Background:
Syphilis cases in San Francisco increased from 41 in 1998 to 493 in 2002. Most cases were among men who have sex with men: only 11 cases were identified among women in 2002. Feedback from MSM focus groups suggested a change in focus from education on condoms and numbers of partners to getting tested regularly.

Objective:
Our objective was to evaluate whether a web site could facilitate syphilis testing and identify new cases.

Method:
A web site was created (STDtest.org) where patients could print out a lab slip and get tested for syphilis at a private laboratory. Results were reported to the health department and then posted on the web site, where the patients could obtain them using an anonymous nine-digit ID number. STD staff followed up with every newly-reactive client to ensure that new cases received treatment.

Result:
STDtest.org launched in May, 2003. Through October, 2007, 801 tests have been conducted among 673 unique patients. Of the 51 reactive serologies, 2 (3.9%) were biological false positives, and 22 more (43.1%) were previously treated cases. One client was unable to be located. Of the 19 new cases identified, 1 was late latent, 5 were early latent, 10 were secondary, and 3 were primary syphilis. These represent only 0.9% of the 1937 early syphilis cases identified in San Francisco over this same period.
This project had the highest proportion of cases among tests (2.3%) of all program screening activities, including the STD clinic (1.4%), a gay men's health center (1.2%), and correctional facilities (0.1%).

Conclusion:
This project has been productive in identifying cases in relation to other screening projects, and has done so at very low costs. It has not proven to identify a substantial number of new cases, however.

Implications:
On-line testing may be a cost-effective means to improve syphilis case detection.