Brief Internet prevention intervention can have effect

Even 15-minute message matters

New, unpublished research supports the idea that HIV prevention programs on the Internet could have a positive impact on behavioral change.

"We now are finishing up a study with young adults, and we've employed stronger, more rigorous methodology, and we have shown a very moderate effect of the intervention on condom use among adults with the use of a one-time, 15-minute intervention," says Sheana S. Bull, PhD, MPH, an associate professor in the department of family medicine at the Colorado Health Outcomes Program, the University of Colorado, and the Denver Health Sciences Center in Denver, CO.

"It's encouraging because now we know how to do these interventions on line and how to evaluate them appropriately so people will participate," Bull says. "But the effect is so moderate that we would have to ensure exposure and reach many more people than typically are enrolled in a study to have an impact and show a population-level impact."

Investigators are enthusiastic about the intervention's possibilities, she notes.

"We're excited by the possibility that you could get a very brief intervention, expose a lot of people to it, and show population-level effects," Bull says. "Typically, a behavioral-level intervention requires more exposure and greater intensity before you show an effect, and the effect of the intervention wears off very quickly without multiple visits."

Bull's research involving the Internet has included on-line surveys and collecting surveillance data.

"We learned that people will respond to sensitive questions in the Internet environment, and they will come to your site," Bull says. "So that led us to consider ways we could use the Internet and computers for standardized, tailored kinds of HIV prevention interventions."

The initial Internet intervention was designed to increase HIV/STD testing and increase condom use, she says.

"For that study, we weren't able to show any effect, primarily because our methodology was limited," Bull says. "We erred in that study by trying to protect people's anonymity over anything else."

What happened was that researchers had only email addresses for participants, and this resulted in a large loss of participants to follow-up, she explains.

"So we couldn't determine whether the intervention had any effect," Bull says. "Since then, we've made the methodology more vigorous: we make sure people are who they say they are, and we have the necessary follow-up."

With Internet prevention programs there is a trade-off between obtaining the necessary follow-up numbers and obtaining the best available intervention effect.

"We're showing that one 15 to 20 minute intervention can have a notable effect," Bull says. "We can increase the size of the effect by having multiple interventions, but you lose the guarantee that people will come back."

In an Internet environment, an intervention competes with different Web sites and different objectives, so while people might want information about HIV, attracting people who are at highest risk for infection is a challenge, she says.

Researchers are experimenting with strategies like embedding HIV prevention information in social networking sites, so people don't have to navigate away from their favorite site to view the information.

"We're targeting young adults particularly because we want to start doing an intervention for some of the highest risk groups, including African-American youth," Bull says. "If we're going to develop HIV intervention preventions, then we need to go where the [high-risk people] are and put our content on existing sites they visit."

A final evolution in thinking about using the Internet and technology to reach high-risk groups involves the philosophical reality that the Internet may not be the best technology for reaching target audiences.

"When we're trying to reach lots of people, there might be other technologies out there that are more ubiquitous and popular with the highest-risk groups," Bull says. "These include mobile phone technology, so we're starting to look at how we can use text messaging for HIV prevention intervention."

This stage is down the road because of infrastructure limitations, she says.

But a similar strategy has been piloted in studies involving young girls and nutrition work in Colorado, she notes.

"We're exploring how to get a sense of opportune moments to send prevention messages," Bull says. "We're sending HIV prevention messages to people on their phones to increase their awareness."

The key is to find the type of messages that will be the most resilient and resonant for the target audience.

"We'll use social theory to guide those messages," Bull explains. "We may take an opportune time like Friday night and send out a text message about being careful and carrying a condom with them, or a message about decision-making if they're out partying."

Then on Monday morning, the prevention message could be sent to get tested for HIV or STDs if they've done something over the weekend that put them at risk, she says.

"We need to time messages to cue action and also raise their awareness and get them to practice carrying condoms with them," Bull adds.

This intervention project is in its infancy, she says.

And even if these new technology approaches succeed, they shouldn't replace other interventions, Bull says.

"I see it much more as one tool among many interventions," Bull says. "I think we can use the technology to shape norms and attitudes very effectively, and it also may increase access to services so that people can get prevention messages and better understand where to go and how to access services."

Latinos and HIV epidemic

[Editor's note: This is the second in a two-part series that examines the HIV/AIDS epidemic among Latinos in the United States. In this issue, there is the following story about an HIV intervention that spreads HIV education and condoms to Latino men in the rural, Southeastern United States. In the December 2007 issue of AIDS Alert, there were stories about the extent of the problem and about an effective intervention that is aimed at reducing HIV transmission among Latino youths.]