease Comfort
A: “Well, you're talking to someone and you see him and you have no sense of shame like on the street where everybody can hear what you say”.
A: “I think if someone asked me to be there tomorrow at 1 o'clock for an interview – no fat chance”.
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit What other advantages?
–Geographically flexible –Simple logistics save effort, time & cost –No transcript : less bias, effort & cost –Higher inter-interviewer standardization via for example copy/paste functions.
–Webcam increases the validity of chat interviews
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Health Promotion
The case of tailoring: why do we believe it works?
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Tailoring process IMB model
Intervention output
1st intervention module
Knowledge deficiencies
Defcy. 1 Defcy. 2 Defcy. 3
Present
Not present Not present 4th intervention module
Motivational deficiencies
Defcy. 4 Defcy. 5 Defcy. 6
Present Present
Not present 5th intervention module 7th intervention module
Skill deficiencies
Defcy. 7 Defcy. 8 Defcy. 9
Present
Not present Not present
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Tailored versus non-tailorted intervention – RCT
• Stimulation of safe sex in steady relationships among MSM (negotiated safety) •
Single
men – cognitive vaccine approach
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Effect evaluation
Online RCT:
control x non-tailored x tailored
Cognitive effect behavioral effect
(directly after intervention) & (6 months follow-up via e-mail) N=1013; recruitment online via banners and links
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit Cognitive effect: Univariate analysis of variance contrasting the control condition with the non-tailored and the tailored conditions
Response efficacy (2 items) Intention ‘condom use’ (2 items) Intention ‘negotiated safety’ (6 itmes) Attitude ‘condom use’ (3 items) Attitude ‘warning partner’ (3 items) Perceived control ‘condom use’ (2 items) Condition non Tailored X Tailored X X X X X X X
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Behavioral effect at 6 months
100% 33 80% 52 63 60% 40% 2 5 17 Risky UAI Negotiated safety Condom 20% 46 50 32 0% Control Non tailored Tailored
Practice of negotiated safety for the tailored condition: OR=10.50 95%CI 1.19 - 92.72
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit Bull SS, Lloyd L, Rietmeijer C. McFarlane M. (2004). Recruitment and retention of an online sample for an HIV prevention intervention targeting men who have sex with men: the Smart Sex Quest Project. AIDS Care, 16, 931-43.
Ross MW. Rosser BR. Stanton J. Konstan J. Characteristics of latino men who have sex with men on the internet who complete and drop out of an internet-based sexual behavior survey. AIDS Education & Prevention. 16(6):526-37, 2004
Drop by
&
Drop out – trade off
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Drop out during interventions…
How do we keep them interested?
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
www.vrijlekker.nl
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Vrijlekker.nl - Objectives
To remove barriers to safe sex and STI screening among youth 16-24, (TG 18-19) Evidence based
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Theoretical Background
Tailoring: based on IMB Modeling for engagement & empowerment Direct network/environment approach TPB elements: Beliefs Perceived control Actual behavioral control
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Key features
No personal risk feedback Tailoring ( increase relevance and concision) The love-coaches (modeling) The films (as topic openers / contemplative – preparatory)
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Key features for engagement
Interactive text: e.g. the
Excuse-Fighter
(communication skills)
UCONN 2010
2009
Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Key features for engagement
E-cards as conversation opener (sexual
network)
UCONN 2010
2009
Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Interactieve modules
Communicatie naar de seksuele omgeving
UCONN 2010
2009
Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Interactieve modules
partners Communicatie richting de seksuele
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Key features for engagement
C
ondoms and lube supply online
.
Pay with the mobile or regular phone - 10 condoms voor 99 euro cent! (
Actual behavioral control
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Does it work?
6 months follow-up intervention versus control: baseline: n=2944, follow-up: n=1553 (mean age 19, SD 2.4).
Significantly more condom use with the last casual partner [ OR=1.82 95%CI 1.08 - 3.04, n=311] Significant more condom use with the steady partner [ OR=2.17 95%CI 1.48 - 3.18, n=765]
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Sexual Health Services
The case of HIV & STD testing online The case of Hep C screening online The case of population-based mass-screening for Chlamydia
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Sexual Health Services
The case of HIV & STD testing online
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit 35
Test Lab procedures
1.
Participants visit the website for an intake Selection: online test procedure or referral to the STI clinic (symptomatic or partner with STI) Print referral letter (personal code)
2.
Participants visits one of the diagnostic laboratory’s in the city Collection of urine, blood, (self)-swabs ( anal, throat) Anonymous and free (registration on personal code and Nickname)
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Test Lab procedures:
Test locations Amsterdam Rotterdam 36
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Test Lab procedures
3.
The test results are sent to the STI clinic. Diagnosed by the dermatologist of the STI clinic and put online. 37
4.
Participants obtain test result online with their personal code
5.
Man who tested positive visit the STI clinic for further examination and treatment.
UCONN 2010
Test package
Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit 1.
Chlamydia: 2.
Gonorrhea: urogenital (urine PCR), Proctum (self-swab PCR) urogenital (urine PCR), Proctum (self-swab PCR), throat (swab PCR) 3.
Syphilis: 4.
HIV (opting-out): anti-TP + => VDRL and FTA combo Antibody & Antigen test Amsterdam and Rotterdam 38
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Procedure:
referral letter 39
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Procedure:
Back office 40
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service
Procedure:
Email Udi Davidovich - ORP – Online Research & Prevention unit 41 Soa*Hiv
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Procedure:
Results online 42 Soa*Hiv
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit 43
Evaluation
Data collection for 11 months, from February 2008 till January 2009 Use & feasibility User data: number of visits, visitors, referred to online procedure or STI clinic, men tested, results put online, results viewed Efficacy % positives in Test Lab compared to % positives at the STI-clinic Data selection: Test Lab: users from Amsterdam STI-clinic Amsterdam: asymptomatic, same period, same STI tests
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit 44
Method
Usability and acceptability As operationalized by Davis [1998].
Usability: the perceived ease of use Acceptability: the level in which the service corresponds to the needs and beliefs of the user.
Answers on a 5 point scale; (negative O O O O O positive) Usability 12 items (Cronbach’s alpha .84) Acceptability 16 items (Cronbach’s alpha .83)
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Use of Testlab
20 10 0 80 70 60 50 40 30
Weeknumber
Referred Tested Lineair (Referred) Lineair (Tested) 45
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Results:
Unique users Visitors Amsterdam/Rotterdam Referred Referred to STI clinic Referred to laboratory Tested Results put online (procedural) Viewed results online 2121 60 % (1273/2121) 18 % (232 /1273) 82 % (1041/1273)
51 % (532/1041) 100% (532 /532) 99% (530 / 532)
•
31% never visited an STI clinic before
46
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Results:
Efficacy STI prevalence Test Lab Amsterdam: 18% (59/334) STI clinic Amsterdam: 15% (260/1701)
All positives visited the clinic for treatment & diagnosis
47
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Results:
Usability en Acceptability Questionnaires offered: 532 Questionnaires completed: 265
Usability:
–
Total:
– Negative test result: – Positive test result:
4.5 (SD = 0.6)
4.6 (SD = 0.5) 4.0 (SD = 0.7)
Acceptability
–
Total:
– Negative test result: – Positive test result:
4.0 (SD =0.5)
4.1 (SD = 0.5) 3.6 (SD = 0.6) N
265
227 38
265
227 38 48 Koekenbier RH, Davidovich HS. users •Int. AIDS
testing: feasibility, efficacy,
conference Vienna
and usage.
July 2010
Sex Transm Dis.
2008 •Test-specific results –how!?
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit Hepatitis C Internet Project (HIP) – Freke Zuure Overall aim: To evaluate whether a
hidden population
of HCV infected individuals can be identified through a public
media campaign
alongside an
internet risk assessment
and
low-threshold blood screening
procedure
Supporting Health by UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit HIP strategy 1.
Public, regional media campaign
Supporting Health by UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit HIP strategy 1.
2.
Public, regional media campaign Tailored HCV risk assessment questionnaire FR Zuure, U Davidovich, GJ Kok, ACTM Depla, CJPA Hoebe, JAR van den Hoek, PLM Jansen, P van Leeuwen Gilbert, CJ Weegink, RA Coutinho, M Prins.
Evaluation of a risk assessment questionnaire to assist hepatitis C screening in the general population.
Eurosurveillance, in press
.
Questionnaire was evaluated before its online use in a study among liver patients with known HCV status (before HIP): Sensitivity: 84.6% Specificity: 63.8%
Supporting Health by UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit HIP strategy 1.
2.
3.
Public, regional media campaign Tailored HCV risk assessment questionnaire at WWW.HEPTEST.NL
Free and anonymous blood test
Supporting Health by UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit HIP strategy 1.
2.
3.
4.
5.
Open media campaign Tailored HCV risk assessment questionnaire at WWW.HEPTEST.NL
Free and anonymous blood test Free and anonymous confirmation test at the Public Health Service Direct referral to a specialist at the hospital
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit Additional online services 1.
2.
Free email and/or SMS reminder for blood testing Free email and/or SMS alert when the test’s result could be obtained online
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service
Results: Usage
Udi Davidovich - ORP – Online Research & Prevention unit 27,540 unique ip-addresses 12,052 (43.8%) have read all information pages (35.3%) 10,511(87.2%) have answered all questions on demographics and started the risk assessment 9,712 (92.4%) have finished risk assessment A’dam N=1,030/ 3,556 (29%) 2,607 (26.8%)
At risk of HCV
S-Limburg N=479/1,839 (26%) Outside pilot-regions N=1,098/4,317 (25.4%) 1,509 were offered blood testing Referred to GP for HCV test
Supporting Health by UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit 1,509 were offered blood testing 421 (28%) have used blood testing procedure. 4.5% did not obtain test result yet (all neg) 19/421 (4,5%) anti-HCV positive 12 diagnosed with chronic HCV infection
Supporting Health by UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Results usability and acceptability (n=2,154)
Usability: risk questionnaire’s ease of use Usability: risk questionnaire’s usefullness Acceptability: online risk assessment Acceptability: hypothetical paper risk assessment Mean score 5 point scale Std. deviation 4.8
0.4
4.4
4.6
2.9
0.7
0.6
1.1
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
HEP prevalence update among MSM Anouk Urbanus
2/532 HIV-negative MSM were HCV infected (0.4%) 28/157 HIV-positive MSM co-infected with HCV (18%) Increasing trend over time – May 2007: 7/48 (14.6%) HCV/HIV co-infected – November 2007: – April 2008: 7/42 (16.7%) HCV/HIV co-infected 14/67 (20.9%) HCV/HIV co-infected
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Results- acute infections and HCV awareness
7/28 (25.0%) HCV/HIV co-infected MSM had an acute infection – 4 Anti-HCV negative, HCV RNA positive – 3 weak Anti-HCV response combined with negative (n=1) or indeterminate (n=2) immunoblot, HCV RNA positive Increased over time 31,8% is not aware of their HCV status (most had an acute infection) Urbanus AT, van de Laar TJ, Stolte IG, Schinkel J, Heijman T, Coutinho RA
, et al.
Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic.
AIDS
2009;
23(12)
:F1-F7.
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Where do we go from here?
Individuality within the social network
Harnessing individuality and norm formation within online social networks for sexual health promotion
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Acknowledgments
Vrijlekker: City of Amsterdam & Hanna Uhr-Daal
Testlab: Rik Koekenbier, Wim Zuilhof & Pjer Vriens
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Supporting Health by UCONN 2010 Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit
Acknowledgements HEP C – HEPTEST.NL
Public Health Service of Amsterdam
: Maria Prins, PhD Udi Davidovich, PhD Anneke van den Hoek, MD, PhD
South Limburg Public Health Service:
Christian Hoebe, MD, PhD Hans Frantzen Natacha Gelissen
National Hepatitis Center
:
Academic Medical Center, Amsterdam
: Paula van Leeuwen, MSc Christine Weegink, MD, PhD prof. Peter Jansen, MD
Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven School of Psychology, University of Maastricht
: : prof. Roel Coutinho, MD prof. Gerjo Kok
And all other participants and co-workers of the departments
This project is funded by Roche Netherlands provided an unrestricted grant for broadcasting of the television commercial Schering-Plough provided an unrestricted grant for the translation of www.heptest.nl