STD Prevention

Introduction

Sexually transmitted diseases (STDs) are an underrecognized public health concern among sexually active youth and adults in the United States. Among the major STDs, HIV (human immunodeficiency virus) poses the greatest threat to public health, having caused nearly 500,000 deaths in the United States and more than 20 million deaths worldwide since the beginning of the epidemic. Other commonly occurring STDs, when left untreated, can also lead to severe, long-term health problems, including infertility, complications during pregnancy, and several forms of life-threatening cancer. Health psychologists play an important role in STD prevention and treatment efforts by developing interventions to promote sexual behavior change, and by assisting already infected individuals with mental health adaptation, medication adherence, and health behavior change efforts.

Scope Of The Problem

In the United States, STDs constitute a major epidemic, with approximately 15 million people becoming infected with an STD each year. The Centers for Disease Control and Prevention report that chlamydia and gonorrhea are the first and second leading reported infectious illness in the United States, respectively, and together constitute 80% of the notifiable cases reported to the agency. Although the incidence of one STD—syphilis—has declined substantially in recent years, other prominent STDs continue to spread through the population, with little evidence of abatement.

All sexually active people, regardless of gender, race, sexual orientation, and economic status, are affected by STDs. Teenagers and young adults under the age of 25 years are among those who are most vulnerable to STDs, accounting for nearly two-thirds of all identified cases. Young people are at increased risk because they are more likely than older adults to have multiple sexual partners and to engage in unprotected sex. Other people who are at increased risk for contracting an STD include those living in poverty, people who lack access to adequate health care resources, and members of disenfranchised populations (e.g., sex workers, homeless persons, persons with mental illness).

STDs are often referred to as a hidden epidemic, and many people are unaware of their broad impact and serious health con-sequences. At least two factors contribute to the lack of public awareness concerning STDs. First, many people who contract an STD do not experience symptoms, or, in some cases, experience symptoms only after a long lag time following initial infection. Thus, STDs, including HIV, are often transmitted by individuals who are free of symptoms and unaware of their infection. Second, stigmatizing attitudes directed toward those who contract an STD contribute to the hidden nature of the STD epidemic. Because of stigma and shame, many people delay seeking STD testing and medical care, and avoid disclosing their infection to others.

Impact On Health

Among the major STDs, HIV disease clearly poses the greatest health risks. Improved treatments for HIV, which include the use of protease inhibitors and other antiretroviral therapies, have led to a decline in AIDS-related deaths in the United States and other nations with access to modern medicine. However, there is still no cure for HIV, and AIDS-related illnesses continue to claim many lives in the United States. Indeed, AIDS was the fifth-leading cause of death among young adults in the United States in 2000.

Women experience far greater burden in terms of health problems stemming from non-HIV-related STDs. Sexually transmitted human papillomavirus (HPV) is the leading risk factor for the development of cervical cancer. Although preventable through early detection, cervical cancer remains the most common cause of death attributable to sexually transmitted infections other than HIV. Reproductive health difficulties are also a major concern among women who contract an STD. Infections of the upper genital tract in women, referred to as pelvic inflammatory disease (PID), are a common consequence of gonorrhea and chlamydia infections. Women who develop PID are at increased risk for infertility because of damage to the fallopian tubes. PID also increases the likelihood of ectopic pregnancy, a serious and potentially fatal condition in which a fetus develops outside of the uterus. Because STDs can be transmitted to the fetus (through the placenta) and to a developing infant through breast-feeding, STDs that occur during pregnancy can result in a number of complications, including miscarriage, still birth, and premature delivery. STD acquisition in newborns often results in severe health consequences, including damage to the brain, spinal cord, and major organs.

Among men, health-related consequences stemming from STDs include increased risk for cancer of the penis and anus, liver disease, and increased occurrence of epididymitis, a treatable condition involving inflammation around the testicle. Other difficulties, including penile discharge, pain during urination, and testicular swelling and pain, are generally responsive to treatment and do not, in and of themselves, lead to serious medical complications. Although men experience far fewer health-related consequences stemming from STDs, early detection and treatment remains critical because new infections are commonly spread by infected men to their female partners.

Many prevalent STDs also increase a person s susceptibility to HIV. Furthermore, among individuals who are already infected with HIV, STD coinfections can increase the likelihood that HIV is transmitted to sexual partners. Thus, STD treatment and prevention programs not only can minimize health risks stemming from specific STDs, but can also serve to reduce the likelihood of HIV infection. The health impact of STDs could be greatly reduced through STD screening programs, which promote early STD detection and treatment. Most bacterial STDs can be cured through the use of antibiotic treatments. For viral STDs, potent antiretroviral treatments are available that can suppress symptoms and reduce the likelihood that the virus will be spread to other sexual partners. However, STDs typically go undetected, often until serious symptoms emerge.

Prevention Of STDs

STDs are most commonly transmitted to an uninfected partner through vaginal, anal, or oral sex. Some STDs (e.g., HIV and hepatitis) are also transmitted through needle sharing among intravenous drug users. In general, sexual transmission occurs less efficiently through oral sexual contact relative to anal or vaginal sex. Latex condoms, when used correctly, reduce the risks of transmitting most major STDs (including HIV).

Efforts to prevent the spread of STDs include both behavioral and biomedical approaches. Behavioral approaches to STD prevention emphasize efforts to promote adoption of safer sex strategies, including consistent use of condoms during sexual intercourse, avoiding sex with multiple partners (monogamy), or abstinence. Biomedical approaches to STD prevention emphasize the identification and treatment of those who are already infected with an STD. Prompt treatment of both viral and bacterial infections can dramatically reduce or eliminate the possibility of further STD transmission. Biomedical approaches also include vaccination programs, although effective vaccines are only widely available to prevent several forms of hepatitis.

A central challenge for STD prevention efforts is to develop interventions that promote modification of a pleasurable, albeit risky behavior (i.e., sex without a condom). As such, interventions based on psychological theory have proven to be instrumental in efforts to reduce such risky behaviors. For STDs other than HIV, many people are simply unaware of or misinformed about the risks and health consequences. However, even people who are well informed about STDs are often unmotivated to change their sexual behavior. For example, most people are aware of HIV and its severe health consequences, but often underestimate the degree to which they are personally vulnerable to HIV infection. Thus, a major emphasis for STD/HIV prevention programs is to increase awareness of personal vulnerability to STDs, increase the social acceptability of sexual behavior change, and provide training that enhances interpersonal skills needed to initiate condom use with a reluctant partner.

Historically, efforts to promote safer sex have focused on HIV prevention, with relatively little emphasis on prevention of other STDs. However, health psychologists and other specialists are increasingly aware of the importance of combining HIV and STD prevention efforts. Combining HIV and general STD prevention is advantageous both because non-HlV-related STDs cause serious health complications and because prevalent STDs increase a person’s susceptibility to HIV infection.

Project RESPECT, a large-scale study involving men and women recruited through STD clinics, provides an example of an ambitious program to reduce the spread of both HIV and other STDs. Compared with patients receiving standard care, participants who received one of two counseling interventions emphasizing formulation of personalized risk reduction plans reported more condom use at 3- and 6-month follow-up assessments, and fewer new STDs at both 6- and 12-month follow-ups. These findings highlight the potential for using clinic-based interventions as an efficient means of reducing the occurrence of STDs.

Mental Health Adaptation And Adherence

Persons diagnosed with an STD often face formidable challenges and stressors. STD-related stigma, shame, and discrimination often prevent individuals from seeking social support and disclosing their illness to others. Furthermore, an STD diagnosis often puts a strain on existing intimate relationships, raising concerns about partner fidelity and further transmission of the STD. Finally, treatments and medical complications can themselves be a source of considerable distress. Such illness-related coping challenges are most apparent among persons living with HIV disease, where long-term survival is by no means assured, and day-to-day existence involves coping with demanding treatment regimens, recurrent side effects, and worry over possible disease progression. Clinical health psychologists play an important role in the development and implementation of interventions to reduce stress, depression, and other mental health difficulties among persons with an STD. For example, cognitive-behavioral stress management programs have shown promise as an approach to reducing distress and improving health among persons living with HIV.

Medication adherence is an additional challenge faced by many STD patients. Adherence in the context of STD care refers to the act of closely following or sticking to a recommended drug regimen. In the case of HIV disease, patients who report even modest deviations from a regimen often experience more rapid disease progression. For this reason, behavioral scientists are developing intervention approaches designed to improve medication adherence among patients with HIV. Behavioral strategies, including multiple reminders (e.g., daily pill boxes, daily checklists, watch alarms), self-management skills training, and problem solving to facilitate integration of medication regimens into daily activities, are components that are likely to be useful when developing individually tailored adherence interventions. Poor adherence can also be problematic in the context of non-HIV-related STD care. For example, persons with PID are sometimes hospitalized solely for the purpose of assuring adequate adherence to a complete round of antibiotic treatment. Fortunately, several common STDs are now treatable through the use of single-dose therapies, which can be directly observed by a treatment provider.

Conclusions

STDs will remain a major public health concern for the foreseeable future. HIV disease has served to raise awareness of the importance of safer sex, but has often overshadowed efforts to promote awareness of other, more prevalent STDs, which also carry significant health risks. Health psychologists will continue to play an important role in developing interventions to prevent STD transmission and promote improved adaptation among those who contract STDs. In the future, behavioral interventions will likely feature greater integration of STD and HIV treatment and prevention.