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Summary

INTRODUCTION

Of the top ten most frequently reported diseases in 1995 in the United States, five are sexually transmitted diseases (STDs) (CDC, 1996c). With approximately 12 million new cases of STDs occurring annually (CDC, DSTD/HIVP, 1993), rates of curable STDs in the United States are the highest in the developed world.1 In 1995, STDs accounted for 87 percent of all cases reported among the top ten most frequently reported diseases in the United States (CDC, 1996c). Despite the tremendous health and economic burden of STDs, the scope and impact of the STD epidemic are underappreciated and the STD epidemic is largely hidden from public discourse. Public awareness and knowledge regarding STDs are dangerously low, but there has not been a comprehensive national public education campaign to address this deficiency. The disproportionate impact of STDs on women has not been widely recognized. Adolescents and young adults are at greatest risk of acquiring an STD, but STD prevention efforts for adolescents remain unfocused and controversial in the United States. There are many biological and social factors that hinder effective prevention efforts, but few have been elucidated and addressed on a national basis. In addition, the roles

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For the purposes of this report, developed countries are western and northern European countries, Canada, Japan, and Australia. For example, th reported incidence of gonorrhea in 1995 was 150 cases per 1000,000 persons in theUnited States versus 3 cases per 100,000 in Sweden (CDC, DSTDP, 1996; Swedish Institute for Infectious Disease Control, unpublished data, 1996).



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The Hidden Epidemic: SUMMARY Summary INTRODUCTION Of the top ten most frequently reported diseases in 1995 in the United States, five are sexually transmitted diseases (STDs) (CDC, 1996c). With approximately 12 million new cases of STDs occurring annually (CDC, DSTD/HIVP, 1993), rates of curable STDs in the United States are the highest in the developed world.1 In 1995, STDs accounted for 87 percent of all cases reported among the top ten most frequently reported diseases in the United States (CDC, 1996c). Despite the tremendous health and economic burden of STDs, the scope and impact of the STD epidemic are underappreciated and the STD epidemic is largely hidden from public discourse. Public awareness and knowledge regarding STDs are dangerously low, but there has not been a comprehensive national public education campaign to address this deficiency. The disproportionate impact of STDs on women has not been widely recognized. Adolescents and young adults are at greatest risk of acquiring an STD, but STD prevention efforts for adolescents remain unfocused and controversial in the United States. There are many biological and social factors that hinder effective prevention efforts, but few have been elucidated and addressed on a national basis. In addition, the roles 1   For the purposes of this report, developed countries are western and northern European countries, Canada, Japan, and Australia. For example, th reported incidence of gonorrhea in 1995 was 150 cases per 1000,000 persons in theUnited States versus 3 cases per 100,000 in Sweden (CDC, DSTDP, 1996; Swedish Institute for Infectious Disease Control, unpublished data, 1996).

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The Hidden Epidemic: SUMMARY and responsibilities of public versus private health care professionals in STD prevention have not been clarified in light of recent changes in health care delivery and financing. Given the above observations regarding STDs in the United States, the Institute of Medicine (IOM) convened the 15-member Committee on Prevention and Control of Sexually Transmitted Diseases in 1994 to “(a) examine the epidemiological dimensions of STDs in the United States and factors that contribute to the epidemic; (b) assess the effectiveness of current public health strategies and programs to prevent and control STDs;2 and (c) provide direction for future public health programs, policy, and research in STD prevention and control.3” The committee was charged to focus its study on STDs other than HIV infection. BROAD SCOPE AND IMPACT OF STDS The term “STD” is not specific for any one disease but denotes the more than 25 infectious organisms that are transmitted through sexual activity and the dozens of clinical syndromes that they cause.4 STDs are almost always transmitted from person to person by sexual intercourse.5 These infections are most efficiently transmitted by anal or vaginal intercourse, and generally less efficiently by oral intercourse. Some STDs, such as hepatitis B virus infection and HIV infection, are also transmitted by parenteral routes—particularly among intravenous drug users through contaminated injecting drug equipment. In addition, pregnant women with sexually transmitted infections may pass their infection to infants in the uterus, during birth, or through breast-feeding. STDs are transmitted among all sexually active people, including heterosexual persons, men who have sex with men, and women who have sex with women (AMA, Council on Scientific Affairs, 1996). Men who have sex with men 2   Although the committee examined the effectiveness of major strategies and programs in STD prevention, it did not conduct a systematic, in-depth evaluation of every STD-related program in the public and private sector. In this report, the committee focuses its discussions on effective strategies and highlights major effective programs. 3   The terms “STD prevention” and “STD control” traditionally have been used by public health workers without clear distinction. These terms have been commonly used to refer to behavioral interventions (e.g., counseling for behavior change), treatment of symptomatic disease, and other interventions that prevent the spread of infection (e.g., partner notification). The committee believes that most interventions for STDs both “prevent” and “control” STDs and all prevent acquisition or transmission of STDs in a population. Essentially, effective prevention of STDs brings STDs under control. Therefore, in this Summary and the full report, the committee uses the term “STD prevention” rather than “STD prevention and control” to encompass all interventions, whether behavioral, curative, environmental, or otherwise, that are needed to reduce the spread of infection in a population. 4   See Appendix A of the full report. 5   The term “sexual intercourse” is used throughout this summary and the full report to refer to all forms of intercourse, including vaginal, anal, and oral intercourse.

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The Hidden Epidemic: SUMMARY are at greater risk for many life-threatening STDs, including HIV infection, hepatitis B virus infection, and anal cancer compared to heterosexual men (AMA, Council on Scientific Affairs, 1996). Less is known about the risk of STD transmission among women who have sex with women (Kennedy et al., 1995; AMA, Council on Scientific Affairs, 1996), but women who have sex only with women (and whose partners do likewise) are generally at substantially lower risk for acquisition of STDs compared with men who have sex with men and heterosexual persons. Impact of STDs on Women's and Adolescents' Health Complications of STDs are more severe and occur more frequently among women than men for a number of reasons (Wasserheit and Holmes, 1992). Many STDs are transmitted more easily from a man to a woman than from a woman to a man (Harlap et al., 1991). Sexually transmitted infections also are more likely to remain undetected in women, resulting in delayed diagnosis and treatment. Every year, approximately 3 million American teenagers acquire an STD (CDC, DSTD/HIVP, 1993). Adolescents and young adults are the age groups at greatest risk of acquiring an STD for a number of reasons: they are more likely to have multiple sex partners; they may be more likely to engage in unprotected intercourse; and their partners may be at higher risk of being infected (CDC, DSTDP, 1995; AGI, 1994; Quinn and Cates, 1992; Cates, 1990). Compared with older adult women, female adolescents and young women are more susceptible to cervical infections, such as gonorrhea and chlamydial infection, because the cervix of female adolescents and young women is especially sensitive to infection by certain sexually transmitted organisms (Cates, 1990). In addition, adolescents and young people are at greater risk than older persons for substance use and other behaviors that may increase risk for STDs. STDs as Emerging Infections STDs are not a stationary group of infections and syndromes; eight new sexually transmitted pathogens have been identified since 1980, including HIV. In contrast to newly recognized viral STDs, some bacterial STDs, such as syphilis and gonorrhea, have been documented for centuries and have recently reemerged in the United States along with a spectrum of barriers to prevention (Wasserheit, 1994). As demonstrated by the recent finding that bacterial vaginosis in pregnant women increases the risk for premature delivery of a low-birthweight infant (Hillier et al., 1995; Hauth et al., 1995), the full clinical spectrum of many STDs is still being described. STDs are severe social, health, and economic burdens worldwide. The World Bank estimates that STDs, excluding AIDS, are the second leading cause of healthy life lost among women between the ages of 15 and 44 in the developing

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The Hidden Epidemic: SUMMARY world (World Bank, 1993; Over and Piot, 1993). The World Health Organization (WHO) recently estimated that there were 333 million new cases of the four curable STDs (gonorrhea, chlamydial infection, syphilis, and trichomoniasis) worldwide in 1995 among adults 15– 49 years of age (WHO, Global Programme on AIDS, 1996). New sexually transmitted infections appear on a regular basis in the United States and are likely to continue to do so as long as the rates of risky sexual behaviors remain high and global economic and demographic factors continue to promote the emergence of STDs. HEALTH CONSEQUENCES OF STDS The general population is largely unaware of the health consequences of STDs, and STDs are “hidden” from public attention for three reasons. First, many STDs are often asymptomatic and thus go undetected (Judson, 1990; Fish et al., 1989; Stamm and Holmes, 1990). Second, major health consequences, such as infertility, certain cancers, and other chronic diseases, occur years after the initial infection, so that there is a lack of awareness of any link to the original STD. Third, the stigma associated with having an STD has inhibited public discussion and education concerning the consequences of STDs and frequently prevents clinicians from educating their patients regarding STDs. These factors are discussed later in this summary. Cancers Caused by STDs Several sexually transmitted pathogens cause cancer. Certain types of sexually acquired human papillomavirus are now considered to cause nearly all cancers of the cervix, vagina, vulva, anus, and penis. Cervical infections with oncogenic types of human papillomavirus are associated with at least 80 percent of invasive cervical cancer cases (NIH, 1996a); and women with human papillomavirus infection of the cervix are 10 times more likely to develop invasive cervical cancer than are women without such infection (Schiffman, 1992). Approximately 4,900 American women will die from cervical cancer in 1996, and approximately 16,000 new cases of cervical cancer are diagnosed each year, making cervical cancer the third most common reproductive tract cancer in women and the seventh most common type of cancer overall in women (ACS, 1996). Much of the cervical cancer burden related to human papillomavirus infection may be averted by preventing high-risk sexual behaviors (Brinton, 1992). Screening with the Pap smear is currently the best available method for reducing both incidence of and mortality associated with invasive cervical cancer, but this technique is not widely utilized among certain population groups (NIH, 1996a). Hepatitis B virus is a sexually transmitted virus that causes hepatocellular carcinoma (liver cancer), one of the most common forms of cancer. Other sexually transmitted pathogens that are associated with cancers include

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The Hidden Epidemic: SUMMARY human T-cell lymphotrophic virus type I (HTLV-I), linked to adult T-cell leukemia and lymphoma; human herpes virus type 8 (HHV8), linked to Kaposi's sarcoma; and Epstein-Barr virus (EBV), linked to lymphoma and nasopharyngeal (nasal cavity and pharynx) carcinoma. Reproductive Health Problems One of the most serious threats to the reproductive capability of women is pelvic inflammatory disease, a preventable complication of certain STDs, most commonly chlamydial infection and gonorrhea (Washington et al., 1991; Jossens et al., 1994). Each year more than one million U.S. women experience an episode of pelvic inflammatory disease (Rolfs et al., 1992; Washington and Katz, 1991). At least one-quarter of women with acute pelvic inflammatory disease experience serious long-term sequelae, the most common and important of which are ectopic pregnancy (the development of a fetus outside the uterus) and tubal-factor infertility (infertility resulting from blockage or damage to the fallopian tubes). Ectopic pregnancy usually results from partial tubal blockage associated with pelvic inflammatory disease. In 1992, the estimated number of ectopic pregnancies was 108,800, or one in 50 pregnancies (CDC, 1995a). In the same year, approximately 9 percent of all pregnancy-related deaths were a result of ectopic pregnancy (NCHS, 1994), making ectopic pregnancy one of the leading and most preventable causes of maternal death during pregnancy (Marchbanks et al., 1988). At least 15 percent of all infertile American women are infertile because of tubal damage caused by pelvic inflammatory disease. Of all women infertile because of tubal damage, no more than one-half have previously been diagnosed and treated for acute pelvic inflammatory disease. Health Consequences for Pregnant Women and Infants STDs are associated with multiple acute complications for pregnant women and their infants (Brunham et al., 1990). Various sexually transmitted pathogens may be transmitted to the fetus, newborn, or infant through the placenta (congenital infection), during passage through the birth canal (perinatal infection), or after birth through breast-feeding or close direct contact. Active sexually transmitted infection during pregnancy may result in spontaneous abortion, stillbirth, premature rupture of membranes, and preterm delivery. Preterm delivery accounts for approximately 75 percent of neonatal deaths not caused by congenital malformations (Main and Main, 1991). Women with bacterial vaginosis are 40 percent more likely to deliver a premature infant compared with women without this condition (Hillier et al., 1995). In addition, up to 80 percent of pregnancies associated with untreated early syphilis result in stillbirth or clinical evidence of congenital syphilis in the newborn (Schulz et al., 1990). Sexually transmitted pathogens that have serious consequences among adults tend to cause even more

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The Hidden Epidemic: SUMMARY severe, potentially life-threatening health conditions in the fetus or newborn, whose immune system is immature. Damage to the central nervous system, eyes, and auditory system is of particular concern. Deaths Associated with STDs Of 513,486 persons with AIDS reported in the United States through December 1995, more than 62 percent (319,849) have died (CDC, 1995b). The largest number of deaths related to STDs other than AIDS is caused by cervical and other human papillomavirus-related cancers; liver disease (e.g., chronic liver disease and liver cancer) caused by hepatitis B virus; pelvic inflammatory disease; ectopic pregnancy; and various pregnancy, fetal, and neonatal complications. A recent study found that more than 150,000 deaths were directly attributed to STDs, including AIDS, from 1973 through 1992 among American women 15 years of age and older (Ebrahim et al., 1995). The three leading causes of STD-related deaths in 1992 among these women were all related to viral STDs: cervical cancer, AIDS, and hepatitis B virus infection. The high rate of viral STD-related deaths and morbidity and the high costs of managing viral STDs and their complications in the United States underscore the importance of effective prevention programs for viral STDs. IMPACT OF STDS ON HIV TRANSMISSION Both “ulcerative” STDs, such as chancroid, syphilis, and genital herpes, and “inflammatory” STDs, such as gonorrhea, chlamydial infection, and trichomoniasis, increase the risk of HIV infection. Prospective cohort studies in Africa have demonstrated increased risk of HIV infection following genital ulcer disease as well as with inflammatory STDs (Cameron et al., 1989; Plummer et al., 1991; Laga et al., 1993; Nyange et al., 1994). Genital ulcer disease may increase the risk of transmission per exposure by a factor of 10 to 50 for male-to-female transmission and by a factor of 50 to 300 for female-to-male transmission (Hayes et al., 1995). Numerous studies support the concept that STDs increase both infectivity of and susceptibility to HIV (Kreiss et al., 1994; Plummer et al., 1991; Clemetson et al., 1993; Mostad et al., 1996; John et al., 1996; Gys et al., 1996; Moss et al., 1995; Hoffman et al., 1996; de Vincenzi, 1994; Deschamps et al., 1996). Early detection and treatment of STDs can have a major impact on sexual transmission of HIV (Moss et al., 1995; Hoffman et al., 1996; Laga et al., 1994). For example, a large, prospective, randomized controlled trial in Tanzania found that the incidence of HIV infection was 42 percent lower in communities with improved management of STDs after two years compared with control communities (Grosskurth et al., 1995a, b). In the absence of prospective studies or formal trials of strengthened STD

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The Hidden Epidemic: SUMMARY interventions to reduce sexual transmission of HIV in the United States (which may not be feasible), mathematical modeling may be essential to assess the potential impact of reducing STDs on HIV transmission. Robinson and colleagues (1995) predicted that a 50 percent reduction in the duration of STDs in Uganda could decrease HIV transmission by 43 percent—a prediction remarkably close to that observed in the intervention trial in nearby Tanzania. Boily has developed a model that shows that HIV infection could not be established in the general U.S. heterosexual population in the absence of chlamydial infection (or other STDs with comparable effects on HIV transmission). 6 In addition, it is estimated that successfully treating or preventing 100 cases of syphilis among high-risk groups for STDs would prevent 1,200 HIV infections that are ordinarily linked to those 100 syphilis infections during a 10-year period (Over and Piot, 1993). ECONOMIC CONSEQUENCES OF STDS The costs of a few STDs have been estimated (IOM, 1985; Washington et al., 1987; Washington and Katz, 1991), but no comprehensive, current analysis of the direct and indirect costs of STDs is available. Partly based on updated estimates of the economic burden of STDs by Siegel, 7 the committee estimates that the total costs for a selected group of major STDs and related syndromes, excluding HIV infection, were approximately $10 billion in 1994. This rough, conservative estimate does not capture the economic consequences of several other common and costly STDs and associated syndromes such as vaginal bacteriosis and trichomoniasis. The estimated annual cost of sexually transmitted HIV infection in 1994 was approximately $6.7 billion.8 Including these costs raises the overall cost of STDs in the United States to nearly $17 billion in 1994. These cost estimates underscore the enormous burden of STDs on the U.S. economy. Much of the direct costs of STDs result from failure to detect and effectively manage STDs in their initial, acute stages. For example, nearly three-fourths of the $1.5 billion cost of chlamydial infections is due to preventable complications resulting from untreated, initially uncomplicated infections (Washington et al., 1987). FACTORS THAT CONTRIBUTE TO THE HIDDEN EPIDEMIC Biological Factors Behavioral, biological, and social factors contribute to the transmission of STDs (Wasserheit, 1994). In addition to preexisting or concurrent STDs, biologi- 6   See Appendix C of the full report. 7   See Appendix D of the full report. 8   See Chapter 2 of the full report.

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The Hidden Epidemic: SUMMARY cal factors that contribute to the hidden nature and spread of STDs include the lack of conspicuous signs and symptoms in infected persons (asymptomatic infections), the long lag time from initial infection to signs of severe complications, and the propensity for STDs to more easily infect young women and female adolescents than men. Many STDs, such as chlamydial infection, do not produce acute symptoms or clinical signs of disease, or they do not produce symptoms sufficiently severe for an infected individual to seek medical attention (Stamm et al., 1982; Keim et al., 1992). The long period of time (sometimes years or decades) from initial infection until the appearance of clinical problems, such as in the cases of human papillomavirus infection and genital cancer, and hepatitis B virus infection and liver cancer, often results in failure to attribute cases of STD-related cancers and other long-term complications to sexually transmitted infections. This failure, in turn, reduces the perceived seriousness of STDs and the motivation to undertake preventive action. Other biological factors that may increase risk for acquiring, transmitting, or developing complications of certain STDs include presence of male penile foreskin, vaginal douching, risky sexual practices, use of hormonal contraceptives or intrauterine contraceptive devices, cervical ectopy, immunity resulting from prior sexually transmitted or related infections, and nonspecific immunity conferred by normal vaginal flora. Social Factors Some fundamental societal problems such as poverty, inadequate access to health care, inadequate education, and social inequity indirectly increase the prevalence of STDs in certain populations. In addition, lack of openness and mixed messages regarding sexuality create obstacles to STD prevention for the entire population and contribute to the hidden nature of STDs. Poverty and Inadequate Access to Health Care Health insurance coverage enables individuals to obtain professional assistance in order to prevent potential STD exposures and to seek care for suspected STDs. Persons who are uninsured delay seeking care for health problems longer than those who have private insurance or Medicaid coverage (Donelan et al., 1996; Freeman et al., 1987). The age and ethnic groups with the highest rates of STDs are also the groups with the poorest access to health services. One-third of persons in age groups at high risk for STDs are uninsured or covered by Medicaid (UCLA Center for Health Policy Research, unpublished data, 1996). Inadequate access to STD-related services may also be a problem for those with private health insurance. For example, those with private health insurance who are living at or near the poverty level have limited access to health care because of copayments and deductibles that are typically part of private insurance coverage (Freeman and Corey, 1993). In addition, many health plans either do

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The Hidden Epidemic: SUMMARY not cover certain important preventive reproductive health services related to STDs or they require copayments and deductibles for these services (WREI, 1994). Poverty and other socioeconomic factors also contribute to STD risk in other ways. Even if a person in poverty perceives himself or herself to be at risk for an STD, he or she may not practice preventive behaviors if there are other risks that appear more imminent or more threatening or both (Ramos et al., 1995; Mays and Cochran, 1988). Substance Use Substance use, especially drug and alcohol use, is associated with STDs. At the population level, rates of STDs are high in geographic areas where rates of substance use are also high, and the rates of substance use and STDs have also been shown to co-vary temporally (Greenberg et al., 1991). At the individual level, persons who use substances are more likely to acquire STDs than those who do not (Marx et al., 1991; Anderson and Dahlberg, 1992; Shafer et al., 1993). Use of drugs and other substances may undermine an individual's cognitive and social skills, making it more difficult to take protective actions against STDs (Marx et al., 1991). Numerous studies show that drug use is associated with increased risk of STDs, including HIV infection (Marx et al., 1991; Edlin et al., 1994). Crack use, in particular, strongly contributes to STD transmission by discouraging health-care-seeking behavior (Webber et al., 1993) and modifying social norms with respect to behavior such as engaging in unprotected sex (Finelli et al., 1993) or having multiple sex partners (Greenberg et al., 1991); these factors may lengthen the duration of infectiousness. A number of studies have reported strong associations between alcohol use and high-risk sexual behaviors among the general population (Anderson and Dahlberg, 1992; Caetano and Hines, 1995), adolescents (Shafer et al., 1993; Hingson et al., 1990; Lowry et al., 1994), men who have sex with men (Siegel et al., 1989; Stall et al., 1986), runaway youth (Koopman et al., 1994), and mentally ill adults (Kalichman et al., 1994). Sexual Abuse and Violence Sexual violence against women and sexual abuse of children contribute to the transmission of STDs. Women who have been sexually abused during childhood are twice as likely to have gynecological problems, including STDs, than women who do not have such a history (Plichta and Abraham, 1996). In addition, women with a history of involuntary sexual intercourse are more likely to have voluntary intercourse at an earlier age (a risk factor for STDs) and to have subsequent psychological problems (Miller et al., 1995). Many women who experience sexual violence may not be able to implement practices to protect against STDs or pregnancy (Plichta and Abraham, 1996; O'Leary and Jemmott, 1995).

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The Hidden Epidemic: SUMMARY STDs among children presenting for care after the neonatal period almost always indicate sexual abuse (CDC, 1993a; Gutman et al., 1991; AAP, Committee on Child Abuse and Neglect, 1991). Sexually abused children may have severe and long-lasting psychological consequences, may become sexual abusers themselves, and may abuse other children (Guidry, 1995). In addition, they may participate in a pattern of high-risk behavior that often puts them at risk for further abuse and subsequent STDs. STDs Among Disenfranchised Populations STDs disproportionately affect disenfranchised groups, including sex workers9 (Plummer and Ngugi, 1990; Rosenblum et al., 1992), runaways (Sherman, 1992), homeless persons (Johnstone et al., 1993; Breakey et al., 1989), adolescents in detention (AMA, Council on Scientific Affairs, 1989; Shafer et al., 1993; Shafer, 1994), adults in detention (CDC, 1996a; Hammett et al., 1995), and migrant workers (CDC, 1992a; Jones et al., 1991). These groups are important from an STD prevention perspective because they represent “core” transmitters of STDs and are potential reservoirs of infection for the general population (Thomas and Tucker, 1996). Rates of STDs, including HIV infection, are many times higher among incarcerated adolescents and adults than among the general population (CDC, 1996a; CDC, 1992b). Within prisons, unprotected sex, intravenous drug use, and tattooing are potential modes of transmission of STDs, including HIV infection (Dolan et al., 1995; Hammett et al., 1995; Doll, 1988). A wide range of unprotected consensual and nonconsensual sexual activity occurs among prisoners and between prisoners and staff (Mahon, 1996). In detention facilities, more emphasis is placed on HIV education than on education about other STDs, and very few correctional facilities provide access to condoms because of security concerns (Hammett et al., 1995; CDC, 1996a). The high annual rate of turnover among prisoners, 800 and 50 percent in jails and prisons, respectively, is a major barrier to screening programs and follow-up treatment for STDs (Glaser and Greifinger, 1993). SECRECY AS A CONTRIBUTING FACTOR Although sex and sexuality pervade many aspects of American culture and sexuality is a normal aspect of human functioning, sexual behavior is a private—and secret—matter in the United States. The committee uses the term “secrecy” in this report to describe certain aspects of sexuality in the United States. By the 9   The term “sex worker” is commonly used by public health workers to refer to persons who exchange sex for drugs, money, or other goods. This term is preferable to the term “prostitute.”

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The Hidden Epidemic: SUMMARY term “secrecy,” the committee includes both the passive by-product of the inherent difficulties of discussing intimate aspects of life, and the ongoing efforts by some groups to prevent open dissemination of information regarding sexuality and its health consequences. The secrecy surrounding sexuality in the United States may have origins in the late Victorian social system (Brandt, 1988, 1985; Sokolow, 1983). The depiction of sexuality has been paradoxical within modern American culture. On the one hand, there is a saturation and sensationalism of sexual images and messages in the mass media, and the public is fascinated with sexual subjects. On the other hand, sexuality remains an extremely private and uniquely complex sphere of human behavior with sociocultural taboos and rules of behavior that make talking openly and comfortably about sexuality difficult. The secrecy surrounding sexuality and STDs adversely impacts on STD prevention in the United States by impeding sexuality and STD education programs for adolescents, hindering communication between parents and their children and between sex partners, promoting unbalanced sexual messages in mass media, compromising education and counseling activities of health care professionals, hindering community activism regarding STDs, and impeding research on sexual behaviors. Barriers to open discussion regarding sexuality include gender roles; modesty; and cultural, family, or religious taboos against discussions of sex. Ironically, it may require greater intimacy to discuss sex than to engage in it. The kind of communication that is necessary to explore a partner's sexual history, establish STD risk status, and plan for protection against STDs is made difficult by the taboos surrounding sex and sexuality (Lear, 1995). The discomfort that many Americans feel discussing sexual behavior is reflected in a recent nationwide survey showing that, including married couples, approximately one of four women and one of five men surveyed had no knowledge of their partner's sexual history (EDK Associates, 1995). Only 11 percent of teenagers get most of their information regarding STDs from parents and other family members (ASHA, 1996). Because many parents do not talk to their children about sex, children are more likely to learn about sex through clandestine and secretive exchanges with peers that result in a massive amount of misinformation (Smith and Lanthrop, 1993). Americans, especially adolescents, receive unbalanced mass media messages about sexuality, sexual behavior, and sexual responsibility. Premarital sex, cohabitation, and nonmarital relationships are depicted as the norm for adults (Lichter et al., 1994), but the mass media provide little frank and informed advice about STDs, sexuality, contraception, or the harsh realities of early pregnancy and parenting. Television is currently the most significant mass media influence for adolescents (Strasburger, 1990), and children spend more time watching television than they do in school (Dietz and Strasburger, 1991). A recent study found an average of 10 incidents of sexual behavior per hour on network television during prime time

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The Hidden Epidemic: SUMMARY Anderson JE, Dahlberg LL. High-risk sexual behavior in the general population. Results from a national survey, 1988-1990. Sex Transm Dis 1992;17:320-5. Anderson JE, McCormick L, Fichtner R. Factors associated with self-reported STDs: data from a national survey. Sex Transm Dis 1994;21:303-8. Andrus JK, Fleming DW, Harger DR, Chin MY, Bennet DV, Horan JM, et al. Partner notification: can it control epidemic syphilis [see comments]? Ann Intern Med 1990;112:539-43. Aral SO. Sexual behavior in sexually transmitted disease research. An overview. Sex Transm Dis 1994;21(March-April Suppl):S59-S64. Arevalo JA, Washington AE. Cost-effectiveness of prenatal screening and immunization for hepatitis B virus. JAMA 1988;259:365-9. ARHP, ANPRH (Association of Reproductive Health Professionals and Association of Nurse Practitioners in Reproductive Health). STD counseling practices and needs survey. Silver Spring, MD: Schulman, Ronca, and Bucuvalas, Inc., January 1995. ASHA (American Social Health Association). International survey reveals lack of knowledge about STDs. STD News 1995;3(Fall):1, 10. ASHA. Teenagers know more than adults about STDs, but knowledge among both groups is low. STD News 1996;3(Winter):1, 5. Bandura A. Perceived self-efficacy in the exercise of control over AIDS infection Eval Program Plann 1990;13:9-17. Barone C, Ickovics JR, Ayers TS, Katz SM, Voyce CK, Weissberg RP. High-risk sexual behavior among young urban students. Fam Plann Perspect 1996:28;69-74. Berg AO. The primary care physician and sexually transmitted diseases control In: Holmes KK, Mårdh PA, Sparling PF, Wiesner PJ, Cates W Jr, Lemon SM, et al., eds. Sexually Transmitted Diseases. 2nd ed. New York: McGraw-Hill, Inc., 1990:1095-8. Boekeloo BO, Marx ES, Kral AH, Coughlin SC, Bowman M, Rabin DL. Frequency and thoroughness of STD/HIV risk assessment by physicians in a high-risk metropolitan area. Am J Public Health 1991;81:1645-8. Bowman MA, Russell NK, Boekeloo BO, Rafi IZ, Rabin DL. The effect of educational preparation on physician performance with a sexually transmitted disease-simulated patient. Arch Intern Med 1992;152:1823-8. Brandt AM. AIDS in historical perspective: four lessons from the history of sexually transmitted diseases. Am J Public Health 1988;78:367-71. Brandt AM. No Magic Bullet: A Social History of Venereal Disease in the United States Since 1980. New York: Oxford University Press, Inc., 1985. Breakey WR, Fischer PJ, Kramer M, Nestadt G, Romanovski AJ, Ross A, et al. Health problems of homeless men and women in Baltimore. JAMA 1989;262:1352-7. Brinton LA. Epidemiology of cervical cancer—overview. In: Munoz N, Bosch FX, Shah KV, Meheus A, eds. The Epidemiology of Cervical Cancer and Human Papillomavirus. Lyon, France: IARC, 1992:3-23. Britton TF, DeLisle S, Fine K. STDs and family planning clinics: a regional program for chlamydia control that works. Am J Gynecol Health 1992;6:80-7. Brown JD, Steele JR. Sex and the mass media. Report prepared for the Henry J. Kaiser Family Foundation and presented at the meeting “Sex and Hollywood: should there be a government role? ” American Enterprise Institute, June 21, 1995, Washington, D.C. Brunham RC, Holmes KK, Embree JE. Sexually transmitted diseases in pregnancy. In: Holmes KK, Mårdh P-A, Sparling PF, Weisner PJ, Cates W Jr, Lemon SM, et al., eds. Sexually Transmitted Diseases. 2nd ed. New York: McGraw-Hill, Inc., 1990:771-801. Caetano R, Hines AM. Alcohol, sexual practices, and risk of AIDS among blacks, Hispanics, and whites. J Acquir Immune Defic Syndr 1995;10:554-61.

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The Hidden Epidemic: SUMMARY Cameron DW, Simonsen JN, D'Costa LJ, Ronald AR, Maitha GM, Gakinya MN, et al. Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet 1989; 2:403-7. Catania JA, Coates TH, Kegeles S, Fullilove MT, Peterson J, Marin B, et al. Condom use in multi-ethnic neighborhoods of San Francisco: the population-based AMEN (AIDS in Multi-Ethnic Neighborhoods) Study. Am J Public Health 1992;82:284-7. Cates W Jr. Epidemiology and control of sexually transmitted diseases in adolescents In: Schydlower M, Shafer MA, eds. AIDS and Other Sexually Transmitted Diseases. Philadelphia: Hanly & Belfus, Inc., 1990:409-27. Cates W Jr, Stone KM. Family planning, sexually transmitted diseases, and contraceptive choice: a literature update. Fam Plann Perspect 1992;24:75-84. Cates W Jr, Stewart FH, Trussell J. Commentary: the quest for women's prophylactic methods—hopes vs science. Am J Public Health 1992;82:1479-82. CDC (Centers for Disease Control and Prevention). Alternate case-finding methods in a crack-related syphilis epidemic —Philadelphia. MMWR 1991a;40:77-80. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991b;40(RR-13):1-20. CDC. HIV infection, syphilis, and tuberculosis screening among migrant farm workers—Florida, 1992. MMWR 1992a;41:723-5. CDC. HIV prevention in the U.S. correctional system, 1991. MMWR 1992b;41:389-91, 397. CDC. HIV-risk behaviors of sterilized and nonsterilized women in drug-treatment programs—Philadelphia, 1989–1991. MMWR 1992c;41;149-52. CDC. Premarital sexual experience among adolescent women—United States, 1970–1988. MMWR 1992d;39;929-32. CDC. Surgical sterilization among women and use of condoms—Baltimore, 1989–1990. MMWR 1992e;41;568-75. CDC. 1993 Sexually transmitted diseases treatment guidelines. MMWR 1993a;42(No. RR-14);56-66. CDC. Update: barrier protection against HIV infection and other sexually transmitted diseases. MMWR 1993b ;42;589-91, 597. CDC. Hepatitis B vaccination of adolescents—California, Louisiana, and Oregon, 1992–1994. MMWR 1994;43;605-9. CDC. Ectopic pregnancy—United States, 1990–1992. MMWR 1995a ;44;46-8. CDC. HIV/AIDS Surveillance Report. Atlanta: Centers for Disease Control and Prevention, 1995b; 7(2). CDC. Prevention and managed care: opportunities for managed care organizations, purchasers of health care, and public health agencies. MMWR 1995c ;44(No. RR-14);1-12. CDC. Trends in sexual risk behavior among high school students—United States, 1990, 1991, and 1993. MMWR 1995d;44;124-5, 131-2. CDC. Update: recommendations to prevent hepatitis B virus transmission —United States. MMWR 1995e ;44;574-5. CDC. HIV/AIDS education and prevention programs for adults in prisons and jails and juveniles in confinement facilities—United States, 1994. MMWR 1996a ;45;268-71. CDC. School-based HIV-prevention education—United States, 1994. MMWR 1996b ;45;760-5. CDC. Ten leading nationally notifiable infectious diseases—United Sates, 1995. MMWR 1996c ;45;883-4. CDC. Undervaccination for hepatitis B among young men who have sex with men—San Francisco and Berkeley, California, 1992-1993. MMWR 1996d;45;215-7.

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The Hidden Epidemic: SUMMARY CDC, DSTDP (Division of STD Prevention). Sexually transmitted disease surveillance 1994. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, 1995. CDC, DSTDP. Sexually transmitted disease surveillance 1995. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, September 1996. CDC, DSTD/HIVP (Division of STD/HIV Prevention). Annual report 1992. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, 1993. CDC, DSTDP/HIVP. Plan for a national partnership to prevent STD-related infertility Draft internal document, January 10, 1995a. Celum CL, Hook EW, Bolan GA, Spauding CD, Leone P, Henry KW, et al. Where would clients seek care for STD services under health care reform? Results of a STD client survey from five clinics. Eleventh Meeting of the International Society for STD Research, August 27-30, 1995, New Orleans [abstract no. 101]. Cleary PD, Barry MJ, Mayer KH, Brandt AM, Gostin L, Fineberg HV. Compulsory premarital screening for the human immunodeficiency virus: technical and public health considerations. JAMA 1987;258:1757-62. Cleary PD, Van Devanter N, Steilen M, Stuart A, Shipton-Levy R, McMullen W, et al. A randomized trial of an education and support program for HIV-infected individuals. AIDS 1995;9:1271-8. Clemetson DB, Moss GB, Willerford DM, Hensel M, Emonyi W, Holmes KK, et al. Detection of HIV DNA in cervical and vaginal secretions. Prevalence and correlates among women in Nairobi, Kenya. JAMA 1993;269:2860-4. Collins JL, Small ML, Kann L, Collins Pateman B, Gold RS, Kolbe LJ. School health education. J School Health 1995;65:302-11. David HP, Morgall JM, Osier M, Rasmussen NK, Jensen B. United States and Denmark: different approaches to health care and family planning. Stud Fam Plann 1990;21:1-19. DeBuono BA, Zinner SH, Daamen M, McCormack WM. Sexual behavior of college women in 1975, 1986, and 1989. N Engl J Med 1990;322:821-5. Deschamps MM, Pape JW, Hafner A, Johnson WD. Heterosexual transmission of HIV in Haiti. Ann Intern Med 1996;125:324-30. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. European Study Group on Heterosexual Transmission of HIV [see comments]. N Engl J Med 1994;331:341-6. Dietz WH, Strasburger VC. Children, adolescents and television. Curr Probl Pediatr 1991;21:8-32. di Mauro D. Executive summary of sexuality research in the United States: an assessment of the social and behavioral sciences. New York: Social Science Research Council, 1995. Dolan K, Wodak A, Penny R. AIDS behind bars: preventing HIV spread among incarcerated drug injectors AIDS 1995;9:825-32. Doll DC. Tatooing in prison and HIV infection [letter]. Lancet 1988;331:66-7. Donelan K, Blendon RJ, Hill CA, Hoffman C, Rowland D, Frankel M, et al. Whatever happened to the health insurance crisis in the United States? Voices from a national survey. JAMA 1996;276:1346-50. Donovan P. Taking family planning services to hard-to-reach populations. Fam Plann Perspect 1996;28:120-6. Ebrahim SH, Peterman TA, Zaidi AA, Kamb ML. Mortality related to sexually transmitted diseases in women, U.S., 1973–1992. Eleventh Meeting of the International Society for STD Research, August 27-30, 1995, New Orleans [abstract no. 343]. EDK Associates. Women & sexually transmitted diseases: The dangers of denial. New York: EDK Associates, 1994.

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The Hidden Epidemic: SUMMARY EDK Associates. The ABCs of STDs. New York: EDK Associates, 1995. Edlin BR, Irwin KL, Faruque S, McCoy CB, Word C, Serrano Y, et al. Intersecting epidemics—crack cocaine use and HIV infection among inner-city young adults The Multicenter Crack Cocaine and HIV Infection Study Team. N Engl J Med 1994;31:1422-7. Engelgau MM, Woernle CH, Rolfs RT, Greenspan JR, O'Cain M, Gorsky, RD. Control of epidemic early syphilis: the results of an intervention campaign using social networks. Sex Transm Dis 1995;22:203-9. Fanburg JT, Kaplan DW, Naylor KE. Student opinions of condom distribution at a Denver, Colorado, high school. J Sch Health 1995;65:181-5. Felman Y. Repeal of mandated premarital tests for syphilis: a survey of state health officers. Am J Public Health 1981;71:155-9. Finelli L, Budd J, Spitalny KC. Early syphilis. Relationship to sex, drugs, and changes in high-risk behavior from 1987-1990. Sex Transm Dis 1993;20:89-95. Fish AN, Fairweather DV, Oriel JD, Ridgeway GL. Chlamydia trachomatis infection in a gynecology clinic population: identification of high-risk groups and the value of contact tracing Eur J Obstet Gynecol Reprod Biol 1989;31:67-74. Fisher RS. Medicaid managed care: the next generation? Acad Med 1994;69:317-22. Flay BR. Mass media and smoking cessation: a critical review. Am J Public Health 1987;77:153-60. Flora JAM, Miabach EW, Holtgrave D. Communication campaigns for HIV prevention: using mass media in the next decade. In: Institute of Medicine. Assessing the Social and Behavioral Science Base for HIV/AIDS Prevention and Intervention. Background Papers. Washington, D.C.: National Academy Press, 1995:129-54. Freeman HE, Corey CR. Insurance status and access to health services among poor persons Health Serv Res 1993;28:531-41. Freeman HE, Blendon RJ, Aiken LH, Sudman S, Mullix CF, Covey CR. Americans report on their access to health care. Health Aff Millwood 1987;6:6-18. GHAA (Group Health Association of America, currently American Association of Health Plans). 1995 National Directory of HMOs. Washington, D.C.: Group Health Association of America, 1995. Glaser JB, Greifinger RB. Correctional health care: a public health opportunity. Ann Intern Med 1993;118:139-45. Greenberg MSZ, Singh T, Htoo M, Schultz S. The association between congenital syphilis and cocaine/crack use in New York City: a case-control study. Am J Public Health 1991;81:1316-8. Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke A, Senkoro K, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial [see comments]. Lancet 1995a ;346:530-6. Grosskurth H, Mosha F, Todd J, Senkoro K, Newell J, Klokke A, et al. A community trial of the impact of improved STD treatment on the HIV epidemic in rural Tanzania: 2 baseline survey results. AIDS 1995b;9:927-34. Guidry HM. Childhood sexual abuse: role of the family physician. Am Fam Physician 1995;51:407-14. Gunn RA, Montes JM, Toomey KE, Rolfs RT, Greenspan JK, Spitters CE, et al. Syphilis in San Diego County 1983–1992: crack cocaine, prostitution, and the limitations of partner notification. Sex Transm Dis 1995;22:60-6. Gutman LT, St. Claire K, Herman Giddens ME. Prevalence of sexual abuse in children with genital warts [letter; comment]. Pediatr Infect Dis J 1991;10:342-3. Guttmacher S, Lieberman L, Ward D, Radosh A, Rafferty Y, Freudenberg N. Parents' attitudes and beliefs about HIV/AIDS prevention with condom availability in New York City public high schools. J Sch Health 1995;65:101-6. Gys PD, Fransen K, Diallo MO, Ettiegne-Traore V, Maurice C, Hoyi-Adansou YM, et al. The association between cervico-vaginal HIV-1 shedding and STD, immunosuppression, and serum

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The Hidden Epidemic: SUMMARY HIV-1 load in female sex workers in Abidjan, Cote D'Ivoire. Eleventh International Conference on AIDS, July 7-12, 1996, Vancouver [abstract no. WeC 332]. Hammett TM, Widom R, Epstein J, Gross M, Sifre S, Enos T. 1994 Update: HIV/AIDS and STDs in correctional facilities. Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, National Institute of Justice/U.S. Department of Health and Human Services, Public Health Service, CDC, December 1995. Handsfield HH, Jasman LL, Roberts PL, Hanson VW, Kothenbeutel RL, Stamm WE. Criteria for selective screening for Chlamydia trachomatis infection in women attending family planning clinics. JAMA 1986;255:1730-4. Harlap S, Kost K, Forrest JD. Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States. New York: Alan Guttmacher Institute, 1991. Harris L and Associates. Attitudes about television, sex and contraception. A survey of a cross-section of adult Americans. Conducted for Planned Parenthood Federation of America. February 1987. Haskell RJ. A cost-benefit analysis of California's mandatory premarital screening program for syphilis. West J Med 1984;141:538-41. Hauth JC, Goldenberg RL, Andrews WW, Dubard MD, Copper RL. Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. N Engl J Med 1995;333:1732-6. Hayes RJ, Schulz KF, Plummer FA. The cofactor effect of genital ulcers on the per-exposure risk of HIV transmission in sub-Saharan Africa. J Trop Med Hyg 1995;98:1-8. Hessol NA, Priddy FH, Bolan G, Baumrind N, Vittinghoff E, Reingold AL, et al. Management of pelvic inflammatory disease by primary care physicians: a comparison with Centers for Disease Control and Prevention Guidelines Sex Transm Dis 1996;23:157-63. Hillier SL, Nugent RP, Eschenbach DA, Krohn MA, Gibbs RS, Martin DH, et al. Association between bacterial vaginosis and preterm delivery of a low birth-weight infant. N Engl J Med 1995;333:1737-42. Hillis SD, Nakashima A, Amsterdam L, Pfister J, Vaughn M, Addiss D, et al. The impact of a comprehensive chlamydia prevention program in Wisconsin Fam Plann Perspect 1995;27:108-11. Hingson RW, Strunin L, Berlin BM, Hereen T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J of Public Health 1990;80:295-9. Hofferth SL, Kahn JR, Baldwin W. Premarital sexual activity among U.S. teenage women over the past three decades. Fam Plann Perspect 1987;19:46-53. Hoffman I, Maida M, Royce R, Costello-Daly C, Kazembe P, Vernazza P, et al. Effects of urethritis therapy on the concentration of HIV-1 in seminal plasma. Eleventh International Conference on AIDS, July 7-12, 1996, Vancouver [abstract no. mo.C.903]. Holtgrave DR, Qualls NL, Curran JW, Valdiserri RO, Guinan ME, Parra WC. An overview of the effectiveness and efficiency of HIV prevention programs. Public Health Rep 1995;110:134-46. IOM (Institute of Medicine). New Vaccine Development: Establishing Priorities; Vol. I, Diseases of importance in the United States. Washington, D.C.: National Academy Press, 1985. IOM. Understanding the Determinants of HIV Risk Behavior. In: Auerbach JD, Wypijewska C, Brodie HKH, eds. AIDS and Behavior. Washington, D.C.: National Academy Press, 1994:78-123. IOM. Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Brown SS, Eisenberg L, eds. Washington, D.C.: National Academy Press, 1995. IOM. Contraceptive Research and Development: Looking to the Future. Harrison PF, Rosenfield A, eds. Washington, D.C.: National Academy Press, 1996a. IOM. Primary Care: America's Health in a New Era. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Washington, D.C.: National Academy Press, 1996b.

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The Hidden Epidemic: SUMMARY John G, Nduati R, Mbori-Ngacha D, Overbaugh J, Welch M, Richardson B et al. Cervico-vaginal HIV-1 DNA in pregnancy. Eleventh International Conference on AIDS, July 7-12, 1996, Vancouver [abstract no. WeC 331]. Johnstone H, Tornabene M, Marcinak J. Incidence of sexually transmitted diseases and Pap smear results in female homeless clients from the Chicago Health Outreach Project Health Care Women Int 1993;14:293-9. Jones JL, Rion P, Hollis S, Longshore S, Leverette WB, Ziff L. HIV-related characteristics of migrant workers in rural South Carolina South Med J 1991;84:1088-90. Jossens MO, Schachter J, Sweet RL. Risk factors associated with pelvic inflammatory disease of differing microbial etiologies. Obstet Gynecol 1994;83:989-97. Judson FN. Gonorrhea. Med Clin North Am 1990;74:1353-67. The Kaiser Commission on the Future of Medicaid. Medicaid and managed care: lessons from the literature. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 1995. Kalichman SC, Carey MP, Johnson BT. Prevention of sexually transmitted HIV infection: a metaanalytic review of the behavioral outcome literature. Ann Behav Change 1996;18:6-15. Kalichman SC, Kelly JA, Johnson JR, Bulto M. Factors associated with risk for HIV infection among chronic mentally ill adults. Am J Psychiatry 1994;151:221-7. Kamb ML, Douglas JM, Rhodes F, Bolan G, Zenilman J, Iatesta M, et al. A multi-center, randomized controlled trial evaluating HIV prevention counseling (Project RESPECT): preliminary results. Eleventh International Conference on AIDS, July 7-12, 1996 Vancouver [abstract no. Th.C.4380]. Keim J, Woodard MP, Anderson MK. Screening for Chlamydia trachomatis in college women on routine gynecological exams. J Am Coll Health 1992;41:17-9, 22-3. Kelly JA. Sexually transmitted disease prevention approaches that work. Interventions to reduce risk behavior among individuals, groups, and communities Sex Transm Dis 1994;21[No.2 supplement]: S73-S75. Kelly JA, St. Lawrence JS, Diaz YE, Stevenson LY, Hauth AC, Grasfield TL, et al. HIV risk behaviors reduction following intervention with key opinion leaders of population: an experimental analysis. Am J Public Health 1991;81:168-71. Kelly JA, St. Lawrence JS, Stevenson LY, Hauth AC, Kalichman SC, Diaz YE, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities. Am J Public Health 1992; 82:1483-9. Kennedy MB, Scarlett MI, Duerr AC, Chu SY. Assessing HIV risk among women who have sex with women: scientific and communication issues. J Am Med Wom Assoc 1995;50:103-7. Kirby D. Research and evaluation. In: Samuels SE, Smith MD, eds. Condoms in the Schools. Menlo Park, CA: Henry J. Kaiser Family Foundation, 1993:89-109. Kirby D. Sexuality and HIV education programs in schools. In: Garrison J, Smith MD, Besharov DJ, eds. Sexuality and American Social Policy: A Seminar Series. Sex Education in the Schools. Menlo Park, CA: Henry J. Kaiser Family Foundation, 1994;1-41. Kirby DM, Brown NL. Condom availability programs in U.S. schools. Fam Plann Perspect 1996;28:196-202. Kirby D, Short L, Collins J, Rugg D, Kolbe L, Howard M, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Rep 1994;109:339-60. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Fam Plann Perspect 1991;23:6-16. Klovdahl AS, Potterat JJ, Woodhouse DE, Muth JB, Muth SQ, Darrow WW. Social networks and infectious disease: the Colorado Springs study Soc Sci Med 1994;38:79-88. Kollar LM, Rosenthal SL, Biro FM. Hepatitis B vaccine series compliance in adolescents. Pediatr Infect Dis J 1994;13:1006-8. Koopman C, Rosario M, Rotheram-Borus MJ. Alcohol and drug use and sexual behaviors placing runaways at risk for HIV infection. Addict Behav 1994;19:95-103.

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The Hidden Epidemic: SUMMARY Kost K, Forrest JD. American women's sexual behavior and exposure to risk of sexually transmitted diseases Fam Plann Perspect 1992;24:244-54. Kreiss JK, Willerford DM, Hensel M, Emonyi W, Plummer F, Nkinya-Achola J, et al. Association between cervical inflammation and cervical shedding of human immunodeficiency virus DNA. J Infect Dis 1994;170:1597-601. Laga M, Alary M, Nzila N, Manoka AT, Tuliza M, Behets F, et al. Condom promotion, sexually transmitted diseases treatment, and declining incidence of HIV-1 infection in female Zairian sex workers. Lancet 1994;344:246-8. Laga M, Manoka A, Kivuvu M, Malele B, Tuliza M, Nzila N, et al. Nonulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS 1993;7:95-102. Landry DJ, Forrest JD. Public health departments providing STD services. Fam Plann Perspect 1996;28, in press. Laumann EO, Gagnon JH, Michael RT, Michaels S. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: University of Chicago Press, 1994. Laumann EO, Michael RT, Gagnon JH. A political history of the National Sex Survey of Adults. Fam Plann Perspect 1994;26:34-8. Lear D. Sexual communication in the age of AIDS; the construction of risk and trust among young adults. Soc Sci Med 1995; 41:1311-23. Leavy Small M, Smith Majer L, Allensworth DD, Farquhar BD, Kann L, Pateman BC. School health services. J Sch Health 1995;65:319-26. Lebow MA. Contraceptive advertising in the United States. Women's Health Issues 1994;4:196-208. Lewis CE, Freeman HE. The sexual history-taking and counseling practices of primary care physicians. West J Med 1987;147:165-7. Lewis CE, Freeman HE, Corey CR. AIDS-related competence of California's primary care physicians. Am J Public Health 1987;77:795-9. Lichter SR, Lichter LS, Rothman S. Prime time. How TV Portrays American Culture. Washington, D.C.: Regnery Publishing, Inc., 1994. Lowry DT, Schidler JA. Prime time TV portrayals of sex, “safe sex” and AIDS: a longitudinal analysis. Journalism Q 1993;70:628-37. Lowry R, Holtzman D, Truman BI, Kann L, Collins JL, Kolbe LJ. Substance use and HIV-related sexual behaviors among US high school students: are they related? Am J Public Health 1994;84:1116-20. MacKay HT, Toomey KE, Schmid GP. Survey of clinical training in STD and HIV/AIDS in the United States Proceedings of the IDSA Annual Meeting, September 16-18, 1995, San Francisco [abstract no. 281]. Mahon N. New York inmates' HIV risk behaviors: the implications for prevention policy and programs Am J Public Health 1996;86:1211-5. Main DM, Main EK. Preterm birth. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: Normal and Problem Pregnancies. 2nd ed. New York: Churchill Livingstone, Inc., 1991:829-80. Marchbanks PA, Annegers, JF, Coulam CB, Strathy JH, Kurland LT. Risk factors for ectopic pregnancy. A population-based study. JAMA 1988;259:1823-7. Marx R, Aral SO, Rolfs RT, Sterk CE, Kahn JG. Crack, sex, and STD. Sex Transm Dis 1991;18:92-101. Mays VM, Cochran SD. Issues in the perception of AIDS risk and risk reduction activities by black and Hispanic/Latina women. Am Psychol 1988;43:949-57. Merrill JM, Laux LF, Thornby JI. Why doctors have difficulty with sex histories. Southern Med J 1990;83:613-17. Miller BC, Monson BH, Norton MC. The effects of forced sexual intercourse on white female adolescents Child Abuse Negl 1995;19:1289-301.

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The Hidden Epidemic: SUMMARY Moss GB, Overbaugh J, Welch M, Reilly M, Bwayo J, Plummer FA, et al. Human immunodeficiency virus DNA in urethral secretions in men: association with gonococcal urethritis and CD4 depletion. J Infect Dis 1995;172:1469-74. Mostad S, Welch M, Chohan B, Reilly M, Overbaugh J, Mandaliya K, et al. Cervical and vaginal HIV-1 DNA shedding in female STD clinic attenders Eleventh International Conference on AIDS, July 7-12, 1996, Vancouver [abstract no. WeC 333]. NARAL (National Abortion Rights Action League) Foundation. Sexuality education in America: a state-by-state review, 1995. [Rev. ed.] Washington, D.C., September 1995. NCHS (National Center for Health Statistics). Advanced report of final mortality statistics, 1992. Hyattsville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, 1994. Monthly vital statistics report 43;(6 Suppl). NCQA (National Committee for Quality Assurance), Committee on Performance Measurement. HEDIS 3.0 Draft for public comment. Washington, D.C.: National Committee for Quality Assurance, July 1996. Nelson KE, Celentano DD, Eiumtrakol S, Hoover DR, Beyrer C, Suprasert S, et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. New Engl J Med 1996;335:297-303. NIH (National Institutes of Health). Consensus Development Conference statement on cervical cancer. Bethesda, MD: National Institutes of Health, April 1-3, 1996a. NIH. The Jordan report: accelerated development of vaccines 1996. Bethesda, MD: National Institutes of Health, National Institute of Allergy and Infectious Diseases, Division of Microbiology and Infectious Diseases 1996b. Norris AE, Ford K. Associations between condom experiences and beliefs, intentions, and use in a sample of urban, low-income, African-American and Hispanic youth. AIDS Educ Prev 1994;6:27-39. Nyange P, Martin H, Mandaliya K, Jackson D, Ndinya-Achola JO, Ngugi E, et al. Cofactors for heterosexual transmission of HIV to prostitutes in Mombasa Kenya. Ninth International Conference on AIDS and STD in Africa, December 10-14, 1994; Kampala, Uganda. Oakley A, Fullerton D, Holland J. Behavioural interventions for HIV/AID prevention. AIDS 1995;9:479-86. Oakley A, Fullerton D, Holland J, Arnold S, France-Dawson M, Kelley P, et al. Sexual health education interventions for young people: a methodological review. Br Med J 1995;310:158-62. O'Leary A, Jemmott LS. Future directions. In: O'Leary A, Jemmott, LS, eds. Women at Risk: Issues in the Primary Prevention of AIDS. New York: Plenum Press, 1995:257-9. O'Reilly KR, Higgins DL. AIDS Community Demonstration Projects for HIV prevention among hard-to-reach groups. Public Health Rep 1991; 106:714-20. O'Reilly KR, Piot P. International perspectives on individual and community approaches to the prevention of sexually transmitted disease and human immunodeficiency virus infection. J Infect Dis 1996;174(Suppl 2):S214-S222. Over M, Piot P. HIV infection and sexually transmitted disease. In: Jamison DT, Mosley WH, Measham AR, Bobadilla JL, eds. Disease Control Priorities in Developing Countries. New York: Oxford University Press, 1993:455-527. Oxman GL, Doyle L. A comparison of the case-finding effectiveness and average costs of screening and partner notification. Sex Transm Dis 1996;23:51-7. Petersen LR, White CR. Premarital screening for antibodies to human immunodeficiency virus type 1 in the United States. The Premarital Screening Study Group Am J Public Health 1990;80:1087-90. Peterson LS. Contraceptive use in the United States: 1982–90. Advance Data, No. 260. Hyattsville, MD: National Center for Health Statistics, February 14, 1995.

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The Hidden Epidemic: SUMMARY Piot P, Islam MQ. Sexually transmitted diseases in the 1990s. Global epidemiology and challenges for control. Sex Transm Dis 1994;21(2 Suppl):S7-S13. Pleck JH, Sonenstein FL, Ku L. Changes in adolescent males' use of and attitudes toward condoms, 1988–1991. Fam Plann Perspect 1993;25:106-10, 17. Plichta SB, Abraham C. Violence and gynecological health in women < 50 years old. Am J Obstet Gynecol 1996;174:903-7. Plummer FA, Ngugi EN. Prostitutes and their clients in the epidemiology and control of sexually transmitted diseases. In: Holmes KK, March P-A, Sparling, PF, Wiesner PJ, Cates W Jr, Lemon SM, et al., eds. Sexually Transmitted Diseases. 2nd ed. New York: McGraw-Hill, Inc., 1990:71-6. Plummer FA, Simonsen JN, Cameron DW, Ndinya-Achola JO, Kreiss JK, Gakinya MN, et al. Co-factors in male-female transmission of human immunodeficiency virus type 1. J Infect Dis 1991;163:233-9. Poorman S, Albrecht L. Human sexuality and the nursing process. Norwalk, CT: Appleton & Lange Publishing Co., 1987. Quinn TC, Cates W Jr. Epidemiology of sexually transmitted diseases in the 1990s. Adv Host Defen Mech 1992; 8:1-37. Ramos R, Shain, RN, Johnson L. “Men I mess with don't have anything to do with AIDS”: Using ethno-theory to understand sexual risk perception. Sociol Q 1995;36:483-504. Randolph AG, Washington AE. Screening for Chlamydia trachomatis in adolescent males: A cost-based decision analysis. Am J Public Health 1990;80:545-50. Risen CB. A guide to taking a sexual history. Clinical Sexuality 1995;18:39-53. Robinson NJ, Mulder DW, Auvert B, Hayes RJ. Modeling the impact of alternative HIV intervention strategies in rural Uganda. AIDS 1995; 9:1263-70. Rolfs RT, Galaid EI, Zaidi AA. Pelvic inflammatory disease: trends in hospitalizations and office visits, 1979 through 1988. Am J Obstet Gynecol 1992;166:983-90. The Roper Organization. AIDS: public attitudes and education needs. 1991. New York. Roper WL, Peterson HB, Curran JW. Commentary: condoms and HIV/STD prevention—clarifying the message. Am J Public Health 1993;83:501-3. Rosenberg MJ, Gollub EL. Commentary: methods women can use that may prevent sexually transmitted diseases, including HIV. Am J Public Health 1992;82:1473-8. Rosenblum L, Darrow W, Witte J, Cohen J, French J, Gill PS, et al. Sexual practices in the transmission of hepatitis B virus and prevalence of hepatitis delta virus infection in female prostitutes in the United States. JAMA 1992;267:2477-81. Roter DL, Knowles N, Somerfield M, Baldwin J. Routine communication in sexually transmitted disease clinics: an observational study. Am J Public Health 1990;80:605-6. Rothenberg R, Narramore J. The relevance of social network concepts to sexually-transmitted disease-control. Sex Transm Dis 1996;23:24-9. Rothenberg RB, Potterat JJ. Strategies for management of sex partners. In: Holmes KK, Mårdh P-A, Sparling PF, Wiesner PJ, Cates W Jr, Lemon SM, et al., eds. Sexually Transmitted Diseases. 2nd ed. New York: McGraw-Hill, Inc., 1990:1081-6. Rothenberg RB, Potterat JJ. Partner notification for STD/HIV. In: Holmes KK, Sparling PF, Mårdh P-A, Lemon SM, Stamm WE, Piot P, et al., eds. Sexually Transmitted Diseases. 3rd ed. 1997. New York: McGraw-Hill, Inc., in press. Santelli JS, Kouzis AC, Hoover DR, Polacsek M, Burwell LG, Celentano DD. Stage of behavior change for condom use: the influence of partner type, relationship and pregnancy factors. Fam Plann Perspect 1996;28:101-7. Schiffman MH. Recent progress in defining the epidemiology of human papillomavirus infection and cervical neoplasia. J Natl Cancer Inst 1992;84:394-8.

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The Hidden Epidemic: SUMMARY Trotter RT 2d, Rothenberg RB, Coyle S. Drug abuse and HIV prevention research: expanding paradigms and network contributions to risk reduction. Connections 1995;18:29-45. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Washington, D.C.: U.S. Department of Health and Human Services, 1996. Washington AE, Katz P. Cost of and payment source for pelvic inflammatory disease. Trends and projections, 1983 through 2000 [see comments]. JAMA 1991;266:2565-9. Washington AE, Cates W Jr, Wasserheit JN. Preventing pelvic inflammatory disease [see comments]. JAMA 1991;266:2574-80. Washington AE, Johnson RE, Sanders LL. Chlamydia trachomatis infections in the United States: what are they costing us? JAMA 1987;257:2070-2. Wasserfallen F, Stutz ST, Summermater D, Hausermann M, Duboi-Arber F. Six years of promotion of condom use in the framework of the National Stop AIDS Campaign: experiences and results in Switzerland. Ninth International Conference on AIDS, June 6-11, 1993, Berlin [abstract no. WS-D27-3]. Wasserheit JN. Effect of changes in human ecology and behavior on patterns of sexually transmitted diseases, including human immunodeficiency virus infection Proc Natl Acad Sci 1994;91:2430-5. Wasserheit JN, Holmes KK. Reproductive tract infections: challenges for international health policy, programs, and research. In: Germain A, Holmes KK, Piot P, Wasserheit JN, eds. Reproductive Tract Infections: Global Impact and Priorities for Women 's Health. New York: Plenum Press, 1992. Webber MP, Lambert G, Bateman DA, Hauser WA. Maternal risk factors for congenital syphilis: a case-control study Am J Epidemiol 1993;137:415-22. Weller SC. A meta-analysis of condom effectiveness in reducing sexually transmitted HIV. Soc Sci Med 1993;36:1635-44. WHO (World Health Organization, Global Programme on AIDS). Global prevalence and incidence of selected curable sexually transmitted diseases: overview and estimates. Geneva: WHO, 1996. Wolk LI, Rosenbaum R. The benefits of school-based condom availability—cross-sectional analysis of a comprehensive high school-based program J Adolesc Health 1995;17:184-8. World Bank. World development report, 1993: investing in health. New York: Oxford University Press, 1993. WREI (Women's Research and Education Institute). Women's health care costs and experiences. Washington, D.C.: Women's Research and Education Institute, 1994. Wulfert E, Wan CK. Condom use: a self-efficacy model. Health Psychol 1993;12:346-53. Zenilman JM. Gonococcal susceptibility to antimicrobials in Baltimore, 1988–1994. What was the impact of ciprofloxcin as first-line therapy for gonorrhea? Sex Transm Dis 1996;23:213-8.