19th ISSTDR Quebec, Canada
July 10-13, 2011
Jens Boman
Smittskyddsläkare
Region Skåne
What are they asking? An analysis of
STD related calls to CDC-INFO
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Launched in 2005, 24 hours, 7 days a week
2010: 44,339 STD-related calls, 2,123 emails
11 categories and sub-categories
Top ten questions
– 1) Can you help me locate a STD testing site in my area?
– 2) What are the signs and symptoms of genital herpes?
– 3) If I am experiencing symptoms, how do I know if I have a sexually
transmitted disease or infection?
– 4) Are herpes simplex typ 1 and 2 spread the same way?
– 5) How is genital herpes transmitted?
– 6) How is genital human papillomavirus transmitted?
What are they asking? An analysis of
STD related calls to CDC-INFO
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7) How long does human papillomavirus infection last?
8) Is there a blood test to diagnose herpes simplex virus infection?
9) How is chlamydia transmitted?
10) Can human papillomavirus be treated or cured?
– The findings correlate with findings from traffic to the STD prevention
website (www.cdc.gov/std).
– 91% reported learning new information as a result of the call
– 68% indicated a desire to change a behavior based on the new
information
– Reducing risky sexual behavior was the most common type of
behavior change indicated
Chlamydia screening in an
International Resort Community
• An event-based outreach program to expand
access to asymptomatic Chlamydia screening
for young people who may not otherwise seek
testing
• 15 outreach screening sessions – 2-3 hours
• N = 112; 57,1 % males; 8,9 % CT-positive
• Conclusion: Free, event-based outreach
Chlamydia screening attracted people who
may not otherwise have been tested
STI rates and risk factors among
female sex workers in Germany
• 1 Jan-10—1-Apr-11; 1425 sex workers
attending STI testing sites in Germany
• HIV 0,2%, Syphilis 1,1%, CT 6,9%, GC 3,2%,
Trich 3,0%
• STI rates are highest among the younger,
uninsured, street-based women who do not
speak German + visit the STI clinic for the first
time + recently starting + unprotected sex
Integrating public health into the sex
worker community in Indianapolis
Cues to action
– Think back to the last time you received a female
wellness exam or got tested for STD. What
prompted you to schedule that appointment?
Integrating public health into the sex
worker community in Indianapolis
Perceived susceptibility
– Describe what worries you most when you think
about your health and how it’s affected by being
on the street
Integrating public health into the sex
worker community in Indianapolis
• Perceived barriers
– What are some of the reasons why women who
are working on the streets don’t get tested for
STD?
Identifying key topics for a description of sexual
behaviour among Danish adolescents
• Four semi-structured focus group interviews
of 19 adolescents, aged 18 to 23, who had
sexual experience
• Risk factors for unsafe sex/one-night-stands:
– alcohol consumption
– nights on the town, foreign countries, festivals
– low self-esteem (regretted sexual activity)
– increased sexual experience
Multiple bacterial STI in Ontario
• Approx. 100 000 clients with 113 097 reported bacterial
STI from 2006 to 2009 (four years)
• 24 % of STI were in individuals with multiple STI:s
• 12 % had more than one STI
• 2.4 % had 3 or more STI:s
• Maximum number of STI:s in one client was 12
• 27.8 % of women and 25.9% of men with their first STI
between age 10-14 had multiple STI:s
• Public health resources may be well spent because
almost 90 % of individuals only have one STI reported
Multiple bacterial STI in Ontario
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1 = 86 602
2 = 9 312
3 = 1 697
4 = 415
5 = 135
6=
31
7=
21
8-12= 13
Age of first sex is a factor in gay men’s
hiv/STI vulnerability
• Melbourne, Australia
• 854 Australian gay men born 1944-1993
• The younger that men were for their first anal
intercourse, the more likely they were to
report having HIV and other STIs today
• Significant: number of sex partners 12
months, group sex, hiv-positive, >2 STI 12
months, ever diagnosed hepatit A, B, C
HIV sexual risk factors among hivnegative msm using Internet
• Net Gay Baromètre, Quebec
• 3 718 msm, 2 345 hiv-negative
• Included = 1 794 msm seeking partners in
dating websites + at least one casual partner
in the last year
• UAI(HIV +/?) = live in Montreal region, are
seeking sensation, are seeking partners in sex
venues, and are regularly seeking partners on
dating websites
Don’t look at your patients, look at
their partners
• Questionnaire at 4 GUM-clinics in England
• Detailed questions on the (max) 3 most recent partners in the
3 months prior to clinic visit
• 24% of men and 14% of women had recent concurrent
partnerships (ps)
• 68% of men’s and 54% of women’s ps were < 3 months
• 43% of men’s and 27% of women’s ps were one-off
encounters
• Consistent condom use was low: 19% in women and 25% in
men
• High potential for STI transmission
Identifying women at risk
• Miami-Fort Lauderdale – high hiv rates
• Can future hiv infection be predicted based on GC, CT, early
syphilis and demographics?
• Hiv in women 11-89 years > 60 days after STD diagnosis
• An STD diagnosis and a few demographic variables (30+ and
zip code) can identify women at very high risk of acquiring hiv
(24% within a few years) – e.g. women with syphilis and older
women with GC.
• These women should be counseled to reduce their risk.
• CT is very common in young women and not a good predictor
of hiv.
Dual contraceptive use among
adolescents and young adults
• Simultaneous use of condoms and other contraceptive
methods provides maximum protection against unintended
pregnancies and STD
• Sexually active 12-25 years, California, 50.6 % female
• Contraceptive use:
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Nothing 21 %
Condoms only 53.9 %
Hormonal contraception only 9.2 %
Dual methods 15.5 %
Other 0.5 %
Dual contraceptive use among
adolescents and young adults
• Given the high STD rates among adolescents
and young adults:
– Population-level interventions should aim to
maximum condom use
– Individual-level interventions should take risk into
consideration, as well as patients’ preferences
Oral sex and risk of STI
Elaine Flagg, CDC
• All oral sex practices are associated with risk
of acqusition of one or more STI
– Insertive and receptive fellatio
– Insertive and receptive cunnilingus
– Insertive and receptive anilingus
• Eg: CT, GC, HSV, HPV, HIV
Chlamydia screeing
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www.chlamydiatest.nl
280 000 persons 16-29 years invited annually
Retest after 6 months in CT-positives
Amsterdam, Rotterdam, South Limburg
Low and decreasing participation
Annual uptake: 16 % - 11 % - 8 %
No significant decrease in positivity and
prevalence estimates
• NOT roll out this program
Group sex – Samuel Friedman, NY
• Linked to several STI and HIV outbreaks
• Huge gaps in what we know - this lack of
knowledge hampers prevention
• Group sex participation is quite common
– Rapid partner exchange
– Potential bridge environments between networks
– Men not always changing condoms
– Fingers, penises, and/or sex toys can transmit
Swingers – Anne-Marie Niekamp,
South Limburg, Netherlands
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Measure: level of concurrency past 6 months
106 partcipants, mean age 43 years
13,2 % pos STI
96 % steady relationship
9 % casual sex outside swinging with median 4
sex partners
• 59 % practiced group sex with median 3
partners
Swingers – Anne-Marie Niekamp,
South Limburg, Netherlands
• Median 10 times swinging with median 7
different swing partners in 6 months
• Increased STI risk (CT and GC)
– Frequency of swinging (> 12 times)
– Group sex without steady partners
– Total number of sex partners (11-15)
– Total number of sex partners (> 15)
– 32%
– 38 %
– 19 %
– 32 %
Gender differences in behavioral
correlates of biologically confirmed STI
• Amanda Berger, University of Maryland, USA
• Risk factors for STI:
• Men
– Young age at first sex
– Failure to use condom at last sex
• Women
– Multiple partnerships (>3 in 12 months)
– Lifetime number of sex partners
High CT and GC incidence, reinfection, and HIV
among workers in the adult film industry
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Christina Rodriguez-Hart, Los Angeles
2004-2008: 3 227 CT & GC cases
14,3 – 21,5 % had at least one CT-infection
5,1 – 7,7 % had at least one GC-infection
Reinfections within 12 months: 27 %
HIV 2004-2010: 10 HIV +
2010: 1 acute HIV+ - 2+/14 (14 %) – 8 weeks
2004: 1 acute HIV+ - 3+/14 (21 %) – 4 weeks
HIV in MENA – Middle East/North
Africa
• Concentrated hiv epidemics in several
countries – increasing incidence since 2005
• FSW 0,1-1 % of women; 0-70 % HIV+
• MSM 2-3 % of men; 0-52 % HIV+
• Linked epidemics eg.
– Iran IDUs 15 % hiv+, MSM 15 % HIV+
– Egypt 2006 IDUs 0,6 % HIV+, MSM 6,2 % HIV+
– Egypt 2010 IDUs 6,7 % HIV+, MSM 5,9 % HIV+
HIV in MENA – Middle East/North
Africa
• Overlap of risk behaviors among high-risk
populations
• MSM
– Consistent condom use < 25 %
– Low knowledge of HIV/AIDS
• Need for
– Increased surveillance
– Expand access to hiv-testing, prevention, and
treatment services
HPV –lunch meeting
• Genital warts are a marker of oncogenic HPV
infection
• HPV and cancer
– Cervical cancer
– Vulvar cancer
– Vaginal cancer
– Anal cancer
– Penile cancer
– Head & Neck cancer
100 %
40 %
60-90 %
80-90 %
45 %
12-70 %
HIV transmission – Myron S Cohen
• 38 % of HIV because of acute infections
• Infectiousness
– Blood viral load
– Genital viral load
– Inflammatory STD
• HPTN 052
– 1763 discordant couples – immediate or delayed
treatment (CD4 200-250 – normalt > 500)
– 28 linked infections: 27 delayed and 1 immediate –
96 % prevention
HIV strategies
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Counseling
ARV treatment
Circumcision
(Vaccine)
STD treatment?
Acute HIV infection?
PrEP
PEP
Concurrency – Jami Leichliter, CDC
• First & last date for three most recent
opposite sex partners
• Average duration increasing by age
• Current concurrency
– Women
– Men
0,3 %
2,1 %
Neglected issues
• HIV risk – anal intercourse in women 4-20 x
increased HIV risk compared to vaginal sex
• Increase in risk similar to primary infection
Anal sex in women
Joelle Brown, UCLA
• 141 women > 18 years
• Anal intercourse (AI) last month:
– White 17 %, unprotected 63 %, lube 75 %
– Black
14 %, unprotected 50 %, lube 38 %
– Hispanic 27 %, unprotected 40 %, lube 60 %
• Lube (=lubricant): commercial 38 %, saliva 23 %, petroleum jelly
(Vaseline) 15 %, lotion 12 %
• AI and HIV:
aOR 7,8 (1,6-37,6)
• AI and HSV-2: aOR 3,3 (1,2-9,1)
Rectal CT and GC in LA women
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Reported anal intercourse in previous 90 days
Limit: reporting bias for sensitive behaviors
716 women mean age 28 years (14-60)
CT (n = 114)
GC (n = 26)
– Urogenital only
14 (12 %)
– Urogenital + rectal 69 (61 %)
– Rectal only
31 (27 %)
– Rectal sampling: CT + 37 %, GC + 37 %
5 (19 %)
14 (54 %)
7 (27 %)
Jessica Ladd, JHU, Baltimore – Internet
testing for CT, GC, Tric ”I want the kit”
• CT in women who were rectally tested (n = 205)
– 15+ in both rectum and vagina (48 %)
– 7+ in vagina only (23 %)
– 9+ in rectum only (plus 2 who were not tested
vaginally) (29 %)
• GC in women who were rectally tested (n = 205)
– 3+ in both rectum and vagina (43 %)
– 2+ in vagina only (29 %)
– 2+ in rectum only (29 %)
Jessica Ladd, JHU, Baltimore
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14 % anal intercourse and always condom
8,2 % forced anal sex
70 % asymptomatic infection
36,8 % of rectal infections (CT,GC, Tric) would
not have been diagnosed with urogenital
sampling only
• CT + 41 % when rectal sampling added
• GC + 40 % when rectal sampling added
Netherlands – MSM and female
swingers
• 6 000 visits/year South Limburg STD clinic
• Female swingers rectal sampling
– Self reported anal intercourse: bad indicator
– Symptoms: bad indicator
– MSM: add oral + rectal sampling
– Female swingers: add rectal sampling
Quebec: www.msss.gouv.qc.ca
• Key public health functions
– Protection, Surveillance, Prevention, Promotion
• STI strategies
– Targeted communiction
– Early access to condoms and promotion of their
use
– Access to youth clinics
– Access to screening services
Quebec: www.msss.gouv.qc.ca
• 2010-2011 campaign
• Campaign for young people aged 15 to 24
• The campaign for preventing STI's aims at
encouraging young people to use condoms with
their partners and to continue using condoms
after their initial relations. Like last year, the
theme is "Beware and Be Aware." It reminds
young people that infected individuals do not
always have visible symptoms, which is why
always using condoms is so important. Condoms.
100% on.
Quebec - Poster 1
• More often than not, Chlamydia doesn't
reveal itself. 3 out of 4 people with Chlamydia
ignore the fact that they're infected.
• Poster "Girl" (1.7 MB)
Quebec - Poster 2
• More often than not, herpes doesn't reveal
itself. 9 out 10 people with herpes ignore the
fact that they're infected.
• Poster "Boy" (1.7 MB)
www.msss.gouv.qc.ca
• Campaign for adults aged 25 to 35
• The "Let's Take Action to Stop the Spread of
STIs" awareness campaign is calling on the
people of Québec to rally together. It aims at
informing the public about a significant rise in
STBBIs over the last several years and
convincing adults to protect themselves and
their close contacts.
Quebec- Poster 3
• Poster
• Sexually transmitted infections and bloodborne pathogens are spreading more than
ever. Let's take action to stop transmission.
(769.2K)
http://www.hivbigdeal.org/
• ”Josh is a 26-year-old gay man in New York
City. This is his story”
• Episode I: ”The morning after”
• Episode II: “The Test”
• To test or not to test? Find out what Josh
decides.
SEE THE VIDEO FOR GAY MEN
http://www.hivbigdeal.org/
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Taking about HIV is hard…
Having HIV is even harder.
Talk with all of your sexual partners about HIV.
If you don’t know your status, get tested.
• HIV is still a big deal.
– a project of the Medical and Health Research
Association of New York City, Inc. and New York
University
GC – HIV testing - USA
• HIV-testing in GC-positive patients
• Why?
– Sexually transmitted
– Within same networks
• Results (1 845 GC+)
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33 % never HIV-tested
16 % tested > 2 years
18 % tested 6 months - 2 years
33 % tested < 6 months
• Conclusion: suboptimal HIV-testing in the US
Oral and genital HPV in boys 14-17 y.
• N = 33, tested every 3 months, Roche PCR – 37
HPV-types
• 12/33 (36 %) HPV+ at visit 1
– HR-HPV 7/33 (5 = HPV-51)
– LR-HPV 13/33 (7 = HPV-84)
• 10/33 (30 %) HPV+ at visit 2
– Oral HPV 2/33 (1 HR-HPV)
– Multiple types at a single point and at follow up
BV risk in wsw
• Australia WSW 27 % BV (bacterial vaginosis)
• BV – the normal balance of bacteria in the vagina
is disrupted and replaced by an overgrowth of
certain bacteria.
• BV is sometimes accompanied by discharge, odor,
pain, itching, or burning.
• Risk factors
– Increased partner change
– Receptive oral sex
– Smoking
HPV-prevalence England
• NATSAL 2000
• Urine HPV-test
• Men 17 % HPV
– 9.6 % HR-HPV
– 3.9 % HPV-16/18
• Women 29 % HPV
– 15.9 % HR-HPV
– 5.5 % HPV-16/18
Predicting HIV in MSM
• 1 421 HIV+ MSM
– 6.3 % had been CT/GC pos within 1 year before
HIV-diagnosis
– 9.6 % had been CT/GC pos within 2 years before
HIV-diagnosis
– 11.9 % had been CT/GC pos within 3 years before
HIV-diagnosis
Internet
• http://www.sfcityclinic.org/
– STD basics
– STD risks chart
– What you can get if your partner is infected
– Example: Performing oral sex on a man
• Known risks: CT, GC, HPV, Syphilis, Herpes,
Hepatitis A, Shigella
• Possible risks: hepatitis B, HIV
• Unknown: hepatit is C
Internet
• http://www.stdpreventiononline.org/
– Press Release: Simple changes to dating websites
could decrease spread of HIV and STD
• http://www.syfilistest.nl/
• http://www.iwantthekit.org/
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Since June 2004
2 796 women – 8.9 % CT pos
1 029 men – 13.0 % CT pos
Now: CT, GC, Tric and rectal sampling
Now: Risk quiz
What’s your risk of having an STD
• Are you less than or equal 25 years old? Yes – No (1, 0 p)
• Have you had either (or both) a new sex partner or multiple
partners in the last 90 days? Yes – No (1, 0 p)
• Do you have more than one current sex partner at the present
time? Yes – No (1, 0 p)
• Have you ever been told you had or been treated for a
sexually transmitted infection in the past? Yes – No (1, 0p)
• How many sex partners have you had in the last 90 days?
– 0-1; 2-4; 5-9; 10 or more (0, 1, 2, 3 p)
• When you have sex do you use a condom?
– Always; Sometimes ; Never (0, 3, 3p)
Risk score 0-10
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0-1 = low risk
2-3 = intermediate risk
4-6 = high risk risk
7-10 = very high risk
Based on your score of 10 you are at Very High
Risk risk for having a sexually transmitted
infection now.
• Click here to order a free kit for a home collection
of a sample to mail for a free test.