Rachel Kachur

Interim guidelines for prevention of sexual transmission of Zika virus — United States, 2016

Zika virus is a mosquito-borne flavivirus primarily transmitted by Aedes aegypti mosquitoes (1,2). Infection with Zika virus is asymptomatic in an estimated 80% of cases (2,3), and when Zika virus does cause illness, symptoms are generally mild and self-limited. Recent evidence suggests a possible association between maternal Zika virus infection and adverse fetal outcomes, such as congenital microcephaly (4,5), as well as a possible association with Guillain-Barré syndrome. Currently, no vaccine or medication exists to prevent or treat Zika virus infection. Persons residing in or traveling to areas of active Zika virus transmission should take steps to prevent Zika virus infection through prevention of mosquito bites (http://www.cdc.gov/zika/prevention/).

Internet-based health promotion and disease control in the 8 cities: successes, barriers, and future plans.

Objectives: The objective of this paper is to provide a detailed description of Internet-based sexually transmitted disease/human immunodeficiency virus prevention in the 8 US cities most affected by syphilis in men who have sex with men. Goal: By reviewing the efforts under way in these 8 cities, we will understand the barriers and facilitators associated with Internet-based prevention efforts. Study: This is a review of Internet activities taking place in 8 major US cities. Results: Efforts in the 8 cities vary, with some cities reporting little or no Internet-based prevention activities. Other cities have attempted banner advertising, online outreach, online partner notification, online laboratory slips for syphilis testing, and auditorium-style chat sessions. Conclusion: Though a number of policy-related barriers prevent some cities from engaging in Internet-based prevention, these activities are clearly important to the overall prevention effort. In order to surmount local policy barriers, it is essential to obtain evaluation data from the programs initiated.

Finding sex partners on the internet: what is the risk for sexually transmitted infections?

Objective: To assess the association between sexual encounters with internet partners and current Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) infections. Methods: Between August 2006 and March 2008, patients at the Denver Metro Health Clinic were routinely asked about sexual encounters with internet partners. This retrospective case-control study was limited to patients who tested for Ct/GC at their visit. Analyses were stratified by sexual orientation to account for differences in baseline risk behaviours. Results: Of 14 955 patients with a valid Ct/GC test result, 2802 (19%) were infected with Ct/GC. Stratified by sexual orientation, the prevalence of Ct/GC infection was 17% for men who have sex with men (MSM), 21% for men who have sex with women (MSW) and 16% for women. A total of 339 (23%) MSM, 192 (3%) MSW and 98 (2%) women reported having a sexual encounter with a person they met on the internet in the past 4 months. The estimates of the association between recent internet sex partner and current Ct/GC infection were not significant for MSM (risk ratio (RR): 1.12, 95% confidence interval (CI): 0.84 to 1.49) and women (RR: 0.81, 95% CI 0.45 to 1.48). However, the association appeared to be significantly protective among MSW (RR: 0.66, 95% CI 0.44 to 0.98). Conclusions: Sexual encounters with internet partners did not appear to be associated with increased risk of current Ct/GC infection among people seeking care at a sexual health clinic. Seeking sexual partners on the internet is a complex behaviour and its implications for STI/HIV infection are not fully understood.

Update: Interim Guidance for Prevention of Sexual Transmission of Zika Virus--United States, 2016.

CDC issued interim guidance for the prevention of sexual transmission of Zika virus on February 5, 2016. The following recommendations apply to men who have traveled to or reside in areas with active Zika virus transmission and their female or male sex partners. These recommendations replace the previously issued recommendations and are updated to include time intervals after travel to areas with active Zika virus transmission or after Zika virus infection for taking precautions to reduce the risk for sexual transmission. This guidance defines potential sexual exposure to Zika virus as any person who has had sex (i.e., vaginal intercourse, anal intercourse, or fellatio) without a condom with a man who has traveled to or resides in an area with active Zika virus transmission. This guidance will be updated as more information becomes available.

Evaluation of an Online Partner Notification Program

Background: Internet-based programs for sexually transmitted infections (STI)/HIV partner notification have generated considerable interest as public health interventions; yet data are lacking to support widespread dissemination. We report on a clinic-based and web-based evaluation of the Colorado inSPOT online partner notification program. Methods: Clinic-based surveys were conducted at a large urban STI clinic before and after the implementation of feasible clinic interventions as well as nonclinic campaigns to promote the use of inSPOT Colorado. Questions assessed recognition and use of the site. Website statistics were provided by the inSPOT service, including the number of site hits, e-cards sent, and specific STI exposures identified on the card. Results: Recognition and use of the service among STI clinic patients remained low (<6%) despite the interventions. Site statistics demonstrated an immediate but quickly diminishing response after placement of a banner ad on a popular gay website. Newspaper advertisements and radio public service announcements showed small increases in website use. Analysis of STIs specified on the e-cards, showed scabies and pediculosis as the most-identified STIs, accounting for nearly 30% of all e-cards sent. Clinic survey data indicated that when respondents were faced with the hypothetical situation of being diagnosed with an STI, more than 90% would notify partners in person; only 5% would use e-mail or the Internet. Conclusions: Our data did not support the effectiveness of the inSPOT intervention among a predominantly heterosexual population in a large urban STI clinic.

Internet partner notification: another arrow in the quiver.

AS WE LOOK AT THE EVER-INCREASING technological innovation in public health, one of the authors recalls the suspicion with which a nameless health department treated e-mail in the late 1990s, something akin to how the Luddites felt about the horseless carriage. Times have changed, however, and innovation in partner management for STD and HIV has expanded to the Internet.1,2 In this issue of Sexually Transmitted Diseases, Mimiaga and colleagues surveyed men who have sex with men (MSM) using an online site to meet sex partners.3 Given the high rates of anonymous and semianonymous sex that results from online-initiated encounters, sometimes the only means of contacting those partners subsequently is through the Internet, assessed in Mimiaga’s article via e-mail. Results from Mimiaga et al.3,4 clarify some basic points about partner notification with MSM. They found high overall acceptability of partner notification via e-mail across respondents: 92%. This is a similar finding to acceptance of partner notification among MSM in surveys of in-person patient referral or health department involvement,5 and reminds us that partner notification is about as widely acceptable as a concept among MSM as among other partitions of society.6 Partner notification effectiveness with MSM is also comparable to that for heterosexual patients, albeit if judged by traditional indices of effectiveness. A review of partner notification efforts among cities with largely MSM-driven syphilis outbreaks in the early 2000s found proportions of partners notified and brought to treatment that were similar to statistics for the population at large.7 A specific comparison of syphilis partner notification with MSM patients compared to heterosexual male patients in Georgia found almost identical yields for partner notification in each group.8 The differences between MSM and heterosexual men lie in the proportion of total partners claimed: MSM claimed more partners overall and more partners for whom no in-person investigation could be started.7,8 For these partners especially, innovations in contact methods such as e-mail are sorely needed. Roughly two-thirds of respondents in Mimiaga et al. reported that they would use the health department to send notification e-mails to some or all partners, while a little under a quarter reported they would notify all of their partners on their own.3 Substantial preference existed for patient referral of main partners versus health department referral of other partners. HIV-infected men were less enamored of health department-based notification than were uninfected men, with 29% preferring to notify all their partners themselves, versus 21% of uninfected men. Those HIVinfected men and men with other prior STD experience were less inclined to involve health departments in partner notification reminds one of the history of STD/HIV stigma and, as the authors conclude, points to the need for carefully calibrated and marketed partner notification efforts. For that matter, many HIV-infected men are likely comfortable enough with disclosure to view notifying partners as perfectly manageable without health department help. Not that too much should be made of the differences between responses from infected and uninfected men: responses were never more than 8% points apart, so the general portrait holds for each group. Health departments certainly have an interest in some level of involvement with e-mail notification in particular and Internetbased partner notification (IPN) in general, although the level and nature of that involvement is an evolving story. For HIV infection, this means bringing people to vital long-term care, so the relative efficiency of notification methods in case-finding has serious implications for infected people. How relevant “offline” partner notification evaluations are to online models is hard to say, but one Colorado program evaluation in which patients had a choice of health department or patient-led referral with health department referral as a back-up showed that patient referral yielded only about a fifth of all notifications.9 Interestingly, in the above evaluation, health department investigators were able to find partners who the patient had chosen to notify, but not done so (90% or more of partners were notified eventually, regardless of whether the patient has chosen patient referral or health department referral as the first option). Thus, the health department was able to offer a choice of notification strategies to infected patients without reducing the effectiveness of their infection control efforts. One hopes that this approach can be applied via the Internet; it involves the patient and the health department in a collaborative venture in which each party at least implicitly recognizes the stake the other holds in partner notification and subsequent management. The Colorado data were collected in 1988; if patients and public health could collaborate in that era of the HIV epidemic, they certainly ought to be able to do so now. Other recent data have shown that electronic partner notification appears to be less efficient in bringing people to care than inperson efforts.10 In a Texas evaluation, partners of persons infected Correspondence: Matthew Hogben, PhD, or Rachel Kachur, MPH, Centers for Disease Control and Prevention, Mail Stop E-44, Atlanta, GA 30333. E-mail: mhogben@cdc.gov, rkachur@cdc.gov. Received for publication December 3, 2007, and accepted December 3, 2007. Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia Sexually Transmitted Diseases, February 2008, Vol. 35, No. 2, p.117–118 DOI: 10.1097/OLQ.0b013e31816408dd Copyright

Evaluation of an Innovative Internet-based Partner Notification Program for Early Syphilis Case Management, Washington, DC, January 2007―June 2008

Background: The Internet has become a common venue for meeting sex partners and planning participation in risky sexual behavior. In this article, we evaluate the first 18 months of the Washington, DC, Department of Health Internet-based Partner Notification (IPN) program for early syphilis infections, using the standard Centers for Disease Control and Prevention (CDC) Disease Investigation Specialist (DIS) disposition codes, as well as Washington, DC, Department of Healths IPN-specific outcomes for pseudonymous partners. Methods: We analyzed DIS disposition codes and IPN-specific outcomes from all early syphilis investigations initiated January 2007–June 2008. Internet partners were defined as sex partners for whom syphilis exposure notification was initiated by e-mail because no other locating information existed. If the e-mails resulted in additional locating information, we used the standard CDC disposition codes. Alternatively, the following IPN-specific outcomes were used: Informed of Syphilis Exposure, Informed of General STD Exposure, Not Informed or Unable to Confirm Receipt of General STD Exposure. Results: From the 361 early syphilis patients, a total of 888 sex partners were investigated, of which 381 (43%) were via IPN. IPN led to an 8% increase in the overall number of syphilis patients with at least one treated sex partner, 26% more sex partners being medically examined and treated if necessary, and 83% more sex partners notified of their STD exposure. Conclusions: IPN augmented traditional syphilis case management and aided in the location, notification, testing, and treatment of partners. Conversely, without IPN, these 381 partners would not have been investigated.

Perceptions of HIV-related websites among persons recently diagnosed with HIV.

Many HIV-positive persons use the Internet to address at least some of their needs for HIV-specific information and support. The aim of this multimethod study was to understand how a diverse sample of persons who were recently diagnosed with HIV (PRDH) used the Internet after an HIV diagnosis and their perceptions of online HIV-related information and resources. HIV-positive persons (N = 63) who had been diagnosed since the year 2000 were recruited primarily through HIV-related websites and HIV medical clinics. One third of participants (33%, n = 21) were gay or bisexual men, 25% (n = 16) were heterosexual men, 32% (n = 20) were heterosexual women, and 10% (n = 6) were transgender women (male to female). Semistructured interviews and brief postinterview surveys were used to collect qualitative and quantitative data. Qualitative findings suggested that the most appealing websites to PRDH included those that: (1) provided usable information on topics of immediate concern; (2) used accessible formats that were easy to navigate; (3) were perceived as trustworthy, and (4) provided access to diverse perspectives of persons living with HIV/AIDS. Topics that PRDH found most useful included various medical treatment-related issues, tools for coping with depression and fear, and learning how others cope with HIV. Incorporating the perspectives of HIV-positive persons into the design and content of HIV-related websites is important to enhance their appeal for this diverse and growing population.

An Assessment of the GYT: Get Yourself Tested Campaignc An Integrated Approach to Sexually Transmitted Disease Prevention Communication

Background Youth in the United States bear a disproportionate burden of sexually transmitted diseases (STDs). Stigma, misconceptions, and access challenges keep many from getting tested or treated. The GYT: Get Yourself Tested campaign was launched in 2009 to reduce stigma and promote STD communication and testing. This evaluation sought to assess the first 2 years of campaign engagement and associations with STD testing among youth. Methods Campaign engagement with select GYT on-the-ground events, social media sites, and STD testing locator tools was measured through process/media tracking metrics. Sexually transmitted disease testing patterns were assessed using data from Planned Parenthood affiliates (2008–2010) and national trend data from clinics participating in national infertility prevention activities (2003–2010). Results On-the-ground events reached an estimated 20,000 youth in 2009 and 52,000 youth in 2010. Across 2009 to 2010, GYT’s Facebook page gained 4477 fans, Twitter feed gained 1994 followers, and more than 140,000 referrals were made to the STD testing locator. From April 2008 to 2010, there was a 71% increase in STD testing and a 41% increase in chlamydia testing at reporting Planned Parenthood affiliates (representing ∼118 health centers). Chlamydia case positivity rates during this period were stable at 6.6% (2008) and 7.3% (2010). Trend data indicate that testing was higher in spring 2009 and 2010 compared with other periods during those years; this pattern is commensurate with STD Awareness Month/GYT activities. Conclusions Data quality is limited in a manner similar to many STD prevention efforts. Within these limitations, evidence suggests that GYT reaches youth and is associated with increased STD testing.

Evaluating the Internet as a sexually transmitted disease risk environment for teens: findings from the communication, health, and teens study.

Background Few studies have examined the association between sexual health risks and online sex-seeking among teenagers. The purpose of this study was to assess the associations between meeting sex partners online and a range of sexual risk behaviors and outcomes among adolescents. Methods Participants aged 13 to 19 years were recruited from a publicly funded teen clinic in Florida. After obtaining informed consent/assent, 273 participants completed an audio computer-assisted self-interview that included questions on demographics, sexual behavior, sexually transmitted disease (STD) history, and online sex-seeking behaviors and experiences. Participants also provided urine samples for chlamydia and gonorrhea testing. Data were analyzed using logistic regression to identify the association between having an online sex partner and sexual behaviors/outcomes. Results After adjusting for significant bivariate correlates, teens reporting online sex partners were more likely to be male, be multiracial, have a history of same-sex sexual activity, report a higher number of vaginal sex partners, and report a lower age at first vaginal sex. However, teens with online sex partners were no more likely to have ever had an STD or a current biological STD. Conclusions This study is one of the first to correlate biological STD results to online sexual partnering data in a youth population. Although meeting a sex partner online was not associated with past or current STDs, it was associated with other sexual risk behaviors. Future research is needed to examine the complex nature of online sexual partnering among adolescents and to develop intervention approaches.