Making The Case For Abstinence

Making the Case for Abstinence The Medical Perspective Kim K. Dernovsek, M.D. Associate Clinical Professor University of Colorado Health Sciences Center Board Certified Internal Medicine and Dermatology Private Practice: Dermatology contact information: 1600 N. Grand Ave. #140, Pueblo, CO, 81003 USA Phone: 719-564-4500 FAX 719-564-0304 Email: [email protected]

STI or STD? Infection: Invasion by and multiplication of bacteria or microorganisms that can produce tissue injury. Many infections can be treated and cured and the tissue returned to normal; other infections result in disease.

Disease: Pathologic condition, impairment, abnormal function, i.e. anatomic or physiologic change, protracted or prolonged, sometimes permanent. Many processes can cause disease, including some infections.

Teens and SEX • 65 Million Americans living with an incurable STD

PREVELANCE

– CDC, “Tracking the Hidden Epidemics 2000”

• 19 Million new cases in US yearly INCIDENCE

Up to 1/2 in ages 15-24 years old – Weinstock H, et al. Perspectives on Sexual and Reproductive Health 2004;36[1]:6-10.

• $14.6 Billion annually in the USA – Chesson HW et al. 2004 National STD Prevention Conference, Philadelphia, PA, March 8-11, 2004. Abstract PO75

•

Reasons for Concern for Sexual Health of our Youth

• • • • • • • • •

Bacterial Vaginosis Non-GC Urethritis Chlamydia Trichomoniasis Gonorrhea Pregnancy Hepatitis A Hepatitis B Hepatitis C

• Scabies • Molluscum Contagiosum • Lice • Herpes I • Lymphogranuloma Venereum • Granuloma Inguinale • Chancroid • Syphilis • HIV/AIDS • Emotional effects

Note: these first 4 are skin-to-skin, not always STI’s but transmit easily with sexual activity

Dermatologic

• HPV • Herpes II

STInfections

STDiseases

• Bacterial Vaginosis • Non-GC Urethritis • Trichomoniasis (1.9 million//7.4 million) • Molluscum Contagiosum

• • • • • • • • • • • • •

STInfestations Scabies Lice Estimated Incidence 2000 15-24 y//overall 9.1 million//18.9 million Weinstock et al. Perspectives on Sexual and Reproductive Heatlh 2004:36(1)

Chlamydia (1.5 million//2.8 million) Gonorrhea (431.000/718,000) LymphogranulomaVenereum Granuloma Inguinale Chancroid Hepatitis A Hepatitis B (7,500//78,000) Hepatitis C (NA//25.000) Syphilis (8,200//70,000) HIV (15,000//40,000) HPV (4.6 million//6.2 million) Herpes I genital Herpes II genital (640,000//1.6 million)

Genital Warts (HPV)

• 1.5-13 % Sexually active adults have ever had • HPV types 6 or 11 – 16, 18, 31, 33 and 35 are found occasionally

Subclinical Genital HPV Infection • Peak prevalence in women < 25 years old: 28-46% • Reactivation or Reinfection possible • 5.5 Million new infections annually • 20 Million currently infected Tracking the Hidden Epidemics 2000, cdc.gov/nchstp

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HPV Infection… Primary Prevention Reduce Duration of Infectivity: Treatment? Genital Warts (HPV) • Primary goal: removal of warts • Treatment possibly reduces, but does not eradicate HPV infectivity • Whether reduction of HPV DNA in genital tissue impacts future transmission remains unclear Subclinical Genital HPV (SIL absent) • No treatment that eradicates infection • Genital HPV “frequently goes away on its own” • Tx not recommended

Cervicovaginal HPV Infection in College Women: Natural History Ho 1998 608

Winer 2003 444

Already infected at entry 26%

19.7%

Others infected during study 43%

38.8% (over 2 yrs)

# Enrolled in study

(over 3 yrs) Ho,G.Y.F., et al: NEJM 1998;338:423-8

CDC STD Treatment Guidelines 2006

Cervicovaginal HPV Infection in Young Women: Natural History 9% remain infected at 2 years 10% remain infected at at 5 years

Winer,R.L.,et al: Am J Epidemiol 2003;157(3):218-226

CDC Study of HPV Prevalence in Women JAMA 2007 297:813-819 Erratum JAMA 2007;298(2):178

(Ho 1998) (NEJM 2003)

Risk of developing Squamous Intraepithelial Lesion (SIL) is associated with persistent infection with a high risk type for at least 6 months . Wright TC, NEJM 2003;348:489-490,518-527

– 2003-2004: women age 14-59 – Self-collected vaginal swab for HPV DNA PCR

Overall HPV prevalence 26.8% HPV vaccine types 6/11/16/18 detected in 3.4% carcinogenic types 16/18 prevalence of 2.3% Conclusion: HPV common but prevalence of HPV vaccine types relatively low JAMA editorial on mandatory vaccine: “unwise”

Ho,G.Y.F., et al: NEJM 1998: 338:423-8

Cervical Cancer USA: estimated 11,070 cases and 3,870 deaths in 2008 Am. Cancer Soc., 3/26/08 For USA women: HPV-related mortality is at least twice that of HIV 2nd most costly $ STD (after HIV) CDC, Dec 1999

95% Cervical CA associated with HPV (8 types) Munoz N, et al., NEJM 2003;348:518-527

Susceptibility of Adolescent Cervix • Squamous-columnar cell junction transformation zone is more exposed in adolescence • Adult cervix less susceptible to HPV –

Kahn JA, Hillard PA. Human papillomavirus and cervical cytology in adolescents. Adolesc Med Clin 2004; 15:301-321.

• Adolescent cervix has ectropion (exposed columnar epithelium; for which chlamydia and gonorrhea have predilection) • With age and after pregnancies, this ectropion converts to squamous epithelium –

Neinstein LS: Adolescent Health Care: A Practical Guide, 4 th edition, 2002, Philadelphia , Lippincott Williams and Wilkins

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Prevention of Cervical Cancer

How important is the Pap test? Of those diagnosed with cervical cancer… half have been non-adherent to screening: 28.5% had never had a Pap test 32.8% no Pap x 5 or more yrs Am J Public Health. 1995 Jun;85(6):791-4

46% had never had a Pap test or no Pap x 3 yrs CMAJ. 1997 Sep 1;157(5):513-9

HPV in men/boys • • • • •

Most develop no symptoms or problems 1% sexually active men have had genital warts HPV vaccine not licensed for men Penile cancer rare (1250 in 2008) American Cancer Society 7/11/08 Anal cancer rare (2020 men, 3050 women in 2008) -American Cancer Society 4/25/07 – However, 17 X more common in MSM – ?Anal PAP tests

53% no Pap x 3 yrs Cancer. 2000 May 15;88(10):2283-9

56% no Pap x 3 yrs

» HPV and Men CDC Fact Sheet 4/3/08

Natl Cancer Inst. 2005 May 4;97(9):675-83

Risk Factors for HPV Infection • Early sexual debut • Multiple partners • Partners with multiple partners • Association of sex and alcohol • Cigarette Smoking • Anal intercourse Ho et al. NEJM 1998,338:423-8

• Presence of transformation zone (ie, Adolescence) • Chronic inflammation from co-infection with other STDs ie Herpes, Chlamydia • Cigarette Smoking • BCP (linked to cervical cancer) • Multiparity

CDC Report to Congress January 2004

Prevention of Genital HPV Infection 1) refrain from any genital contact with another 2) long term mutual monogamy 3) reduce # partners and careful partner selection 4)

Available scientific evidence is not sufficient to recommend condoms as a primary prevention strategy …2006 HPV vaccine

Castle PE. J Low Genit Tract Dis 2004 Jul;8(3):224-230. http://www.cdc.gov/std/HPV/2004HP V%20Report.pdf

HPV Vaccine

6/8/06 FDA licensed

Target HPV 16 and 18 which cause up to 70% of CIN II/III and anogenital CA Vaccine also targets HPV 6 and 11 which cause up to 90% genital warts Unger ER, Barr E. Human papillomavirus and cervical cancer Emerg Infect Dis 2004 Nov available www.cdc.gov/ncidod/EID/vol10no11/04-0623_09.htm

Overview : Made from non-infectious HPV-like particles Safe and no serious side-effects (4/5 injection site pain) 100% efficacy against HPV 16,18,6 and 11 Duration at least five years (no waning immunity) from current studies

HPV Vaccine Vaccine Information Statement, HPV Vaccine, CDCP (6/30/08)

3 injections (0-2-6 months) $360 Not if pregnant /yeast allergic/during acute illness Recommended: Routine/catch-up for 11-26 year old females ).

Females who already have been infected with one or more HPV types would still get protection from the vaccine types they have not acquired. Currently, there is no test available for clinical use to determine whether a female has had any or all of the four HPV types targeted by the vaccine.

Cervical testing (“PAP”) will still be necessary: 30% HPV types that cause cancer will NOT be prevented Will NOT prevent 10% of genital warts

Vaccine Information Statement, HPV Vaccine, and Q and A Sheet, CDCP (1/12/07)

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Mandatory HPV Vaccine

Mandatory HPV Vaccine

Public Health vs Private Wealth: 2007 JAMA EDITORIAL

Public Health vs Private Wealth: 2007 JAMA EDITORIAL

Gostin LO, DeAngelis CD, JAMA. 2007;297:1921-1923.

1) Given that the overall prevalence of HPV types associated with cervical cancer is relatively low (3.4%)* REVISED 2.3%** and that the longterm effects are unknown, it is unwise to require a young girl with a very low lifetime risk of cervical cancer to be vaccinated without her assent and her parent's consent. *Dunne et al.

Prevalence of HPV infection among females in the United States. JAMA. 2007;297:813819 **Erratum JAMA 2007;298(2):178

2) Generous religious and conscientious exemptions may cause legislators to extend these to other childhood vaccinations, which would be detrimental to the public's health. Salmon DA, et al. Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future. Lancet. 2006;367:436-442

Gostin LO, DeAngelis CD, JAMA. 2007;297:1921-1923.

3) Compensating injured vaccine recipients: if state-mandated, courts may hold that manufacturer has no (or reduced) responsibility 4) Not highly infectious airborne disease, ie Not in compulsory vaccination paradigm 5) Submit girls to vaccine as a condition of publicly funded education, but not boys? 6) Who will pay for the mandated HPV vaccine at the loss to society of what else? 7) Key to success of public health policies is community acceptability

HPV Vaccine

Genital HSV Infection Summary

Vaccine Information Statement, HPV Vaccine, CDCP (6/30/08)

“Vaccine providers should notify vaccinated women that they should continue to practice abstinence or protective sexual

behaviors (I.e., condom use) since the vaccine will not protect against other STIs. Although condoms may not fully protect against HPV, they may lower one’s chances of getting HPV and developing HPV-related diseases, when used all the time and the right way. Women can also lower their chances of getting HPV by being in a mutually faithful relationship with someone who has had no or few sex partners, or by limiting their number of sex partners”

Seroprevalence of HSV-2 National Health and Nutrition Examinations Survey (NHANES) Key large ongoing USA population-based study • HSV-2 Seroprevalence rose 30% from 1976-1994 – NEJM 1997;337:1105-1111

• 1988-1994: 21% of US population age 12 and older (45 million people) positive for HSV-2 • 1999-2004: 17% (indicates reversal of trend) • Prevalence rates higher if – initiated intercourse age < 17 yrs (21.1%) vs > 18 yrs (14.3%) – greater number of lifetime partners: 3.8% w/1 vs 39.9% w/>50)

• Genital herpes is a recurrent, life-long viral infection -CDC MMWR 2002: 51( RR-6) • 45 million Americans are infected with HSV-2 and 90% do not know it -NEJM 1997; 337:1105-1111 • HSV can be detected in genital secretions of most seropositive HSV-2 patients with no history of genital herpes -NEJM 2000; 342:844-50 • HSV infection is a potent facilitator of sexual transmission of HIV -JAMA 2000; 283: 791-794

How is Genital Herpes Spread? • HSV-1 and HSV-2 are transmitted through direct contact: kissing, sexual contact (vaginal, oral, or anal sex), or skin-to-skin contact – Transmitted with or without the presence of sores or other symptoms JAMA 2000;283:791-794 • Up to 30 percent of first episode genital herpes is now HSV-1 in type CDC, STD Treatment Guidelines 2002 MMWR 2002:51[RR-1]

– Oral sex is most likely the source, from shedding in the mouth Tyring, Dialogues in Dermatology 1998

-JAMA 2006;296:964-973

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Increasing Proportion HSV I Genital Infection • U of WI 1993-2001 reviewed genital isolates • HSV I increased from 31% in 1993 to 78% in 2001 • HSV I had become the most common cause of new genital herpes on campus » Sex Transm Ds 2003;30:797-800

What is Sex? Dorland’s Medical Dictionary 1965 Intercourse: mutual exchange, sexual i., coitus Coitus: sexual union between individuals of opposite sex Webster's 1984 Intercourse: 1) exchange between persons… 2) sexual intercourse syn coitus Coitus: : Physical union of male and female sexual organs leading to orgasm and ejaculation of semen Male sex organ = Penis Female sex organ = Vagina (simulations include mouth, anus, other) Dernovsek 2001 Sexual Intercourse: Stimulation of a partner to orgasm via vaginal, oral, anal, non-genital ie “mutual masturbation” Dernovsek KK Pract Derm Dec 2004

Sexual Lifestyle Choices

2004 Survey of 2,958 Clinicians re: their Adolescent Patients CONDOMS 96%-97% state not 100% effective and cannot prevent skin-to-skin transmission in areas not covered 77% believe patients will not use consistently …90% usually/always recommend condoms ABSTINENCE 91% abstinence highly effective 94% believe patients will not abstain …54% recommend it

S. Genius, 1995 (Adaptation)

MMWR 10-2--06,55(41);1117-1120

Sexually Transmitted Diseases Treatment Guidelines 2006

Sexually Transmitted Diseases Treatment Guidelines 2006

• The most reliable way to avoid transmission of STDs is to abstain from sexual

• Counseling that encourages abstinence from sexual intercourse is crucial

intercourse (i.e., oral, vaginal, or anal sex) • or to be in a long-term, mutually monogamous relationship with an uninfected partner. MMWR 2006;55[No.RR-11]3

– for persons who are being treated for an STD – or whose partners are undergoing treatment – and for persons who wish to avoid the possible consequences of sexual intercourse (e.g., STD/HIV and unintended pregnancy).

MMWR 2006:55[No.RR-11]3

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Lifestyle Abstinence • What? – Lifestyle choice – Restraint from all forms of sexual intercourse • How long? – Until selection of lifelong partner

• When? – Now – Never too late • Why? – Prevention of skinto-skin disease transmission – Maintain health

Introduce Topic with Abstinence Brochure • I have this brochure for you ... • Have you ever heard of abstinence? • This has nothing to do with your moles, but… • • • •

this is important for your future health... I don’t want to have to treat you for this in the future... Dermatologists also have to treat STD’s... Did you know that 1 in 5 sexually active people….

• Now is the time in your life to be thinking about where you will stand on this subject

Dernovsek KK. School Hlth Rptr Spring 2003

Follow leads Accordingly... • Support wisdom of decision if already abstinent • Encourage supporting peers in same choice – pass the brochure on to a friend, sibling – leave the brochure in the school restroom

• If teen was clearly choosing to continue being sexual active (pregnancy, BCP, attestation) – Modify to a condom recommendation with a secondary statement that abstinence was truly the ideal ie “informed condom recommendation”

• Consideration of renewed virginity – never too late to change – preservation of current good health

Can Condoms Fail? • LABORATORY – intact condoms prevent STDs • MMWR,’93;42(30)58991,STD’89;16(2):51-55

– minute leakage of viral size particles but infection highly unlikely • STD’97;24(3):161-4, • STD ‘99;26(4):216-20

• REAL LIFE – often fail to protect • FamPlanPersp’92;24(2)75 -84,GUMed’94;70:41017,CanFamPhys’93;39:81 9-27

Condom Terminology • Perfect Use of condom • 100% of time • Correctly

• Efficacy – Improvement achieved in a desired health outcome in a research setting in expert hands under ideal conditions

• Typical Use of Condom • “some”, “most”, or “all” of time • both correct and incorrect use

• Effectiveness – Amount of improvement in the health outcome in the real world with typical implementation

Factors Influencing Condom Failure in Real Life • Method Failure – breakage during intercourse or withdrawal – slippage during intercourse, partial or complete – manufacturing defects (rare)

– FamPlanningPersp’94;26(3):107-12, STD’99;26(8):450-458, Contraception’92;45(1):11-19

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“Always” use / “Consistent” use

Factors Influencing Condom Failure in Real Life • User Failure (Incorrect Use) – Genital contact before putting condom on – Flipping condom over after initial application – Fingernail holes poked in condom – Use of oil based lubricants – Improper positioning of condom – Not holding on to condom during withdrawal – Not withdrawing while penis erect

AND Correctly every time? • College males: “Consistent Users” – 1 in 10 episodes of condom use exposed individual to risk of disease via method or user failure – Leaving 33% at risk in prior month • >>STD’98;25(6):273-277

• HIV serodiscordant heterosexual couples – 171 ALWAYS used condoms – 3 seroconversions occurred over 24 months (1.1% incidence rate) JlAcqImmDefSyn’93;6(5)497-502

MMWR, 1993; 42(30):589-91

REAL LIFE: What is typical use of a condom? • Approximately 20% always use a condom (15-44 yo unmarried female condom users) FamPlanningPersp’96;28(1):25-39,AmJPubHlth’95;85(11):1526-30

• Of Herpes discordant couples, 23% always used a condom » Wald A, et al, JAMA, 2001;285:3100-3106

• Of HIV serodiscordant couples, 48.4% always used a condom

Factors Influencing Condom Failure in Real Life • • • • • • • •

Degree of infectivity of the particular STD Prevalence of the STD in the community Number of acts of intercourse Prior Experience with condoms Age and sex of the individual Natural immunity of the individual Presence of other STDs Inadequacy of coverage of all the infected skin

>>NEJM’94;331:341-6

The Condom Report: July 2001 138 papers reviewed by panel of 28 Experts

• HPV – …no epidemiologic evidence that condom use reduced the risk … – might afford some protection… Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention, summary report prepared by NIAID,NIH,DHHS,July 20, 2001

The Condom Report: July 2001 138 papers reviewed by panel of 28 Experts Strong evidence for the effectiveness of condoms for reducing sexually transmitted…gonorrhea for men

HIV/AIDS: Consistent condom use decreased

the risk of HIV/AIDS transmission by approximately 85% Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention, summary report prepared by NIAID,NIH,DHHS,July 20,2001

Sexually Transmitted Diseases Treatment Guidelines 2006

70% reduction in HPV infection in newly sexually active college women when partners used condoms CONSISTENTLY and CORRECTLY -Winer et al, NEJM 2006;354:2645-54

“HIV-negative partners in heterosexual serodiscordant relationships in which condoms were consistently used were

80% less likely to become HIV-infected compared with persons in similar relationships in which condoms were not used” MMWR 2006;55[NoRR-11]4

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Risk Compensation Definition: Perception of reduced risk paradoxically increasing the risky behavior, resulting in actual increased risk Examples: Condom use by Ugandan men offset by # sex partners HIV prevalence (1990-2001) as condom sales Cameroon, Kenya, Botswana 1989-2000, South Africa, Kenya and Botswana had highest rates of condom availability and highest HIV prevalence (20%-36%) (Kajubi et al J Acq Immune Defic Syndr 2005 Sep 1;40(1):77-82)

Hearst, Chen, Evidence that Demands Action Medical Institute

Green EC, Evidence that Demands Action Medical Institute

Who’s Teaching Our Kids? “Sexual Media Diet” 12-14 yo white teens 2.2x more likely to Have had sex by 14-16 -Brown et al Pediatrics 117:4 April 2006 “Degrading Sexual Lyrics” Related to advances in a range of sexual activities -Martino et al Pediatrics 118:2 August 2006

YAZ Package Insert “PI” says… …YAZ is indicated for the treatment of moderate acne vulgaris in women at least 14 years of age, who have no known contraindications to oral contraceptive therapy and have achieved menarche. YAZ should be used for the treatment of acne only if the patient desires an oral contraceptive for birth control…

January 29,2007

berlex.bayerhealthcare.com/html/products/pi/fhc/YAZ_PI.pdf Accessed 7/21/08

Who Should Counsel? Faith-based? Strong religious views decrease teens’ likelihood of having sex Social Forces, 3-03, NICHHD/NIH

Parents? Peers? – Black teens more influenced by their perception of parents’ expectations and friends’sexual behavior than what they see/hear in media Brown et al Pediatrics 117:4 April 2006 – Parental disapproval of adolescent sex and contraception: protective for early sexual debut National Longitudinal Study of Adolescent Health

What role Media? Schools? Doctors/Nurses?

“Where Do People Go for Treatment of STDs?” • 49% had gone to a Private Practice • 5% had gone to an STD clinic • greater likelihood to have gone to STD clinic if bacterial (non-chlamydial), male, young, poor, black

– National Health and Social Life Survey • 3432 people interviewed ages 18-59

Does Physician Advice Matter? YES • Patients who received physician advice on diet and exercise were significantly more likely to engage in risk reduction activities – Behavioral Risk Factor Surveillance System data analysis (MMWR 1999;48:74-77) • Seven states and Pueto Rico

Family Health Perspectives Vol 31,#1, Jan/Feb 99, p10-15

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Is Abstinence Realistic?

Effecting Positive Behavior Change: Successes • • • • • • •

Who Has Never Had Sexual Intercourse? • 75% of 7-12th graders Kaiser Family Foundation Rpt, 9-26-00

Alcohol Related Automobile Deaths Child Bicycle Helmets Seat Belts Tobacco Awareness and Cessation 911/CPR /Awareness of Early Sx and Signs Decreased Use of Inappropriate Antibiotics Increased Skin Cancer Awareness

• 70% of teens ages 15-17 Kaiser Family Foundation, May 2001 • 66% of 9th graders MMWR 9-27-2002 /51(38);856-859 • 64% of teens ages 15-17 KFF/Seventeen:Relationships, 10-2002 • 10.5% more 11 th Grade Boys in 2001 than in 1991 •

Adults:Sexual Health Knowledge, Attitudes and Experiences 2003

• 67% of teens ages 15-17 KFF/National Survey of Teens about Sex: Birth Control and Protection 7-2004

• 52% of teens ages 15-19 (MMWR 6/6/08)

EVER Had Sexual Intercourse

Sexual Intercourse:Significant Trends

Youth Risk Behavior Survey MMWR 9-27-02 / 51(38);856-859 MMWR 6-9-06 /55(No.SS-05);78 MMWR 6-6-08)

Youth Risk Behavior Survey: 9th through 12th graders MMWR 6-6-08

60

70

55

60 50 Ever had sex Sex w/4 or more Used condom

45 40

61.5 54.1 46.2

30 18.7

10

Females

Males

06 20

99 19

92 19

85 19

19

78

30

All

USA in 2007 47.8 high schoolers (aged 15-19) have “ever” had sex (YRBS-US 2007 MMWR 6-6-08)

means 52.2% have NEVER had sex i.e. “over half of older teens have never had sex”

2 0 0 7

47.8

40

20

35

71

%

50

19

% 15-19 yo

MMWR 9-27-2002 /51(38);856-859

• 67% of teens ages 15-17 KFF/Seventeen:Virginity and the First Time 10-2003 • 63% of teens ages 15-17 KFF/National Survey of Adolescents and Young

14.9

0 1991

2007

There are patients who commit to continuous abstinence Prescribing Requirements: • ISOTRETINOIN 2 forms of contraception ©ACCUTANE required (tubal • Pregnancy Category X ligation,vasectomy, IUD or due to severe birth hormonal PLUS a second form) defects unless pt commits to • BLACK BOX continuous abstinence warning from hetereosexual contact • FDA restricted to or has had hysterectomy, bilateral oophorectomy or registered prescribers is postmenopausal only

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With One Voice 2007 Ages 12-19 • 75% (73%) do not think it is embarrassing to admit they are virgins – 73% Males (66%) 78% Females (80%) – 75% Ages 12-14 (2002) 81% Ages15-19 (2002) –

• 82% said teens should NOT be sexually active (2003) (80% in 2002) (2003) (2002)

With One Voice 2007 • 91%: important to have a strong message from society to abstain from sex until they are at least out of high school ( 93% reported same in both The Cautious Generation: What Do the Teens Say? NCTPTP 4-27-00 and With One Voice 2002, 92% in With One Voice 2003, 94% in With One Voice 2004))

• Of teens who had had sex: 60% (66) (67) (63)

wished they had waited longer 63% (60) (55) boys 71 % (83) (81) ages 12-14

69% (77) (70) girls 63% (60) (55) ages 15-19

(2004) (2003) (2002)

NCTPTP 2-2007 www.teenpregnancy.org

NCTPTP 2-2007 www.teenpregnancy.org

…Uganda has experienced the most significant decline in HIV prevalence of any country in the world… E.C. Green

Faith-Based Organizations: Contributions to HIV Prevention Green, E.C.,USAID,September2003

HIV prevalence in adults in sub-Saharan Africa, 1986-2001 1986

HIV prevalence in adults in sub-Saharan Africa, 2005

1991

20 – 39% 10 – 20% 5 – 10% 1 – 5% 0 – 1% trend data unavailable outside region

-----------Uganda 6.7% HIV prevalence 2005 1996

2001

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UGANDA: “Zero Grazing” You tether your animal around a tree, and it can only feed where it is tethered Dr V. Nantulya, ID consultant to President Museveni

A B

bstinence

e Faithful

Or wear a Condom The Monitor 2-04-04 (Ugandan newspaper)

"Young people must be taught the virtues of abstinence, self-control and postponement of pleasure and sometimes sacrifice” and teaching them a different lifestyle

"will ensure their survival" Ugandan First Lady Janet Museveni February 20, 2002

What Happened in Uganda? Summary of Presentation to USAID, Washington DC, 2/5/2002 Hogle, JA,Green,E, Nantulya,V,Stone burner,R,Stover,J

• “The most important determinant of the reduction in HIV incidence in Uganda appears to be a decrease in multiple sexual partnerships and networks” • “The effect of HIV prevention interventions in Uganda (particularly partner reduction) during the past decade appears to have had a similar

impact as a potential medical vaccine of 80% efficacy.”

http://usinfo.state.gov/topical/global/ hiv/02022710.htm

Changing Worldwide HIV Elimination Strategy: Key Publications

Uganda: Decline in sex with non-regular partner Increase in never having had sex(ages 15-24)

www.sciencemag.org SCIENCE VOL 304 30 APRIL 2004

2003 ISBN 0-86569-316-1

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The Ugandan Success is Key to Combat AIDS Worldwide The Ugandans showed that sexual behavior patterns could be changed by an entire population with resultant improved health: -HIV prevalence in Uganda was already irrefutably decreasing before 1995 (WHO/UNAIDS maps and Hogle, JA et al. What Happened in Uganda? Washington DC, 2/5/2002)

HIV: A Worldwide Crisis • Every eight seconds a person is infected with HIV somewhere in the world (6800 new infx/day) • 68% of the 33.2 million people with HIV live in Sub-Saharan Africa » (WHO/UNAIDS 11/07)

- Increase in abstinence and reduction of multiple partners documented before 1995 (Stoneburner RL, Science, 2004 Apr 30;304:714-7.)

- Condoms did not enter Uganda until 1995 or later (Green EC et al. AIDS Behav. 2006 Jul;10(4):335-46)

• Young people between 15 and 24 account for 40 percent of new infections worldwide » (WHO/UNAIDS 12/06)

Perhaps there should be….greater

Impact of AIDS on life expectancy in five African countries,

equity in resource allocation between HIV/AIDS prevention programs (promoting monogamy/fidelity) and condom programs?

1970–2010 70 65

Botswana

60 55

Life expectancy at birth (years)

South Africa

50 45

Swaziland

Green,EC, STI 2000, 76:145

40

Zambia

35 30

Zimbabwe

25 1970–1975 1980–1985 1990–1995 2000–2005 1975–1980 1985–1990 1995–2000 2005–2010

Source: United Nations Population Division (2004). World Population Prospects: The 2004 Revision, database.

The Lancet November 27, 2004

The time has come for common ground on preventing sexual transmission of HIV

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Daniel T Halperin, Markus J Steiner, Michael M Cassell, Edward C Green, Norman Hearst, Douglas Kirby, Helene D Gayle, Willard Cates Followed by one and one-half columns of endorsees 4.1

?????

Intensifying HIV Prevention

UNAIDS Policy Position Paper August 2005 Essential Programmatic Actions for HIV Prevention

#1: Prevent the sexual transmission of HIV (included alongside condoms for the first time are)… • abstinence • delay in onset of sexual debut • mutual fidelity • reduction of the number of sexual partners

Essential Policy Actions for HIV Prevention

Uganda Success 6.7%

? USA

#2: Build and maintain leadership from all sections of society including…faithbased organizations…

#4: …those norms, practices and beliefs that potentially can support HIV prevention need to be fully harnessed.

Kenya

? Zimbabwe

Reduced HIV Prevalence

? Botswana Condom Social Marketing Increasing Web Pornography

?

Fidelity =/> AgeSexDebut

Haiti

Malawi

The future course of the world’s HIV epidemics hinges in many respects on the behaviors young people adopt or maintain, and the contextual factors that affect those choices. 2006 AIDS Epidemic Update UNAIDS

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