1. Anal sex is a Behavioral Marker for Laboratory-Confirmed STDs and HIV-Associated Risk Among African American Female Adolescents
Ralph J. DiClemente, PhD
Gina M. Wingood, ScD, MPH
Richard A. Crosby, PhD
Laura F. Salazar, PhD
Sara Head, MPH
Eve Rose, MPH
Jessica McDermott-Sales, PhD
Angela M. Caliendo, MD, PhD

2. Background
Sexually transmitted diseases (STDs) are a significant source of morbidity among adolescents ages 15-24
African-American females in the South are disproportionately affected by the intersecting epidemics of HIV and STDs.
One risk behavior that is understudied is anal sex.
Anal sex may be a marker for other risks behaviors and STD acquisition
A number of sexual behaviors have been identified as influencing African American adolescents’ risk for STD acquisition, including; poor condom use10-13, early sexual debut14, 15, and greater number of male sex partners.14, One behavior, however, that is understudied among adolescents is anal sex, particularly in the context of other STD/HIV-associated behaviors19 Anal intercourse, unprotected by condom use, may be a direct risk factor associated with a higher risk for HIV transmission relative to vaginal intercourse20-24 and is also linked to anorectal STDs Furthermore, anal sex may be a behavioral marker for other risk behaviors and STD acquisition

3. New AIDS cases across the US, 2005
Here, point out gaps in research: 30 Of the few studies that have examined the association between anal sex and other risk behaviors, these studies have not used a recent measure of anal sex, but instead have included measures of anal sex over broader time periods (e.g., lifetime, past 6 months) from study enrollment. Thus, the temporal association between anal sex and other, current risk behaviors is tenuous. Furthermore, most studies focus on a single risk outcome, with few examining the association of anal sex with a diverse profile of sexual risk behaviors and biological outcomes.
Among adolescents, there are a limited number of studies describing the prevalence of anal sex,31-35 and fewer examining the association between anal sex and adverse biological outcomes (i.e., STDs) and other HIV-associated risk behaviors.36 Furthermore, most of these studies have been conducted among older populations and have been geographically limited to California28, 30, 37, 38 or the northeastern U.S.29, 36 No study has been conducted in the Deep South; a region of the U.S. characterized by high rates of STDs and HIV.8, 9, 39 Furthermore, no study has focused exclusively on African American adolescent females nor provides subgroup analyses specifically for African American adolescent females; a subgroup disproportionately adversely impacted by the intersecting STD and HIV epidemics.28-30, 36-38
Try this slide out in Presentation mode – the map shows up first, and then when you click, the red dots appear. The red dots represent all cities / regions where anal sex (and associated behaviors) have been studied.
The Brown states are 2.2%-15.0% and the Light Yellow are 0.0%-0.2%
FYI: This image comes from avert.org, a website based in the UK. The map (in interactive form) can be found on the Kaiser website at the link cited in the slide. Kaiser got their data directly from: [Table 14, HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2005, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Department of Health and Human Services, Available at ]
Brown = highest concentration, Light yellow = lowest
Source: Statehealthfacts.org (Accessed October 2007) ‘New AIDS Cases, reported in 2005’, The Henry J. Kaiser Family Foundation.

4. Objective
To determine whether among African American adolescent females engaging in penile-anal sex is associated with a profile of other high risk sexual behaviors and laboratory-confirmed STDs

5. Methods: Sample 715 African-American females Recruitment sites:
Urban STD clinic
Teen clinic in large hospital
Family planning clinic
Eligibility:
15-21 years old
Sexually active past 60 days

6. Methods: Data Collection
Cross-sectional study
Audio-computer assisted self-interview (ACASI)
Sexual risk behaviors
Anal sex (past 60 days)
Self-collected vaginal swab
Chlamydia trachomatis
Neisseria gonorrhoeae
Trichomonas vaginalis
Approved by Emory IRB

7. Methods: Data Analysis
Bivariate analyses: prevalence ratios, 95% confidence intervals, P-value; significance was set at α < .05
Hierarchical logistic regression model
Conducted to adjust analyses for key covariates:
Age
Residing with family member
Please check the data analysis slides

8. Results: Sample Characteristics
Mean age 17.8 years (+ 1.7)
75.8% reside with family member
65.3% enrolled in school
28.8% positive for 1 of 3 STDs
17.6% C. trachomatis
4.9% N. gonnorhoeae
12.9% T. vaginalis
10.5% prevalence of anal sex (past 60 days)

9. Results: Bivariate Associations
Outcome Anal Sex No Anal Sex PR 95% CI P
(n = 75) (n = 640)
Positive for at least one STD
40.0% 27.5%
Sexual Risk Profile
Any unprotected vaginal sex
78.7% 56.9%
Last vaginal sex was unprotected
77.3% 65.8%
Boyfriend has sex with other females
40.7% 29.0%
Had sex while high or drunk
56.0% 29.5%
Had sex while partner was high or drunk
60.0% 43.1%
Could you please direct me as to how you’d like this displayed? The text will not increase further without bad formatting. I could put it in bullets / text, but you lose the ability to get an overall view. For one of my other presentations, I graphed the four significant variables… but you have nearly 8 significant variables…

10. Results: Bivariate Associations cont.
Outcome Anal Sex No Anal Sex PR 95% CI P
(n = 75) (n = 640)
Sexual Risk Profile cont.
Lifetime # of vaginal sex partners > 4
(58) 77.3 (421)
Had vaginal sex with 2 or more partners
(35) 46.7 (202)
Had sex with a casual partner
(26) 34.7 (199)
Had sex with a partner recently incarcerated
(17) 22.7 (105)
Had sex with partner at least 5 years older
(19) (79)

11. Multivariate Analysis

12. Multivariate Analysis

13. Limitations Cross-sectional study design
Self-reported data for sensitive behaviors, potential recall bias
Convenience sample
Findings limited to African-American female adolescents
Would you like a conclusions slide after this? I inserted one and thought it may be repetitive or put you over your time limit.

14. Discussion
Adolescents reporting recent anal sex had a higher prevalence of STDs and other risk behaviors.
Of 10 risk behaviors examined, 6 remained statistically significant after adjustment.
Anal sex as a behavioral marker may be useful to facilitate efficient sexual health screening.
From a clinical perspective, separating cause and effect as to the temporal association between anal sex and other HIV/STD-associated risk behaviors may be less important than understanding that experiencing anal sex among African American female adolescents is a useful marker for other risk behaviors. Whether anal sex preceded other HIV/STD-associated risk behaviors, co-occurred with other HIV/STD-associated risk behaviors, or is a consequence of one or more of these other risk behaviors is a complex question that awaits additional, more detailed study. Nonetheless, the evidence suggests that many health risk behaviors, sexual risk behaviors being no exception, do not occur in isolation; rather they often cluster with other risk behaviors and adverse health outcomes, as our findings indicate when examining the association between anal sex and other sexual risk indices.45, 46

15. Implications for Practice
Healthcare providers can screen for anal sex as a marker of other risk behaviors
Assessing history of anal sex in clinical assessment
straightforward
allows clinicians to screen adolescents efficiently
Pediatricians, adolescent medicine specialists, and family practitioners have an integral role to play in adolescent health promotion47, 48 as they are primarily responsible for providing care to adolescents. Moreover, pediatricians can assess adolescents’ sexual risk behaviors and adverse health outcomes (i.e., STDs) and provide preventive education, risk-reduction counseling, and referral for a more detailed physical and laboratory evaluation and specialized counseling.49–54 Specifically, findings from this study suggest that screening for anal sex is a critically important practice given its relatively high prevalence in a short time period and because anal sex may serve as a useful indicator of other sexual risk and STDs. Assessing a history of anal sex in a clinical assessment during the intake procedure or comprehensive medical history is relatively straightforward, thus allowing clinicians to screen adolescents efficiently in general medical settings.

16. Acknowledgement
This study was supported by a grant from the Center for Mental Health Research on AIDS, National Institute of Mental Health, NIH