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Taylor Erickson
Epi 220 Section AB
19 November 2016
Introduction
Sexually Transmitted Infections (STIs) are not new infections; they have been
documented since the era of the Egyptians, and are extremely common today, and STIs should be
considered a significant public health problem. In 2013, the Centers for Disease Prevention and
Control (CDC) estimated that there were 110 million cases of STIs in the United States [1],
highlighting just how common STIs are. The syndromes associated with STIs present a number
of health issues, including Pelvic Inflammatory Disease (PID), Genital Ulcer Disease (GUD),
infertility, cancers, and even death, are concerning for health care providers, epidemiologists, and
public health specialists as they figure out strategies to decrease the prevalence and incidence of
these infections. Although the risk of acquiring an STI is always present for those participating in
sexual activities, there are some populations that are more at risk than others. Young women age
16-24 in the United States make up one of these high-risk populations in comparison to their
male counterparts for a number of behavioral and biological reasons. Chlamydial infections are
especially prevalent in this population, but implementing an intervention called CHAT could
potentially decrease the incidence of new infections by targeting risky sexual behaviors that
female adolescents participate in.
Target Population
As previously stated, there are a number of contributing factors at put young women in
the United States at an increased compared to young men in the same age range of 16 to 24.
Young women are subject to biological and behavioral risk factors that can increase the odds of

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STI acquisition, and this predisposition is evident in the prevalence of STIs among women. In
2013, the CDC reported that the prevalence of STIs in women in the US was 59 million cases
compared to 50 million cases in men (No confidence interval stated) [1].
Biological predispositions affect a womans risk of STIs including the condition of
cervical ectopy. This condition common among young women creates a greater entry portal for
pathogens as the more vulnerable cells of the cervix are exposed during sex [2].
The behaviors that are typical of young women in this age group also affect the risk of
acquiring STIs. These behaviors include having multiple sex partners, and inconsistent condom
use also increases a womans risk as many adolescents do not use condoms every time they have
sex, or lack the skills to use them properly [3].
Some populations experience a greater risk of STI acquisition than others, and similarly,
some STIs have a greater prevalence among these populations than others. One STI that is very
common among young women age 16-24 is chlamydia.
STI
Known as the silent infection, chlamydia was first recognized in 1907 and is now
known to be caused by the intercellular bacterium Chlamydia trachomatis [4]. Chlamydia
infections are referred to as silent due to the asymptomatic nature of the infections, as 90% of
men and 70-95% of women do not show symptoms [5]. Because many people do not show
symptoms, many do not realize that they are infected until a laboratory test involving a vaginal
swab or urine test is conducted.
The asymptomatic nature of chlamydia can present many concerning health issues. In
young women, untreated chlamydial infections can lead to PID, which can result in the damage
of tissue in the reproductive tract of women, leading to infertility when left untreated [5]. The

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CDC estimates that 200,000 cases of infertility in the United States occur each year as a result of
untreated chlamydia [1]. The lack of symptoms can also make estimating prevalence and
incidence of chlamydial infections very difficult as many people do now know that they are
infected. Despite this difficulty of measurement, the CDC estimates that 1 in 20 sexually active
young women will acquire chlamydia [1]. Another concern is that after a womans chlamydial
infection is occurred, she can reacquire the pathogen and experience another infection, putting
herself once again at risk for the previously noted syndromes. Implementing an intervention that
could decrease the incidence of chlamydia in young women could potentially decrease the rate of
infertility caused by chlamydial infections.
Intervention and4 Effectiveness
Because the typical behaviors of young women increase their risks of chlamydia, the
CHAT Intervention, originally conducted in Baltimore, Maryland, is a strategy that could help
decrease the incidence of this particular infection [6]. CHAT is a form of behavioral intervention
that studied the incidence of STIs in a population of 169 heterosexual women age 18-55 years
old that participated in particular counseling sessions targeting risky sexual behaviors. These six
behavioral counseling sessions were held semi-weekly over three weeks and targeted specific
risk behaviors including unprotected vaginal or anal sex, having multiple sex partners in the last
90 days, and choosing high risk partners (i.e. intravenous drug users, HIV seropositive, or a man
that has sex with men). The main goal of this intervention was to reduce the incidence of STIs,
increase condom use, and increase STI communication in the study population [6].
This study was conducted as a randomized controlled trial, with 85 women randomized to
the study arm participating in the CHAT intervention, and 84 women randomized to the
comparison group that involved one behavioral counseling session that focused predominantly

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on Human Immunodeficiency Virus (HIV) risks. The previously mentioned risky sexual
behaviors were measured in each subject at 6, 12, and 18 months post-intervention. The study
found that 18 months after the intervention, CHAT participants were significantly less like to
participate in risky sexual behaviorsunprotected anal sex, unprotected vaginal sex, engaging
with multiple sex partners, and having partners that were drug users, MSM, or had an STIthan
the control group (AOR = 0.30, CI = 0.14, 0.64, p<0.01) [6].
Impact of Intervention
While CHAT did measure a statistically significant reduction in the noted risky sexual
behaviors in its study subjects, it did not explicitly measure the incidence of STIs in the 169
selected women [6]. The behavioral counseling reduced the rates of sexual behaviors that are
known to lead to higher risks of STIs and are especially common in the population of young
women age 16-24 which again include unprotected anal and vaginal sex, having multiple
partners, and having high-risk partners. Decreasing these sexual behaviors in young women
could decrease the incidence of chlamydia as young women would be experiencing less
opportunities of engaging in sex with an infected person or if they are engaging in sexual acts
with an infected person, condoms could stop transmission of the pathogen [. However, enacting
this intervention in a community-wide setting would be extremely difficult. The study contained
169 women that attended six 2-hour sessions over 3 weeks and featured both group sessions and
individual sessions. Funding the salaries of professionals to facilitate this counseling and also
gathering resources such as pamphlets and presentations necessary could be difficult with a high
capacity of participants. The study also did not address the biological risk factor that remains
which is cervical ectopy. Cervical ectopy is mostly found in young women [2] and while

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condoms can prevent transmission when used correctly, they are often not used correctly and the
vulnerable cells of the cervix are still exposed to pathogens.
If implemented, CHAT could reduce the incidence of chlamydia as it has been found to
effectively reduce risk behaviors in its participants, but any reduction in chlamydia incidence
will be small or short-lived. The follow-up assessments of participants lasted 18 months, with an
80% participant retention [6]. As time goes, women could revert to their old behaviors and the
interventions effects could be diminished. There is no data that shows a decrease in risky sexual
behaviors following the 18 months to prove that the effects are long-lasting. CHAT could
potentially be an example of a study that experiences high efficacy during the trial, but a low
effectiveness when implemented under real-world conditions at a community level.
Conclusion
Facing biological and behavior risk factors, young women age 16-24 in the United States
face an increased risk of acquiring STIs compared to their male counterparts. While cervical
ectopy is an uncontrollable condition of a womans cervix, risky sexual behaviors are very much
in control. These behaviors include having unprotected vaginal or anal sex, as well as having
multiple sex partners in a short time period. Intervening in the behaviors of young women is
important as many STIs in women are asymptomatic. Chlamydia is an example of an
asymptomatic STI that when left untreated can lead to PID, which can in turn cause infertility.
While the CHAT Intervention does target the aforementioned sexual behaviors, implementing
this intervention at a community level would not be worthwhile as the population is too large to
effectively reach for behavioral counseling. Also, the intervention was only measure for 18
months afterwards, thus leaving the long-term effects of the counseling unclear. Perhaps similar
behavioral counseling could be implemented in high schools as a possible alternative.

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References
1. US Centers for Disease Control and Prevention. Chlamydia-Rates of Reported Cases by Age
and Sex, United States, 2013 [Internet]; 2013. [Cited 2016 November 20]. Available from:
http://www.cdc.gov/nchhstp/newsroom/docs/factsheets/std-trends-508.pdf.
2. Lee V, Tobin JM, Foley E. Relationship of cervical ectopy to chlamydia infection in young
women. J Fam Plann Reprod Health Care. 2006; 32(2):104106.
3. Vasilenko SA, Kugler KC, Butera NM, Lanza ST. Patterns of adolescent sexual behavior
predicting young adult sexually transmitted infections: a latent class analysis approach. Arch Sex
Behav. 2015; 44(3):705715.
4. Budai I. Chlamydia trachomatis: milestones in clinical and microbiological diagnostics in the
last hundred years: a review. Acta Microbiol Immunol Hung. 2007; 54(1):522.
5. Cooksey CMJL, Berggren EK, Lee J. Chlamydia trachomatis Infection in minority adolescent
women: a public health challenge. Obstet Gynecol Surv. 2010; 65(11):729735.
6. Davey-Rothwell MA, Tobin K, Yang C, Sun CJ, Latkin CA. Results of a randomized
controlled trial of a peer mentor HIV/STI prevention intervention for women over an 18 month
follow-up. AIDS Behav. 2011; 15(8):16541663.