The Internet is the New Gay Bar

1
The Internet is the New Gay Bar

• World AIDS Day Conference
• December 2, 2005
• Tarrytown, NY
• Scout, Ph.D.

2
Outline of Presentation

• Background
• Culture
• National Response
• Information from specific programs
• Steps to start your own program
• Resources and acknowledgements

3
Background
4
CDC says

• The Internet has become an important venue for
  initiating behaviors that put people at risk for
  STD/HIV.
• Among people in California with primary or
  secondary syphilis, the Internet is one of the
  two most popular venues for meeting sex partners.
  
• Though many sex partnerships are geographically
  local, research shows that approximately 40
  percent of people with syphilis have traveled at
  least 100 miles to meet an Internet-contacted sex
  partner in person.
• The implication of this travel is that risk
  behaviors, and potentially the disease outbreaks,
  may spread across health jurisdictions.
• CDC. Program in Brief HIV/AIDS. Using the
  Internet for HIV/STD Prevention. Downloaded from
  http//www.cdc.gov/programs/hiv11.htm on December
  1, 2005.

5
History

• In the summer of 1999, the SF Dept of Health
  traced a syphilis outbreak to AOL internet chat
  rooms.
• Subsequently, 1000 rise in early syphilis among
  SF MSM.
• Majority reported meeting sexual partners online.
  
• Klausner, JD. Levine, DK. Kent, CK.
  Internet-based site-specific interventions for
  syphilis prevention among gay and bisexual men.
  AIDS CARE (November 2004), VOL. 16, NO. 8, pp.
  964/970

6
The Phenomena

• I was seeing a patient at one of the STD clinics
  one dayI asked this one guy how many sexual
  partners he had had in the past two monthsAnd he
  said fourteen. And then I asked him how many he
  had had in the past year. And he said fourteen.
  I said, well, what happened two months ago?
• The man replied, I got online.
• When Dr. Klausner asked him to explain it, the
  patient replied,
• Well, I am a fifty-year-old, overweight,
  HIV-positive man. I am balding Im not that
  attractive. But I can go online anytime of the
  day and I can get a sexual hookup. I can go to
  this site on AOL and I can say I want to meet
  somebody now for sex. And thats all there is to
  it.
• KLAUSNER, J.D., WOLF, W., FISHCER-PONCE, L.,
  ZOLT, I. KATZ, M.H. (2000). Tracing a syphilis
  outbreak through cyberspace. Journal of the
  American Medical Association , 284, 447/449.

7
Changing world

• Internet now exceeds bathhouses or bar as
  most-reported venue for initiating MSM sexual
  encounters.

8
How widespread is it?

• In Young Mens Study, conducted from 2000-2001,
  35 of participants reported looking for sex
  online. Rebchook, 2003.
• In 2002, a British study of gay internet users
  found 82 looked for sex online. Bolding, 2004.
• A 2003 Gay.Com survey reported that 84 of its
  visitors met sexual partners online. Larson, 2005

9
Culture
10
Warning

• Information on the slides in this section is
  explicit. It is provided solely as a training
  aid to assist in HIV prevention activities, and
  should not be taken out of context to
  misrepresent this intent.

11
Where do people start?

• Preferences have changed over time.
• Early reports show AOL gay chatrooms,
  www.manhunt.net, www.gay.com, and www.m4m4sex.com
  as very popular.
• Recent reports de-emphasis AOL for some, and add
  new websites that cater to men of color, like
  Brother for Brother.

12
How do they find sex?

• Chat rooms
• Browsing profiles of members
• Bulletin board posts (i.e. Craigs List)

13
Excerpt from Craigs List
WARNING Information on this slide is explicit.
It is provided solely as a training aid to assist
in HIV prevention activities, and should not be
taken out of context to misrepresent this intent.

• Men Seeking Men - Wed Nov 30
• NEED A HOT SUGAR DADDY - 25 (PROVIDENCE)
• Massage wanted right now... I can come to you -
  30 (prov)
• bi discreet nsa looking to btm for one or
  more-now - 34 (RI/MA - Line)
• Jock for Scat - 35 - 35 (East side)
• 26 y.o. or younger... for........
• Married Guy Looking To Mess Around With A Guy For
  His First Time
• Masculine Discrete Dude looking to give no
  strings DEEPTHROAT HEAD - 38 (RI)
• Need a TOP man for hot fun - 40 (Cranston)
• 27 looking for late night bj/f___k warwick
  (HOTEL)
• Federal Hill Gay Couple Looking for a Hot Time
  With A 3some or More...
• Horny and need a HJ or a BJ? - 37 (Providence)

14
Interesting points
WARNING Information on this slide is explicit.
It is provided solely as a training aid to assist
in HIV prevention activities, and should not be
taken out of context to misrepresent this intent.

• Internet can be effective venue for immediate
  gratification.
• Horny and need a HJ or a BJ? - 37 Be under 40,
  weight prop to height and hiv neg and dd free
  and I'll relieve your frustrations tonight. Let
  me know at xxx-xxx-xxxx tonight only otherwise
  dont call. Thanks.
• Massage wanted right now... I can come to you -
  30
• Date 2005-11-30, 1027PM ESTworked all day
  and could use a full massage deep and hard works
  for me. Good set of hands to massage me well a
  must. Im available to come to you right now.

15
Interesting points
WARNING Information on this slide is explicit.
It is provided solely as a training aid to assist
in HIV prevention activities, and should not be
taken out of context to misrepresent this intent.

• Internet can be a venue for non-gay MSM to link
  with others.
• Married Guy Looking To Mess Around With A Guy
  For His First Time Don't know what I am looking
  for really, my curiosity is getting the best of
  me. You have to be patient and take the lead.
  don't know exactly what I want to do. thin and
  smooth would help maybe, good transition from a
  woman to a man. really depends on how
  comfortable I am and how good it feels. not
  looking for any kinky stuff, looking for more of
  a slow and sensual thing. I know one thing for
  sure would really like to touch and feel another
  mans body. run my fingers through his hair, glide
  my hands down his muscular back, squeeze a firm
  buttocks. stick my hand down his pants,feel his
  manhood pulsate in my hand as I gently massage
  it. i'll stop because as you can tell my
  imagination is getting out of hand. if you think
  you can oblige me in this endeavor please email
  me and let me know. I can not do this at my house
  because of my family so it would have to be at
  your place. thank you oh I'm 5'9 180lbs slightly
  stocky

16
Interesting points
WARNING Information on this slide is explicit.
It is provided solely as a training aid to assist
in HIV prevention activities, and should not be
taken out of context to misrepresent this intent.

• Internet culture can promote unprotected anal
  intercourse and drug use
• Horny Vers Pig - 25
• Like hot no strings piggy sex..pnp ok . Bb
  ok.. Neg here.. Hit me up if u r feeling piggy.
• Looking for a sub boy for tonight - 26 Bi
  discreet guy, like to take charge, fuck your
  throat and ass long hard and deep. Into college
  aged guys. Shoot a big load. me - 6'2" 220 7
  thick just shaved. Enjoy alot of ass play
  (fingers, toys, ff) and skilled at it, and alot
  of other kinds of kinky fun (ws, bb, rimming
  etc). Into all kinds of guys, skinny to chubby,
  like smooth/shaved privates, most important is
  you being into submiting to a few hours of
  intense action. Hosting in Smithfield tonight.

17
Decoding it

• PnP party and play, drugs and sex
• bb bareback
• ff fistfucking
• ws watersports
• Hosting ok to meet at my house/office/hotel/car
• d/d free drugs disease free

18
Interesting points

• Many are expressing concern about disease
  transmission in their ads

19
Concern about STDs
WARNING Information on this slide is explicit.
It is provided solely as a training aid to assist
in HIV prevention activities, and should not be
taken out of context to misrepresent this intent.

• Jock for Scat - 35 - 35
• Seeking other dirty minded kinky guys for wet
  and messy toilet play. Looking to explore SCAT
  with fit masculine guys 25-42yo. Mutual dumping,
  smearing, shitfucking, ws and more Not into bb
  or drugs. Poppers are cool.
• 27 looking for late night bj/f___k warwick
  (HOTEL) Looking for some fun tonight after
  1030. Looking to suck, rim and be fucked. Bigger
  the better. Safe PLEASE 18-40. Be in control.
• Federal Hill Gay Couple Looking for a Hot Time
  With A 3some or More... Hi, I'm 6'3,
  br,bl,wrkout and average build 200 lbs, 8" thick
  cut top. 39, Masculine. Told VGL. My partner is
  5'10",br,bl,average built, 31, Boyish,VGL.
  7"thick cut bottom. We are looking for someone
  prefertably hung, but no big deal if you are not.
  Into hot body contact, Bj's,safe fucking.
  Basically a hot fucing time. Only looking for
  3some's or group. Sorry no single sex action. We
  are looking for a Hot Top/Bottom, Caucasian,
  25-45 who's only into a hot safe, fun time. We
  are both HIV- and are clean from STD's. You must
  be also. You're photo gets ours. Looking to host,
  but can travel if in the Providence area. We hope
  to hear from you. Let's have some hot fun. We
  will be answering emails Thursday-Sunday for
  those looking to have a fun, safe, hot time
  throughout this weekend.

20
Concern about STDs

• Other research has confirmed this ongoing concern
  around STDs, and reports strategies to minimize
  risk, including
• Sero-sorting (only sex with same status)
• Disclosure of status (d/d free)
• Requirement for safe sex
• Avoiding anal sex Rebchook, 2003

21
Unprotected anal intercourse (UAI)

• In a sample of men recruited from MSM internet
  chat rooms, 58 of those not in long term
  monogamous relationships reported UAI in last 2
  months. Rebchook 2003.
• Another study reported 56 of all online recruits
  reported UAI in last six months. Hirshfield,
  2004.

22
Where do they meet?

• Following online solicitation, men tended to
  meet in public restrooms (86), partners homes
  (74) and their own home (57). Salyers Bull,
  2004.

23
People are receptive to online health promotion

• A recent study of online MSM sex seekers reports
  Three-quarters (75) of the men said they
  thought Internet sites should allow health
  workers into chat-rooms, the majority (84) said
  that if they met a health worker in a chat-room
  they would find out what they had to say, while
  78 said they would click on a banner to find out
  about sexual health. Bolding 2004.

24
National Response
25
ISIS

• In response to the SF syphilis outbreak, Internet
  Sexuality Information Services (ISIS) tested
  seminal online prevention and education program.
  
• Strategies included
• educational outreach
• informational website
• online banner ads
• online testing program

26
Growth of online outreach programs

• By 2003, UCSF reports finding 64 online outreach
  programs nationwide
• Program budgets ranged from 4.7k to 200k
• Median budget of 12 organizations interviewed was
  17k Curotto 2004.

27
CDC Conference

• In 2003, the CDC convened a conference on this
  issue, HIV/STD Prevention on the Internet.
• Papers from that conference were assembled in a
  special issue of AIDS Care in November 2004.

28
Information from Specific Programs
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Case Profiles

• Information from this section came from
  interviews with the following people
• Frank Busconi and Jon Vincent from Fenway
  Community Healths Hotmale Program. Boston, MA.
• Elsa Larson from Rhode Island AIDS Projects
  Sexperts program.
• It is supplemented with information from Rebchook
  and Curottos provider interviews. Curotto, 2004.

30
Its not like other outreach

• Staff must be sensitive to nuances of online MSM
  sex-seeking culture
• Training and oversight are different
• It is very difficult to conduct outcome
  evaluations since so many encounters are 1x
  only and anonymous.
• Jumping in without careful consideration of these
  issues limits efficacy.

31
Its very cost effective

• Each of the interviewed sites used a volunteer
  base for most of their online outreach.
• Volunteers were allowed to work out of their
  house, reducing overhead.
• Main organizational costs were training and
  supervision.

32
Cost example

• Fenway Community Healths Hotmale program
• Average 900 contacts/year
• With an average of 55 hrs online/month
• Funded project budget 12k
• 1.36 contact/hr
• 13.30/individual contact

33
Its very in-depth

• Providers consistently report an unprecedented
  depth of interaction with people
• Likely facilitated by the anonymity of the
  internet
• Educators must build skills in containing the
  scope of interactions, this is not free MH
  counseling.

34
Its very in-depth

• The health departments reaction of surprise
  once they got to sit with me and witness an
  actual online intervention they could not
  believe the depth of the conversations I was
  having with strangers online, much more effective
  than in other outreach environments they
  thought it would be much more superficial
  men, online, feel protected by the anonymity of
  the environment, they feel no angst and fear no
  repercussions, so they open up. Curotto, 2004.

35
Specific strategies

• Most common strategy is passive approach where
  you put the outreach workers near the clients and
  they wait for contact
• lurking in online chat rooms with a
  name/profile identifying that you are a health
  educator.
• posting messages on bulletin boards

36
Specific strategies

• Commercial organizations are sometimes very
  helpful.
• www.manhunt.net will establish a free account for
  you if you are running a health education
  program.
• They ask you to meet standards particularly
  that you do not intrude or misrepresent yourself.
  

37
Problems with active approach

• Active approach is when outreach workers initiate
  contact with clients
• Steering conversations to health topics
• Possibly hiding their role until later in the
  interaction
• Be careful the active approach has risks
• Actively contacting people in a chat room can
  turn people off, and initiate complaints to host
  vendors
• This can violate peoples privacy and/or trust

38
Other strategies

• Purchasing banner ads on popular sites
• Creating an informational website to refer people
  to
• Posting ads on bulletin boards

39
Content of interactions

• Educators used the contacts to do a variety of
  things
• Answer specific risk-assessment questions
• Discuss successful risk-management strategies
• Refer the person to programs
• Refer the person to medical care
• Enroll the person in prevention or research
  programs
• Link with a website offering more information

40
Backup websites

• Sometimes programs link with websites that allow
  clients to ask in-depth prevention questions.
• Fenway Community Health Ask Dr. Cox,
  www.fenwayhealth.org
• SF City Clinic Ask Dr. K, http//www.dph.sf.ca.u
  s/sfcityclinic/drk/

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Steps to Start Your Own Program
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Learn from others

• Talk to the people whove been doing it.
• And read up on it see the resource section.

43
Plan the program

• Develop your training
• Recruit volunteers/staff
• Train them
• Launch intervention
• Monitor progress routinely
• Use monitoring information to evolve

44
Training

• RI Sexperts training manual chapters
• Introduction
• Outreach protocols
• Technical matters
• Risk reduction counseling basics
• Referrals
• Data collection and program evaluation
• HIV contacts special considerations

45
Training Resource

• RI Sexperts program will share their training
  manual with other interested agencies.
• Contact the AIDS Project Rhode Island Director of
  Prevention Education, Elsa Larson, at
  elsa_at_aidsprojectri.org

46
Monitoring

• Projects routinely ask educators to print out
  transcripts of their chat sessions
• Be sure to redact all individual identifiers
• Reviewing these can help assess educator
  performance
• And can help guide program evolution

47
Monitoring

• Educators are also often asked to record
• of contacts
• Any demographic information disclosed by person
  (i.e. from profile, or in discussion)
• Potential for f/up (i.e. did they give an email
  address?)

48
Followup

• If a person gives their email, the educator can
  contact them in the future
• The client can be asked to tell the referral site
  how they were referred
• If you are referring to in-house programs, be
  sure to ask if they were referred by online
  outreach.

49
Evaluation markers

• of contacts
• of referrals
• of HIV contacts
• of non-gay identified contacts (bennie over
  traditional outreach)
• Self-assessment of client responsiveness

50
Resources and Acknowledgements
51
Resources

• Link to all these resources at www.scoutout.org
• Elsa Larson powerpoints on this topic at
  www.scoutout.org.
• AIDS Project Rhode Island Sexperts Internet
  Outreach Training Manual, available thru Elsa
  Larson, elarson_at_aidsprojectri.org
• Greg Rebchook/Alberto Curotto powerpoint
  presentations on his research
• 2003-Online research and Internet based HIV/STD
  prevention strategies for MSM
• 2004-Opening a virtual door into a vast real
  world community-based organizations are reaching
  out to at-risk MSM with creative, online programs
• 2004-How MSM manage HIV-risk behavior within the
  online party and play (PnP) subculture
• Available at the website for UCSF Center for AIDS
  Projects - http//www.caps.ucsf.edu/
• Nov 2004 Special issue of AIDS Care on this
  topic. Many, many good articles there.
• Websites for Ask Dr. K and Ask Dr. Cox
• Ask Dr. K www.dph.sf.ca.us/sfcityclinic/drk/
• Ask Dr. Cox www.fenwayhealth.org

52
Acknowledgements

• Many, many thanks to Elsa Larson, the head of
  prevention at AIDS Project Rhode Island, for
  generously sharing her time and previous research
  on this subject.
• Many thanks to Greg Rebchook, for sharing his
  perspective, presentations, and work in press.
• Thanks to Frank and Jon at Fenway, for the
  interview time.
• Thanks to Christopher Murray at The LGBT
  Community Center, you know why.