2IU Health Center Services Massage: $33 with paid health feeNutrition: 1 session free/semesterTobacco Cessation: Free, including cessation productsCAPS therapy sessions: 2 free semesterSexual Assault Counseling: free, unlimited sessionsGynecological exams: free (tests, pay)
3INTRODUCTION“This is a hidden and silent epidemic. Normally an epidemic of this proportion would have attracted more attention.”1996, Chancellor of Baylor College of MedicineRefers to the 12 million new STI cases/year in1996; now estimated to be 15 million/year (increase due to higher numbers and better testing)ideshow/article.htm
4INTRODUCTION Hidden – 2 meanings Silent – 3 meanings 1. taboo subject of sex; not talked about publicly in a serious way2. most Americans not aware of this epidemicSilent – 3 meanings1. some STIs have no symptoms2. lack of communication between individuals and their health care providers3. lack of communication between sexual partners
5STI vs. STD STI STD Someone who is an infected person ASYMPTOMATIC may not have any symptoms,Could be unaware that they are even sick.STDA disease is any abnormal conditionof the body or mind with some type of symptom,in other words your body tells you that you are unwell.
6BACTERIA VIRUS Living organism May be stopped with appropriate antibioticMild SevereNot “alive;” lives on hostNo known curesControlled by vaccineMild Severe
7IMPACT ON WOMENLack of symptoms; more difficult to diagnose until serious problems develop150,000 (estimate) women become infertile each year due to PID (pelvic inflammatory disease)as a result of an STI15-30% (estimate) of the 2.3 million US couples who are infertile may by result of an STI
8RISK FACTORS Most STIs more easily transmitted to women than to men Co-factor: infected with an STI makes one more likely to contract another STI, including HIV, after unprotected sexual contact with an infected partnerMultiple sex partners increase risk of exposure over one’s lifetime
10HERPES GENITALIS Caused by: Herpes Simplex Virus (HSV); Type 1: 50-80% exposure rate; prefers facial area;Type 2: 20% exposure rate; prefers genital areas;Once in body, migrates to a nerve cluster (ganglia) and goes dormant; evades detection from body’s immune system; probably not contagious at this time.May stay dormant forever or may migrate back to its first entry point on skin (active phase); it infects healthy cells, making new viruses. The immune system attacks and destroys infected cells; this “battle” is a herpes “outbreak.”
11Herpes - symptomsIncubation period: 1-12 days after sex with an infected person; may not appear for months or yearsDuration: may last 12 days; flu-like symptoms; average of 4-5 outbreaks per year;Sores: single or multiple fluid-filled blisters; painful; some outbreaks are mild and go unnoticed, especially in menOutbreaks: not known for sure what causes successive outbreaks; they seem to occur more often when a person is rundown, under extreme stress, sick or sunburned, when the body is weak, in some way.Future outbreaks? Duration, frequency and severity depend on: 1. is virus in preferred site (HSV-1 on genitals recurs less often than HSV-2; HSV-2 can be transmitted to the mouth, although rare);2. each individual’s immune system;3. how long person has had the virus.
12Herpes - transmissionSkin to skin contact with infected person; includes oral, anal and vaginal sex; most contagious when sores are present;Asymptomatic viral shedding (virus on skin surface but no symptoms); probably most common way virus is transmitted; approximately 80-90% of those with genital HSV do not know they’re infected; viral shedding most significant in year following first outbreak;Viral shedding continues about 5-10% of each year; days can’t be predicted;No documented cases of transmission from inanimate object such as toilet seat
13Genital Herpes - Penis Genital Herpes - Vulva Picture Credits: University of Erlangen, Department of Dermatology and American College Health Association
14Human Papilloma Virus Caused by: Mode of Transmission: Symptoms: Human papilloma virus (HPV) on genitals (vagina, cervix, urethra, penis, anus)Over 100 types of HPV, of which can infect genitalsMode of Transmission:Skin-to-skin contact with an infected person; penetration not needed; could happen during anal, vaginal and oral sexVirus can be transmitted when no warts or symptoms are presentSymptoms:Dry, painless, firm, rough warts – may be large or small, multiple or single. May itch or cause irritated area (only small percentage will have warts)Cervical changes detected on Pap testHPV may be present without visible warts or cervical changes
15Genital Warts Penis Genital Warts (HPV) Vulva Picture Credits: University of Erlangen, Department of Dermatology and Health Awareness Connection
16Human Papilloma Virus (Cont.) Diagnosis:Clinical observation of genital warts. Symptoms may appear 1-8 months or longer after exposure.Colposcopy - a procedure in which a colposcope (a lighted magnifying device) is used to identify the area of HPV infection on the cervix.Pap test which detects cervical cell changes and HPV typing (determines high or low risk)When an HPV test is positive, it does not mean that the virus is new or that a partner has been unfaithful. HPV can persist in cells for decades.No diagnosis for asymptomatic malesTreatment:Removal of warts by caustic chemical treatment, cryosurgery (freezing), laser treatment, electrocautery, or surgical removal of genital warts.Careful follow-up of abnormal Pap testMay be transient infection. Immune system may clear HPV from the body over time or suppress the virus. Contagious? Probably not.
17Human Papilloma Virus (Cont.) Potential Complications:Several strains, 23 types of HPV, are associated with an increased risk of cervical cancer (These strains generally do not cause visible warts.) Persistent infection with high risk type increases risk for cervical cancer.Less common, but also reported, are increased risk of cancer of the vagina, penis, and anus as well as mouth cancers.Transmission rate to newborn is unknown, but thought to be low.VACCINE is now available; Gardasil is for females AND males ages 9-26; works against 2 strains most often implicated in cervical cancer and 2 strains that cause about 90% of genital warts; series of 3 shots ($155/shot at HC);NEW VACCINE just FDA approved: Cervarix; only for females and only protects against the 2 most common strains related to cancerpap test for women still necessary due to 30% of cervical cancers caused by other strains.Women age 27+ may obtain shot from HC; must see dr. or NP first, sign consent form. May not be as effective as compared to younger women.
18Human Papilloma Virus (Cont.) Comments:5.5 million new cases are diagnosed yearly; numbers are probably higherMost common STI in the U.S.Recent study reports: more than ½ of young adults in a new sexual relationship were infected with HPV; among those infected, nearly ½ were from an HPV type that causes cancer. Take away message? All young people should expect to be exposed to HPV.HPV is the leading cause of cervical cancerCondoms may help but may not cover all areas
19Hepatitis B Caused by: Mode of Transmission: Hepatitis B virus Unprotected anal, oral, or vaginal sex with an individual infected with Hep BSharing Hep B contaminated needles and syringesMother-to-child transmission during breastfeeding or childbirth
20Hepatitis B (Cont.) Diagnosis: Treatment: Potential Complications: Blood test for Hep BTreatment:No specific treatmentSupportive care is givenNutritious diet is importantAlpha interferon for treatment of chronic Hep B infectionVaccination availablePotential Complications:Chronic Hep B infection increases risk of liver disease, liver cancer, death5-10% of adults and adolescents become chronic carriers
21HIV Infection Caused by: Human Immunodeficiency Virus Mode of transmission:SEX: Unprotected anal, oral, or vaginal sex with an individual infected with HIV/AIDSBLOOD: Sharing contaminated needles and syringes with an HIV positive individualBIRTH: Mother-to-child via breastfeeding or childbirth
22HIV Infection (Cont.) Symptoms: Flu-like symptoms – usually 2-4 weeks; up to 12 weeksAntibodies usually develop within three months, but can take up to six monthsAsymptomatic (No symptoms)Symptomatic HIV disease – average 8-11 years between exposure to virus and symptoms appear. May be longer with treatmentAIDS: Specific diseases, opportunistic infections. Weakened immune system - < 200 T-cell; the virus works by invading specific immune system cells, makes more copies of itself so that immune system is unable to fight off infections.
23HIV Infection (Cont.) Diagnosis: HIV antibody test, accurate at 3-6 months after exposure to virus.Two ways of being tested:1. anonymous: no identifying information associated with your test results;2. confidential: test results put into your medical records.Newer form of testing that does not require a blood sample; a sample of mouth cells is used; Positive link offers anonymous and confidential testing with Oraquick, results available in approximately minutes; cost
25Prevention – What can you do? Abstain from risky sexual behaviorsBe sexually monogamous with an uninfected partnerCommunicate with a sexual partner; self-esteem issuesNeedle Exchange programAZT Medications
26Do condoms work all the time? Effectiveness: 95-98% when used correctly and consistentlyHeterosexual couple study – 1994256 discordant couples (163 HIV+ M; 93 HIV+ F)½ couples reported condom use every time (vaginal or anal intercourse); no HIV+ conversionsOf the 121 couples reporting inconsistent or never using condoms, 12 HIV+ conversions
28Chlamydia Caused by: Mode of transmission: Chlamydia trachomatis bacteriaPrevalence: 4 million new cases per yearMode of transmission:Unprotected oral, vaginal, or anal sex with an infected person in which there is an exchange of vaginal or cervical secretions or semenMother-to-infant during childbirth
29Chlamydia (Cont.) Symptoms: Symptoms may appear 1-3 weeks after sex with an infected partner (incubation period)MenDischarge from urethraPainful urination20-40% of men have no symptoms of infectionWomenVaginal dischargeBurning and bleeding with intercourseFeverAbdominal painSwollen lymph glands60-80% of women have no symptoms of infection
30Chlamydia (Cont.) Diagnosis: Treatment: Cell culture Microscopic examination of dischargeUrine test for menTreatment:Specific antibiotic regimen such as doxycycline, zithromax, or tetracyclineThose infected and their partners should be treated at the same time to prevent the passing of infection back and forth between partners.
31Gonorrhea Caused by: Mode of transmission: Neisseria gonorrhea bacteriaMode of transmission:Unprotected oral, vaginal, or anal sex with an infected person in which there is an exchange of vaginal or cervical secretions or semenMother-to-infant during childbirth
32Gonorrhea (Cont.) Symptoms: Symptoms may appear 2-10 days after sex with infected partnerMenDischarge from urethraIncreased frequency and pain during urination25% of men have no symptomsWomenVaginal dischargeAbnormal mensesPainful urination80% of women have no symptoms
33Syphilis (Cont). Symptoms: Primary Secondary Latent Late (Tertiary) 1-12 weeks after sex with infected partner, painless sore on genitals (chancre)Secondary2 weeks to 6 ½ months after exposure, a skin rash (on entire body, hands or soles of feet) and flu-link symptoms may developLatentPatients are without clinical signs of infection – not contagious and no symptomsLate (Tertiary)1/3 of persons not treated will develop complications such as damage to the heart, brain, eyes, nervous system, bones, and joints
34Primary Syphillis (sore on penis) Secondary Syphillis (rash on hands) Picture Credits:University of Erlangen, Department of Dermatology
35Syphilis (Cont.) Diagnosis: Treatment: Potential complications: Serologic (blood) test for syphilisTreatment:Penicillin by injection or other antibioticPotential complications:If left untreated – blindness, heart disease, brain damage, deathComments:Rare
36VaginitisCaused by:Trichomonas vaginitis – protozoan: women will most likely be symptomatic while most men will be asymptomaticBacterial vaginosis – bacteriaYeast (candida) – fungusMode of transmission:Unprotected oral, anal, or vaginal intercourseNot always sexually transmitted
37Vaginitis (Cont.) Symptoms: Diagnosis: Men Women If symptomatic, inflammation of the urethraSkin irritation of the penisWomenSwellingItching or pain of the external genitaliaDischarge is excessive or malodorousDiagnosis:Microscopic examination of discharge
38Vaginitis (Cont.) Treatment: Potential complications: Trichomonas Metronidazole – partner also treated to prevent reinfectionBacterial vaginosisMetronidazole or clindamycinYeast (Candida)Miconazole nitrate or clotrimazolePotential complications:Recurrent infections are common
40Pubic Lice (Crabs) Cause: Mode of Transmission: Symptoms: Lice that infect the genital region in both men and womenPhthirus pubisMode of Transmission:Skin-to-skin contact with someone who is infectedContact with bedding or clothing of some who is infectedSymptoms:For some, there is noticeable itchingIndividuals may notice nits – tiny white specks on hair folliclesMay take a few days to a month to develop symptomsPicture Credits:
41Pubic Lice (Crabs) Cont. Diagnosis:Usually only a visual exam of the genitalia is needed to diagnose pubic liceMedial providers may also look at nits and lice under a microscopeTreatment:Usually treated with a medicated shampooThose infected do not necessarily have to shave pubic hairImportant also to wash clothing, bedding etc. with which the infected individual has had contactComments:May be transmitted from an inanimate object like a toilet seat.
42Scabies Cause: Mode of Transmission: Symptoms: A skin mite Sarcopetes scabeiMode of Transmission:Skin-to-skin contact with someone who is infectedContact with bedding or clothing of some who is infectedSymptoms:A rash that appears about 2-4 weeks after infection usually on the hands, wrists, and genitalsItching – more prominent at night and after showersPicture Credit:
43Scabies (Cont.) Diagnosis: Treatment: A visual exam of the genitals may be all that is neededIt is possible for the symptoms of scabies to be confused with the symptoms of other skin conditionsMedical provider may choose to scrape a lesion and examine using using magnification.Treatment:Usually a cream is applied topically to the skin from the neck down.Important also to wash clothing, bedding etc. with which the infected individual has had contact
44Bloomington Men’s S.T.R.O.N.G. Project Men between 17-24Free STD testing (812)ChlamydiaGonorrheaTrichomonas$20 gift cardConfidential and voluntary
45WEB SITESAmerican Social Health Association: and (for teens)Centers for Disease Control:IUHC lab:Columbia University Health EducationKinsey Institute Sexuality Information Service for StudentsGay and Lesbian Medical AssociationGay Men’s Health Crisis:Planned Parenthood:PP for teens:Advocates for Youth:chlamydia
46Women & HIV/AIDS Overview and statistics “Today the HIV/AIDS epidemic represents a growing and persistent health threat to women in the US, especially young women of color.” (CDC )
47Cumulative EffectsWomen make up an increasing part of the epidemic. Increased from only 8% (in 1985 ) to 14% (1992) to 23% (1995) to 26% of new HIV/AIDS diagnoses in 2007.Of the approximately 1 million people living with HIV in the US, between 120, ,000 women have HIV. Nearly ¼ of these women don’t know they’re infected; this puts them at high risk of passing the virus to their babies.Annual number of AIDS diagnoses increased 15% among women compared to 1% for men .
48Cumulative Effects (continued) According to a recent CDC study of more than 19,000 patients in 10 US cities, HIV+ women were slightly less likely than infected men to receive prescriptions for the most effective treatments for HIV infection.In 2005, an estimated 4,128 women with AIDS died, representing 25% of the 16,316 persons with AIDS who died in the 50 states and the District of Columbia
49Cumulative Effects (continued) Of the women given an HIV or AIDS diagnosis in 2007, high risk heterosexual contact was the source for almost 83% of these infections; IDU in 16% of infections; 1% not identified. (CDC reported from 34 states)Most women with HIV/AIDS receiving medical care had children under age 18 living at home (76%); child care may compromise a woman’s ability to manage her own illness
50Cumulative Effects (continued) Geography: HIV in some states more likely to have a woman’s face;1/3 of those estimated to be living with AIDS in Maryland, Connecticut, NJ are female(compared to 23% nationally)New AIDS cases in women highest:northeastsouthWomen with HIV disproportionately low-income;64% had annual income below $10,000compared to 41% for HIV infected males
51Living with HIV/AIDS: females by race & ethnicity 2007-CDC report from 34 states:*66% African American women*18% white women*14% Hispanic/Latino womenCompared to their % of population (34 states):*70% white women*14% African American women*11% Hispanic/Latino
52African-American Women & HIV http://www. youtube. com/watch African-American Women & HIV Gloria Rueben-- Positive Voices: Women & HIVRate of HIV diagnoses for AA women decreased significantly from 82.7/100,000 in 2001 to 60.2/100,000 in 2005; rate still remains 20x rate for white women.The rate of AIDS diagnoses for AA women (45.5/100,000) was approximately 23x the rate for white women (2/100,000) and 4x the rate for Hispanic women (12/100,000).AA and Hispanic women together make up 24% of US women, yet they account for 82% of AIDS diagnoses (2003).
53African-American Women & HIV 2002: Was leading cause of death among AA women age 25-34compared to 6th leading cause of death for women overall in this age group.Good news: 2006 no longer leading cause of death (4th) for AA women in this age groupYoung AA women are at highest risk for STIs compared to other young women.(Ex. Gonorrhea rate among AA women age15-19 is 14x greater than white females in same age group.According to the CDC, AA youth (m & f) comprised the largest single group of young people affected by HIV
54HIV Risk Factors Lack of recognition of partner’s risk: Unprotected sex with multiple partnersincluding partners of both sexes andIntravenous Drug Use;Sexual Inequality in relationships with men:lack of condom use due to fear of partner abuse or leaving the relationship;power differential especially with younger women and older men.Recent CDC study of urban high schools,more than 1/3 of black and Hispanic women had their first sexual encounter with a male 3 or more years older.These women, compared to those whose partners were approximately their own age, had been:Younger at first intercourse,Less likely to use a condom during first & most recent intercourseLess likely to have used condoms consistently.
55HIV Risk Factors Continued Biologic vulnerability and STIs: a woman is twice as likely as a man to contract HIV during vaginal intercourse because the lining of the vagina provides a large area of potential exposure to HIV-infected semen; young women at even greater risk due to immature reproductive tract, especially the cervix.Co-factors: having an STI greatly increases the likelihood of acquiring or transmitting HIV (can include those STIs which cause sores or breaks in the skin [herpes] or those which do not cause breaks [chlamydia]. Even with no breaks or sores, the infection can stimulate an immune response in the genital area that can make HIV transmission more likely.)
56HIV Risk Factors continued Substance Abuse: An estimated 1/5 new HIV infections are related to IDU; trading sex for drugs; both casual and chronic substance abusers more likely to engage in high risk behaviors such as unprotected sex. Socioeconomic and other societal factors: Nearly ¼ AA and 1/5 Hispanics live in poverty. Associated problems: limited access to high quality health care; higher levels of substance abuse; exchange of sex for drugs, $ or to meet other needs can directly or indirectly increase HIV risk factors.
57HIV Risk Factors continued Multiple risk factors: NC study of HIV infection in AA women, commonly reported that their reasons for risky sexual behavior were:Financial dependence on a maleFeeling invincibleLow self-esteemThe need to feel loved by a male figureAlcohol and drug use.
58HIV Risk Factors for: Women who have sex with Women (WSW) Woman to woman transmission appears to be rare.Of HIV+ WSW98% had another risk- difficulty in assessing true risk.IV drug use in most cases orsex with men.Case reports indicate that vaginal secretions and menstrual blood arepotentially infectious especially during early and late-stage HIV infectionwhen amount of virus in blood is thought to be highest;mucous membrane exposure (i.e. oral, vaginal) to these fluids have potential to lead to HIV infection.
59IMPORTANT - Early HIV Diagnosis Take advantage of antiretroviral treatments & preventive medicines for opportunistic infections when appropriateDrug therapies can forestall AIDS-related symptoms and prolong lifeAllow for more informed reproductive choicesTreatments can greatly reduce the chance of passing infection to baby
60BARRIERS to Early Diagnosis Poor access to health careDenial; do not believe they’re HIV infectedMay ignore symptoms/warnings of HIV infectionSome women are even afraid to tell their doctors they have HIV, fearing they won’t get good treatment. (PID and other symptoms should signal health care providers to offer women HIV testing and counseling.)
61Gender-specific Manifestations of HIV/AIDS Frequent and difficult-to-treat vaginal yeast infectionsOther vaginal infections occur more frequently & with greater severity: bacterial vaginosis, and STIs such as chlamydia, gonorrhea and trichSevere herpes outbreaks, sometimes unresponsive to standard drug therapyHPV occurs more frequently; cervical dysplasia, a pre-cancerous condition associated with HPV, also more common, severe & recurring
62Prevention Issues Abstain from risky sexual behaviors Be sexually monogamous with an uninfected partner; brings up issues of trust; may not know that partner is doing things that put him and her at risk for HIV; partner may not be aware of their own HIV status.Communicate with a sex partner; self-esteem issues:Talk about HIV and other STIs with each partner before you have sex.Learn about each partner’s past behavior (sex and drug use) and consider the health risks before having sex.Ask partners if they have recently been tested for HIV; encourage those who have not been tested to do so.
63Prevention Issues (continued) Problem: women may lack control in relationships and may be scared to say no to sex; scared to insist on condom use;Problem: Substantial proportions of HIV+ adults engage in oral, anal or vaginal sex without telling a partner of their HIV status;*13% of partnerships between an infected person and one who is HIV- or their status unknown, have involved unprotected intercourse without disclosure; this is against the law in most states.Conclusion: substantial numbers of new HIV infections occur among partners of HIV+ persons who do not disclose. (American Journal of Public Health, 2003)
64Prevention Issues (continued) Use male or female condoms for sexual intercourse. Female condoms offer greater “area” of protection from STIs.Even if both partners have HIV, use condoms to prevent possible infection with a different strain of HIV which could be drug-resistent.Use latex barriers (dental dam or cut open non-lubricated latex condom) for oral sex.Do not count on most birth control methods to protect against HIV.
65Prevention Issues (continued) Avoid use of IV drugs or shared needles. Drug use can affect treatment success. A recent study of HIV+ women found that women who use drugs, compared to those who do not, were less likely to take their medications as prescribed.Do not douche; douching removes some of your body’s natural protection.
66WSW: Prevention Issues Sexual identity does not necessarily predict behavior; i.e. women who identify as lesbian may be at risk for HIV through unprotected sex with men;Prevention interventions directed to WSW need to include messages about always using latex condoms for vaginal-penile intercourse;No barrier methods for use during oral sex have been evaluated as effective by the FDA. However, natural rubber latex sheets, dental dams, condoms that have been cut and spread open, or plastic wrap may offer some protection from contact with body fluids during oral sex and thus may reduce the possibility of HIV transmission.Not sharing sex toys;Know their HIV status as well as that of their partner(s);Include prevention messages about avoiding IV drug use or shared needles;
67Prevention Research Microbicides: virus-killing gel applied vaginally prior to sex;now in testing phase;should kill HIV before it latches onto cells of the person;important for woman whose male partner(s) won’t use a condom;Women can control the method without a partner’s knowledge;may provide protection against herpes, gonorrhea and chlamydia;will allow conception to occur;(African Study, Britain’s Medical Research Council; Herald-Times, Nov., 2005A few studies have been suspended due to higher numbers of women becoming HIV infected. This is a huge disappointment to researchers and prevention educators. (2/07)However, one large study from South Africa in 2009 shows promising results."Getting a negative result for one product certainly doesn't signal failure for the microbicide field or broader biomedical HIV prevention research effort as a whole. Each trial result is a puzzle piece and, together, they make up the complex picture that will show us how to develop successful new HIV prevention tools."(Mitchell Warren , AIDS Vaccine Advocacy Coalition. [2/07]
68Prevention: What is being done? “Advancing HIV Prevention” A CDC (2003) initiative to include preventing new infections by working with HIV+ persons and their partners.CDC: Looking at ways to utilize women’s social networks to reach high-risk persons in communities of color; (i.e. beauty parlors)One Test. Two Lives. New CDC campaign focuses on ensuring that all women are tested for HIV early in their pregnancy. Provides quick access to resources for providers, materials for patients to help encourage universal voluntary prenatal testing for HIV.
69Prevention: What is being done? (continued) Conducting outreach and testing for partners of HIV+ men;A program to increase the number of AA women who can negotiate condom use with their male partners;Develop and widely implement social marketing campaigns designed to increase knowledge of HIV status and to promote HIV risk reduction. One such campaign - Take Charge, Take the Test - has been shown to increase HIV testing among African American women.To ensure that people know whether or not they are infected and to ensure that those who are HIV+ can receive life-extending treatment and take steps to protect their partners, the CDC issued recommendations to make HIV screening a routine part of medical care for all patients between the ages of 13 and 64.
70Mother to Baby Transmission During the early 1990s, before treatments, an estimated 1-2,000 HIV+ infants were born each year in the US.An estimated 50-70% of transmission probably occurs late in pregnancy or during birth. Exact mechanism is unknown, believed to occur when mother’s blood enters fetal circulation or by mucosal (i.e. mouth, eyes) exposure to the virus during labor and delivery.Since about 1994, dramatic declines reported due to recommendations for routine counseling and testing for pregnant women; offering antiretroviral treatment to infected women during pregnancy and delivery and to infant following birth;Between , perinatally acquired AIDS cases declined 93% in the US.
71Mother to Baby (continued) Without treatment intervention, there is a 25% mother to baby transmission rate; with treatment to mother and baby it drops to about 2%.CDC: since 1999 has distributed $10 million to states with high HIV rates to carry out prevention programs for pregnant women.Doctors should determine the cause of a patient’s reluctance to be tested, so that it can be addressed.