Académique Documents
Professionnel Documents
Culture Documents
STInfections STDiseases
STI or STD? • Bacterial Vaginosis • Chlamydia (1.5 million//2.8 million)
• Non-GC Urethritis • Gonorrhea (431.000/718,000)
Infection: Invasion by Disease: Pathologic
• Trichomoniasis • LymphogranulomaVenereum
and multiplication of condition,
(1.9 million//7.4 million) • Granuloma Inguinale
bacteria or impairment,
• Molluscum Contagiosum • Chancroid
microorganisms that abnormal function,
i.e. anatomic or • Hepatitis A
can produce tissue physiologic change, STInfestations • Hepatitis B (7,500//78,000)
injury. Many protracted or Scabies • Hepatitis C (NA//25.000)
infections can be prolonged, Lice • Syphilis (8,200//70,000)
treated and cured and sometimes • HIV (15,000//40,000)
the tissue returned to permanent. Many Estimated Incidence 2000 • HPV (4.6 million//6.2 million)
processes can cause 15-24 y//overall • Herpes I genital
normal; other
9.1 million//18.9 million
infections result in disease, including Weinstock et al. Perspectives on Sexual
• Herpes II genital (640,000//1.6 million)
disease. some infections. and Reproductive Heatlh 2004:36(1)
1
HPV Infection… Primary Prevention
Reduce Duration of Infectivity: Treatment? Cervicovaginal HPV Infection in
Genital Warts (HPV) College Women: Natural History
• Primary goal: removal of warts Ho 1998 Winer 2003
• Treatment possibly reduces, but does not eradicate # Enrolled in study 608 444
HPV infectivity
• Whether reduction of HPV DNA in genital tissue
impacts future transmission remains unclear
Already infected at entry 26% 19.7%
Subclinical Genital HPV (SIL absent)
• No treatment that eradicates infection Others infected during study 43% 38.8%
• Genital HPV “frequently goes away on its own” (over 3 yrs) (over 2 yrs)
• Tx not recommended
Ho,G.Y.F., et al: NEJM 1998;338:423-8 Winer,R.L.,et al: Am J Epidemiol
CDC STD Treatment Guidelines 2003;157(3):218-226
2006
10% remain infected at at 5 years (NEJM 2003) – 2003-2004: women age 14-59
– Self-collected vaginal swab for HPV DNA PCR
Overall HPV prevalence 26.8%
Risk of developing Squamous Intraepithelial HPV vaccine types 6/11/16/18 detected in 3.4%
Lesion (SIL) is associated with persistent carcinogenic types 16/18 prevalence of 2.3%
infection with a high risk type for at least 6 Conclusion: HPV common but prevalence of HPV
months vaccine types relatively low
. JAMA editorial on mandatory vaccine: “unwise”
Wright TC, NEJM 2003;348:489-490,518-527
Ho,G.Y.F., et al: NEJM 1998:
338:423-8
2
Prevention of Cervical Cancer
How important is the Pap test? HPV in men/boys
Of those diagnosed with cervical cancer… • Most develop no symptoms or problems
half have been non-adherent to screening: • 1% sexually active men have had genital warts
28.5% had never had a Pap test • HPV vaccine not licensed for men
32.8% no Pap x 5 or more yrs • Penile cancer rare (1250 in 2008) American Cancer Society 7/11/08
Am J Public Health. 1995 Jun;85(6):791-4
• Anal cancer rare (2020 men, 3050 women in 2008)
46% had never had a Pap test or no Pap x 3 yrs
CMAJ. 1997 Sep 1;157(5):513-9
-American Cancer Society 4/25/07
53% no Pap x 3 yrs – However, 17 X more common in MSM
Cancer. 2000 May 15;88(10):2283-9 – ?Anal PAP tests
56% no Pap x 3 yrs » HPV and Men CDC Fact Sheet 4/3/08
Natl Cancer Inst. 2005 May 4;97(9):675-83
3
Mandatory HPV Vaccine Mandatory HPV Vaccine
Public Health vs Private Wealth: 2007 JAMA EDITORIAL Public Health vs Private Wealth: 2007 JAMA EDITORIAL
Gostin LO, DeAngelis CD, JAMA. 2007;297:1921-1923. Gostin LO, DeAngelis CD, JAMA. 2007;297:1921-1923.
1) Given that the overall prevalence of HPV types 3) Compensating injured vaccine recipients: if
associated with cervical cancer is relatively low state-mandated, courts may hold that
(3.4%)* REVISED 2.3%** and that the long- manufacturer has no (or reduced)
term effects are unknown, it is unwise to responsibility
require a young girl with a very low lifetime 4) Not highly infectious airborne disease, ie Not
risk of cervical cancer to be vaccinated without in compulsory vaccination paradigm
her assent and her parent's consent. *Dunne et al. 5) Submit girls to vaccine as a condition of
Prevalence of HPV infection among females in the United States. JAMA. 2007;297:813-
819 **Erratum JAMA 2007;298(2):178 publicly funded education, but not boys?
2) Generous religious and conscientious 6) Who will pay for the mandated HPV vaccine at
exemptions may cause legislators to extend the loss to society of what else?
these to other childhood vaccinations, which
7) Key to success of public health policies is
would be detrimental to the public's health.
Salmon DA, et al. Compulsory vaccination and conscientious or philosophical community acceptability
exemptions: past, present, and future. Lancet. 2006;367:436-442
Seroprevalence of HSV-2
National Health and Nutrition Examinations Survey How is Genital Herpes Spread?
(NHANES) Key large ongoing USA population-based study • HSV-1 and HSV-2 are transmitted through direct
• HSV-2 Seroprevalence rose 30% from 1976-1994 contact: kissing, sexual contact (vaginal, oral, or
– NEJM 1997;337:1105-1111 anal sex), or skin-to-skin contact
• 1988-1994: 21% of US population age 12 and older (45 – Transmitted with or without the presence of
million people) positive for HSV-2
sores or other symptoms JAMA 2000;283:791-794
• 1999-2004: 17% (indicates reversal of trend)
• Prevalence rates higher if
• Up to 30 percent of first episode genital herpes is
– initiated intercourse age < 17 yrs (21.1%)
now HSV-1 in type CDC, STD Treatment Guidelines 2002 MMWR
2002:51[RR-1]
vs > 18 yrs (14.3%) – Oral sex is most likely the source, from
– greater number of lifetime partners: 3.8% w/1 shedding in the mouth Tyring, Dialogues in Dermatology
vs 39.9% w/>50) 1998
-JAMA 2006;296:964-973
4
Increasing Proportion HSV I What is Sex?
Genital Infection Dorland’s Medical Dictionary 1965
Intercourse: mutual exchange, sexual i., coitus
• U of WI 1993-2001 reviewed genital Coitus: sexual union between individuals of opposite sex
Webster's 1984
isolates Intercourse: 1) exchange between persons… 2) sexual
• HSV I increased from 31% in 1993 to 78% intercourse syn coitus
in 2001 Coitus: : Physical union of male and female sexual organs
leading to orgasm and ejaculation of semen
• HSV I had become the most common cause Male sex organ = Penis Female sex organ = Vagina
of new genital herpes on campus (simulations include mouth, anus, other)
» Sex Transm Ds 2003;30:797-800 Dernovsek 2001
Sexual Intercourse: Stimulation of a partner to orgasm via
vaginal, oral, anal, non-genital ie “mutual masturbation”
Dernovsek KK Pract Derm Dec 2004
ABSTINENCE
91% abstinence highly effective
94% believe patients will not abstain
…54% recommend it
• The most reliable way to avoid transmission • Counseling that encourages abstinence
of STDs is to abstain from sexual from sexual intercourse is crucial
intercourse (i.e., oral, vaginal, or anal – for persons who are being treated for an STD
sex) – or whose partners are undergoing treatment
– and for persons who wish to avoid the possible
• or to be in a long-term, mutually consequences of sexual intercourse (e.g.,
monogamous relationship with an STD/HIV and unintended pregnancy).
uninfected partner.
MMWR 2006;55[No.RR-11]3 MMWR 2006:55[No.RR-11]3
5
Introduce Topic with Abstinence Brochure
Lifestyle Abstinence
• I have this brochure for you ...
• What? • When?
• Have you ever heard of abstinence?
– Lifestyle choice – Now
• This has nothing to do with your moles, but…
– Restraint from all – Never too late • this is important for your future health...
forms of sexual • Why? • I don’t want to have to treat you for this in the future...
intercourse – Prevention of skin- • Dermatologists also have to treat STD’s...
• How long? to-skin disease • Did you know that 1 in 5 sexually active people….
– Until selection of transmission • Now is the time in your life to be thinking about
lifelong partner – Maintain health where you will stand on this subject
Dernovsek KK. School Hlth Rptr
Spring 2003
6
“Always” use / “Consistent” use
Factors Influencing Condom
AND
Failure in Real Life
Correctly every time?
• User Failure (Incorrect Use)
• College males: “Consistent Users”
– Genital contact before putting condom on – 1 in 10 episodes of condom use exposed individual to
– Flipping condom over after initial application risk of disease via method or user failure
– Fingernail holes poked in condom – Leaving 33% at risk in prior month
• >>STD’98;25(6):273-277
– Use of oil based lubricants
– Improper positioning of condom
• HIV serodiscordant heterosexual couples
– Not holding on to condom during withdrawal – 171 ALWAYS used condoms
– 3 seroconversions occurred over 24 months
– Not withdrawing while penis erect
(1.1% incidence rate) JlAcqImmDefSyn’93;6(5)497-502
MMWR, 1993; 42(30):589-91
The Condom Report: July 2001 The Condom Report: July 2001
138 papers reviewed by panel of 28 Experts 138 papers reviewed by panel of 28 Experts
Strong evidence for the effectiveness of condoms for
• HPV
reducing sexually transmitted…gonorrhea for men
– …no epidemiologic evidence that HIV/AIDS: Consistent condom use decreased
condom use reduced the risk … the risk of HIV/AIDS transmission by
– might afford some protection… approximately 85% Scientific Evidence on Condom Effectiveness for Sexually
Transmitted Disease (STD) Prevention, summary report prepared by NIAID,NIH,DHHS,July
Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention,
summary report prepared by NIAID,NIH,DHHS,July 20, 2001 20,2001
7
Risk Compensation
Definition: Perception of reduced risk paradoxically
increasing the risky behavior, resulting in actual
increased risk
Examples:
Condom use by Ugandan men offset by # sex
YAZ Package Insert “PI” says…
partners (Kajubi et al J Acq Immune Defic Syndr 2005 Sep 1;40(1):77-82)
…YAZ is indicated for the treatment of
HIV prevalence (1990-2001) as condom sales moderate acne vulgaris in women at least
14 years of age, who have no known
Cameroon, Kenya, Botswana Hearst, Chen, Evidence that Demands Action Medical Institute
contraindications to oral contraceptive
therapy and have achieved menarche. YAZ
1989-2000, South Africa, Kenya and Botswana had should be used for the treatment of acne
highest rates of condom availability and highest only if the patient desires an oral January 29,2007
HIV prevalence (20%-36%) Green EC, Evidence that Demands Action Medical Institute
contraceptive for birth control…
berlex.bayerhealthcare.com/html/products/pi/fhc/YAZ_PI.pdf Accessed
7/21/08
8
Is Abstinence Realistic?
Effecting Positive Behavior
Who Has Never Had Sexual Intercourse?
Change: Successes • 75% of 7-12th graders Kaiser Family Foundation Rpt, 9-26-00
• Alcohol Related Automobile Deaths • 70% of teens ages 15-17 Kaiser Family Foundation, May 2001
• 66% of 9th graders MMWR 9-27-2002 /51(38);856-859
• Child Bicycle Helmets • 64% of teens ages 15-17 KFF/Seventeen:Relationships, 10-2002
• Seat Belts • 10.5% more 11 th Grade Boys in 2001 than in 1991
• MMWR 9-27-2002 /51(38);856-859
• Tobacco Awareness and Cessation • 67% of teens ages 15-17 KFF/Seventeen:Virginity and the First Time 10-2003
• 63% of teens ages 15-17 KFF/National Survey of Adolescents and Young
• 911/CPR /Awareness of Early Sx and Signs Adults:Sexual Health Knowledge, Attitudes and Experiences 2003
• 67% of teens ages 15-17 KFF/National Survey of Teens about Sex: Birth Control and
• Decreased Use of Inappropriate Antibiotics Protection 7-2004
• Increased Skin Cancer Awareness • 52% of teens ages 15-19 (MMWR 6/6/08)
55 60 61.5
54.1
50
% 15-19 yo
50 46.2 47.8
Ever had sex 40
45 Sex w/4 or more
%
Used condom 30
40
20 18.7
35 14.9
10
30
2 0
71
78
85
92
99
06
0 1991 2007
19
19
19
19
19
20
0
Females Males All 7
9
With One Voice 2007
Ages 12-19
With One Voice 2007
• 91%: important to have a strong message
• 75% (73%) do not think it is embarrassing from society to abstain from sex until they
to admit they are virgins are at least out of high school ( 93% reported same in
– 73% Males (66%) 78% Females (80%) both The Cautious Generation: What Do the Teens Say? NCTPTP 4-27-00 and With
One Voice 2002, 92% in With One Voice 2003, 94% in With One Voice 2004))
– 75% Ages 12-14 (2002) 81% Ages15-19 (2002)
– • Of teens who had had sex: 60% (66) (67) (63)
• 82% said teens should NOT be sexually active wished they had waited longer
63% (60) (55) boys 69% (77) (70) girls
(2003) (80% in 2002)
71 % (83) (81) ages 12-14 63% (60) (55) ages 15-19
(2003) (2002) (2004) (2003) (2002)
1986 1991
20 – 39%
10 – 20%
5 – 10%
1 – 5%
0 – 1% -----------Uganda 6.7% HIV prevalence 2005
trend data unavailable 1996 2001
outside region
10
UGANDA: “Zero Grazing”
You tether your animal around a tree, and it can
only feed where it is tethered
Dr V. Nantulya, ID consultant to President Museveni
A bstinence
B e Faithful
Or wear a Condom
The Monitor 2-04-04
(Ugandan newspaper)
pleasure and sometimes sacrifice” • “The most important determinant of the reduction
in HIV incidence in Uganda appears to be a
and teaching them a different lifestyle decrease in multiple sexual partnerships and
"will ensure their survival" networks”
• “The effect of HIV prevention interventions in
Uganda (particularly partner reduction) during
Ugandan First Lady Janet Museveni the past decade appears to have had a similar
February 20, 2002 impact as a potential medical vaccine of
80% efficacy.”
http://usinfo.state.gov/topical/global/
hiv/02022710.htm
www.sciencemag.org
SCIENCE VOL 304 30 APRIL 2004 2003 ISBN 0-86569-316-1
11
The Ugandan Success is Key to
HIV: A Worldwide Crisis
Combat AIDS Worldwide
The Ugandans showed that sexual behavior patterns • Every eight seconds a person is
could be changed by an entire population with infected with HIV somewhere in the
resultant improved health: world (6800 new infx/day)
-HIV prevalence in Uganda was already irrefutably
decreasing before 1995 (WHO/UNAIDS maps and Hogle,
• 68% of the 33.2 million people with
JA et al. What Happened in Uganda? Washington DC, 2/5/2002) HIV live in Sub-Saharan Africa
» (WHO/UNAIDS 11/07)
- Increase in abstinence and reduction of multiple
partners documented before 1995 (Stoneburner RL, • Young people between 15 and 24
Science, 2004 Apr 30;304:714-7.) account for 40 percent of new
- Condoms did not enter Uganda until 1995 or later infections worldwide
(Green EC et al. AIDS Behav. 2006 Jul;10(4):335-46) » (WHO/UNAIDS 12/06)
Impact of AIDS on life expectancy in five African countries, Perhaps there should be….greater
1970–2010 equity in resource allocation
70 between HIV/AIDS prevention
65
60 Botswana
programs (promoting
Life
55
South Africa
monogamy/fidelity) and
50
expectancy
at birth 45
Swaziland
condom programs?
(years) 40 Green,EC, STI 2000, 76:145
35 Zambia
30
Zimbabwe The Lancet November 27, 2004
25
20 The time has come for common ground on
1970–1975 1980–1985 1990–1995 2000–2005
1975–1980 1985–1990 1995–2000 2005–2010 preventing sexual transmission of HIV
Daniel T Halperin, Markus J Steiner, Michael M Cassell, Edward C Green,
Norman Hearst, Douglas Kirby, Helene D Gayle, Willard Cates
Source: United Nations Population Division (2004). World Population Prospects: The 2004 Revision, database. Followed by one and one-half columns of endorsees
4.1
12