STD Postcards: You've Got More than Mail

Thanks to a new Internet-based service called inSPOT, people are now receiving anonymous e-mails about sex, but they aren’t spam and there is no hidden ad for herbal concoctions to increase the size of anything. Rather, the “e-cards” are notices from a previous sex partner that the recipient may have been exposed to a sexually transmitted disease.

The site, , is a way for people newly diagnosed with an STD to notify their partners to be tested, too. The e-cards, a sort of greeting card you’d rather not receive, are direct and to the point.

“Who? What? When? Where?” one available e-card begins. “It doesn’t matter. I got an STD; you might have it too. Please get checked out.”

Recipients can then click links to learn more about STDs, possible treatments, and clinics in their cities where they can be tested.

The service started in San Francisco in 2004 mainly to serve the gay community, but it has since been broadened to include heterosexuals and expanded to cities across North America. This month, early data reported in the journal PLoS Medicine shows the STD e-mail alerts are a success.

The service is the creation of Deb Levine, a sex educator and author of a book called The Joy of Cybersex, and of Dr. Jeffrey D. Klausner, director of STD Prevention and Control Services for the San Francisco Department of Public Health.

“In 2001 I noticed a big rise in the number of syphilis cases among gay men,” recalls Klausner. “In 1998 it was about five cases. By 2001 we had 150 cases.”

Klausner set out to discover why the rate jumped and learned that men had begun meeting each other online for casual encounters. Those encounters may be anonymous, but usually involve an exchange of e-mails. “That turned on a light for me and I realized we needed to do something online.”

He tracked down Levine, who was living in Oakland, Calif., and the two created ISIS, a non-profit community organization to put sexual health information online. One of their first projects was the e-mail notification system.

49,500 postcards sent since 2004
More than 750 people visit the inSPOT site daily. Since 2004, the service has sent more than 49,500 e-cards. Syphilis and gonorrhea cases have each accounted for approximately 15 percent of the total cards sent, followed by chlamydia at 11.6 percent and HIV at 9.3 percent. More than half a dozen other diseases account for the rest, including crabs and scabies; hepatitis A, B and C and trichomoniasis, a parasitic STD.

Importantly, the “click-through” rates, the number of recipients who click to see testing site information, is high for an e-mail response, ranging from 48 percent in Idaho to 20.4 percent in Los Angeles.

“I think that is great,” says Andrew J. Woodruff, ISIS project director. “If you take 100 people, that is 20 who are finding out an important piece of information and being linked to services so they can take care of themselves. They might be 20 people who would never have known.”

Receiving such an e-mail could elicit some pretty negative feelings, of course, but Klausner says that while recipients may not be thrilled, they are grateful.

“I talk with them about how comfortable they would feel using it and their attitude is that ‘It works for me. I would be happy to help someone else,’” he says. Many recipients tell him they had not been, and probably would not have been, notified by any other means.

So far he has received only about three angry e-mails “from people who said ‘This is clearly a mistake! How can you make this so easily available?’” But almost all comments are positive.

Data on inSPOT’s real effectiveness is still spotty. Nobody knows the number of people who use the service who would not have otherwise notified partners, for example. And it’s too soon to know the effects, if any, on the rate of STD infections, diagnoses, or numbers treated in the cities where inSPOT is operating.

But the idea makes sense, according to Mary McFarlane, a behavioral scientist with the Division of STD Prevention at the Centers for Disease Control and Prevention in Atlanta. “The Internet is a good place to generate risk behavior, and if we want to do public health, and stop the spread of diseases, we need to be where those risk behaviors are, and introduce health into this venue."

Dr. Emily Erbelding, an associate professor of medicine at Johns Hopkins University and the director of clinical services for STD clinics run by the city of Baltimore’s Department of Public Health, believes that “if this leads to more people knowing they might have been exposed to STDs and leads to them getting an evaluation and treatment, it is a good thing.”

Lack of face-to-face contact is worrisome
One drawback, Erbelding says, may be the lack of face-to-face conversation about sex and risk between partners. And in some ways it may be too convenient. In San Francisco, for example, a person receiving a notice about being exposed to chlamydia can click to download a prescription to cure the disease and bypass a doctor’s visit. But seeing a doctor could reveal other STDs or health issues a patient should address.

However, the inSPOT service may already be slightly behind the technology wave, the CDC's McFarlane believes. “More and more people are going with mobile phone technology” to facilitate casual hookups she says. “I think it is very important that we in public health pay attention to these innovations and provide health information in those places.”

Still, Erbelding and Klausner say the cost to health departments to set up and operate such a system is low (about $15,000 initial outlay) at a time when public health budgets are stagnant or even declining. In many locations across the country, patients diagnosed with reportable diseases like syphilis may or may not get a call from the local health department.

Even if they do, and agree to identify partners, many agencies do not have the manpower to contact those people. Often, it is left to the diagnosing doctor to urge partner notification. Now, such a doctor can simply hand the patient a palm card with inSPOT’s Internet address.

Brian Alexander is the author of the new book “America Unzipped: In Search of Sex and Satisfaction."

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