Infectious Diseases in an Age of Change The Impact of Human Ecology and Behavior on Disease Transmission (1995) / Chapter Skim
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Effect of Human Ecology and Behavior on Patterns of Sexually Transmitted Diseases, Including HIV Infection
Effect of Human Ecology and Behavior on Patterns of Sexually Transmitted Diseases, Including HIV Infection
Pages 141-156
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From page 141... ...
Finally, I will highlight the implications of these links for effective STD prevention programs. CHANGING PAlTERNS OF SEXUALLY TRANSMI11ED DISEASES The last 20 years have witnessed six striking changes in STD patterns: emergence of new STD organisms and etiologies, reemergence of old Judith N
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From page 142... ...
Exciting insights into the pathophysiology and natural history of both bacterial and viral STDs have led to the discovery of sexually transmitted etiologies for such diverse syndromes as infertility, ectopic pregnancy, other adverse outcomes of pregnancy, anogenital cancers, and proctocolitis. However, human immunodeficiency virus (HIV)
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From page 143... ...
Data are adjusted for delays in reporting but not for incomplete reporting. occurred among homosexual or bisexual men, almost 60% of heterosexually transmitted AIDS cases occurred in women, and, for the first time, more women were reported with AIDS as a result of heterosexual transmission than as a result of injecting-drug use.
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From page 144... ...
Despite the common mode of transmission shared by these STDs, gonorrhea and infectious syphilis trends have consistently diverged over the past 25 years (Figure 3~. From 1965 to 1975, gonorrhea rates more than doubled, while infectious syphilis rates increased slightly.
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From page 145... ...
The recognition of penicillinase-producing Neisseria gonorrhoeae in 1976 has been followed by appreciation of an increasingly diverse array of resistance patterns and mechanisms, including both plasmid- and chromosomally mediated resistance to penicillins and tetracyclines, the two former mainstays of treatment (12~. Between 1988 and 1991, national surveillance of gonococcal isolates conducted by the Centers for Disease Control and Prevention documented an increase in the proportion of resistant isolates from 21% to 32.4%, more than a 50% increase in only 3 years (9, 13, 14~!
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What environmental changes continue to drive the evolution of these disease patterns? Let us consider three interrelated types of environments affecting STD patterns (Figure 4~.
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Lee Physiological Microenvironment Trend data are not available for most of the biological indices of the microenvironments affecting STD patterns (Table 2~. For example, while we know that the vaginal flora and acidity (pH)
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This trend is particularly disturbing because early age of TABLE 3 Personal environments affecting STD patterns Sexual behaviors Substance-use behaviors Health behaviors Age at coital debut Number of sex partners Commercial sex Sexual practices Intravenous drug use Crack cocaine Exchange of sex for drugs Alcohol use Condom use Pill and IUD use Vaginal douching Circumcision Early health-care utilization Compliance with therapy Provider screening IUD, intrauterine device.
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From page 149... ...
Thus, for young adolescents, behavioral risk factors such as multiple, risky partners conspire with biological risk factors such as large zones of cervical ectopy to result in high STD rates. Younger cohorts also report more sexual partners than older groups, and the proportion of young adults with multiple sexual partners appears to be increasing over time (24, 25, 2~31~.
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From page 150... ...
Health-related behaviors are the third component of the personal environments affecting STD patterns (Table 3~. Several of these behaviors, such as early health-care utilization, compliance with therapy, and provider screening, primarily affect the distribution of the curable STDs by reducing the duration of infectiousness of these diseases and by limiting the incidence of long-term complications.
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From page 151... ...
Data on health-care utilization, compliance with therapy, and provider screening behaviors are also quite limited, and conflicting information on racial or ethnic differentials makes definitive interpretation difficult (31~. Furthermore, a reporting bias may arise because racial/ethnic minority populations often seek care from publicly funded providers who are more likely to test for and report STDs than are private providers (21~.
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It is noteworthy that in the United States relatively large and growing segments of minority populations are sexually active adolescents and young adults, while the proportion of the White population in these groups has been declining since the mid-1980s (21, 45)
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At the same time that chlamydia, herpes, HPV infection, and AIDS emerged, and as syphilis rates climbed and treatment of gonorrhea required increasingly expensive antibiotics, support for STD services flagged and the public health infrastructure in the United States deteriorated. Many STD clinics across the country were unable to meet the demand for services and, increasingly, were forced to turn patients away without care.
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Finally, the community can play a pivotal role in modulating the impact of macroenvironmental factors on the personal environments that shape STD and HIV patterns. SUGARY The last 20 years have witnessed six striking changes in patterns of sexually transmitted diseases (STDs)
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(1991) in Research Issues in Human Behavior and Sexually Transmitted Diseases in the AIDS Era, eds.
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Third Triennial Report to Congress on Drug Abuse and Drug Abuse Research (Natl.
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