The Hidden Epidemic Confronting Sexually Transmitted Diseases (1997) / Chapter Skim
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PREVENTION OF STDs
PREVENTION OF STDs
Pages 118-174
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From page 118... ...
· There are many individual- and community-based interventions and tools that are effective and can be used immediately to prevent STDs. ISSUES IN PREVENTION Americans have not done well in confronting issues associated with sexual behavior in general and with STDs in particular.
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From page 119... ...
119 Sexual Exposure to Infected Person 1\ \ Acquisition of Infection mathematical model, Ro= pcD (May and Anderson, 1987; Anderson, 1991~. In this model, Ro, the reproductive rate of infection, represents the average number of secondary cases of STDs that arise from a new case; c is the mean rate of sexual partner change within the population; ~ is the mean probability of transmission per exposure; and D is the mean duration of infectiousness of newly infected persons.
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From page 120... ...
examined six changes in patterns of STDs and described how physical and social environmental changes drive these disease patterns. She called for the development of STD prevention programs based on "an appreciation of the role of risk behaviors and macroenvironmental forces" using compan
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Examples of this are school-based interventions that seek to delay the onset of sexual intercourse and also promote condom use. Nevertheless, research on behavioral interventions to reduce the rate of partner change have been underemphasized.
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The model was also described in "Resource allocation model for public health planning a case study of tuberculosis control," supplement to Vol. 84 of the Bull World Health Organ, 1973.
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From page 123... ...
Risk factors for exposure include the frequency and type of one's sexual behaviors, use or nonuse of contraceptive methods that provide protection against transmission of STDs, and the likelihood that one's partner is infected. The same behavior (e.g., unprotected intercourse with a new partner)
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From page 124... ...
The greater is the frequency of intercourse with an infected partner, the greater are the chances of transmission. Risk of HIV infection, hepatitis B virus infection, and other STDs is greater with anal intercourse than with vaginal or oral intercourse.
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From page 125... ...
studied adolescents who were incarcerated in the juvenile justice system. These adolescents, who reported engaging in high-risk sexual behaviors, had a good deal of knowledge regarding STDs and condoms, but this knowledge was not related to more positive attitudes toward use of condoms.
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126 a' so Cal EM VO Cq a' a' C)
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From page 128... ...
In addition to the reasons mentioned previously for why individuals fail to adopt protective behaviors, there are other explanations for why the association between perceived risk and protective behaviors is weak. Link Between Perceived Risk and Protective Behaviors Given the centrality of perceived risk to the theoretical models as well as to many intervention programs, it is surprising that the empirical evidence linking
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From page 129... ...
Perceived risk of STDs may be necessary to motivate healthprotective behavior or behavior change but may not be sufficient. There are other powerful factors that influence these behaviors.
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As the gay movement matured during the 1970s in the United States, a growing number of gay men equated their sexual practices with their own identity. Thus, admonitions to alter sexual behaviors were in direct conflict with the self-identities of gay men, and this conflict frustrated well-meaning attempts to alter behavior.
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From page 131... ...
A meta-analysis of 12 controlled studies of risk-reduction interventions for HIV infection found that the mean weighted effect of such behavioral interventions on self-reported sexual behaviors was positive and statistically significant (Kalichman et al., 1996~. In addition, two recent studies have demonstrated that certain feasible behavioral interventions are effective in reducing the risk of STDs (Kamb et al., 1996; Shain et al., 1996)
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From page 132... ...
Altering precursors of sexual decision making and actual sexual practices, such as increasing rates of condom use, reducing number of partners, or decreasing rates of unprotected sex, will ultimately reduce the number of new cases of STDs. While reduced STD incidence and sexual behavior change are the primary endpoints in STD risk-reduction interventions, other endpoints also have merit.
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From page 133... ...
Theoretical Approaches to STD and HIV Risk Reduction A number of theoretical approaches drawn from the social and behavioral sciences have been employed in developing STD prevention interventions (Cleary et al., 1986, 1995~. These models were derived from efforts to promote change in nonsexual health-risk behaviors, such as smoking cessation, cardiovascular risk reduction, and cancer prevention.
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From page 134... ...
Preventive Services Task Force concluded that the ability of primary care clinicians to influence high-risk sexual behavior is limited, but that there is consistent evidence that Americans have changed their
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From page 135... ...
Community-Based Interventions Community-based interventions to promote behavior change include interventions that target specific high-risk groups, such as female sex workers and adolescents, as well as interventions that attempt to change community norms, most commonly through mass media messages. A number of intervention trials involving high-risk groups such as gay men (Kelly et al., 1991, 1992)
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From page 136... ...
The initiative uses commercial marketing techniques, including mass media messages, and community involvement to promote healthy sexual behaviors. The social marketing approach adapted by the CDC includes the concepts of the right product, the right price, the right place, and the right promotion (DeJong, 1989~.
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From page 137... ...
These interventions are intended to either remove barriers to adoption of protective behaviors or to erect barriers to risky behaviors. An example of how structural or environmental changes can significantly reduce risky sexual behaviors is the "100% Condom Program" that was implemented nationwide in Thailand by the Thai HIV/AIDS Prevention and Control Program in 1992, along with a mass media condom-promotion campaign and wide distribution of condoms to prevent the spread of HIV among sex workers (Rojanapithayakorn and Hanenberg,1996~.
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From page 138... ...
; and other topics related to risk factors for STDs (Collins et al., 1995~. In the CDC survey mentioned previously, among teachers who taught in health education classes, 78 percent taught about sexual behaviors that transmit HIV (and other STDs)
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From page 139... ...
The quality of studies that have evaluated the effectiveness of school-based programs to reduce risky sexual behaviors varies greatly. Many studies that have evaluated the effectiveness of schoolbased programs in reducing risky sexual behaviors have used some type of experimental design, commonly randomization of students or schools to intervention and control groups to measure program effectiveness.
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From page 140... ...
In fact, programs that provide both messages appear to be effective in delaying the onset of sexual intercourse and encouraging contraceptive use once sexual activity has begun, especially among younger adolescents. A recent nationwide survey revealed that respondents wanted information on STDs from multiple sources and rated health care professionals and school-based
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From page 141... ...
Condom Availability in Schools. To address barriers to adolescent condom usage, approximately 431 schools in 50 school districts in 21 states have condom availability programs as part of HIV and STD prevention efforts, primarily in large urban public high schools (Kirby and Brown, 1996~.
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From page 142... ...
An analysis of utilization of condom availability programs showed that students in alternative schools, smaller schools, schools that made condoms available through bowls and baskets, and schools with health clinics obtained more condoms per person per year than did students in other schools (Kirby and Brown, 1996~. There are only limited data on the effectiveness of condom availability programs in schools to increase protective sexual behaviors and decrease STD rates, since these programs are relatively few and newly established (Kirby, 1993; Stryker et al., 1994~.
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From page 143... ...
Some of the other the major issues associated with condom availability programs are related to parental consent, funding of condom purchases, staffing and counseling, and legal liability. Opponents of condom availability in schools believe that providing or promoting condoms to adolescents hastens the onset of sexual intercourse, increases sexual activity, and violates parental autonomy in this area.
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From page 144... ...
Yet, because there is widespread lack of awareness and information regarding STDs, it is possible that national campaigns would have a greater impact on STDs compared to well-recognized issues such as smoking. A recent review of HIV prevention mass media campaigns (Flora et al., 1995)
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Outside of limited federal demonstration projects, there are no major programs or public funds to increase vaccination of adults at high risk for sexually transmitted hepatitis B virus infection. Frequency of coverage for adult hepa
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From page 146... ...
In addition, data from the CDC's Youth Risk Behavior Surveillance System show that, from 1990 through 1993, the proportion of high school students who reported using condoms at last sexual intercourse increased significantly from 46.2 percent to 52.8 percent (CDC, 1995a)
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The female condom is an effective mechanical barrier to viruses including HIV (CDC, 1993b)
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From page 148... ...
African American women are almost twice as likely to use condoms compared to women of other races (Anderson et al., 1996~. In addition, African American men are more likely to have used condoms during their last episode of intercourse compared to either European American or Hispanic men (Laumann et al., 1994~.
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From page 149... ...
The impact of other contraceptive use on condom use is discussed in the following section. Other Contraceptives and Dual Protection Among sexually active women 15-44 years of age at risk of unintended pregnancy, 12 percent do not use a method of contraception (Peterson, 1995~.
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From page 150... ...
However, most believe that the effectiveness of spermicides against STDs other than gonorrhea and chlamydial infection is uncertain and that condoms should remain the primary recommended strategy for STDs including HIV infection (Cates et al., 1992~. Hormonal contraceptives may actually increase the risk for cervical infections, but their effects on STD transmission and sequelae remain unclear (Cates and Stone, 1992~.
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From page 151... ...
and chlamydial infection (Katz et al., 1988; Alary et al., 1991) , the rationale for partner notification had to be modified, since the incubation periods are shorter for gonorrhea (usually a week or less)
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From page 152... ...
Originally called "contact tracing" and now referred to as "provider referral," this method of partner notification relies on intensive interviews with patients about their sexual histories and partners, followed by active outreach by public health staff to identify and locate partners to ensure that they are examined and treated. Although labor intensive and costly, provider referral is still carried out within most public health programs for syphilis and selected other STDs (Rothenberg and Potterat, in press)
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From page 153... ...
Although disease intervention specialists make intensive efforts to identify partners of syphilis patients seen in public STD clinics and in private practice and to follow up on positive tests reported by laboratories, little effort is generally made to support partner notification for patients treated for gonorrhea or chlamydial infection in private health care settings such as physician offices and hospital emergency rooms (Toomey, 1990~. Little is known about the practices of private providers regarding partner follow-up, and no systematic national efforts have been made to educate private sector providers regarding the importance of partner treatment as an essential component of STD-related care.
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From page 154... ...
. Research evidence concerning the effectiveness of partner notification is sparse at best.
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From page 155... ...
The success of a CDC and Office of Population Affairs initiative begun in 1988 in Public Health Service Region X to reduce chlamydia rates led to the Preventive Health Amendments of 1992 that authorized federal funding for expansion of activities to prevent infertility associated with chlamydial and gonococcal infections. Appropriated funds of $12.2 million in fiscal year 1995 have allowed the CDC to screen and treat at least half of at-risk women and their sex partners using family planning and STD clinics in 4 of 10 regions; to initiate screening and treatment services in the other 6 regions; and to implement research and evaluation activities at 5 sites (CDC, Division of STD Prevention, unpublished data, 1996~.
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From page 156... ...
The intent is that clinicians would choose from the specific recommended interventions and tailor them to the health needs of the individual patient. The task force evaluated and made specific recommendations for the following diseases and conditions related to sexual intercourse: hepatitis B virus infection, syphilis, gonorrhea, HIV infection, chlamydial infection, genital herpes, cervical cancer, and unintended pregnancy.
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From page 157... ...
Diagnostic Tests for STDs Traditionally, diagnostic tests for STDs are used by clinicians to evaluate either persons who suspect they have an STD or sex partners of infected individuals. Appropriate diagnosis of an STD often requires multiple specific diagnostic tests because of the variety of STDs.
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From page 158... ...
Unfortunately, some specific laboratory tests are often not available at clinical sites other than dedicated STD clinics and, even when available, the test results are often not available during the initial patient visit. In addition, the expense of these tests may limit their availability and utility.
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From page 159... ...
Microscopic evaluation of Papanicolaou (Pap) stained smears of cervical specimens is a useful test for detection of malignant and premalignant cellular changes related to human papillomavirus infection.
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From page 160... ...
Antigen Detection Tests These tests use pathogen-specific antibodies to detect proteins, carbohydrates, or lipid-carbohydrates present on the surface of STD pathogens. They have been extensively used for the diagnosis of STDs such as hepatitis B virus infection, chlamydial infection, and genital herpes and are potentially very useful for syphilis.
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From page 161... ...
Prototype tests for the diagnosis of syphilis, genital herpes, human papillomavirus, trichomonas, and most other sexually transmitted pathogens are in various stages of development. Because these assays amplify genetic material from infectious organisms, their specificity can approach 100 percent if the proper genetic sequences are selected for the test; their sensitivity is a function of the amplification process.
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From page 162... ...
In addition, although newer laboratory tests hold much promise for improved screening and diagnosis, financial and physical accessibility to these tests presents a barrier to 7The CDC-negotiated price (only available to public STD clinics and family planning programs) for azithromycin, the single-dose therapy for chlamydial infection, is $9.50 per dose, compared to approximately $2 (average cost to public STD clinics and family planning programs)
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From page 163... ...
Clinical methods that are effective in preventing exposure and reducing transmission include prophylaxis and partner notification and treatment. Although treatment of sex partners of infected persons is critical to STD prevention, the traditional methods for identifying partners
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From page 164... ...
In: Wasserheit JN, Aral SO, Holmes KK, Hitchcock PJ, eds. Research issues in human behavior and sexually transmitted diseases in the AIDS era.
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From page 165... ...
Family planning, sexually transmitted diseases, and contraceptive choice: a literature update. Fam Plann Perspect 1992;24:75-84.
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CDC. 1993 Sexually transmitted diseases treatment guidelines.
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From page 167... ...
Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial [see comments]
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From page 168... ...
Syphilis in San Diego County 1983-1992: crack cocaine, prostitution, and the limitations of partner notification. Sex Transm Dis 1995;22:60-6.
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From page 169... ...
Efficiency and cost-effectiveness of field followup for patients with Chlamydia trachomatis infection in a sexually transmitted diseases clinic. Sex TransmDis 1988;15:11-6.
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From page 170... ...
Condom availability in the schools: lessons from the courtroom. Fam Plann Perspect 1996;28:75-7.
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From page 171... ...
Oxman AD, Scott EA, Sellors JW, Clarke JH, Millson ME, Rasooly I, et al. Partner notification for sexually transmitted diseases: an overview of the evidence.
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From page 172... ...
Partner notification and the control of human immunodeficiency virus infection. Two years of experience in San Francisco.
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Psychosocial and behavioral factors associated with risk of sexually transmitted diseases, including human immunodeficiency virus infection, among urban high school students. J Pediatr 1990;119:826-33.
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Effect of changes in human ecology and behavior on patterns of sexually transmitted diseases, including human immunodeficiency virus infection.
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