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The Need to Promote Sexual Health in America: A New Vision for Public Health Action

imageAbstract: Sexual health is considered to be a state of wellness with physical, emotional, mental, and social dimensions. Sexual health can contribute to our overall well-being in each of these dimensions. However, despite the intrinsic importance and positive aspects of sexuality in our lives, the United States presently faces significant challenges related to the sexual health of its citizens, including human immunodeficiency virus, other sexually transmitted infections, viral hepatitis, unintended pregnancies, sexual violence, sexual dysfunction, and cancers in reproductive tracts with serious disparities among the populations affected. In particular, high rates of poverty, income inequality, low educational attainment, stigma, racism, sexism, and homophobia can make it more difficult for some individuals and communities to protect their sexual health. Given that many pressing public health issues in the United States are related to sexual health and that sexual health has been increasingly recognized as an important national health priority, now is the time to energize and focus our efforts toward optimal sexual health of the population. In this paper, we outline the rationale for addressing sexual health as a means to better promote overall health and address sexuality related morbidities. In addition, we present a logic model outlining an approach for advancing sexual health in the United States, as well as a range of action steps for consideration by public health practitioners, researchers, and policymakers. 10/01/2017 01:00 AM

Neisseria gonorrhoeae Transmission Among Men Who Have Sex With Men: An Anatomical Site-Specific Mathematical Model Evaluating the Potential Preventive Impact of Mouthwash

imageBackground: Gonorrhoea notifications are rapidly rising in men who have sex with men (MSM). We developed a model to assess mouthwash as a novel intervention for gonorrhoea control. Methods: We developed a model of Neisseria gonorrhoeae (NG) transmission to explain anatomic site-specific prevalence of gonorrhoea among MSM. The model was calibrated to available epidemiological and behavioral data. We estimated the contribution of various sexual acts to gonorrhoea incidence and evaluate the potential impacts of screening scale-up and utilization of mouthwash on the gonorrhoea epidemic. Results: We calibrated the model to prevalence of oropharyngeal, anal, and urethral gonorrhoea of 8.6% (7.7–9.5%), 8.3% (7.4–9.1%), and 0.20% (0.04–0.35%), respectively, among MSM. Oropharynx to oropharynx transmission through kissing is estimated to account for nearly three quarters of all incident cases (71.6% [64.4–80.5%]) of gonorrhoea in MSM. Substantially increasing annual oropharynx screening for gonorrhoea from the current 40% to 100% may only halve the prevalence of gonorrhoea in MSM. In contrast, the use of mouthwash with moderate efficacy (additional 1% clearance per daily use) would further reduce the corresponding prevalence rates to 3.1% (2.2–4.4%), 3.8% (2.3–4.9%), and 0.10% (0.06–0.11%), and a high-efficacy mouthwash (additional 1.5% clearance per daily use) may further halve the gonorrhoea prevalence. Without oropharynx to oropharynx transmission, we could not replicate current prevalence data. Conclusions: Despite a dearth of empirical data, our model suggests that kissing could potentially play an important role in NG transmission among MSM. Control through sexually transmitted infection screening alone is unlikely to have a substantial impact on the gonorrhoea epidemic in MSM. 10/01/2017 01:00 AM

Self-Reported Use of Mouthwash and Pharyngeal Gonorrhoea Detection by Nucleic Acid Amplification Test

imageBackground: Use of alcohol-containing mouthwash has been found to have an inhibitory effect against pharyngeal gonorrhoea. The aim of this study was to investigate the association between self-reported mouthwash use and pharyngeal gonorrhoea detection among men who have sex with men (MSM). Methods: A cross-sectional survey was conducted between March 23, 2015, and June 30, 2015 among MSM attending the Melbourne Sexual Health Centre in Australia. Men who have sex with men were invited to complete a short questionnaire on mouthwash use and they were also tested for pharyngeal gonorrhoea by nucleic acid amplification test. Multivariate logistic regression was performed to examine the association between mouthwash use and pharyngeal gonorrhoea detection. Results: Of the 823 MSM, pharyngeal gonorrhoea detection decreased significantly with increasing age group (≤24 years, 14.5%; 25–34 years, 10.7%; ≥35 years, 6.0%; ptrend = 0.003). The proportion reporting daily use of mouthwash increased significantly with increasing age group (from 10.1% to 14.5% to 19.8%; ptrend = 0.005). However, there was no significant association between pharyngeal gonorrhoea detection and daily use of mouthwash after adjusting for age, number of male sexual partners, human immunodeficiency virus status, and type of mouthwash use. Conclusions: Although the proportion of daily use of mouthwash increased with age, and pharyngeal gonorrhoea detection decreased with age, the association between self-reported mouthwash use and pharyngeal gonorrhoea detection by nucleic acid amplification test was not statistically significant. 10/01/2017 01:00 AM

Kiss and Tell: Limited Empirical Data on Oropharyngeal Neisseria gonorrhoeae Among Men Who Have Sex With Men and Implications for Modeling

No abstract available 10/01/2017 01:00 AM

Modernizing Field Services for Human Immunodeficiency Virus and Sexually Transmitted Infections in the United States

imageAbstract: Public health field services for sexually transmitted infections (STIs) have not adequately evolved to address the expanding scale of the STI problem, its concentration among men who have sex with men, the emergence of new communication technologies and the availability of antiretroviral therapy as a cornerstone of human immunodeficiency virus (HIV) prevention. Field services need to modernize. Modernization should seek to expand field services objectives beyond sex partner STI testing and treatment to include: HIV testing of persons with bacterial STI and their partners, including efforts to promote frequent HIV/STI testing; increased condom access; linkage and relinkage to HIV care and promotion of viral suppression; preexposure prophylaxis promotion; linkage to long-acting contraception; and referral for health insurance. Field services programs cannot advance these new objectives while simultaneously doing all of the work they have traditionally done. Modernization will require a willingness to reconsider some longstanding aspects of field services work, including the centrality of face-to-face interviews and field investigations. Health departments seeking to modernize will need to carefully assess their ongoing activities and reorganize to align the use of field services resources with program priorities. In some instances, this may require reorganization to allow the staff greater specialization and closer integration with surveillance activities. Adapting programs will require new staff training, improvements in data management systems, and a greater investment in monitoring and evaluation. Although modernization is likely to evolve over many years, the time to start is now. 10/01/2017 01:00 AM

Men Who Have Sex With Men Seek Timely Human Immunodeficiency Virus Confirmation and Care After Rapid Human Immunodeficiency Virus Self-Test: Data From Partner Services Program, New York City

imageBackground: The rapid human immunodeficiency virus (HIV) self-test in the United States has expanded opportunities for HIV testing in nonclinical settings which may increase early diagnosis of HIV infection. However, broad application may be limited by the cost of the test and concerns that self-testers who test positive will not seek timely HIV care. Methods: We used data from HIV partner services program to compare the sociodemographic characteristics, transmission risk, and clinical stage of persons diagnosed with HIV by report of rapid self-test. Among self-tested persons, we assessed timeliness of seeking definitive testing after self-test and linkage to care. Results: From January 2013 to August 2016, 8032 HIV-positive persons were interviewed. Compared with the 7905 persons who did not self-test, self-tested persons were significantly (all P = <0.0001) male (96% vs 78%), white/non-Hispanic (46% vs 16%), men who have sex with men (92% vs 58%), college educated (67% vs 35%), and residing in medium-high income NYC neighborhoods (51% vs 44%). Higher proportions of self-tested (91%) than non–self-tested persons (81%) linked to care within three months of diagnosis. Significantly (P = <0.0001) more persons that self-tested positive (39/44, 89%) than persons that self-tested negative (14/36, 39%) sought laboratory-based HIV test within 1 month of last self-testing; and negative than positive self-tested persons were diagnosed with acute HIV infection (44% vs. 9%, P = <0.0001). Conclusions: Our findings suggest that men who have sex with men sought timely HIV confirmatory testing and linkage to care after self-test. However, the cost of self-test kit may be an important barrier to its wide adoption across sociodemographic groups. 10/01/2017 01:00 AM

Understanding the Effects of Forced Sex on Sexually Transmitted Disease Acquisition and Sexually Transmitted Disease Care: Findings From the National Survey of Family Growth (2011–2013)

imageBackground: Although there is evidence for heightened sexually transmitted disease (STD) acquisition among women who experienced sexual violence, little is known about their patterns of STD testing, STD diagnosis, and STD treatment. Methods: Data was drawn from cycle eight of the National Survey of Family Growth (2011–2013). Logistic regression analyses used SUDAAN to examine the link between forced sex and risky sexual behavior as well as forced sex and STD testing, diagnoses, treatment, and connection to care. Results: Women who experienced forced sex were more likely to have risky sex (adjusted odds ratio [AOR], 1.56; 95% confidence interval [CI], 1.08–2.24), risky partners (AOR, 1.90; 95% CI, 1.11–3.23), and report substance abuse (AOR, 1.80; 95% CI, 1.28–2.53) than women who never experienced forced sex. Women who reported forced sex were more likely to be tested for an STD (AOR, 1.67; 95% CI, 1.34–2.09), and be diagnosed with herpes (AOR, 1.94; 95% CI, 1.13–3.32), genital warts (AOR, 2.55; 95% CI, 1.90–3.41), and chlamydia (AOR, 1.83; 95% CI, 1.03–3.25) than those who have never had forced sex. Results indicated a direct relationship between particular STD diagnoses and treatment in the past 12 months (AOR, 6.81; 95% CI, 4.50–10.31). Further analyses indicate that forced sex moderated the link between STD diagnoses and STD treatment (AOR, 0.43; 95% CI, 0.19–0.98). Conclusions: Results indicate that women who reported experiencing forced sex were more likely to be diagnosed with chlamydia, herpes, and genital warts than women who never had forced sex. There may be a need to pay particular attention to women who experienced forced sex and a history of STDs to ensure that they are retained in care. 10/01/2017 01:00 AM

Using Multiple Outcomes of Sexual Behavior to Provide Insights Into Chlamydia Transmission and the Effectiveness of Prevention Interventions in Adolescents

imageBackground: Mathematical models are important tools for assessing prevention and management strategies for sexually transmitted infections. These models are usually developed for a single infection and require calibration to observed epidemiological trends in the infection of interest. Incorporating other outcomes of sexual behavior into the model, such as pregnancy, may better inform the calibration process. Methods: We developed a mathematical model of chlamydia transmission and pregnancy in Minnesota adolescents aged 15 to 19 years. We calibrated the model to statewide rates of reported chlamydia cases alone (chlamydia calibration) and in combination with pregnancy rates (dual calibration). We evaluated the impact of calibrating to different outcomes of sexual behavior on estimated input parameter values, predicted epidemiological outcomes, and predicted impact of chlamydia prevention interventions. Results: The two calibration scenarios produced different estimates of the probability of condom use, the probability of chlamydia transmission per sex act, the proportion of asymptomatic infections, and the screening rate among men. These differences resulted in the dual calibration scenario predicting lower prevalence and incidence of chlamydia compared with calibrating to chlamydia cases alone. When evaluating the impact of a 10% increase in condom use, the dual calibration scenario predicted fewer infections averted over 5 years compared with chlamydia calibration alone [111 (6.8%) vs 158 (8.5%)]. Conclusions: While pregnancy and chlamydia in adolescents are often considered separately, both are outcomes of unprotected sexual activity. Incorporating both as calibration targets in a model of chlamydia transmission resulted in different parameter estimates, potentially impacting the intervention effectiveness predicted by the model. 10/01/2017 01:00 AM