1. 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

2. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 % 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

3. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Sexual health & Internet Brilliant match for Research & for Sexual Health Promotion Scientific research, Prevention interventions & Screening/testing Services

4. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Interactivity Connectivity all the time Increasingly everywhere Increasingly easier with same set of rules as for sexual contact

5. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Sexual health & the internet, what more…  Anonymity  Comfort: physical & mental How does that help sexual-health related research and prevention ?

6. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Research (qualitative) the case of online chat interviews with webcams

7. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Goal Examine barriers to protective behavior against HIV and other STI among heterosexual youth aged 14-24 in the Netherlands.

8. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010

9. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Evaluation of the usability and acceptability  N= 203 –Sex: 51% males –Age: 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

10. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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”. 

11. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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 ”

12. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Comfort & emotional easeComfort 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”.

13. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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

14. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Health Promotion The case of tailoring: why do we believe it works?

15. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Tailoring process IMB model Defcy. 1 Knowledge deficiencies Motivational deficiencies Skill deficiencies Present Defcy. 2Not present Defcy. 3Not present Defcy. 4Present Defcy. 5Present Defcy. 6Not present Defcy. 7Present Defcy. 8Not present Defcy. 9Not present 1st intervention module 4th intervention module 5th intervention module 7th intervention module Intervention output

16. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Tailored versus non-tailorted intervention – RCT Stimulation of safe sex in steady relationships among MSM (negotiated safety) Single men – cognitive vaccine approach

17. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010  Online RCT: control x non-tailored x tailored  Cognitive effect (directly after intervention) & behavioral effect (6 months follow-up via e-mail)  N=1013; recruitment online via banners and links Effect evaluation

18. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Cognitive effect: Univariate analysis of variance contrasting the control condition with the non-tailored and the tailored conditions

19. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Behavioral effect at 6 months Practice of negotiated safety for the tailored condition: OR=10.50 95%CI1.19 - 92.72

20. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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

21. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Drop out during interventions… How do we keep them interested?

22. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 www.vrijlekker.nl

23. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Vrijlekker.nl - Objectives  To remove barriers to safe sex and STI screening among youth 16-24, (TG 18-19)  Evidence based

24. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Theoretical Background  Tailoring: based on IMB  Modeling for engagement & empowerment  Direct network/environment approach  TPB elements:  Beliefs  Perceived control  Actual behavioral control

25. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Key features  No personal risk feedback  Tailoring (increase relevance and concision)  The love-coaches (modeling)  The films (as topic openers / contemplative – preparatory)

26. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Key features for engagement Interactive text: e.g. the Excuse-Fighter (communication skills)

27. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Galjaard Prijs 2009 GGD Amsterdam

28. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Key features for engagement E-cards as conversation opener (sexual network)

29. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Galjaard Prijs 2009 GGD Amsterdam Interactieve modules Communicatie naar de seksueleomgeving

30. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Galjaard Prijs 2009 GGD Amsterdam Interactieve modules Communicatie richting de seksuele partners

31. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Key features for engagement Condoms and lube supply online. Pay with the mobile or regular phone - 10 condoms voor 99 euro cent! (Actual behavioral control

32. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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%CI1.08 - 3.04, n=311]  Significant more condom use with the steady partner [ OR=2.17 95%CI1.48 - 3.18, n=765]

33. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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

34. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Sexual Health Services The case of HIV & STD testing online

35. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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)

36. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 36 Test Lab procedures: Test locations AmsterdamRotterdam

37. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 37 Test Lab procedures 3.The test results are sent to the STI clinic. Diagnosed by the dermatologist of the STI clinic and put online. 4.Participants obtain test result online with their personal code 5.Man who tested positive visit the STI clinic for further examination and treatment.

38. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 38 1.Chlamydia: urogenital (urine PCR), Proctum (self-swab PCR) 2.Gonorrhea: urogenital (urine PCR), Proctum (self-swab PCR), throat (swab PCR) 3.Syphilis: anti-TP + => VDRL and FTA 4.HIV (opting-out): combo Antibody & Antigen test  Amsterdam and Rotterdam Test package

39. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 39 Procedure: referral letter

40. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 40 Procedure: Back office

41. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 41 Procedure: Email Soa*Hiv

42. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 42 Procedure: Results online Soa*Hiv

43. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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

44. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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)

45. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 45 Use of Testlab

46. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 46 Results: Unique users Visitors Amsterdam/Rotterdam2121 Referred 60 % (1273/2121) Referred to STI clinic 18 % (232 /1273) Referred to laboratory 82 % (1041/1273) Tested 51 % (532/1041) Results put online (procedural) 100% (532 /532) Viewed results online 99% (530 / 532) 31% never visited an STI clinic before

47. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 47 Results: Efficacy STI prevalence  Test Lab Amsterdam: 18% (59/334)  STI clinic Amsterdam: 15% (260/1701)  All positives visited the clinic for treatment & diagnosis

48. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 48 Results: Usability en Acceptability  Questionnaires offered: 532  Questionnaires completed: 265  Usability:N –Total: 4.5 (SD = 0.6) 265 –Negative test result:4.6 (SD = 0.5) 227 –Positive test result: 4.0 (SD = 0.7) 38  Acceptability –Total: 4.0 (SD =0.5) 265 –Negative test result:4.1 (SD = 0.5) 227 –Positive test result:3.6 (SD = 0.6) 38 Qualitative research among non-users & users Int. AIDS conference Vienna July 2010 Test-specific results –how!? Koekenbier RH, Davidovich U, van Leent EJ, Thiesbrummel HF, Fennema HS. Online-mediated syphilis testing: feasibility, efficacy, and usage. Sex Transm Dis. 2008 Aug;35(8):764-9.

49. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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

50. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Supporting Health by Technology II 1.Public, regional media campaign HIP strategy

51. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Supporting Health by Technology II 1.Public, regional media campaign 2.Tailored HCV risk assessment questionnaire HIP strategy 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% 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.

52. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Supporting Health by Technology II 1.Public, regional media campaign 2.Tailored HCV risk assessment questionnaire at WWW.HEPTEST.NLWWW.HEPTEST.NL 3.Free and anonymous blood test HIP strategy

53. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Supporting Health by Technology II 1.Open media campaign 2.Tailored HCV risk assessment questionnaire at WWW.HEPTEST.NLWWW.HEPTEST.NL 3.Free and anonymous blood test 4.Free and anonymous confirmation test at the Public Health Service 5.Direct referral to a specialist at the hospital HIP strategy

54. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Additional online services 1.Free email and/or SMS reminder for blood testing 2.Free email and/or SMS alert when the test’s result could be obtained online

55. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Results: Usage

56. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Supporting Health by Technology II

57. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Supporting Health by Technology II Results usability and acceptability (n=2,154) Mean score 5 point scaleStd. deviation Usability: risk questionnaire’s ease of use4.80.4 Usability: risk questionnaire’s usefullness4.40.7 Acceptability: online risk assessment4.60.6 Acceptability: hypothetical paper risk assessment 2.91.1

58. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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 2007:7/42 (16.7%) HCV/HIV co-infected –April 2008: 14/67 (20.9%) HCV/HIV co-infected

59. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 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.

60. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Individuality within the social network Harnessing individuality and norm formation within online social networks for sexual health promotion Where do we go from here?

61. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010

62. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 62 Acknowledgments  Vrijlekker: City of Amsterdam & Hanna Uhr-Daal  Testlab: Rik Koekenbier, Wim Zuilhof & Pjer Vriens

63. Sexual Health & the Internet Amsterdam Public Health Service Udi Davidovich - ORP – Online Research & Prevention unit UCONN 2010 Supporting Health by Technology II 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:Paula van Leeuwen, MSc  Academic Medical Center, Amsterdam:Christine Weegink, MD, PhD prof. Peter Jansen, MD  Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven:prof. Roel Coutinho, MD  School of Psychology, University of Maastricht: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.nlwww.heptest.nl