19th ISSTDR Quebec, Canada July 10-13, 2011

1. 19th ISSTDR Quebec, CanadaJuly 10-13, 2011 Jens Boman Smittskyddsläkare Region Skåne

2. What are theyasking? An analysis of STD relatedcalls to CDC-INFO • Launched in 2005, 24 hours, 7 days a week • 2010: 44,339 STD-related calls, 2,123 emails • 11 categories and sub-categories • Top ten questions • 1) Can you help me locate a STD testing site in my area? • 2) What are the signs and symptoms of genital herpes? • 3) If I am experiencing symptoms, how do I know if I have a sexually transmitted disease or infection? • 4) Are herpes simplex typ 1 and 2 spread the same way? • 5) How is genital herpes transmitted? • 6) How is genital human papillomavirus transmitted?

3. What are theyasking? An analysis of STD relatedcalls to CDC-INFO • 7) Howlongdoes human papillomavirusinfection last? • 8) Is there a blood test to diagnose herpes simplex virus infection? • 9) How is chlamydiatransmitted? • 10) Can human papillomavirus be treated or cured? • The findingscorrelate with findings from traffic to the STD prevention website (www.cdc.gov/std). • 91% reportedlearning new information as a result of the call • 68% indicated a desire to change a behaviorbased on the new information • Reducingriskysexualbehaviorwas the mostcommontype of behaviorchangeindicated

4. Chlamydia screening in an International Resort Community • An event-basedoutreach program to expand access to asymptomaticChlamydia screening for youngpeople who may not otherwiseseek testing • 15 outreach screening sessions – 2-3 hours • N = 112; 57,1 % males; 8,9 % CT-positive • Conclusion: Free, event-basedoutreachChlamydia screening attractedpeople who may not otherwisehavebeentested

5. STI rates and risk factorsamongfemale sex workers in Germany • 1 Jan-10—1-Apr-11; 1425 sex workers attending STI testing sites in Germany • HIV 0,2%, Syphilis 1,1%, CT 6,9%, GC 3,2%, Trich 3,0% • STI rates are highest among the younger, uninsured, street-based women who do not speak German + visit the STI clinic for the first time + recently starting + unprotected sex

6. Integrating public healthinto the sex workercommunity in Indianapolis Cues to action • Think back to the last timeyoureceived a femalewellnessexam or got tested for STD. Whatpromptedyoutoschedulethatappointment?

7. Integrating public healthinto the sex workercommunity in Indianapolis Perceivedsusceptibility • Describewhatworriesyoumostwhenyouthinkaboutyourhealth and howit’saffected by being on the street

8. Integrating public healthinto the sex workercommunity in Indianapolis • Perceived barriers • What are some of the reasons why women who are working on the streets don’t get tested for STD?

9. Identifying key topics for a description of sexual behaviour among Danish adolescents • Four semi-structured focus group interviews of 19 adolescents, aged 18 to 23, who had sexual experience • Risk factors for unsafe sex/one-night-stands: • alcohol consumption • nights on the town, foreign countries, festivals • low self-esteem (regretted sexual activity) • increased sexual experience

10. Multiple bacterial STI in Ontario • Approx. 100 000 clients with 113 097 reportedbacterial STI from 2006 to 2009 (fouryears) • 24 % of STI were in individuals with multiple STI:s • 12 % hadmorethanone STI • 2.4 % had 3 or more STI:s • Maximum number of STI:s in oneclientwas 12 • 27.8 % of women and 25.9% of men with their first STI between age 10-14 had multiple STI:s • Public healthresourcesmay be wellspentbecause almost 90 % of individualsonlyhaveone STI reported

11. Multiple bacterial STI in Ontario • 1 = 86 602 • 2 = 9 312 • 3 = 1 697 • 4 = 415 • 5 = 135 • 6 = 31 • 7 = 21 • 8-12= 13

12. Age of first sex is a factor in gay men’s hiv/STI vulnerability • Melbourne, Australia • 854 Australian gay men born 1944-1993 • The younger that men were for their first anal intercourse, the more likely they were to report having HIV and other STIs today • Significant: number of sex partners 12 months, group sex, hiv-positive, >2 STI 12 months, ever diagnosed hepatit A, B, C

13. HIV sexual risk factorsamong hiv-negative msmusing Internet • Net Gay Baromètre, Quebec • 3 718 msm, 2 345 hiv-negative • Included = 1 794 msmseeking partners in datingwebsites + at leastonecasual partner in the last year • UAI(HIV +/?) = live in Montreal region, are seeking sensation, are seeking partners in sex venues, and are regularlyseeking partners on datingwebsites

14. Don’t look at your patients, look at their partners • Questionnaire at 4 GUM-clinics in England • Detailedquestions on the (max) 3 most recent partners in the 3 months prior to clinic visit • 24% of men and 14% of womenhad recent concurrentpartnerships (ps) • 68% of men’s and 54% of women’s ps were < 3 months • 43% of men’s and 27% of women’s ps wereone-offencounters • Consistentcondomusewaslow: 19% in women and 25% in men • High potential for STI transmission

15. Identifying women at risk • Miami-Fort Lauderdale – high hiv rates • Can future hiv infection be predicted based on GC, CT, early syphilis and demographics? • Hiv in women 11-89 years > 60 days after STD diagnosis • An STD diagnosis and a few demographic variables (30+ and zip code) can identify women at very high risk of acquiring hiv (24% within a few years) – e.g. women with syphilis and older women with GC. • These women should be counseled to reduce their risk. • CT is very common in young women and not a good predictor of hiv.

16. Dual contraceptiveuseamongadolescents and youngadults • Simultaneous use of condoms and other contraceptive methods provides maximum protection against unintended pregnancies and STD • Sexually active 12-25 years, California, 50.6 % female • Contraceptive use: • Nothing 21 % • Condoms only 53.9 % • Hormonal contraception only 9.2 % • Dual methods 15.5 % • Other 0.5 %

17. Dual contraceptiveuseamongadolescents and youngadults • Given the high STD rates among adolescents and young adults: • Population-level interventions should aim to maximum condom use • Individual-level interventions should take risk into consideration, as well as patients’ preferences

18. Oral sex and risk of STI Elaine Flagg, CDC • All oral sex practices are associated with risk of acqusition of one or more STI • Insertive and receptive fellatio • Insertive and receptive cunnilingus • Insertive and receptive anilingus • Eg: CT, GC, HSV, HPV, HIV

19. Chlamydia screeing • www.chlamydiatest.nl • 280 000 persons 16-29 yearsinvitedannually • Retestafter 6 monthsin CT-positives • Amsterdam, Rotterdam, South Limburg • Low and decreasingparticipation • Annualuptake: 16 % - 11 % - 8 % • No significantdecrease in positivity and prevalenceestimates • NOT roll out this program

20. Group sex – Samuel Friedman, NY • Linked to several STI and HIV outbreaks • Huge gaps in what we know - this lack of knowledge hampers prevention • Group sex participation is quite common • Rapid partner exchange • Potential bridge environments between networks • Men not always changing condoms • Fingers, penises, and/or sex toys can transmit

21. Swingers – Anne-Marie Niekamp, South Limburg, Netherlands • Measure: level of concurrency past 6 months • 106 partcipants, mean age 43 years • 13,2 % pos STI • 96 % steady relationship • 9 % casual sex outside swinging with median 4 sex partners • 59 % practiced group sex with median 3 partners

22. Swingers – Anne-Marie Niekamp, South Limburg, Netherlands • Median 10 times swinging with median 7 different swing partners in 6 months • Increased STI risk (CT and GC) • Frequency of swinging (> 12 times) – 32% • Group sex without steady partners – 38 % • Total number of sex partners (11-15) – 19 % • Total number of sex partners (> 15) – 32 %

23. Gender differences in behavioralcorrelatesofbiologicallyconfirmed STI • Amanda Berger, University of Maryland, USA • Risk factors for STI: • Men • Young age at first sex • Failure to use condom at last sex • Women • Multiple partnerships (>3 in 12 months) • Lifetime number of sex partners

24. High CT and GC incidence, reinfection, and HIV among workers in the adult film industry • Christina Rodriguez-Hart, Los Angeles • 2004-2008: 3 227 CT & GC cases • 14,3 – 21,5 % had at leastone CT-infection • 5,1 – 7,7 % had at leastoneGC-infection • Reinfectionswithin 12 months: 27 % • HIV 2004-2010: 10 HIV + • 2010: 1 acute HIV+ - 2+/14 (14 %) – 8 weeks • 2004: 1 acute HIV+ - 3+/14 (21 %) – 4 weeks

25. HIV in MENA – Middle East/North Africa • Concentrated hiv epidemics in several countries – increasing incidence since 2005 • FSW 0,1-1 % of women; 0-70 % HIV+ • MSM 2-3 % of men; 0-52 % HIV+ • Linked epidemics eg. • Iran IDUs 15 % hiv+, MSM 15 % HIV+ • Egypt 2006 IDUs 0,6 % HIV+, MSM 6,2 % HIV+ • Egypt 2010 IDUs 6,7 % HIV+, MSM 5,9 % HIV+

26. HIV in MENA – Middle East/North Africa • Overlap of risk behaviorsamonghigh-risk populations • MSM • Consistentcondomuse < 25 % • Lowknowledge of HIV/AIDS • Need for • Increasedsurveillance • Expand access to hiv-testing, prevention, and treatment services

27. HPV –lunch meeting • Genital warts are a marker of oncogenic HPV infection • HPV and cancer • Cervical cancer 100 % • Vulvar cancer 40 % • Vaginal cancer 60-90 % • Anal cancer 80-90 % • Penile cancer 45 % • Head & Neck cancer 12-70 %

28. HIV transmission – Myron S Cohen • 38 % of HIV because of acuteinfections • Infectiousness • Blood viral load • Genital viral load • Inflammatory STD • HPTN 052 • 1763 discordantcouples – immediate or delayedtreatment (CD4 200-250 – normalt > 500) • 28 linked infections: 27 delayed and 1 immediate – 96 % prevention

29. HIV strategies • Counseling • ARV treatment • Circumcision • (Vaccine) • STD treatment? • Acute HIV infection? • PrEP • PEP

30. Concurrency – Jami Leichliter, CDC • First & last date for three most recent opposite sex partners • Average duration increasing by age • Current concurrency • Women 0,3 % • Men 2,1 %

31. Neglected issues • HIV risk – anal intercourse in women 4-20 x increased HIV risk compared to vaginal sex • Increase in risk similar to primary infection

32. Anal sex in womenJoelle Brown, UCLA • 141 women> 18 years • Anal intercourse(AI) last month: • White 17 %, unprotected 63 %, lube 75 % • Black 14 %, unprotected 50 %, lube 38 % • Hispanic 27 %, unprotected 40 %, lube 60 % • Lube (=lubricant): commercial38 %, saliva23 %, petroleum jelly(Vaseline) 15 %, lotion 12 % • AI and HIV: aOR 7,8 (1,6-37,6) • AI and HSV-2: aOR 3,3 (1,2-9,1)

33. Rectal CT and GC in LA women • Reported anal intercourse in previous 90 days • Limit: reportingbias for sensitive behaviors • 716 womenmean age 28 years (14-60) • CT (n = 114)GC (n = 26) • Urogenitalonly 14 (12 %) 5 (19 %) • Urogenital + rectal 69 (61 %) 14 (54 %) • Rectalonly 31 (27 %) 7 (27 %) • Rectal sampling: CT + 37 %, GC + 37 %

34. Jessica Ladd, JHU, Baltimore – Internet testing for CT, GC, Tric ”I want the kit” • CT in women who wererectallytested (n = 205) • 15+ in bothrectum and vagina (48 %) • 7+ in vagina only (23 %) • 9+ in rectumonly (plus 2 who were not testedvaginally) (29 %) • GC in women who wererectallytested (n = 205) • 3+ in bothrectum and vagina (43 %) • 2+ in vagina only (29 %) • 2+ in rectumonly (29 %)

35. Jessica Ladd, JHU, Baltimore • 14 % anal intercourse and always condom • 8,2 % forced anal sex • 70 % asymptomatic infection • 36,8 % of rectal infections (CT,GC, Tric) would not have been diagnosed with urogenital sampling only • CT + 41 % when rectal sampling added • GC + 40 % when rectal sampling added

36. Netherlands – MSM and female swingers • 6 000 visits/year South Limburg STD clinic • Female swingers rectal sampling • Self reported anal intercourse: bad indicator • Symptoms: bad indicator • MSM: add oral + rectal sampling • Female swingers: add rectal sampling

37. Quebec: www.msss.gouv.qc.ca • Key public health functions • Protection, Surveillance, Prevention, Promotion • STI strategies • Targeted communiction • Early access to condoms and promotion of their use • Access to youth clinics • Access to screening services

38. Quebec: www.msss.gouv.qc.ca • 2010-2011 campaign • Campaign for young people aged 15 to 24 • The campaign for preventing STI's aims at encouraging young people to use condoms with their partners and to continue using condoms after their initial relations. Like last year, the theme is "Beware and Be Aware." It reminds young people that infected individuals do not always have visible symptoms, which is why always using condoms is so important. Condoms. 100% on.

39. Quebec - Poster 1 • More often than not, Chlamydia doesn't reveal itself. 3 out of 4 people with Chlamydia ignore the fact that they're infected. • Poster "Girl" (1.7 MB)

40. Quebec - Poster 2 • More often than not, herpes doesn't reveal itself. 9 out 10 people with herpes ignore the fact that they're infected. • Poster "Boy" (1.7 MB)

41. www.msss.gouv.qc.ca • Campaign for adults aged 25 to 35 • The "Let's Take Action to Stop the Spread of STIs" awareness campaign is calling on the people of Québec to rally together. It aims at informing the public about a significant rise in STBBIs over the last several years and convincing adults to protect themselves and their close contacts.

42. Quebec- Poster 3 • Poster • Sexually transmitted infections and blood-borne pathogens are spreading more than ever. Let's take action to stop transmission. (769.2K)

43. http://www.hivbigdeal.org/ • ”Josh is a 26-year-old gay man in New York City. This is his story” • Episode I: ”The morning after” • Episode II: “The Test” • To test or not to test? Find out what Josh decides. SEE THE VIDEO FOR GAY MEN

44. http://www.hivbigdeal.org/ • Takingabout HIV is hard… • Having HIV is evenharder. • Talk with all of your sexual partners about HIV. • If you don’tknow your status, get tested. • HIV is still a big deal. • a project of the Medical and Health Research Association of New York City, Inc. and New York University

45. GC – HIV testing - USA • HIV-testing in GC-positive patients • Why? • Sexuallytransmitted • Within same networks • Results (1 845 GC+) • 33 % neverHIV-tested • 16 % tested > 2 years • 18 % tested 6 months - 2 years • 33 % tested < 6 months • Conclusion: suboptimal HIV-testing in the US

46. Oral and genital HPV in boys 14-17 y. • N = 33, testedevery 3 months, Roche PCR – 37 HPV-types • 12/33 (36 %) HPV+ at visit 1 • HR-HPV 7/33 (5 = HPV-51) • LR-HPV 13/33 (7 = HPV-84) • 10/33 (30 %) HPV+ at visit 2 • Oral HPV 2/33 (1 HR-HPV) • Multiple types at a singlepoint and at follow up

47. BV risk in wsw • Australia WSW 27 % BV (bacterial vaginosis) • BV – the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of certain bacteria.  • BV is sometimes accompanied by discharge, odor, pain, itching, or burning. • Risk factors • Increased partner change • Receptive oral sex • Smoking

48. HPV-prevalence England • NATSAL 2000 • Urine HPV-test • Men 17 % HPV • 9.6 % HR-HPV • 3.9 % HPV-16/18 • Women 29 % HPV • 15.9 % HR-HPV • 5.5 % HPV-16/18

49. Predicting HIV in MSM • 1 421 HIV+ MSM • 6.3 % had been CT/GC pos within 1 year before HIV-diagnosis • 9.6 % had been CT/GC pos within 2 years before HIV-diagnosis • 11.9 % had been CT/GC pos within 3 years before HIV-diagnosis

50. Internet • http://www.sfcityclinic.org/ • STD basics • STD risks chart • What you can get if your partner is infected • Example: Performing oral sex on a man • Known risks: CT, GC, HPV, Syphilis, Herpes, Hepatitis A, Shigella • Possible risks: hepatitis B, HIV • Unknown: hepatit is C