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  • 1. section i INTRODUCTION Sexual Health: Expanding Our Frame for Action 003 Historical Aspects of Sexually Transmitted Infections 010Ch001.indd 1 20/09/11 10:27 AM
  • 2. Ch001.indd 2 20/09/11 10:27 AM
  • 3. Sexual Health: Expanding Our 1 Frame for Action Kevin A. Fenton Introduction limitations on education, employment, and housing), which affect the household’s ability to generate income or to use its income Sexually transmitted infections (STIs) are among the most to secure improved quality of life. Clearly, STIs, including HIV commonly diagnosed and notifiable infectious diseases in many infection, remain major global public health concerns. parts of the world, with more than 450 million new cases of Historical approaches to the prevention and control of these curable STIs occurring in adults each year.1,2 In 2005, the total infectious diseases have largely centered around the principles number of new cases of the four curable STIs was estimated to of prompt diagnosis and treatment of infected individuals be 448 million—101.5 million cases of chlamydia, 87.7 million and their infected or exposed partners; community and risk- cases of gonorrhea, 10.6 million cases of syphilis, and 248.5 group education and awareness; effective program leadership million cases of trichomoniasis.3 STIs constitute a huge health and governance; and program integration and health systems and economic burden, especially for developing countries, where strengthening.7 However, despite the availability of effective they account for 17% of the economic losses caused by ill health.4 clinical, behavioral, and community-level interventions,8 we The associated costs include direct costs, both medical and continue to wage a losing battle against STIs in many settings, nonmedical, for care and materials, and indirect costs of time and in some populations, previously controlled STI epidemics are spent sick, when individuals are unable to engage in productive now resurgent.9 These challenges have led to calls for a strategic activities.5 In the United States, STIs account for an estimated refocusing of global HIV/STI prevention priorities and efforts, $15.9 billion annually to the healthcare system.6 However, accompanied by increases in program-relevant research that aim to treatment costs for STIs vary tremendously between countries bring to scale the most effective interventions; combine effective and are influenced by a range of factors, including delivery by approaches for greater effect; and address both the individual the public or private sector; economies of scale; economies of and contextual determinants of these adverse health outcomes.10 scope; prevalence and incidence; epidemic phase; transmission It is within this context that recent discussions at national, efficiency; resource combinations and input prices; incentives to regional, and global levels have focused on the benefits of providers for high quality and quantity of service delivery; and incorporating the more holistic approach of sexual health to willingness to pay for treatment as a function of price, income, complement and enhance current prevention efforts. Sexual and distance. health has been defined by the World Health Organization as “a STIs consistently rank among the top 10 reasons for healthcare state of physical, emotional, mental and social well-being in relation visits in most developing countries and substantially drain national to sexuality; it is not merely the absence of disease, dysfunction or health budgets and household income. Care for the complications infirmity. Sexual health requires a positive and respectful approach of untreated STIs accounts for a large proportion of tertiary to sexuality and sexual relationships, as well as the possibility of healthcare costs in terms of screening and treatment of cervical having pleasurable and safe sexual experiences, free of coercion, cancer, management of liver disease, investigation of infertility, discrimination and violence”.11 Sexual health has considerable care for perinatal morbidity, childhood blindness, and chronic potential as a framework to guide and support national efforts to pelvic pain. Stigma and discrimination constitute an additional control STIs, to reduce associated adverse health outcomes, and burden on people living with and affected by STI/HIV, and their to promote prevention and wellness. This introductory chapter effect is partly mediated through economic mechanisms (e.g., introduces the concept of sexual health as a broader, more holistic DISCLAIMER: The findings and conclusions in this chapter are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Agency for Toxic Substances and Disease Registry.Ch001.indd 3 20/09/11 10:27 AM
  • 4. Introduction framework for understanding both the multi-level determinants antimicrobial resistance of some of these agents and the growing of STI epidemics, and for refocusing on prevention and control number of restrictions on the range of available antimicrobial efforts. The chapter also explores some of the challenges and agents for treating these conditions.18,19 Other changes may make potential benefits of adopting this strategic framework, and the infectious agents more virulent or may change their clinical highlights potential steps for future action. manifestations.17 Finally, their impact is determined not only by their effect on the immediate genital environment, but also by Determinants of Sexual Health their more widespread effects and complications, further driving up costs, and causing additional morbidity and mortality.20 Sexuality is a fundamental aspect of human life, carrying the potential to create new life and fulfilling both personal and social needs.12 However, many adverse health outcomes result INDIVIDUAL FACTORS from unhealthy or otherwise uninformed sexual behaviors and attitudes, including HIV and other sexually transmitted infections, Individual characteristics, including patterns of individual sexual unintended pregnancies, and coercive behavior. If health is risk behavior, remain major determinants of the risk of acquiring more than the mere absence of disease, then current conceptual an STI and therefore of sexual health.21,22 There are several frameworks for describing the distribution and determinants of biological factors that make it easier or more difficult for STI CHAPTER disease within a population (a dynamic interaction among the host, (including HIV) acquisition, including the presence of other STIs, tissue or membrane vulnerability, and viral load.23–25 In1 environment and treatment and care services) should be expanded since the fundamental determinants of health at the population addition, an individual’s pattern of sexual behavior, including level are patterns of exposure and the social and economic, as the number of partners, and the spacing and rate of partner well as physical, environments.13–15 Similarly, adopting a sexual change, and the types and frequency of sexual practices, greatly health approach requires a more inclusive frame in which not only influence STI transmission risk.21 Given the highly social nature the characteristics of the infectious agent; the nature, form, and of sexual partnerships, individual behavior takes place within the effectiveness of prevention, treatment, and care services; individual context of sexual partnerships and often of sexual networks (a characteristics; patterns of sexual behavior; and the characteristics set of people who are linked directly or indirectly through sexual of sexual networks; but also the more distal social and cultural contact).26,27 The pattern of linkages can drastically influence environment, including norms and values, are incorporated into our such health outcomes in a population as the transmission of understanding of determinants and help to shape our intervention HIV and other STIs.28 With regard to disease transmission, the responses. To optimize the benefits of sexual health throughout the important characteristics of a network are its size and its density or lifespan and to reduce the adverse consequences stemming from connectivity.29 Because networks are dynamic, with new linkages unhealthy sexual behaviors, intervention opportunities to improve forming and old ones dissolving, time and place are important sexual health should be considered at every level of society from dimensions of networks which may evolve rapidly, especially individuals and sexual partnerships to communities and public in an era in which the internet, travel, and migration all play infrastructure (including government).16 important roles in disease transmission and in the creation and dissemination of sexual norms and social values.30–32 Other individual characteristics such as, educational attainment, INFECTIOUS AGENTS occupation, income level, sex and race or ethnicity, and sexual A wide variety of microorganisms (bacteria, viruses, fungi, and orientation can influence a person’s position in the social hierarchy protozoa) and a few ectoparasitic arthropods (Pediculosis pubis, and consequently can influence one’s risk of acquiring HIV Sarcoptes scabiei) have evolved to depend, in whole or in part, and STIs.33–35 When we take a broader view of sexual health, upon the human genital tract and human sexual behavior for their we see that these individual-level factors may directly affect the survival.17 Including HIV-1, more than 30 pathogenic sexually probability both of one’s being exposed to the infectious agent transmissible agents identified to date are responsible globally and to one’s increased vulnerability of exposure to transmission for an enormous degree of aggregate morbidity and mortality. networks. They also represent an opportunity for intervention. The dynamic interaction between these agents, individual sexual Traditional approaches to STI prevention have focused primarily behavior and networks, and health systems drives the observed on getting individuals screened, tested, and treated for STIs, but patterns and distribution of disease in the population. Because it is increasingly recognized that approaches must be tailored both sexual behavior is essential to preservation of the species and is to meet the specific characteristics of the individual and to ensure driven by a highly developed neurochemical pleasure reward system, the acceptability and cultural competency of the intervention. it offers both a reliable ecological niche for infectious agents and a From a practical standpoint, it is essential that STI care providers daunting challenge to modern-day practitioners of medicine and be familiar with locally prevalent sexual practices and that they public health who endeavor to treat and control them.17 be able to assess individual risk of infection for STI and for The continued spread and evolution of these infectious transmission to partners. It is important to know which sexual agents greatly influence the patterns of disease transmission and, behaviors can transmit which specific agents and to avoid making ultimately, sexual health. Of major concern is the emergence of assumptions about who is practicing what types of behaviors. 4Ch001.indd 4 20/09/11 10:27 AM
  • 5. Sexual Health: Expanding Our Frame for Action PREVENTION, TREATMENT, AND CARE SERVICES Efforts to promote sexual health must therefore incorporate and engage the health system as a major determinant of health The earlier STIs can be diagnosed, the earlier they can be treated outcomes. In addition to the traditional approaches of diagnosing, and further transmission interrupted. Therefore ready access treating, and reporting infections, the health system provides to, and uptake of high-quality and effective care are essential an opportunity for improving linkages through program components of effective STI control strategies. This requires at- collaboration, for strengthening holistic service provision through risk or infected persons to have access to stable, simple, rapid, appropriate client-level service integration, and for facilitating inexpensive, and accurate diagnostic tests; high-quality clinical seamless referrals to supportive services that address the wider services that allow easy, affordable, and stigma-free treatment; determinants. Training of healthcare providers to manage STIs effective behavioral and biomedical interventions to arrest competently is critical, but so too is building the workforce disease spread and reduce high-risk behaviors; trained, culturally capacity to understand, recognize, and manage the broader competent healthcare workers to provide consistent service; and determinants of sexual ill health. data and information systems that allow monitoring of progress, impact evaluation, and quality improvement.36 SOCIAL CONTEXTS There continues to be major progress with new diagnostic tests for STIs, including newer-generation nucleic acid amplification The term “social context” refers to demographic, socioeconomic, CHAPTER tests and an expansion of novel point-of-care diagnostics.37,38 New macroeconomic, sociopolitical, and related features of the 1 preventive vaccines provide mixed hope for viral STI control. An individual’s environment. Economic forces, demographic features, effective, inexpensive, safe vaccine against hepatitis B has been and other structural aspects of society outside the individual’s available worldwide for almost 40 years, yet elimination remains control play an important role in epidemiological factors and a question of time, public will, and priorities.39 The availability individual behaviors, including sexual behaviors, transmission of of new human papillomavirus (HPV) preventive vaccine is STIs, and other health outcomes.51,52 Community attributes— encouraging, although the expense and limited availability including poverty, rates of substance abuse, sex roles, norms globally will severely restrict its potential to make great inroads on for sexual behavior, and prevalence of STIs—can increase the disease incidence in resource-poor settings.40,41 For herpes simplex frequency of and risk associated with individual behaviors and can virus 2 (HSV-2), except for partial protection of seronegative impede the ability of individuals to adopt preventive behaviors. women provided by one vaccine candidate, controlled trials of These social determinants, which are complex and, integrated with several others have failed.42 Efforts to develop vaccines to prevent overlapping social structures and economic systems, are linked HIV have been complicated, costly, and disappointing, and to a lack of opportunity and to a lack of resources to protect, although work on HIV vaccine continues, it will likely be 5–10 improve, and maintain health. Structural and societal factors years or more before an effective vaccine is marketed.43 While such as social and physical environments, and availability, cost of, there is not yet a cure for HIV infection, there are a growing and access to health services, create pathways or barriers to good number of treatments that can extend life expectancy for those health. These factors are affected by the distribution of money, who have access to them.44 power, and other resources, all of which can be addressed through Access to high-quality curative services remains a challenge policy. Environmental factors, such as housing conditions, social around the world, and too many people with acute STIs, or networks, and social support also are key drivers for infection with HIV and other STIs.34 Many have argued that a sustained living with HIV, do not have access to the medical care that they and effective response to STIs and their adverse outcomes will need. Furthermore, the recent global economic crisis has caused be achieved only when we move beyond controlling disease on the a number of countries to scale back or reduce funding for STI individual level and address the root causes of disease, including the programs, further complicating access and impact. Waiting lists social and environmental determinants of health.53–56 Adopting to gain access to clinical services and other limitations on life a sexual health framework provides an opportunity to look saving HIV medications are increasing concerns in developing beyond simply managing disease outcomes to incorporating a and developed country settings.45–47 Having an adequate and more holistic approach to achieving health. accessible health workforce is fundamental to an integrated health system and for providing essential health services in developing countries.48 The severe shortage of healthcare workers Sexual Health: Challenges and Opportunities in many developing countries constitutes a major threat to the Numerous countries now have experience with adopting or performance of health systems and undermines the ability of integrating a sexual health approach to enhance their HIV/STI these countries to achieve the Millennium Development Goals prevention efforts.57–59 While rigorous evaluations of this strategy and other internationally agreed upon development priorities.49 remain to be undertaken, the literature suggests that there are The situation is exacerbated by the emigration of highly educated likely to be both varied understandings of the utility of this and trained healthcare personnel from countries with health approach, as well as challenges and benefits to implementation.60 systems in crisis, further weakening the health systems in their The highly stigmatized nature of STIs (including HIV infection), countries of origin.50 sexual behavior, and human sexuality in many societies often 5Ch001.indd 5 20/09/11 10:27 AM
  • 6. Introduction complicates efforts to speak openly about these issues, or to and control efforts.68,69 Similarly, there has been increasing interest broaden the conversation to include sexual health. In other to deliver and evaluate the quality and benefits of integrating settings, sexual health-related issues, including HIV stigma and health messages between and across health concerns, as well as criminalization, discrimination on the basis of sexual orientation, evaluating the combined benefits of effective actions.70–72 This sexual violence, and reproductive health have come to be focal integrated approach to messaging and to providing services may points for political, religious, or social debate. Misunderstanding be facilitated through adopting the broader sexual health frame, or misinterpreting what is included in, or intended by, sexual and it remains an area for evaluation and research. health, and how it can be achieved, may also make providers, policy makers, and communities reluctant to adopt this approach. Sexual Health: From Theory to Action Questions about the role of the public sector in what is perceived Incorporating and implementing sexual health as part of our by many as an intensely private matter further complicate the issue. targeted efforts to prevent, treat, and control STIs provides While none of these challenges is insurmountable, the ability to an opportunity to take a broader approach to prevention, one promote sexual health effectively at local, state, national, and that acknowledges and incorporates external contexts and the global levels requires a realistic assessment of the opportunities for wider determinants of adverse outcomes related to HIV and change; identification of the challenges facing implementation; other STIs. However, change is challenging and will require a CHAPTER engagement and mobilization of a wide cross-section of partners; commitment to articulating the rationale for and vision of change; and a commitment to utilize long-term strategic approaches to to building coalitions for change; to utilizing a strategic approach1 achieve change. to implementation; and to assessing and evaluating progress. Nevertheless, there are potential benefits and opportunities Key among these is the importance of national leadership in for adopting or integrating sexual health into current HIV/STI facilitating change, whether through supportive policies, adequate prevention efforts. Sexual health provides a holistic approach resourcing, providing infrastructure, or coordinating partnership to addressing STIs and related conditions that may be more efforts. Efforts to promote sexual health should incorporate legitimately added to, or integrated into broader governmental proactive strategies to engage political and other influential initiatives aimed at promoting health and wellness.57–59 Placing leaders at the national, state, and local levels to commit to sexual health alongside mental or cardiovascular health may sustained action, and to ensure that supportive and culturally legitimize conversations on STIs, HIV and reproductive health competent policies are instituted, based on the best available in otherwise challenging contexts. Sexual health has already evidence. Implementing effective sexual health policies requires been included in national strategic approaches to address HIV/ a supportive policy context. As sexual health programs are scaled AIDS,57–59 allowing for a broader discussion and integration of up, the policy framework—laws, regulations, norms—have to be other STIs, sexual behaviors, and reproductive health issues and supportive for programs to succeed. Practitioners must commit for addressing stigma related to these issues. to working with governmental and nongovernmental partners Incorporating a sexual health frame to complement existing to identify and provide a supportive environment to implement vertical programs may allow those involved in HIV/STI control evidence-based policies related to sexual health. to move beyond the siloed nature of their efforts, and to engage a Implementing a robust sexual health approach will require wider range of strategic partners in their efforts, including those investments to strengthen the prevention, treatment, and care in reproductive, adolescent, school health and mental health.61,62 infrastructure (public and private) needed to provide appropriate This may be especially useful for engaging constituencies who may sexual health services that are adequately linked to allied and consider disease-specific targeted approaches more sensitive or support services, and to provide a seamless interface for clients to stigmatizing. For example, great strides are being made in engaging address complex health and social needs. Governments will need faith communities around HIV/AIDS and sexual health, and to ensure that comprehensive sexual health services are available many of these communities recognize the intrinsic value of to the public, and that health professionals are trained to provide sexual health and the glaring and urgent health inequities.63,64 such services. Other key requirements include commitments to Similarly, for social or economically marginalized groups, address sexual health across the lifespan and to understanding including migrants; for lesbian, gay, bisexual, and transgender that age-appropriate needs exist at all levels; and that effective (LGBT) communities; and for drug users, a focus on sexual partnerships with communities, service providers and policy- health may provide a more empowering way to engage in and makers will be required to achieve change and to maximize to support positive action for change by focusing on the social health impact. context that places them at risk, not solely on the individual risk Research, evaluation and surveillance are needed to support behaviors and adverse health outcomes.65,66 and optimize national sexual health efforts. Research is needed to Adopting a sexual health frame may also facilitate improved develop and assess new prevention approaches that utilize a sexual integration and synergy through promoting combined messages health framework, and to assess the feasibility and acceptability and services.67 Collaboration across prevention programs and of such a framework to clients and providers. Research is needed appropriate service integration at the client level has been identified also to understand the best way of integrating related services and as a key structural intervention to enhance HIV/STI prevention approaches and to understand better the benefits and potential 6Ch001.indd 6 20/09/11 10:27 AM
  • 7. Sexual Health: Expanding Our Frame for Action costs of such integration. Improved surveillance will be needed 2. World Health Organization. Global prevalence and incidence of curable both to monitor individual health outcomes related to sexual STIs. Geneva, 2001 (WHO/CDS/CDR/EDC/2001.10) 3. Schmid G. Global incidence and prevalence of four curable sexually health and to assess comorbidities by behavior, socioeconomic transmitted infections (STIs): New Estimates from WHO. Presentation at status and geographic clustering to better target prevention the 2nd Global HIV/AIDS Surveillance Meeting. March 2009. Bangkok, efforts. Ultimately, a sexual health approach will require the Thailand. Available at http://hivsurveillance2009.org/pages/presentations. identification of more robust indicators of sexual health, including html. Last accessed January 19, 2010. disease outcomes, risk behaviors, patterns of healthcare access, 4. Bertozzi S, Opuni M. An economic perspective on sexually transmitted network characteristics, and societal norms, attitudes and policies. infections including HIV in developing countries. In: Holmes K, Sparling This will enable jurisdictions to both evaluate their health status PF, Stamm W, et al. eds. Sexually Transmitted Diseases. 4th ed. New York: McGraw Hill; 2008. and to define appropriate goals for optimal sexual health. 5. Chesson HW, Blandford JM, Gift TL, et al. The estimated direct medical Finally, adopting a sexual health approach will require that cost of sexually transmitted diseases among American youth, 2000. Perspect new and dynamic partnerships be created, with a wider range of Sex Reprod Health 2004;36:11–9. constituents outside of the traditional HIV/STI prevention and 6. Siegel JE. Estimates of the economic burden of STDs: review of the literature control field. These partnerships can reinforce the importance with updates. In: Eng TR and Butler WT, eds. The Hidden Epidemic: of individual and community responsibilities in achieving the Confronting Sexually Transmitted Diseases, Washington, DC: National CHAPTER goal of creating societies in which individuals, families and Academy Press, 1997, pp. 330–56; and American Social Health Association (ASHA), Sexually Transmitted Diseases in America: How Many Cases and communities are encouraged to understand human sexuality 1 at What Cost? Menlo Park, CA: Kaiser Family Foundation, 1998. and to cultivate sexual health and responsible sexual behavior. 7. Douglas JM Jr, Fenton KA. STD/HIV Prevention Programs in Developed While each person is responsible for maintaining one’s own Countries. In: Holmes K, Sparling PF, Stamm W, et al. eds. Sexually sexual health and for protecting the sexual health of others, there Transmitted Diseases. 4th ed. New York: McGraw Hill; 2008. are also important dimensions of community responsibility for 8. Merson M, Padian N, Coates TJ, et al. HIV Prevention Series Authors. sexual health in which the social environment provides freedom Combination HIV prevention. Lancet 2008;372:1805–6. from sexual violence, coercion, exploitation and discrimination.73 9. Fenton KA, Breban R, Vardavas R, et al. Infectious syphilis in high-income settings in the 21st century. Lancet Infect Dis 2008;8:244–53. These multilayered determinants of sexual health suggest that 10. Hayes R, Kapiga S, Padian N, et al. HIV prevention research: taking corporations, nonprofit organizations, faith communities, schools stock and the way forward. AIDS 2010;24:S81–92. and federal agencies must be included in the partnerships to 11. World Health Organization. Defining sexual health: report of a technical improve sexual health, and that care must be taken to include consultation on sexual health 28–31 January 2002, Geneva, Switzerland; a more diverse range of constituencies from across the political, 2006. Available at http://www.who.int/reproductivehealth/topics/ religious and social spectra. These strategic partnerships are gender_rights/defining_sexual_health.pdf. essential to the broad acceptance and overall effectiveness of a 12. Centers for Disease Control and Prevention. NCHHSTP Green Paper: A Public Health Approach for Advancing Sexual Health in the U.S.: sexual health effort. Rationale and Options for Implementation. Atlanta GA. April 2010. 13. Adimora AA, Schoenbach VJ. Social context, sexual networks, and racial Summary disparities in rates of sexually transmitted infections. J Infect Dis 2005;191 Suppl 1:S115–22. The urgent, complex, and enduring nature of the global STI epidemics, 14. Link BG, Phelan J. Social conditions as fundamental causes of disease. including HIV infection, suggests that we should not continue doing J Health Soc Behav 1995; Spec No:80–94. the same things and expecting different outcomes. Recent additions 15. Koopman JS, Lynch JW. 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