# Presentation: 053800

## “Can You Hear Me Now?” Linking STIs and HIV infection

- David B. Johnson – Sr. Public Health Advisor
- Dr. Roxanne Barrow – Medical Epidemiologist
- Division of STD Prevention

## From Coast to Coast

- We got Issues

## Gonorrhea — Rates by race/ethnicity and sex:  United States, 2005

## Gonorrhea — Rates among 15- to 19-year-old females by race/ethnicity:United States, 1996–2005

## Gonorrhea — Rates among 15- to 19-year-old males by race/ethnicity:United States, 1996–2005

## Chlamydia — Rates by race/ethnicity and sex:  United States, 2005

## Primary and secondary syphilis — Rates by race/ethnicity and sex: United States, 2005

## What’s the link between STIs and HIV/AIDS?

## The STD-HIV/AIDS Connection

**Increased susceptibility**
- Individuals who are infected with STDs are at least two to five times more likely than uninfected individuals to acquire HIV
- 	***Genital ulcers*** (e.g., _[syphilis](http://www.cdc.gov/std/Syphilis/default.htm)_, _[herpes](http://www.cdc.gov/std/Herpes/default.htm)_, or chancroid) result in breaks in the genital tract lining or skin which create a portal of entry for HIV
- 	***Non-ulcerative STDs*** (e.g., _[chlamydia](http://www.cdc.gov/std/Chlamydia/default.htm)_, _[gonorrhea](http://www.cdc.gov/std/Gonorrhea/default.htm)_, and _[trichomoniasis](http://www.cdc.gov/std/Trichomonas/default.htm)_) increase the concentration of cells in genital secretions that can serve as targets for HIV (e.g., CD4+ cells)

## The STD-HIV/AIDS Connection

**Increased infectiousness**
- HIV-infected individuals co-infected with another STD are more likely to transmit HIV through sexual contact than other HIV-infected persons (Wasserheit, 1992)
- HIV-infected individuals co-infected with other STDs are more likely to have HIV in their genital secretions
- Men infected with both _gonorrhea_ and HIV are more than twice as likely to shed HIV in their genital secretions than are those who are infected only with HIV
- The median concentration of HIV in semen is as much as 10 times higher in men who are infected with both _[gonorrhea](http://www.cdc.gov/std/Gonorrhea/default.htm)_ and HIV than in men infected only with HIV

## What does any of this mean?

- Clarity, Choices, and Networks

## Clarity

## Sexual behavior measured in terms of 
number of partners
sexual practices
condom use
other individual level parameters

	does not account for the observed racial disparities in STI

- number of partners
- sexual practices
- condom use
- other individual level parameters
- 	does _not_ account for the observed racial disparities in STI

## African American women have the highest rates of STI in most analyses – they do NOT have the highest levels of risk behavior.
Having a sexually transmitted infection does not mean the person is engaging in risky sexual behaviors.

- Having a sexually transmitted infection does not mean the person is engaging in risky sexual behaviors.

## Choices

## Sexual Mixing Patterns

**Assortative Mixing**
- Partnerships between people who are at similar risk for infection
- Keeps infection within the risk subpopulation
- Most social and sexual networks are relatively assortative
**Dissortative Mixing**
- High and low risk people form partnerships
- Disseminates infection throughout the population

## Mixing Among African Americans

- Limited published data re: general black population
- National Health and Social Life Survey
- 	More frequent contact between individuals with many partners (core) and those with few partners (dissortative)
- 	Sexual networks relatively segregated by race
*Laumann E, Youm Y. Sex Transm Dis 1999;26:250-261*

## Population Level Interventions

## Population Level Intervention

**Los Angeles County**
- Initiated a Women of Color Advisory Committee
- Initiated a Media Campaign with Power 106 Targeting African Americans
- Public Housing Project – Nickerson Gardens, Jordan Downs, Imperial Courts

## Population Level Intervention

**Maryland and Baltimore Health Department**
- Initiated a self-administered test for chlamydia using the Internet - _[www.iwantthekit.org](http://www.iwantthekit.org/)__  _
- In 2004, tested 400 women and 41 tested positive for chlamydia
- Continued use of the Internet site that has been expanded to include men

## Population Level Intervention

**US Public Health Region IV**
- Infertility initiative to screen women for chlamydia and gonorrhea
- Annually screen African American women that attend historically Black colleges and universities within the Region

## Networks

## Consultation to Address STD Disparities in African American Communities

- Meeting held June 5-6, 2007
- Consultants included external and internal partners
- Meeting activities
- Review the epidemiology of bacterial STDs
- Discuss the determinants
- Discuss the individual, social, and health impact of the disparities
- Develop an action plan for CDC and meeting consultants to address STD disparities among African Americans
- Identify opportunities for collaboration with other sexual health issues such as HIV, herpes, and hepatitis B

## Consultation to Address STD Disparities in African American Communities

**Initial activities**
- Commitment of four workgroups consisting of CDC and external partners to continue collaborative post-meeting activities for at least the next year
- Development of preliminary goals and action items
- Conduct community outreach to improve screening especially for males
- Establish a community coalition to foster policy changes
- Promote advocacy for reimbursement of screening costs by healthcare providers

## Consultation to Address STD Disparities in African American Communities

**Lessons learned (Fenton Five)**
- Expand the public health paradigm
- Partner with diverse groups and organization
- Define a new dialectic about sexuality and sexual health in African American communities
- Promote cultural competent interventions
- Move from general principles to specific actions

## “The important stuff is always simple.”

- “The simple things are always hard.”