PowerON: The use of instant message counseling and the Internet to facilitate HIV/STD education and prevention

Abstract

Objective

In recent years, Internet-based or online counseling has emerged as an effective way to assess psychological disorders and discuss destructive behaviors with individuals or groups of individuals. This study explores the application of online counseling to HIV/STD risk-taking behavior among men who have sex with men (MSM).

Methods

PowerON, an organization that provides sexual health information to MSM exclusively online, used instant message technology to counsel MSM in real time through computer-mediated means. A sample of 279 transcripts of instant message exchanges between PowerON counselors and Gay.com users were recorded and qualitatively analyzed.

Results

Approximately 43% of the instant message sessions discussed information about HIV/STD testing. Risk-taking behaviors were addressed in 39% of the sessions. Information about HIV/STDs and general counseling were given in 23% and 18% of the counseling sessions respectively.

Conclusion

The data showed these instant message sessions to be a potentially feasible forum for HIV/STD counseling.

Practice Implications

Information ordinarily disseminated at health clinics could be successfully distributed through the Internet to MSM.

1. Introduction

Over the past few years researchers and healthcare service providers have recognized the possibilities for using the Internet as a venue for tailored prevention programs for those most at risk for contracting the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) [1–3]. This recognition may be particularly important for men who have sex with men (MSM): this group consistently reports the highest prevalence of HIV and STDs [4]; almost one in two MSM report using the Internet to find sexual partners [5]; and research suggests such men who use the Internet to seek sex may increase their risks for HIV and STDs [6–7]. However, only a handful of attempts have been made to study the Internet as a forum to reach high-risk communities [3, 8–11]. Difficulties associated with measuring behavioral change (attributable to online interventions) have impeded research into online counseling programs for those most at-risk for HIV [12]. It is hard to retain individuals who begin an online program or initiate Internet-based counseling, and therefore tracking psychological and behavioral changes is problematic [9–10]. Despite the lack of rigorous studies assessing the efficacy of online HIV prevention interventions, some community-based organizations, healthcare providers, and researchers remain devoted to bringing Internet-based programs, counseling, and other HIV/STD prevention techniques to MSM online.

While Internet HIV/STD interventions differ from offline prevention programs in their methods of reaching target populations, they still try to communicate the same prevention messages found in more traditional HIV prevention approaches [14]. For example, in Bowen and colleagues’ [8] randomized control of an Internet-delivered program, online participants watched modules of HIV-negative and HIV-positive men talking to each other about risky sex. These modules stimulated awareness of unsafe sex and encouraged condom use. Similarly, Bull and colleagues [9] attempted an Internet-mediated intervention in which MSM were exposed to either didactic messages regarding HIV and STDs or to first-person vignettes in which the characters were demographically matched to participants. In both cases, the Internet-based interventions had limited participant engagement: Participants tended to passively watch or read online content. This model of intervention contrasts with what has been learned from efficacy studies of traditional offline interventions. Active participant engagement, such as through group interactive sessions [15], one-on-one counseling [16], and peer leadership [17] usually results in the most significant decreases in risk behavior.

Current technology can accommodate such active and live participant engagement. With the increased speed of Internet connections and proliferation of the interactive capabilities of websites, computer-mediated interpersonal communication between interventionists and at-risk individuals is available [2]. This online counseling has emerged in other realms as an effective way to assess and treat psychological conditions (e.g., post-traumatic stress), discuss maladaptive or unhealthy behaviors (e.g., sexual fetishes), and provide support for individuals or groups of individuals (e.g., cancer survivors) [18]. Community-based organizations have begun to use this sort of methodology to counsel MSM with respect to risk-taking behavior (e.g., Internet counseling and referrals by Howard Brown Health Center in Chicago, Illinois; the “IMsexED” program by the AIDS Resource Center of Wisconsin in Milwaukee). However, instant message counseling as applied to HIV/STD prevention has appeared only a few times in the literature [19].

1.1. PowerON

The Prevention Organization with Empowerment Resources on the Net, or PowerON, was first designed in 2002 as a website that could meet the health information needs of the MSM community in Seattle, Washington. As part of PowerON, Washington State health education counselors visited various Internet “men-4-men” chatrooms, and when appropriate, referred participants to the website or to specific information on the site. In 2004, Kansas-based Healthy Living Projects, Inc. (HLP) adopted the PowerON model for the Kansas City metropolitan area. Poweronkansascity.org, a PowerON website, was created, and HLP outreach workers went through the PowerON HIV/STD training certification program. This certification program was not particularly different than that required for most offline workers in its content, however it had more of an emphasis on computer and Internet literacy. Counselors were instructed to orient any communication exchanges with the Kansas City MSM towards HIV/STD information dissemination. However, any topics could be introduced by the MSM (e.g., reconciling sexuality, depression) and the content of the instant message sessions had the potential to vary highly. Thus, the effectiveness of using instant message sessions to disseminate HIV/STD information and counsel MSM needed to be explored.

Our specific research questions were: What questions were introduced by MSM via instant messaging and what information was covered during the exchanges? Additionally, how often were questions or information exchanged in the sessions? Was instant messaging a good potential method for HIV/STD information interventions?

2. Methods

From 2005 to 2007, two counselors based in Kansas City created profiles on Gay.com in order to counsel MSM by using instant messaging. There was one main counselor, but another HLP worker trained to counsel occasionally worked online too; we received no complaints from MSM in the chatrooms about either of the counselors. Because no terms of service were broken and we were not advertising through banners or purchasable webspace, we did not need permission from, or need to negotiate with, Gay.com to become members (with the intent to counsel). This particular website was selected because it offered group chatting space for up to 200 individuals to enter into geographic-based rooms (e.g., Kansas City) in order to connect, browse each other's profile, and instant message for one-on-one conversations. Anything posted to the group could be seen by individuals who were virtually connected to that chatroom. PowerON outreach counselors entered this chatroom between eight and ten times a month, usually at peak cruising times (6pm-midnight), under the screen name, “PowerONKansasCity.” They never denied they were counselors but did not broadcast it. They did broadcast messages, which were suggested by the PowerON training certification program, soliciting men with questions to privately contact the outreach worker for more information. Example messages included, “Catch more than a kiss on Valentines Day? Private me for more information on STDs or HIV testing.” This back and forth messaging process, or instant messaging, was visible by only the counselor and the individual Gay.com user, and was therefore confidential. Additionally, because individuals logged on to Gay.com using a personally created screen name, it was nearly impossible for the counselor to know the offline identity of the MSM. After the sessions concluded, the outreach worker stored the conversations in a password-protected, encrypted database online, visible only to the authors of this paper and the counselors. In the 36 months of operation, 279 instant message counseling sessions were conducted.

2.1. Data Coding and Measures

An iterative process was employed whereby we used structural coding to identify large informational segments. Then, we reviewed the transcripts for emergent themes [20]. Conducting additional sessions would not have produced new evidence, and we achieved saturation after four rounds of extensive transcript review by two researchers. According to Internet-based HIV/STD interventions, and data presented by HIV/STD specialists [8–12, 21], HIV prevention information usually covers (but is not limited to) four broad categories: testing, risk-taking behaviors, information regarding HIV/STDs, and general counseling. A coding scheme was structured on these four broad categories and applied to transcripts of the instant message exchanges between counselors and MSM. This coding scheme was further refined through in vitro coding of the transcripts, resulting in 11 codes. Table 1 describes each category, subcategory, the inter-rater reliabilities of each subcategory, and a truncated version of the coding scheme used by the two raters.

Table 1.

Coding scheme for the instant message counseling sessions

Category	Subcategory	κ	Coding scheme examples
Testing
	HIV/STD testing locations	.89	centers at which HIV/STD testing is taking place, addresses, hours of operation, websites listing other HIV/STD testing clinics
	Testing processes	.94	the HIV/STD testing procedures, the costs, sorts of tests available, the wait time, confirmatory testing, testing anonymously vs. confidentially
	Testing referrals	.79	any explicit suggestion(s) that the MSM should get tested given the information they had discussed
Risk-taking behaviors
	Safety of sexual behaviors (aside from oral sex)	.80	the risks between different sorts of sex acts (besides oral sex), getting HIV through kissing, the risks from insertive vs. receptive anal sex, fisting
	Safety of oral sex	.91	the safety of oral sex (and no other sex acts), the integrity of the mouth vs. the genitals, the risk differences between receptive vs. insertive oral sex
	Condom use and barebacking	.91	condom use during sex acts, why condoms should be used, barebacking, internal ejaculation vs. external ejaculation, pulling out, use of the female condom
	Serodiscordant sex	.84	hooking up or sex between an HIV-negative and HIV-positive MSM, the risks associated with such a hook-up
	Other prevention techniques	.72	other prevention techniques besides condom use such as HIV disclosure, circumcisions, post-exposure prophylaxis, avoiding party-n-play or drug use,
HIV/STD Information		.67	HIV/STD symptoms, concomitant STD infections, epidemiology of diseases, treatments and medications, local physicians
Counseling
	Coping with HIV/STDs	.77	positive vs. negative coping, steps after an HIV/STD contraction, strategies to minimize depression and anxiety, stigmatization, HIV/STD hypochondria
	Coping with sexuality	.89	same-sex attraction, heterosexual relationships and sexual satisfaction with women, marriage, coming out, how to meet other MSM, promiscuity

Note: The Kappa statistics reported reflect inter-rater reliabilities before discussing discordant cases.

A total of 279 instant message sessions occurred between counselors and MSM. After the removal of the men’s usernames, two independent behavioral psychologists coded the sessions according to our scheme. These raters coded for the presence of the 11 different topics that could be contained in each of the sessions. Because all of the topics were measured on a binary scale and chance agreement could have been a substantial factor, Cohen’s Kappa (κ) was calculated for each coded topic in order to establish inter-rater reliability. All 11 categories and subcategories were coded with acceptable inter-rater reliability given previously published standards [22]. After this initial reliability was assessed, the raters debated discordant cases in a second round until there was 100% agreement between them. The results reflect that second round, complete agreement.

3. Results

3.1. The Sample

Table 2 describes the demographic composite of MSM engaging in the instant message sessions. The mostly White sample tended to be between 20 and 50 years old. Though this was a largely gay self-identifying group of MSM, Table 2 shows that a little less than 10% reported a bisexual sexual orientation. Three-quarters of the men were HIV-negative.

Table 2.

Distribution of demographic and other variables

		n	% of N
Age (in years)
Under 20		11	4.6
20–29		94	39.0
30–39		79	32.8
40–49		48	19.9
50–59		8	3.3
60 or Older		1	0.4
Race/ethnicity
White		232	94.7
Black		2	0.8
Hispanic		2	0.8
Asian		3	1.2
Multiracial		4	1.6
Other		2	0.8
Location
Kansas		133	52.8
Missouri		97	38.5
All other states		22	8.7
Sexual orientation
Gay		229	90.4
Bisexual		23	9.2
Unsure		1	0.4
HIV serostatus
HIV-negative		143	77.7
HIV-positive		16	8.7
Serounknown		25	13.6

Note. The sample size for each demographic variable did not remain constant due to missing data. MSM did not have to report any of the above before engaging in their session. This data was taken from each MSMs Gay.com profile. The Race/ethnicity demographic sums to 99.9% due to rounding the individual numbers and is not an error.

3.2. Prevalence of the Categories Discussed in the Sessions

Table 3 shows the number, percentages, and rank order of the topics discussed in the counseling sessions. Only 34 of the 279 sessions recorded, or 12.2%, failed to contain any categories or subcategories. These occurred when the MSM instant messaged the counselor with “Hi,” or “Hey there,” and then made no more responses.

Table 3.

Instant message session topic prevalence

Category	Subcategory	n	% of N	Rank
Testing		119	42.7	-
	HIV/STD testing locations	83	29.7	1
	Testing processes	82	29.4	2
	Testing referrals	14	5.0	11
Risk-taking behaviors		108	38.7	-
	Safety of sexual behaviors (aside from oral sex)	44	15.8	5
	Safety of oral sex	49	17.6	4
	Condom use and barebacking	36	12.9	6
	Serodiscordant sex	22	7.9	9
	Other prevention techniques	19	6.8	10
HIV/STD Information		63	22.6	3
Counseling		50	17.9	-
	Coping with HIV/STDs	28	10.0	7
	Coping with sexuality	26	9.3	8

Note. The counts are out of a possible 279 cases. Rank indicates the most to the least discussed subcategory, or alternatively, category in which there were no subcategories (e.g., HIV/STD information). Categories are not mutually exclusive.

3.2.1. Testing

Of the four main categories, testing was the most common theme appearing in two-fifths of the sessions. Three subcategories emerged that were grouped under testing: locations, processes, and referrals. Conversations that discussed testing locations were typically short, pointed, and began with, “Where is the testing happening tonight?” Individuals asked for precise directions to the testing site, or where the nearest testing site was relative to their home. For the second subcategory, testing processes, counselors were often asked to explain or define the testing experience. Individuals tended to ask PowerON counselors questions regarding the logistics of the HIV rapid oral test and its accuracy. Others asked for institutional procedures in the result of a reactive HIV test. With respect to STD testing, the MSM asked about alternatives to the penile swab test, or whether HIV and STD tests could be conducted together.

Testing referrals were present in fewer sessions than were the other two testing subcategories, mainly due to the amount of information needed to assess whether the PowerON counselor should suggest an HIV test. Testing referrals required the men to reveal unsafe behaviors and ask the counselor for a risk assessment. An example of a non-referral case would be a Gay.com user who asked a counselor, “I only jerked off a guy who I later found out was HIV+…do I need to get tested?” However, in some instances, counselors made referrals:

• <CLIENT> are there any signs of aids?

• <CLIENT> like… any

• <poweronkansascity> HIV or AIDS?

• <CLIENT> either

• <CLIENT> i know the main symptoms…

• <poweronkansascity> they are totally seperate

• <poweronkansascity> tell me what is going on

• <CLIENT> but what about an upset stomach

• <poweronkansascity> do you think you were recently exposed to HIV

• <CLIENT> possibly

• <poweronkansascity> tell me about that

• <CLIENT> well, I had unprotected sex…

• <CLIENT> and i found out this guys is a whore….

• <poweronkansascity> as a bottom or a top?

• <poweronkansascity> did he cum in you?

• <CLIENT> no….

• <CLIENT> i was the top

• <poweronkansascity> are you circumsized?

• <CLIENT> yes

• <poweronkansascity> ok you have a lower risk than being a bottom

• <poweronkansascity> my suggestion is get tested 3 months from the last time you had

•   sex

• <CLIENT> mmmk‥

•       (White gay male in his twenties, HIV-negative, Missouri)

As this example shows, the client revealed having unprotected intercourse with a partner he perceived to be promiscuous. The counselor asked additional questions to better understand the degree of risk and ultimately suggested an HIV test. Generally, admissions of unprotected anal intercourse triggered counselors to recommend an HIV test.

3.2.2. Risk-taking behaviors

Results showed that MSM often sought clarification regarding the degrees to which specific behaviors could put them at risk for HIV/STD contraction. Due to emergent themes from the transcripts, we coded discussions of safety of sexual behaviors into two separate categories: sexual behaviors aside from oral sex and oral sex by itself. Typically, counseling sessions regarding the safety of sexual behaviors aside from oral sex discussed, for example, whether insertive anal intercourse (topping) was safer than receptive anal intercourse (bottoming) or whether sex acts such as “watersports” (urinating on another, or being urinated on, during sex) could place an individual at risk for HIV. Gay.com users, on many occasions, asked about HIV infectivity from kissing. For example:

• <CLIENT> Can HIV or other STD be transfered to me via kissing?

• <poweronkansascity> STD's yes

• <poweronkansascity> many are contact infections

• <CLIENT> how about HIV?

• <CLIENT> Should I be worried about kissig someone with HIV?

• <poweronkansascity> no you shouldn't unless he bleeds in to an open sore

• <poweronkansascity> which usually is never ever the case

• <CLIENT> i see

• <CLIENT> Thanks a lot man

• <poweronkansascity> not a problem

•        (White gay male in his twenties, HIV-negative, Kansas)

As shown in Table 3, questions regarding the safety of oral sex were posed as often as questions about other sexual behaviors. In particular, MSM asked, “hey can you get HIV from getting or giving a blowjob?” PowerON counselors typically responded with, “well it is possible, theoretically. But if everyone could get HIV from a blowjob from someone who was HIV +, there would be more HIV cases—however you can get STDs very easily.” The counselors used the instant message session to clarify questions regarding HIV risk from specific behaviors, and often emphasized the uncertainty regarding the relative safety of the behavior. For instance, counselors routinely told the men that with respect to HIV, oral sex was a “gray area that depended on the integrity of the genitalia and mouth.”

Subcategories such as other HIV/STD prevention techniques, condom use and barebacking (i.e., intentionally practicing unsafe anal intercourse), and serodiscordant sex also emerged in the instant message sessions. Topics under other prevention techniques tended to involve discussions of HIV disclosure and post-exposure prophylaxis. In some cases, the Gay.com users wanted to know why male circumcision mattered with respect to HIV contraction. Many of the questions regarding condom use were straightforward—“how safe am I if I use a condom and am the top?,” or “how often do condoms break?” Discussions of serodiscordant sex, however, were more difficult. Counselors were less likely to give definitive answers regarding behaviors:

• <CLIENT> im hiv + and my bf gets tested often

• <CLIENT> if he fucks me, how at risk is he of contracting it? and I was wondering if you knew or knew where I could find out the percentage rate of people who top and get it

• <CLIENT> weve been talking about him barebacking me sometime so we would know what it felt like

• <poweronkansascity> is he circumsized

• <CLIENT> yes

• <CLIENT> and he has a hard time cumming from fucking me

• <CLIENT> he usually has to finish hiself off with a few pulls

• <poweronkansascity> is he pierced?

• <poweronkansascity> well it is not about him cumming it is about the intigrity of his cock

• <poweronkansascity> open sores, abrasions, wounds,

• <poweronkansascity> all that increases the risk

• <CLIENT> hes not peirced, totally clean

• <poweronkansascity> it is a risk but a lower risk

• <CLIENT> alright

• <CLIENT> so we should probably avoid it then

• <poweronkansascity> it has to be your alls choice

• <CLIENT> ok

•       (White gay male in his thirties, HIV-positive, Kansas)

In this exchange, the client was looking for information from the counselor about serodiscordant unprotected anal intercourse in order to make a more informed choice about enacting the behavior. The counselor indicated that there was risk involved, but never instructed the client to abstain from such sex; it was their choice to make. Generally, counselors never discouraged or encouraged serodiscordant relationships or serodiscordant sexual intercourse. They only warned men of the potential risks.

3.2.3. HIV/STD information

Table 3 indicates that in a little more than one-quarter of the counseling sessions, the Gay.com users had questions or concerns regarding the signs, symptoms, and transmission of HIV and STDs. Discussions regarding HIV/STD information tended to focus on medical problems of the men and whether these qualified as STD symptoms:

• <CLIENT> can you get an STD from saliva? I had a jo session or handjob where the guy spit on his hand and then jerked me off

• <poweronkansascity> not from saliva itself

• <CLIENT> cool

• <poweronkansascity> STD's are mostly contact

• <poweronkansascity> but touching the STD directly

• <CLIENT> because i have been having the urge to pee all the time

• <CLIENT> no burning, just the urge

• <poweronkansascity> that could be a UTI, but that can happen if you don't pee enough - you should always piss after you cum… it will clear the urethra

• <CLIENT> cool

• <CLIENT> i have not had any yucky discharge

• <poweronkansascity> you won't always

• <CLIENT> so i don't think it is an STD

• <poweronkansascity> if you are worried my suggestion is to go to make an appointment at KC Free or your doctor

• <CLIENT> i have never had oral or anal sex with a guy

• <poweronkansascity> ok well then it more than likely is something like a UTI, if it continues it might be best to see a doctor

• <CLIENT> thanks for the advice

• <CLIENT> your awesome

•       (White bisexual male in his twenties, HIV-negative, Kansas)

Some MSM merely wanted to know the infectivity of HIV and other STDs within nonsexual contexts—“What is the likelihood of me becoming infected if I ran into some dried blood?” In other counseling sessions, the men requested the signs of acute HIV infection—“hey what r some of the symptoms of intial hiv infection…i have had in the last 3wks not really pimples but maybe 5 or so 2mm size fluid filled like things on my neck….past 2 days diahrea…head ache today.”

Instant message exchanges that focused on HIV/STD information also tended to address questions by HIV-positive Gay.com users regarding the availability of local physicians specializing in infectious disease and information on HIV treatments. The men tended to ask at what point they should begin highly active antiretroviral therapies. With respect to this category, PowerON counselors let the men know they were not physicians themselves. The counselors responded to these questions by quoting from a manual created and updated by public health specialists and physicians specializing in infectious disease to ensure accuracy. Yet, in cases in which MSM were actually describing possible symptoms or requesting health policy decisions that should best be made by an attending physician, consultation with an offline doctor was always recommended.

3.2.4. Counseling

On several occasions, PowerON counselors took on the role of therapist for the MSM. Men were looking for support in two areas: HIV/STDs and sexuality. Whereas HIV/STD information provision guided individuals through the more epidemiological facets of diseases, the HIV/STDs counseling subcategory documented instances in which the MSM sought help regarding depression or anxiety with respect to their disease. Self-reported fear (“I’m scared…”), regret (“I’m sorry that I…”), and indecision (“what should I do?”) were encountered during sessions in which coping with HIV/STDs occurred.

Individuals, who seemed to be HIV-negative and/or STD-free based on the information given online, were also counseled regarding HIV/STDs. This often occurred as cases in which men expressed fear and anxiety regarding the possibility of infection with HIV or another STD. That is, some MSM were convinced that they were HIV-positive, or otherwise infected with some other STD by means of extremely low risk behaviors or behaviors in which STD transmission would be virtually impossible. Men who had never had anal intercourse at all, and men who had not had unprotected sex in years and had tested HIV-negative since asked counselors of the likelihood they had contracted HIV through kissing, hand-genital manipulation, or by touching semen. PowerON counselors, though unable to completely relieve the Gay.com users’ anxiety of the possibility of infection, were able to indicate that, from a medical perspective, they were unlikely to have these diseases.

Finally, some men (about 9%) asked for counseling regarding their sexuality. Men married to women tended to complain of the inability to exit their relationships. Bisexual youths asked PowerON counselors about ways in which they could meet more men interested in same-sex sexual encounters. Alternatively, men identifying as gay were worried about being perceived as too promiscuous in the smallish Kansas City MSM community.

4. Discussion and conclusion

4.1. Discussion

Previous studies cite several effective ways in which the Internet can be used to actively counsel individuals [18, 23–24]; however, such methods are only now being formally applied to HIV/STD counseling. PowerON counselors were available for MSM with sexual health questions, and the results showed that information relevant for HIV/STD prevention could be disseminated through instant messaging. Specifically, the process facilitated the transmission of sexual health information and/or counseling in almost 90% of the sessions (245 out of 279 sessions). Initial concerns about random content being discussed within the sessions were unfounded. Finding no random emergent themes when creating the coding scheme further supported this conclusion. Therefore, instant message counseling has great potential as a forum for administering facts and answering questions that might lead to decreased risk-taking behavior in MSM.

Our research focused on the types of information and the prevalence of HIV/STD related information discussed in instant message counseling sessions with MSM only. Other populations (e.g., young women) susceptible to other problems (e.g., eating disorders) could benefit from this type of counseling, given its accessibility and interactive format. As popular websites such as Myspace.com and Facebook.com increase their technological capacities and interactive features [25], instant message counseling has the potential to be incorporated into such social networking sites. Adolescents who use these sites, who may have questions or concerns about any number of issues (e.g., unintended pregnancy, bullying, drugs), and who may be too embarrassed or frightened of being stigmatized to seek face-to-face counseling, might be an ideal population that could take advantage of instant message counseling. More research is necessary with respect to this potential.

4.2. Conclusion

The Internet offers the potential to expand HIV/STD prevention efforts to new audiences. This study provides evidence for continued support of the Internet as a medium through which tailored programs can be implemented. The data also show its potential as an intermediary between MSM and actual offline healthcare clinicians. For example, using instant message sessions might be helpful for indicating individuals’ risk levels. Use of this process might encourage men with lapses in condom use during anal intercourse to get tested. This process has the potential to conserve resources, to encourage the most at-risk individuals towards testing and treatment (i.e., those cruising for sex online), and to ease some of the burden on the highly stressed and under-funded community-based, non-governmental, and governmental organizations responsible for HIV/STD prevention.

4.2.1. Future Directions

There were limitations to our research that future studies might overcome: testing in only one city, no comparison to offline methods, and no assessment of program efficacy. Future research might repeat our design in differently populated cities and using different MSM websites with chat-capabilities. It also might utilize an offline comparison group to compare the amount and diversity of topics discussed online within the sessions with a methodologically similar, but offline technique. Furthermore, future research could explore if something intrinsic to the online counseling relationship, such as its high degrees of anonymity and convenience, facilitates frank discussions among stigmatized groups. For example, MSM married to women reported during their sessions an inability to go to clinics, centers, or groups for fear of being identified. The instant message sessions provided a way to be counseled and to find information unavailable to them through offline means.

Additionally, further research is needed to determine if the instant message counseling process facilitates actual action. The precise efficacy of the process PowerON used remains unmeasured, given the difficulty of tracking anonymous Internet participants [9–10, 12]. Future studies, such as [26], might create and test different methodologies that address the problems intrinsic to assessing behavioral change through the Internet. As for PowerON, the organization intends to conduct such an outcome evaluation of the Internet counseling methods described in this article by comparing testing rates and condom use between cities that plan on adopting such counseling (i.e., waitlist cities) and those already implementing it. Poweronkansascity.org is no longer operational, however, other cities have begun using PowerON (e.g., Poweronalaska.org). Its long-term goal is to become an evidence-based intervention (EBI) that can be distributed to, and used in, domestic and international communities of MSM.

4.3. Practice Implications

With future data collection and analysis, the instant message counseling used by PowerON will likely be widely recognized by non-governmental and governmental organizations as an important component of next generation, HIV/STD interventions. As it currently stands, there are comparatively few agencies that employ such techniques across the United States and internationally. This is primarily due to the scant research available on their processes and effectiveness. More research must be conducted to facilitate the move from offline interventions to those that might be performed online. The youngest and most computer-literate generation of MSM to-date is currently at risk for HIV and STD infections. Instant message counseling, as employed by PowerON to potentially aid in behavioral change, is positioned to meet the unique needs and requirements of MSM, and to reduce the increased HIV/STD prevalence among this high-risk population.