Malhotra S, Khurshid A, Hendricks K

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Promoting STI Screening Through an Innovative
Online Tool

• Malhotra S, Khurshid A, Hendricks K

Funded by the Centers for Disease Control and
Prevention through the Association of Prevention
Teaching and Research
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Background

• At least 70 million people currently infected1
• 19 million new STIs in the US annually1
• gt50 new STIs occur in 15- to 24-year-olds1

1. Weinstock, et al., Perspect Sex Reprod
Health 200436(1)6-10.
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Estimate of STIs
Sources 1. CDC. 2000. Tracking the Hidden
Epidemics 2. CDC. 2003. HIV/AIDS
Surveillance Report.
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Chlamydia Age- and sex-specific rates United
States, 2004
Source CDC STD Surveillance report 2004
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Gonorrhea Age- and sex-specific rates United
States, 2004
Source CDC STD Surveillance report 2004
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STIs in Texas

• Among the US states, Texas ranks
• 3rd for all stages of syphilis (19/100,000)1
• 5th for congenital syphilis (17.5/100,000)1
• 8th for 1 and 2 syphilis (3.7/100,000)1
• Houston, Dallas, San Antonio, and Austin in top
  20 cities
• 12th for HIV/AIDS (14.7/100,000)2
• 18th for gonorrhea (110.2/100,000)1
• 20th for chlamydia (317.5/100,00)1

• CDC. STD Surveillance Report 2004
• CDC. HIV Surveillance Report 2004.

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Asymptomatic nature of STIs

• gt 90 of people with HPV1
• 90 of those with pharyngeal gonorrhea2
• 70 of females with chlamydia3
• Most acute hepatitis B and C infections4
• HIV infection5

1. Koutsky L. 1997. Am J Med. 2. Hook EW,
III, et al. In Holmes KK, et al, eds. 1999.
Sexually Transmitted Diseases. 3. CDC.
Chlamydia Fact Sheet. 2003. Available at
http//www.cdc.gov/std/chlamydia/chlamydia.pdf.
4. Lemon SM, et al. Viral hepatitis. In
Holmes KK, et al, eds. Sexually Transmitted
Diseases.1999 5. Ambroziak J, et al. Levy
JA.In Holmes KK, et al. Sexually Transmitted
Diseases.1999
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CDC Sexually Transmitted Diseases Treatment
Guidelines

• 84 pages in length
• Diseases characterized by
• Genital ulcer
• Vaginal discharge
• Urethritis and cervicitis

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Problems with physician uptake of STI screening

• National survey to assess syphilis, chlamydia,
  gonorrhea, HIV screening1
• lt1/3 routinely screened for STIs1
• 1/2 of OB/GYNs screened nonpregnant women for
  chlamydia and gonorrhea only 1/5.for syphilis2
• 42 of primary care providers reported annual
  chlamydia screening of sexually-active
  adolescents3

• 1. St Lawrence, et al., Am J Public Health
  200292(11)1784-1788.
• Hogben, et al., Obstet Gynecol 2002100(4)801-807
  .
• McClure JB, et al. J Adol Health 2006 38 (6)
  726-33

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National Guideline Clearinghouse

• Initiative of the Agency for Healthcare Research
  and Quality (AHRQ)
• Currently contains 2071 individual guidelines1
• 1290 superseded
• 707 withdrawn2
• Huge challenge for physicians
• Wizard interfaces could help

• NGC. Guideline Index. 2006. http//www.guidelin
  e.gov/browse/guideline_index.aspx
• NGC. Guideline Summary Archive. 2006.
  http//www.guideline.gov/browse/summaryarchive.asp
  x

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Examples of screening marketed directly to the
public

• Mammograms1,2
• Pap smears 2,3
• Glucose4 and cholesterol5 levels
• Blood pressure checks 6
• Prostate-specific antigen7

• Mayer, et al., Am J Prev Med 19928(1)23-29.
• Paskett, et al., Cancer Epidemiol Biomarkers Prev
  19998(5)453-459.
• Dignan, et al., Health Educ Res
  19916(3)259-266.
• Harwell, et al. J Public Health Manag Pract
  200511(6)537-541.
• Centers for Disease Control and Prevention (CDC),
  MMWR Morb Mortal Wkly Rep 200554(35)865-870.
• Hozawa, et al. J Hypertens 200624(7)1265-1271.
• McFall, Ann Fam Med 20064(5)433-436.
  

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Internet use

• More than 1 billion people online worldwide1
• 170 million users in America2,3
• Over 550 billion Web-connected documents4
• gt2 of websites are health related5

1 Miniwatts Marketing Group, Internet usage
statistics, 2006 http//www.webcitation.org/5Jvoh
qbcu. 2 Madden, Internet penetration, 2006,
http//www.webcitation.org/5Jvpqm9DA. 3
Lenhart, et al., Teens and Technology, 2006,
http//www.webcitation.org/5JvqeTRG4. 4
Lyman, et al., How much information, 2000,
http//www2.sims.berkeley.edu/research/projects/ho
w-much-info/. 5 Powell, et al., J Med
Internet Res 2002, http//www.jmir.org/2002/1/e4/.

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Health and the Internet

• 80 of adult Internet users ( 95 million) have
  searched for health topics online1
• specific disease or medical problem 66
• certain medical treatment or procedure 51
• sexual health information 11
• 136 million Internet users have visited an online
  support group or website for a specific medical
  condition2

• Fox, Health Information Online, 2005.
• Harris Interactive. "Cyberchondriacs," 2006,
  http//www.webcitation.org/5JwxUAaSq.

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Reasons for going online

• Search for health information
• Research a diagnosis or prescription
• Prepare for surgery or find out how to recover
  from one
• Seek and provide support

1. Harris Interactive. "Cyberchondriacs,"
2006, http//www.webcitation.org/5JwxUAaSq.
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American adults seeking health information on the
Internet
Sources Fox, et al., Internet Health Resources,
2003. Fox, Health Information Online, 2005.
Harris Interactive. "Cyberchondriacs," 2005,
http//www.webcitation.org/5JwyuhThU.
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Development of the STD Wizard

• The Wizard program
• Runs in Internet browser
• Uses a "logic file"
• Server end uses C programming language
• Browser end uses HTML and JavaScript
• Server and browser communicate with CGI

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Logic file
C prog language
HTTP/CGI script
HTML
Wizard program
Server end
User end
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• Demonstration
• Evaluation
• Next steps

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STD Screening Guidelines Wizard
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Note to user of STD Wizard Print out this page
and take it to a healthcare provider.
Note to healthcare provider
Guidelines URL State STD divisions URLs
Recommendations . Questions and Responses . Links
Recommendations, based on your responses
Questions asked, responses, and resulting
recommendations
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Note to user of STD Wizard - Print out this page
and take it to a healthcare provider. This
website only shows you what the CDC recommends.
These recommendations are not a substitute for
medical advice. You should consult a doctor for
your healthcare needs.
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Could you
have an STD?
Note to healthcare provider - The recommendations
on this page were generated by an Internet-based
expert system (www.stdwizard.org). It asks
patients simple questions and, based on their
answers, suggests whether they should be tested
for STDs or evaluated for certain conditions. The
recommendations are based on the 2002 Sexually
Transmitted Diseases Treatment Guidelines from
the CDC (Centers for Disease Control and
Prevention).
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• Recommendations, based on your responses
• Seek medical attention (today)
• For lower abdominal pain
• For sexual assault
• Blood test
• HIV screening test
• Cervical swab
• Pap test (Pap smear)
• Cervical swab or urine test
• Chlamydia
• Gonorrhea

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• Questions asked, responses, and resulting
  recommendations
• How old are you, in years? 21-25
• .
• .
• 5) Have you ever had vaginal sex with a male? Yes
• 6) Have you completed a 3-dose (3-shot) series of
  hepatitis B vaccine? No
• .. A) Hepatitis B vaccination

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Evaluation objectives

• To assess the STD Wizards
• Usability
• Impact on self-reported screening uptake in
  college students

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Methods

• Enrolled gt400 college students at 2 universities
• Randomized to control or treatment
• 377 complete pretests, posttests, and 2-month
  follow-up tests
• Online surveys and data collection
• Anonymous subject ID codes used

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Results

• Control intervention groups were similar
• All found the STD Wizard easy to use
• Of those receiving recommendations
• gt20 had already seen a doctor
• gt50 of the remainder planned to see one in the
  near future

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Control and intervention groups had similar
sexual behaviors
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All respondents found the Wizard easy to use
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Action taken after receiving recommendations
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Reasons for not going to the doctor

• Low perceived risk
• Perceived monogamy
• Already tested or treated
• No symptoms
• Confusion with Pap test
• Dont want to know
• Money

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Conclusions of the evaluation

• The STD Wizard is an easy-to-use and effective
  online tool for the promotion of STI screening

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Implications for STI screening

• Free
• Easy access
• Credible source
• Attractive format
• Customized education
• Personalized risk assessment
• Promotion of screening uptake

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Next steps

• Funded and free version
• adding educational facts page
• adding vaccination recommendations
• English version live 12/01/06
• Spanish version live 2/01/07
• update to 2006 recommendations
• Future proprietary versions
• clinic version will capture local data
• low literacy audio version various languages

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Next steps educational facts
While the Wizard figures out your risk

• Check this out
• Even if you have no symptoms, you may still have
  an STD
• 1 out of 4 people with HIV dont know they are
  infected
• Your partner may not tell you if they have an
  STD. They ...may not know!

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• Malhotra S, MBBS, MS - Epidemiologist
• The Medical Institute for Sexual Health
• Khurshid A, MBBS,MPAff - Manager
• The Medical Institute for Sexual Health
• Hendricks K, MD, MPHTM - PI
• The Medical Institute for Sexual Health