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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.

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Presentation on theme: "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."— Presentation transcript:

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. Grant/Research Support:NIH, CDC, WHO, GlaxoSmithKline, Becton Dickinson, Cepheid, Gen- Probe, Roche Molecular, Cempra Consultant: MedHelp.org Speakers Bureau:None

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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– Fig 16. SR

7 Syphilis—Reported Cases by Stage of Infection, United States, 1941– 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 Fig 1. SR

9 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 Northeast45.5% Midwest38.5% West45% South37.3% United States41.6% 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 – Case Finding – Serologic Screening Programs 2.Prompt Therapy 3.Contact Identification, Testing, and Therapy 4.Mandatory Serological Evaluations – Premarital and Early Pregnancy 5.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 Women - Victims or Vixens Men – Vectors +/or Victims STDs Don’t Affect “Us” and Are Not Our Concern

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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 StigmaIntolerance

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 JCDH STD Clinic Visits14,063 Clients10,358 Women4977 (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 N = 347 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 (%) All African American % % % > % *2002 NSFG, National Center for Health Statistics Van Wagoner N, Harbison H, Jones M, Turnipseed E, Hook EW. Sex Trans Dis 2010; 38: Van Wagoner N, Harbison H, Jones M, Turnipseed E, Hook EW. Sex Trans Dis 2010; 38:

25 Performance of NAATs for Diagnosis of Pharyngeal N. Gonorrhoeae Infection Pharyngeal Gonococcal Infection By Site SiteNo (%) 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. 2009; 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% ( )96% ( ) Aptima Combo2 (TMA)100% ( )95.5% ( ) Culture71.9% ( )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 SiteNo (%) 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 EducationFamily Planning STD/HIV ManagementReproductive Track Care Interpersonal RelationshipsErectile 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. 2011

33 Sexual Health Models for STD/HIV Prevention Disease Model Disease – To be avoided STD/HIV –Consequence of socially unacceptable behavior –Embarrassment –Stigmatizing Control Requires: Testing Treatment Partner notification Sexual Health Model 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

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

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