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Opening a virtual door into a vast real world: Communitybased organizations are reaching out to atri

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Title: Opening a virtual door into a vast real world: Communitybased organizations are reaching out to atri


1
Opening a virtual door into a vast real
worldCommunity-based organizations are reaching
out to at-risk MSM with creative, online programs
  • Alberto Curotto, PhD, Gregory M. Rebchook,
    PhD,Susan M. Kegeles, PhD
  • Center for AIDS Prevention Studies
  • AIDS Research Institute
  • University of California, San Francisco

2
Objectives
  • This studys main objective was to learn from
    community-based organizations how they are using
    the Internet in their HIV-prevention programs for
    MSM.

3
Significance
  • Data from this study can assist CBOs in learning
    from others successes and challenges so that
    better online intervention models can be
    developed to reach at-risk populations more
    effectively, especially those that may have been
    overlooked by traditional programs.
  • Nearly all interviewed voiced the need for more
    research data about these new online prevention
    programs.

4
Im really glad that research is being done
about Internet prevention because there are so
many questions from funding sources and other
CBOs, and theres a really big need for support
among people doing this right now we all need
more research to satisfy all these doubts and
questions and suspicions.
5
Methods
  • We obtained our sample by e-mailing an invitation
    to participate in the study to approximately 550
    agencies that had previously been in contact with
    us, however sporadically, for other projectsin
    some cases, the original recipients independently
    forwarded our invitation to others, creating a
    snowball effect.

6
Methods
  • In the summer of 2003, we were able to identify
    64 organizations nationwide, currently running
    online HIV-prevention programs for MSM.
  • We conducted qualitative interviews by telephone
    with 26 of them, with an eye to providing
    representation from as many different
    geographical areas and communities as possible.

7
Methods
  • Each participant signed a consent form and was
    reimbursed 20 for her/his participation.
  • Each interview lasted approximately 1.5 to 2
    hours.
  • Written notes of each interview were taken in the
    course of the interview itself.
  • The notes were then coded for emerging themes and
    analyzed.

8
Methods
  • This presentation is a brief summary of the
    results of that analysis.
  • These data are not meant to be exhaustive or to
    illustrate all existing online HIV-prevention
    programs since the agencies that we have not
    interviewed may very well be using different
    methods.

9
Background
  • Online venues are becoming one of the preferred
    locales for MSM to socialize with each other and,
    consequently, find sexual partners.
  • It makes it safer to be bold about ones
    preferences and sexual choices and thus find
    like-minded individuals.

10
Background
  • This phenomenon has resulted in the rapid
    development of sexual networks, whose spread and
    accessibility match those of the Internets
    overarching communication structure.
  • Our online program was funded because so many
    MSM who tested positive for syphilis were naming
    the Internet as a venue to find sex partners.

11
Background
  • Internet use is correlated to MSMs number of sex
    partners, potentially increasing their exposure
    to HIV risk.
  • The biggest thing is that their number of
    partners has increased. Most people didnt have
    as many partners before the Internet.

12
Rationale for Internet-based outreach
  • It is overall a cost effective form of outreach.
  • It was also a way to figure out a cost-efficient
    way to reach our population, which is largely
    rural and scattered over a huge area that spans
    across 15 counties.

13
Rationale for Internet-based outreach
  • It facilitates in-depth interventions.
  • It turned out these conversations were much
    more in depth than those taking place by phone
    on a hotline theyre more quality-oriented,
    more like counseling sessions.

14
  • The health departments reaction of surprise
    once they got to sit with me and witness an
    actual online intervention they could not
    believe the depth of the conversations I was
    having with strangers online, much more
    effective than in other outreach environments
    they thought it would be much more superficial
    men, online, feel protected by the anonymity of
    the environment, they feel no angst and fear no
    repercussions, so they open up.

15
Rationale for Internet-based outreach
  • It reaches a broad range of MSM.
  • Some MSM are hard to reach by other prevention
    programs, either because they do not identify
    their sexual behavior with other men openly or
    because they do not or cannot assemble with their
    peers, making it difficult for in-person,
    outreach programs to locate them.

16
Rationale for Internet-based outreach
  • It overcomes barriers faced by in-person
    prevention outreach programs.
  • Some MSM who socialize online would not do so
    in physical venues, for many different reasons.
    Our interviews gave us important clues of how the
    Internet empowers men to overcome such obstacles
    the attendant result being that online prevention
    programs can reach them with unprecedented ease.

17
  • Societal pressure
  • The Internet makes it easy not to identify
    yourself as anything They may go into a
    chatroom saying to themselves that theyre
    looking for a buddy to hang out with but then,
    later, it turns out they want to get off with
    each other There are rooms called str8 guys
    hanging out together or str8 guys in their
    underwear. But how many straight guys, in the
    real world, would hang out in their underwear
    with other guys?

18
  • Physical obstacles
  • It defeats the sense of isolation of MSM in
    rural counties who, thanks to the Internet, can
    find each other without having to travel to a
    city.

19
  • Legal prohibitions
  • Because of their age, young men cannot go to
    bars and most clubs, so the Internet represents
    the only venue where they can meet other MSM.
  • A lot of guys are very young or in the military
    so its very important that they do not get
    recognized as MSM.

20
  • Fear of social repercussions
  • The only thing they really care about is making
    sure their homosexuality stays secret, for fear
    of repercussions in their homophobic
    environment.

21
  • Cultural norms
  • A lot of guys are in relationshipsboth gay and
    straightand dont want their partner to know
    theyre hooking up and, online, they can do so
    anonymously.

22
  • Personal preferences
  • You dont have to dress up, go to a bar, endure
    cigarette smoke if you dont like it, or be in a
    drinking environment if you dont care for it
    you can stay home and avoid any idle chitchat
    it cuts through all the crap and gets you to the
    point which, online, is getting laid.

23
  • Economic reasons
  • Its cheap. At approximately 20 a month, its
    cheaper than any other venue available to them,
    and its convenient, always there, with hook-ups
    available 24/7.

24
  • Homophobia as agent of social control
  • One of the most successful components of our
    program has been the online outreach because
    there is so much homophobia in this area that,
    with in person outreach, it was really
    difficult to even locate MSM.

25
  • Homophobia as agent of social control
  • The majority of the youth in this area are
    from Haiti, the Dominican Republic, and Cubaso
    theyre a minority within a minority. They dont
    have anybody to talk to about their sexuality
    homosexuality is not accepted in their families
    and culture of origin, sex is a taboo in general
    and, even in school, when they get sex ed, they
    are only taught about hetero sex, theyre taught
    how to avoid pregnancy, which really doesnt
    help them, and nothing about sex between men.

26
  • Homophobia as agent of social control
  • The Internet is an easy outlet to meet people
    unlike their straight counterparts, they dont
    have the same opportunities to go on dates or
    even find each other to get a date, which is
    something that straight people take for granted
    at that age. They dont believe they even have a
    chance of winning someone over and the only
    thing they can hope for, or at least so they
    think, is to get some furtive sex or into some
    sexual situation with a man as a way to feel
    less isolated and affirm their identity.

27
Venues for online prevention
  • Outreach in existing online venues
  • AOL and Gay.com chatrooms being the most widely
    used but also on free or pay websites with
    personal ads, known to be used by MSM, such as
    Yahoo! Groups, or ManHunt.net and M4M4Sex.com.

28
Venues for online prevention
  • Interventions with exclusive Web resources
  • Either as Web pages hosted on the parent
    agencys site or as an independent site
    specifically created for the program. In either
    case, they are used to distribute information and
    referrals, to educate, or to assist in building
    behavior-modification skills with a range of
    Web-based tools, including video streams about
    safer-sex negotiation, testimonials by role
    models, online forums, and interactive games.

29
Specific goals of online programs
  • Providing safer-sex education and referrals to
    in-person services
  • Probably the most common form of online
    intervention reported since it is the easiest
    and, possibly, the least expensive to implement.
    It also targets men based exclusively on their
    behavior without the prerequisite expectation
    that they identify with a publicly stigmatized
    sexual minority.

30
Specific goals of online programs
  • Engaging the participants in a dialogue over risk
    reduction
  • To achieve this, some programs are adapting
    various theoretical models to the online
    environment, such as the Stages of Change and the
    Popular Opinion Leader models, or using
    role-modeling stories as recommended by Community
    PROMISE.

31
Specific goals of online programs
  • Recruitment of participants into existing
    in-person prevention programs
  • This is more typical of outreach programs aimed
    at youths. The in-person activities are generally
    modeled on the Mpowerment program and seek to
    support young MSM in coming together as a
    community in which safer-sex norms have been
    established and will be diffused.

32
  • We found that talking to them online was great
    but that, if we could talk to them in person, it
    would have made a bigger difference. So we
    started the Cyber Café, located on our premises,
    to which we invite the guys we contact online
    they can come here and have free Internet access
    (but with a filter for nudie sites, as we call
    them).

33
How MSM are reached online
  • Passive approach
  • The outreach workers limit their active
    interference in the venue to announcing their
    presence and capacity to the chatroom then
    passively wait to be contacted by Instant Message
    or email.
  • Less common is the use of online ads in specific
    online venues known to be frequented by MSM.
    While only few agencies have the resources for
    online advertising, it was frequently mentioned
    as desirable.

34
How MSM are reached online
  • Active approach
  • While not common, because of the implications of
    infringing into someones privacy, this approach
    is adopted by few programs outreach workers may
    intervene in and steer the conversation in a
    chatroom, or even approach someone directly
    when they deem he would benefit from the
    intervention. In rare cases, outreach workers
    may not reveal their role immediately, trying
    first to establish rapport and trust with the
    participant.

35
How MSM are reached online
  • Intermediate or mixed approach
  • Participants are invited to an online venue
    specifically created for the intervention, where
    the focus and tone of all materials are informed
    by prevention models. Initially, participants are
    recruited by direct promotion and then encouraged
    to forward the information (typically as visually
    appealing HTML e-cards) to their friends, so as
    to create a snowball effect. This approach is
    costlier as it requires the development and
    management of exclusive Web-based tools.

36
What are the numbers?
  • Mean contacts per month 87
  • Mean hours online per month 73
  • These numbers do not include website hits or
    clicks on banner ads. Its probably a
    combination of in-depth, one-on-one chats and
    broader discussions in chatrooms.

37
What are the numbers?
  • Nearly half of the agencies did not have any
    precise budget information, usually because they
    do their online outreach as part of a larger
    program.
  • For the 12 programs that reported some meaningful
    financial information, the median yearly budget
    was 17,050 (the range being 4,700 to 200,000).

38
What are the numbers?
Most of the organizations could not provide any
reliable estimate of the ethnic/racial breakdown
of the men they contact online because, in order
to guarantee the participants anonymity, they
avoid collecting specific demographic information
directly.
39
What are the numbers?
  • Some of the programs, however, address the needs
    of specific ethnic/racial groups by targeting
    areas (off- and online) in which certain
    populations are known to live and/or hang out.
    Out of 26 programs,
  • 4 were directed at African-Americans,
  • 2 programs worked specifically with Latinos, and
  • 1 exclusively with East and South-East Asians.

40
Successes of current online programs
  • Numbers and range of MSM reached online.
  • Quality of the interactions.
  • Positive reception from the interventions
    participants as well as most of the online
    community.

41
Successes of current online programs
  • Outreach to HIV-positive MSM and their inclusion
    into prevention programs.

We reach as many HIV-positive guys online as we
do in person. Were very serious about getting
positive guys to receive good treatment and
participate in prevention programs.
42
Theres one guy, for instance, who tested
positive after I persuaded him to get tested,
and now he calls me regularly for support and
trusts me in a way he doesnt feel comfortable
doing with his primary care physician. Its the
whole issue of disclosure and the sense of
protection given by the relative anonymity of
the medium.
43
Successes of current online programs
  • Reducing the spread of STDs among chatroom
    participants.
  • We had a guy test positive for gonorrhea and we
    were able to get 11 guys from the same chatroom
    he used to come in and get tested.

44
Challenges faced by online programs
  • Lack of institutional support and resources.

We had about 8,000 for the development of the
website I was able to afford it only because of
the exceptional generosity of the people who
designed and programmed it ... We had gotten bids
ranging anywhere from 30K to 45K.
45
My brother is a web designer so I asked him to
help a good cause and he donated his time to
create our site. If I had more resources, I
could be reaching out to MSM on different hours,
including at night, when its probably the peak
time for online activity and when there is
probably a very different population,
demographic-wise.
46
Challenges faced by online programs
  • The evaluation component is expensive and,
    especially in an anonymous environment, difficult
    to develop.
  • Staying up to date on new Web sites and
    technologies.

47
Recommendations for success
  • Avoid competing with other online programs for
    the same population. Pool resources, instead.
  • Learn to adapt to the different norms and
    conventions of the specific online venues in
    which you are operating.
  • Be ready to compromise when working with
    commercial Web service providers.

48
Recommendations for success
  • Learn to straddle the subtle line between
    friendly flirting and professionalism so as to
    appeal to the online users of highly sexualized
    environments as a peer.
  • Establish rapport and build trust with the
    chatroom participants.

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