Sexuality education policies and sexually transmitted disease rates in the United States of America.

The aim of the study was to test for relationships between state-level sex educational policies and sexually transmitted disease (STD) rates. We analysed US case reports of gonorrhoea and chlamydial infection for 2001-2005 against state policies for abstinence coverage in sexuality education, using the proportion of the population per state who identified as black (aged 15-24 years) as a covariate. We also tested for effects on 15-19 year olds versus 35-39 year olds and tuberculosis rates (the latter to ensure findings applied only to STD). States with no mandates for abstinence had the lowest mean rates of infection among the overall population and among adolescents. States with mandates emphasizing abstinence had the highest rates; states with mandates to cover (but not emphasize) abstinence fell in between. Rates in some states covering abstinence changed faster than in others, as reflected in sharper declines (gonorrhoea) or slower increases (chlamydial infection). These effects were not shown for tuberculosis or 35-39 year olds. Having no abstinence education policy has no apparent effect on STD rates for adolescents. For states with elevated rates, policies mandating coverage may be useful, although policies emphasizing abstinence show no benefit.

Emotional intimacy predicts condom use: findings in a group at high sexually transmitted disease risk.

Previous studies have reported an inverse relationship between condom use and emotional intimacy. The aim of this study was to determine the relationship between condom use and emotional intimacy. The study was a gonorrhoea case-comparison study with the samples being drawn from public health clinics (cases) and select bars/nightclubs (places) of Houston, TX (n = 215). Data were collected by questionnaires administered on a laptop computer. The majority of respondents were African-American (97.7%), women (69.3%) and had either high school or GED education (72.6%). Condom use with the last sexual partner was analysed along with intimacy with that partner assessed on a 3-point scale. Analysis showed that higher intimacy was related to greater condom use which was significant in men but not in women. In conclusion, these data were opposite to those of previous studies, which showed an inverse relationship between condom use and emotional intimacy. We hypothesize that in a high-risk environment, people exert more effort in protecting those they feel closer to. These data suggest a need to further explore the complex relationship between emotional intimacy and condom use.

A study on HIV and hepatitis C virus among commercial sex workers in Tallinn.

INTRODUCTION: Estonia is confronted by a dramatic expansion of the initially injection drug use-driven HIV epidemic. Little is known about HIV occurrence in population groups at high risk other than injection drug users. OBJECTIVE: To obtain data on the prevalence of HIV and hepatitis C virus (HCV) among female sex workers (FSW) in Tallinn. DESIGN: An unlinked, anonymous, cross-sectional survey of FSW recruited in Tallinn from October 2005 to May 2006. METHODS: 227 FSW were recruited for the survey and biological sample collection (HIV, HCV antibodies detection) using a combination of time-location, community and respondent-driven sampling. RESULTS: Among 227 women the HIV and HCV prevalences were 7.6% (95% CI 4.6% to 12.5%) and 7.9% (95% CI 4.5% to 12.6%), respectively. HIV prevalence was higher among FSW working in the street (odds ratio (OR) 6.4; 95% CI 1.1 to 35.6) and at the brothels and apartments supervised by the organised sex industry (OR 5.0; 95% CI 1.3 to 18.4). The duration of sex work was negatively associated with HIV prevalence (OR 0.78; 95% CI 0.63 to 0.97). CONCLUSIONS: Prevention needs of FSW in this area include increasing rates of HIV testing and putting in place effective programmes that can help extend HIV prevention behaviours across a range of sexual and drug use risk behaviours.

Process, efficacy and sample demographics of three approaches to behavioural surveillance for gonorrhoea: case interviews, place surveys, and network studies.

We investigated the process and time required to collect 450 interviews in a project to determine the most efficacious behavioural surveillance approaches to detect changes in gonorrhoea prevalence. In total, 150 respondents were recruited in each method. For each of place surveys (bars), gonorrhoea case interviews, and network studies based on seeds from the case and place interviews, we determined the recruitment rate and process. Urine testing for gonorrhoea and chlamydia took place in the place interviews. We present data from Houston, Texas that illustrate the sample characteristics, recruitment rates, and, where appropriate, infection rates. Data indicate that there was high uptake and a rapid recruitment rate from the place surveys, an intermediate rate from the network studies, and that the gonorrhoea case interviews were the most inefficient accrual method for behavioural surveillance. Sample characteristics and biases in each method are described, and conclusions drawn for the relative efficacy of each method for gonorrhoea behavioural surveillance.

Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.

Rates of HIV-1 infection are growing rapidly, and the epidemic of sexually transmitted infections is continuing at an alarming rate, in the Russian Federation. We did a cross-sectional study of sexually transmitted infections, HIV infection, and drug use in street youth at a juvenile detention facility, adults at homeless detention centres, and women and men at a remand centre in Moscow. 160 (79%) women at the remand centre were sex workers. 91 (51%) homeless women had syphilis. At least one bacterial sexually transmitted infection was present in 97 (58%) female juvenile detainees, 120 (64%) women at the remand centre, and 133 (75%) homeless women. HIV seroprevalence was high in women at the remand centre (n=7 [4%]), adolescent male detainees (5 [3%]), and homeless women (4 [2%]). In view of the interaction between sexually transmitted infections and HIV infection, these findings of high prevalence of sexually transmitted infections show that these disenfranchised populations have the potential to make a disproportionately high contribution to the explosive growth of the HIV epidemic unless interventions targeting these groups are implemented in the Russian Federation.

Patterns of age mixing and sexually transmitted infections.

Age mixing is an important indicator of sexually transmitted infection (STI) prevalence in partner pools. We use the 1995 National Survey of Family Growth (NSFG), a nationally representative sample of reproductive-age American women, to assess the extent of age mixing and to examine the association between age mixing and STI history. Almost half (48%) of the women in our sample report partnerships with much older or younger men. The likelihood of an STI diagnosis or receipt of STI care (test or treatment) increases as the age difference increases among adolescents. Women in their mid-to-late 20s with much younger partners report receipt of STI care more often than other women. Report of an STI diagnosis is more common among older women with much younger partners than among others of their age. Age-mixing information may be helpful for screening initiatives and targeting interventions aimed at decreasing STI rates, their sequelae, and STI transmission.

Quantitative non-radioactive clonality analysis of human leukemic cells and progenitors using the human androgen receptor (AR) gene.

Clonal analysis of FACS-purified primitive hematopoietic stem cells and of their progeny as assessed by the progenitors obtained from long-term cultures requires PCR-based approaches, mainly because of the low number of cells available. We have developed a non-radioactive androgen receptor (AR) assay which allows a simple and quantitative evaluation of the clonality of hematopoietic cells and progenitors. In this approach 5' AR primer is labelled by fluorescein and the amplified product is run on a sequencing gel which allows evaluation of the intensity of the fluorescent peaks generated. A computer software then analyzes the reduction of the intensity of the peaks on HpaII-digested samples. In order to determine the feasibility of the technique, we analyzed the clonality of leukemic cells from a patient with an acute-phase CMML which showed a typical clonal pattern of her leukemic DNA sample (WBC = 300 x 10(9)/I) using phosphoglycerate kinase (PGK) analysis. The same sample was then analyzed with either radioactive- or fluorescein-labelled AR primers, showing a typical clonal pattern (complete disappearance of one allele after HpaII digestion). A short-term clonogenic assay was then set up on methylcellulose and clonogenic progenitors were individually analyzed. All 24 colonies tested showed a typical clonal pattern with the disappearance of the same allele on each sample after HpaII digestion, indicating that they all derived from the same leukemic stem cell. Using this approach we then analyzed 94 patients with several hematologic malignancies and quantification of their fluorescent peaks. Fifty-four percent of the patients were clearly heterozygous (ie, a difference of > or = 2 CAG repeats was present between the two copies of the gene) and could be analyzed in an automatic sequencer using the fluorescent primers. Bone marrow mononuclear cells from all patients with acute myeloid leukemia (AML) showed a clonal or oligoclonal pattern at diagnosis whereas a polyclonal pattern was seen when remission was obtained. Similarly, out of 21 patients with a diagnosis of myelodysplastic syndrome (MDS), a clonal pattern was demonstrated in 10 whereas an oligoclonal or non-clonal pattern was shown in 11. These results show that this non-radioactive and safe technology can now be used on a large scale to evaluate the clonality of highly purified hematopoietic stem cells and their progenitors in hematopoietic malignancies and this might allow new insights into the targets of clonal amplification.

Fertility and use of cigarettes, alcohol, marijuana, and cocaine.

This study demonstrated that cigarette smoking was associated with an increase in both time to conception (among 2817 fertile women) and risk of primary infertility (among 1818 infertile women and their primiparous control subjects). The average time to conception was 4.3 months for women who never smoked, 4.6 months for those who smoked in the past, and 5.1 months for those who currently smoked. The delay in conception for current smokers remained significant after adjusting for confounders (risk ratio of 0.9 (0.8 to 1.0)). Additionally, current smokers were at increased risk of primary infertility (odd ratios of 1.9 (1.5 to 2.3)). For alcohol use, the average time to conception and risk of primary infertility did not vary by level of consumption. The average time to conception was significantly shorter for women who had used marijuana regularly and for women who had ever used cocaine than for women who had never used these drugs. Because of the increased use of marijuana and cocaine among young adults, further investigations of these associations are needed.

STD control in less developed countries: the time is now.

PIP: This discussion of sexually transmitted diseases (STDs) in less developed countries covers incidence/prevalence, antimicrobial resistance, sequelae, future trends, and new opportunities for STD control -- technological changes, health service changes, and social and political changes. For most countries, current, population-based information on STD is lacking, yet STDs appear to be common problems in nearly all countries. The prevalence of gonococcal infection in non-STD clinic populations has been as high as 5-20%, and incidence estimates made in a few settings have ranged from 3-10% per annum. These observations may overrepresent the STD problem, yet they have been identified in countries in Asia, Africa, and the Americas. The prevalence of reactive serological tests for syphilis among antenatal clinic attendees has been as high as 10-15% in some countries of Africa and the Western Pacific. Chancroid infection is extremely common in many of the developing countries of Asia, Africa, and the Americas. Penicillinase-producing "N. gonorrhoeae" (PPNG) infections are a dramatic example of the emergence and worldwide dissemination of resistant gonococci since 1976. At this time PPNG isolates constitute over 10% of all gonococcal infections in nearly all southeast Asian and Africa settings where this problem has been explored. PPNG cause more than 50% of gonococcal infections in some settings. As a result of increasing PPNG prevalence, penicillin, previously the standard therapy for gonorrhea, has been replaced by alternative agents in many settings. A variety of antimicrobial agents are effective for PPNG infections, but these are too expensive or unavailable in many developing countries. Sequelae of STD produce enormous direct and indirect costs. Acute pelvic inflammatory disease (PID) caused by gonorrhea, chlamydia, and other STD agents is common throughout the world. In developing countries ectopic pregnancy is a common surgical emergency. Improved diagnostic tests, new approaches to treatment of STD, and development of vaccines provide opportunities for better STD control, as have changes in health care delivery. The promotion of the primary health care concept, a shift in emphasis of the international family planning programs, as well as a focus on support systems of health programs all are crucial to STD efforts, and their improvement enhances STD control possibilities. Also, greater discussion of the STD health problems has led to more serious consideration of these diseases and their control.^ieng

Defining behavioral methods to prevent sexually transmitted diseases through intervention research.

This article focuses on efforts to use behavioral interventions to prevent STDs. Presented is a history of attempts to prevent and control STDs through behavior change and a summary of the main theoretic approaches to human behavior that have provided the scientific base for behavioral public health interventions. The authors also review the important behavior intervention studies, most of which have addressed chronic disease prevention. They specify the differences between behaviors that are associated with chronic disease and those that increase risk for STDs, as well as the implications of these differences for behavioral prevention of STDs. Finally, a review of the accumulating empiric evidence in the area of behavioral prevention of STDs is presented and a strategy for the development of methods to help change risk behaviors for STDS (including AIDS) is proposed.

Psychosocial aspects of genital herpes virus infection.

Genital herpes virus infection is one of the most prevalent and perhaps the most emotionally difficult of the sexually transmitted diseases. This article examines the current empirical and clinical understanding of the psychosocial aspects of the disease and proposes a framework for future investigation. Psychosocial issues of importance in the disease are discussed and responses characteristic of the psychosocial adjustment process are presented. Evidence of the role of stress and psychosocial factors is reviewed. Finally, a biopsychosocial research approach to the psychoneuroimmunological mechanisms of the disease is suggested as a way of understanding etiology and process.

The relationship among genital herpes simplex virus, stress, and social support.

Despite widespread popular belief in the activation of recurrent lesions in genital herpes simplex virus (HSV) by psychosocial stress, little empirical evidence supports that contention. This study retrospectively examined the role of stress in activation of HSV lesions as mediated by social support. Participants were 59 volunteers who had self-reported culture-positive genital HSV for at least 10 months. Measures of stress proneness (State-Trait Anxiety Inventory; STAI-Trait), recent stressful events (Schedule of Recent Events; SRE), and subjective appraisal of stress (global self-rating) were administered along with measures of general social support and herpes-specific social support. When retrospective reports of HSV symptoms were examined using a multiple-regression approach, duration of disease and amount of herpes-specific social support were found to be significant moderators of the relation between stress and number of HSV recurrences in the preceding 12 months. When duration of disease was short (less than 4 years), stress (SRE) and number of recurrences were positively associated; when disease duration was longer, there was no relationship. Similarly, at low levels of herpes-specific social support, a positive relation between stress (SRE) and number of recurrences was found. However, at higher levels of herpes-specific social support, no association was found. No relation was found between stress proneness (STAI-Trait) and HSV symptoms. However, subjective appraisal (global rating) of stress in the preceding 12 months was positively and significantly correlated with reported number of recurrences. Results are discussed in terms of their clinical implications.

Primary infertility: characteristics of women in North America according to pathological findings.

STUDY OBJECTIVE: To determine, in women with primary infertility, whether specific characteristics or behavioural factors are associated with the various pathological conditions identified as contributing to the infertility. DESIGN: Case-control study. SETTING: Seven institutions in the USA or Canada. PARTICIPANTS: Study subjects were 1750 women who presented with primary infertility, among whom the main pathological cause of infertility was male factor (417), tubal obstruction (231), endometriosis (194), luteal phase defects (153), other ovulatory problems (193), cervical abnormalities (92), and polycystic ovarian disease (84) and 1765 control women who delivered their first child at the same institution. MAIN RESULTS: Except for tubal obstruction and polycystic ovarian disease, the characteristics and behaviours of the women with infertility did not differ appreciably according to the pathological conditions recorded. Women with tubal obstruction had had more sexual partners, an earlier age at first intercourse, were more likely to have used an intrauterine device but less likely to have used a condom, and were more likely to have smoked cigarettes and to have used various recreational drugs than the other women. Women with polycystic ovarian disease were more obese, had had fewer sexual partners, and were less likely to have used cigarettes, contraceptives, and recreational drugs than the other women. CONCLUSIONS: Sexually transmitted infections seem to increase the risk of tubal obstruction but not other causes of infertility. Obesity is associated with polycystic ovarian disease. These data offer few clues to the aetiology of infertility attributed to endometriosis, cervical abnormalities, luteal phase defects, other ovulatory defects, or to male factors.

STD/HIV prevention in Turkey: planning a sequence of interventions.

This study was initiated to assess which mix of early STD/HIV prevention interventions would potentially be effective, cost-effective and sustainable in Turkey; and to program an intervention sequence to maximize synergy among the interventions. During rapid assessment we: 1) reviewed past issues of 3 leading newspapers; 2) collected information on TV coverage; 3) interviewed key informants including taxicab drivers, hotel employees, grocery store owners, academicians in public health and law, investigators of STD/HIV and reproductive tract infections, and officials in the ministry of health; 4) reviewed available evidence on STD/HIV morbidity, sexual behavior patterns, migration patterns and same/opposite gender sex trade. We found: 1) discrepancies between decision makers' perceptions and social realities with respect to the epidemiology of sexual behavior and STDs, and the state of public health programs; 2) discrepancies between sexual practices and public expression regarding sexual practices; 3) economic, demographic, and political pressures in Turkey and in surrounding countries for the expansion of prostitution; 4) a sexual double standard and gender specific migration patterns which sustain a high demand for commercial sex; 5) patterns of health care seeking behaviors and provision of STD clinical services which indicate other STDs may play a very important role in spread of HIV infection; 6) an important mass media role in opinion formation; 7) consensual denial of risk for the majority based on beliefs embedded in machismo, nationalism and religion, and a resulting marginalization and externalization of STD/HIV risk; 8) high prevalence of syphilis among both Turkish and immigrant female prostitutes in Istanbul (early latent 8 and 13%; late latent 0 and 4%; previous history 9 and 22%) 9) and high rates of syphilis among male prostitutes (early latent 11%, late latent 21% and previous history 58%). We concluded that interventions should initially include, in the following order; 1) awareness raising for decision makers and opinion leaders including members of parliament and mass media; 2) awareness raising for members of the general population; 3) needs assessment and intervention development for sex workers; 4) training in HIV and other STDs for medical personnel; and 5) quality assurance and control for laboratory procedures for STDs/HIV.

Sexually transmitted diseases: magnitude, determinants and consequences.

Sexually transmitted diseases (STDs) including human immuno-deficiency virus (HIV) infections constitute a major reproductive health burden for sexually-active individuals. The short-term and long-term consequences of STD have been well documented and include genital and other cancers, pelvic inflammatory disease, ectopic pregnancy, infertility, and adverse outcomes of pregnancy including pre-term delivery and low birth weight. The burden of sexually transmitted infections falls disproportionately on the young, the poor, minorities and women. At the societal level, there is a continuing need to educate people, particularly adolescents, about their risk for STDs and their sequelae and to increase the use of barrier methods including condoms. Policy decisions that facilitate more open discussion of sexuality and STDs, and that expand the accessibility and acceptability of sexual risk assessment, STD screening and treatment services would help decrease STD rates in the United States to levels similar to those observed in other industrialized countries.

Predictors of high-risk behavior in unmarried American women: adolescent environment as risk factor.

BACKGROUND: Heterosexual intercourse with two or more partners in a short time period represents a high-risk behavior for acquisition and transmission of sexually transmitted pathogens (STDs). Identification of factors that may predict high-risk sexual behavior can help to focus primary prevention strategies on women at risk for future acquisition of infection. METHODS: We analyzed survey data obtained in 1988 from a nationally representative sample of 8,450 American women of reproductive age in order to identify such factors. RESULTS: Of all sexually experienced unmarried women, 6.6% reported having had two or more sexual partners in the preceding three months. Earlier age at first sexual intercourse was associated with multiple recent partners, and with lower reports of abstinence. Birth region in the West, lack of attendance at religious services as an adolescent, and having a mother who had her first child before she was 25 years of age were factors associated with multiple recent partners. Among unmarried white women having a mother who worked full time and not living with both parents during adolescence were associated with multiple recent partners; among unmarried black women, the inverse was true (p for racial difference < .05). Multivariate analysis showed western birth region and earlier age at first sexual intercourse to be significant predictors of having multiple recent sex partners. CONCLUSIONS: Early environment and race influence later sexual behavior. These factors should be considered in targeting and planning education for STD prevention.

Emerging and reemerging infectious diseases: a multidisciplinary perspective.

Predictions that infectious diseases would be eliminated as a major threat to human health have been shattered by emerging and reemerging infections, among them acquired immunodeficiency syndrome (AIDS), hemorrhagic fevers, marked increases in infections caused by antimicrobial-resistant bacteria, and the resurgence of tuberculosis and malaria. Understanding the dynamics of emerging and reemerging infections is critical to efforts to reduce the morbidity and mortality of such infections, to establish policy related to preparedness for infectious threats, and for decisions on where to use limited resources in the fight against infections. In order to offer a multidisciplinary perspective, 23 infectious disease specialists, epidemiologists, geneticists, microbiologists, and population biologists participated in an open forum at Emory University on emerging and reemerging infectious diseases. As summarized below, the group addressed questions about the definition, the identification, the factors responsible for, and multidisciplinary approaches to emerging and reemerging infections.

The impact of sexually transmitted diseases on minority populations.

Sexually transmitted diseases (STD) are more prevalent among some minority populations in the United States than they are among the white majority. Primary and secondary syphilis occurs 45 times as often among non-Hispanic blacks as among non-Hispanic whites and 13 times as often among Hispanics as among non-Hispanic whites, according to morbidity reports received in 1988 by the Centers for Disease Control. Gonorrhea is reported more commonly among some minorities, with 1988 rates per 100,000 population being 54 for whites, 1,801 for blacks, and 201 for Hispanics. The reasons for the higher incidence of STD among some minorities are unknown. Data on racial differences in behavior and disease susceptibility are meager and do not account for the observed differences. Poverty, which is more common among some minorities than among the white majority, is closely associated with the prevalence of STD and may be a link between membership in a minority population and an increased risk.

HIV seroprevalence surveys in sexually transmitted disease clinics.

The Centers for Disease Control, in cooperation with State and local health departments, is conducting human immunodeficiency virus, type 1 (HIV), seroprevalence surveys, using standard protocols, in sexually transmitted disease (STD) clinics in selected metropolitan areas throughout the United States. The surveys are blinded (serologic test results not identified with a person) as well as nonblinded (clients voluntarily agreeing to participate). STD clinics are important sentinel sites for the surveillance of HIV infection because they serve persons who are at increased risk as a result of certain behaviors, such as unprotected sex, homosexual exposure, or intravenous drug use. HIV seroprevalence rates will be obtained in the sentinel clinics each year so that trends in infection can be assessed over an extended period of time. Behaviors that place clients at risk for infection, or protect against infection, are being evaluated in voluntary, nonblinded surveys to define groups for appropriate interventions and to detect changes in response to education and prevention programs. Although inferences drawn from the surveys are limited by the scope of the clinics and clients surveyed, HIV trends in STD clinic client populations should provide a sensitive monitor of the course of the acquired immunodeficiency syndrome (AIDS) epidemic among persons engaging in high-risk sexual behaviors.