1. 19th ISSTDR Quebec, Canada July 10-13, 2011 Jens Boman Smittskyddsläkare Region Skåne

2. What are they asking? An analysis of STD related calls to CDC-INFO Launched in 2005, 24 hours, 7 days a week 2010: 44,339 STD-related calls, 2,123 emails 11 categories and sub-categories Top ten questions – 1) Can you help me locate a STD testing site in my area? – 2) What are the signs and symptoms of genital herpes? – 3) If I am experiencing symptoms, how do I know if I have a sexually transmitted disease or infection? – 4) Are herpes simplex typ 1 and 2 spread the same way? – 5) How is genital herpes transmitted? – 6) How is genital human papillomavirus transmitted?

3. What are they asking? An analysis of STD related calls to CDC-INFO – 7) How long does human papillomavirus infection last? – 8) Is there a blood test to diagnose herpes simplex virus infection? – 9) How is chlamydia transmitted? – 10) Can human papillomavirus be treated or cured? – The findings correlate with findings from traffic to the STD prevention website (www.cdc.gov/std). – 91% reported learning new information as a result of the call – 68% indicated a desire to change a behavior based on the new information – Reducing risky sexual behavior was the most common type of behavior change indicated

4. Chlamydia screening in an International Resort Community An event-based outreach program to expand access to asymptomatic Chlamydia screening for young people who may not otherwise seek testing 15 outreach screening sessions – 2-3 hours N = 112; 57,1 % males; 8,9 % CT-positive Conclusion: Free, event-based outreach Chlamydia screening attracted people who may not otherwise have been tested

5. STI rates and risk factors among female sex workers in Germany 1 Jan-10—1-Apr-11; 1425 sex workers attending STI testing sites in Germany HIV 0,2%, Syphilis 1,1%, CT 6,9%, GC 3,2%, Trich 3,0% STI rates are highest among the younger, uninsured, street-based women who do not speak German + visit the STI clinic for the first time + recently starting + unprotected sex

6. Integrating public health into the sex worker community in Indianapolis Cues to action – Think back to the last time you received a female wellness exam or got tested for STD. What prompted you to schedule that appointment?

7. Integrating public health into the sex worker community in Indianapolis Perceived susceptibility – Describe what worries you most when you think about your health and how it’s affected by being on the street

8. Integrating public health into the sex worker community in Indianapolis Perceived barriers – What are some of the reasons why women who are working on the streets don’t get tested for STD?

9. Identifying key topics for a description of sexual behaviour among Danish adolescents Four semi-structured focus group interviews of 19 adolescents, aged 18 to 23, who had sexual experience Risk factors for unsafe sex/one-night-stands: – alcohol consumption – nights on the town, foreign countries, festivals – low self-esteem (regretted sexual activity) – increased sexual experience

10. Multiple bacterial STI in Ontario Approx. 100 000 clients with 113 097 reported bacterial STI from 2006 to 2009 (four years) 24 % of STI were in individuals with multiple STI:s 12 % had more than one STI 2.4 % had 3 or more STI:s Maximum number of STI:s in one client was 12 27.8 % of women and 25.9% of men with their first STI between age 10-14 had multiple STI:s Public health resources may be well spent because almost 90 % of individuals only have one STI reported

11. Multiple bacterial STI in Ontario 1 = 86 602 2 = 9 312 3 = 1 697 4 = 415 5 = 135 6 = 31 7 = 21 8-12= 13

12. Age of first sex is a factor in gay men’s hiv/STI vulnerability Melbourne, Australia 854 Australian gay men born 1944-1993 The younger that men were for their first anal intercourse, the more likely they were to report having HIV and other STIs today Significant: number of sex partners 12 months, group sex, hiv-positive, >2 STI 12 months, ever diagnosed hepatit A, B, C

13. HIV sexual risk factors among hiv- negative msm using Internet Net Gay Baromètre, Quebec 3 718 msm, 2 345 hiv-negative Included = 1 794 msm seeking partners in dating websites + at least one casual partner in the last year UAI(HIV +/?) = live in Montreal region, are seeking sensation, are seeking partners in sex venues, and are regularly seeking partners on dating websites

14. Don’t look at your patients, look at their partners Questionnaire at 4 GUM-clinics in England Detailed questions on the (max) 3 most recent partners in the 3 months prior to clinic visit 24% of men and 14% of women had recent concurrent partnerships (ps) 68% of men’s and 54% of women’s ps were < 3 months 43% of men’s and 27% of women’s ps were one-off encounters Consistent condom use was low: 19% in women and 25% in men High potential for STI transmission

15. Identifying women at risk Miami-Fort Lauderdale – high hiv rates Can future hiv infection be predicted based on GC, CT, early syphilis and demographics? Hiv in women 11-89 years > 60 days after STD diagnosis An STD diagnosis and a few demographic variables (30+ and zip code) can identify women at very high risk of acquiring hiv (24% within a few years) – e.g. women with syphilis and older women with GC. These women should be counseled to reduce their risk. CT is very common in young women and not a good predictor of hiv.

16. Dual contraceptive use among adolescents and young adults Simultaneous use of condoms and other contraceptive methods provides maximum protection against unintended pregnancies and STD Sexually active 12-25 years, California, 50.6 % female Contraceptive use: – Nothing 21 % – Condoms only 53.9 % – Hormonal contraception only 9.2 % – Dual methods 15.5 % – Other 0.5 %

17. Dual contraceptive use among adolescents and young adults Given the high STD rates among adolescents and young adults: – Population-level interventions should aim to maximum condom use – Individual-level interventions should take risk into consideration, as well as patients’ preferences

18. Oral sex and risk of STI Elaine Flagg, CDC All oral sex practices are associated with risk of acqusition of one or more STI – Insertive and receptive fellatio – Insertive and receptive cunnilingus – Insertive and receptive anilingus Eg: CT, GC, HSV, HPV, HIV

19. Chlamydia screeing www.chlamydiatest.nl 280 000 persons 16-29 years invited annually Retest after 6 months in CT-positives Amsterdam, Rotterdam, South Limburg Low and decreasing participation Annual uptake: 16 % - 11 % - 8 % No significant decrease in positivity and prevalence estimates NOT roll out this program

20. Group sex – Samuel Friedman, NY Linked to several STI and HIV outbreaks Huge gaps in what we know - this lack of knowledge hampers prevention Group sex participation is quite common – Rapid partner exchange – Potential bridge environments between networks – Men not always changing condoms – Fingers, penises, and/or sex toys can transmit

21. Swingers – Anne-Marie Niekamp, South Limburg, Netherlands Measure: level of concurrency past 6 months 106 partcipants, mean age 43 years 13,2 % pos STI 96 % steady relationship 9 % casual sex outside swinging with median 4 sex partners 59 % practiced group sex with median 3 partners

22. Swingers – Anne-Marie Niekamp, South Limburg, Netherlands Median 10 times swinging with median 7 different swing partners in 6 months Increased STI risk (CT and GC) – Frequency of swinging (> 12 times) – 32% – Group sex without steady partners – 38 % – Total number of sex partners (11-15) – 19 % – Total number of sex partners (> 15) – 32 %

23. Gender differences in behavioral correlates of biologically confirmed STI Amanda Berger, University of Maryland, USA Risk factors for STI: Men – Young age at first sex – Failure to use condom at last sex Women – Multiple partnerships (>3 in 12 months) – Lifetime number of sex partners

24. High CT and GC incidence, reinfection, and HIV among workers in the adult film industry Christina Rodriguez-Hart, Los Angeles 2004-2008: 3 227 CT & GC cases 14,3 – 21,5 % had at least one CT-infection 5,1 – 7,7 % had at least one GC-infection Reinfections within 12 months: 27 % HIV 2004-2010: 10 HIV + 2010: 1 acute HIV+ - 2+/14 (14 %) – 8 weeks 2004: 1 acute HIV+ - 3+/14 (21 %) – 4 weeks

25. HIV in MENA – Middle East/North Africa Concentrated hiv epidemics in several countries – increasing incidence since 2005 FSW 0,1-1 % of women; 0-70 % HIV+ MSM 2-3 % of men; 0-52 % HIV+ Linked epidemics eg. – Iran IDUs 15 % hiv+, MSM 15 % HIV+ – Egypt 2006 IDUs 0,6 % HIV+, MSM 6,2 % HIV+ – Egypt 2010 IDUs 6,7 % HIV+, MSM 5,9 % HIV+

26. HIV in MENA – Middle East/North Africa Overlap of risk behaviors among high-risk populations MSM – Consistent condom use < 25 % – Low knowledge of HIV/AIDS Need for – Increased surveillance – Expand access to hiv-testing, prevention, and treatment services

27. HPV –lunch meeting Genital warts are a marker of oncogenic HPV infection HPV and cancer – Cervical cancer 100 % – Vulvar cancer 40 % – Vaginal cancer 60-90 % – Anal cancer 80-90 % – Penile cancer 45 % – Head & Neck cancer 12-70 %

28. HIV transmission – Myron S Cohen 38 % of HIV because of acute infections Infectiousness – Blood viral load – Genital viral load – Inflammatory STD HPTN 052 – 1763 discordant couples – immediate or delayed treatment (CD4 200-250 – normalt > 500) – 28 linked infections: 27 delayed and 1 immediate – 96 % prevention

29. HIV strategies Counseling ARV treatment Circumcision (Vaccine) STD treatment? Acute HIV infection? PrEP PEP

30. Concurrency – Jami Leichliter, CDC First & last date for three most recent opposite sex partners Average duration increasing by age Current concurrency – Women 0,3 % – Men 2,1 %

31. Neglected issues HIV risk – anal intercourse in women 4-20 x increased HIV risk compared to vaginal sex Increase in risk similar to primary infection

32. Anal sex in women Joelle Brown, UCLA 141 women > 18 years Anal intercourse (AI) last month: – White 17 %, unprotected 63 %, lube 75 % – Black 14 %, unprotected 50 %, lube 38 % – Hispanic 27 %, unprotected 40 %, lube 60 % Lube (=lubricant): commercial 38 %, saliva 23 %, petroleum jelly (Vaseline) 15 %, lotion 12 % AI and HIV: aOR 7,8 (1,6-37,6) AI and HSV-2: aOR 3,3 (1,2-9,1)

33. Rectal CT and GC in LA women Reported anal intercourse in previous 90 days Limit: reporting bias for sensitive behaviors 716 women mean age 28 years (14-60) CT (n = 114) GC (n = 26) – Urogenital only 14 (12 %) 5 (19 %) – Urogenital + rectal 69 (61 %) 14 (54 %) – Rectal only 31 (27 %) 7 (27 %) – Rectal sampling: CT + 37 %, GC + 37 %

34. Jessica Ladd, JHU, Baltimore – Internet testing for CT, GC, Tric ”I want the kit” CT in women who were rectally tested (n = 205) – 15+ in both rectum and vagina (48 %) – 7+ in vagina only (23 %) – 9+ in rectum only (plus 2 who were not tested vaginally) (29 %) GC in women who were rectally tested (n = 205) – 3+ in both rectum and vagina (43 %) – 2+ in vagina only (29 %) – 2+ in rectum only (29 %)

35. Jessica Ladd, JHU, Baltimore 14 % anal intercourse and always condom 8,2 % forced anal sex 70 % asymptomatic infection 36,8 % of rectal infections (CT,GC, Tric) would not have been diagnosed with urogenital sampling only CT + 41 % when rectal sampling added GC + 40 % when rectal sampling added

36. Netherlands – MSM and female swingers 6 000 visits/year South Limburg STD clinic Female swingers rectal sampling – Self reported anal intercourse: bad indicator – Symptoms: bad indicator – MSM: add oral + rectal sampling – Female swingers: add rectal sampling

37. Quebec: www.msss.gouv.qc.ca Key public health functions – Protection, Surveillance, Prevention, Promotion STI strategies – Targeted communiction – Early access to condoms and promotion of their use – Access to youth clinics – Access to screening services

38. Quebec: www.msss.gouv.qc.ca 2010-2011 campaign Campaign for young people aged 15 to 24 The campaign for preventing STI's aims at encouraging young people to use condoms with their partners and to continue using condoms after their initial relations. Like last year, the theme is "Beware and Be Aware." It reminds young people that infected individuals do not always have visible symptoms, which is why always using condoms is so important. Condoms. 100% on.

39. Quebec - Poster 1 More often than not, Chlamydia doesn't reveal itself. 3 out of 4 people with Chlamydia ignore the fact that they're infected. Poster "Girl" (1.7 MB) Poster "Girl"

40. Quebec - Poster 2 More often than not, herpes doesn't reveal itself. 9 out 10 people with herpes ignore the fact that they're infected. Poster "Boy" (1.7 MB) Poster "Boy"

41. www.msss.gouv.qc.ca Campaign for adults aged 25 to 35 The "Let's Take Action to Stop the Spread of STIs" awareness campaign is calling on the people of Québec to rally together. It aims at informing the public about a significant rise in STBBIs over the last several years and convincing adults to protect themselves and their close contacts.

42. Quebec- Poster 3 Poster Sexually transmitted infections and blood- borne pathogens are spreading more than ever. Let's take action to stop transmission. (769.2K) Sexually transmitted infections and blood- borne pathogens are spreading more than ever. Let's take action to stop transmission.

43. http://www.hivbigdeal.org/ ”Josh is a 26-year-old gay man in New York City. This is his story” Episode I: ”The morning after” Episode II: “The Test” To test or not to test? Find out what Josh decides. SEE THE VIDEO FOR GAY MEN SEE THE VIDEO FOR GAY MEN

44. http://www.hivbigdeal.org/ Taking about HIV is hard… Having HIV is even harder. Talk with all of your sexual partners about HIV. If you don’t know your status, get tested. HIV is still a big deal. – a project of the Medical and Health Research Association of New York City, Inc. and New York University

45. GC – HIV testing - USA HIV-testing in GC-positive patients Why? – Sexually transmitted – Within same networks Results (1 845 GC+) – 33 % never HIV-tested – 16 % tested > 2 years – 18 % tested 6 months - 2 years – 33 % tested < 6 months Conclusion: suboptimal HIV-testing in the US

46. Oral and genital HPV in boys 14-17 y. N = 33, tested every 3 months, Roche PCR – 37 HPV-types 12/33 (36 %) HPV+ at visit 1 – HR-HPV 7/33 (5 = HPV-51) – LR-HPV 13/33 (7 = HPV-84) 10/33 (30 %) HPV+ at visit 2 – Oral HPV 2/33 (1 HR-HPV) – Multiple types at a single point and at follow up

47. BV risk in wsw Australia WSW 27 % BV (bacterial vaginosis) BV – the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of certain bacteria. BV is sometimes accompanied by discharge, odor, pain, itching, or burning. Risk factors – Increased partner change – Receptive oral sex – Smoking

48. HPV-prevalence England NATSAL 2000 Urine HPV-test Men 17 % HPV – 9.6 % HR-HPV – 3.9 % HPV-16/18 Women 29 % HPV – 15.9 % HR-HPV – 5.5 % HPV-16/18

49. Predicting HIV in MSM 1 421 HIV+ MSM – 6.3 % had been CT/GC pos within 1 year before HIV-diagnosis – 9.6 % had been CT/GC pos within 2 years before HIV-diagnosis – 11.9 % had been CT/GC pos within 3 years before HIV-diagnosis

50. Internet http://www.sfcityclinic.org/ – STD basics – STD risks chart – What you can get if your partner is infected – Example: Performing oral sex on a man Known risks: CT, GC, HPV, Syphilis, Herpes, Hepatitis A, Shigella Possible risks: hepatitis B, HIV Unknown: hepatit is C

51. Internet http://www.stdpreventiononline.org/ – Press Release: Simple changes to dating websites could decrease spread of HIV and STD http://www.syfilistest.nl/ http://www.iwantthekit.org/ – Since June 2004 – 2 796 women – 8.9 % CT pos – 1 029 men – 13.0 % CT pos – Now: CT, GC, Tric and rectal sampling – Now: Risk quiz

52. What’s your risk of having an STD Are you less than or equal 25 years old? Yes – No (1, 0 p) Have you had either (or both) a new sex partner or multiple partners in the last 90 days? Yes – No (1, 0 p) Do you have more than one current sex partner at the present time? Yes – No (1, 0 p) Have you ever been told you had or been treated for a sexually transmitted infection in the past? Yes – No (1, 0p) How many sex partners have you had in the last 90 days? – 0-1; 2-4; 5-9; 10 or more (0, 1, 2, 3 p) When you have sex do you use a condom? – Always; Sometimes ; Never (0, 3, 3p)

53. Risk score 0-10 0-1 = low risk 2-3 = intermediate risk 4-6 = high risk risk 7-10 = very high risk Based on your score of 10 you are at Very High Risk risk for having a sexually transmitted infection now. Click here to order a free kit for a home collection of a sample to mail for a free test. Click here