# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 25 {#section-1 .Chapter-#}

# Sexually Transmitted Diseases

Lead Agency: Centers for Disease Control and Prevention

### Contents {#contents .Heading-Special}

[Goal Page 25-3](#__RefHeading___Toc489706315)

[Overview Page 25-3](#overview)

[Issues Page 25-3](#issues)

[Trends Page 25-7](#trends)

[Disparities Page 25-7](#disparities)

[Opportunities Page 25-10](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
25-12](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
25-14](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
25-15](#healthy-people-2010-objectives)

[Bacterial STD Illness and Disability Page
25-15](#bacterial-std-illness-and-disability)

[Viral STD Illness and Disability Page
25-19](#viral-std-illness-and-disability)

[STD Complications Affecting Females Page
25-21](#std-complications-affecting-females)

[STD Complications Affecting the Fetus and Newborn Page
25-24](#std-complications-affecting-the-fetus-and-newborn)

[Personal Behaviors Page 25-25](#personal-behaviors)

[Community Protection Infrastructure Page
25-29](#community-protection-infrastructure)

[Personal Health Services Page 25-30](#personal-health-services)

[Related Objectives From Other Focus Areas Page
25-31](#related-objectives-from-other-focus-areas)

[Terminology Page 25-32](#terminology)

[References Page 25-33](#references)

[]{#__RefHeading___Toc489706315 .anchor}

## Goal

Promote responsible sexual behaviors, strengthen\
community capacity, and increase access to quality services to prevent
sexually transmitted diseases (STDs) and their\
complications.

## Overview

Sexually transmitted diseases (STDs) refer to the more than 25
infectious organisms transmitted primarily through sexual activity. STDs
are among many related factors that affect the broad continuum of
reproductive health agreed on in 1994 by 180 governments at the
International Conference on Population and Development (ICPD). At ICPD,
all governments were challenged to strengthen their STD programs.[^1]
STD prevention as an essential primary care strategy is integral to
improving reproductive health.

Despite the burdens, costs, complications, and preventable nature of
STDs, they remain a significant public health problem, largely
unrecognized by the public, policymakers, and public health and health
care professionals in the United States. STDs cause many harmful, often
irreversible, and costly clinical complications, such as reproductive
health problems, fetal and perinatal health problems, and cancer. In
addition, studies of the worldwide human immunodeficiency virus (HIV)
pandemic link other STDs to a causal chain of events in the sexual
transmission of HIV infection.[^2] (See Focus Area 13. HIV.)

### Issues

A 1997 Institute of Medicine (IOM) report characterized STDs as "hidden
epidemics of tremendous health and economic consequence in the United
States" and stated, "STDs represent a growing threat to the Nation's
health and that national action is urgently needed."Error: Reference
source not found IOM's principal conclusion was that the United States
needs to establish a much more effective national system for STD
prevention, which takes into account the complex interaction between
biological and social factors that sustain STD transmission in
populations; focuses on preventing the disproportionate effect that STDs
have on some population groups; applies proven, cost-effective
behavioral and biomedical interventions; and recognizes that education,
mass communication media, financing, and health care infrastructure
policies must foster change in personal behaviors and in health care
services.[^3] (See Focus Area 23. Public Health Infrastructure.)

**Biological factors.** STDs are behavior-linked diseases that result
from unprotected sex.Error: Reference source not found Several
biological factors contribute to their rapid spread.

*Asymptomatic nature of STDs.* The majority of STDs either do not
produce any symptoms or signs, or they produce symptoms so mild that
they often are disregarded, resulting in a low index of suspicion by
infected persons who should, but often do not, seek medical care. For
example, as many as 85 percent of women and up to 50 percent of men with
chlamydia have no symptoms.[^4]**^,^** [^5]**^,^** [^6]**^,^** [^7] A
person infected with HIV may be asymptomatic and may transmit the
disease to another person. That person may, in turn, be infected for
years but remain unaware until symptoms manifest themselves.

*Lag time between infection and complications.* Often, a long
interval---sometimes years---occurs between acquiring a sexually
transmitted infection and recognizing a clinically significant health
problem. Examples are cervical cancer caused by human papillomavirus
(HPV), liver cancer caused by hepatitis B virus infection,[^8] and
infertility and ectopic pregnancy resulting from unrecognized or
undiagnosed chlamydia or gonorrhea.[^9] The original infection often is
asymptomatic, and, as a result, people frequently do not perceive a
connection between the original sexually acquired infection and the
resulting health problem.

*Gender and age.* Women are at higher risk than men for most STDs, and
young women are more susceptible to certain STDs than are older women.
The higher risk is partly because the cervix of adolescent females is
covered with cells that are especially susceptible to STDs, such as
chlamydia.[^10]

**Social and behavioral factors**. The spread of STDs, especially in
certain vulnerable population groups, is directly affected by social and
behavioral factors. Social and cultural factors may cause serious
obstacles to STD prevention by adversely influencing social norms
regarding sex and sexuality.

*Poverty and marginalization.* STDs disproportionately affect
disenfranchised persons and persons who are in social networks in which
high-risk sexual behavior is common and either access to care or
health-seeking behavior is compromised. Some disproportionately affected
groups include sex workers (people who exchange sex for money, drugs, or
other goods), adolescents, persons in detention, and migrant
workers.Error: Reference source not found Without publicly supported STD
services, many people in these categories would lack access to STD care.

Substance abuse, sex work, and STDs are closely connected, and substance
abuse and sex work frequently are causes for arrest and detention.
Studies show that comprehensive screening of incarcerated populations
can be done successfully and safely within the criminal justice
system.[^11]**^,^** [^12]**^,^** [^13] Discussed below are several
connected themes relevant to any discussion of poverty and
marginalization\
issues.

*Access to health care.* Access to high-quality health care is essential
for early detection, treatment, and behavior-change counseling for STDs.
Often, groups with the highest rates of STDs are the same groups in
which access to health services is most limited. This limitation relates
to (1) lacking access to publicly supported STD clinics (present in only
50 percent of U.S. public health jurisdictions),[^14] (2) having no
health care coverage, (3) having coverage that imposes a copayment or
deductible, or (4) having coverage that excludes the basic preventive
health services that help avert STDs or their complications. (See Focus
Area 1. Access to Quality Health
Services.)![](media/image2.wmf){width="4.5993055555555555in"
height="6.058333333333334in"}

*Substance abuse.* Many studies document the association of substance
abuse, especially the abuse of alcohol and drugs, with STDs.[^15] At the
population level, the introduction of new illicit substances into
communities often can drastically alter sexual behavior in high-risk
sexual networks, leading to the epidemic spread of STDs.[^16] Behavioral
factors that can increase STD transmission in a community include
increases in the exchange of sex for drugs, increases in the number of
anonymous sex partners, decreases in motivation to use barrier
protection, and decreases in attempts to seek medical treatment. The
nationwide syphilis epidemic of the late 1980s, for example, was fueled
by increased crack cocaine use.[^17] Other substances, including
alcohol, may affect an individual's cognitive and negotiating skills
before and during sex, lowering the likelihood that protection against
STD transmission and pregnancy will be used.

*Sexual coercion.* Analysis of adolescent female sexual activity reveals
the frequency of coercive behaviors and brings to light that not all
young women enter sexual relationships as willing partners.[^18] In
fact, sexual coercion is a major problem for significant numbers of
young women in the United States. In 1995, 16 percent of females whose
first sexual intercourse took place when they were aged 15 years or
under reported that it was not voluntary.[^19] This aspect of adolescent
sexual behavior demands increased national and local attention, both for
social justice and for health reasons. Sexual violence against women
contributes both directly and indirectly to STD transmission. Directly,
women experiencing sexual violence are less able to protect themselves
from STDs or pregnancy. Indirectly, research demonstrates that women
with a history of involuntary sexual intercourse are more likely to have
voluntary intercourse at earlier ages---a known risk factor for
STDs---than women who are not sexually abused.[^20]

*Sexuality and secrecy.* Perhaps the most important social factor
contributing to the spread of STDs in the United States and the factor
that most significantly separates the United States from those
industrialized countries with low rates of STDs is the stigma associated
with STDs and the general discomfort of people in the United States with
discussing intimate aspects of life, especially those related to
sex.[^21] Sex and sexuality pervade many aspects of the Nation's
culture, and people in the United States are fascinated with sexual
matters. Paradoxically, while sexuality is considered a normal aspect of
human functioning, people in the United States nevertheless are
secretive and private about their sexual behavior. Talking openly and
comfortably about sex and sexuality is difficult even in the most
intimate relationships. One survey showed that, for married couples,
about one-fourth of women and one-fifth of men had no knowledge of their
partner's sexual history.[^22] In its study, IOM stated, "The secrecy
surrounding sexuality impedes sexuality education programs for
adolescents, open discussion between parents and their children and
between sex partners, balanced messages from mass media, education and
counseling activities of health care professionals, and community
activism regarding STDs."[^23]

Changing sexual behaviors and sexual norms will be an important part of
any long-term strategy to develop a more effective national system of
STD prevention in the United States. A new sexual openness needs to
become the norm to ensure that all sexual relationships are consensual,
nonexploitive, and honest and to protect against disease and unintended
pregnancy. This openness would allow (1) parents to talk frankly and
comfortably with their children, and teachers and counselors with their
students, about responsible behavior and avoiding risks (for example,
abstaining from intercourse, delaying initiation of intercourse,
reducing the number of sex partners, and increasing the use of effective
barrier contraception), (2) sex partners to talk openly about safe
behaviors, and (3) health care providers to talk comfortably and
knowledgeably with patients about sexuality and sexual risk, to counsel
them about risk avoidance, and to screen them regularly for STDs when
indicated.[^24] (See Focus Area 11. Health Communication.)

The entertainment industry, particularly television, has noticed
interest in sexual themes. While people in the United States are
bombarded by sexual messages and images, very little informed,
high-quality STD prevention advice or discussion exists regarding
contraception, sexuality, or the risks of early, unprotected sexual
behavior. Popular television programs depict as many as 25 instances of
sexual behaviors for every 1 instance of protected behavior or
discussion about STDs or pregnancy prevention.[^25] Media companies can
play an important part in reshaping sexual behaviors and norms in the
United States in the next decade.

### Trends

STDs are common, costly, and preventable. Worldwide, an estimated 333
million cases of curable STDs occur annually.[^26] In 1995, STDs were
the most common reportable diseases in the United States.[^27] They
accounted for 87 percent of the top 10 infections most frequently
reported to the Centers for Disease Control and Prevention (CDC) from
State health departments. Of the top 10 infections, 5 were STDs
(chlamydia, gonorrhea, AIDS, syphilis, and hepatitis B). Each year an
estimated 15 million new STD infections occur in the United States, and
nearly 4 million teenagers are infected with an STD.[^28] The direct and
indirect costs of the major STDs and their complications, including
sexually transmitted HIV infection, are conservatively estimated at \$17
billion annually.Error: Reference source not found

Despite recent progress toward controlling some STDs, when compared to
other industrialized nations, the United States has failed to go far
enough or fast enough in its national attempt to contain acute STDs and
STD-related complications.Error: Reference source not found STD rates in
this Nation exceed those in all other countries of the industrialized
world (including the countries of western and northern Europe, Canada,
Japan, and Australia). Through a sustained, collaborative, multifaceted
approach, other countries have reduced significantly the burden of STDs
on their citizens, an accomplishment the United States also should
strive to achieve.

### Disparities 

All racial, cultural, economic, and religious groups are affected by
STDs. People in all communities and sexual networks are at risk for
STDs. Nevertheless, some population groups are disproportionately
affected by STDs and their complications.

**Gender disparities.** Women suffer more frequent and more serious STD
complications than men do. Among the most serious STD complications are
pelvic inflammatory disease (PID), ectopic pregnancy, infertility, and
chronic pelvic pain.[^29] Women are biologically more susceptible to
infection when exposed to a sexually transmitted agent. Often, STDs are
transmitted more easily from a man to a woman.[^30] Acute STDs (and even
some complications) often are very mild or are completely asymptomatic
in women. STDs are more difficult to diagnose in women due to the
physiology and anatomy of the female reproductive tract. This
combination of increased susceptibility and "silent" infection
frequently can result in women being unaware of an STD, which results in
delayed diagnosis and treatment.

STDs in pregnant women can cause serious health problems or death to the
fetus or newborn.[^31] Sexually transmitted organisms in the mother can
cross the placenta to the fetus or newborn, resulting in congenital
infection, or these organisms can reach the newborn during delivery,
resulting in perinatal infections. Regardless of the route of infection,
these organisms can permanently damage the brain, spinal cord, eyes,
auditory nerves, or immune system. Even when the organisms do not reach
the fetus or newborn directly, they can significantly complicate the
pregnancy by causing spontaneous abortion, stillbirth, premature rupture
of the membranes, or preterm delivery.[^32] For example, women with
bacterial vaginosis are 40 percent more likely to deliver a preterm, low
birth weight infant than are mothers without this condition.[^33]**^,^**
[^34] (See Focus Area 16. Maternal, Infant, and Child Health.)

**Age disparities.** For a variety of behavioral, social, and biological
reasons, STDs also disproportionately affect adolescents and young
adults.[^35] In 1997, females aged 15 to 19 years had the highest
reported rates of both chlamydia and gonorrhea among women; males aged
20 to 24 years had the highest reported rates of both chlamydia and
gonorrhea among men.[^36] The herpes infection rate of white youth aged
12 to 19 years increased nearly fivefold from the period 1976--80 to the
period 1988--94.[^37] Indeed, because not all teenagers are sexually
active, the actual rate of STDs in teens is probably higher than the
observed rates suggest.Error: Reference source not found There are
several contributing factors:

-   Sexually active teenagers are at risk for STDs. In 1995, 50 percent
    of females aged 15 to 19 years interviewed for the National Survey
    of Family Growth (NSFG) indicated that they had had sexual
    intercourse.Error: Reference source not found In the same year, 54
    percent of adolescent males in high school reported having had
    sexual intercourse, including 49 percent of white males, 62 percent
    of Hispanic males, and 81 percent of African American males.[^38]

-   Teenagers are increasingly likely to have more sex partners at
    earlier ages. Compounding this factor is the fact that these
    partners are active in sexual networks already highly infected with
    untreated STDs.**^36^** In 1971, 39 percent of sexually active
    adolescent females aged 15 to 19 years had more than one sex
    partner; in 1988 the percentage had increased to 62 percent.[^39]

-   Sexually active teenagers often are reluctant to obtain STD
    services, or they may face serious obstacles when trying to obtain
    them. In addition, health care providers often are uncomfortable
    discussing sexuality and risk reduction with their patients, thus
    missing opportunities to counsel and screen young people for
    STDs.Error: Reference source not found

**Racial and ethnic disparities.** Certain racial and ethnic groups
(mainly African American and Hispanic populations) have high rates of
STDs, compared with rates for whites. Race and ethnicity in the United
States are risk markers that correlate with other fundamental
determinants of health status, such as poverty, limited or no access to
quality health care, fewer attempts to get medical treatment, illicit
drug use, and living in communities with a high number of cases of STDs.
National surveillance data may overrepresent STDs in racial and ethnic
groups that are more likely to receive STD services from public-sector
STD clinics where timely and complete illness reporting is generally the
rule. However, studies using random sampling techniques document higher
rates of STDs in marginalized populations, particularly African
Americans as compared with whites.Error: Reference source not found
Surveillance data from 1997 show:Error: Reference source not found

-   Although chlamydia is a widely distributed STD in population groups,
    it occurs more frequently in certain racial and ethnic groups.

-   African Americans (non-Hispanic blacks) accounted for about 77
    percent of the total number of reported cases of gonorrhea---31
    times the rate in whites (non-Hispanic whites). African American
    rates were on average about 24 times higher than those of white
    adolescents aged 15 to 19 years; the rate for African Americans aged
    20 to 24 years was almost 28 times greater than that in whites.
    Gonorrhea rates in Hispanic persons were nearly three times the rate
    in whites.

-   The most recent syphilis epidemic occurred largely in heterosexual
    minority populations. Since 1990, rates of primary and secondary
    (P&S) syphilis have declined in all racial and ethnic groups except
    American Indians or Alaska Natives. However, rates for African
    Americans and Hispanics continue to be higher than those for whites.
    In 1997, African Americans accounted for about 82 percent of all
    reported cases of P&S syphilis.

-   In 1997, the rate of congenital syphilis was 113.5 per 100,000 live
    births in African Americans and 34.6 per 100,000 live births in
    Hispanics, compared with 3.3 per 100,000 live births in whites.

Finally, young heterosexual women, especially minority women, are
increasingly acquiring HIV infection and developing AIDS. In 1998, 41
percent of reported AIDS cases in persons aged 13 to 24 years occurred
in young women, and more than four of every five AIDS cases reported in
women occurred in certain racial and ethnic groups (mostly African
American or Hispanic).[^40] The U.S. spread of HIV infection through
heterosexual transmission closely parallels other STD epidemics.Error:
Reference source not found

Compelling worldwide evidence indicates that the presence of other STDs
increases the likelihood of both transmitting and acquiring HIV
infection.**^2^** Prospective epidemiologic studies from four
continents, including North America, have repeatedly demonstrated that
when other STDs are present, HIV transmission is at least two to five
times higher than when other STDs are not present. Biological studies
demonstrate that when other STDs are present, an individual's
susceptibility to HIV infection is increased, and the likelihood of a
dually infected person (having HIV infection and another STD) infecting
other people with HIV is increased. Conversely, effective STD treatment
can slow the spread of HIV at the individual and community levels.

### Opportunities

Prevention opportunities arise from an understanding of STD transmission
dynamics. The rate of STD infection in a population is determined by the
interaction of three principal factors:[^41]**^,^** [^42]

-   The rate at which uninfected individuals have sex with infected
    persons (rate of sex partner exchange or exposure).

-   The probability that a susceptible exposed person actually will
    acquire the infection (transmission).

-   The time period during which an infected person remains infectious
    and able to spread disease to others (duration).

Effective STD prevention requires effective population-level and
individual-level interventions that can alter the natural course of
these factors. IOM advised in its report, "Use of available information
and interventions could have a rapid and dramatic impact on the
incidence and prevalence of STDs in the United States. Many effective
and efficient behavioral and biomedical interventions are\
available."Error: Reference source not found

Behavioral interventions can be brought to bear on exposure,
transmission, and duration factors. They help persons abstain from
sexual intercourse, delay initiation of intercourse, reduce the number
of sex partners, and increase the use of effective physical barriers,
such as condoms, or emerging chemical barriers, such as microbicides.
Further attention must be given to helping parents become better at
imparting STD information. Currently, a small percentage of adolescents
receive STD prevention information from parents.[^43] Schools are the
main source of STD information for most teenagers,Error: Reference
source not found indicating that school-based interventions can play a
significant role in informing young people about STD exposure and
transmission issues and in motivating them to modify their
behaviors.Error: Reference source not found (See Focus Area 7.
Educational and Community-Based Programs.) Both school-based health
information and school-based health service programs are potentially
beneficial to young persons.[^44]

Mass media campaigns have been effective in bringing about significant
changes in awareness, attitude, knowledge, and behaviors for other
health problems, such as smoking.[^45] National communication efforts
are needed to help overcome widespread misinformation and lack of
awareness about STDs.

Biomedical interventions can affect aspects of transmission and duration
factors. Vaccines minimize the probability of infection, disease, or
both, after exposure (transmission). While vaccines for some STDs are in
various stages of development, the only effective and widely available
STD vaccine is for hepatitis B.[^46]**^,^** [^47] Unfortunately,
hepatitis B vaccine coverage remains minimal, especially in high-risk
groups, mainly due to a lack of awareness on the part of health care
providers, limited opportunities to reach high-risk youth in traditional
health care settings, and limited financial support for wide-scale
implementation of this effective intervention. (See Focus Area 14.
Immunization and Infectious Diseases.)

Correct and consistent condom use decreases STD transmission.[^48] While
condom use has been on the rise in the United States over the past few
decades,[^49] women who use the most effective forms of contraception
(sterilization and hormonal contraception) are less likely to use
condoms for STD prevention.[^50]**^,^** [^51]**^,^** [^52] IOM stated in
its report, "Because no single method of preventing STDs or pregnancy
confers the maximum level of protection against both conditions, use of
dual protection---that is, a condom and another effective contraceptive
for pregnancy---is especially important. Not clear, however, is how well
the public understands the need for dual protection against STDs and
pregnancy."Error: Reference source not found Dual methods could prevent
unwanted pregnancy and STDs.[^53] Yet most sexually active young people
do not employ this strategy.[^54] (See Focus Area 9. Family Planning.)

Identifying and treating partners of persons with curable STDs to break
the chain of transmission in a sexual network always have been integral
to organized control programs.[^55] Early antimicrobial prophylaxis of
the exposed partner reduces the likelihood of transmission and thwarts
infection. With partner treatment, the initially infected person
benefits from a reduced risk of reinfection from an untreated partner,
and the partner avoids acute infection and its potential complications.
Future sex partners are protected by treating partners; thus, this
treatment strategy also benefits the community.

Active partner notification and partner treatment generally have been
the responsibility of personnel in public STD clinics. New approaches
for getting more partners treated are being assessed both in traditional
and nontraditional STD treatment settings. One approach actively
involves initially infected patients in the process of referring their
partners for evaluation and treatment.[^56] Another approach uses new
techniques to assess sexual networks in outbreak situations in order to
identify infected patients and their partners more quickly.[^57] Because
most STD care in the United States is delivered in the private sector,
private health care providers, managed-care organizations, and health
departments need to work together to overcome barriers to rapid and
effective treatment of the nonplan sex partners of health plan members.

Screening and treatment of STDs affect both transmission and duration
factors. For curable STDs, screening and treatment can be
cost-effective, or even cost-saving, in altering the period during which
infected persons can infect others. Screening for STDs clearly meets the
criteria for an effective preventive intervention.[^58] For STDs that
frequently are asymptomatic, screening and treatment benefit those who
are likely to suffer severe complications (especially women) if
infections are not detected and treated early.[^59] For example, in a
randomized controlled trial conducted in a large managed-care
organization, chlamydia screening reduced by 56 percent new cases of
subsequent pelvic inflammatory disease in a screened group.[^60]
Selective screening for chlamydia in the Pacific Northwest reduced the
burden of disease in the screened population by 60 percent in 5
years.[^61]

When combined with a new generation of sensitive and rapid diagnostic
tests, some of which can be performed on a urine specimen, STD screening
of specific high-risk populations in nontraditional settings appears to
be a promising control strategy that expands access to underserved
groups.[^62] The success of screening programs will depend on the
availability of funds, the willingness of communities and institutions
to support them, and the availability of well-trained health care
providers and of well-equipped and accessible laboratories.

## Interim Progress Toward Year 2000 Objectives

Significant progress was made during the 1990s toward reducing the
burden of the common bacterial STDs in the United States, such as
gonorrhea, syphilis, and congenital syphilis---diseases for which
national control programs have existed for the longest period.
Encouraging data are emerging from a new and expanding chlamydia
prevention program, suggesting that chlamydia screening is reducing
disease burden and preventing complications. Nevertheless, STD
complications, such as PID, continue to take a heavy toll on women's
health and increase health care costs.

Because so many people are already infected, and millions more are
infected annually, viral STDs continue to present challenges for
prevention and control. One of the most serious health problems
associated with STDs is sexually acquired HIV infection that is
facilitated by the presence of an inflammatory or ulcerative STD in one
or both sex partners. In 1998, females accounted for 23 percent of all
AIDS cases in the United States, with African American and Hispanic
females incurring a disproportionate share (similar to other STDs) of
heterosexually transmitted HIV infection.Error: Reference source not
found A nationally representative study showed that genital herpes
infection is very common in the United States.Error: Reference source
not found Nationwide, 45 million persons aged 12 years and older, or 1
out of 5 of the total adolescent and adult population, are infected with
herpes simplex virus type 2. As many as 20 million persons in the United
States already are infected with strains of the human papillomavirus,
and an estimated 5.5 million new infections occur annually.Error:
Reference source not found

Of the 17 STD-related Healthy People 2000 objectives, 10 either met or
moved toward their targets. The Nation is making strides in efforts to
reduce the occurrence of STDs, educate people about condom use, increase
clinic services for HIV and other sexually transmitted diseases, and
encourage abstinence from sexual intercourse among adolescents. Routine
counseling by clinicians to prevent STDs has slipped away from its
target. Two objectives have held steady: adolescents engaging in sexual
intercourse and annual first-time consultations about genital herpes and
warts. Another four could not be assessed.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Sexually Transmitted Diseases {#sexually-transmitted-diseases-1 .Heading-Special-Sub}

**Goal:** Promote responsible sexual behaviors, strengthen community
capacity, and increase access to quality services to prevent sexually
transmitted diseases (STDs) and their complications.

  ------------------ --------------------------------------------------------------
  **Number**         **Objective Short Title**

  **Bacterial STD    
  Illness and        
  Disability**       

  25-1               Chlamydia

  25-2               Gonorrhea

  25-3               Primary and secondary syphilis

  **Viral STD        
  Illness and        
  Disability**       

  25-4               Genital herpes

  25-5               Human papillomavirus infection

  **STD              
  Complications      
  Affecting          
  Females**          

  25-6               Pelvic inflammatory disease (PID)

  25-7               Fertility problems

  25-8               Heterosexually transmitted HIV infection in women

  **STD              
  Complications      
  Affecting the      
  Fetus and          
  Newborn**          

  25-9               Congenital syphilis

  25-10              Neonatal STDs

  **Personal         
  Behaviors**        

  25-11              Responsible adolescent sexual behavior

  25-12              Responsible sexual behavior messages on television

  **Community        
  Protection         
  Infrastructure**   

  25-13              Hepatitis B vaccine services in STD clinics

  25-14              Screening in youth detention facilities and jails

  25-15              Contracts to treat nonplan partners of STD patients

  **Personal Health  
  Services**         

  25-16              Annual screening for genital chlamydia

  25-17              Screening of pregnant women

  25-18              Compliance with recognized STD treatment standards

  25-19              Provider referral services for sex partners
  ------------------ --------------------------------------------------------------

##  Healthy People 2010 Objectives

### Bacterial STD Illness and Disability

25-1. Reduce the proportion of adolescents and young adults with
*Chlamydia trachomatis* infections.

Target and baseline:

+----------+-------------------------------------+---------+---------+
| O        | Reduction in *Chlamydia             | 1997\   | 2010\   |
| bjective | trachomatis\                        | B       | Target  |
|          | *infections                         | aseline |         |
+----------+-------------------------------------+---------+---------+
|          |                                     | #       |         |
|          |                                     | ######  |         |
|          |                                     | Percent |         |
+----------+-------------------------------------+---------+---------+
| **       | Females aged 15 to 24 years         | 5.0     | 3.0     |
| 25-1a.** | attending\                          |         |         |
|          | family planning clinics             |         |         |
+----------+-------------------------------------+---------+---------+
| **       | Females aged 15 to 24 years         | 12.2    | 3.0     |
| 25-1b.** | attending STD clinics               |         |         |
+----------+-------------------------------------+---------+---------+
| **       | Males aged 15 to 24 years attending | 15.7    | 3.0     |
| 25-1c.** | STD clinics                         |         |         |
+----------+-------------------------------------+---------+---------+

**Target setting method**: Better than the best.

**Data source:** STD Surveillance System, CDC, NCHSTP.

Note: The table below may continue to the following page.

+--------------------------------+------------+-----------+------------+
| **Persons Aged 15 to 24 Years\ | **Infected |           |            |
| Attending Clinics, 1997**      | With       |           |            |
|                                | C          |           |            |
|                                | hlamydia** |           |            |
+================================+============+===========+============+
|                                | **25-1a.\  | **25-1b.\ | **25-1c.\  |
|                                | Females    | Females\  | Males\     |
|                                | (Family    | (STD\     | (STD\      |
|                                | Planning   | C         | Clinics)** |
|                                | Clinics)** | linics)** |            |
+--------------------------------+------------+-----------+------------+
|                                | Percent    |           |            |
+--------------------------------+------------+-----------+------------+
| > **TOTAL**                    | 5.0        | 12.2      | 15.7       |
+--------------------------------+------------+-----------+------------+
| **Race and ethnicity**         |            |           |            |
+--------------------------------+------------+-----------+------------+
| > American Indian or Alaska    | 6.3        | 13.1      | 12.6       |
| > Native                       |            |           |            |
+--------------------------------+------------+-----------+------------+
| > Asian or Pacific Islander    | 4.7        | 12.0      | 16.6       |
+--------------------------------+------------+-----------+------------+
| > Asian                        | DNC        | DNC       | DNC        |
+--------------------------------+------------+-----------+------------+
| > Native Hawaiian and\         | DNC        | DNC       | DNC        |
| > other Pacific Islander       |            |           |            |
+--------------------------------+------------+-----------+------------+
| > Black or African American    | DNC        | DNC       | DNC        |
+--------------------------------+------------+-----------+------------+
| > White                        | DNC        | DNC       | DNC        |
+--------------------------------+------------+-----------+------------+
|                                |            |           |            |
+--------------------------------+------------+-----------+------------+
| > Hispanic or Latino           | 5.2        | 14.0      | 18.5       |
+--------------------------------+------------+-----------+------------+
| > Not Hispanic or Latino       | DNC        | DNC       | DNC        |
+--------------------------------+------------+-----------+------------+
| > Black or African American    | 11.1       | 15.2      | 18.1       |
+--------------------------------+------------+-----------+------------+
| > White                        | 3.1        | 9.2       | 11.5       |
+--------------------------------+------------+-----------+------------+
| **Family income level**        |            |           |            |
+--------------------------------+------------+-----------+------------+
| > Poor                         | DNC        | DNC       | DNC        |
+--------------------------------+------------+-----------+------------+
| > Near poor                    | DNC        | DNC       | DNC        |
+--------------------------------+------------+-----------+------------+
| > Middle/high income           | DNC        | DNC       | DNC        |
+--------------------------------+------------+-----------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

25-2. Reduce gonorrhea.

**Target:** 19 new cases per 100,000 population.

**Baseline:** 123 new cases of gonorrhea per 100,000 population occurred
in 1997.

**Target setting method:** Better than the best.

**Data source:** STD Surveillance System, CDC, NCHSTP.

Note: The table below may continue to the following page.

+------------------------------+---------------+-----------+-----------+
| **Total Population, 1997**   | **New         |           |           |
|                              | Gonorrhea     |           |           |
|                              | Cases**       |           |           |
+==============================+===============+===========+===========+
|                              | **25-2.\      | **Fe      | **        |
|                              | Both\         | males\*** | Males\*** |
|                              | Genders**     |           |           |
+------------------------------+---------------+-----------+-----------+
|                              | Rate per      |           |           |
|                              | 100,000       |           |           |
+------------------------------+---------------+-----------+-----------+
| > **TOTAL**                  | 123           | 119       | 125       |
+------------------------------+---------------+-----------+-----------+
| **Race and ethnicity**       |               |           |           |
+------------------------------+---------------+-----------+-----------+
| > American Indian or Alaska  | 100           | 131       | 67        |
| > Native                     |               |           |           |
+------------------------------+---------------+-----------+-----------+
| > Asian or Pacific Islander  | 20            | 21        | 18        |
+------------------------------+---------------+-----------+-----------+
| > Asian                      | DNC           | DNC       | DNC       |
+------------------------------+---------------+-----------+-----------+
| > Native Hawaiian and\       | DNC           | DNC       | DNC       |
| > other Pacific Islander     |               |           |           |
+------------------------------+---------------+-----------+-----------+
| > Black or African American  | DNC           | DNC       | DNC       |
+------------------------------+---------------+-----------+-----------+
| > White                      | DNC           | DNC       | DNC       |
+------------------------------+---------------+-----------+-----------+
|                              |               |           |           |
+------------------------------+---------------+-----------+-----------+
| > Hispanic or Latino         | 69            | 72        | 67        |
+------------------------------+---------------+-----------+-----------+
| > Not Hispanic or Latino     | DNC           | DNC       | DNC       |
+------------------------------+---------------+-----------+-----------+
| > Black or African American  | 808           | 714       | 912       |
+------------------------------+---------------+-----------+-----------+
| > White                      | 26            | 32        | 20        |
+------------------------------+---------------+-----------+-----------+
| **Family income level**      |               |           |           |
+------------------------------+---------------+-----------+-----------+
| > Poor                       | DNC           | DNC       | DNC       |
+------------------------------+---------------+-----------+-----------+
| > Near poor                  | DNC           | DNC       | DNC       |
+------------------------------+---------------+-----------+-----------+
| > Middle/high income         | DNC           | DNC       | DNC       |
+------------------------------+---------------+-----------+-----------+
| **Age**                      |               |           |           |
+------------------------------+---------------+-----------+-----------+
| > 15 to 24 years             | 512           | 617       | 414       |
+------------------------------+---------------+-----------+-----------+
| > 25 to 34 years             | 198           | 161       | 235       |
+------------------------------+---------------+-----------+-----------+
| > 35 to 44 years             | 71            | 40        | 101       |
+------------------------------+---------------+-----------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females and males are displayed to further characterize the
issue.

Note: The table above may have continued from the previous page.

25-3. Eliminate sustained domestic transmission of primary\
and secondary syphilis.

**Target:** 0.2 cases per 100,000 population.

**Baseline:** 3.2 cases of primary and secondary syphilis per 100,000
population occurred in 1997.

**Target setting method:** Better than the best and consistent with the
National Plan to Eliminate Syphilis from the United States, CDC, 1999.

**Data source:** STD Surveillance System, CDC, NCHSTP.

+--------------------------------+-------------+----------+---+--------+
| **Total Population, 1997**     | **Primary   |          |   |        |
|                                | and         |          |   |        |
|                                | Secondary   |          |   |        |
|                                | Syphilis    |          |   |        |
|                                | Cases**     |          |   |        |
+================================+=============+==========+===+========+
|                                | **25-3.\    | **Fem    | * |        |
|                                | Both\       | ales\*** | * |        |
|                                | Genders**   |          | M |        |
|                                |             |          | a |        |
|                                |             |          | l |        |
|                                |             |          | e |        |
|                                |             |          | s |        |
|                                |             |          | \ |        |
|                                |             |          | * |        |
|                                |             |          | * |        |
|                                |             |          | * |        |
+--------------------------------+-------------+----------+---+--------+
|                                | Rate per    |          |   |        |
|                                | 100,000     |          |   |        |
+--------------------------------+-------------+----------+---+--------+
| > **TOTAL**                    | 3.2         | 2.9      |   | 3.6    |
+--------------------------------+-------------+----------+---+--------+
| **Race and ethnicity**         |             |          |   |        |
+--------------------------------+-------------+----------+---+--------+
| > American Indian or Alaska    | 2.0         | 1.8      |   | 2.3    |
| > Native                       |             |          |   |        |
+--------------------------------+-------------+----------+---+--------+
| > Asian or Pacific Islander    | 0.3         | 0.4      |   | 0.3    |
+--------------------------------+-------------+----------+---+--------+
| > Asian                        | DNC         | DNC      |   | DNC    |
+--------------------------------+-------------+----------+---+--------+
| > Native Hawaiian and other\   | DNC         | DNC      |   | DNC    |
| > Pacific Islander             |             |          |   |        |
+--------------------------------+-------------+----------+---+--------+
| > Black or African American    | DNC         | DNC      |   | DNC    |
+--------------------------------+-------------+----------+---+--------+
| > White                        | DNC         | DNC      |   | DNC    |
+--------------------------------+-------------+----------+---+--------+
|                                |             |          |   |        |
+--------------------------------+-------------+----------+---+--------+
| > Hispanic or Latino           | 1.6         | 1.0      |   | 2.1    |
+--------------------------------+-------------+----------+---+--------+
| > Not Hispanic or Latino       | DNC         | DNC      |   | DNC    |
+--------------------------------+-------------+----------+---+--------+
| > Black or African American    | 22.0        | 19.3     |   | 25.0   |
+--------------------------------+-------------+----------+---+--------+
| > White                        | 0.5         | 0.5      |   | 0.6    |
+--------------------------------+-------------+----------+---+--------+
| **Family income level**        |             |          |   |        |
+--------------------------------+-------------+----------+---+--------+
| > Poor                         | DNC         | DNC      | D |        |
|                                |             |          | N |        |
|                                |             |          | C |        |
+--------------------------------+-------------+----------+---+--------+
| > Near poor                    | DNC         | DNC      | D |        |
|                                |             |          | N |        |
|                                |             |          | C |        |
+--------------------------------+-------------+----------+---+--------+
| > Middle/high income           | DNC         | DNC      | D |        |
|                                |             |          | N |        |
|                                |             |          | C |        |
+--------------------------------+-------------+----------+---+--------+
| ###### Sexual orientation      | DNC         | DNC      | D |        |
|                                |             |          | N |        |
|                                |             |          | C |        |
+--------------------------------+-------------+----------+---+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females and males are displayed to further characterize the
issue.

The United States has a unique opportunity to eliminate syphilis within
its borders. Syphilis is easy to detect and cure, given adequate access
to and use of care. Nationally, it is at the lowest rate ever recorded
and is confined to a very limited number of geographic areas. The last
epidemic peaked in 1990, with the highest syphilis rate in 40 years. By
1997, the number of cases had declined by 84 percent.Error: Reference
source not found In addition, where syphilis does persist in the United
States, it disproportionately affects African Americans living in
poverty. Although the black:white ratio for reported syphilis has
decreased since the early 1990s, the 1997 primary and secondary syphilis
rate for non-Hispanic blacks was still 44 times greater than that for
non-Hispanic whites.Error: Reference source not found In 1997, of the
1,034 reported congenital syphilis cases with known race or ethnicity of
the mother, non-Hispanic blacks and Hispanics accounted for 88 percent
of these reported cases, while accounting for only 23 percent of the
female population and 33 percent of all births.Error: Reference source
not found The persistence of high rates of syphilis in the United States
is a sentinel event identifying communities in which there is a
fundamental failure of basic public health capacity to control
infectious diseases and ensure reproductive health.

Elimination of syphilis would have far-reaching public health
implications because it would remove two devastating consequences of the
disease---increased likelihood of HIV transmission and compromised
ability to have healthy babies due to spontaneous abortions,
stillbirths, and multisystem disorders caused by congenital syphilis
acquired from mothers with syphilis. Eliminating syphilis in the United
States would be a landmark achievement because it would remove these
direct health burdens and would significantly decrease one of this
Nation's most glaring racial disparities in health.

While many other endemic diseases, such as polio, measles, and smallpox,
have been eliminated through widespread use of vaccines, the strategies
for syphilis elimination differ from these efforts largely because there
currently is no vaccine. Five strategies are critical for eliminating
syphilis from the United States. Two strategies---strengthened community
involvement and partnerships and rapid outbreak response---will be new
in many parts of the United States. The three remaining
strategies---enhanced surveillance, expanded clinical and laboratory
services, and enhanced health promotion---have been used for syphilis
control and will be intensified and expanded for syphilis elimination.

### Viral STD Illness and Disability

25-4. Reduce the proportion of adults with genital herpes\
infection.

**Target:** 14 percent.

**Baseline:** 17 percent of adults aged 20 to 29 years had genital
herpes infection in 1988--94 (as measured by herpes simplex virus type 2
\[HSV-2\] antibody).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

Note: The table below may continue to the following page.

+-------------------------------------------------+--------------------+
| **Adults Aged 20 to 29 Years, 1988--94**        | **Infected With    |
|                                                 | Genital Herpes**   |
+=================================================+====================+
|                                                 | Percent            |
+-------------------------------------------------+--------------------+
| > **TOTAL**                                     | 17                 |
+-------------------------------------------------+--------------------+
| **Race and ethnicity**                          |                    |
+-------------------------------------------------+--------------------+
| > American Indian or Alaska Native              | DSU                |
+-------------------------------------------------+--------------------+
| > Asian or Pacific Islander                     | DSU                |
+-------------------------------------------------+--------------------+
| > Asian                                         | DNC                |
+-------------------------------------------------+--------------------+
| > Native Hawaiian and other Pacific Islander    | DNC                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 34                 |
+-------------------------------------------------+--------------------+
| > White                                         | 15                 |
+-------------------------------------------------+--------------------+
|                                                 |                    |
+-------------------------------------------------+--------------------+
| > Hispanic or Latino                            | DSU                |
+-------------------------------------------------+--------------------+
| Mexican American                                | 15                 |
+-------------------------------------------------+--------------------+
| > Not Hispanic or Latino                        | DNA                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 33                 |
+-------------------------------------------------+--------------------+
| > White                                         | 15                 |
+-------------------------------------------------+--------------------+
| **Gender**                                      |                    |
+-------------------------------------------------+--------------------+
| > Female (all ages)                             | 26                 |
+-------------------------------------------------+--------------------+
| > Male (all ages)                               | 18                 |
+-------------------------------------------------+--------------------+
| **Family income level**                         |                    |
+-------------------------------------------------+--------------------+
| > Poor                                          | 28                 |
+-------------------------------------------------+--------------------+
| > Near poor                                     | 14                 |
+-------------------------------------------------+--------------------+
| > Middle/high income                            | 15                 |
+-------------------------------------------------+--------------------+
| ###### Age                                      |                    |
+-------------------------------------------------+--------------------+
| > 12 to 19 years\*                              | 6                  |
+-------------------------------------------------+--------------------+
| > 20 to 29 years                                | 17                 |
+-------------------------------------------------+--------------------+
| > 30 to 39 years\*                              | 28                 |
+-------------------------------------------------+--------------------+
| > 40 to 49 years\*                              | 27                 |
+-------------------------------------------------+--------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for persons aged 12 to 19 years, 30 to 39 years, and 40 to 49
years are displayed to further\
characterize the issue.

Note: The table above may have continued from the previous page.

25-5. (Developmental) Reduce the proportion of persons\
with human papillomavirus (HPV) infection.

**Potential data source:** National Health and Nutrition Examination
Survey (NHANES), CDC, NCHS.

Reducing the number of new HPV cases can help to minimize the overall
number of cases of high-risk subtypes associated with cervical cancer in
females aged 15 to 44 years. Over the past 15 years, molecular,
biochemical, and epidemiologic data have firmly established the central
role of several types of HPV (types 16, 18, 31, and 45) in the
pathogenesis of cervical cancer.[^63]

### STD Complications Affecting Females

25-6. Reduce the proportion of females who have ever required treatment
for pelvic inflammatory disease (PID).

**Target:** 5 percent.

**Baseline:** 8 percent of females aged 15 to 44 years required
treatment for PID in 1995.

**Target setting method:** Better than the best.

**Data source:** National Survey of Family Growth (NSFG), CDC, NCHS.

+-------------------------------------------------+--------------------+
| **Females Aged 15 to 44 Years, 1995**           | **Treated for      |
|                                                 | PID**              |
+=================================================+====================+
|                                                 | Percent            |
+-------------------------------------------------+--------------------+
| > **TOTAL**                                     | 8                  |
+-------------------------------------------------+--------------------+
| **Race and ethnicity**                          |                    |
+-------------------------------------------------+--------------------+
| > American Indian or Alaska Native              | DSU                |
+-------------------------------------------------+--------------------+
| > Asian or Pacific Islander                     | DSU                |
+-------------------------------------------------+--------------------+
| > Asian                                         | DNC                |
+-------------------------------------------------+--------------------+
| > Native Hawaiian and other Pacific Islander    | DNC                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 11                 |
+-------------------------------------------------+--------------------+
| > White                                         | 7                  |
+-------------------------------------------------+--------------------+
|                                                 |                    |
+-------------------------------------------------+--------------------+
| > Hispanic or Latino                            | 8                  |
+-------------------------------------------------+--------------------+
| > Not Hispanic or Latino                        | 8                  |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 11                 |
+-------------------------------------------------+--------------------+
| > White                                         | 7                  |
+-------------------------------------------------+--------------------+
| **Family income level** (aged 22 to 44 years)   |                    |
+-------------------------------------------------+--------------------+
| > Poor                                          | 12                 |
+-------------------------------------------------+--------------------+
| > Near poor                                     | 11                 |
+-------------------------------------------------+--------------------+
| > Middle/high income                            | 8                  |
+-------------------------------------------------+--------------------+
| **Education level** (aged 22 to 44 years)       |                    |
+-------------------------------------------------+--------------------+
| > Less than high school                         | 14                 |
+-------------------------------------------------+--------------------+
| > High school graduate                          | 9                  |
+-------------------------------------------------+--------------------+
| > At least some college                         | 7                  |
+-------------------------------------------------+--------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

PID is among the most serious threats to female reproductive capability.
PID is caused most frequently by chlamydial infections and gonorrhea
that ascend past the cervix into the upper reproductive tract.[^64] More
than 1 million women have an episode of PID annually.[^65]**^,^** [^66]
PID often results in scarring and either complete or partial blockage of
the fallopian tubes. As a result, as many as one-quarter of women with
acute PID experience serious long-term sequelae, most often an ectopic
pregnancy or tubal factor infertility. Women who have had PID are 6 to
10 times more likely to have an ectopic pregnancy compared with women
who have not had PID.Error: Reference source not found In 1992,
approximately 9 percent of all pregnancy-related deaths were caused by
ectopic pregnancy.[^67]

25-7. Reduce the proportion of childless females with fertility problems
who have had a sexually transmitted disease\
or who have required treatment for pelvic inflammatory disease (PID).

**Target:** 15 percent.

**Baseline:** 27 percent of childless females aged 15 to 44 years with
fertility\
problems had a history of STDs or PID treatment in 1995.

**Target setting method:** 44 percent improvement.

**Data source:** National Survey of Family Growth (NSFG), CDC, NCHS.

Note: The table below may continue to the following page.

+-------------------------------------------------+--------------------+
| **Childless Females Aged 15 to 44 Years\        | **STD History or   |
| With Fertility Problems, 1995**                 | PID Treatment**    |
+=================================================+====================+
|                                                 | Percent            |
+-------------------------------------------------+--------------------+
| > **TOTAL**                                     | 27                 |
+-------------------------------------------------+--------------------+
| **Race and ethnicity**                          |                    |
+-------------------------------------------------+--------------------+
| > American Indian or Alaska Native              | DSU                |
+-------------------------------------------------+--------------------+
| > Asian or Pacific Islander                     | DSU                |
+-------------------------------------------------+--------------------+
| > Asian                                         | DNC                |
+-------------------------------------------------+--------------------+
| > Native Hawaiian and other Pacific Islander    | DNC                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 33                 |
+-------------------------------------------------+--------------------+
| > White                                         | 27                 |
+-------------------------------------------------+--------------------+
|                                                 |                    |
+-------------------------------------------------+--------------------+
| > Hispanic or Latino                            | 27                 |
+-------------------------------------------------+--------------------+
| > Not Hispanic or Latino                        | 27                 |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 32                 |
+-------------------------------------------------+--------------------+
| > White                                         | 27                 |
+-------------------------------------------------+--------------------+
| **Education level** (aged 22 to 44 years)       |                    |
+-------------------------------------------------+--------------------+
| > Less than high school                         | 30                 |
+-------------------------------------------------+--------------------+
| > High school graduate                          | 27                 |
+-------------------------------------------------+--------------------+
| > At least some college                         | 28                 |
+-------------------------------------------------+--------------------+
| ###### Age                                      |                    |
+-------------------------------------------------+--------------------+
| > 15 to 24 years                                | 23                 |
+-------------------------------------------------+--------------------+
| > 25 to 34 years                                | 26                 |
+-------------------------------------------------+--------------------+
| > 35 to 44 years                                | 31                 |
+-------------------------------------------------+--------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

In 1995, there were approximately 24.2 million women aged 15 to 44 years
who had not given birth to a child and had not had a sterilizing
operation. Most of them (21.2 million) were presumed to be able to have
a child. Perhaps these women were not aware of fertility problems (see
Terminology) because they had not yet tested their fertility potential.
This presumption is supported by the fact that most of these 21.2
million childless women were using contraception in 1995. While some
fraction of them may remain voluntarily childless and never choose to
test their fertility, most are likely to pursue childbearing at some
point in the future. Approximately 2.3 million of these "untested" women
in 1995 had a history of STDs or PID treatment, increasing the
likelihood that some of them will experience a fertility problem in the
future. If the social stigma associated with STDs resulted in any
underreporting of STDs in this self-report survey, the 2.3 million women
at risk for future fertility problems may be a low estimate.

At the time of the NSFG in 1995, nearly 3 million of the 24.2 million
childless women had a fertility problem. A subset of this group,
approximately 800,000 women, had a history of STDs or PID treatment.
This subset comprised 27 percent of the women with known fertility
problems, which may be a low estimate of the contribution made by
previous STDs or PID to the fertility problems among childless women.
Because bacterial STDs and PID may be asymptomatic when present and
because diagnosing tubal factor infertility caused by PID is both
difficult and expensive, many women with fertility problems may not be
aware of having had an STD or PID in the past. Evidence has shown that
reducing the burden of bacterial STDs in reproductive age women can
dramatically reduce the amount of PIDError: Reference source not found
and through this mechanism could reduce fertility problems.

25-8. (Developmental) Reduce HIV infections in adolescent\
and young adult females aged 13 to 24 years that are\
associated with heterosexual contact.

**Potential data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

### STD Complications Affecting the Fetus and Newborn

25-9. Reduce congenital syphilis.

**Target:** 1 new case per 100,000 live births.

**Baseline:** 27 new cases of congenital syphilis per 100,000 live
births were\
reported in 1997.

**Target setting method:** Better than the best and consistent with the
National Plan to Eliminate Syphilis from the United States, CDC, 1998.

**Data sources:** STD Surveillance System, CDC, NCHSTP; National Vital\
Statistics System (NVSS), CDC, NCHS.

+-------------------------------------------------+--------------------+
| **Live Births, 1997**                           | **New Congenital\  |
|                                                 | Syphilis Cases**   |
+=================================================+====================+
|                                                 | Rate per 100,000   |
+-------------------------------------------------+--------------------+
| > **TOTAL**                                     | 27                 |
+-------------------------------------------------+--------------------+
| **Mother's race and ethnicity**                 |                    |
+-------------------------------------------------+--------------------+
| > American Indian or Alaska Native              | 11                 |
+-------------------------------------------------+--------------------+
| > Asian or Pacific Islander                     | 8                  |
+-------------------------------------------------+--------------------+
| > Asian                                         | DNC                |
+-------------------------------------------------+--------------------+
| > Native Hawaiian and other Pacific Islander    | DNC                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | DNC                |
+-------------------------------------------------+--------------------+
| > White                                         | DNC                |
+-------------------------------------------------+--------------------+
|                                                 |                    |
+-------------------------------------------------+--------------------+
| > Hispanic or Latino                            | 34                 |
+-------------------------------------------------+--------------------+
| > Not Hispanic or Latino                        | DNC                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 123                |
+-------------------------------------------------+--------------------+
| > White                                         | 4                  |
+-------------------------------------------------+--------------------+
| ###### Family income level                      |                    |
+-------------------------------------------------+--------------------+
| > Poor                                          | DNC                |
+-------------------------------------------------+--------------------+
| > Near poor                                     | DNC                |
+-------------------------------------------------+--------------------+
| > Middle/high income                            | DNC                |
+-------------------------------------------------+--------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

25-10. (Developmental) Reduce neonatal consequences from\
maternal sexually transmitted diseases, including\
chlamydial pneumonia, gonococcal and chlamydial\
*ophthalmia neonatorum*, laryngeal papillomatosis (from human
papillomavirus infection), neonatal herpes, and\
preterm birth and low birth weight associated with\
bacterial vaginosis.

**Potential data source:** STD Surveillance System, CDC, NCHSTP.

### Personal Behaviors

25-11. Increase the proportion of adolescents who abstain from sexual
intercourse or use condoms if currently sexually\
active.

**Target:** 95 percent.

**Baseline:** 85 percent of adolescents in grades 9 through 12 abstained
from\
sexual intercourse or used condoms in 1999 (50 percent had never had\
intercourse; 14 percent had intercourse but not in the past 3 months;
and 21\
percent currently were sexually active and used a condom at last
intercourse).

**Target setting method:** 12 percent improvement.

**Data source:** Youth Risk Behavior Surveillance System (YRBSS), CDC,\
NCCDPHP.

Note: The table below may continue to the following page.

+-----------------------+--------+--------+--------+------+---+---+--------+
| > **Students in       | **     | **NOT  |        | **C  |   |   |        |
| > Grades 9 Through    | 25-11. | Cur    |        | urre |   |   |        |
| > 12, 1999**          | Abs    | rently |        | ntly |   |   |        |
|                       | tained | Se     |        | Sexu |   |   |        |
|                       | From   | xually |        | ally |   |   |        |
|                       | Sexual | Ac     |        | Acti |   |   |        |
|                       | Inter  | tive** |        | ve** |   |   |        |
|                       | course |        |        |      |   |   |        |
|                       | or     |        |        |      |   |   |        |
|                       | Used   |        |        |      |   |   |        |
|                       | Condom |        |        |      |   |   |        |
|                       | \[     |        |        |      |   |   |        |
|                       | Column |        |        |      |   |   |        |
|                       | a =    |        |        |      |   |   |        |
|                       | b +    |        |        |      |   |   |        |
|                       | c +    |        |        |      |   |   |        |
|                       | d\]**  |        |        |      |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
|                       |        | *      | **No   | **   |   |   | **Did  |
|                       |        | *Never | Inter  | Used |   |   | NOT    |
|                       |        | Had    | course | Co   |   |   | Use    |
|                       |        | I      | in     | ndom |   |   | Condom |
|                       |        | nterco | Past 3 | at   |   |   | at     |
|                       |        | urse\* | Mo     | Last |   |   | Last   |
|                       |        | \[     | nths\* | I    |   |   | Inter  |
|                       |        | Column | \[     | nter |   |   | course |
|                       |        | b\]**  | Column | cour |   |   | \[     |
|                       |        |        | c\]**  | se\* |   |   | Column |
|                       |        |        |        | \[Co |   |   | e\]**  |
|                       |        |        |        | lumn |   |   |        |
|                       |        |        |        | d    |   |   |        |
|                       |        |        |        | \]** |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
|                       | P      |        |        |      |   |   |        |
|                       | ercent |        |        |      |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > **TOTAL**           | 85     | 50     | 14     | 21   |   | 1 |        |
|                       |        |        |        |      |   | 5 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| **Race and            |        |        |        |      |   |   |        |
| ethnicity**           |        |        |        |      |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > American Indian or  | DSU    | DSU    | DSU    | DSU  |   | D |        |
| > Alaska Native       |        |        |        |      |   | S |        |
|                       |        |        |        |      |   | U |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Asian or Pacific\   | DSU    | DSU    | DSU    | DSU  |   | D |        |
| > Islander            |        |        |        |      |   | S |        |
|                       |        |        |        |      |   | U |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Asian               | DNC    | DNC    | DNC    | DNC  |   | D |        |
|                       |        |        |        |      |   | N |        |
|                       |        |        |        |      |   | C |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Native Hawaiian and | DNC    | DNC    | DNC    | DNC  |   | D |        |
| > other Pacific\      |        |        |        |      |   | N |        |
| > Islander            |        |        |        |      |   | C |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Black or African\   | 83     | 30     | 17     | 36   |   | 1 |        |
| > American            |        |        |        |      |   | 7 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > White               | 86     | 55     | 13     | 18   |   | 1 |        |
|                       |        |        |        |      |   | 4 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
|                       |        |        |        |      |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Hispanic or Latino  | 84     | 46     | 18     | 20   |   | 1 |        |
|                       |        |        |        |      |   | 6 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Not Hispanic or     | 85     | 51     | 13     | 21   |   | 1 |        |
| > Latino              |        |        |        |      |   | 5 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Black or African\   | 84     | 29     | 18     | 37   |   | 1 |        |
| > American            |        |        |        |      |   | 6 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > White               | 85     | 55     | 12     | 18   |   | 1 |        |
|                       |        |        |        |      |   | 5 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| **Gender**            |        |        |        |      |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Female              | 81     | 52     | 11     | 18   |   | 1 |        |
|                       |        |        |        |      |   | 8 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > Male                | 87     | 48     | 16     | 23   |   | 1 |        |
|                       |        |        |        |      |   | 3 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| ###### Grade          |        |        |        |      |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > 9th                 | 90     | 61     | 12     | 17   |   | 1 |        |
|                       |        |        |        |      |   | 0 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > 10th                | 87     | 53     | 14     | 20   |   | 1 |        |
|                       |        |        |        |      |   | 3 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > 11th                | 84     | 47     | 15     | 22   |   | 1 |        |
|                       |        |        |        |      |   | 6 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > 12th                | 73     | 35     | 14     | 24   |   | 2 |        |
|                       |        |        |        |      |   | 7 |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| ####                  | DNC    | DNC    | DNC    | DNC  |   | D |        |
| ## Sexual orientation |        |        |        |      |   | N |        |
|                       |        |        |        |      |   | C |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| ####                  |        |        |        |      |   |   |        |
| ## Select populations |        |        |        |      |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| Number of sex         |        |        |        |      |   |   |        |
| partners (past 3      |        |        |        |      |   |   |        |
| months)               |        |        |        |      |   |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > None                | 100    | 79     | 21     | NA   | N |   |        |
|                       |        |        |        |      | A |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > 1                   | 57     | NA     | NA     | 57   | 4 |   |        |
|                       |        |        |        |      | 3 |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > 2 to 3              | 62     | NA     | NA     | 62   | 3 |   |        |
|                       |        |        |        |      | 8 |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+
| > 4 or more           | 60     | NA     | NA     | 60   | 4 |   |        |
|                       |        |        |        |      | 0 |   |        |
+-----------------------+--------+--------+--------+------+---+---+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable. NA = Not applicable.

\*Data for never had intercourse, had intercourse but not in the past 3
months, and currently sexually active and used a condom at last
intercourse are displayed to further characterize the issue.

Note: The table above may have continued from the previous page.

Promoting responsible adolescent sexual behavior targets three
protective behaviors that reduce the risk of STDs (including HIV
infection) and unintended pregnancy. These behaviors are especially
relevant to young people who, as a group, experience a disproportionate
share of STDs and unintended pregnancies when they engage in sexual
intercourse.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** The protective
behaviors of interest are completely abstaining from sexual intercourse
during adolescence (primary abstinence), reverting to abstinence for
long periods of time after having had intercourse in the past (secondary
abstinence), and at least using condoms (a single method that offers
protection against both pregnancy and some STDs) consistently and
correctly if regular intercourse is occurring. In 1999, 85 percent of
high school youth demonstrated at least one of these behaviors. In
contrast, the remaining 15 percent were sexually active and did not use
a condom at last intercourse, placing them at high risk for STDs and
unwanted pregnancy. Increasing and maintaining the proportion of youth
who exhibit the above protective behaviors reduce the risks of HIV
infection, other STDs, and unintended pregnancies for adolescents
because the proportion of youth who are currently sexually active and do
not use condoms will be reduced.

Various societal institutions (such as parents and families, schools,
health care providers, postsecondary institutions, religious
organizations, media, employers, community agencies that serve youth,
celebrities, and government agencies) can positively influence the
health and behaviors of the Nation's youth. Collaboration among these
institutions can (1) help adolescents abstain from sexual intercourse,
(2) help them overcome pressure to become sexually active prematurely,
and (3) ensure accessible, confidential community counseling and
clinical services for young people who are or have been sexually active.

Abstaining from sexual intercourse offers maximum protection to
adolescents who are generally poorly prepared to deal with the physical
and psychological consequences of HIV infection, other STDs, and
pregnancy. Overall, 50 percent of high school youth fell into this
category (see objective 25-11 population data table). Abstaining from
sexual intercourse while in high school varied by race and ethnicity,
for example, from 55 percent among white youth to 29 percent among
African American youth. Abstaining from intercourse decreased as young
people progressed through high school, from 61 percent among 9th graders
to 35 percent among 12th graders. These data point out that while 61
percent of 9th graders had never had sexual intercourse, at least 39
percent had intercourse during or before 9th grade. Among the 39
percent, 12 percent had not had intercourse in the past 3 months, 17
percent were currently sexually active and used a condom at last
intercourse, and the remaining 10 percent were sexually active and did
not use a condom at last intercourse. These data suggest a need for
counseling, support, education, and services for many young people even
before high school begins.

Young people who have had sexual intercourse in the past but are not
currently sexually active need special attention and services. Overall,
14 percent of high school youth fall into this category. Slightly more
males (16 percent) than females (11 percent) fit into this category.
More African American (18 percent) and Hispanic (18 percent) youth fit
into this category than do white (12 percent) youth. Even if pregnancy
were avoided in the past, the same may not be true for STDs. Some youth
may have acquired viral or bacterial STDs that have not been recognized
or treated. Previously sexually active adolescents need to be educated
about this possibility, and medical evaluation and counseling are
strongly suggested both to identify treatable conditions and to
reinforce abstinence messages.

Young people who are currently sexually active also require special
attention and services. This requirement applies both to the 21 percent
of high school youth who were sexually active and used a condom at last
intercourse and the remaining 15 percent of youth who were currently
sexually active and did not use a condom at last intercourse. These data
illustrate wide variation in current sexual activity by race/ethnicity.
For African American high school youth, 53 percent were sexually active
(37 percent were sexually active and used a condom at last intercourse,
and 16 percent were sexually active but did not use a condom at last
intercourse). For Hispanic youth, 36 percent were sexually active (20
percent were sexually active and used a condom, and 16 percent were
sexually active and did not use a condom). Among white youth, 33 percent
were sexually active (18 percent used a condom at last intercourse, and
15 percent did not use a condom). Also, fewer sex partners among
currently sexually active youth does not equate with a much higher
degree of condom use. Regardless of the number of sex partners in a
given interval, approximately one of every two sexually active
adolescents did not use a condom at last intercourse. For example, for
adolescents who had four or more sex partners in the past 3 months, 40
percent of them would be considered to be at very high risk for STDs
(including HIV infection) and possibly pregnancy by not using condoms
consistently. Even for youth with one sex partner in the past 3 months,
43 percent did not use condoms consistently. In addition to reinforcing
abstinence messages, adult counselors of currently sexually active
adolescents must be aware that there is ongoing, very high risk of HIV
infection, other STDs, and pregnancy. Responsible and influential adults
should help young males and females gain easy access to high quality,
confidential, comprehensive reproductive health care in their
communities that can help them reduce HIV infection, STD, and pregnancy
risk. This is especially true for adolescent females, who bear all the
physical consequences of unintended pregnancy and bear disproportionate
short- and long-term complications from STDs.

25-12. (Developmental) Increase the number of positive\
messages related to responsible sexual behavior during weekday and
nightly prime-time television programming.

**Potential data source:** CDC, NCHSTP.

Television messages hold the potential to promote responsible sexual
behaviors, such as abstinence, delaying sexual intercourse, or using
effective methods to prevent STDs and pregnancy, such as use of condoms
and hormonal contraception.

### Community Protection Infrastructure

25-13. Increase the proportion of Tribal, State, and local sexually
transmitted disease programs that routinely offer hepatitis B vaccines
to all STD clients.

**Target:** 90 percent.

**Baseline:** 5 percent of State and local STD programs offered
hepatitis B\
vaccines to clients in accordance with CDC guidelines in 1998.Error:
Reference source not found**^,^** [^68] Tribal STD program data are
developmental.

**Target setting method:** 85 percentage point improvement.

**Data sources:** Survey of STD Programs, National Coalition of STD
Directors (NCSD); IHS.

Routine vaccination of infants is expected to produce a highly immune
population to eliminate hepatitis B virus transmission in the United
States. However, high rates of acute hepatitis B continue to occur in
young adult risk groups, particularly persons with a history of another
sexually transmitted disease and persons with multiple sex partners.
Approximately 50 percent of new infections occur in persons with a
sexual risk factor for transmission, and most of these persons have had
a missed opportunity to be vaccinated. For example, 42 percent of acute
hepatitis B cases reported in the CDC Sentinel Counties Study of Viral
Hepatitis in 1996 had been treated for a sexually transmitted disease in
the past.

25-14. (Developmental) Increase the proportion of youth\
detention facilities and adult city or county jails that screen for
common bacterial sexually transmitted diseases within 24 hours of
admission and treat STDs (when necessary) before persons are released.

**Potential data sources:** Annual Survey of Correctional Facilities,
CDC, NCHSTP and National Institute of Justice; U.S. Department of
Justice, Bureau\
of Justice Statistics.

25-15. (Developmental) Increase the proportion of all local health
departments that have contracts with managed care\
providers for the treatment of nonplan partners of patients with
bacterial sexually transmitted diseases (gonorrhea, syphilis, and
chlamydia).

**Potential data source:** Survey of STD Programs, National Coalition of
STD\
Directors (NCSD).

### Personal Health Services

25-16. (Developmental) Increase the proportion of sexually active
females aged 25 years and under who are screened\
annually for genital chlamydia infections.

**Potential data sources:** Family Planning Annual Report, OPA; STD\
Surveillance System, CDC, NCHSTP.

Routine screening for asymptomatic infection with *Chlamydia
trachomatis* during pelvic examination is recommended for all sexually
active female adolescents and for other women at high risk for
chlamydial infection. While evidence is insufficient to make a
recommendation concerning routine screening of sexually active males, in
situations where asymptomatic chlamydial infection is high in males,
screening using urine-based tests may be recommended to prevent spread
of the infection.Error: Reference source not found Reported chlamydial
infection rates in males are highest among those aged 20 to 24 years.

25-17. (Developmental) Increase the proportion of pregnant\
females screened for sexually transmitted diseases\
(including HIV infection and bacterial vaginosis) during prenatal health
care visits, according to recognized\
standards.

**Potential data source:** STD Surveillance System, CDC, NCHSTP.

While evidence is insufficient to make a recommendation concerning
routine screening of pregnant females for STDs, the benefits of early
intervention in HIV-asymptomatic pregnant women, for example, are known.
Similar benefits have been demonstrated in detecting and treating
asymptomatic chlamydia infection in pregnancy.Error: Reference source
not found

25-18. Increase the proportion of primary care providers who treat
patients with sexually transmitted diseases and who\
manage cases according to recognized standards.

**Target:** 90 percent.

**Baseline:** 70 percent of primary care providers treated patients with
STDs\
according to CDC STD Treatment Guidelines in 1988.

**Target setting method:** Retain 2000 target.

**Data sources:** National Disease and Therapeutic Index, IMS America;
National Ambulatory Medical Care Survey (NAMCS), CDC, NCHS.

25-19. (Developmental) Increase the proportion of all sexually
transmitted disease clinic patients who are being treated for bacterial
STDs (chlamydia, gonorrhea, and syphilis) and who are offered provider
referral services for their sex partners.

**Potential data source:** STD Surveillance System, CDC, NCHSTP.

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-3. Counseling about health behaviors

1-7. Core competencies in health provider training

3\. Cancer

3-4. Cervical cancer deaths

3-11. Pap tests

7\. Educational and Community-Based Programs

7-2. School health education

9\. Family Planning

9-8. Abstinence before age 15 years

9-9. Abstinence among adolescents aged 15 to 17 years

9-10. Pregnancy prevention and sexually transmitted disease (STD)
protection

9-11. Pregnancy prevention education

9-12. Problems in becoming pregnant and maintaining a pregnancy

13\. HIV

13-5. New HIV cases

13-6. Condom use

13-9. HIV/AIDS, STD, and TB education in State prisons

13-12. Screening for STDs and immunization for hepatitis B

14\. Immunization and Infectious Diseases

14-3. Hepatitis B in adults and high-risk groups

14-28. Hepatitis B vaccination among high-risk groups

15\. Injury and Violence Prevention

15-35. Rape or attempted rape

15-36. Sexual assault other than rape

16\. Maternal, Infant, and Child Health

16-1. Fetal and infant deaths

16-6. Prenatal care

16-10. Low birth weight and very low birth weight

16-11. Preterm births

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Bacterial and protozoal STDs:** Refer to curable sexually transmitted
infections caused by *Chlamydia trachomatis* (chlamydia), *Neisseria
gonorrhoeae* (gonorrhea), *Treponema pallidum* (syphilis), *Haemophilus
ducreyi* (chancroid), *Trichomonas vaginalis* (trichomoniasis),
*bacterial vaginosis*, and other organisms.

**Congenital syphilis:** A condition in a fetus or newborn caused by
infection with the syphilis bacteria from an untreated mother. Infected
newborns show a wide spectrum of clinical signs, and only severe cases
are clinically apparent at birth. Severe illness or death can result
after birth if the newborn is not treated.

**Fertility problems:** Refer to the standard medical definitions of
infertility (have not used contraception and have not become pregnant
for 12 months or more) or impaired fecundity (women reporting no
sterilizing operation and classified as finding it difficult or
impossible to get pregnant or carry a baby to term).

**Provider referral:** Formerly called contact tracing, the process
whereby health department personnel directly and confidentially notify
the sex partners of infected individuals about their exposure to a
sexually transmitted disease for the purposes of education, counseling,
and referral to health care services.

**STD complications:** Refer to serious health problems that occur
following an acute bacterial or viral STD. Among the most serious of
these complications:

> **Cancer:** Includes cervical cancer and its precursors (due to some
> strains of human papillomavirus) and liver cancer that can result
> after chronic infection with hepatitis B virus.
>
> **Infection of a fetus or newborn:** Includes conditions such as
> congenital syphilis, neonatal herpes, HIV infection, eye infections,
> and pneumonia.
>
> **Pelvic inflammatory disease (PID):** Can cause permanent damage to
> the female reproductive tract and lead to ectopic pregnancy,
> infertility, or chronic pelvic pain.
>
> **Preterm birth:** Can result from maternal infection.
>
> **Sexually transmitted HIV infection:** Can be facilitated by the
> presence of an inflammatory or ulcerative STD in one or both sex
> partners.

**Syphilis elimination:** Refers to the elimination of sustained
domestic transmission of syphilis. Term means that there is no
continuing transmission of the disease within a community or
jurisdiction and absence of transmission within a jurisdiction except
within 90 days of report of an imported case.

**Viral STDs:** Refer to the sexually transmitted viral infections---HIV
infection, genital herpes, and HPV infection. Initial infections with
these organisms may be asymptomatic or may cause only mild symptoms.
Hepatitis B virus and hepatitis C virus can be transmitted through
sexual activity.

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