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MSM, Sex, and Internet Chat Rooms: Epicenter of an Epidemic?

On June 23, 2004 HIV InSite and the Center for AIDS Prevention Studies convened a panel of experts to discuss the increasing popularity of the Internet as a medium to meet sexual partners among men who have sex with men.

Mark Vogel (convener and moderator)
Project Manager, HIV InSite, UCSF Center for HIV Information

Participants: Philip Huang, Asian Health Service, Oakland, California; Jeff Klausner, MD, San Francisco Department of Public Health; Deb Levine, Internet Sexuality Information Services, San Francisco; Greg Rebchook, UCSF Center for AIDS Prevention Studies; Frank Strona, Safesexcity.com


Related Resources
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Mark Vogel: Welcome to today's roundtable discussion sponsored by HIV InSite and The Center for AIDS Prevention Studies, both at UCSF. The roundtable discussion today is about MSM, sex and Internet chat rooms. My name is Mark Vogel and I am the project manager at HIV InSite, and I will be the moderator of today's discussion. Most of us are here because we are probably familiar with the recent studies that report high rates of unprotected sex and outbreaks of STDs among men who meet other men in Internet chat rooms. But we are here to address the questions of why this is the case, what evidence there is to support these studies and these trends, and to set out what makes Internet chat rooms different from other venues.

Joining me today are several individuals, all of whom either as public health officials, researchers, safe sex advocates or some combination thereof, have a particular interest and expertise in Internet chat room use among MSM. I will start with my left with Frank Strona. Frank has worked on men's sex and health issues for more than 15 years. He is co-creator of a new website called SafeSexCity.com, which is a cyber-community geared towards creating a community of like-minded MSM who are committed to promoting and practicing of safe sex.

Phillip Huang is the HIV Program Coordinator at the Asian Health Service in Oakland and has experience of doing online prevention outreach in Internet chat rooms.

To my right is Greg Rebchook. Greg is with CAPS. He is assistant research psychologist and has studied and worked on a number of community-based interventions among gay men. He has conducted research on the role of the Internet in the sexual lives of MSM and has found a number of interesting trends that I am sure he will share with us in our discussion today.

Deb Levine is the Executive Director of Internet Sexuality Information Services, or ISIS, which has contracted with the City and County of San Francisco to provide syphilis elimination services to men who have sex with men in the City, and also to identify their partners on the Internet. ISIS has worked with online providers to provide online prevention initiatives.

And finally is Dr. Jeff Klausner, the Director of STD Prevention and Control Services for the San Francisco Department of Public Health.

So I would like to welcome all of the panelists today and thank you for joining us here. I am going to go ahead and begin with the first set of questions. I wanted to start the discussion more with evidence because there might be people who are skeptical or do not really understand what evidence there is out there that men who have sex with men and meet their sexual partners online have higher rates of unprotected sex and sexually transmitted diseases. So if I can get you to comment on that. Greg, do you want to start?

Greg Rebchook: Sure, I can start addressing that question about evidence that MSM recruited from online venues or using chat rooms have higher rates of, or they are reporting higher rates of, unprotected anal intercourse with their partners than men in other venues. Several different studies have been done. National studies in the U.S. have documented high rates of unprotected sex among men recruited from online venues and there are several European studies that have looked at comparing, guys who say that they actually are using chat rooms to those that are not using chat rooms and there is a lot of information, a lot of data, showing that the chat room users are actually reporting higher rates of unprotected sex than the non-chat room users. There are also higher rates of men reporting STD infections, who are using chat rooms, and so it is a very consistent finding that a lot of different studies and a lot of different research groups are picking up that these higher rates are existing. Our own data actually show that even when you are controlling for the number of sexual partners that men are having, that Internet use still contributes to unprotected sex significantly, even controlling for the number of sex partners. If other panelists want to comment on that.

Jeff Klausner: We first identified the association of Internet use and STD transmission in 1999 during an outbreak investigation of a cluster of syphilis cases among gay men here in San Francisco. We did a case-control study, which is kind of your typical type of evaluation to determine what risk factors are associated with cases and non-cases. In this investigation, we found that 67% of these syphilis cases versus 19% of matched men who were non-syphilis cases had met recent partners in the chat room, and this was a statistically significant association. It was actually one of the first published studies of a strong association between Internet sex partnering and syphilis transmission. As part of that study, we continued to monitor the use of Internet chat rooms and Internet sites among syphilis case patients and non-patients seen at the STD clinic in San Francisco and how about half of new cases have met recent partners online and the Internet sites have continued to be a place where we focus prevention efforts.

MV: What do you suspect makes the Internet as a venue different than any other venue where men would meet each other for sex, such as bars or bath houses?

Frank Strona: One of the things to keep in mind with Internet behavior is there is a perception of anonymity. It is a cultural norm to be able to put a photograph in the profile out there that does not have a face, it does not have a name associated and I think that there is a level of personal safety that you believe you have, giving the fact that you think people cannot identify you. So you can write your profile as a modified code, hoping other people will read it the same way and then you can have a combination of emails exchanged or messages exchanged that allows you to kind of refine where and what behavior you choose to go to and then, if you want to have that next step, you can display your face. The downside of that is, more often than not, in such small locations that we have, you end up knowing who the people are even before you see the face shot, and once you get more and more comfortable and you find less and less fear based on whatever program you are in, you start to change those images. But I really do think a lot of it is based on comfort level of perceived anonymity.

Deb Levine: I would like to add one...I do not want to start off by blaming the Internet and saying, you know, "This medium is the reason that there are higher transmission rates." It is yet another way that men can meet men and a lot of the people who are meeting men on the Internet are also meeting men in bars and clubs and bath houses and parks and everywhere else. So, just to put that in perspective. Adding to that, though, the Internet allows men to meet each other faster. You get on line, you want to get laid, you can have somebody at your house within an hour -- probably less in San Francisco! Depending on Muni, right?! If you are experience is one that you are not crazy about, you can get back online and you can find somebody else to come over or to go to their house afterwards. It is a lot harder when you are working face-to-face because you have to sort of summon up the effort to talk to somebody and to break the ice and to ask them to come home with you; whereas the Internet, everybody is there for the same reason; it is very quick, it is very easy.

The other reason why I think that there are problems with communication via the Internet, is -- and I think it is really just a continuum of what is happening offline -- is that safer sex does not seem to hold much meaning on the Internet anymore. Whereas a lot of people in their profiles will put down "safer sex only," then they meet up, that means we do not have to have a discussion about it because, let's say I responded to an ad that said "safer sex only" or we both wrote "safer sex only." However, for me, "safer sex" is "no unprotected anal intercourse" and, for you, "safer sex" is "no anal intercourse at all." And then that is not being discussed. That is probably not the best example, but let's say for the other person, let's say they won't even have oral sex without a condom. Okay, so then you get together and you think that you are going to have a particular kind of experience, you are already there, you are already aroused, you give up some of the discussion because it is much easier to just follow through and then afterwards you are like, "Man, you know? That wasn't my idea of safe sex!" Okay, but then, it does not matter. Then you go out and try to find somebody else who potentially has your same thoughts and beliefs. So communication. It seems clear online and it is not.

MV: So, is there a misperception with the Internet where it seems clear that you can say, "I'm HIV-negative, STD-free" but that does not get into when you were last tested or what that means for you, and so that it appears that it is all out there in the open but it is really not being addressed?

DL: Exactly. Thank you, Mark.

JK: Yes, I think Al Cooper down at Stanford and Michael Ross in Houston, talk about why the Internet is so popular based on these five A's. So these five A's of accessibility. The Internet is very accessible to many people, particularly in this demographic, particularly here in San Francisco. Internet access to places where you can meet sex partners is very affordable. It is a lot cheaper to just go online and go to a chat room than to get up, go out of the house and go to a bar or a club or some other venue. The Internet affords anonymity (There is a great New Yorker slide that says, "On the Internet, no one knows you're a dog.") So you can be whoever you want to be on the Internet. Internet partnering has become very acceptable, so that it has become the new relative norm of how to meet partners. Right now, recent data show that more than 80% of sexually active MSM who meet new partners are meeting online in San Francisco, and then what Deb mentioned is approximation that allows people in dense urban areas who are interested to meet up very quickly in a short amount of time.

GR: I just want to add that we have been doing online qualitative interviews with gay and bisexual men or men who have sex with men they meet in Internet chat rooms, or that we were recruiting from Internet chat rooms, and even the guys in rural America are saying that, you know, "I can get online, and in 45 minutes, I can have someone tied up to my bedpost..." So, you know, this is not just in San Francisco or New York; we are seeing this phenomenon in many other places in the country as well. And we really ask people how they thought the Internet was affecting their sexual behaviors and to the T, almost everyone said that it has been increasing the number of partners they have and then either look at that as something really positive-that it is convenient, it is accessible, that it is sort of the greatest thing-and other people are sort of indicating some level of frustration with that, well, while they can get their physical needs met pretty easily, sometimes their unexpressed needs around intimacy might not be getting met, although that can be true in other venues as well, but I think the explosion in the number of partners people are meeting online is really changing that for some of the guys that we have been interviewing.

MV: So, what sort of comparisons can we make between Internet chat rooms and other venues where the goal the sort of the same and very obvious, such as sex clubs; there are sex clubs in the City and a lot of other cities. What sort of trends or similarities do you see in terms of behavior, safety, and expectations?

GR: I think there are a few things. One is I do think it is important to recognize that when people are hooking up, when they are meeting each other online and then going home, that it is happening in an environment that has traditionally been isolated from HIV prevention messages and that whatever your perceptions are of the campaigns that are going on currently in the bars and bath houses, there are posters there; there are condoms available there; there are very visible and active campaigns happening in many communities across the U.S. And at some point, in some of the communities where we were asking people online if they were aware of online HIV prevention campaigns, many of the participants said they were not aware or they had not seen them because, I mean, I think the Internet is so large that it takes a really concerted effort to make your presence known and so that when hookups are being arranged completely outside of the arena that HIV prevention campaigns have hit, I think that is worth talking about.

PS: It is also important, I think, to keep in mind that these websites are businesses -- the owners are out making money. What differs from the local sex club, though, in one factor is they are not community-based. The owners could be in New York or be in Ohio and that is where they launched your national website from, and you could have people all over the country using the site. That does not make you a "local" community organization tied to that particularly community, which then creates a challenge in terms of working with the local sex venue to say, "Okay, we would like you to put up more posters." They are there to make money and they are going to after the situation that is going to cause their membership the least trauma, the least discomfort and the least reality, in some cases.

JK: In our work, it seems that people who attend sex clubs and seek sex at sex clubs seem to be somewhat different than people who are seeking sex online, different from people who may seek sex through more kind of casual street-based or social encounters, and surprisingly, there is actually not a lot of overlap. People tend to shop in the same store; they go to the same place for sex partners. So, it may be somewhat of a generalization, but people who seek sex in clubs or bookstores generally keep going back to clubs and bookstores; people go on the Internet, go to the Internet. These different venues somewhat attract and bring together different sexual networks. So right now, in terms of STD transmission, which is a lot easier to monitor than HIV transmission, we can find these high risk networks associated with Internet use, which we really do not see with the sex clubs or the adult bookstores anymore.

GR: I think there are data that were presented at the National HIV Prevention Conference last year showing that in California, the proportion of new syphilis diagnoses that were accounted for in bath houses and other sex clubs was shrinking while the proportion of syphilis diagnoses that were attributed to men meeting in online venues was increasing and that that shift was really documented now.

Mark, can I ask, is there a way for other people to give their input in the audience as well?

MV: Sure, people can do that and perhaps we could just repeat the comments or the questions.

AUDIENCE: Are you saying that you are finding that the population that traditionally went to sex clubs or adult bookstores is now going to the Internet?

JK: I really see it as a shift. I see the Internet as really opening up a whole new world of sexual networks to a lot of people who maybe never felt comfortable going into sex clubs or never felt comfortable about going into specific bars or venues to meet partners, and this whole thing really started, for me at least, in the Spring of 1999, when I was seeing a patient in the clinic and I said, "How many sex partners have you had in the past two months?" He said, "Fifteen." I said, "How many have you had in the past year?" He said, "Fifteen." I said, "Well, what happened two months ago?" He said, "I got online. You can't believe it! It's unbelievable!" And here was a guy who never traditionally went to these other venues but the online communities opened up a whole new sexual marketplace for him.

AUDIENCE: So is it possible that perhaps there is a demographic change where younger people tend to be more involved in the Internet and older guys go to bookstores and things like that?

JK: Yes, I think that is a reasonable idea, but I don't think it's been well studied.

PH: I do not think that those are clear categories, with bath houses here, Internet here. There are a number of sex venues and sex partners that happen whose only mode of recruitment is through the Internet. I can go online right now and probably find, especially since it is Pride Weekend, 10 sex parties that are happening in hotel rooms, people's garages, out in places like Martinez...[audience laughter] Sex in Martinez to me sounds so... But one of the things our project is trying to do is we are trying to hookup with the people who go to these sex parties. So increasingly you have people not just hooking up one-on-one through the Internet, but they are signing onto Yahoo! groups and once every three, four months, there is a huge sex party happening,

MV: Yes, I guess, that is sort of my puzzlement. I mean, Dr. Klausner, said that there is often not a lot of overlap -- and I can see where that is true -- but then in cases like this, there is a lot of overlap. So if someone presents with an STD, it is hard to know where they got it from if they are going to a sex party over Pride Weekend, that they may have learned about over the Internet, but it was not a hookup in an AOL chat room per sé. So sometimes I think a lot of the distinctions are perhaps made artificially and so there is some overlap, it seems.

FS: I think you might also want to look at the fact that there is collaboration. There are guys who are saying, "I am going to be at XYZ club tonight. Meet me there."

MV: Right...

FS: That is part of the availability but I think if you do some research in terms of bar owners and their receipts over the last 8-10 years, they have shown a marked decrease in clients and some of that has been smoking, lack of smoking, some of that is-at least in this city-economics are such that people are working more hours per day and their personal time is more important to them and if they know that their goal is to get off, then they may be less likely to have the bar venue as a social event. Maybe they will save that for the Saturday or Sunday night but on a Monday or a Tuesday, Happy Hour is not as important as "I know I can get off efficiently and economically." And $19.95 a month is a lot cheaper than $7.95 or $8.50 a cocktail. So I think it is important to also look at some of those dynamics and where this process is making it more convenient and more attractive.

DL: I want to speak to the age issue for a second, and this is hypothetical based on we put together a community advisory board to build a website recently and one of the younger people on the board was basically saying that he was invited to a sex party that he learned about from the Internet and he went, and, however months later, he got the "you may have been exposed to..." phone call, and what came across was that all of the -- this is my perception of what happened -- but the older -- there are many people here who were there, so you can help me -- but the older people in the group were saying, "In the old days, if we were going to a sex party, we all went and got our STD checkup before and we did afterwards. We didn't even talk about it. You know, it was just like, 'Hey, you going Saturday night? Great!' Let's all go to the clinic and we'll get our shots. We'll checked out, da-da-da-dah, and then we'll go; we'll party" and afterwards, everybody would show up again. This guy basically said, "I had no idea!" So he had learned about the party online; he did not know about community norms because there is not that same sort of mentoring that used to go on within the gay and bisexual community, and the next thing you know, he is getting pumped with penicillin. So, and not in a.... In a scary way as opposed to in a "I'm taking care of my health" way. So, it is just to think about the age and the communication and again, the difference between online and offline and how norms are changing.

GR: I guess I just want to add sort of a personal anecdote, taking off my researcher hat and putting on my "Gay Man in San Francisco" hat. A few years ago when I was online a lot, I think that it was interesting to me to sort of observe how in one night being online, I could get asked maybe 15 or 20 times if I barebacked and if I would have sex without a condom or guys that were really hot and cute, and then they would talk about wanting to fuck without condoms and you know, at some level, that starts to almost be the normative behavior that I was experiencing at least. And maybe it was something about my profile, I do not know -- even though it had that I use condoms in my profile -- but you know, when I went to a bar, that same experience was not happening to me. It was not like people kept coming up to me and asking me, "Do you want to fuck without condoms?" I do think that with the way communication happens online, it really does make me wonder if new norms can be transmitted very quickly through the Internet, not only because the networks are intermingling a lot but also just because of the vast number of communications that you are having with different people in any given few-hours period is just exponentially gigantic, and I do think that looking at how norms can be disseminated online is really important.

I remember in some of our interviews, we asked people how they thought their online life was affecting their offline sexual life, which we had a better way to phrase the question (which I cannot remember now) but some of the guys said, "No, it's really no different at all. It's just like meeting guys in other venues." But other people were saying, "It wasn't until I got online that I learned about barebacking" or "That was the first time I ever heard that. The first time I had unprotected sex was with someone I met online." And as we start hearing those themes over and over again, it does make me wonder that maybe there is something sort of qualitatively different in online venues as opposed to offline venues, just because of the nature that being on the Internet, you are in a communication environment where all of your interactions are happening through written communication.

FS: I think it has been proven through a variety of circumstances that any kind of prevention message that works for people, and whether it be smoking cessation or sexual programs, the person has to see their risk and the person they are with as people, and the initial conversations online, you do not actually recognize that as a person on the other end of that chat. Especially the first, "Are you a top? I want to get fucked. Do you bareback?" If you say "yes, no, and no," you do not even get a "Okay, no problem. I'm moving on." You do not get a reply. So there is that side of this where you are not real on the other end of that Internet connection until you show up at the door. So some of the conversations can be very direct; on the other hand, it is the exact opposite. You may think you know who that person based on the profile and then maybe they are much hotter than you normally would get in real time and you are not willing to actually step back and say, "I am not going to throw this out. I will wait 'til they get there to discuss this." We also know, anecdotally, I believe that there is more coming in terms of, if you mention condoms in your ad, you are likely to get less attraction for a variety of reasons, whether people make assumptions that you are going to have issues around playing with positive men or negative men. There are the differences people read ... every profile can be read two or three different ways. And you put all that together, this is a complicated -- and it is actually not as easy -- it gets complicated because you are dealing with emotions, you are dealing with human nature, you are dealing with sexual desire and half of the equation is not in front of you until 20 minutes before you are ready to take your pants off.

DL: And then to add to that, Frank, if you put "condoms" in your ad, nobody replies. If you put "positive" in your ad, nobody replies. And so what is happening is the top three questions, as Frank can you do that again really fast?

FS: "Are you a top? Do you fuck? Do you wear condoms?"

DL: So the guys who will only wear condoms and are positive, are learning very quickly how to answer the top three questions in the way that they will get response because they still want to get laid, and then only later, when the person comes to the door, being able to say, "Oh, by the way, this is my situation..." and then the other person will either negotiate at that point or not, or the negotiation just never happens at all.

FS: There was a fellow I have chatted with over the last five years and he shared with me some of his logs. He is a top, he is an HIV-positive man, tests regularly but his idea of "safe sex" is that he does not ejaculate in his partner if they have sex without a condom. And he will use a condom when the partner negotiates it with him. But it was really interesting when he would say, "Oh, I played safe" and I would follow up, "Did you have the rest of that conversation?" "No; when we got home, when I got there, then we found out what [safe sex] meant." And it was very different and he was flexible enough depending on whom he was with but I do not know if others are, and that is where you start, especially then when you add in drugs or alcohol to the mix and the ability to make the healthier decision, or just that whole hungriness. If you have been online for four hours and nobody is giving you any attention, it is going to bring up some personal issues around how much you are going to say "yes" to the next option.

MV: But when does that negotiation then happen in real time or offline? It is perplexing at times because a lot of the same issues happen if you meet someone at a bar. Would you necessarily have these conversations there or wait until you have the person home and then, you know, say, "These are my boundaries. This is my situation."?

DL: I think the difference is that in real time, we do not expect it to happen beforehand but online, based on profiles and based on these quick three questions, people are assuming it is happening beforehand.

MV: Right.

DL: So that it is an assumption, you know, and do I even have to say it? When you assume, you make "an ass of u and me".

AUDIENCE: I think while everything you have said is true, I find that in sex clubs, for example, there is no communication at all; it is zero, and, as unclear as communication online is, it is still something, and now there are data from a researcher here at U.C. that show that the Internet is used by HIV-positive guys to serosort as a prevention strategy. So, while I think all the things you guys have said are true, they are also very positive for prevention strategies that can be implemented on the Internet.

FS: There can be. I think while we are highlighting on some of the challenges of [the Internet], I think we all agree that there can be positive attributes to it and it is part of why SafeSexCity.com has over 1,200 men with no advertising in very little time, simply because people wanted to use it, both positive and negative. They had made some choices and they wanted to make it useful for them. Some of the other sites have made it easier to set up things such as you get a choice to say "safer sex to be discussed" or not, to help along that way. So it can be great whether you use serosorting, age sorting, other interests. There are a variety of positive attributes to this encounter.

GR: I just want to add to the serosorting. I mean, it is one thing when you are talking about two positive guys using the Internet to conveniently and efficiently serosort but I also think negative guys are trying to use it to serosort and to find other negative guys, and that is more complicated. Those issues get much less cut and dry.

AUDIENCE: Can you guys talk a little bit more about drugs and alcohol, and how communication is happening around that?

DL: I can just say again, anecdotally as opposed to scientifically, but there are lots of people in their ads who are using PnP, party and play, and that that contributes to higher numbers of sex partners, you know, sex going all night, more friction, more chance for transmission of STDs and HIV. However, as far as prevention goes, we have not figured out any way to reach these guys. When they are online, there is one thing, one thing only. They are online often late at night and not at all interested in anything else that is going on online. If they, perhaps, are having a week where they are not using and then they are going online to look at the news, they are not thinking about health at that point. Whereas men who are not using, particularly meth, will actually look at health messages when they are not cruising. But that is where it can start.

JK: It would be actually interesting to study to see whether really the Internet has made it truly any easier to get crystal in San Francisco. I mean, it is pretty easy to get and whether the Internet actually makes it easier, I am not sure but people can certainly search for PnP partners, they can certainly go to certain websites which are more associated with substance users that network and kind of sort its way out, and there is the UC Prevention site Tweaker.org, which is linked to a lot of other health sites, which does get a lot of traffic. So that is kind of in response to try use the Internet as a prevention tool to bring people to a harm reduction website like Tweaker.org.

FS: It is also you have to keep in mind, I think, that especially with methamphetamine users, you get so hyperfocused on particular things that the Internet becomes and the use of the computer becomes a great tool; you do not have to go out in publicespecially if you are in the place where you are going to have psychosis or mental health conditions, you are in that place where you are already getting nervous that people are watching you -- you can then pick and choose, you can get ... you can really get focused on your screen, you get in to what you are doing so strongly and you do not have to go out. You do not have to leave. You do not have to leave your drugs. You do not have to worry about who is going to see your stash. There is a level that it is a very suitable mechanism for that particular person. I do not find people who use alcohol as likely to be drunk because of their ability to not type when drunk! You can socialize drunk, you do not have to worry about your eye-hand motor coordination [crosstalk].

AUDIENCE: It seems like, particularly in San Francisco, that the assumption is that the best way to reach people is online? And I would like to suggest that I think that is not the case. Cabra Diseno just launched a new campaign [www.be-clear.org] in the subway yesterday morning, and, in their focus gropus, they asked guys who go online, "How do you want to be reached?" And they said, "Not online." What is on my mind is cruising, that is what I am doing; that is my space and I don't want to be invaded. So they decided that the campaign isn't doing anything online. They have a website that they have created that they are not doing banner ads and I don't know what else they have done but I wanted to caution about that assumption that the best way to reach online users is online. And my second comment is, so however we intend to reach these guys, what is the message? And is the message "use condoms" or "disclose" or ...? I think this was all done historically and they do not work very well. They may have worked at some point historically but in 2004, and, in San Francisco, I do not think they are the best. I would like to suggest that possibly the message is "How to have a more satisfying sex life - emotionally and physically."

MV: I would actually like people on the panel to comment on that because there is a certain intersection between, "failure" is not the right word, but "less than satisfying results" in traditional prevention, which has changed the whole CDC paradigm in terms of prevention in general, for better or worse. But the perception is that things were not working as well as they could. So, it does raise the question, then, in terms of when you go out on the Internet, do you repeat the same things that in the last 5-10 years maybe have not worked as well as they did earlier in the epidemic?

DL: I guess I will speak to this first, just because I actually was on the community advisory board for Cabra and agreed that it was a really good idea to take if offline, as well as someone who heads a service that does online outreach and prevention. One thing is that there have been studies shown that gay men in particular, but as well as the bulk of the American population, gets their sexual health information online and reason being, "Well, where else are you going to get your sexual health information?" Okay? People are not talking to their physicians. In the land of HMOs and 15-minute appointments, you are not really sitting down and saying, "Well, what risks do I have based on I did this last night and this last week?" It is just not happening. We are not really an open society in talking to our friends about it, and from parent to child, you know, take it away! This has never been the greatest source of sexual health information. As adults, people are turning to the Internet because it takes away the shame and embarrassment. So I think there is some difference between a prevention message and sexual health information, and I am learning -- and I think we have enough statistics from the work that we have done together with banner ads on Gay.com -- that men who are in the chat rooms and are on personal ads -- our click-through rate is much lower than ads that run throughout the service on Gay.com, which basically means it is just called "run of service." They rotate through all different content areas. So we are reaching ... and it is actually geo-targeted by zip code, so since this is a particular San Francisco project, it is reaching San Francisco gay and bisexual men presumably who are using Gay.com, who are looking for other information. They are reading the news, they are reading Dan Savage's column, you know, whatever it is that they are doing online, looking for a movie timetable, and they are clicking. The click-through rate on those ads is much higher than the click-through rates on chat and personals. And then what is happening is they are actually going to the sexual health information sites that we have set up and they are running through those pages, they are spending 3-7 minutes on pages -- that is a long time to be spending reading about sexual health. So, I do not think we can completely dismiss online prevention but I do think we have to be careful and not assume that everything is going to work. We were doing one-on-one outreach for a full year and decided that not only was it not cost-effective, but it was really hard to tell whether men were then going in to get tested after they had an interaction with an online outreach worker. Their follow-through, we provided some incentives for men who did get tested at City Clinic. The incentives were actually used and redeemed -- about 150 in three months -- which we were pretty happy with as far as testing, but it was not necessarily a clear link and evaluation is sort of what it all goes back to. Very, very hard to evaluate but the online prevention methods, partially because it is new and partially because you have to translate what happens online into action offline.

FS: We have done the same. SafeSexCity.com is less specific prevention and more about sexual health. We made that choice not to take CDC or federal funds or, in some cases, city funds so that we can do other things. Often because I have been a sexual health educator and am known for some of the same programs that get other folks in trouble: Sex club etiquette, you know, things like that. People have asked, "When are we going to put those on the site, so we have been in the studio about a month now doing video clips, right down from how to give a blow job, how to clean out your butt using a shower shot or an enema system, to relaxation techniques so that you can avoid tearing, to a full gamut of toys to condoms, how to choose different condoms. So we are mixing them in to create a catalog of sexual health because there is no ... it is limited in what is out there and sometimes they can go to the websites, especially ones that are publicly funded with dollars, and they stop a little too short because of various guidances or controls, and we need the next step. We need to have more clear visual and written messages that create gay male and gay bi-male sex as a healthy opportunity instead of being limited so often. So it definitely, I think, there is a difference in encouraging education on how to make healthy choices about what you do or do not know sexually and prevention, and incorporating them.

JK: I think you have to put the prevention into the traditional prevention framework. If you think about primary prevention, we are trying to reduce exposure, awareness, education, risk reduction and certainly awareness on the Internet may not be the best way to do an awareness campaign. When there is an outbreak of syphilis in San Francisco, it is usually done through the media, through billboards, through other kind of targeted street or venue-based population techniques. But if you want to get more into the knowledge and more in-depth area, I think that the Internet does afford a great way to enable people who are motivated and interested to really learn more, and then the challenge which in primary prevention right now is can the Internet afford a feasible and effective means for risk reduction? So are there interventions that can be done and to date, there have not been any successful Internet-based risk reduction interventions. It is very difficult to retain people in cohort studies and that is a big challenge. And second part of prevention is what we call secondary prevention or early detection of infection and timely treatment. Now here, the Internet does provide an opportunity through an example of our online syphilis testing service, where we had about 10 people access new syphilis tests a week through this online syphilis testing service and we can in a more rapid diagnose a new case of syphilis and bring them in to treatment, also, treatment services by providing information and linking people to Magnet, to City Clinic, to primary care providers. You can bring people into the fold of medical care. So I think it clearly depends on what your goals are in terms of what kind of prevention you want to achieve.

MV: I wanted to make sure we talked a little bit about successes...

GR: Over the past year or so, we have been doing qualitative interviews with staff at AIDS service organizations around the country who were doing online prevention programs and I thought Alberto [Curotto of CAPS] would like to talk just briefly about we found. I can give you my chair.

Alberto Curotto: Well, I would say that the most common form of intervention that has been reported by CBOs is outreach in chat rooms. It is cheap to do; that is the main reason why a lot of CBOs use it. A lot of times they do not have any funds for this specific type of intervention, so they just use volunteer time or time from existing programs to do it and, in general, they report a lot of success. The successes are very anecdotal, though. There is no evidence that they work but there are a few organizations that have used more complex methods such as creating a website that has education tools or, you know, video streams or a variety of web-based resources and to which men are referred, so intervention does not really happen in real time. It is just people are invited either by email or in physical locations, they are invited to visit the website. These interventions are generally much more expensive. Like everything on the web, there is always a very large cost to initiate something. Then the hope is that if it works, it is there, it is online and live and people will continue to use it, but the initial costs are really, really large and CBOs normally cannot afford it. So that is what we found.

JK: So, Alberto, you talk about help worker outreach, websites and right now the City Clinic website is the second most frequently used website in the City after the jobs website.... and then Deb Levine mentioned about the banner advertisements and the click-throughs, and what is nice about these banner advertisements, you can actually calculate your cost per click-through and if you think a click-through results in some type of awareness or further link, you can further measure that by, as we did, having people printout coupons and take these coupons for a test at the clinic and actually calculate how much did it cost you to get this person down to the clinic. Now without a comparison group, it is difficult to know what other means of outreach would have created. We have also been involved with what is called "moderated chats" on Gay.com, where we will blast that either myself or Nurse Practitioner Chuck Collinger is going to be online for an hour to engage in a moderated chat, where people can put up questions, then we can identify what questions we would like to answer, and we could have about an hour kind of auditorium Q&A with an expert online and then what is nice is we can edit them and archive those questions and Gay.com, that site, ask Dr. K, is one of their more popular sites and then ideally, as Alberto mentioned, you want to do something that is going to be permanent and effective with what you might call a structural intervention. So how can you essentially change the environment and we have been dabbling in this. You really need, obviously, the buy-in of the Internet service provider to really do something significant and the types of things that we have done was on Craigslist, under the Men Seeking Men header, there is kind of an informational warning, if you will, and then some embedded links to safer sex chat forum and you can count how many people go to the safer sex forum on any given week so you can get some outcomes there. On m4m4sex.com and their profiles, we were able to have them add this profile piece about safe sex "now, later, not particularly interested." I mention the online testing services and there are a lot of other sites that are interested in providing more about online testing and online screening. So I think that there is a lot more that could be done. But evaluation, as you mentioned, is very difficult and in one comparison group, you do not really know but you can do other types of studies from street-based interviews, from cases and non-cases and find out whether their exposure to the Internet was protective or facilitated their access to health care.

AC: I think what we also found from our qualitative interviews that we collected over the past three years is that one big problem in this online hookups is communication. Communication online is not clear. It seems clear, but it is not. And this somehow has issued into the campaign that was mentioned earlier in the Castro MUNI Station, that is geared toward people, men who hook up online, but it focuses on communication. It is not about condom use, it is not ... it is "communicate clearly."

JK: Do you know how this is being evaluated? What kind of mini-outcome measures from that type of campaign might be?

GR: We are doing intercept interviews with people to measure regions of the community and get people's reactions but I do not think there is a systematic evaluation.

AUDIENCE: Has anyone looked at the most frequently used chat sites that actually have profiles and characterize the profile information that is included, like what portion of them actually has HIV status, condom use? One of the potential structural interventions is to work with the website designers to locate in these profiles, "Let's add a line that says, 'I will talk about safer sex,' you know" or at least making some of those items that allow people to serosort or find about safer sex use or communications skills that any time that there is a profile, okay, that information is at least there; that is one way to penetrate into the chat room environment which is particularly resistant to actual interaction interventions. Has anyone done anything, any survey like that?

PH: We created a Yahoo! group because we were finding a lot of men who did not want to have anal sex and ...

AUDIENCE: In this town?

PH: Well, yeah. So we created a Yahoo! group for the men who were specifically looking for oral sex. A lot of the men tended to be non MSM-identified; a lot of them were married. Our typical profile is someone who has been married for 15 years, wants to experiment with men. Anal sex is probably too big of a step, so they look for oral sex. So I think [with sites such as SafeSexCity.com] you can create these pockets where you have men who have kind of a community agreement to do certain things, perhaps certain types of discussions. I think you put a line like "I am willing to...", I think most men are ... I do not know. Yahoo! profiles asks a lot of things -- your income, religion -- and I think if you do not want to answer it, you are just going to answer it.

FS: Keeping in mind that there is a cost involved to the company that has to pay the programmer to put that in if it is not already existing. We did not have "Prefer to discuss" under hookup initially until we got feedback from our first three-month review from folks that we then added that as an option under "Hookup now-Hookup later" and "Prefer to discuss first" and "Let's have coffee"; we added those and that was an easy fix because we already had the existing spot but to go into a business and say, "We want you to add another field" could be challenging, right, Deb?

DL: You know what? I do not want to answer the question that way. I remember Mark saying, "Positive successes" and so let's stay there for a second and just say that a few years ago, when San Francisco sort of first started looking at this in a public way, there was a young resident at the time who probably some of you know, he has now finished medical school, is Rick Loftus and he actually sat down and went through a whole bunch of ads on Bareback City at the time as well as Craigslist, and just informally, he said, because he's a med student and stayed up until 4 in morning and went through hundreds and hundreds of ads and started looking at what was the language, what were people looking for and where were the risks. And so, I still have that somewhere and I referred back to it because I think it is really interesting and would be really interesting to do that in a larger way and there may be ... I believe there is research software now that can analyze by terms, yes? By pulling out specific terms. So it may not even have to be done manually and I do think that would be interesting to say, "This is what is there" rather than "This is what we think you need."

And then the second half of your question was about asking the sites to put in some information. I do not necessarily think it is a bad idea. As Alberto said before, is bad communication worse than no communication? Sometimes yes, sometimes no. We have worked with m4m4sex and they have put in a new field that says -- I do not remember the exact details -- but it is "Safer Sex: yes/no" or "I want to discuss later" or "I don't want to talk about it" (I do not remember the exact words) but they did add that. It is not that hard. These guys are making tons of money; you cannot even imagine! And what we hear from the Internet service providers is, "We don't want to do any of this for you because it may turn away our customers. You know, it's a turnoff not to turnon." But the reality is that the sites that have cared for their customers or their membership are actually bigger, stronger. Gay.com: I mean, they are so willing to put public service announcements up, to respond to the needs of the community, to provide sexual health information, to work with community members. Are they having trouble with their membership? No. But even the ones that are sex-specific, not Gay.com, which is also a lifestyle site, but say there is a site down south in Southern Cal that we have been working with, Sexforhotmen.com, they have been amazing! They changed their community norms to include some information like, "We'll work with the health department if we need to," "This is important to us. We care about your health and if you contact us about sexual health, we will talk to them, we will discuss it." They changed their language. It was not a big deal. There was no defensiveness on the other side. That in contrast to other sites where Craigslist, to be honest, we got them to put that what we call the warning label, which basically just says that "Having more sex partners puts you at higher risk for STDs," which is just ... it is nonjudgmental, it is just the truth: The more people you have sex with, the more chance you have of getting an STD, not that you are necessarily going to get one, it just means you are rolling the dice more.

AUDIENCE: The reason why I brought it up and what I was talking about in terms of changing the profiles, in terms of evaluation, is that is a pretty clear-cut way to evaluate something. If you did a pre-post evaluation of a site, the content analysis of the chats and then structurally changed the profiles, you could probably measure the impact of that pre and post by doing an after-point content analysis of chats and connections.

DL: It is sort of how many people took advantage of it?

AUDIENCE: But that also presumes that they are telling the truth.

DL: Right, and it all comes back to how do you measure behavior change? And this is an issue online or offline. I mean, unless you are sitting in the bedroom with the video camera, you know? -- which some people do! -- but scientific researchers too but they are not getting federal funds!

FS: A lot of major Internet providers are open to conversations. I have a kind of different relationship since I have known a lot of these organizations through various venues. One of their big challenges, not only are they getting spoken to by professionals like ISIS and public health, but every small community-based organization that decides they want to do Internet outreach is also hitting them up, and you know, when you have 15 or 20 or 30 people all wanting to do the same thing -- different messages, different styles, different needs -- you are going to at some point just say, "STOP!" and have to pick and choose and figure out a protocol that is going to be useful. So I think it is important to keep in mind that, you know, we are looking at it from one perspective. We are only one location, who is all trying to hit the same pot of pie for their own individual locations. We, I think, have a little bit different experience level with some of our programs but just to try to keep that in mind, too.

AUDIENCE: Question in terms of a relevant percentage of interventions that are going on, two different categories. When we started this discussion, we were talking about what the problems were. They were all centered on forums and then when we launched into a discussion about what the interventions were. The first ones that were spontaneous interventions but there also this thing called education. Do we know anything about behavior change models? Norms predict behavior and knowledge predicts behavior, but they are two different predictors. We cannot address norms by simply sticking up a health education message, yet that is what we are doing. We are wasting our energy. And now more recently in this discussion, there have been some things about norms coming up here in terms of restructuring the profiles and stuff, and when we talk about hitting up these agencies for permission to change sites and stuff, it seems to me that if we are wasting our time with a lot of health education messages that actually do not get at this issue, we are sort of taking up capital that we could otherwise use to focus on the more straightforward issue of norms, which really seems to be what is driving the issue.

PH: Right, but that is assuming that all health education efforts have a message, which I do not think ours do. We do not promote a specific message about anything. The only norm we are trying to change is actually that maybe if you are in the chat room enough and you see us enough, the norm would be that you talk to us. That is the only thing that we can really control. We have taken a very specific ... like, we had a lot of discussion at our agency and we really did not want to have a specific message intervention. What our project is selling is a personal interaction with an outreach staff that they otherwise would not have anywhere else. So we are selling Phillip and Travis who are the two outreach workers. A lot of guys ask us for three-ways or they will ask, "Are you the white one or the Asian one?" And they may or may not talk to you based on that, but, yeah, I think that is the norm. Our goal in doing ... I think a lot of interventions are about having banner ads. I think we still believe in promoting in interaction a chat, so I do not know; I think health education lives! I believe in gay men's health and I think that the men who go to the Gay.com Oakland chat room, I think there is a familiarity with our program, just because they see us there week after week after week after week after week.

AC: I agree with what you said, that to change the norms, you need more structural interventions. What I was reporting is what CBOs are doing and their anecdotal reports of successes or failures.

JK: But through education, you can change norms about preventative behavior. People are knowledgeable and educated that it is recommended by the Gay and Lesbian Medical Association, by the UCSF AIDS Program, to get a syphilis test every three months, to get a full screening for gonorrhea and chlamydia from the throat, from the rectum, to get a herpes test. I think those are educational messages that can be used to change people's sexual health and prevention norms. How that changes their sexual behavior is a whole different set of norms. It depends on what you are talking about.

AUDIENCE: A norm, at least the way a psychologist would talk about it, is something that appears to change in the community; just because the SFDPH tells you that you should go get a syphilis test every several months, it does not mean people will ... I mean, that is just a recommendation

JK: Right, well, you use that to promote the idea that this is the norm, that 70% of sexually active gay men have had a syphilis test in the past six months, so that is the normative behavior; a majority of people got a syphilis test. You can be in the majority or out of majority. So I think you can use that as information sharing to allow people to know what the norms are.

DL: One thing to take into consideration is that people hear messaging in different ways. So some people are going to respond to this very clinical message that says that 70% of guys in your town are getting STD checks every three months, so you do it, too. That is not even clinical, that is casual clinical. But then there are other people who are going to respond much more to the "Are you a slut? Go get tested!! You know, like, what are you thinking!?!" So, you know, at least for ISIS and we, in good faith, San Francisco Department of Public Health got a community-based organization to do the prevention messaging. We work by any means necessary. We have done everything; our banner ads change every month and we have done everything from very clinical -- "This is what a sore looks like. Get freaked out and go get tested!" -- to we ran on Gay.com, we took one of their personal ads and sort of put in dummy information and it was a real hotty and da-da-dah, and then under the part where it says, "Other information about me," it says "Has syphilis and does not know it" because as we know, most STDs are asymptomatic. Those are actually, believe it or not, the sores and the profile were the two most clicked-on ads where people then went to get information. In addition, when if you talk changing norms, each of these websites has their own community norm within the giant World Wide Web and so we cannot actually sit here and say that what is going to work on one site is going to work on another site. Let's say just really briefly Craigslist is a text-only service. There are no fees. It is a revolving door over there, and that is a really different thing than on Manhunt or m4m4sex, which is a fee service with photos only for sex, which is a very different service than Gay.com, which is a lifestyle magazine that also has personal ads and chat. So when we approach the Internet service providers, we first of all familiarize ourselves with the sites intensely, spending time on the sites, like living in the community to see what is going on, and then approaching them to say, "This is what we see on your site. What do you think about ... how do you think your membership would like to hear sexual health messages or sexual health information? Or how can we help you show your concern for your membership?" And you know, it works in various ways. I started to say before with Craigslist, the way we got that sort of fear message on was because Craigslist had just gotten busted because people were selling drugs; there was an undercover bust, where a cop went to someone's house, I do not know if it said "PnP" but they were definitely selling crack or meth, and the cops went, they got busted. Craigslist got scared; out of fear, they let us put up a fear message, okay? So...by any means necessary.

FS: We created our own norms. So our norm is when you sign up in a free membership, it is explained about that our norm of our creator and our directors body, a group of gay men who participate, suggest that every three to four months get an STD test, and as a matter of fact, to help you encourage you, put in the date of your last STD test and you get an I-mail message in three months saying, "Oh, by the way, it's that time." And we are seeing people using it but, oh! It comes directly; it does not go... The other side of that was we created a dummy URL for men who did not want to be on Hotmail or Yahoo! So you can sign up; it is like $30 a year and you get something that is very innocuous, it looks like a professional email address that becomes your email. It is driven so that you can go up to a website, get mail, so now men who have wives or girlfriends who do not want to have any track record of AOL or Hotmail that they cannot get in to at work, we gave them an opportunity to maintain that place. So we created different norms. We created the norm is "Positive or negative, we want to use condoms, we want to test." We also created the norm that "You could be HIV-positive and also be okay with using condoms, that that is not the only way to go." So we changed a couple of our norms to create what we wanted to see and really did not care what other people's norms were because this is what we wanted to do and it attracts those men.

AC: And also some of these problems with norms are not specific to the Internet. You mentioned earlier the younger guy went to the sex party and came down with syphilis, and the older guys said, "Well, in our times, we used to go to the clinic before and after," but that was probably before 25 years of the HIV epidemic, it was before 25 years of a conservative political environment that suppressed sex-positive messages, and younger guys are ... you do not think about it. So, those norms are true as well. They are not all caused by the Internet.

MV: So I think this is probably a good way to end actually about transitioning to some of those different norms within the community and sense of community building and creating different norms. I would like to thank all of the panelists for being here for a great discussion, I thought, and for all of you here in the audience. We will have a transcript and real audio of today's roundtable on HIV InSite soon, probably in the next few weeks. So again, thank you.