and Cell Phone–based HIV Prevention
and Intervention Programs
Michele L. Ybarra, MPH, PhD, and Sheana S. Bull, MPH, PhD
Corresponding author Michele L. Ybarra, MPH, PhD
Internet Solutions for Kids, Inc., 1820 East Garry Avenue #105, Santa Ana, CA 92705, USA.
E-mail: Michele@ISolutions4Kids.org Current HIV/AIDS Reports 2007, 4:201–207 Current Medicine Group LLC ISSN 1548-3568 Copyright © 2007 by Current Medicine Group LLC
As the reach of the Internet and cell phones increases, their use as health intervention and prevention tools has been increasingly researched. To identify recent advances in technology-based HIV prevention and intervention research, we conducted a literature search in the Spring of 2007. Only a handful of articles have been published in the last year describing evaluations of technology-based HIV programs. Nonetheless, many programs have recently been funded and are being developed or imminently evaluated. Results to date suggest the Internet and cell phones are feasible technologies to deliver HIV prevention and intervention programs for some target populations. Opportunities for future research are identified, including the development of programs for populations other than men who have sex with men who also are at risk for HIV (eg, adolescents, elderly), the integration of advances from other fields, examination of the potential for using text messaging to affect HIV behavior change, and applications of Internet-based programs in developing countries.
Introduction
As the reach of the Internet and cell phones increases, their use as health intervention and prevention tools has been increasingly examined [1•,2,3•,4,5]. An esti-mated 78% of Americans age 12 years and older are now online [6], and 35% of adults who have cell phones use text messaging [7]. Internet- and cell phone–based programs can overcome barriers to traditional inter-ventions including facilitator issues (eg, discomfort with topics, incomplete implementation) and individual obstacles (eg, transportation, insurance, physical limi-tations, the need for child care). Programs can be made
available to a much larger and geographically dispersed audience, substantially increasing reach and impact of health interventions. Messages can be individually tailored based upon a risk-assessment, increasing their self-relevancy, and content can quickly and easily be updated. In the case of HIV specifically, the Internet is widely used by some populations at risk [8•,9–13]. As such, these new technologies are where we as HIV prevention and intervention researchers need to be.
Interventions in the 1990s were centered on pro-viding information and interpersonal connection for people who are HIV positive. Improved social support was reported [14,15], with findings also suggesting improvements in decision making [15] and cognitive functioning [14]. In the early 2000s, research expanded into interactive, online interventions. Two promis-ing programs were developed and tested [16,17]. The researchers demonstrated the feasibility of online HIV prevention and intervention work but simultaneously showcased challenges in retention for longitudinal online research.
Detailed reviews of Internet-based HIV interven-tions [2,3•] and survey research [1•] have been published recently. In this paper, we focus our discussion on new and emerging research on HIV related Internet and cell phone interventions since these reviews.
Methods
Literature searches were conducted in May 2007. Two resources, PubMed and the National Institutes of Health Computer Retrieval of Information on Scientific Projects website, were consulted. The three main search terms, “World Wide Web,” “Internet,” and “cell phone,” were combined with “HIV,” “AIDS,” “intervention,” and “prevention.” Professional contacts also were consulted. To be included in the current literature review, programs were required to be research-oriented (as opposed to solely business or marketing endeavors) and focus on improving HIV-related behavior or outcomes. Computer and CD-ROM programs, although promising [18,19], are not included because they do not share the benefits
of Internet-based programs (eg, reach, ability to quickly update and modify program content).
Results
Recently published evaluations of Internet-based programs
Three studies have been published in the last year related to Internet-based intervention programs, each demonstrat-ing the feasibility of the Internet as a HIV risk reduction tool (Table 1). Bowen et al. [20] have developed a tailored, two-module Internet intervention for men who have sex with men (MSM) living in rural areas. Each module is about 20 minutes in length and depicts two gay men (one HIV positive, the other HIV negative) discussing a recent risky sexual encounter by the man who is HIV negative. The storyline is narrated with text bubbles and interac-tive graphics. Messages are reinforced with interacinterac-tive activities. A diverse sample of men was recruited for the evaluation. Ninety participants were recruited from 29 states, and 40% were from towns with less than 20,000 people. Seventy-nine percent retention was observed over the 1-week study period. Higher scores of HIV knowledge outcome expectancies and self-efficacy were observed in the intervention versus waitlist control group. HIV risk behavior was not measured. Nine out of 10 men in the intervention group said they would participate in the study again and would recommend it to a friend, demon-strating high feasibility.
Kok et al. [21] developed an Internet-based inter-vention for MSM who use the Internet to find sexual partners. Users are recruited in a popular gay chat room (http://www.chatboy.nl). The intervention is based around events that take place on a gay cruise. Users first pick a “pursuer” from one of four cartoon-depicted men. The chosen figure then engages the user in a conversation in a real voice about the user’s personal information, provides tailored feedback, and guides the user through the various “trips.” Content of the trips focus on HIV knowledge, attitudes, subjective norms, self-efficacy, and accurate risk perceptions. Initial response has been promising; 12,000 people visited the site in a 4-week period. Almost 94% of the 5982 who provided consent to participate in the ran-domized, controlled trial (RCT) and started the pretest completed it. Two thousand eight hundred eighty-six par-ticipants randomized to the intervention group completed all seven sessions. Evaluation of the site’s effectiveness in reducing HIV risk behavior is ongoing.
Access to reliable disease information online can affect positive behavior change, spur health seeking behavior, and increase social support and coping [22,23]. To improve the efficiency and impact of health information searches, Kalich-man et al. [24] recruited 448 adults who were HIV positive into a 9-month RCT. Participants in the intervention group received eight sessions aimed at improving their Internet consumer skills. At follow-up, this group reported using the
Internet more frequently to obtain health information and a higher degree of social support than the control group. HIV risk behavior was not queried.
Recently published evaluations of cell phone–based programs
In addition to Internet-based studies, emerging research sug-gests that cell phones may also be an important tool in the HIV prevention and intervention toolkit. Levine et al. [25], in collaboration with the San Francisco Department of Pub-lic Health, developed SEXINFO, a text messaging–based sexually transmitted infection (STI) and HIV prevention program for adolescents in the San Francisco area. Users text message “SEXINFO” to a 5-digit number from a cell phone. Then, they receive a message instructing them to text back a specific code which corresponds to their question (eg, “B2” for pregnancy information). Based upon the code entered, users receive a text message that includes tailored facts about sexual health and referral to local youth-friendly health clinics and social services. Preliminary impact data are promising. Over 4500 text messages were received in the first 25 weeks of the program. Awareness of the program was reported by 11% of 322 respondents surveyed at three referral health clinics. In a survey of 214 youth at 10 other health clinics, knowledge of the program was associated with reportedly increased concern about STIs. Youth who recalled seeing the advertisements noted that the modality was especially intriguing. Further evaluation is ongoing.
Puccio et al. [26] tested the feasibility of cell phone call reminders to improve medication adherence for adolescents who were HIV positive, ages 16 to 24 years. Eight patients were recruited into the study, with five completing the 24-week evaluation. Participants received reminder calls daily for the first 4 weeks, Monday through Friday for the following 4 weeks and Sunday, Tuesday, and Thursday for the final 4 weeks of the intervention. Twenty-eight–day adherence was measured using self-report during 4-week follow-up telephone assessments. Viral load and CD4 count was measured at the same time intervals. High adherence was reported by the five participants (99.97%). More convincingly, viral suppres-sion decreased for the majority of participants when the reminders were discontinued. Although the intervention required little staff time, the authors note a larger sample over a longer observation period is needed to determine the optimal length of intervention and appropriate wean-ing of participants off the reminders.
In-progress evaluation
Many promising studies have been recently funded by National Institutes of Health or are imminently being evaluated [27]. Although these studies have yet to pub-lish outcomes, we highlight them here to inform the field about forthcoming efficacy data. Bull et al. [28] developed YouthNet, a website that delivers tailored HIV prevention messages for at-risk youth (men and women, hetero- and
homosexual) ages 18 to 24 years. Five stories were devel-oped to 1) increase HIV risk awareness, 2) increase positive and decrease negative outcome expectancies towards condom use, 3) increase perception that condom use is normative, 4) increase self-efficacy for condom negotia-tion, and 5) increase condom use. Stories use pictures, text, and audio from a role model matched to the participant’s sex and race/ethnicity (eg, black females see and hear the stories delivered by a black female).
Two RCTs of the website have recently concluded, one recruited from clinic settings (n = 1955) and one recruited online (n = 2623). In both studies, partici-pants completed an HIV risk assessment survey at the beginning of each of the five modules. Control par-ticipants then were shown text-based, informational messages about HIV and other STIs, including infor-mation currently available on the Internet. Intervention participants were exposed to the risk-tailored story.
Analyses of data from the Internet-recruited RCT suggest that the intervention has no effect on HIV risk behaviors but may positively affect norms for condom use.
Analyses of data from the clinic-based RCT are ongoing. The study investigators believe that short interventions online such as this one-time, 15-minute intervention may be an effective approach for reaching the millions of youth who access the Internet. It seems likely that in order to affect behavior change, interventions of longer duration, higher intensity, and greater frequency of exposure are needed. The methodologic challenges of attracting people who are engaging in HIV risk behaviors to a program online for multiple doses are substantial. Methods to overcome these challenges might include embedding the intervention on websites where target audiences frequently visit (eg, social networking sites) or linking online interventions focusing on affecting norms with more intensive face-to-face inter-ventions in traditional settings. The investigators will be examining these methods in future research.
Efforts in development or not-yet-evaluated
Chat rooms
Data consistently show that the Internet is being used by some MSM to meet sexual partners [8•,9–13]. Chat
Table 1. Recently reported and in-development technology-based HIV prevention and intervention programs
Author(s) Study name Target population Target outcome N Recruitment Internet-based programs with published evaluation
Bowen et al. [20] N/A Rural MSM Reduction in HIV risk behavior 90 Online (generally) Kok et al. [21] Gay cruise MSM seeking sex
partners online Reduction in HIV risk behavior 5982 Internet chat room Kalichman et al.
[24] N/A HIV-positive adults Increased efficiency in Internet searching 448 Offline (generally)
Cell phone–based programs with published evaluation
Levine et al. [25] SEXINFO Adolescents Increased STI/HIV knowledge,
referral to services 536 Traditional media Puccio et al. [26] N/A HIV-positive
adolescents Increased adherence to medication 8 Clinic
Internet-based programs with ongoing evaluation
Bull et al. [28] YouthNet At-risk young adults
(ages 18–24 yrs) Increase HIV risk awareness, condom use 4578 Clinic + online (generally)
Internet-based programs in development
Benotsch N/A MSM seeking sex
partners online Reduction in HIV risk behavior using POLs N/A Internet chat room
Hightow N/A Black MSM in
college Reduction in HIV risk behavior N/A College
Hirshfield N/A MSM seeking sex
partners online Reduction in HIV risk behavior N/A Unknown
Mustanski N/A MSM young adults
post-HIV test Off-set possible risk behavior due to negative test result N/A Clinic
Rosser MINTS-II MSM seeking sex
partners online Reduction in HIV risk behavior N/A Internet chat room MSM—men who have sex with men; N/A—not available; POL—popular opinion leader; STI—sexually transmitted infection.
rooms are one of the most common places to meet part-ners, and as such, are an important place for targeted prevention activities. Several chat room–based programs are in development. University of Minnesota’s HIPS unit is developing MINTS-II (Rosser, personal communica-tion). Noting increased incident rates of STIs among MSM, MINTS-II is an Internet-based intervention aimed at reducing HIV risk behaviors among MSM who use the Internet to find sexual partners. The four-module program covers issues surrounding self-exploration, assessment of intimacy needs and intentions, sex, and building a sense of community online. Pilot-testing is ongoing. Measures include verbal and on-screen reactions of users, as well as their eye movements to discern which program compo-nents are attracting the most attention. Once the program has been developed, the authors aim to test the impact of the website on reducing HIV risk behavior at 3, 6, and 12 months post-intervention.
An effort is underway to develop an online adaptation of the popular opinion leader (POL) community-based intervention (Benotsch, personal communication). To date, the authors have interviewed webmasters and chat room users (including MSM, heterosexual men, and women) regarding user preferences. They also have developed web tools and pilot-tested some intervention ideas. POLs, defined in this intervention as health educators or peer educators, will receive a three-session training to deliver effective risk reduction messages to other chat room mem-bers and then interact with other chat room memmem-bers over a 4-month period. Twelve chat rooms, six MSM-focused and six heterosexual adult–focused, will define the sam-pling frame. After completion of the baseline survey, four chat rooms (two MSM, two heterosexual) will receive the POL intervention, four will receive general online outreach, and four will serve as a control. To assess the effects of the intervention on reducing HIV risk behaviors in the chat room community as a whole, the program will be evalu-ated via three cross-sectional assessments completed by chat users selected at random. Formative work to develop the program is ongoing.
Several MSM chat room outreach programs exist [5], including programs offered by the San Francisco Depart-ment of Public Health, the Howard Brown Health Center in Chicago, Illinois, Project CORE in Houston, Texas, and the United Foundation for AIDS in Florida, which devel-oped the Crystal Alert program for methamphetamine users specifically. Outreach workers passively answer questions generated by chatters and also actively post information or a question without waiting to be approached. Although efficacy of these efforts has not been documented, these programs are an important example of taking the interven-tion to where those at greater risk are.
Non-chat room–based programs
Partner notification is an essential component of outbreak containment and ongoing disease prevention efforts.
Health departments and community-based organiza-tions are using e-mail and chat rooms to perform partner notification [29]. A popular Internet-based partner notification tool is inSPOT.org, developed by ISIS [30]. Users can send anonymous, electronic greeting cards that notify partners that they may be infected with a sexually transmitted disease and urge partners to seek testing and treatment. It is a popular service and recently expanded across the United States and internationally.
Several Internet-based intervention programs are in development. An Internet-based prevention program is in development for young MSM ages 18 to 24 years who are being tested for HIV (Mustanski, personal com-munication). Noting that negative tests are associated with increased sexual risk behaviors among MSM, the creators propose to adapt content from existing, evi-denced-based interventions. Using the transtheoretical model of behavior change as a guide, content from three programs (the AIDS Community Demonstration Project, the Behavioral Intervention to Reduce AIDS Risk Activi-ties, and the affect regulation skills training module of Project BALANCE) will be translated into an eight- or nine-module online intervention. The project team is still in the planning stages. Once the program is developed, it will be evaluated in a pilot RCT of 80 young MSM who have recently obtained an HIV test at the local clinic. Six- and 12-week follow-up data collections are planned to examine program effect over time as well as to evalu-ate tracking and retention strevalu-ategies.
Additionally, an Internet-based HIV intervention to reduce behavioral risk of MSM seeking sex partners online using digital video vignettes and a website aimed at reducing HIV risk of black MSM in college are being developed [27].
Methodologic Considerations
Recent reviews of Internet-based HIV survey research [1•] and interventions [3•] highlight important methodologic considerations when planning Internet interventions. Of fur-ther note, Rhodes et al. [31] demonstrate the importance of tailoring the recruitment strategy to the target audience. In a comparison of 238 men recruited in MSM-focused chat rooms passively (ie, without having to talk with the research assistant directly) versus 210 participants recruited actively (ie, having to talk with the research assistant to receive a study invitation), the researchers report that those in the passive group were significantly more likely to report HIV risk behaviors (eg, insertive anal sex with multiple partners in the past 3 months, HIV-positive status). Importantly too, minority and bisexual participants were significantly more likely to be recruited passively.
With the digital divide decreasing and more low-income and older people connecting to the Internet [32], technology-based HIV prevention and intervention pro-grams show promise in reaching a diversity of populations. That does not mean that Internet-based interventions are
appropriate for all populations. In most cases, they should be seen as an adjunct to rather than a replacement of tra-ditional programs. Furthermore, in-person approaches are still better for motivating and training individuals [33] and for persons or groups that prefer face-to-face contact or lack consistent access to the Internet (eg, homeless and indigent drug users [34]). Researchers should consider the target population they are trying to reach when determin-ing the preferred modality of dissemination. Formative work to identify preferred modality is imperative, particu-larly when working with diverse groups and populations at elevated risk for HIV.
Opportunities for Future Research
For obvious reasons, MSM have been overwhelmingly the most common target group for Internet-based work [8–13]. Other at-risk groups, such as black, adolescent women [35], also may be appropriate targets for Inter-net-based research. More generally, no InterInter-net-based programs have been evaluated for youth under age 18 years, yet they are wide adopters of Internet and cell phone technology [36] and face ongoing risk for HIV infection [35]. On the other end of the spectrum, older adults are just as likely to use the Internet to seek health information as adolescents [37] and are at increasing risk for HIV/AIDS [38]. No studies have reported the feasi-bility of Internet- or cell phone–based HIV prevention approaches for this important at-risk population.
An effort should be made to integrate findings from other fields. Several fields, including smoking cessa-tion [39] and mental health [40,41], have an emerging Internet prevention and intervention research base. For example, Levine and Klausner [42] suggest applying lessons learned from tobacco control, including “sin taxes” on risky websites, the creation of a sexual health “seal of approval,” and donated space for public ser-vice announcement banner advertisements. Researchers should look beyond the HIV research to identify promising new techniques for online prevention and intervention research.
Text messaging has been used to increase HIV preventive knowledge and referral to services among adolescents in San Francisco, California [25], demon-strating its feasibility as an HIV prevention tool. In the smoking cessation field, text messaging has been used to affect smoking behavior in a general popula-tion sample [4], suggesting that this technology can be used to change or modify persistent behaviors that are difficult to change. Text messages should be looked as a tool to affect HIV preventive behavior change, espe-cially for younger, at-risk populations. For example, tailored messages could be sent to one’s cell phone on-demand or at self-identified higher risk periods (eg, at a bar late on Saturday night). Considering the volume of content and enormous number of websites accessible
online, approaches should be developed that embed and integrate HIV prevention messages as well as ser-vices [43] to where at-risk groups are most likely to be online. Ways to tailor the technology to the target age group should also be examined. For example, adults who are more familiar with movies will respond bet-ter to video-based inbet-terventions whereas youth who are more familiar with video games will respond better to cartoon-based interventions.
Several studies in Africa have reported success in their efforts to use the Internet to connect academics and physicians to current medical literature [44] and to each other for telemedicine activities [45]. However, little Inter-net- or cell phone–based work at either the individual or organizational level has been done in developing countries. Bensley et al. [46] explored the possibility of modifying a Western Internet–based prevention program centered on the e-Health Behavior Management model to promote HIV preventive behaviors among adult women in South Africa. Although the necessary online infrastructure was lacking, focus group results suggested high interest and acceptance of an Internet-based prevention program. Recent surveys indicate that adolescents in major urban areas [47] as well as more rural areas [48] in sub-Saharan Africa are using the Internet to obtain health information. These data sug-gest Internet-based programs in developing countries are a feasible but as-of-yet untapped opportunity.
Conclusions
The state of Internet-based HIV prevention and inter-vention research is still preliminary. Studies to date highlight the feasibility and likability of Internet- and cell phone–based HIV programs for the target popu-lation and also report promising results in terms of sample retention and possible behavior change. The number of currently funded, in-the-field studies prom-ises a rapid evolution of our understanding of how to best harness newly emerging technologies to capitalize on their reach for improved HIV prevention. Prelimi-nary findings presented here offer an intriguing peak into upcoming advances and provide clues for future opportunities to advance the field.
Acknowledgment
The authors would like to thank Ms. Deborah Levine for her enthusiastic support and assistance in identifying appropriate articles.
Clinical Trial Acronyms
CORE—Cyber OutReach Education; HIPS—HIV Intervention and Prevention Studies; ISIS—Internet Sexuality Information Services; MINTS-II—Men’s INTernet Study II.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as:• Of importance •• Of major importance
1.• Pequegnat W, Rosser BR, Bowen A, et al.: Conducting internet-based HIV/STD prevention survey research: considerations in design and evaluation. AIDS Behav 2007, 11:505–521.
This recent review of HIV survey research online provides a com-prehensive discussion of the technology, methodology, and recent findings that have implications for feasibility. Specific components of online survey design are tabulated for easy reference.
2. Noar SM, Clark A, Cole C, Lustria MLA: Review of interactive safer sex web sites: practice and potential. Health Commun 2006, 20:233–241.
3.• Chiasson MA, Parsons JT, Tesoriero JM, et al.: HIV behav-ioral research online. J Urban Health 2006, 83:73–85. This review examines interactive HIV prevention websites that are currently online. Websites were identified through a variety of means, ensuring discussion of sites otherwise not mentioned in the literature. 4. Rodgers A, Corbett T, Bramley D, et al.: Do u smoke after
txt? Results of a randomised trial of smoking cessation using mobile phone text messaging. Tob Control 2005, 14:255–261. 5. McFarlane M, Kachur R, Klausner JD, et al.: Internet-based
health promotion and disease control in the 8 cities: successes, barriers, and future plans. Sex Transm Dis 2005, 32:S60–S64. 6. USC Annenberg School: The 2007 Digital Future Report.
2007. Los Angeles, CA. http://www.digitalcenter.org/pages/ site_content.asp?intGlobalId=22.
7. Rainie L: Americans Say Their Cell Phones Aid Them During Emergencies and Fill in Their Free Time. Washington, DC: Pew Internet & American Life Project; 2006.
8.• Liau A, Millet G, Marks G: Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with met. Sex Transm Dis 2006, 33:576–584. This review discusses a comprehensive range of topics related to current HIV online research, including how MSM are using the Internet, outreach and prevention efforts, and methodologic and ethical challenges of online intervention research. Their discus-sions of “risk” and “informed consent” are especially instructive. 9. Rietmeijer CA, Lloyd LV, McLean C: Discussing HIV
serostatus with prospective sex partners: a potential HIV prevention strategy among high-risk men who have sex with men. Sex Transm Dis 2007, 34:215–219.
10. Carballo-Dieguez A, Miner M, Dolezal C, et al.: Sexual negotiation, HIV-status disclosure, and sexual risk behavior among Latino men who use the internet to seek sex with other men. Arch Sex Behav 2006, 35:473–481.
11. Horvath K, Bowen A, Williams M: Virtual and physical venues as contexts for HIV risk among rural men who have sex with men. Health Psychol 2006, 25:237–242. 12. Davis M, Hart G, Bolding G, et al.: E-dating, identity and
HIV prevention: theorising sexualities, risk and network society. Sociol Health Illn 2006, 28:457–478.
13. Fields S, Wharton M, Marrero A, Little A, Pannell K, Morgan J: Internet chat rooms: Connecting with a new generation of young men of color at risk for HIV infection who have sex with other men. J Assoc Nurses AIDS Care 2006, 17:53–60.
14. Gustafson DH, Hawkins RP, Boberg EW, et al.: The use and impact of a computer-based support system for people living with AIDS and HIV infection. Proc Annu Symp Comput Appl Med Care 1994, 604–608.
15. Flatley-Brennan P: Computer network home care demon-stration: a randomized trial in persons living with AIDS. Comput Biol Med 1998, 28:489–508.
16. Bull SS, Lloyd L, Rietmeijer CA, McFarlane M: Recruitment and retention of an online sample for an HIV prevention intervention targeting men who have sex with men: the Smart Sex Quest Project. AIDS Care 2004, 16:931–943.
17. Davidovich U, deWit JB, Stroebe W: The effect of an Internet intervention for promoting safe sex between steady male partners - results and methodological implica-tions of a longitudinal randomized controlled trial online. Presented at the XV International Conference on AIDS. Bangkok, Thailand; July 11–16, 2004.
18. Roberto AJ, Zimmerman RS, Carlyle KE, Abner EL: A computer-based approach to preventing pregnancy, STD, and HIV in rural adolescents. J Health Commun 2007, 12:53–76.
19. Kiene S, Barta WD: A brief individualized computer-deliv-ered sexual risk reduction intervention increases HIV/AIDS prevention behavior. J Adolesc Health 2006, 39:404–410. 20. Bowen AM, Horvath K, Williams M: A randomized control
trial of Internet-delivered HIV prevention targeted rural MSM. Health Educ Res 2007, 22:120–127.
21. Kok G, Harterink P, Vriens P, et al.: The gay cruise: developing a theory- and evidenced-based Internet HIV-pre-vention interHIV-pre-vention. Sex Res Social Policy 2006, 3:52–67. 22. Fox S, Rainie L, Horrigan J, et al.: The Online Healthcare Revolution: How the Web Helps Americans Take Better Care of Themselves. Washington, DC: Pew Internet & American Life Project; 2000.
23. Bolding G, Davis M, Sherr L, et al.: Use of gay Internet sites and views about online health promotion among men who have sex with men. AIDS Care 2004, 16:993–1001. 24. Kalichman S, Cherry C, Cain D, et al.: Internet-based health
information consumer skills intervention for people living with HIV/AIDS. J Consult Clin Psychol 2006, 74:545–554. 25. Levine D, McCright J, Dobkin L, et al.: SEXINFO: a sexual
health text messaging service for San Francisco Youth. Am J Public Health 2007, In press.
26. Puccio JA, Belzer M, Olsen J, et al.: The use of cell phone reminder calls for assisting HIV-infected adolescents and young adults to adhere to highly active antiretroviral therapy: a pilot study. AIDS Patient Care STDS 2006, 20:438–444. 27. National Institutes of Health: CRISP—A Database of
Biomedical Research. http://crisp.cit.nih.gov. Accessed August 2, 2007.
28. Bull S, Phibbs S, Watson S, McFarlane M: What do young adults expect when they go online? Lessons for develop-ment of an STD/HIV and pregnancy prevention website. J Med Syst 2007, 31:149–158.
29. Klausner JD, Wolf W, Fischer-Ponce L, et al.: Tracing a syphi-lis outbreak through cyberspace. JAMA 2000, 284:447–449. 30. Levine D, Scott KC, Ahrens K, et al.: inSPOT.org: A
unique online partner notification system. Presented at the National STD Prevention Conference. Jacksonville, FL; May 8–11, 2006.
31. Rhodes SD, Hergenrather KC, Yee LJ, Ramsey B: Com-paring MSM in the Southeastern United States who participated in an HIV prevention chat room-based outreach intervention and those who did not: how different are the baseline HIV-risk profiles? Health Educ Res 2007, [Epub ahead of print].
32. Taylor H: Those with Internet access continue to grow but at a slower rate. Harris Interactive Poll #8;2003.
33. Temesgen Z, Knappe-Langworthy JE, St. Marie MM, et al.: Comprehensive Health Enhancement Support System (CHESS) for people with HIV infection. AIDS Behav 2006, 10:35–40.
34. Redpath DP, Reynolds GL, Jaffe A, et al.: Internet access and use among homeless and indigent drug users in Long Beach, California. Cyberpsychol Behav 2006, 9:548–551.
35. Centers for Disease Control and Prevention: HIV/AIDS among youth. CDC HIV/AIDS Fact Sheet. http://www. cdc.gov/hiv/resources/factsheets/youth.htm. Accessed August 3, 2007.
36. Lenhart A, Madden M, Hitlin P: Teens and Technol-ogy: Youth are Leading the Transition to a Fully Wired and Mobile Nation. Washington, DC: Pew Internet and American Life Project; 2005.
37. Ybarra M, Suman M: Reasons, assessments, and actions taken: sex and age differences in uses of Internet health information. Health Educ Res 2006, [Epub ahead of print]. 38. National Prevention Information Network: The Elderly.
http://www.cdcnpin.org/scripts/population/elderly.asp. Accessed August 3, 2007.
39. Walters ST, Wright JA, Shegog R: A review of computer and Internet-based interventions for smoking behavior. Addict Behav 2006, 31:264–277.
40. Ybarra M, Eaton WW: Internet-based mental health interventions. Ment Health Serv Res 2005, 7:75–87. 41. Pull CB: Self-help Internet interventions for mental
disorders. Curr Opin Psychiatry 2006, 19:50–53. 42. Levine D, Klausner JD: Lessons learned from tobacco
control: a proposal for public health initiatives to reduce the consequences of high-risk sexual behavior among men who have sex with men and use the Internet. Sex Res Soc Policy 2005, 2:51–58.
43. Gaydos CA, Dwyer K, Barnes M, et al.: Internet-based screening for Chlamydia trachomatis to reach non-clinic populations with mailed self-administered vaginal swabs. Sex Transm Dis 2006, 33:451–457.
44. Royall J, van Schayk I, Bennett M, et al.: Crossing the digital divide: the contribution of information technology to the professional performance of malaria researchers in Africa. Afr Health Sci 2005, 5:246–254.
45. Bagayoko CO, Muller H, Geissbuhler A: Assessment of Internet-based tele-medicine in Africa (the RAFT project). Comput Med Imaging Graph 2006, 30:407–416.
46. Bensley RJ, Mercer N, Brusk JJ, et al.: The eHealth Behavior Management Model: a stage-based approach to behavior change and management. Prev Chronic Dis 2004, 1:A14.
47. Borzekowski DL, Fobil JN, Asante KO: Online access by adolescents in Accra: Ghanaian teens’ use of the internet for health information. Dev Psychol 2006, 42:450–458. 48. Ybarra M, Kiwanuka J, Emenyonu N, Bangsberg D:
Internet use among Ugandan Adolescents: Implications for HIV intervention. PLoS Med 2006, 3:e433.
