Using tech to battle STDs

As public health budgets are slashed, and money for sex education and outreach evaporates, California public health officials are slowly introducing new technologies including texting and computer-based training to combat climbing rates of STDs.

Around the state, schools and county health departments are testing these innovative strategies to reach target areas most affected by STDs, often in underserved areas.

Deb Levine of the Oakland-based Internet Sexuality Information Services (ISIS) says that for America’s youth – those most affected by sexual disease – technology isn’t just a helpful tool.

“It’s integrated into their life,” says Levine, executive director and founder of ISIS. “When they have a question about sex, the first place they go is Google or another search engine.”

Levine said there’s “a generational divide” between the way youth access information and traditional sex education. The “distancing” of an electronic screen, she says, helps younger users avoid the shame and embarrassment associated with sex “which really makes it easier for people to ask and discuss sensitive topics.”

Around the state, young users are responding positively to electronic gateways to sexual health.

“It’s Your Game: Keep It Real” is an animated computer program for middle school students that explores the lives of fictional characters in all-too-real sexual predicaments.

After a successful one-year pilot, the program is now being spread to 24 Los Angeles middle schools – 16 in the Los Angeles Unified School District, and all eight middle schools in the Compton Unified School District.

The goal of the program is to delay onset of sexual behavior until at least the 9th grade.

Using an engaging mixture of humor and drama, the interactive tales place teenage users squarely inside real-life sexual situations, which provides opportunities to make real-world decisions.

Pioneered by the Prevention Research Center at the University of Texas School of Public Health, the program has so far proven a success. Follow-up studies by the university have shown that the program reduced the onset of vaginal sex by 29%, oral sex by 50%, and anal sex by 66%.

“Those are really big impacts and those that we in LA County hope to emulate,” says Emily Chung, project coordinator for the program in the Los Angeles area. Hopes are to extend the program to the hundreds of other middle schools in Los Angeles county.

The LA school district breaks down to about 85% Latino and 11% African-American, two target communities “where surrounding neighborhoods have high rates of teenage pregnancy, chlamydia and gonorrhea,” says Chung, research analyst for the county’s Sexually Transmitted Disease Program.

Chung says the game – along with in-class lectures and discussion – make one lesson abundantly clear.

“Everybody has their own rules and norms,” says Chung, whether it’s sexual activity or abstinence. “You have your own personal rules and it’s all OK.”

One teacher who used the pilot program said students were eagerly involved in the computer training – a giant leap from simple PowerPoints used in the past.

“This was evident in discussions that took place afterwards,” said Shaune Edwards, who teaches 7th grade at the Los Angeles Academy Middle School. “Classroom disruption was minimal to non existent, even with my more challenging students.”

Levine says that successful sexual health programs aimed at youth have several common features: they involve youth in the development process, are interactive, use contemporary scenarios, and engage all ages. Successful programs are also flexible in design, so that when fashions change so does content.

A pioneer in blending health and technology, Levine is one of the founders of the health website Go Ask Alice. Websites that discuss sexual and reproductive health include Scarleteen, Go Ask Alice, True Love Waits, and Sex, Etc.

The ISIS report TECHsex USA: Youth Sexuality and Reproductive Health in the Digital Age warns that current sources of sexual health information – schools, parents, the internet – are “only moderately successful in educating youth about sexual and reproductive health.”

In 2006, ISIS worked with the San Francisco Department of Public Health to launch the nation’s first text messaging service, targeting rising rates of chlymadia and gonorrhea among African-American youth in the Bayview-Hunter’s Point neighborhood.

Today, Levine says there are hundreds of online or mobile programs addressing STDs throughout the country.

In California, HookUp lays claim to the first statewide texting program in the nation to combat STDs.

The California Family Health Council (CFHC) encourages youth aged 15-24 to text “hookup” to 61827 and receive information about reproductive health, including nearby testing sites.

A partnership with ISIS and the California Department of Health’s STD Control Branch, HookUp now has more than 3,000 subscribers, although nearly twice that number have used the service at least once.

The goals of the program are to provide subscribers with in-depth information about improving sexual health. Subscribers receive tips on sexual health and relationships, and are also linked to, CFHC’s sexual health website.

“Tips include topics like healthy relationships, positive communication, parental involvement, issues around consent and confidentiality, and substance abuse and self-esteem,” says Amy Moy, vice president of public affairs for CHFC. “California teens are hungry for the kind of information HookUp provides.”

Four out of five users are female. Almost 90% of them are in the 15-24 target age group, although 5% are under age 15.

One 17 year-old female from San Diego said HookUp “makes me reconsider some of my choices when it comes to my sexual health.”

New STD outreach programs are becoming more critical as state health officials worry over rising transmission rates.

Last year, California officials saw a 7% rise in new cases of chlymadia and gonorrhea over 2009 – 155,000 reported cases.

A state health official said the increase could be due to the loss of health insurance, along with budget cuts for public health programs.

“If they don’t have insurance and don’t know where to get tested… they may not know they’re infected” says Heidi Bauer, chief of program development and evaluation for the state’s STD Control Branch.

In a survey of 40 of the state’s 61 health jurisdictions, “more than half of them had pretty dramatic cuts in STD service or staff,” adds Bauer.

Los Angeles county suffered over 44,000 reported cases of chlymadia and 9,500 of gonorrhea in 2010, disproportionately in the Latino and African-American communities. County health officials say one densely populated area of the county was responsible for nearly half of the county’s gonorrhea cases.

In response, the county created the “I Know” mail testing program targeting Latino and African-American women ages 12-25 in southern and central Los Angeles, using a familiar model.

“We used an e-commerce model for ordering the kit on the website,” said Jorge Montoya, director, Communications Outreach and Program Evaluation for the county’s Sexually Transmitted Disease Program.

Women order the home testing kits online, receive them by mail, perform a vaginal swab at home, and return the test postage paid. Users can choose whether to receive test result alerts by email, text or both.

Results can be retrieved online, say health officials, which is a major improvement over traditional phone calls that can be uncomfortable for users.

Montoya says the entire process is similar to ordering products online, with matching feedback like “Your order is being processed.”

The mail-in program overcomes the stigma and shame of visiting a health clinic, being seen by friends, or the hassle of finding transportation, says Harlan Rotblatt, the county’s project coordinator for “I Know.”

The first year, nearly 3,000 kits were requested, although only 1,600 completed tests were returned – a 55% return rate. Positive results were found in over 8% of the returned tests. County health nurses follow up with those who test positive, to make sure they get treatment at no-cost clinics.

Based on a similar program at Johns Hopkins University, LA county officials marketed the program using a wide variety media, ranging from cable TV ads to neighborhood posters, as well as postcards in beauty salons and on Facebook.

Rotblatt says anonymity is a huge benefit: “They vastly prefer online to the phone.”

Further south, San Diego County health officials are now using texting to reduce infectious syphilis in the gay community.

State public health officials have targeted infectious syphilis in San Diego county, where 2010 results showed a more than 900% increase in the disease over the past decade – 435 new cases.

The “We All Test” program targets gay men (and men who have sex with other men), encouraging them to sign up for text and email testing reminders. The program now has over 1,200 registrants.

First launched last year using a minimal media campaign, program coordinators re-launched the program this January after closer collaboration with STD control clinics, yielding greater success.

“As soon as we worked with the clinicians and nurses, our signups increased dramatically,” said Tom Gray, the state’s Syphilis Elimination Liaison.

Participants can sign up online, at county STD clinics, or family health centers. They choose to receive testing reminders every three or six months, which the Centers for Disease Control encourages for high-risk behavior. Testing sites and STD facts are included on the website.

Gray says gay men have HIV testing “drilled into their heads” but not tests for other STDs. Besides syphilis, the San Diego sites also test for chlamydia and gonorrhea, which Gray says often go undetected. Effective testing for chlamydia and gonorrhea should include throat and rectal swabs; without those, said Gray, 30-50% of gonorrhea cases in gay men may often go undetected.

Nationally, the Centers for Disease Control and Prevention maintains a website to find STD testing sites.

ISIS holds an annual spring conference dedicated to reproductive health and technology attended by health professionals, technologists, and youth. It also moderates the Facebook page for sexual health Just/Us.

“When we put public health and Silicon Valley together,” says Levine, “the opportunities for raising our next generation to be sexually healthy are enormous.”

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