A new medium for prevention and research

The exact same elements of the Internet (namely its anonymity, reach, and accessibility) which make it a potential threat for the spread of infectious diseases may also make it an ideal tool for curbing the spread of disease. Never before has information been so widely available to so many people of such a wide variety of demographic and social backgrounds in so many geographic locations. The reach and accessibility of the Internet can be harnessed to inform and protect against disease acquisition; anonymity can be a convincing ally in the fight against disease transmission.

Although the extraordinary capacity of the Internet has yet to be fully tapped for this purpose, fledgling efforts have demonstrated its potential. It has been used for partner notification and the distribution of education, prevention, and health information. In 1999 in San Francisco and in 2003 in Los Angeles, public health officials notified users of gay chat rooms and sexual contacts of known syphilis cases of the potential for syphilis exposure, and urged them to seek medical care (Klausner et al, 2000; CDC, 2004). In the Netherlands, MSM recruited in chat rooms indicated that they would utilize a website which posted HIV/STI-prevention information, and provided question-and-answer, e-mail and live-chat forum services devoted to safe-sex topics (Hospers et al., 2002). MSM in the UK also reported positive attitudes toward receiving health information online and interacting live with public health experts (Chiasson et al., 2005). Structured HIV-prevention interventions need to utilize the Internet to recruit affected and disenfranchised individuals for offline programs, and develop the ability to implement intervention curricula online; a few (Gaither, 2000; Davis et al., 2004) are following in the footsteps of successful online efforts, such as online smoking cessation programs.

This generation's adolescents and young adults are already using the Web as a source of health information (Kaiser Family Foundation, 2001). The vast majority of 15- to 24-year-olds access the Internet, and two-thirds have accessed health information. Of these, four in ten have accessed information on pregnancy, HIV/ AIDS, STI, and birth control (Kaiser Family Foundation, 2001). Minority youth and teenage youth seem to be the most receptive to such information, and report intent to change behavior (Kaiser Family Foundation, 2001). The fact that most remain skeptical as to the validity of the posted information, however, underscores the need for public health agencies to maintain current and reliable information.

Recent HIV/STI prevention, outreach, and education efforts in the US on both local (McFarlane et al., 2005) and federal (Anderton and Valdiserri, 2005) levels, however, have encountered a number of barriers. Evaluation of online efforts, proper training of involved staff, and a close collaboration between online venue owners and public health workers are critically important (McFarlane et al., 2005). The core differences that exist between the corporate and public health worlds also present a challenge. Internet service providers and website owners have legal liability and confidentiality issues, and must conform to a market-driven, business environment. Meanwhile, public health practitioners and researchers request access to these same clients with the goal of discussing sensitive issues (Anderton and Valdiserri, 2005). Only through mutual understanding and shared benefit can the two worlds collaborate successfully.

As Internet-based research and prevention grows, clear priorities are emerging. Methods for online behavioral and prevention research need to be further developed, and standardized methods for online outreach and educational activities need to be further refined. Sound research methodology will not only inform prevention programs, but also evaluate them. The strengths of the Internet - its ability to reach and recruit large numbers of geographically, demographically, and socially isolated or disenfranchised individuals and subgroups in a cost-effective way - must be balanced against concerns about biased recruitment methods, the validity and generalizability of data collected online, and the ethical implications of recruiting participants online (Chiasson et al., 2006). Online surveys do eliminate interviewer and response bias, allowing participants to report their experiences in greater detail and in an anonymous fashion. Inconsistent results from online studies thus far, however, also suggest the possibility of sampling bias, and that sampling and recruitment methods need greater standardization. Furthermore, while the promise of anonymity may encourage individuals to participate, ethical questions remain about true anonymity (e.g. e-mail addresses, Internet Protocol (IP) addresses, etc.), as well as duplicate participation, and validity of informed consent. Regardless, use of the Internet as an additional tool for research in the area of HIV continues to grow. At the 2006 International AIDS Conference, the number of abstracts referencing HIV and the Internet had increased by 41 percent since the 2004 meeting.

The connection between online and offline behavioral research and infectious disease surveillance systems also needs to be considered. In today's social climate, assessments of the prevalence of infectious diseases and behavioral outcomes in various populations should take into consideration online populations and behaviors resulting from online interactions (Link and Mokdad, 2005). Research efforts that include both online and offline sample populations will also need to evaluate any qualitative differences between these participants.

The Internet is the latest in a series of social forces that offers both real opportunity and real risk. The degree to which these opportunities and risks are considered and managed will determine what role the Internet ultimately plays in infectious diseases that are transmitted through sexual contact. With thoughtful analysis and guidance, the Internet, with its broad reach and wide accessibility, has the potential to become a force of unprecedented power in the pursuit of widespread public health.

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