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Outreach Guidelines

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Outreach Guidelines Powered By Docstoc
					New York State Department of Health

  Guidelines for Internet Outreach
                                                   Table of Contents
Acknowledgments ........................................................................................................................... 3
Introduction..................................................................................................................................... 3
Background...................................................................................................................................... 4
Rationale.......................................................................................................................................... 5
Deciding to Conduct Internet Outreach .......................................................................................... 5
Internet Outreach Interventions ..................................................................................................... 6
   Promotional ................................................................................................................................. 7
   Research Recruitment ................................................................................................................. 7
Limitations of Internet Outreach..................................................................................................... 7
   Limitations of expertise ............................................................................................................... 7
   Limitations related to venue terms ............................................................................................. 8
Identifying the Target Population ................................................................................................... 8
Community Assessment .................................................................................................................. 8
Internet Outreach Program Core Elements .................................................................................... 9
Goals and Objectives ....................................................................................................................... 9
Cultural Competence/Understanding ........................................................................................... 10
Linguistic Competency................................................................................................................... 11
Client-Centered Counseling ........................................................................................................... 13
Client Engagement ........................................................................................................................ 13
Online Risk Reduction Counseling ................................................................................................. 13
Referrals ........................................................................................................................................ 15
Follow Up....................................................................................................................................... 16
Tracking ......................................................................................................................................... 16
Harm Reduction............................................................................................................................. 16
Emerging Community Health Issues.............................................................................................. 17
Respecting Online Space ............................................................................................................... 18
Accessing Adult Sites ..................................................................................................................... 18
Honesty of Intent........................................................................................................................... 18
Training .......................................................................................................................................... 19
Inappropriate Elements ................................................................................................................. 19


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Discussions and Self-Disclosure ..................................................................................................... 20
Use of Volunteer Peer Educators .................................................................................................. 21
Supervision .................................................................................................................................... 21
Confidentiality and Privacy ............................................................................................................ 21
Safety ............................................................................................................................................. 22
Internet Addiction ......................................................................................................................... 23
Addressing Burnout ....................................................................................................................... 24
Hours of Operation ........................................................................................................................ 25
Location of Outreach ..................................................................................................................... 25
Equipment ..................................................................................................................................... 25
Social, dating, and Sexual Networking Sites defined .................................................................... 26
Profile Development...................................................................................................................... 26
Common Features in Online Venues ............................................................................................. 27
Chat Rooms ................................................................................................................................... 31
Instant Messaging.......................................................................................................................... 33
Private Chat ................................................................................................................................... 33
Email .............................................................................................................................................. 33
Evaluation ...................................................................................................................................... 34
Summary........................................................................................................................................ 35
Resources ...................................................................................................................................... 35




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Acknowledgments
These guidelines have been developed based on the model provided by the National
Coalition of STD Directors‟ (NCSD); “National Guidelines for Internet Outreach” and
contain many examples of forms and tools specifically designed for internet outreach.
This is meant to be a companion document, providing a more detailed and directive guide
to the development of local protocols, training curricula, and other tools that should be
used by agencies contracting with the AIDS Institute.

Additional resources used in the development of the document include: the Montrose
Clinic‟s Project CORE‟s “Cyber Health Educator Handbook”, the Institute for Gay
Men‟s Health‟s “Internet-based Outreach Project Protocol”, Project YEAH‟s “Internet
Outreach Protocol”, the AIDS Council of Northeastern New York Project HOPE‟s;
“Internet Interventions Manual”, as well as experience gleaned from New York City‟s
Internet Interventions Advisory Group, Adelson Consulting and community-based
organizations conducting Internet outreach throughout New York State and the nation.

Introduction
While outreach conducted online is similar to traditional street outreach, some differences
do exist. Regardless of these differences, the same program standards that apply to other
funded activities also apply to internet outreach. This document will provide agencies
with detailed and directive guidance to be used in HIV/STD prevention outreach
conducted through the internet.

Outreach is a planned HIV/AIDS educational intervention that is often the first point of
contact an agency has with an individual. All outreach activities have specific goals,
objectives, and methods of reaching populations at highest risk for HIV. Outreach
activities may include face-to-face encounters conducted with high-risk individuals in
their neighborhoods and other places where they typically congregate. Outreach can also
be conducted using the internet. Internet outreach can be conducted through chat rooms,
instant message, dating websites, email, webcams, live streaming venues, and/or through
a combination of other internet-based tools and approaches. Such approaches can be
used for setting up appointments and/or referrals to services designed to engage high-risk
individuals. Internet outreach includes targeted activities with the intent to get people
tested for HIV; recruit individuals into structured face-to-face HIV-related interventions;
and/or educate individuals about HIV transmission and other HIV-related information.

Internet outreach is defined in the NCSD‟s “National Guidelines for Internet Outreach”,
as “A virtual interaction between an STD/HIV prevention professional, such as an
outreach worker, and a person or persons at risk for STDs or HIV, for the purposes of
providing STD/HIV related: health information and education, referrals and access to
services, recruitment for testing and treatment, and support for reducing risk behaviors.”




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Outreach activities must reach individuals where they are both physically and
behaviorally. Epidemiologic data, combined with anecdotal evidence and research, show
that most New Yorkers use the internet for a variety of purposes including
communication, socialization and arrangement of sexual encounters.

Agencies must keep in mind that as the demographics of disease and other health
disparities change, so will the target population. These changes will also affect the
cultural and linguistic challenges that must be overcome in order to establish and
maintain effective communication.

Tools that can assist in reaching large numbers of individuals and, specifically, those at-
risk, must provide health information, risk reduction materials, prevention messages, and
referral to services. Before engaging in internet outreach, agencies must determine if an
outreach program will be cost effective, feasible for the agency to implement, acceptable
to the population(s) being served and effective in ultimately facilitating behavioral
change.

Since internet outreach has been used extensively with MSM, particular attention is paid
in this guide to that population. When considering internet outreach for other
populations, issues specific to that group should be identified and given attention prior to
starting the outreach efforts.


Background
With the advent of Web 2.0 (a term used to describe the evolution of web-culture
communities and services, such as social-networking sites [SNS], video sharing sites,
wikis, and blogs) online communities have become a significant part of American culture
and a seemingly never-ending resource for obtaining new sex partners. These new venues
also often serve as the primary platform for the social life of many individuals. Venues
traditionally used by gay men and other men who have sex with men (MSM) to meet sex
partners have been augmented, and in some cases replaced, by internet venues as they are
quick and efficient tools for communication used by large numbers of individuals.
(Cybercartography of Popular Internet Sites Used by New York City Men Who Have Sex
with Men Interested In Bareback Sex, Elford, Bolding, Davis, Sheer & Hart, 2004) While
Internet communities continue to evolve, other MSM venues such as clubs, bars, events
and neighborhoods are feeling the effects from the communal shift to the internet.
According to a recent study by the University of Minnesota, the virtual gay community
was identified as larger than the offline physical community. (Rosser Simon B.R., et. al.
“Are gay communities dying or just in transition?”, AIDS CARE, May 05, 2008. - Vol.
20. - pp. 588-595.)

Internet venues include virtual communities such as social networking sites (SNS),
bulletin boards, chat rooms, and niche or dating websites. These venues often provide
real and perceived anonymity that may not be found in traditional physical venues.



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There are advantages to being able to deliver outreach services through the internet.
Such interactions do not require the worker to leave the office. They can vary in duration
and intensity, and can reach a large numbers of people within the virtual spaces provided.
Many educational and testing resources are readily accessible simply by providing links.
In addition, internet outreach can be provided by any well-trained individual 24 hours a
day, seven days a week.

Because the internet is a tool used by the public as a communications device, as a place
for gathering health information, and as a venue for finding sex partners, it can also be an
efficient tool for outreach.

Rationale
Given the adoption of the internet as a significant tool for social interactions, an efficient
means to facilitate pseudo-anonymous sexual encounters and as a resource for health
seeking information, it is useful as a vehicle to conduct intervention methods aimed at
educating Web 2.0 technology users. The need to develop creative online outreach
strategies is thus a necessity.

Although internet outreach is applicable to any population, outreach strategies
specifically tailored to young Men Who Have Sex With Men (MSM) of color are
strongly encouraged because of this population‟s disproportionately high rates of HIV
and STDs. These guidelines specifically refer to interactions with gay men and other
MSM, but the underlying principles and guidance can be applied to all populations,
cultures and communities. As the target population changes, cultural and linguistic
challenges must be addressed by agencies implementing such interventions.

The annual number of new HIV infections among Black and Hispanic men who have sex
with men in New York rose 34 percent between 2001 and 2006, and rose for all men
under 30 who have sex with men by 32 percent. The trend of disproportionately high
rates in these populations has been attributed in large part to the unique cultural issues
MSM of color face regarding their race/ethnicity and sexual orientation. (Correlates of
Risk Patterns and Race/Ethnicity Among HIV-Positive Men Who Have Sex With Men;
Williams, Wyatt, Resell, & Asuan-O‟Brien, 2004) Furthermore, the sharpest growth in
Internet access and use is seen among young people. Blacks and other members of
communities of color of various ages are also accessing the digital information highway
in ever-greater numbers. According to a Pew & Internet National Survey of people 18
and older, 74 percent of whites, 61 percent of African-Americans and 80 percent of
English-speaking Hispanic-Americans report using the Internet. The “digital divide,” a
phrase describing the gap between those that access the Internet and those who do not, is
steadily shrinking.

Deciding to Conduct Internet Outreach
A series of steps should be taken to determine if an agency should embark on an internet
outreach program. Internet outreach can be time consuming and demanding and may


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require additional computer security, training, and supervision. For these reasons and
others, it is imperative that there is agreement among key stakeholders that an internet
outreach effort is needed and desired.

Prior to developing an internet outreach program, the agency must be clear on the amount
of time, resources, and the level of commitment that will be required. Several steps and
considerations will help to determine if an Internet outreach program is right for an
agency:

      Ensure the financial resources to support an outreach program are available
      Engage other community members in your process.
      Hold a series of meetings to discuss the idea and determine your organizational
       readiness.
      Be very clear and honest about the pros and cons of developing such an effort.
      Review the physical space to determine if there is space, hardware, software, and
       an appropriate area within which to conduct internet outreach in private.
      Define your target population, goals, and objectives.
      Determine if the target population is using the internet and is accessible online.
      Review confidentiality agreements, computer use agreements, and other policies
       and practices that may need to be modified to accommodate internet outreach
       activities.
      Determine what other agencies are currently conducting internet outreach and
       ensure that new efforts would not be redundant.
      Ensure that there are documented resources, such as STD/HIV educational
       materials and referral information, that is ready to share over the internet.
      Ensure that staff available for internet outreach understand the target populations,
       are effective communicators through email and instant message, and understand
       confidentiality as it relates to the internet.

Internet Outreach Interventions
The outreach worker‟s role is to promote and encourage healthy behaviors. These health
promotion activities should be in line with the program‟s goals and at minimum:

      Increase knowledge and awareness of HIV/STD.
      Promote safer sex and sexual risk-reduction techniques.
      Promote participation in online individual and group level interventions
       promoting healthy behavior.
      Promote the normalization of the partner services process as conducted by local,
       county or state department of health.
      Provide clients with local resources for HIV/STD testing and treatment services,
       substance abuse programs, including alcohol and mental health services.
      Offer web-based resources that promote health.
      Provide contact information for local health services and other providers.



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This section is intended to support, not replace, all previously established standards and
requirements, such as training requirements, evaluation activities, policies/procedures,
and material review remain in place.

Promotional

Outreach conducted online to promote a specific activity or events is promotional
outreach. Events and other activities that require some type of promotion may be
advertised through a profile, on a website, or within a chat room.

Research Recruitment

Most research recruitment will be conducted through banners or other graphics, printed
or otherwise. Chat sessions, private chats, instant messages, and profile text may be used
for research recruitment but are not recommended for the sole purpose of research
recruitment.

The primary purposes of online outreach are to educate clients about prevention
strategies; encourage and offer testing and counseling; assist clients with personal risk
reduction and offer other services provided by the agency or through referral.

Limitations of Internet Outreach
The National Guidelines for Internet Outreach state, “The most significant portion of
costs involved with internet outreach is related to staff salaries and time”. Other
limitations related to internet outreach do exist, such as limitations of expertise, and
limitations related to venue terms.

Limitations of expertise

At times, outreach workers may be faced with situations that are beyond the scope of
their knowledge. Outreach workers may not be adequately trained in suicide intervention,
rape counseling, pandemic flu or other circumstances that transcend their area of
expertise. Workers must have access to local resources that can address such concerns
and also have direct access to a supervisor who can support them in their daily duties and
provide direction as needed.

If a situation arises that an outreach worker feels unable to handle, the worker must ask
the client for permission to discuss with a supervisor. Outreach workers should never
attempt to answer questions for which they lack sufficient information. Stating “I will get
back with you, if that is ok.” or “Let me refer you to my supervisor (or to x agency that
can provide you with more information)” is better than attempting to answer a question
for which staff do not have the information.




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Limitations related to venue terms

Each venue chosen for online outreach will have its own characteristics as well as its own
terms of services and privacy policies. Most websites do not directly communicate with
or engage public health in a formal way but many will allow the execution of public
health strategies such as partner notification and/or outreach within their sites. For more
information on the limitations of outreach, please see the National Guidelines for Internet
Outreach: Working in Online Venues, Limitations of Internet Outreach. More resources
and details for creating profiles for outreach may be found on the website
www.Internetinterventions.org.

Identifying the Target Population
Agencies must be realistic and very specific when choosing a community in which to
conduct internet outreach. The outreach plan must be based on the precise segment of the
broader community that an agency wishes to reach.

Reviewing the community, understanding the demographics of infection rates, and the
level of health and resources within each population will assist in to identifying the target
population. Several questions can be answered to assist in identifying the target
population, they include:

      What populations are most affected by HIV/STDs and in need of additional
       support?
      What populations are at greatest risk for HIV/STDs?
      Are those at greatest risk using the Internet in your local area?
      What are the general demographics in the local area?
      What high-risk populations are currently underserved online?

Community Assessment
For purposes of internet outreach, community assessment is a process of gathering,
analyzing and reporting information regarding the needs of a particular Internet-based
community.

A community assessment conducted prior to the development of an internet outreach
program should focus on details such as the attitudes, behaviors, language, norms, and
values of the target community similar to a community assessment would be conducted
for a traditional outreach program.

Ideally, a community assessment will be conducted as a collaborative effort, including
providers, other CBOs and individual community members. A complete community
assessment will identify the community‟s weaknesses as well as its strengths.

Information gathered during a community assessment should ascertain:


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      websites that are most popular with the local members of the target population
      needs that are currently unfulfilled
      health concerns that are a priority for the community
      strengths existing within the community that can serve as support for outreach
       efforts

For further information please see the National Guidelines for Internet Outreach;
Community Assessment.

Internet Outreach Program Core Elements
The CDC‟s „HIV Health Education and Risk Reduction Activities Guidelines‟(HERR)
http://www.cdc.gov/hiv/resources/guidelines/herrg/index.htm lists a number of core
elements that should be considered in a health education and risk reduction program and
evaluation activities. These core elements also apply to internet outreach. They are listed
below.

      State realistic, specific, measurable, and attainable program goals and objectives.
      Identify methods and activities to achieve specific goals and objectives.
      Clearly define staff roles, duties, and responsibilities.
      Define the populations to be served by: geographic locale, risk behaviors, gender,
       sexual orientation, age, and race/ethnicity.
      Assure that educational materials and messages are relevant, culturally competent,
       and language/age-appropriate.
      Consult with IT staff to ensure program capability with network and firewalls,
       enable access to online venues, and support confidentiality measures, like
       password-protecting computers.
      Establish and implement policies and procedures that address inappropriate
       computer/Internet use and client interactions.
      Include professional development for all program staff.
      Include a written policy and personnel procedures that address stress and burnout.
      Include written procedures for the referral and tracking of clients to appropriate
       services inside and outside of the agency.
      Provide for collaboration with other local service providers to assure access to
       services for clients.
      Assure confidentiality of persons served.

Goals and Objectives
The primary goal of online outreach is to meet at-risk populations where they are, in this
case virtually, and to provide health information, risk reduction materials and messages,
and referrals to services, thereby promoting and supporting positive behavioral changes.




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Beginning with a logic model (see the National Guidelines for Internet Outreach:
Appendix F) and defining goals are crucial to the overall success of any outreach effort.
Identifying areas of need in the target populations and planning on how to address those
needs will also help to determine intended outcomes. Some internet outreach efforts may
emphasize testing, while others may simply seek to encourage safer sex behavior.

Typical goals and objectives include:

      Increase knowledge and awareness about HIV/AIDS.
      Increase knowledge about safer sex practices.
      Promote sexual risk-reduction techniques and safer-sex options including but not
       limited to, condom use, monogamy, risk reduction strategies, and abstinence.
      Encourage harm reduction techniques for the people who use drugs and alcohol.
      Open lines of communication about all aspect of human sexuality.
      Provide online education support using group-level facilitation strategies to
       enable chat room members to make informed decisions about their overall and
       sexual health.
      Provide online educational support using individual-level risk-reduction
       counseling strategies to offer healthier options to clients who seek one-on-one
       sessions.
      Provide a safe and accepting environment for testing and education.
      Identify and reach the community in locations that are convenient for them.
      Provide referrals for HIV, STD, and hepatitis A, B & C screening.
      Help establish an environment that supports healthy behaviors.

Cultural Competence/Understanding
Culture is an integrated pattern of human behavior which includes, but is not limited to,
thought, communication, languages, beliefs, values, practices, customs, courtesies,
rituals, manners of interacting, roles, relationships and expected behaviors of a racial,
ethnic, religious, social or political group; the ability to transmit the above to succeeding
generations; dynamic in nature. (“Key Definitions”, National Center for Cultural
Competence, 1999, Revised 2002).

Cultural competence refers to an ability to interact effectively with people of different
cultures. Cultural competence comprises four key components:

(1) Awareness of one's own cultural worldview
(2) Attitude towards cultural differences
(3) Knowledge of different cultural practices and worldviews
(4) Cross-cultural skills

In order to be culturally competent, outreach workers must be able to examine their own
biases and prejudices while developing cross-cultural skills. To assist in the advance of




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cultural competency and the understanding of an online community, outreach workers
must receive training specific to this issue.

The competent outreach professional is able to cultivate a non-judgmental attitude of
respect, interest, and inquiry. From this viewpoint, interactions with individuals from
cultures other than one‟s own can be an opportunity for learning and growth.

Having information regarding specific cultures may contribute to understanding but
superficial knowledge may also lead to stereotyping. During outreach, workers must
acknowledge, accept, and respect practices different from their own. While this is an
opportunity for growth and enrichment, it may also cause discomfort. Tension arises
when different belief systems confront one another. Common responses to the unknown
or unfamiliar are anxiety, wariness, and even anger or fear. Outreach workers must learn
to regard clients as unique individuals and develop skills to assess and address the role of
culture in their communication with them.

Developing cultural competence results in an ability to understand, communicate with,
and effectively interact with people across cultures. ("Strategic Diversity & Inclusion
Management" Mercedes Martin & Billy Vaughn, 2007) Cultural competence helps
ensure that programs and individuals have the ability to value diversity and similarities
among all peoples, understand and effectively respond to differences, engage in self-
assessment and make adaptations accordingly.

Online communities will each have their own individual culture and language. Internet
outreach must always be conducted in a competent manner that reflects this
understanding. All staff conducting online outreach should provide the services requested
and never promote inappropriately groups, special events, political ideologies, or
personal biases of any kind including individual viewpoints surrounding sexual
behaviors, safer-sex practices or spiritual beliefs.

For more information regarding Cultural Competence, please see the National Prevention
Information Network (NPIN) website:
http://www.cdcnpin.org/scripts/population/culture.asp

Linguistic Competency
According to the National Center for Cultural Competency, linguistic competence is the
capacity of an organization and its personnel to communicate effectively in a manner that
is easily understood by diverse audiences.
http://www11.georgetown.edu/research/gucchd/nccc/

Effective communication requires that agencies have policies, practices, procedures, and
resources that support linguistic competency.

Resources that can enhance the linguistic competency of an agency include:



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      Bilingual/bicultural or multilingual/multicultural staff
      Cross-cultural communication approaches
      Foreign language interpretation services
      Materials that have been developed and tested for specific cultural, ethnic, and
       linguistic groups

Language is more than just a means of communication. Language influences our culture
and even our thought processes. Culturally based beliefs and traditions can affect the
course and outcome of an outreach session. Both the outreach worker and the clients each
bring their respective linguistic backgrounds to an outreach session. These differences in
language and methods of communication can present barriers to effective dialogue as
well as have the potential to impact the quality of outreach. Outreach workers must
understand the beliefs, attitudes, behaviors, norms, and values of a population as well as
be able to understand and convey information in its language.

It is essential that outreach workers research the culture and communication conventions
of prospective clients. When language skills are unequal, there are ways to improve
communication:

      Avoid using slang and figurative speech.
      Read carefully. If in doubt, ask for confirmation. It is far better to admit
       unfamiliarity with a cultural custom or slang then it is to attempt to pretend to
       understand.
      Respect the client‟s communication style.
      Investigate the culture of your client and your culture by reading, observing, and
       surveying the venue / community used as the vehicle for communication.
      Do not rush. Choose words that will convey the most specific and literal meaning
       intended. Be concise but complete.
      Read before sending. Always consider how the words will be received.

In addition to reflecting language differences within communities and cultures, electronic
communication, such as email and chat, leaves out tone of voice, body-language and
context, which can lead to misunderstandings. Because of this, communication-conducted
through the Internet can be easily misunderstood. Careful consideration of each word and
phrase must be given. Outreach workers must also have a strong grasp of the language
used in online communication. All workers must be trained to understand the nuance of
how online dialogue differs from in-person dialogue. Capital letters, the use of
quotations, emoticons, exclamation points, other punctuation, bullet points, style and
even color can help the sender communicate the meaning of a word or message.

Internet outreach workers must be familiar with the use of tools such as emoticons or
expressions and abbreviations, such as LOL (laugh out loud). For a complete list of
abbreviations used in IM, chat rooms, SMS, text messages, and email please see:
http://www.webopedia.com/quick_ref/textmessageabbreviations.asp




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The outreach worker must spend time on the targeted venue to gather information about
the population, understand the community norms, understand and adopt the language, and
complete a formal community assessment prior to conducting outreach within that
community. In addition, understanding that individuals will join online communities for
a host of reasons, not just for a sexual encounter, and that there are a variety of
motivating factors, such as a desire for intimacy and love, is a key step towards cultural
and linguistic competency. Additionally, communication over the Internet differs from
real time communication in that internet time is much more rapid and a delay in response
could be interpreted as disinterest, dismissal or confusion. Workers must always be aware
of the time it takes to respond to a client and notify them if more time is needed for a
response or if they are busy with another individual.


Client-Centered Counseling
Workers must accept clients “where they are at” at that moment and provide an
environment of empathy, acceptance and unconditional positive regard. Outreach must be
conducted without regard to personal beliefs and biases. All correspondence must be
written with great care and attention, avoiding terms, language and nuance that may
appear harsh, fear inducing, disapproving or critical.


Client Engagement
A Client‟s participation must always be voluntary and with the client‟s consent. In online
outreach, the client must make the initial contact. This contact is considered consent for
chat and the virtual interaction only. When contact is made through email, print and file
the first and all subsequent emails. Several of the on-line venues prohibit the outreach
worker from making initial contact or even going into a chat room and introducing
themselves. Doing so can result in having the agency profile removed from the site.

If at some point the client opts to seek services at the agency, it should follow its standard
practice for documenting enrollment and obtaining any necessary consent.


Online Risk Reduction Counseling
Online risk reduction counseling is similar to traditional risk reduction counseling with
the same goal: to identify risky behaviors and explore ways that clients can reduce their
risk of HIV/STD. This approach acknowledges that everyone has the right to make their
own decisions about their health, and that any reduction in risk is a move in the right
direction.

Some examples of risk reduction strategies include:



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      Using a latex condom during anal sex
      Making sure condoms are easily available during possible sexual encounters
      Using plenty of lube to reduce the chance of tearing and bleeding during anal sex,
       especially if barebacking
      Checking for sores, lesions, or other abnormalities during foreplay
      Getting tested for HIV, syphilis, and other STDs with a sex partner before
       engaging in sexual activity
      Asking a sex partner if they‟ve been tested for HIV, syphilis, and other STDs
       recently
      Not letting someone ejaculate during penetration without a condom
      Not allowing someone to ejaculate in one‟s mouth while performing oral sex on
       them
      Engaging in lower risk activities with anonymous sex partners, such as mutual
       masturbation, oral sex without ejaculation, frottage, etc.
      Not brushing or flossing teeth prior to performing oral sex
      Adhering to antiretroviral medications if HIV-positive to keep viral loads low and
       decrease probability of transmitting HIV to a sex partner

Risk reduction counseling involves two key parts:

           1. The outreach worker asks the client questions and provides support once
              the client has made initial contact.
           2. The client decides what they can realistically do to decrease their chances
              of infection.

The dialogue can be started by taking an informal sexual history through a casual
conversation. Goals of the conversation should include ascertaining:

      Number of sex partners within the last 6 months
      HIV status
      STD history
      Date and place of their last STD/HIV test
      Sexual behaviors they engage in
      History of substance use

Asking open ended questions such as; “What do you think puts you at risk for HIV?” and
“What are you doing to reduce your risk?” will help you to determine how concerned the
client is about HIV/STDs.

Once the worker has a clear picture of the client‟s risk level and their viewpoint, they
then have the opportunity to help the client develop a behavior change plan. Asking;
“What could help you to reduce your chances of infection?” can be a lead-in question and
assist them in creating concrete steps they can take.




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It is important to use a client-centered approach. Listen to the client‟s needs and feelings
while maintaining an open, non-judgmental attitude. Outreach workers should never tell
clients what they should or should not do. They must provide clients with the information
and resources they need to make informed choices.

Referrals
Making the most appropriate referral is a critical component to an outreach program.
While online outreach workers can offer information on HIV/STD transmission, any
necessary additional support, such as behavioral counseling, and person-to-person
support and encouragement, must be provided in person through a referral.

Ideally, a primary goal of outreach activities should include reaching men and moving
them into a phone conversation or face-to-face meeting in an on-site prevention program
or HIV/STD testing location. To make an appropriate referral, the worker must accurately
assess the needs of the contact and determine the area in which the referral is needed.
Such referrals can be for HIV/STD testing, medical care, support services (such as
housing or other basic needs) or simply a location for more information.

By asking key questions, outreach workers can ensure that they are providing the most
appropriate referral possible. To obtain all the details the worker must have the capacity
to “read between the lines” without making assumptions. What the client does not say
may reveal more than what is explicitly communicated. Once the worker has obtained all
the important facts, he may then make an appropriate referral. Reviewing the client‟s
profile should help to reveal details such as location (city, town), age, race and gender.
Key questions can help to reveal other details such as:

      In what setting the client would feel most comfortable for testing or counseling?
      Where is the nearest testing location?
      What the screening should include?
      Were any of the tests positive?
      What treatment was received?
      Has the client has been vaccinated against hepatitis?
      When was the client last screened for HIV and other STDs?
      Does the client have medial support, such as a primary care doctor?
      Does the client have health insurance?
      Does the client use and/or abuse alcohol or other substances?
      Is the client in crisis?

Knowing the HIV status of the client will help to ensure that special needs an HIV
positive person may have can be met by an appropriate provider.

Outreach workers must have an up-to-date resource list that provides detailed information
about what is available locally, regionally, and statewide. The resource list should
include information on: doctors specializing in HIV; physicians who are familiar with


                                                                                         15
gay men‟s health issues, resources for substance abuse, locations for STD/HIV and
hepatitis screening; mental health services; locations that can assist with basic needs such
as housing and financial services; food pantries; soup kitchens; emergency shelters;
suicide hotlines; organizations providing domestic violence intervention services, and
organizations that provide services to victims of rape and assault. Workers must also be
prepared to provide information on social/support groups (including groups that are adult
or youth specific, and groups that focus on a particular issue or aspects of life such as
living with HIV) and information pertaining to HIV/STD prevention. For these types of
referral, times and locations must be included.

Follow Up
To ensure that clients are getting the information and services they need, follow-up is
crucial. Conducting follow-up also helps in evaluation and in demonstrating that internet
outreach is an effective intervention.

Prior to the end of any session, outreach workers must always ask for the client‟s
permission to follow-up via e-mail or IM. Information obtained during follow-up must
be logged as follow-up or an outcome, along with the other data that has been collected
about the client.

Tracking
All activities that are conducted should be captured in a recording system such as the
AIDS Institute Reporting System (AIRS), just as in traditional outreach.

To ascertain whether online projects are successfully connecting clients to services, there
must be a feedback mechanism documenting a connection between the services to which
clients are referred and the outreach activity. Ideally, a relationship will be established
between the providers of services and agencies so that referral tracking may take place
and statistics regarding the number of clients served may be provided in a timely fashion.
If it is not possible to establish agreements with service providers, simply following up
with clients and asking if they followed through on a referral is another way to measure
whether outreach has had an impact on health-seeking behaviors.

The most basic measurement of a program‟s impact is accomplished by simply tracking
the number of people reached through online outreach. Using a spreadsheet, basic
information such as date, time, ethnicity, status, age, topic, and website name can be
collected providing basic information on an agency‟s internet outreach efforts.
Maintaining good logs and documentation will assist in evaluation.

Harm Reduction
Harm reduction is a set of strategies that meets clients where they are, allowing them to
develop practical strategies to reduce the negative consequences of behaviors in their


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lives. The traditional concept of harm reduction has been applied to drug use but can also
be used in regards to sexual behavior.

Harm reduction acknowledges that there are ways of using drugs and engaging in some
sexual behaviors that are less likely to facilitate disease transmission. Illicit drug use and
sex without condoms are real behaviors and they will not go away by ignoring or
condemning them.

A harm reduction approach toward sex without condoms neither condemns nor condones
the behavior, it acknowledges that people are having sex without condoms, and it
encourages the exploration of the behavior in a nonjudgmental manner. Although
consistent condom use remains the most effective way of preventing HIV transmission,
harm reduction strategies may reduce risk. Sexual harm reduction strategies may include:

      Negotiated Safety: Condom use
      Serosorting
      Strategic positioning based on known or presumed HIV status
      Withdrawal prior to ejaculation
      Making decisions about sexual behavior and practices based on the viral load of
       an HIV-positive partner
      Viral Load Calculating
      Non-anal sex, including oral sex, mutual masturbation, frottage, etc.

Outreach workers must be aware of, and communicate the fact that, these strategies have
limitations. When outreach workers provide information on risk reduction strategies, they
must be able to provide in-depth accurate information that discloses the limitations that
are inherent in each strategy.

For more information on Harm Reduction go to the Harm Reduction Coalition
www.harmreduction.org The Harm Reduction Coalition is a national advocacy and
capacity-building organization that promotes the health and dignity of individuals and
communities impacted by drug use. Topics related to HIV, hepatitis C, syringe access,
and safer use can be found on their site.

Emerging Community Health Issues
Community discussion can reveal a great deal about the general health within a particular
community. Where evidence emerges of a heretofore unidentified health concern (such as
pandemic flu) beyond the current program‟s parameters, outreach workers must notify
their supervisor. Some emerging health concerns may have a high level of impact and
override the scope of the current outreach effort. In such cases, the outreach supervisor
should instruct outreach workers on how best to provide community support and
information.




                                                                                            17
Respecting Online Space
Websites and other online venues created as communities that welcome MSM are
generally considered “safe” spaces where men can meet each other and interact without
concern of discrimination based on sexual orientation. It is imperative that outreach
workers take care not to disturb this environment. Most individuals using the internet
and its many social venues view these meeting places as private places.

When joining websites to conduct outreach the worker must first spend time
understanding the website‟s terms of service, privacy policy, rule of conduct, community
and cultural norms by observing the members, conducting member searches, reading
through profiles, joining chat rooms as an observer, reading and understand the website‟s
help or frequently asked questions section (FAQ), and having a clear image of the overall
goal of the website and its members (i.e.; friendship, dating, community building, sexual
encounters, etc.)

The internet is an ideal environment for men who have sex with men and do not identify
as gay. Closeted men in heterosexual marriages, men seeking to explore another side of
their sexuality, transsexual persons, and those that engage in fetishes between consenting
adults, all call for a non-judgmental approach from the outreach worker.

Accessing Adult Sites
It must be clearly stated to potential outreach workers that will most likely encounter
adult materials such as images and text. For more information regarding accessing adult
sites, please see the National Guidelines for Internet Outreach; Accessing Adult Sites,
and section Ethics & Safety

Honesty of Intent
When using chat, instant message, or online communities for outreach activities, it is
imperative that profiles, images, and messages clearly indicate that your intentions are to
provide outreach. At no time should any outreach worker deliberately mislead a client or
community member.

When internet outreach was first conceived, some agencies would use and recommend
tactics such as bait and switch (posting a picture of an attractive man, and engaging
members as that person, then introducing sexual health into the conversation). Experience
has shown that such inauthentic tactics are not productive in the short term as well as
potentially hazardous to internet outreach in the long term. Persons using internet sites
appreciate honesty and websites with health related policies require health care
professionals to be honest in their intentions.

Part of this clarity should be the result of being able to deal with flirtation honestly, so
that intentions are clear and so contacts are not alienated or angered. Workers who are


                                                                                               18
confronted with individuals attempting to arrange a sexual encounter or personal contact
must respond appropriately and distance themselves from the individual by clearly
establishing professional boundaries.

Websites such as Adam4Adam and MANHUNT require that outreach workers remain
passive (logging in and waiting to be contacted by the members).
For more information regarding an appropriate approach, please see the National
Guidelines for Internet Outreach; Approaching Your Audience.

Training
Since online outreach is a specialized activity, not all staff will have the skills required to
provide internet-based HIV/STD prevention. All prospective internet outreach staff and
volunteers must be thoroughly screened to assure appropriateness for participation in the
online outreach project. Whenever possible a peer-to-peer approach, conducing outreach
with staff who are members of the target population, should be adopted.

Agency staff who conduct online outreach must complete general outreach training that
includes topics such as those found within the CDC‟s HIV Health Education and Risk
Reduction Guidelines (HERR).

Training that is specific to working within online communities must be provided and
regularly updated and/or revised to meet the standards that are specific to the agency. On-
going training must also be conducted to ensure that prevention/education efforts remain
relevant to the evolving internet environment.

Outreach workers should be provided with skills-based training in the use of Stage-based
Behavioral Counseling and/or the Stages of Change / Trans-theoretical Model of
behavioral change.

Training must also include topics that cover computer and internet basics. Hands-on
training that includes web surfing, email use, and other internet/computer basics must be
included in all online outreach training.

Once training is complete, one-on-one, post-training supervision must be conducted with
each worker. Workers should actively seek opportunities for professional development.

Inappropriate Elements
Sexual or romantic involvement with a client or patient to whom the employee provides
services should result in disciplinary action, which may include termination. Any
involvement with a client by staff is a potential conflict of interest. Staff must exercise
caution and good judgment when interacting with clients, both while performing their job
duties and in the larger community. If a situation arises where a client or patient makes
advances towards a staff person, full disclosure to a supervisor will ensure that employees
are protected from a conflict of interest.


                                                                                             19
Employees must adhere to the highest standards of ethical conduct. Outreach workers
may not:

      Accept offers for dating, sexual or romantic, from any client at any time.
      Knowingly engage in romantic or sexual activity with a client to whom they are
       providing services.
      Solicit special consideration for friends or partners.
      Use a website profile created for outreach or other official business for personal
       pursuits.
      Misrepresent themselves or mislead clients.
      Pursue illegal activities in any way.
      Attempt to make a medical diagnosis of a person‟s condition or symptoms.
      Encourage sexual activity.
      Judge people who are online seeking sex with others.
      Make decisions for people or tell them what they should and should not do.
      Make statements that could be construed as condemning, discriminatory, or
       judgmental.
      Introduce, arrange dates, or facilitate sexual encounters on behalf of clients with
       other clients, friends, associates, acquaintances, partners, or family members.

To ensure that the intentions of the outreach worker are clear to clients, all profiles and/or
emails, should include statements such as; “My purpose is to provide information,
support and referrals as they related to HIV/STD prevention”.

It is impossible for these guidelines to cover every situation that may arise. Simply
because a potential boundary issue is not explicitly covered in this document does not
mean that a boundary violation is not involved. Outreach staff workers must understand
the scope of potential boundary issues and should seek guidance from a supervisor if they
have concerns about issues that may affect their interactions with clients.

Discussions and Self-Disclosure
Self-disclosure occurs when an outreach worker shares something personal with a client,
either in response to a question or voluntarily.

There are two types of self-disclosure interventions. The „feeling type‟ is used to let a
client know how the outreach worker is feeling about their situation. Outreach workers
may say “I am concerned about what you are saying” or “It worries me that you are not
taking care of yourself.” By sharing these feelings, the outreach worker engages the
contact in a supportive way.

The „fact type‟ of self-disclosure is used to create a connection through experience with
the contact, or to normalize a situation by sharing a similar experience. A client may ask
“Have you ever been tested for HIV/STDs?” or “How old are you?” or “Are you single?”


                                                                                            20
Answering these questions should only be in the interest of the client. The
communication should not focus on the outreach worker‟s needs or experiences.

Before disclosing, the outreach worker should consider these three questions:
    Has the client received enough support to make her/his own decision?
    Is it appropriate to shift focus away from the client?
    Do I self-disclose this with many clients?

Be sure to document, log, and print all of your discussions with clients.




Use of Volunteer Peer Educators
As stated in the National Guidelines for Internet Outreach; Use of Volunteer Peer
Educators, “…the use of volunteer peer educators can sustain intervention efforts in the
community, often influencing community norms, long after the professional service
providers are gone.” For more information regarding the use of peer educators, please
see; the National Guidelines for Internet Outreach and CDC‟s HIV Health Education and
Risk Reduction Guidelines (HERR).

Supervision
 A system of accountability must be established and maintained to ensure that outreach
workers perform as expected, that protocols are followed, and that the workers are
supported in their daily duties. Once an outreach worker is selected, trained, and
conducting outreach online, random monitoring should take place.

All documented chat sessions and email exchanges should be documented and subject to
periodic review through supervision. Consistent supervision will assist in protecting
clients as well as the outreach worker. All new outreach workers should be paired with a
trainer or supervisor until the supervisor and/or trainer has approved the trainee to
conduct online outreach alone.

Program staff should meet on a regular basis to discuss challenges and successes in
conducting Internet outreach and to make modifications to the program accordingly. Prior
to staff meetings, outreach workers should be prepared to discuss any barriers, concerns,
and/or successes, in the Internet outreach meetings with their supervisor.

Internet outreach supervisor will conduct regular checks of documentation, logs and other
forms, to ensure that the information recorded is accurate and completed properly.

Confidentiality and Privacy



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 All agencies are expected to have confidentiality policies in place. These policies must
comprehensively cover Internet-related topics and address the handling and maintaining
of HIV-related confidential information in conformity with state and federal laws and
ensure that strict confidentiality is maintained for all persons who are screened, assessed,
and/or participate in activities.

Screen names, email addresses, HIV status, and any personal or sexual history
information that is obtained are confidential and in some cases may be considered to be
identifying information. All information that could be considered identifying information
must be held to the same level of confidentiality as a client‟s name.

Standard practices for confidentiality of client information must include:

      All employees and volunteers must sign a Confidentiality Agreement.*
      Client information must be restricted to essential personnel only.
      Discussions regarding clients must be kept confidential and conducted in a private
       area.
      Discussions with clients will be conducted in a private area.
      Information concerning a client will be released only with the client‟s informed
       signed, consent, with a subpoena or with a court order as allowed under law.
      Confidential information stored digitally must be password protected.
      Computers used for outreach must be password protected as should all devices on
       which client information is stored.
      Confidential files, including computer disks, will be placed in a locked container,
       such as a file cabinet or desk drawer.
      Client information must never be left unattended or observable to other clients
       and/or employees and volunteers.
      When transporting client information, the information must be contained in an
       envelope and marked confidential.
      Confidential records may only be faxed when no other means of transport is
       available. All identifying information such as name, screen name, email address,
       etc. must be removed from the faxed document and replaced with a unique
       identifier. Once transmitted the receiving agency should be contacted to confirm
       that the transmission was complete and to release the client‟s information
       according to the unique identification number.
      Confidential client information can only be transmitted via the internet if the
       information is digitally signed and encrypted.
      Paper documents containing client information must be shredded before disposal.

* More information on Confidentiality Agreements may be found in the National
Guidelines for Internet Outreach; Appendix A

Safety



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Staff conducting online outreach must maintain personal anonymity. They should
disclose very limited personal information if any and should always be clear as to their
purpose for being online: providing HIV/STD related information and resources. When
conducting online outreach, staff must never use their personal email address, provide
other personal information such as a screen name, phone number, or address for any
purpose.

Staff must have a clear understanding of boundaries and know when to disengage clients
who are acting inappropriately by being sexually aggressive or abusive. Engaging a client
who is indignant, angry, or abusive will generally prove futile and may actually incite
him further. Once a client has been disengaged, website features that inhibit the
disengaged client from contacting the outreach workers, such as „block‟, disconnect, or
„ignore‟, must be employed to protect the worker from further abuse. All conversations
that are conducted with a client who is indignant, angry, or abusive must be printed out
and the online outreach supervisor must be notified immediately. If the agitated behavior
is accompanied by threats of violence and there is reason to believe the client knows the
location of the agency the supervisor should inform management and law enforcement
should be contacted.

Internet Addiction
Internet addiction disorder (IAD) is defined as excessive computer use that interferes
with daily life. There is debate over whether or not to include “Internet Addiction” as a
diagnosis in the DSM-V 2012 edition. Some argue that internet addiction disorder exists
and should be included while others state that it is neither an addiction nor a specific
disorder. Supporters of the disorder often divide IAD into sub-types: excessive viewing
of pornography; overwhelming and excessive gaming; inappropriate involvement in
social networking or blogging, and Internet shopping addiction. For more information on
Internet addiction visit: www.netaddiction.com and
http://www.cybersexualaddiction.com/

Internet addiction has the potential to be an issue both for clients and employees.
Employees should be made aware of the possible symptoms of Internet addiction and
should discuss any possible issues with their supervisor. Internet outreach workers should
sign an “Internet Addiction Agreement” that ensures that workers will inform their
supervisor if they experience symptoms, which include:

      Going online everyday without skipping a day;
      Losing track of time while being online;
      Going out less and less;
      Staying online longer then is intended;
      Neglecting household chores to spend more time online;
      Choosing to be online over being with friends or your partner;
      Frequent complaints from others that you are spending too much time online;
      Sneaking online with a sense of relief when others are not aware of you being
       online;


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      Becoming defensive when others ask about your activity online;
      Feeling depressed when you are not online or able to access the internet;
      Obsessive thinking about the internet;
      Frequently checking your email before doing something else that may be a higher
       priority;
      Accessing the internet while at work and reducing your productivity resulting in
       poor job performance;
      Blocking out disturbing thoughts about your life while thinking about soothing
       thoughts in regards to the internet;
      Losing sleep to stay online;
      Being preoccupied with the internet when off-line; and
      Feeling moody, nervous or depressed when you are off-line and feeling better
       when you are back online.

To avoid over-stimulation and the potential for fostering addictive behavior shifts for
online outreach should be limited to a maximum of three to four hours in length.

Ongoing supervision must also be provided to allow workers an opportunity to talk about
issues that arise during outreach activities as well as any possible effects of prolonged
exposure to the Internet and sexually charged environments.

Addressing Burnout
Burnout is defined as long-term exhaustion and diminished interest. To reduce the
chance of burnout, outreach workers should have concurrent projects that can be worked
on between outreach sessions. Having a variety of tasks in addition to internet outreach
will assist in avoiding mental fatigue and burnout.

While mental fatigue and burnout are potential results of conducting outreach for a long
period without breaks, there is an emotional cost to conducting outreach. All outreach
workers may be subject to burnout and steps must be taken to reduce its risk.

Not every website user is going to be supportive or encouraging of the outreach efforts. It
is important that outreach workers be able to focus their efforts with individuals who are
seeking behavioral change or health related information. Defensively arguing with people
who do not agree with the effort, or repeatedly trying to explain the purpose of internet
outreach is generally not a productive activity.

The result of outreach work may not be fully known as workers may be helping people in
ways that are not expected or reported back. Even when outreach seems to be
unproductive, a worker may be helping a client make a behavioral change simply by
engaging in a conversation or motivating him to seek help elsewhere.

To minimize burnout, workers should not expect too much of individual clients. Clients
may do well one day and return to high-risk behaviors the next. This is often part of the



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process of change. It is important that workers hold themselves responsible for the quality
of their work and do not focus only on the simply the outcomes over which they have no
control.




Hours of Operation
Understanding the general behavior of a target audience will help to determine the best
times to conduct outreach. For example, it has been observed that men who are looking to
arrange sexual encounters but have a primary relationship, such as a wife or partner, will
tend to use sex-seeking websites during time periods when they would not be at home,
such as during the normal work hours of 9am – 5pm. Men logging in after 6pm and
before midnight will generally be gay men, while men logging in after midnight generally
tend to be users who frequent the site on a more consistent basis. Conducting outreach at
various times throughout the day and night and choosing different days to conduct
outreach, will help to familiarize the outreach worker with the population and the
times/days that are best to reach the target population within a specific website.

Being flexible and conducting outreach at different times of day will help to determine
the ideal hours of operation when starting a new program or when joining a new website.

Location of Outreach
Outreach staff should primarily work from their office. Internet outreach is a work
activity and should never be conducted from home. Performing internet outreach,
intervention, referral, and recruitment from a home computer does not offer the same
security measures that are in place when using a computer at an agency.

The tools that support online outreach conducted off-site must address the additional
measures that will be required to supervise work activities, protect client confidentiality,
and ensure that the outreach worker is safe.

Equipment
To conduct internet outreach will require an up-to-date computer with broadband internet
access. It is recommended that the computer to be used for Internet outreach is one that is
not directly connected or networked with other computers in the agency. This is to reduce
the risk of virus infection. Other equipment needs will include a printer, secure storage
for applicable client records and other confidential information.

The agency‟s information technology (IT) departments must be informed and included in
the development of an internet outreach program. They can assist with the development



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of standards, policies, and practices related to equipment such as the computer, firewalls,
antivirus software, and internet access.

Social, dating, and Sexual Networking Sites defined
Social Networking Sites

For purposes of internet outreach, we define a Social Networking Site (SNS) is defined as
a web-based service that allows individuals to construct a public or semi-public profile
within a bounded system that lists other users with whom they share a connection and can
view and traverse this list of connections and the connections made by others within the
system. In other words, a Social Networking Site is different from other online
communities in that members on an SNS may publically collect friends and these friends
then become links to others (one person‟s page can easily leads to another person‟s page).

Dating Websites

Dating Websites are a web-based service that allows individuals, couples and groups to
create a public or semi-public profile with the objective of developing a personal
romantic or sexual relationship. Online dating services generally provide un-moderated
matchmaking over the internet through use of personal computers.

Niche Websites

Some websites refer to all dating websites with adult content created to facilitate sexual
hookups as “Niche Internet Dating Sites”. An example of these sites and ratings can be
found here:
http://www.onlinepersonalswatch.com/news/niche_Internet_dating_rankings.html Adult
oriented MSM websites often fall within this category.

Profile Development
Profiles are created on social websites as a way for members of the site to get to know
each other. A profile is a quick sketch of who the member is. Profiles are geared toward
individuals, not organizations. Careful attention, therefore, must be paid to each request
for information found in each field of a profile.

When it is determined that a profile must be created to conduct outreach, personal
information must be provided. When personal information is requested, program
objectives and agency information must be kept in mind. Ideally, one profile will be
created for each outreach program and shared if there are multiple outreach workers
within an agency.

Some websites with standards for internet outreach will request that outreach workers
provide images of the workers themselves while others will permit an agency logo to be
posted.


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Integration into the community is an important element contributing to the long term
success of internet outreach. Providing honest, detailed personal information about the
outreach worker is one way to ensure that the profile is considered authentic by the
community.

Outreach workers must clearly describe their function and intention so that other
members will understand exactly who they are and what their function is. This minimizes
the likelihood of confusion regarding the outreach worker‟s role.

Profiles created on websites will be subject to review by website administrators. Website
administrators review the profile text and images to ensure that they conform to the
website‟s terms of service.

Websites will require outreach workers to conform to many of the same standards as
general members with some exceptions, which are specific to profiles created for health.

Some elements should not appear in a profile when possible:

      Sexually-oriented attributes, such as penis size, preferred sexual position, and
       activities, etc.
      Personal email addresses, or other contact information
      Links to websites that are not authorized by the supervisor
      Links to pornographic sites
      Discriminatory statements or judgmental statements
      HIV status

All profiles created for internet outreach must be reviewed by the outreach supervisor
prior to being submitted to the website.

Common Features in Online Venues
Many of the features found on community websites are standard features. There are,
however, occasional exceptions. Some of the most common features, in alphabetical
order, are:

Availability / Online Status: On most sex-seeking websites, knowing where and when
other members are available is important. Many men logging on to an MSM website are
seeking men who are online and available now. Most websites will provide an option to
search for and find men who are online. This option is usually obvious. The online results
will generally be based on either the location of a profile or the setting of viewing
location.

Some sites will offer a „stealth‟ or offline option. Selecting this option allows you to be
online but appear offline. In order to engage this option, you may need to explore the
Settings, Account, or Preferences sections of the site.


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When available, a profile created for outreach should also be seen as „Online‟ and „Not
Looking‟.

Blocking and blocked List: To protect their members from harassment and abuse, many
websites offer a feature that allows their members to block other members. When you
block another member, that member will not be able to see your profile or contact you
through the site. Most will provide a list of the members who have been blocked. This list
is called a Blocked list and should be used to block abusive members or members who
persistently make sexual advances.

Email Confirmation / Profile Activation: You will often be required to confirm that
you have created an account on a website through email before the profile will actually
be visible or useable. In this case, a confirmation/activation email will be sent to the
address you used when you signed up. This email will contain your username, password,
and instructions. Keep this email in a safe place as it contains your password.

Email Preferences: Gay.com and adam4adam offer members the use of their proprietary
email systems (email sent and received on the site) or they will forward the email
received on your profile to the external email address you have provided.

Email types and options: There are two basic types of email systems used by
community based websites; closed (or proprietary) and open. In a closed system, all
email is sent, received, and stored on the website itself. An open email system allows
email to be sent from the website to an external email address. Hotmail is an example of
an open system. Some websites (such as adam4adam) use a combination of both open
and proprietary systems, allowing members to „forward‟ mail received on the site to an
external email address.

Friends / Buddies: Many sites offer the option to collect buddies; others offer the option
to collect friends. There are important differences between buddies and friends. You must
use great care when adding any member as a friend or a buddy. In most cases, especially
on Social Networking sites, a „Friend‟ will be publically displayed on your profile or
page. Buddies are generally a private list of other members and cannot be seen or viewed
by other members. A buddy list may be used to track clients but before you add a
member to any list, you must ensure that the list is private.

FAQs: Sites generally offer assistance to members through Frequently Asked Questions
(FAQ) and help files. FAQs are provided to answer questions and serve to explain the
site and its offerings. Before conducting outreach, the worker should review all FAQs
and Help options.

Hide: Some sites offer the option to make your profile invisible or hide. (See the topic
online for additional information)




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Location (Home Location): Your location should be set according to your physical
location. When setting the profile‟s home location, you are telling the website where your
profile will reside.

Location (View Location): Most websites will place your profile in one city (where you
are physically located) and while viewing profiles in another country, state, city, region,
or neighborhood. This will usually be stated using verbiage such as; “view guys from”.

Mail – Email is the primary means of communication between members. When you
receive new mail, there will usually be some type visual and/or audio notification. Some
sites will display a flashing image; some will show a message count such as „1 New
Message‟, other will play a sound when new mail arrives. If a notification for new mail is
not seen, check to see if receiving notification is an option. On most sites, the mail box
will be structured much like a mailbox on Outlook or Lotus notes with an Inbox, a Sent
box, a Saved box, and a Trash box. Workers should be sure to read the options within the
mailbox closely. Some websites will remove read mail after a certain period of time,
while others will have limits on how many messages one may have in a mail box.

Many sites will offer a „Saved folder‟ where you may store messages. Generally, email
that is placed in the saved folder will be kept indefinitely but there are usually limits on
how many messages may be saved. Always move mail that you want to keep to the
„saved‟ mailbox.

In most cases, the „Trash‟ folder will emptied regularly, usually every 24-48 hours.

Most sites will inform you of the status of a message such as if it has been read, replied
to, and will occasionally allow you to un-send a message that has not been read. Never
depend on the site providing you with an option to un-send a message. Before sending
any email to any member for any reason on a website, you must review the email
carefully, and not click Send until you have checked the content, spelling, and grammar.

Member Search, (search by Member Name): Most sites offer the option to search for a
member by Screen Name (also known as Member Name). The feature may be labeled or
may simply appear as an empty text box. The member search is used to find a member
quickly when you know their screen name or a portion of their screen name. Simply enter
the portion of the screen name you know and hit the return key on your keyboard. A list
of names that match the search criteria will be displayed.

My Account: Generally speaking, the account section of a website will offer options for
your screen name, password, external email address and other account-related
information such as address, telephone number and billing information.

Plan-a-trip: When members travel from one location to another, this section is used to
set the date and location of their new destination. Their profile will be moved to the new
location on the date specified and then returned to their home location once the trip is
over.



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Preferences / Settings: In most instances the Preferences and Settings options will give
you access to settings such as the location of your profile, your viewing location, your
email preferences, profile text, profile pictures, instant messaging, and options for other
feature named „tracks‟ or „who has viewed my profile‟. Some websites will offer the
option of making your profile publically viewable, meaning that you will have a unique
link that non-members may access to view your profile.

When offered, it is recommended that you set your Email/Text Message Alerts to “Daily‟
so that you are notified when you have new mail on the website as quickly as possible.

Pro and Party Ads: Sites such as Adam4Adam will allow professionals like masseuses,
photographers, escorts, or those who provide other professional services to create what is
called a “Pro” advertisement. This is similar to Craigslist or a newspaper classified
section. Adam4adam also allows individuals to post announcements for parties though a
feature called “Parties and Events”.

Search: Using the search feature will allow you to search for members in specific
locations, with specific words in their profile (key word search), and by personal
preferences, interests, or physical characteristics. Some sites will allow you to save a
search for quick access at a later date. It is recommended that once you have joined a
particular website you practice using the search feature of the site.

Site Tour: In addition to offering FAQs and Help files for assistance, some sites will
have promotional site tours or video guides to the site. Any available marketing tools
should be used to investigate the site and its features.

Smile/ Wink: Sending smiles and winks are forms of introduction. One member will
send a „smile‟ or “wink” to another member as a way to introduce themselves. As an
outreach worker, this option is not needed and should never be used.

Terms of Service and Privacy Policy: When joining any website you are required to
agree to the terms of service (TOS). All TOS are legally binding agreements outlining the
site's operating policies. A privacy policy is a legal document that discloses how a
website retains, processes, discloses, and purges customer data.

Tracks / Recent Visitors / Who has viewed: Some websites will list the members that
have viewed your profile. This means that the profiles that you have viewed will be listed
and known by other members. In most instances, you will be given the option to turn this
feature off. On sites that offer this as a feature, you must turn off this feature to protect
the privacy of your clients, before viewing any profiles. The option to turn off this feature
will most likely be found in the Settings or Preferences section of a site.

Unlock: Sites will often provide the option to lock and unlock images that have been
posted on your profile. Outreach workers should not post private images and should




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ignore members who unlock their pictures for them as any response of unlocked images
may be interpreted as a sexual interest or pursuit.


Chat Rooms
A chat room is a virtual room where people can communicate in real time while on the
Internet. Users type their messages with a keyboard and the entered text appears on the
monitor, along with the text of the other chat room visitors. Most chat rooms do not
require users to have special software. Those that do, usually allow users to download
and install the software directly. Many of the chat rooms requiring specific software use a
programming platform called “Java” which is free and available from the website
www.java.com.

Most chat rooms will require the user to register for the room of their choice or for the
website where the rooms reside. Registration can be as simple as creating a user name
and password while providing an email address. Alternatively, it may entail completing a
membership with the hosting website or creating a user profile for the chat room.

Typically, separate chat rooms are created within the chat client by geographical location
or a specific topic or personal interest. Chat rooms can be found on virtually any aspect
of human endeavor or interest. Often, chat rooms are used as a point of contact,
facilitating sexual encounters.

All chat rooms will provide a list of users who are online and logged in to the chat room.
This list will generally be sorted according to the user‟s login time or screen name.

Messages posted in a chat room are in real-time, meaning that once entered they are
immediately visible to all users in the room. Chat rooms are considered public spaces as
all chat room users can see each other‟s messages.

Users can enter a chat room and read messages without sending any. This is a practice is
known as „lurking‟.

When using a chat room for outreach, the outreach worker should observe the room until
a clear understanding of the language styles, culture, and norms is established. Once an
outreach worker has assessed the room and understands the general culture and norms of
the room, they are ready to engage the group. Outreach workers must introduce
themselves and the program by name, clearly stating their purpose for being in the chat
room while encouraging those in the chat room to view their outreach profile (if
applicable) and inviting other chatters to contact them privately. The goal of using a chat
room for outreach is to engage users in a one-on-one conversation through the use of
Instant Message or private chat. Outreach workers should never initiate unsolicited
contact with an individual member within the chat room, through private chat, or through
Instant Message.



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Some men will want to chat casually with you. A well-trained outreach worker can use
this „small talk‟ to establish a rapport with the chatter and the room (if in a public chat
room). This may also assist in integrating the outreach worker into the community. Some
men feel more comfortable speaking about intimate topics only after they have engaged
the outreach worker in small talk. Outreach, however, should not be too „chatty‟, nor
should the worker attempt to provide therapy. Outreach workers must be able to turn
conversations into HIV/STD education or health promotion. If the worker is unsuccessful
in turning the conversation into a conversation about prevention or health promotion after
several attempts, the conversation should be concluded by the worker politely asking to
be excused while inviting the individual to contact them in the future should they have
any questions regarding their health.

In general, when chatting with clients in a chat room or through IM, remember;

      Never type in all CAPITAL letters; this is considered a form of shouting.
      Encourage the client to discuss his sexual behavior and reveal any risky behavior.
      Do not make assumptions about the client or his behavior.
      Ask open-ended questions to gain more information.
      Do not give advice or tell the client what he should or should not do.
      Speak in the third person, for example, “Most people consider unprotected oral
       sex to be safer sex…”
      Answer questions with facts. For example, “We know that unprotected oral sex
       puts men at risk for STDs like syphilis or gonorrhea.”
      Keep responses on an impersonal level and do not to make statements that are
       your personal opinion.
      Should the need arise to step away while engaged in a chat session the worker
       should tell the client that he will „be right back‟ (BRB).
      Outreach workers must be courteous and respectful at all times.
      Instant messages should never be ignored unless they are potentially abusive.
      If someone tries to engage you sexually, respond by explaining your role as an
       outreach worker and ask him if he would like information regarding safer sex or if
       he has any questions. If he persists in engaging you sexually, stop responding to
       messages. If he becomes abusive or continues to contact you once you have
       stopped responding, it may be necessary to block the person.
      Never make dates to meet clients from a chat room, no matter how innocuous the
       encounter may seem.
      Do not provide men with any work-related, personal screen names or email
       accounts. This will reduce the possibility for a conflict of interest.
      Do not accept or open and files, including images, which may be sent through a
       chat room or instant message. Files or images may contain viruses or graphic
       images of the person and should not be accepted.

For more information on chat and for chat samples please see; the National Guidelines
for Internet Outreach; Chat Rooms.




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Instant Messaging
As stated in the National Guidelines for Internet Outreach; “Instant messaging (IM) is a
real-time interaction that sometimes requires software to be downloaded and/or a profile
to be created. Unlike the group atmosphere of a public chat room, IM provides an
environment where internet outreach workers can have a one-on-one conversation with
an individual. These conversations cannot be viewed by others.”

For IM to function in real-time, both users must be online and available (willing to accept
an instant message) at the same time. Attempts to send an IM to someone that is not
online or available will sometimes result in the message being held until they are online
and/or available but this will be dependent on the type of instant message service that is
used and the individual‟s settings within the IM program or venue itself.

Private Chat
Private chat is generally available through a chat room or individual website such as
MANHUNT.net.

Websites will often offer private chat (also called Instant Message) within their own
website. This type of private chat is usually available through a link located on a
member‟s profile. When the link is clicked, an invitation to chat is sent to the member. If
accepted, a chat session is begun. An outreach worker should never initiate a private chat
session without receiving prior authorization from the member.

Invitations to private chat sessions should always be accepted when initiated by a
member.

Email
Email may be used as a form of outreach as it is a method of communicating with a
client. Conversations conducted through email have limitations and email should be used
as a way to engage the client into deeper conversation through other tools, such as Instant
Message, telephone, or, ideally, face-to-face conversation.

The email address for outreach workers should be made public and advertised in profiles
and wherever else possible.

All email must be responded to within 24 hours. If an email that has been received
contains slanderous language, inappropriate elements, complaints or a grievance it must
be forwarded to the outreach supervisor.

Email responses must be kept brief and should contain the exact information the client
has requested, including information on the source of the information (according to Dr.
Smith” or “the CDC recommends”) and links to more information when available.


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Outreach workers are to never save or use any email address that has been provided by a
client for their personal use.

Email sent from the outreach worker must be sent from an official agency account, not a
free internet-based account like Hotmail. Sending email from an official agency account
lends credibility to the information provided and helps to establish appropriate
boundaries between the client and the outreach worker. When working within websites
such as AOL or Gay.com and when logged in under a screen name, an email address may
be assigned to the account and used for outreach. To ensure that there is no confusion, the
website email address/screen name must only be used for outreach.

Under no circumstances should the contact information of any client be used for
spamming, event marketing, or any other use that is not a direct response to their inquiry.
All contact information for clients must be secured and such information is considered to
be personal identifying information and must be treated as such.

Email communication is to be logged just as a chat session or instant messaging session.
All emails, sent and received, must be printed and stored securely along with any other
records that contain any personal information regarding a client.

Some emails may contain questions that the outreach worker cannot answer. Just as in
any similar situation, the worker must ask their supervisor for assistance and should never
attempt to provide personal advice or answer medical questions that are beyond the scope
of outreach.

If follow up with the client is required, the outreach worker must request permission from
the client to send them email in the future. Providing contact information, including
official agency email address, can be a good way to encourage the client to share their
information.

Evaluation
Evaluation is a critical component to internet outreach. All activities conducted must be
captured and recorded in the AIDS Institute Reporting System (AIRS) as in traditional
outreach.

Data collection and reporting is a system for the collection, analysis and reporting of data
that will demonstrate your program‟s progress and verify that it is meeting all work plan
objectives. It and will help to provide, as appropriate, contact demographic data and
client level information and the data collected will assist in future program development
design, implementation and evaluation.

Various logs and other data collection tools must be used to collect information,
including client level information, activity times, and referrals. All communication such
as emails, IM sessions, and chat room conversations must be printed and abide by all
confidentiality criteria.


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To ensure that your activities are proven effective, data should be processed and reviewed
on a regular basis to ensure that the program is meeting its goals and objectives and to
inform workers on ways to improve performance.

Summary
We hope these guidelines will be useful in the development of protocols, policies,
procedures, training curriculum, and operational support to agencies and their programs.
The internet is an ever-changing environment. As new technologies, tools, products and
communication tools are developed and adopted by the general public it is hoped that this
guidance will assist in including these technologies in STD/HIV prevention intervention
activities.

Resources
Guide to On-line Communities
http://www.stdpreventiononline.org/index.php/resources/download/1327

Guide to SMS/Chat Abbreviations
http://www.stdpreventiononline.org/index.php/resources/download/1372

The 2005-2010 NYS Comprehensive HIV Prevention Plan submitted by the NYS HIV
Prevention Planning Group to the AIDS Institute, NYS Department of Health, September
2005 http://www.health.state.ny.us/diseases/aids/workgroups/ppg/docs/2005-
2010_nys_comprehensive_hiv_prevention_plan.pdf

The Centers for Disease Control: HIV Health Education and Risk Reduction Activities
Guidelines (HERR) http://www.cdc.gov/hiv/resources/guidelines/herrg/index.htm

The National Guidelines for Internet-based STD and HIV Prevention:
http://www.ncsddc.org/upload/wysiwyg/documents/NGuidelinesforInternet.htm

The New York State Training for Providers website:
http://www.health.state.ny.us/diseases/aids/training/index.htm




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