2004 STD Prevention Conference - Plenary and Mini-Plenary Abstracts

The Global Context of STDs in the US: Microbial Threats and the Public Health Response

PF Sparling
University of North Carolina, Chapel Hill, NC

The threat of microbes to the health of the public has received increasing attention in the last several years both because of natural evolutionary causes and concern about intentional forces. In addition, infectious diseases, caused by both new infections and old ones that have changed, remain a considerable burden in both developing and industrialized countries around the world. In the STD prevention and control arena, antibiotic resistance and mutating bacteria have presented a growing challenge to ensuring the public health. The threat of microbes is further challenged by contextual factors. As pointed out in the recently released Institute of Medicine report, Microbial Threats to Health: Emergence, Detection, and Response, such factors include: human vulnerability to infection; human demographics and behavior; international travel and commerce; breakdown of public health measures; poverty and social inequity, and lack of political will. Clearly, microbes and the global context within which they reside demands that we no longer simply address STD prevention in the United States apart from the rest of the world. Rather, we must recognize both natural and intentional microbial threats that cross borders and thus must be addressed globally. Many STD public health staff are all too familiar with efforts to fight bioterrorism, given the disproportionate number who have been asked to join the public response team. This session will challenge assumptions about what is necessary for STD prevention in the United States. Factors that call for STD prevention to be examined from a global vs. national perspective will be examined. The session will further provide additional insight into the latest naturally occurring microbial threats to STD prevention and control. The relationship between STD prevention and readiness efforts for bioterrorism will also be explored.

Program, Policy, and Politics: Reflections of a State Health Official

W Kassler
NH Department of Health & Human Services, Concord, NH

Public health policy development at the state level is often far removed from the science and research done in academic institutions and in federal agencies. Often, those doing the research and translating that research into program guidance do not have the perspective to appreciate the state and local political context. Those working in STD prevention programs at state and local health departments are certainly more familiar with the political context, but are challenged to rise above the view from a categorical program to see the larger political and policy landscape within their state. In the current political and economic climate, policy makers face an increasing number of priorities for a decreasing amount of resources; and STD programs face numerous political barriers in their efforts to successfully compete. State budget shortfalls have resulted in less spending on STD control programs and a contraction of Medicaid benefits, while traditional safety net providers struggle to keep their doors open. Emerging infectious diseases, bioterrorism and emergency preparedness have brought new visibility and new partnerships to public health, but at the cost of traditional programs. Additionally, the basic tenets of many reproductive health and STD prevention programs are being questioned for their effectiveness and acceptability. This session will explore these and related issues from a State perspective. An analysis of the current situation will be addressed as well as recommendations for how to overcome some of the barriers.

Contextual View of STD Prevention in Adolescents: New Perspectives, New Approaches

P Bearman1, L Jemmott2, D Mann3
1Columbia University, NYC, NY; 2University of Pennsylvania, Philadelphia, PA; 3Family Planning Council, Philadelphia, PA

As STD rates among adolescents remain high, we must continue to explore the underlying causes, develop new prevention methodologies, and address barriers to the implementation of effective prevention programs. In all three of these areas, the social context of risk for STD and for the prevention of STDs among youth is paramount. Emerging research findings suggest that the context of adolescent risk for STDs is quite different than for adults. Social and sexual networks differ in their structure and environment, sexual relationships differ in their timing and in their associated contraceptive behavior, and other relationships (e.g., those with parents and peers) have differential impact on risk than they do for adults. These contextual factors must be taken into account in the development of programs targeting youth. Emerging prevention programs attempt to address some of these, by including parents and peers in the prevention process. Directing programs toward schools and youth-oriented community based organizations helps to increase access and youth participation in programs, but these programs face additional barriers and may not reach the most at risk youth. These issues, and others, will be addressed in this session. First, new and emerging findings from research on adolescent STD risk will be presented. Second, successful intervention programs including these issues will be discussed. Finally, the challenges to implementation of research findings in program settings will be explored.

HPV in 2004: Public Health Response to New Tools

L Koutsky1, T Wright2, C Ebel3
1University of Washington, Seattle, WA; 2Columbia University, New York City, NY; 3American Social Health Association, Research Triangle Park, NC

Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the United States, with an estimated 5.5 million new infections each year. Although persistent cervical infection with certain types of HPV is associated with cervical cancer in women, the majority of cervical HPV infections resolve within a few years. Many clinicians and health department staff are unaware of or confused about the natural history of HPV infection, and the association of HPV infection with cervical cancer, options for cervical cancer screening and the role of HPV tests. Vaccines to prevent HPV infection or cervical cancer are showing great promise. Several professional organizations recently issued guidelines for cervical cancer screening and management of cervical abnormalities. Educational messages from a variety of organizations are inconsistent, furthering the level of confusion among the general public. This session will begin with a brief overview of the latest information about genital HPV infection including natural history and prevention, and an update on vaccine development. Following will be a summary of clinical guidelines on the role of HPV tests for management of abnormal Pap smears and for use along with the Pap smear for cervical cancer screening in women over 30, and the resulting challenges for developing clear educational messages. A discussion about public health implications for these new developments will conclude the session.

Doing Good? Ethical Challenges in STD Research and Prevention

A Caplan
University of Pennsylvania, Philadelphia, PA

In the daily practice of both STD prevention research and practice, multiple challenges abound about what is right and what is wrong. While guidelines and laws frequently direct actions taken in the name of public health there are still sometimes tensions between what is morally right for the individual and what might be seen as best for society. This is true in both research and for diseases for which therapies exist. For example, it is unclear what a high risk person should be told about prevention options if involved in research. Should condom use for STD prevention be encouraged or should warnings about the inadequacy of condoms be conveyed in a study of a particular drug for a sexually transmitted disease? Should persons studying sex workers here or in other countries try to change their lifestyle of the sex workers as part of any research activity? If research shows that a microbicide is partially effective against a disease, how much evidence and efficacy would be required to make such a substance available either for research or public health purposes? How much risk can be tolerated in order to achieve a public health good? In such matters, what is one’s ethical obligation to protect individual subjects even if the goal is to protect the public health? Beyond differences of opinion, many questions exist about how much scientific evidence is enough to promote specific prevention practices. In the surveillance and research arena, there are ethical questions about reporting diseases by race and how such reports are interpreted. In addition, much of STD prevention research is conducted on poor and undereducated populations where questions arise about the viability of informed consent as well as the stigmatization that may result from reporting findings from such research. If children or other vulnerable populations are involved, how does that shape the ethical duties and responsibilities of those in public health? This session will challenge the audience to apply ethical principles to guide decision-making about some of these STD issues. STD-specific case scenarios will illustrate the application of these principles.

MSM in 2004: Risk-taking vs. Prevention Practice and the Changing Sexual Marketplace

T Peterman1, D Savage2, K Fenton3
1CDC, Atlanta, GA; 2The Stranger, Seattle, WA; 3Communicable Disease Surveillance Center, London, England

The STD prevention landscape has recently shifted for men who have sex with men. For example, from 2001 to 2002, syphilis rates in the US increased by 12.4%, an increase that occurred only among men, likely only among men who had sex with men. In England, trends are similar. Gonorrhea rates, for example, doubled among MSM in the United Kingdom between 1999 and 2001. Norms favoring unprotected sex is gathering strength. Public health, academic and community leaders are all engaged in discussions about why this is happening and have advanced various hypotheses: HAART has reduced the threat associated with risky behaviors; some of this unprotected sex is taking place between seroconcordant partners; community mobilization of the 1980’s has lost steam; the sexual marketplace has expanded to such venues as bathhouses, circuit parties, and the internet. Clearly, interventions that solely focus on changing individual behaviors will not alone address the rising disease rates among MSM. This session will initially provide an overview and analysis of the latest disease trends among MSM both in the United States and in England. The remainder of the session will focus on: (1) the tension challenging many community leaders and organizations to confront core groups of high risk men, while not risking either dwindling political support from within or further criticism from outside the gay community; and (2) the expanding and more diverse sexual marketplace catering to gay men including bathhouses, the internet, and other environments.

Rapid Cycle Quality Improvement for STD Services in the US Healthcare System

D Stevens1, M Shafer2, M Henderson3 
1AHRQ, Rockville, MD; 2University of California, San Francisco, CA; 3Family Healthcare Center, Fargo, ND

Mounting evidence of racial disparities in health service delivery, low rates of preventive service provision, and threats to patient safety have prompted many new initiatives to improve the quality of clinical care. Growing evidence and experience have pointed to rapid-cycle quality improvement (RQI) interventions as among the most effective and cost-efficient approaches to addressing these issues. Most notable results have been demonstrated through dramatic improvements in chronic disease service delivery and outcomes within short time frames in both public and private settings. These interventions rely on evidence-based guidelines; coordinated health systems that support consistent delivery of care; identification of barriers and solutions by clinical teams; information systems that track needed services, delivery rates, and outcomes; and clinical decision supports that promote appropriate clinician and patient behavior through reminders, feedback, and immediate information access. A critical element of RQI is the partnership of health care systems with the community to ensure continuity of care and follow-up. In short, RQI models have demonstrated a transformation of aspects of the health care system where it has been applied. This session will describe why RQI interventions are needed for STD prevention programs and will describe characteristics of interventions that lead to success. The session will continue with a discussion of the impact of rapid cycle interventions on clinic operations, staffing, resources, information systems, and clinical outcomes in public sector community health center. The session will conclude with a discussion of how rapid cycle methods can improve STD service delivery and describe a rapid cycle intervention that increased adolescent chlamydia screening by nearly 40% within 18 months in one health maintenance organization.

2004 and Beyond: Vision of STD Prevention in an Era of Uncertainty

JM Douglas, Jr.
CDC, Atlanta, GA

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity. . . .we had everything before us, we had nothing before us. . . (Dickens)

These are times of anomaly and challenge. The U.S. economy, the world’s largest, is emerging from recession, yet we have record levels of uninsured citizens, health care cost inflation, job loss, and federal budget deficit. Within the world of public health, STD prevention efforts share an increasingly crowded stage. National priorities have shifted since 9/11 with bioterrorism preparedness vying for attention with such traditional public health activities as disease prevention and health promotion. Even within the world of traditional public health, we see competing infectious disease concerns with the emergence of SARS, new strains of influenza and West Nile virus as well as competing chronic disease concerns like obesity, diabetes and smoking. Against this challenging backdrop, promises abound within the realm of STD prevention with an array of new and developing diagnostics, therapies and vaccines to compliment old ones. Yet in 2004, our nation faces both diminishing financial resources and a dearth of political will to support both new and old STD prevention tools. In our priority areas, we must strategically identify ways to maintain what is working, improve what is not, and begin to implement the newly available tools. Infertility prevention must move beyond its currently plateaued phase with serious consideration of such strategies as enhanced screening of high-risk women, screening of men, re-screening of infected women, and partner management. The early momentum of syphilis elimination must be maintained while forging new strategies and partnerships for the evolving epidemic among MSM. Considering the availability of new diagnostics for HSV-2 and promising vaccines for genital HPV infection, programmatic responses must be identified and prioritized. Finally, we face a variety of issues in the areas of primary prevention (optimizing the benefits of the ABCs—abstinence, partner selection, and condoms, expanding effective partner management, and introducing new technologies such as microbicides and vaccines) and program enhancement (effective translation of new research into program, integration of categorical prevention activities, and program evaluation). This session will address these priority areas more specifically and suggest a vision for successful STD prevention in the context of these uncertain times.