Marcella Herrera, MPA IPN Manager, Disease Intervention Section STD Control Branch California Department of Public Healt

1. Internet Partner NotificationThe California Process: Standardizing Policies and Procedures and Building Capacity for Internet Partner Notification Marcella Herrera, MPA IPN Manager, Disease Intervention Section STD Control Branch California Department of Public Health

2. Overview of IPN in California • History & Background • Process • Policy & Procedures • IPN Training • IPN Implementation • Profiles & Websites • Lessons Learned • IPN Website Partnerships • Next Steps

3. D e l N o r t e S i s k i y o u M o d o c S h a s t a L a s s e n T r i n i t y H u m b o l d t T e h a m a P l u m a s B u t t e M e n d o c i n o S i e r r a G l e n n a a d b a u v e Y N S C o l u s a P l a c e r u L a k e t t e r o t n E l D o r a d o Y o l o e S o n o m a m A l p i n e N a p a a r o r d s c a a m r a e A S v a S o l a n o l a C M a r i n S a n T u o l u m n e C o n t r a J o a q u i n M o n o C o s t a S a n F r a n c i s c o A l a m e d a M a r i p o s a S t a n i s l a u s S a n M a t e o a S a n t a r e M e r c e d d C l a r a a M S a n t a C r u z S a n B F r e s n o e n i t o I n y o T u l a r e M o n t e r e y K i n g s S a n L u i s O b i s p o K e r n S a n B e r n a r d i n o S a n t a B a r b a r a L o s A n g e l e s V e n t u r a R i v e r s i d e O r a n g e I m p e r i a l S a n D i e g o CDPH STD Control Branch California Project Area Disease Intervention Section Other Project Areas in California San Francisco Los Angeles Regional Field Offices Regional Structure Northern CA Region Central CA Region Southern CA Region

4. Venues Used to Meet Sex Partners, Interviewed MSM P&S Syphilis Cases, California 2002-2008 -- provisional 2008 data, last updated 03/26/2009

5. Background of IPN in California • In 2004, CDPH STDCB • Drafted Internet Partner Notification (IPN) Guidelines for DIS • Conducted a two day IPN training • While LHJ were trained to conduct IPN via free email sites, they did not have the infrastructure or resources to conduct IPN via private websites • Assigned three regional IPN DIS to conduct internet partner notification on private websites throughout California • From 2004-2007, CDPH STDCB • Address challenges and barriers • Who? – Qualification and supervision • How? – Internet access and confidentiality

6. Who’s Should Do the IPN? Selection of State IPN DIS • Request for applicants • Describe the knowledge, skills and ability’s that make them a good candidate • Supervisory approval/support • Criteria for selection • Comfortable with the medium • Experienced DIS • Enthusiastic about the internet partner notification process • Culturally sensitive • Displayed competency during the IPN training • IPN Assignment • Regional assignments or located in a high morbidity area • Part of the statewide team for IPN

7. CDPH STD Control Branch California Project Area Disease Intervention Section Regional Field Offices D e l N o r t e S i s k i y o u M o d o c S h a s t a L a s s e n T r i n i t y H u m b o l d t T e h a m a P l u m a s Regionally Assigned Internet Partner Notifiers (Safety Net) Bakersfield Long Beach Orange Sacramento San Diego Other Project Areas in California San Francisco Los Angeles B u t t e M e n d o c i n o S i e r r a G l e n n a a d b a u v e Y N S C o l u s a P l a c e r u L a k e t t e r o t n E l D o r a d o Y o l o e S o n o m a m A l p i n e N a p a a r o r d s c a a m r a e A S v a S o l a n o l a C M a r i n S a n T u o l u m n e C o n t r a J o a q u i n M o n o C o s t a S a n F r a n c i s c o A l a m e d a M a r i p o s a S t a n i s l a u s S a n M a t e o a S a n t a r e M e r c e d d C l a r a a M S a n t a C r u z S a n B F r e s n o e n i t o I n y o T u l a r e M o n t e r e y K i n g s S a n L u i s O b i s p o K e r n Regional Structure S a n B e r n a r d i n o S a n t a B a r b a r a L o s A n g e l e s V e n t u r a Northern CA Region Central CA Region R i v e r s i d e O r a n g e Southern CA Region I m p e r i a l S a n D i e g o

8. How to Gain Access for IPN? Computers? Firewalls? • Access through State network with special permissions for IPN staff • Stand alone laptops with wireless cards and security software • Security screen to ensure privacy of images on the laptops

9. How to Ensure Confidentiality? • Confidentiality and ethics- • All internet outreach activities should be conducted while adhering to the highest standards of STD confidentiality • Internet exchanges/dialogs should be considered privileged and highly confidential • Personal used of these profiles is strictly forbidden and can lead to termination • IPN staff sign an annual internet specific confidentiality agreement • Management oversight of all IPN accounts and communications

10. How to Ensure Confidentiality? • Internet Exchanges and Partner Information- • Screen names, e-mail addresses, HIV status, and/or any personal information are considered to be identifying information and as such are held to the same levels of confidentiality as a patient’s first name and surname and should be locked and secure • Physical descriptions or photos of patients or partners are also deemed confidential • Only share profile names with appropriate affiliated DIS staff on an as need to know basis

11. California’s ProcessRefining Further the IPN Program • In 2007, CDPH STDCB identified need • For more IPN trained staff due to service demands • To expand the number of sites that we were partnering with to address social networks • To enhance internet-based partner messages to improve partner response rate • To standardized procedures for all State and local DIS to conduct email partner notification on free websites • For statewide coordination given more counties began to actively pursue IPN activities

12. California’s ProcessLooking for Best Practices • In 2008, CDPH STDCB • Conducted peer-to-peer consultation to explore • Internet Partner Services Standards • Best Practices with IPN Messaging • Revised CA guidelines through collaboration with Chicago, Washington DC, Massachusetts, New Mexico, Texas, San Francisco and New York • Change the language used to conduct IPN • From: “I’d like to speak with you regarding an urgent health matter.” • To: “I’m emailing you because someone you met recently was diagnosed with a Sexually Transmitted Disease (STD).”

13. CA IPN Goal and Objective • Goal: Facilitate the evaluation and treatment of partners and sexual and social networks • Objective: To have partners contacted via the internet telephone DIS, thus allowing for direct conversation

14. IPN Policy, Procedures & Standards California 2008 • Outlines minimum expectations for IPS (email notification and private sites) • CA IPN standards are in accordance National Coalition of STD Directors (NCSD) and the CDC National Guidelines for Internet-based STD and HIV Prevention • IPN is not meant to replace traditional contact tracing, rather we believe it can augment it • The principles of IPN are the same as traditional partner notification efforts • Confidentiality of index cases or partner(s), must be maintained at all times • At no time is disease specific information exchanged over the internet, e.g. name of specific STD or associated symptoms

15. California IPN Training • Conducted two workshops to increase capacity for IPN • Attended by 105 DIS/CDI/PHIs • Didactic component • Overview for all DIS • Increase understanding of IPN and enhance elicitation of internet partner information • Practicum component • For selected DIS • Hands-on practice for “potential staff” to work with private websites

16. California IPN Training • Objectives/Curriculum • Trends of internet use for meeting sex partners among syphilis cases in California • The rationale for IPN • The context of the sexual networking environment on the internet • Description of the revised California Internet Partner Notification Standards • Protocols on the use of email or handles and viewing sexual network content in the workplace that are appropriate for IPN and is restricted to what is necessary for partner services

17. California IPN Implementation • Oversight for IPN in California • Created an IPN manager position • Centralized Collaboration with Websites • Establishing Health Department Accounts on Private Websites • Creation and Distribution of Policies/Procedures • Training/QA of IPN Staff • Troubleshooting problems • Direct Assistance to LHJs • Coordinate interjurisdictional communication • Conducting Internet Partner Notification on Private Sites • 5 state assigned IPN DIS

18. Profile Requests • Profiles are requested by IPN manager only • Avoid having websites being contacted by various LHJ at different times • What happens if the website refuses? • Explain the Public Health role of disease intervention • Describe the benefits of reducing the rates of STD infected members on the website

19. Reported Use of Internet Sites by Year, Interviewed MSM P&S Syphilis Cases Reporting Internet Use, CA 2002-2008 YTD -- provisional 2008 data, last updated 03/26/2009

20. Reported Use of Internet Sites by Year, Interviewed MSM P&S Syphilis Cases Reporting Internet Use, by Region, California 2002-2007

21. Current IPN Website Partnerships • Adam4adam.com • BarebackRt.com • Facebook.com • Gay.com • Manhunt.net • Myspace.com

22. Lessons Learned • Select culturally sensitive and internet savvy staff • Coordinate to maximize expertise, quality and cost efficiencies • Appropriate supervisory structure and communication around IPN activities • Create working relationships with individual websites • Develop quality assurance measures to keep track of IPN activities • Monitoring of DIS IPN accounts: website name, profile name, passwords, date profile created • Data base development of partner information: profile name, true name if identified, case ID, date initiated

23. Next Steps • Increase peer-to-peer consultation/coordination • Across public health programs, local health jurisdictions and state lines • Coordinated communication with websites • Better evaluation of internet partner notification outcomes and effectiveness • Develop core competencies for staff conducting IPN • Refine current IPN training for internet based delivery • Continue to update current IPN standards according to best practices and lessons learned • Develop additional guidelines for internet outreach and education

24. Acknowledgements • Stephan Adelson, The Adelson Consultant Services Inc. • Angel Carrillo, STD Control Branch, CA Department of Public Health • Christopher Fox, STD Prevention and Control Services, SF Department of Public Health • Jessica Frasure, STD Control Branch, CA Department of Public Health • Marcella Herrera, STD Control Branch, CA Department of Public Health • Terrence Lo, STD Control Branch, CA Department of Public Health • Greg Mehlhaff, STD Control Branch, CA Department of Public Health • Romni Neiman, STD Control Branch, CA Department of Public Health • Rafael Reyes, STD Control Branch, CA Department of Public Health • Frank Strona, STD Prevention and Control Services, SF Department of Public Health • Dan Wohlfeiler, STD Control Branch, CA Department of Public Health

25. Thank You • Marcella Herrera • Email: Marcella.Herrera@cdph.ca.gov • Phone: (562) 570-4086 • Cellular: (562) 355-4244