The rates of sexually transmitted disease rates are skyrocketing in the United States. According to the Centers for Disease Control and Prevention, 1.7 million cases of chlamydia were diagnosed in 2017, a 22% increase since 2013. In the same year, 555,608 cases of gonorrhea were diagnosed, a disconcerting 67% increase since 2013.
At 30,644 cases diagnosed in 2017, syphilis numbers are clearly lagging behind chlamydia and gonorrhea. Until recently largely considered a scourge of the past, syphilis is clearly a distant third when compared to chlamydia and gonorrhea. However, the 30,644 cases represent a distressing 76% increase in four short years.
If syphilis is not treated quickly with antibiotics, it can become secondary syphilis, which can include a skin rash, swollen lymph nodes and fever. During the latent, or tertiary stage, there are no signs or symptoms, but the disease can damage internal organs and may eventually lead to death.
Early-stage syphilis can present with a sore or several sores, but these can go unnoticed. However, if treated early with antibiotics, syphilis can easily be cured. Therefore, getting people who have specific risk factors for syphilis tested early is vital to avoid long-term disease, which can lead to organ damage and even death.
In West Virginia, the rise of syphilis rates can be connected to a variety of behaviors and factors depending on the location. These include drug use, prostitution and itinerate workers who seek companionship when they are away from home.
Thanks to field work conducted by a state public health investigator, when Monongalia County Health Department learned of an uptick in syphilis cases in the county seat of Monongalia County, West Virginia, officials were able to learn very specific information about not only the demographics of people who were almost exclusively being affected, but also the behaviors that made syphilis and other STIs more likely.
It turned out that almost all the new cases were in men ages 24 to 28 who have sex with men. Furthermore, many of them participated in anonymous sexual hookups facilitated via dating apps.
Using a dating app, partners could meet up in a public location, have intercourse and never see each other again, let alone know the other person's name.
Previously, when a patient presented with an STI, the health care provider or public health investigator could get a list of names of other partners who might be infected. In today's modern world, this has become more and more difficult.
Dr. Lee B. Smith, MCHD's executive director and the county health officer, decided to seek help from the companies that create the very services being utilized for these hookups.
Remembering a presentation about a decade ago at a global health conference in which public health providers in sub-Saharan Africa negotiated for 2% of cell phone airtime to be devoted to medical messaging, Dr. Smith explored a way to adapt that to the syphilis outbreak in Morgantown.
Grindr, a dating app geared toward the LBGTQ+ community, was the only organization to offer to run a free public service announcement. A representative of Grindr noted we want to do our best to protect the health and safety of our clientele.” A new MCHD web page was created that detailed what syphilis is, the symptoms, how to prevent it and also connecting people to MCHD's free STD testing and treatment.
As previously stated, determining a figure to assign to the target audience is challenging; so too is figuring out the percentage of that population that was actually reached. Also, the only user numbers Grindr will release is it has 4.5 million active daily users worldwide.
Counting the LBGTQ+ population in the United States historically has been a difficult task leading to inexact numbers. Secondly, the affected population is only a small portion of that number because the LBGTQ+ population is being broken down to a small age group, one gender and a very specific set of behaviors.
Even with numbers for Grindr subscribers and free users, it would be very difficult to pinpoint how many of them were in the 50-mile radius of Morgantown during the message's run who may or may not have opened the app.
However, the initial response exceeded expectations of MCHD staff. The message was posted once a week in the first month. In the first two weeks, after the message had appeared twice, Grindr reported that 9,500 unique individuals had seen the message, and that 11.7% of them had clicked through to the newly created web page. According to Google AdWords, Google's advertising system, a 2% click-through-rate (CTR) is considered average. Using that as a gauge, this initial CTR was nearly six times higher than average.
After one month, the frequency of the ad was reduced to once a month for Grindr's paid subscribers and twice a month for free users. The PSA continued to run at that level of frequency for six months, for a total of seven months.
At the end of November, the final numbers provided by Grindr were a total of 66,000 unique users who saw the ad, with an overall CTR of 7.16%, which is still more than three times the average CTR.
According to MCHD's Grindr contact, Grindr has worked with approximately 30 health organizations, which include health departments in the United States, health ministries and other broad-based health organizations all over the world.
However, gauging by the response of public health officials who have learned about the partnership between MCHD and Grindr, this avenue of advertising is not one that is well-known.
MCHD's public information officer created a poster on the project that was presented at the West Virginia Public Health Association's annual conference in September. This conference was attended by NACCHO officials. Soon after, Dr. Smith was asked to write a blog and record a podcast on the project for NACCHO.
MCHD was told that the podcast and blog generated a lot of interest among NACCHO members as well as the media. More exact numbers were not available. The blog and podcast led to Dr. Smith being interviewed by a reporter for Politico, which ran a story detailing this project as well as similar ones done with other dating apps. Buzzfeed also was prepared to do a story but decided not to after being scooped by Politico.
Once the decision to connect with Grindr had been made, creating the project was very easy. Grindr wrote the message based on information provided by MCHD and on their knowledge of their consumer base. The PIO created a new web page on syphilis, making sure that it not only targeted the demographic in question, men who have sex with men, but also pregnant women, who should be tested for syphilis, as well as the general population, who also face risks of getting the disease.
So, while this practice is not evidence-based, it's utilizing a cutting-edge and modern approach to reach specific populations. As technology progresses, it will be interesting to see how public health officials can create similar campaigns that use current trends to reach their intended targets.
When Monongalia County Health Department's executive director and county health officer, Dr. Lee B. Smith learned this year of a local syphilis outbreak, he began looking into the data. In a college town, it is tempting to simply attribute increased rates of STI's to students as the source, but this was not the case in Monongalia County. Analysis showed that the affected population were 24 to 28-year-old males who have sex with men (MSM).
While STIs are not uncommon in this age group, we were informed by disease intervention specialists from the state that this population frequently used dating apps to hook up. Unfortunately, many times this would result in anonymous and unprotected sexual encounters. These behaviors make identification of contacts difficult and we mused that, because dating apps are getting folks into trouble, perhaps there is a way to use them to get out of trouble.
Since these dating apps were a common denominator, how could we use these apps to target individuals participating in such high-risk behavior and provide education, informing them of health risks, testing opportunities and other linkages to care? We agreed that this would be a great way to alert the public and a quantum leap beyond traditional, old-school notifications with brochures and posters.
Therefore, the goal of this project, which was launched in April 2019, was to get the word out that a syphilis outbreak was occurring in our county and in a specific group of people. As mentioned, because we had information that dating apps had helped facilitate these often-anonymous get-togethers leading to this outbreak, operators of dating apps used in our area were contacted and asked to help by publicizing the situation.
Only one of them, Grindr, agreed to run a free message to publicize the situation. This unique project did not require participation of many community stakeholders. A regional public health investigator first alerted MCHD to the syphilis outbreak and also provided additional information that could be useful in informing this population and in combating it as well. Public health nursing, administration and public information staff devised a message that was then given to our colleagues within the state to offer contributions.
When this process was complete, our messaging was simple and concise, stating only that there was an increased number of syphilis cases being diagnosed. For more information, users could click on the screen, which would take interested parties to a newly-created web page (monchd.org/syphilis.html) on the Monongalia County Health Department website (monchd.org) where additional information could be found.
Because of our close working relationship with our disease information specialist, we were able to monitor impressions and follow up with people and talk to some who had seen the message, including one asymptomatic man in another county who decided to get tested. This man learned he was positive but was able to get testing early enough to be totally cured with antibiotics.
The process of launching this media project consisted of contacting dating apps to request placement of our public service announcement. While there were several apps used in our area, most viewed such requests as yet another attempt to garner some free advertisement. Thankfully, Grindr understood what we were attempting to accomplish and informed us that they were interested in making their dating app as safe as possible for their clientele. They worked with our PIO to devise an acceptable public service announcement to be shown on the opening page of their app.
On our side, our health department website was updated to include a new page on syphilis, describing what it is, what its symptoms are, what protection may be used to avoid it and highlighting MCHD's free and anonymous testing and treatment. In addition to men who have sex with men, the page was also geared to pregnant women and the general population.
The speed with which the project was able to be put into motion was fortuitous considering our goal to find people with and at risk for contracting syphilis, to offer diagnostics and treat them early before the illness progressed and also to prevent new cases from happening.
Grindr was very helpful in providing updates in how many people saw the message and clicked through to the new web page. Because Monongalia County Health Department is fortunate enough to be able to employ a public information officer, the work to collaborate with Grindr and create a new web page was included in the PIO's existing duties and so no new expenses were generated. More importantly, Grindr offered publishing of the PSA on their app for free. A similar project could be done by others for the cost of advertising if a free option wasn't available. Otherwise, this was a very cost-effective campaign for MCHD, literally costing nothing.
This also would not necessarily be an overwhelming project for a health department that does not employ a public information officer. Creation of an updated web page took less than a workday; otherwise, work on this project consisted of the executive director, leadership and PIO communicating together and with disease investigator specialists and Grindr representatives.
All in all, return on investment from this campaign, considering lack of additional or outside costs and the low amount of effort, was overwhelming.
Dr. Lee B. Smith, executive director and county health officer of Monongalia County Health Department, did not know what to expect when MCHD partnered with Grindr, a dating app geared to the LBGTQ+ community, to publicize information about the area's syphilis outbreak among men who have sex with men, sometimes using a dating app that facilitates hookups, which can be anonymous.
The entire project was a learning experience, allowing MCHD staff and leadership to witness the power of social media not only in reaching a large number of people at a very low cost, but also being able to target a message to a very specific audience.
This campaign supports the concept that public health interventions need flexibility and to interact proactively with nontraditional partners. MCHD recognizes that traditional methods of posting warning signs on Broad Street water pumps can be updated and brought into the 21st century, utilizing current and emerging technologies and trends to reach at-risk populations and groups. Today's populations are more apt to use social media as a source for information than traditional media releases of print, radio or television.
If we were to repeat this project, we would consider contacting other health departments and clinics in the 50-mile radius to inform them of the project ahead of time and to ask them to provide before-and-after data, both actual clinic numbers and anecdotal reports, to better gauge how many people who saw the message took action and got tested.
Moving forward, we would consider expanding this type of informational campaign using social media into other areas of public health addressing difficult problems. In today's world, public health's mission has expanded into many areas traditionally not included in budgetary support including outbreaks of Hepatitis A, B and C, HIV, substance use disorder, neonatal abstinence syndrome, homelessness and other STIs. While these unfunded mandates continue to expand, we in public health should remain observant for opportunities to address these issues using existing technology while keeping costs as low as possible.
Because this project occurred at virtually no cost, other than existing employees' salaries, this partnership was extremely cost-effective, and it provided obvious benefits to the community. We know the number of Grindr users who saw the message and what percentage of them clicked through to the new web page on syphilis. We also have anecdotal evidence from MCHD's public health nurse and the public health investigator that alerted us to the outbreak that the message motivated some people to get tested for syphilis even if they did not have symptoms of the illness.
Monongalia County Health Department's partnership with Grindr can continue as long as the outbreak does. Grindr for Equality is willing to run free public service announcements geared toward its users, the LBGTQ+ community, as long as there is an outbreak. We have been informed that Grindr will not expand these type messages to other diseases, unless it's an outbreak taking place among its users; or to other parts of the state, unless upticks in syphilis in those areas are also among men who have sex with men or another group within the LBGTQ+ community.
Another way to sustain this project is to find other partners willing to provide free messaging that targets specific groups of people who would be interested in this information. Because of publicity generated and a story done by a national online publication, MCHD has been made aware of other dating apps to contact to see if they would be responsive to providing free messaging.
It's also an idea for us to utilize in the future when the area faces other types of outbreaks or situations that can impact public health, as long as we can find the right partner that can reach our target audience for free or for a low cost.
The objective of Monongalia County Health Department when it teamed up with Grindr to get the word out about a syphilis outbreak was to inform as many people in the at-risk population so they could be tested and, if necessary, treated for syphilis, especially before the illness moves into secondary and tertiary stages that are more difficult to treat.
In addition, preventing the spread of this sexually transmitted disease into other segments of society and reducing the incidence of congenital syphilis were secondary objectives. Thanks to information provided by a regional public health investigators employed by the state of West Virginia, MCHD learned that most of the people involved in the outbreak were men in their 20s who have sex with other men, sometimes using dating apps for hookups that may or may not be anonymous.
Once MCHD was able to find a dating app that agreed to run a free message, steps to get the project up and running were straightforward and turned out to be very easy. MCHD's public information officer worked with Grindr representatives on wording of the message. The PIO also created a new page on our website discussing what syphilis is, what the symptoms are, how it can be avoided and highlighting the health department's free and anonymous testing and treatment.
Once the project went live on April 24, 2019, the only additional work was to keep in touch with the Grindr representative, who was able to report numbers back to the health department on how many users saw the message in the 50-mile radius of Morgantown that it ran, as well as what percentage of those Grindr users clicked through to the web page.
MCHD officials did not know what to expect with this project and were very pleased with the numbers Grindr provided. In the first nine hours of the message's release, about 5,000 Grindr users saw the message and about 12% clicked through to the web page. After seven months, MCHD learned that about 66,000 unique Grindr users saw the message, with an overall click-through-rate of 7.2%.
These numbers exceeded MCHD's expectations. Anecdotally, we also tracked stories from our public health nurses on patients who mentioned that they had seen this messaging as well as the public health disease investigator specialist, who reported, in one instance, that a man from another county, who did not exhibit any syphilis symptoms, was motivated by seeing this message to be tested for syphilis. As it turned out, he tested positive for syphilis, and while this disease was in the early stages of the illness, was successfully treated with antibiotics. In addition, he was made aware of his infectious status, was educated on sexual protection and how to avoid spreading this to others. He also was educated that continuance of high-risk behavior, in terms of continued unprotected sexual encounters, could result in repeat infection. We are hopeful that this newly educated person will echo this message and become a force multiplier in having additional voices within the community giving correct and factual word-of-mouth advise to others.
As stated above, primary data sources included Grindr. Secondary sources were anecdotal evidence from MCHD's public health nurse who treats STIs and the regional public health investigator.
Because MCHD did not have specific goals or expectations on how many people would be reached this way, and also considering the small size of the target audience, the initial 5,000 unique users after nine hours and 66,000 unique users in seven months seemed like strong numbers. Also, the click-through-rate to the new web page, which started out at nearly 12% and eventually leveled out to 7.2%, is higher by six and three times than what Google AdWord considers to be an average click-through rate of 2%.
In analyzing the data to gauge success, MCHD staff is considering the Google AdWord average click-through-rate of 2% as well as the fact that the 50-mile radius around Morgantown that users received this message is largely rural. Furthermore, the target audience of men who have sex with men and use Grindr is a small portion of that population.
Because the first phase of the project ended at the end of November and final statistics were only received in December, MCHD is now analyzing how to go forward with this project and what modifications, if any, will be made. Grindr will allow us to continue the messaging and the plan is to tweak the message so that users who saw the first one will be more inclined to pay attention to it. Also, MCHD is in the process of finding new dating app partners who would agree to help us reach this target audience with free messaging.
We consider utilization of social media to be a sustainable, low-cost mechanism for community involvement that presents a consistent and factual public service announcement.
Consideration is now being given to increasing areas with high incidence throughout the state and region. In addition to expanding our geographical outreach, we are also considering how we may use this existing technology to address other urgent public health issues and are presently focused on how these lessons and activities might be translated into impacting substance use disorders.
MCHD currently coordinates a grant-funded Quick Response Team to address the opioid epidemic in the area, working with law enforcement, first responders and peer recovery coaches. These peer recovery coaches agree that the majority of persons with substance use disorder utilize cellular telephones to contact friends, family and obtain substances. Therefore, use of cellular data would be a convenient means for providing information on harm reduction services. Negotiations with cell phone providers on a national level will require individuals or organizations with national prominence to convince them to give up a percentage of bandwidth for public service announcements.
As we advance this type of communication skill set, we are looking to local schools of public health and epidemiologists to assist in the collection of data with which to construct meaningful analysis of how effective this type of messaging truly is. In the present example, we saw an actual increase of cases diagnosed. We interpret this as an increase in concern, which translates into an increase in testing.
It remains unknown as to when we may see actual diminishment on high-risk behavior and actual reduction in case load. Another unknown is whether there are saturation points resulting in diminishing returns for this type of messaging. In today's society, where there is a continuous feed of materials, both false and factual, important and meaningless, it is not clear as to when we, as consumers of such nonstop input, reach a point where such messaging becomes background noise and ineffectual.
If lessons of the past are here applicable, when public health began to address the human immunodeficiency viral infections (HIV) identified in the early 1980s, the impact was measured in years and required millions in resources to accomplish. Therefore, we believe that using today's technology to leverage public health messaging is an effective tool which should be expanded, but we should remain wary of its overuse and need to create tools to measure its effectiveness.