• Scabies Note: these first 4

Reasons for Concern for

Making the Case for Abstinence Sexual Health of our
Youth
• Molluscum
Contagiosum
are skin-to-skin,
not always STI’s

The Medical Perspective • Bacterial Vaginosis

• Lice
but transmit easily
with sexual
• Herpes I activity
Kim K. Dernovsek, M.D. • Non-GC Urethritis
• Lymphogranuloma
Associate Clinical Professor • Chlamydia Venereum
University of Colorado Health Sciences Center • Trichomoniasis • Granuloma
• Gonorrhea Inguinale
Board Certified Internal Medicine and Dermatology
Private Practice: Dermatology • Pregnancy • Chancroid
Dermatologic
• Hepatitis A • Syphilis
contact information: • Hepatitis B • HIV/AIDS
1600 N. Grand Ave. #140, Pueblo, CO, 81003 USA • Hepatitis C • Emotional effects
Phone: 719-564-4500 FAX 719-564-0304
Email: kdernovsek@uceglobal.org
• HPV
• Herpes II

STI or STD?
Infection: Invasion by
and multiplication of
bacteria or
microorganisms that
can produce tissue
injury. Many
infections can be
treated and cured and
the tissue returned to
normal; other
infections result in
disease.
STInfections STDiseases
• Bacterial Vaginosis • Chlamydia (1.5 million//2.8 million)
• Non-GC Urethritis • Gonorrhea (431.000/718,000)
Disease: Pathologic
• Trichomoniasis • LymphogranulomaVenereum
condition,
(1.9 million//7.4 million) • Granuloma Inguinale
impairment,
• Molluscum Contagiosum • Chancroid
abnormal function,
i.e. anatomic or • Hepatitis A
physiologic change, STInfestations • Hepatitis B (7,500//78,000)
protracted or Scabies • Hepatitis C (NA//25.000)
prolonged, Lice • Syphilis (8,200//70,000)
sometimes • HIV (15,000//40,000)
permanent. Many Estimated Incidence 2000 • HPV (4.6 million//6.2 million)
processes can cause 15-24 y//overall • Herpes I genital
9.1 million//18.9 million
disease, including Weinstock et al. Perspectives on Sexual
• Herpes II genital (640,000//1.6 million)
some infections. and Reproductive Heatlh 2004:36(1)

Teens and SEX Genital Warts (HPV)

• 65 Million Americans living with an • 1.5-13 % Sexually active adults have ever had
incurable STD PREVELANCE • HPV types 6 or 11
– CDC, “Tracking the Hidden Epidemics 2000” – 16, 18, 31, 33 and 35 are found occasionally

• 19 Million new cases in US yearly Subclinical Genital HPV Infection

INCIDENCE
Up to 1/2 in ages 15-24 years old
– Weinstock H, et al. Perspectives on Sexual and Reproductive
Health 2004;36[1]:6-10.
• $14.6 Billion annually in the USA
– Chesson HW et al. 2004 National STD Prevention Conference,
Philadelphia, PA, March 8-11, 2004. Abstract PO75
•
• Peak prevalence in women < 25 years old:
28-46%
• Reactivation or Reinfection possible
• 5.5 Million new infections annually
• 20 Million currently infected
Tracking the Hidden Epidemics 2000,
cdc.gov/nchstp

1
 HPV Infection… Primary Prevention
Reduce Duration of Infectivity: Treatment? Cervicovaginal HPV Infection in
Genital Warts (HPV) College Women: Natural History
• Primary goal: removal of warts Ho 1998 Winer 2003
• Treatment possibly reduces, but does not eradicate # Enrolled in study 608 444
HPV infectivity
• Whether reduction of HPV DNA in genital tissue
impacts future transmission remains unclear
Already infected at entry 26% 19.7%
Subclinical Genital HPV (SIL absent)
• No treatment that eradicates infection Others infected during study 43% 38.8%
• Genital HPV “frequently goes away on its own” (over 3 yrs) (over 2 yrs)
• Tx not recommended
Ho,G.Y.F., et al: NEJM 1998;338:423-8 Winer,R.L.,et al: Am J Epidemiol
CDC STD Treatment Guidelines 2003;157(3):218-226
2006

CDC Study of HPV Prevalence

Cervicovaginal HPV Infection in
Young Women: Natural History in Women
JAMA 2007 297:813-819
Erratum JAMA 2007;298(2):178
9% remain infected at 2 years (Ho 1998)

10% remain infected at at 5 years
Risk of developing Squamous Intraepithelial
Lesion (SIL) is associated with persistent
infection with a high risk type for at least 6
months
. JAMA editorial on mandatory vaccine: “unwise”
Wright TC, NEJM 2003;348:489-490,518-527
Ho,G.Y.F., et al: NEJM 1998:
338:423-8
(NEJM 2003) – 2003-2004: women age 14-59
– Self-collected vaginal swab for HPV DNA PCR
Overall HPV prevalence 26.8%
HPV vaccine types 6/11/16/18 detected in 3.4%
carcinogenic types 16/18 prevalence of 2.3%
Conclusion: HPV common but prevalence of HPV
vaccine types relatively low

Cervical Cancer Susceptibility of Adolescent Cervix

USA: estimated 11,070 cases and 3,870 • Squamous-columnar cell junction transformation
deaths in 2008 Am. Cancer Soc., 3/26/08 zone is more exposed in adolescence
For USA women: HPV-related mortality is • Adult cervix less susceptible to HPV
at least twice that of HIV – Kahn JA, Hillard PA. Human papillomavirus and cervical cytology in
adolescents. Adolesc Med Clin 2004; 15:301-321.

2nd most costly $ STD (after HIV)

• Adolescent cervix has ectropion (exposed
CDC, Dec 1999 columnar epithelium; for which chlamydia and
95% Cervical CA associated with HPV (8 gonorrhea have predilection)
types) • With age and after pregnancies, this ectropion
Munoz N, et al., NEJM 2003;348:518-527 converts to squamous epithelium
– Neinstein LS: Adolescent Health Care: A Practical Guide, 4 th edition, 2002,
Philadelphia , Lippincott Williams and Wilkins

2
 Prevention of Cervical Cancer
How important is the Pap test? HPV in men/boys
Of those diagnosed with cervical cancer… • Most develop no symptoms or problems
half have been non-adherent to screening: • 1% sexually active men have had genital warts
28.5% had never had a Pap test • HPV vaccine not licensed for men
32.8% no Pap x 5 or more yrs • Penile cancer rare (1250 in 2008) American Cancer Society 7/11/08
Am J Public Health. 1995 Jun;85(6):791-4
• Anal cancer rare (2020 men, 3050 women in 2008)
46% had never had a Pap test or no Pap x 3 yrs
CMAJ. 1997 Sep 1;157(5):513-9
-American Cancer Society 4/25/07
53% no Pap x 3 yrs – However, 17 X more common in MSM
Cancer. 2000 May 15;88(10):2283-9 – ?Anal PAP tests
56% no Pap x 3 yrs » HPV and Men CDC Fact Sheet 4/3/08
Natl Cancer Inst. 2005 May 4;97(9):675-83

CDC Report to Congress January 2004

Risk Factors for HPV Infection
Prevention of Genital HPV Infection
• Early sexual debut • Presence of transformation 1) refrain from any genital contact with another
• Multiple partners zone (ie, Adolescence)
• Chronic inflammation
2) long term mutual monogamy
• Partners with multiple 3) reduce # partners and careful partner selection
from co-infection with
partners other STDs ie Herpes,
• Association of sex and Chlamydia 4) Available scientific evidence is not
alcohol • Cigarette Smoking sufficient to recommend condoms as a
• Cigarette Smoking • BCP (linked to cervical primary prevention strategy
• Anal intercourse cancer)
Ho et al. NEJM • Multiparity …2006
1998,338:423-8 Castle PE. J Low Genit Tract
Dis 2004 Jul;8(3):224-230.
HPV vaccine
http://www.cdc.gov/std/HPV/2004HP
V%20Report.pdf

HPV Vaccine 6/8/06 FDA licensed

HPV Vaccine
Vaccine Information Statement, HPV Vaccine, CDCP (6/30/08)
Target HPV 16 and 18 which cause up to 70% of CIN 3 injections (0-2-6 months) $360
II/III and anogenital CA Not if pregnant /yeast allergic/during acute illness
Vaccine also targets HPV 6 and 11 which cause up to Recommended: Routine/catch-up for 11-26 year old females ).
Females who already have been infected with one or more HPV types would still get
90% genital warts protection from the vaccine types they have not acquired. Currently, there is no test
available for clinical use to determine whether a female has had any or all of the four HPV
Unger ER, Barr E. Human papillomavirus and cervical cancer Emerg Infect Dis 2004 Nov available
www.cdc.gov/ncidod/EID/vol10no11/04-0623_09.htm types targeted by the vaccine.

Overview : Cervical testing (“PAP”) will still be necessary:

Made from non-infectious HPV-like particles
30% HPV types that cause cancer will NOT be
Safe and no serious side-effects (4/5 injection site pain)
100% efficacy against HPV 16,18,6 and 11
prevented
Duration at least five years (no waning immunity) from current Will NOT prevent 10% of genital warts
studies
Vaccine Information Statement, HPV Vaccine, and Q and A Sheet, CDCP (1/12/07)

3
 Mandatory HPV Vaccine Mandatory HPV Vaccine
Public Health vs Private Wealth: 2007 JAMA EDITORIAL Public Health vs Private Wealth: 2007 JAMA EDITORIAL
Gostin LO, DeAngelis CD, JAMA. 2007;297:1921-1923. Gostin LO, DeAngelis CD, JAMA. 2007;297:1921-1923.

1) Given that the overall prevalence of HPV types 3) Compensating injured vaccine recipients: if
associated with cervical cancer is relatively low state-mandated, courts may hold that
(3.4%)* REVISED 2.3%** and that the long- manufacturer has no (or reduced)
term effects are unknown, it is unwise to responsibility
require a young girl with a very low lifetime 4) Not highly infectious airborne disease, ie Not
risk of cervical cancer to be vaccinated without in compulsory vaccination paradigm
her assent and her parent's consent. *Dunne et al. 5) Submit girls to vaccine as a condition of
Prevalence of HPV infection among females in the United States. JAMA. 2007;297:813-
819 **Erratum JAMA 2007;298(2):178 publicly funded education, but not boys?
2) Generous religious and conscientious 6) Who will pay for the mandated HPV vaccine at
exemptions may cause legislators to extend the loss to society of what else?
these to other childhood vaccinations, which
7) Key to success of public health policies is
would be detrimental to the public's health.
Salmon DA, et al. Compulsory vaccination and conscientious or philosophical community acceptability
exemptions: past, present, and future. Lancet. 2006;367:436-442

HPV Vaccine Genital HSV Infection

Vaccine Information Statement, HPV Vaccine, CDCP (6/30/08)
Summary
“Vaccine providers should notify vaccinated
women that they should continue to • Genital herpes is a recurrent, life-long viral
practice abstinence or protective sexual infection -CDC MMWR 2002: 51( RR-6)
behaviors (I.e., condom use) since the vaccine will
not protect against other STIs. Although condoms
• 45 million Americans are infected with HSV-2
may not fully protect against HPV, they may lower and 90% do not know it -NEJM 1997; 337:1105-1111
one’s chances of getting HPV and developing • HSV can be detected in genital secretions of most
HPV-related diseases, when used all the time and seropositive HSV-2 patients with no history of
the right way. Women can also lower their genital herpes -NEJM 2000; 342:844-50
chances of getting HPV by being in a mutually
faithful relationship with someone who has had • HSV infection is a potent facilitator of sexual
no or few sex partners, or by limiting their transmission of HIV -JAMA 2000; 283: 791-794
number of sex partners”

Seroprevalence of HSV-2
National Health and Nutrition Examinations Survey
(NHANES) Key large ongoing USA population-based study
• HSV-2 Seroprevalence rose 30% from 1976-1994
– NEJM 1997;337:1105-1111
• 1988-1994: 21% of US population age 12 and older (45
million people) positive for HSV-2
• 1999-2004: 17% (indicates reversal of trend)
• Prevalence rates higher if
– initiated intercourse age < 17 yrs (21.1%)
vs > 18 yrs (14.3%)
– greater number of lifetime partners: 3.8% w/1
vs 39.9% w/>50)
How is Genital Herpes Spread?
• HSV-1 and HSV-2 are transmitted through direct
contact: kissing, sexual contact (vaginal, oral, or
anal sex), or skin-to-skin contact
– Transmitted with or without the presence of
sores or other symptoms JAMA 2000;283:791-794
• Up to 30 percent of first episode genital herpes is
now HSV-1 in type CDC, STD Treatment Guidelines 2002 MMWR
2002:51[RR-1]
– Oral sex is most likely the source, from
shedding in the mouth Tyring, Dialogues in Dermatology
1998

-JAMA 2006;296:964-973

4
 Increasing Proportion HSV I
Genital Infection
• U of WI 1993-2001 reviewed genital
isolates
• HSV I increased from 31% in 1993 to 78%
in 2001
• HSV I had become the most common cause
of new genital herpes on campus
» Sex Transm Ds 2003;30:797-800
Sexual Lifestyle Choices
S. Genius, 1995 (Adaptation)
Sexually Transmitted Diseases
Treatment Guidelines 2006
• The most reliable way to avoid transmission
of STDs is to abstain from sexual
intercourse (i.e., oral, vaginal, or anal
sex)
• or to be in a long-term, mutually
monogamous relationship with an
uninfected partner.
MMWR 2006;55[No.RR-11]3
What is Sex?
Dorland’s Medical Dictionary 1965
Intercourse: mutual exchange, sexual i., coitus
Coitus: sexual union between individuals of opposite sex
Webster's 1984
Intercourse: 1) exchange between persons… 2) sexual
intercourse syn coitus
Coitus: : Physical union of male and female sexual organs
leading to orgasm and ejaculation of semen
Male sex organ = Penis Female sex organ = Vagina
(simulations include mouth, anus, other)
Dernovsek 2001
Sexual Intercourse: Stimulation of a partner to orgasm via
vaginal, oral, anal, non-genital ie “mutual masturbation”
Dernovsek KK Pract Derm Dec 2004
2004 Survey of 2,958 Clinicians
re: their Adolescent Patients
CONDOMS
96%-97% state not 100% effective and cannot prevent
skin-to-skin transmission in areas not covered
77% believe patients will not use consistently
…90% usually/always recommend condoms
ABSTINENCE
91% abstinence highly effective
94% believe patients will not abstain
…54% recommend it
MMWR 10-2--06,55(41);1117-1120
Sexually Transmitted Diseases
Treatment Guidelines 2006
• Counseling that encourages abstinence
from sexual intercourse is crucial
– for persons who are being treated for an STD
– or whose partners are undergoing treatment
– and for persons who wish to avoid the possible
consequences of sexual intercourse (e.g.,
STD/HIV and unintended pregnancy).
MMWR 2006:55[No.RR-11]3
5
 Introduce Topic with Abstinence Brochure
Lifestyle Abstinence
• I have this brochure for you ...
• What? • When?
• Have you ever heard of abstinence?
– Lifestyle choice – Now
• This has nothing to do with your moles, but…
– Restraint from all – Never too late • this is important for your future health...
forms of sexual • Why? • I don’t want to have to treat you for this in the future...
intercourse – Prevention of skin- • Dermatologists also have to treat STD’s...
• How long? to-skin disease • Did you know that 1 in 5 sexually active people….
– Until selection of transmission • Now is the time in your life to be thinking about
lifelong partner – Maintain health where you will stand on this subject
Dernovsek KK. School Hlth Rptr
Spring 2003

Follow leads Accordingly...

• Support wisdom of decision if already abstinent
Condom Terminology
• Encourage supporting peers in same choice
• Perfect Use of condom • Typical Use of Condom
– pass the brochure on to a friend, sibling
• 100% of time • “some”, “most”, or
– leave the brochure in the school restroom • Correctly “all” of time
• If teen was clearly choosing to continue being • both correct and
incorrect use
sexual active (pregnancy, BCP, attestation) • Efficacy
• Effectiveness
– Modify to a condom recommendation with a secondary – Improvement achieved
statement that abstinence was truly the ideal ie in a desired health – Amount of
“informed condom recommendation” outcome in a research improvement in the
setting in expert hands health outcome in the
• Consideration of renewed virginity real world with typical
under ideal conditions
– never too late to change implementation
– preservation of current good health

Factors Influencing Condom

Can Condoms Fail?
• LABORATORY
– intact condoms
prevent STDs
• MMWR,’93;42(30)589-
91,STD’89;16(2):51-55
– minute leakage of
viral size particles but
infection highly
unlikely
• STD’97;24(3):161-4,
• STD ‘99;26(4):216-20
• REAL LIFE • Method Failure
– often fail to protect
• FamPlanPersp’92;24(2)75
-84,GUMed’94;70:410-
17,CanFamPhys’93;39:81
9-27
Failure in Real Life
– breakage during intercourse or withdrawal
– slippage during intercourse, partial or complete
– manufacturing defects (rare)
– FamPlanningPersp’94;26(3):107-12, STD’99;26(8):450-458,
Contraception’92;45(1):11-19

6
 “Always” use / “Consistent” use
Factors Influencing Condom
AND
Failure in Real Life
Correctly every time?
• User Failure (Incorrect Use)
• College males: “Consistent Users”
– Genital contact before putting condom on – 1 in 10 episodes of condom use exposed individual to
– Flipping condom over after initial application risk of disease via method or user failure
– Fingernail holes poked in condom – Leaving 33% at risk in prior month
• >>STD’98;25(6):273-277
– Use of oil based lubricants
– Improper positioning of condom
• HIV serodiscordant heterosexual couples
– Not holding on to condom during withdrawal – 171 ALWAYS used condoms
– 3 seroconversions occurred over 24 months
– Not withdrawing while penis erect
(1.1% incidence rate) JlAcqImmDefSyn’93;6(5)497-502
MMWR, 1993; 42(30):589-91

REAL LIFE: What is typical use Factors Influencing Condom

of a condom? Failure in Real Life
• Approximately 20% always use a condom • Degree of infectivity of the particular STD
(15-44 yo unmarried female condom users) • Prevalence of the STD in the community
FamPlanningPersp’96;28(1):25-39,AmJPubHlth’95;85(11):1526-30
• Number of acts of intercourse
• Of Herpes discordant couples, 23% always • Prior Experience with condoms
used a condom • Age and sex of the individual
» Wald A, et al, JAMA, 2001;285:3100-3106
• Natural immunity of the individual
• Of HIV serodiscordant couples, 48.4% • Presence of other STDs
always used a condom • Inadequacy of coverage of all the infected skin
>>NEJM’94;331:341-6

The Condom Report: July 2001 The Condom Report: July 2001
138 papers reviewed by panel of 28 Experts 138 papers reviewed by panel of 28 Experts
Strong evidence for the effectiveness of condoms for
• HPV
reducing sexually transmitted…gonorrhea for men
– …no epidemiologic evidence that HIV/AIDS: Consistent condom use decreased
condom use reduced the risk … the risk of HIV/AIDS transmission by
– might afford some protection… approximately 85% Scientific Evidence on Condom Effectiveness for Sexually
Transmitted Disease (STD) Prevention, summary report prepared by NIAID,NIH,DHHS,July
Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention,
summary report prepared by NIAID,NIH,DHHS,July 20, 2001 20,2001

Sexually Transmitted Diseases Treatment Guidelines 2006

70% reduction in HPV infection “HIV-negative partners in heterosexual serodiscordant relationships in
which condoms were consistently used were
80% less likely to
in newly sexually active college women when
partners used condoms CONSISTENTLY and CORRECTLY become HIV-infected compared with persons in similar
-Winer et al, NEJM 2006;354:2645-54 relationships in which condoms were not used” MMWR 2006;55[NoRR-11]4

7
 Risk Compensation
Definition: Perception of reduced risk paradoxically
increasing the risky behavior, resulting in actual
increased risk
Examples:
Condom use by Ugandan men offset by # sex
partners (Kajubi et al J Acq Immune Defic Syndr 2005 Sep 1;40(1):77-82)
HIV prevalence (1990-2001) as condom sales
Cameroon, Kenya, Botswana
1989-2000, South Africa, Kenya and Botswana had
highest rates of condom availability and highest
HIV prevalence (20%-36%)
Who’s Teaching Our Kids?
“Where Do People Go for
Treatment of STDs?”
• 49% had gone to a Private Practice
• 5% had gone to an STD clinic
• greater likelihood to have gone to STD clinic if
bacterial (non-chlamydial), male, young, poor, black
– National Health and Social Life Survey
• 3432 people interviewed ages 18-59
Family Health Perspectives Vol
31,#1, Jan/Feb 99, p10-15
Hearst, Chen, Evidence that Demands Action Medical Institute
Green EC, Evidence that Demands Action Medical Institute
“Sexual Media Diet”
12-14 yo white teens
2.2x more likely to
Have had sex by 14-16
-Brown et al Pediatrics 117:4 April 2006
“Degrading Sexual Lyrics”
Related to advances in a
range of sexual activities
-Martino et al Pediatrics 118:2 August 2006
YAZ Package Insert “PI” says…
…YAZ is indicated for the treatment of
moderate acne vulgaris in women at least
14 years of age, who have no known
contraindications to oral contraceptive
therapy and have achieved menarche. YAZ
should be used for the treatment of acne
only if the patient desires an oral January 29,2007
contraceptive for birth control…
berlex.bayerhealthcare.com/html/products/pi/fhc/YAZ_PI.pdf Accessed
7/21/08
Who Should Counsel?
Faith-based?
Strong religious views decrease teens’ likelihood of having sex Social
Forces, 3-03, NICHHD/NIH
Parents? Peers?
– Black teens more influenced by their perception of
parents’ expectations and friends’sexual behavior than
what they see/hear in media Brown et al Pediatrics 117:4 April 2006
– Parental disapproval of adolescent sex and
contraception: protective for early sexual debut National
Longitudinal Study of Adolescent Health
What role Media? Schools? Doctors/Nurses?
Does Physician Advice Matter?
YES
• Patients who received physician advice on
diet and exercise were significantly more
likely to engage in risk reduction activities
– Behavioral Risk Factor Surveillance System
data analysis (MMWR 1999;48:74-77)
• Seven states and Pueto Rico
8
 Is Abstinence Realistic?
Effecting Positive Behavior
Who Has Never Had Sexual Intercourse?
Change: Successes • 75% of 7-12th graders Kaiser Family Foundation Rpt, 9-26-00
• Alcohol Related Automobile Deaths • 70% of teens ages 15-17 Kaiser Family Foundation, May 2001
• 66% of 9th graders MMWR 9-27-2002 /51(38);856-859
• Child Bicycle Helmets • 64% of teens ages 15-17 KFF/Seventeen:Relationships, 10-2002
• Seat Belts • 10.5% more 11 th Grade Boys in 2001 than in 1991
• MMWR 9-27-2002 /51(38);856-859

• Tobacco Awareness and Cessation
• 911/CPR /Awareness of Early Sx and Signs
• Decreased Use of Inappropriate Antibiotics
• 67% of teens ages 15-17 KFF/Seventeen:Virginity and the First Time 10-2003
• 63% of teens ages 15-17 KFF/National Survey of Adolescents and Young
Adults:Sexual Health Knowledge, Attitudes and Experiences 2003
• 67% of teens ages 15-17 KFF/National Survey of Teens about Sex: Birth Control and
Protection 7-2004

• Increased Skin Cancer Awareness • 52% of teens ages 15-19 (MMWR 6/6/08)

EVER Had Sexual Intercourse

Youth Risk Behavior Survey
MMWR 9-27-02 / 51(38);856-859
MMWR 6-9-06 /55(No.SS-05);78
MMWR 6-6-08)
60
Sexual Intercourse:Significant Trends
Youth Risk Behavior Survey: 9th through 12th graders
MMWR 6-6-08
70

55 60 61.5
54.1
50
% 15-19 yo

50 46.2 47.8
Ever had sex 40
45 Sex w/4 or more
%

Used condom 30
40
20 18.7
35 14.9
10
30
2 0
71

78

85

92

99

06

0 1991 2007
19

19

19

19

19

20

0
Females Males All 7

USA in 2007 There are patients who

commit to continuous abstinence
47.8 high schoolers (aged 15-19)
• ISOTRETINOIN Prescribing Requirements:
have “ever” had sex ©ACCUTANE 2 forms of contraception
required (tubal
(YRBS-US 2007 MMWR 6-6-08) • Pregnancy Category X ligation,vasectomy, IUD or
due to severe birth hormonal PLUS a second
means 52.2% have defects
• BLACK BOX
form)
unless pt commits to
continuous abstinence
NEVER had sex warning
• FDA restricted to
from hetereosexual contact
or has had hysterectomy,
i.e. “over half of older teens have registered prescribers bilateral oophorectomy or
only is postmenopausal
never had sex”

9
 With One Voice 2007
Ages 12-19
With One Voice 2007
• 91%: important to have a strong message
• 75% (73%) do not think it is embarrassing from society to abstain from sex until they
to admit they are virgins are at least out of high school ( 93% reported same in
– 73% Males (66%) 78% Females (80%) both The Cautious Generation: What Do the Teens Say? NCTPTP 4-27-00 and With
One Voice 2002, 92% in With One Voice 2003, 94% in With One Voice 2004))
– 75% Ages 12-14 (2002) 81% Ages15-19 (2002)
– • Of teens who had had sex: 60% (66) (67) (63)
• 82% said teens should NOT be sexually active wished they had waited longer
63% (60) (55) boys 69% (77) (70) girls
(2003) (80% in 2002)
71 % (83) (81) ages 12-14 63% (60) (55) ages 15-19
(2003) (2002) (2004) (2003) (2002)

NCTPTP 2-2007 NCTPTP 2-2007

www.teenpregnancy.org www.teenpregnancy.org

…Uganda has experienced

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

Faith-Based Organizations: Contributions to HIV Prevention

Green, E.C.,USAID,September2003

HIV prevalence in adults

in sub-Saharan Africa, 1986-2001 HIV prevalence in adults in sub-Saharan Africa, 2005

1986 1991

20 – 39%
10 – 20%
5 – 10%
1 – 5%
0 – 1% -----------Uganda 6.7% HIV prevalence 2005
trend data unavailable 1996 2001

outside region

10
 UGANDA: “Zero Grazing”
You tether your animal around a tree, and it can
only feed where it is tethered
Dr V. Nantulya, ID consultant to President Museveni

A bstinence

B e Faithful

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

"Young people must be taught the virtues of What Happened in Uganda?

Summary of Presentation to USAID, Washington DC, 2/5/2002
abstinence, self-control and postponement of Hogle, JA,Green,E, Nantulya,V,Stone burner,R,Stover,J

pleasure and sometimes sacrifice” • “The most important determinant of the reduction
in HIV incidence in Uganda appears to be a
and teaching them a different lifestyle decrease in multiple sexual partnerships and
"will ensure their survival" networks”
• “The effect of HIV prevention interventions in
Uganda (particularly partner reduction) during
Ugandan First Lady Janet Museveni the past decade appears to have had a similar
February 20, 2002 impact as a potential medical vaccine of
80% efficacy.”

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

Changing Worldwide HIV Elimination Uganda:

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

www.sciencemag.org
SCIENCE VOL 304 30 APRIL 2004 2003 ISBN 0-86569-316-1

11
 The Ugandan Success is Key to
HIV: A Worldwide Crisis
Combat AIDS Worldwide
The Ugandans showed that sexual behavior patterns • Every eight seconds a person is
could be changed by an entire population with infected with HIV somewhere in the
resultant improved health: world (6800 new infx/day)
-HIV prevalence in Uganda was already irrefutably
decreasing before 1995 (WHO/UNAIDS maps and Hogle,
• 68% of the 33.2 million people with
JA et al. What Happened in Uganda? Washington DC, 2/5/2002) HIV live in Sub-Saharan Africa
» (WHO/UNAIDS 11/07)
- Increase in abstinence and reduction of multiple
partners documented before 1995 (Stoneburner RL, • Young people between 15 and 24
Science, 2004 Apr 30;304:714-7.) account for 40 percent of new
- Condoms did not enter Uganda until 1995 or later infections worldwide
(Green EC et al. AIDS Behav. 2006 Jul;10(4):335-46) » (WHO/UNAIDS 12/06)

Impact of AIDS on life expectancy in five African countries, Perhaps there should be….greater
1970–2010 equity in resource allocation
70 between HIV/AIDS prevention
65
60 Botswana
programs (promoting
Life
55
South Africa
monogamy/fidelity) and
50
expectancy
at birth 45
Swaziland
condom programs?
(years) 40 Green,EC, STI 2000, 76:145
35 Zambia
30
Zimbabwe The Lancet November 27, 2004
25
20 The time has come for common ground on
1970–1975 1980–1985 1990–1995 2000–2005
1975–1980 1985–1990 1995–2000 2005–2010 preventing sexual transmission of HIV
Daniel T Halperin, Markus J Steiner, Michael M Cassell, Edward C Green,
Norman Hearst, Douglas Kirby, Helene D Gayle, Willard Cates
Source: United Nations Population Division (2004). World Population Prospects: The 2004 Revision, database. Followed by one and one-half columns of endorsees
4.1

Intensifying HIV Prevention

UNAIDS Policy Position Paper
????? Kenya
? Zimbabwe
August 2005
Essential Programmatic Essential Policy Actions for Uganda Fidelity
Haiti
? USA =/> AgeSexDebut
Actions for HIV Prevention HIV Prevention Success
#1: Prevent the sexual #2: Build and maintain 6.7%
transmission of HIV leadership from all sections Reduced HIV Prevalence
(included alongside condoms of society including…faith-
? Botswana
Malawi
for the first time are)… based organizations…
The future course of the world’s
• abstinence #4: …those norms, practices Condom Social Marketing HIV epidemics hinges in many
• delay in onset of sexual debut and beliefs that potentially Increasing Web Pornography respects on the behaviors young
• mutual fidelity can support HIV prevention people adopt or maintain, and the
• reduction of the number of
sexual partners
need to be fully harnessed.
? contextual factors that affect
those choices.
2006 AIDS Epidemic Update UNAIDS

12