1. A Sexual Health Framework for STD/HIV Management and Prevention
Edward W. Hook, III, M.D.
University of Alabama at Birmingham
And
Jefferson County Department of Health
Birmingham, AL

2. Edward W. Hook, III, M.D. Disclosures Grant/Research Support:
NIH, CDC, WHO, GlaxoSmithKline, Becton Dickinson, Cepheid, Gen-Probe, Roche Molecular, Cempra
Consultant:
MedHelp.org
Speakers Bureau:
None

4. U.S. STD Control in the 21rst Century: A Challenge and an Opportunity
Flat or increasing STD Rates
HIV as an STD
Opportunities
Using new tools
Low hanging fruit- improvement of clinical services

5. New Tools For STD Prevention and Management
Nucleic Acid Amplification Tests
- Extra genital testing
HPV Vaccine
Type-Specific Tests for HSV
Suppressive Antiviral Therapy for Prevention of HSV-2 Transmission
Partner Delivered Therapy
Circumcision For HIV Prevention

6. Gonorrhea—Rates, United States, 1941–2011
2011-Fig 16. SR

7. Syphilis—Reported Cases by Stage of Infection, United States, 1941–2011
2011-Fig 36. SR

8. Chlamydia—Rates by Sex, United States, 1991–2011
NOTE: As of January 2000, all 50 states and the District of Columbia have regulations that require the reporting of chlamydia cases.
2011-Fig 1. SR

9. Chlamydia Screening, Sexually Active U. S
Chlamydia Screening, Sexually Active U.S. Women Enrolled in Health Plans, 2007
Goal: Screen all sexually active women < 25 years of age annually
(Healthcare Effectiveness Data & Information Set (HEDIS)
% Sexually Active Screened
Northeast
45.5%
Midwest
38.5%
West
45%
South
37.3%
United States
41.6%
Medicaid HMO
50.5%
Commercial HMO
39.6%
MMWR 58 ; : 2009

10. THE NEXT GREAT PLAGUE TO GO Thomas Parran’s 5-Point Program For Syphilis Control – 1936
Case Finding – Serologic Screening Programs
Prompt Therapy
Contact Identification, Testing, and Therapy
Mandatory Serological Evaluations – Premarital and Early Pregnancy
Public Education = Symptoms, Complications, Treatment

11. STD Health Disparities and Stigma: A Challenge and an Opportunity
Flat or increasing STD Rates
Opportunities
Using new tools
Low hanging fruit- improvement of clinical services
STDs, Stigma and Health Disparities

12. Historical Partners in U.S. STD Prevention
American Society for Sanitary and Moral Prophylaxis (1905) – (Coalition of physicians, social hygienists, charity groups, moral reformer churches) American Social Hygiene Association (1913) Armed Forces U.S. Public Health Services
Brandt, AM. No Magic Bullet, Oxford Univ Press, 1985.

13. Conventional Wisdom Regarding STDs
STDs are the result of inappropriate behavior People with STDs will know they have them Efforts to control STDs should focus on women Sex (and STDs) is not an appropriate topic for conversation

14. Conventional Wisdom Regarding STDs Gender Roles
Women - Victims or Vixens Men – Vectors +/or Victims STDs Don’t Affect “Us” and Are Not Our Concern

18. Widely Health Beliefs About STDs
“Nice” (normal?) people do not get STDs If you are not “promiscuous” you will not get STDs, unless your partner betrays you Testing for STDs is warranted primarily for persons with risks for STD When STDs are present, its obvious Discussion of the need for STD testing is offensive to patients

19. Stigma
Intolerance

20. Consequences of STD-Related Stigma
Personal (Individual) Provider Population

21. Consequences of STD-Related Stigma
Personal (Individual)
Delays in seeking preventative health care
Condoms
Vaccines
Screening
Delays in seeking care for perceived problem
Ineffective partner notification
Provider
Hesitancy in seeking relevant information
Differential testing
Changes to provider-client interactions
Population
Guilt by association
Differential Care
Profiling

22. Sexual Partners Reported by Women, past Year
JCDH STD Clinic
Visits
14,063
Clients
10,358
Women
4977 (48%)
Sexual Partners Reported by Women, past Year
1 – 54%
2 – 29%
3 – 9%
> 4 – 7%

23. Women Attending the JCDH STD Clinic – High Risk?
STD Diagnoses
1 Partner, Past Year
N = 347
> 4 Partners, Past Year
OR (95% CI)
Trichomoniasis
59 (17%)
61 (18%)
1.03 ( )
C. Trachomatis
48 (14%)
74 (21%)
1.67 ( )
N. Gonorrhoeae
24 (7%)
42 (12%)
1.83 ( )
Syphilis
13 (4%)
33 (10%)
2.61 ( )
Van Wagoner N, Harbison H, Jones M, Turnipseed E, Hook EW. Sex Trans Dis 2010; 38:

24. Self Report Sexual Partners, Past Year (%)
U.S. Women 15-44*
Women Attending
JCDH STD+
All
African American
6.9
7.9 1
68.2 60
54% 2
7.6
11.4
29% 3
3.0
4.2 9%
>4
3.8
6.6 7%
*2002 NSFG, National Center for Health Statistics
+Van Wagoner N, Harbison H, Jones M, Turnipseed E, Hook EW. Sex Trans Dis 2010; 38:

25. Pharyngeal Gonococcal Infection By Site
Performance of NAATs for Diagnosis of Pharyngeal N. Gonorrhoeae Infection
Pharyngeal Gonococcal Infection By Site
Site
No (%) Individuals
Genital and Oral
23 (28%)
Genital Only
28 (34.1%)
Oral Only
31 (37.8%)
Total Genital or Oral
82 (100%)
Bachmann, et al. J Clin Micro ; 47:

26. Performance of NAATs for Diagnosis of Rectal N. Gonorrhoeae Infection
Rectal Gonococcal Infection
% Sensitivity (95% CI)
% Specificity (95% CI)
ProbeTec (SDA)
100% ( )
96% ( )
Amplicor (PCR)
95.8% ( )
Aptima Combo2 (TMA)
95.5% ( )
Culture
71.9% ( )
99.7% ( )
Bachmann, L et al. J. Clin Microbiol. 2010;48(5);

27. Performance of NAATs for Diagnosis of Rectal C. trachomatis Infection
Chlamydial Rectal or Genital Infections By Site
Site
No (%) Individuals
Genital and Rectal
20 (40.8%)
Genital Only
6 (12.2%)
Rectal Only
23 (46.9%)
Genital or Rectal
49 (100%)
Bachmann, L et al. J. Clin Microbiol. 2010;48(5);

28. Insanity is doing the same thing over and over again and expecting a different result. Albert Einstein

29. Sexual Health
Sexual health is a broad perspective that spans the entire lifespan encompassing topics which include:
Sex Education
Family Planning
STD/HIV Management
Reproductive Track Care
Interpersonal Relationships
Erectile Dysfunction

30. Why Sexual Health?
Health is a human right Sexual health is a positive message – something to be sought, not avoided Sexual health is operational over the entire life course Sexual health provides a “big tent”

31. A sexual health framework shifts the approach from a more traditional loss frame approach to a gain frame Framing – influenced by context; anticipated to have selective influence on perception, encouraging certain interpretation, discouragement, others (Wikipedia) Gain frame – Emphasizes positives, benefits Loss frame – Emphasizes risks, potential harm, potentially fueling shame and stigma

32. CDC Definition of Sexual Health: A Public Health Perspective
Sexual health is a state of wellbeing in relation to sexuality across the lifespan that involves physical, emotional, mental, social, and spiritual dimensions.
Sexual health is an inextricable element of human health and is based on a positive, equitable, and respectful approach to sexuality, relationships, and reproduction, that is free of coercion, fear, discrimination, stigma, shame, and violence. 
It includes the ability to understand the benefits, risks, and responsibilities of sexual behavior; the prevention of disease and other adverse outcomes; and the possibility of fulfilling sexual relationships. 
Sexual health is impacted by socioeconomic and cultural contexts–including policies, practices, and services–that support healthy outcomes for individuals and their communities.
Developed by the Sexual Health Workgroup of the CDC-HRSA Advisory Committee

33. Sexual Health Models for STD/HIV Prevention
Health = basic human right
Sexual Health – Component of health
STDs – threats to sexual health acquired in the course of sexual activity
Health Preservation Through
Education
Vaccination
Testing (Screening)
Treatment
Communication between partners
Disease Model
Disease – To be avoided
STD/HIV
Consequence of socially unacceptable behavior
Embarrassment
Stigmatizing
Control Requires:
Testing
Treatment
Partner notification

34. Sexual Health Framework: Using health promotion to complement disease control and prevention