The Need to Promote Sexual Health in America: A New Vision for Public Health Action.

Sexual health is considered to be a state of wellness with physical, emotional, mental, and social dimensions. Sexual health can contribute to our overall well-being in each of these dimensions. However, despite the intrinsic importance and positive aspects of sexuality in our lives, the United States presently faces significant challenges related to the sexual health of its citizens, including human immunodeficiency virus, other sexually transmitted infections, viral hepatitis, unintended pregnancies, sexual violence, sexual dysfunction, and cancers in reproductive tracts with serious disparities among the populations affected. In particular, high rates of poverty, income inequality, low educational attainment, stigma, racism, sexism, and homophobia can make it more difficult for some individuals and communities to protect their sexual health. Given that many pressing public health issues in the United States are related to sexual health and that sexual health has been increasingly recognized as an important national health priority, now is the time to energize and focus our efforts toward optimal sexual health of the population. In this paper, we outline the rationale for addressing sexual health as a means to better promote overall health and address sexuality related morbidities. In addition, we present a logic model outlining an approach for advancing sexual health in the United States, as well as a range of action steps for consideration by public health practitioners, researchers, and policymakers.

Outbreak of Human Pneumonic Plague with Dog-to-Human and Possible Human-to-Human Transmission--Colorado, June-July 2014.

On July 8, 2014, the Colorado Department of Public Health and Environment (CDPHE) laboratory identified Yersinia pestis, the bacterium that causes plague, in a blood specimen collected from a man (patient A) hospitalized with pneumonia. The organism had been previously misidentified as Pseudomonas luteola by an automated system in the hospital laboratory. An investigation led by Tri-County Health Department (TCHD) revealed that patient A's dog had died recently with hemoptysis. Three other persons who had contact with the dog, one of whom also had contact with patient A, were ill with fever and respiratory symptoms, including two with radiographic evidence of pneumonia. Specimens from the dog and all three human contacts yielded evidence of acute Y. pestis infection. One of the pneumonia cases might have resulted through human-to-human transmission from patient A, which would be the first such event reported in the United States since 1924. This outbreak highlights 1) the need to consider plague in the differential diagnosis of ill domestic animals, including dogs, in areas where plague is endemic; 2) the limitations of automated diagnostic systems for identifying rare bacteria such as Y. pestis; and 3) the potential for milder plague illness in patients taking antimicrobial agents. Hospital laboratorians should be aware of the limitations of automated identification systems, and clinicians should suspect plague in patients with clinically compatible symptoms from whom P. luteola is isolated.

Measurement of sexual health in the U.S.: an inventory of nationally representative surveys and surveillance systems.

OBJECTIVES: To identify opportunities within nationally representative surveys and surveillance systems to measure indicators of sexual health, we reviewed and inventoried existing data systems that include variables relevant to sexual health. METHODS: We searched for U.S. nationally representative surveys and surveillance systems that provided individual-level sexual health data. We assessed the methods of each data system and catalogued them by their measurement of the following domains of sexual health: knowledge, communication, attitudes, service access and utilization, sexual behaviors, relationships, and adverse health outcomes. RESULTS: We identified 18 U.S.-focused, nationally representative data systems: six assessing the general population, seven focused on special populations, and five addressing health outcomes. While these data systems provide a rich repository of information from which to assess national measures of sexual health, they present several limitations. Most importantly, apart from data on service utilization, routinely gathered, national data are currently focused primarily on negative aspects of sexual health (e.g., risk behaviors and adverse health outcomes) rather than more positive attributes (e.g., healthy communication and attitudes, and relationship quality). CONCLUSION: Nationally representative data systems provide opportunities to measure a broad array of domains of sexual health. However, current measurement gaps indicate the need to modify existing surveys, where feasible and appropriate, and develop new tools to include additional indicators that address positive domains of sexual health of the U.S. population across the life span. Such data can inform the development of effective policy actions, services, prevention programs, and resource allocation to advance sexual health.

Considerations for national public health leadership in advancing sexual health.

Nations across the globe face significant public heath challenges in optimizing sexual health, including reducing human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), sexually transmitted infections (STIs), unintended pregnancies, and sexual violence, and mitigating the associated adverse social and economic impacts. In response, some countries have implemented national strategies and other efforts focused on promoting more holistic and integrated approaches for addressing these syndemics. This article describes opportunities for national leadership to use a more holistic approach to improve the sexual health of individuals and communities.

Heterosexual anal sex activity in the year after an STD clinic visit.

OBJECTIVES: To describe heterosexual anal sex activity during a year and to identify factors associated with heterosexual anal sex and condom use during anal sex. METHODS: Secondary analysis of data from a trial conducted in 3 public sexually transmitted disease (STD) clinics. Patients described sexual behaviors every 3-months for the year. Logistic regression models with generalized estimating equations were used to include multiple observations for each subject. RESULTS: Two thousand three hundred fifty-seven heterosexual subjects reported on 6611 3-month intervals that included 9235 partnerships. About 18.3% of subjects had anal sex in a particular 3-month interval and 39.3% in the year. About 23.5% of subjects had anal sex in at least two 3-month intervals in the year. Anal sex was associated with having more sex acts, 2 or more sex partners, unprotected vaginal sex, and a main partner. For anal sex in the past 3 months, 27.3% of subjects consistently used condoms, and 63% of subjects never used condoms. Consistent condom use for anal sex was associated with having consistent condom use for vaginal sex, 2 or more partners, and anal sex with casual or new partner. CONCLUSION: STD clinic patients were commonly engaged in heterosexual anal sex, and most of them never used condoms during anal sex. Patients who had anal sex tended to also engage in other risk behaviors that put them at risk of STD/human immunodeficiency virus. Clinicians should ask about anal sex, appropriately examine and test patients who have had anal sex, and recommend condom use for both anal and vaginal sex.

Emerging antimicrobial resistance in Neisseria gonorrhoeae: urgent need to strengthen prevention strategies.

Prevention and control of gonorrhea is an important public health concern due to the high burden of disease, the recent increase in reported infection rates, and the reproductive and economic consequences of infection. Effective antibiotic treatment is one essential component of an integrated approach to gonorrhea control. Over the past 60 years, however, development of resistance in Neisseria gonorrhoeae to multiple antimicrobial classes challenges this component of gonorrhea control. An integrated, comprehensive prevention strategy should include enhancement of national and international surveillance systems to monitor antimicrobial resistance and new strategies to maximize the benefit and prolong the utility of antimicrobials, including combination regimens, implementation of screening recommendations for individuals at high risk for infection, and the assurance of prompt and effective treatment for infected persons and their sexual partners. Progress in controlling the epidemic and avoiding a resurgence as treatment options wane will require careful attention to all components of a comprehensive prevention strategy.

Risk factors for prevalent and incident Trichomonas vaginalis among women attending three sexually transmitted disease clinics.

GOAL: Trichomonas vaginalis is the most common nonviral sexually transmitted infection in the United States and may be associated with adverse birth outcomes and may also increase susceptibility to or transmissibility of human immunodeficiency virus. The purpose of this analysis is to describe the epidemiology of T. vaginalis in Sexually Transmitted Disease clinics and characterize the risk factors associated with prevalent and incident T. vaginalis within the same population. METHODS: We analyzed data from visits occurring during February 1999-December 2001 from 3 sexually transmitted disease clinics in Newark, NJ; Long Beach, CA; and Denver, CO. Data were analyzed from 1462 women aged 15 to 39 years who were tested by culture at their initial visit for T. vaginalis, and for 1269 women with at least 1 follow-up visit. Risk factors for prevalent infections at baseline and incident infections among treated or previously uninfected women were assessed. RESULTS: At baseline, 13.0% of the women had a prevalent infection; risk factors included the following: older age (> or =20 years), black race, having less than 12 years of education, and having a concurrent chlamydial infection. At follow-up, 4.6% of women had an incident infection; risk factors included the following: older age (35-39 years), black race, having a concurrent chlamydial infection, having had multiple sexual partners in the 3 months before incident infection, and having had T. vaginalis at the visit before their incident infection. CONCLUSIONS: T. vaginalis incidence is high in women. Risk factors for prevalent and incident infection are similar. T. vaginalis was associated with older age in women, unlike other sexually transmitted infections.

Problems with condom use among patients attending sexually transmitted disease clinics: prevalence, predictors, and relation to incident gonorrhea and chlamydia.

Condom use remains important for sexually transmitted disease (STD) prevention. This analysis examined the prevalence of problems with condoms among 1,152 participants who completed a supplemental questionnaire as part of Project RESPECT, a counseling intervention trial conducted at five publicly funded STD clinics between 1993 and 1997. Altogether, 336 participants (41%, 95% confidence interval: 38, 45) reporting condom use indicated that condoms broke, slipped off, leaked, or were not used throughout intercourse in the previous 3 months. Correspondingly, 8.9% (95% confidence interval: 7.0, 9.5) of uses resulted in STD exposure if partners were infected because of delayed application of condoms (4.3% of uses), breakage (2.0%), early removal (1.4%), slippage (1.3%), or leakage (0.4%). Use problems were significantly associated with reporting inconsistent condom use, multiple partners, and other condom problems. One-hundred thirty participants completing the questionnaire were tested for gonorrhea and chlamydia at this time and also 3 months earlier. Twenty-one (16.2%) were infected with incident gonorrhea and chlamydia, with no infections among consistent users reporting no use problems. Exact logistic regression revealed a significant dose-response relation between increased protection from condom use and reduced gonorrhea and chlamydia risk (p(trend) = 0.032). Both consistency of use and use problems must be considered in studies of highly infectious STD to avoid underestimating condom effectiveness.

Changes in sexual behavior and STD prevalence among heterosexual STD clinic attendees: 1993-1995 versus 1999-2000.

OBJECTIVE: To examine trends in sex behaviors and STD prevalence over time among heterosexual STD clinic populations from 3 urban STD clinics in the United States. STUDY DESIGN: Cross-sectional analysis comparing baseline data on risk (self-reported) and STDs (laboratory defined) from 2 randomized controlled trials evaluating counseling efficacy conducted about 5 years apart, Project RESPECT (1993-1995) and RESPECT-2 (1999-2000). RESULTS: The participants from RESPECT (n = 2457) and RESPECT-2 (n = 3080) were demographically similar. However, the proportion of participants reporting any unprotected anal sex was much higher in RESPECT-2 (women: 7% vs. 18%; men: 7% vs. 17%). Also, substantially more participants reported a new sex partner in RESPECT-2 (women: 43% vs. 61%; men: 54% vs. 72%). In addition, more women reported 2 or more partners (37% vs. 48%) and a partner with another concurrent sex partner (19% vs. 32%). Slightly more women and men in RESPECT-2 reported 2 protective behaviors, having an HIV test and any condom use; however, consistent condom use did not differ. Conversely, the proportion of participants with bacterial STDs (chlamydia, gonorrhea, or syphilis) was much lower in RESPECT-2 (women: 24% vs. 18%; men: 38% vs. 24%). CONCLUSIONS: Despite substantial promotion of safer sex behaviors over the past decade, many risk behaviors were stable over time, and some behaviors, such as unprotected anal sex, appeared substantially higher. Even in the absence of widespread behavior change, the prevalence of common bacterial STDs appeared to have decreased appreciably.

A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults.

Hepatitis B vaccination is the most effective measure to prevent hepatitis B virus (HBV) infection and its consequences, including cirrhosis of the liver, liver cancer, liver failure, and death. In adults, ongoing HBV transmission occurs primarily among unvaccinated persons with behavioral risks for HBV transmission (e.g., heterosexuals with multiple sex partners, injection-drug users [IDUs], and men who have sex with men [MSM]) and among household contacts and sex partners of persons with chronic HBV infection. This report, the second of a two-part statement from the Advisory Committee on Immunization Practices (ACIP), provides updated recommendations to increase hepatitis B vaccination of adults at risk for HBV infection. The first part of the ACIP statement, which provided recommendations for immunization of infants, children, and adolescents, was published previously (CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices [ACIP]. Part 1: immunization of infants, children, and adolescents. MMWR 2005;54[No. RR-16]:1-33). In settings in which a high proportion of adults have risks for HBV infection (e.g., sexually transmitted disease/human immunodeficiency virus testing and treatment facilities, drug-abuse treatment and prevention settings, health-care settings targeting services to IDUs, health-care settings targeting services to MSM, and correctional facilities), ACIP recommends universal hepatitis B vaccination for all unvaccinated adults. In other primary care and specialty medical settings in which adults at risk for HBV infection receive care, health-care providers should inform all patients about the health benefits of vaccination, including risks for HBV infection and persons for whom vaccination is recommended, and vaccinate adults who report risks for HBV infection and any adults requesting protection from HBV infection. To promote vaccination in all settings, health-care providers should implement standing orders to identify adults recommended for hepatitis B vaccination and administer vaccination as part of routine clinical services, not require acknowledgment of an HBV infection risk factor for adults to receive vaccine, and use available reimbursement mechanisms to remove financial barriers to hepatitis B vaccination.

High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening.

BACKGROUND: Studies show 11% to 15% of women treated for Chlamydia trachomatis are reinfected 3 to 4 months after treatment, suggesting the need for rescreening. There is little information on infections among men, infections with Neisseria gonorrhoeae or Trichomonas vaginalis, or long-term follow-up. OBJECTIVE: To determine the incidence of new sexually transmitted infections during the year after a visit to a sexually transmitted disease (STD) clinic and associated risk factors. DESIGN: Secondary analysis of data from a randomized, controlled trial (RESPECT-2). SETTING: 3 urban STD clinics. PATIENTS: Sexually active patients enrolled in an HIV prevention counseling trial. MEASUREMENTS: Patient characteristics at the initial visit; behaviors during follow-up; and new infections with C. trachomatis, N. gonorrhoeae, or T. vaginalis (women only) detected during 4 scheduled return visits and any other interim visits. RESULTS: 2419 persons had 8129 three-month follow-up intervals. Among 1236 women, 25.8% had 1 or more new infections (11.9% acquired C. trachomatis, 6.3% acquired N. gonorrhoeae, and 12.8% acquired T. vaginalis); among 1183 men, 14.7% had 1 or more new infections (9.4% acquired C. trachomatis, and 7.1% acquired N. gonorrhoeae). Black persons and those with sexually transmitted infections at baseline were at highest risk for recurrent infection (adjusted odds ratio, 2.5 and 2.4, respectively). For persons infected at baseline, the risk for infection was high at 3 and 6 months (16.3 per 100 three-month intervals) and remained high at 9 and 12 months (12.0 per 100 three-month intervals). Most (67.2%) infections were diagnosed during study-related visits, and 66.2% of these patients reported no symptoms. LIMITATIONS: Because patients were recruited from STD clinics, results may not be generalizable. CONCLUSIONS: Men and women who receive diagnoses of C. trachomatis, N. gonorrhoeae, or T. vaginalis infections should return in 3 months for rescreening because they are at high risk for new asymptomatic sexually transmitted infections. Although single-dose therapy may adequately treat the infection, it often does not adequately treat the patient.

The relationship between condom use and herpes simplex virus acquisition.

BACKGROUND: Few studies have evaluated the relationship between condom use and herpes simplex virus type 2 (HSV-2) and HSV type 1 (HSV-1) acquisition. OBJECTIVE: To assess the relationship between condom use and acquisition of HSV-2 and HSV-1 among men and women. DESIGN: Analysis of data collected as part of a clinical trial of an ineffective candidate vaccine for HSV-2. SETTING: Sexually transmitted disease clinics. PARTICIPANTS: Men and women at risk for HSV-2 acquisition, defined as having 4 or more sexual partners or having a sexually transmitted disease in the past year. MEASUREMENT: Acquisition of HSV-2 and HSV-1 as measured by viral culture or change to positive HSV serostatus. RESULTS: Of 1843 participants, 118 (6.4%) became infected with HSV-2. In multivariate analyses, participants reporting more frequent use of condoms were at lower risk for acquiring HSV-2 than participants who used condoms less frequently (hazard ratio, 0.74 [95% CI, 0.59 to 0.95]); categories of increasing condom use were 0% to 25%, 25% to 75%, and greater than 75% of sexual acts. Nineteen (2.9%) of 659 participants at risk for infection with HSV-1 became infected. No statistically significant association between condom use and infection with HSV-1 was found (hazard ratio, 0.79 [CI, 0.48 to 1.31]). LIMITATIONS: Use of condoms was measured by self-report, and persons who used condoms may have differed from those who did not. CONCLUSIONS: Consistent use of condoms is associated with lower rates of infection with HSV-2 and should be routinely recommended.