Chapter 3
The Challenge of Prevention

Humans have been trying for centuries to rid themselves of STDs, but not one of these diseases is close to worldwide eradication and deadly new ones have appeared in recent years. Effective cures for many STDs, including gonorrhea and chlamydia, have been available for over sixty years, yet outbreaks of these and other STDs continue to take their toll on human health. If cures do not hold the answer for vanquishing STDs, then the solution may need to come from another source, namely prevention.

According to Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases, "There is no more important goal of medical research than to prevent diseases from occurring in the first place."¹¹ Not only would prevention of STDs alleviate the human misery caused by these diseases, but it would reduce the enormous financial burden incurred by current therapies and the development of new treatments.

Effective, inexpensive methods of STD prevention already exist. The real challenge in preventing STDs lies in getting people to adopt these methods. Making people aware of the dangers of STDs and ways to prevent them is only part of the battle. The success of STD prevention ultimately rests on the ability to instigate changes in sexual attitudes and human behavior, which is not a simple task.

STD-Free—Guaranteed!

The only guaranteed way to prevent sexual transmission of STDs is to abstain from sex altogether. Celibacy, or sexual abstinence, is the most effective way to prevent STDs because it eliminates the primary transmission pathway for these diseases. Nonsexual transmission through contact with contaminated blood is the second most common avenue for STD transmission. However, if a person is not a user of intraveneous drugs, his or her chances of acquiring an STD by this route are close to zero. Clearly, however, though promoting sexual abstinence is a primary prevention strategy aimed at teenagers and young adults, total abstinence is not a realistic or desirable expectation in the long term.

For those who are sexually active, limiting the number of sexual partners is the next best way to reduce the chances of contracting an STD. The optimal situation is a monogamous relationship between two people who are sexually active only with each other. Even in monogamous relationships, however, there is still a tangible risk of STD transmission if either person has had previous sexual partners. Connie, a social worker at an STD clinic, says, "You can't evaluate the chances of getting an STD from a person whose sexual history is unknown to you. I know its been said many times before, but when you have sex with someone, you aren't just [having sex] with them, you are also [having sex] with all of their previous sexual partners."¹² For this reason, people who are initiating a sexual relationship should undergo a medical examination to check for the presence of STDs before having sex with each other. If both partners undergo testing and complete treatments for them, if any are required, the risk of passing an STD to each other is greatly diminished.

Amore aggressive approach to ensuring that people who are sexually active are STD-free is to perform periodic testing for these diseases. Given that many STDs are spread by people who do not realize that they are infected, testing people for infection and treating those who are found to have STDs can greatly help to decrease the overall incidence of these diseases. Due to cost and limited resources it is not feasible to screen everyone. For this reason, all STD-screening programs to date have focused on groups that have a high risk of infection, including youths, commercial-sex workers, some immigrant groups, and health care workers who come in contact with blood products. Some STDs are more appropriate for this strategy than others. Syphilis, in particular, is being targeted through screening programs because the overall incidence of this disease is at an all-time low and most current cases are confined to specific cities or regions of the country. In contrast, screening for STDs like chlamydia, which have a high incidence and are spread over a wide geographic area, require such a large investment in time and money that other methods of prevention may be more effective.

Screening tests alone, however, do not serve to fully inform both partners in a sexual relationship about their mutual STD status. Test results are released only to the patient, who must then broach the subject of positive results with the partner. This sensitive discussion can be difficult in either new or established relationships; embarrassment or fear of rejection can cause people to alter or hide information from a sexual partner. So, from a practical standpoint, it is not always prudent to assume that a sexual partner is free of infection and will remain so for the duration of the relationship. In many situations, additional precautions need to be taken to prevent the transmission of STDs.

Condoms: Good but Not Fail-Safe

One way to prevent the transmission of most STDs between sexual partners is to use a latex condom. This protective device, which is inexpensive and readily available from drugstores and supermarkets, lowers the chance of STD transmission by preventing direct contact between body tissues and bodily fluids, such as sperm, most likely to be infected. Most condoms work by covering the penis with a thin, snug layer of latex. Although male condoms from non-latex materials are available and work well for preventing pregnancy, they do not provide an effective barrier for tiny organisms, such as HIV. Female condoms that are placed within the vagina are also available, although slightly more expensive than those for men.

There is good evidence to show that the use of latex condoms can make a difference in the transmission of many STDs. A study in Europe that looked at the impact of condom use on HIV transmission between couples showed that 123 people remained negative for the virus despite the HIV-positive status of their partners. Other studies have found a strong correlation between the increase in condom use that began in the late 1980s, prompted by fear of AIDS, and the sharp drop that was seen in the incidence of all STDs until the late 1990s. One of the greatest success stories is a national program to decrease HIV transmission, initiated by the Thai government in 1991. Whereas condoms were used in only 25 percent of commercial sex acts in Thailand in 1989, this proportion rose to 94 percent in 1995, halving the transmission of HIV and resulting in a dramatic decrease in new cases of curable STDs.

Encouraging as this seems, the protection afforded by a condom is only as reliable as the person using it. In order to be effective in preventing STD transmission, a condom must be worn correctly and must be used for every act of intercourse. And even when condoms are used correctly and consistently, they are not 100 percent fail-safe. Condoms can slip and tear occasionally during intercourse, permitting contact and fluid transmission, and condoms cannot always adequately cover an infected region such as a herpes breakout.

Vaccines and Preventive Drugs

The protection afforded by condoms is not complete, so researchers have turned to the development of vaccines against STDs, which offer several advantages. In many ways, vaccines are an ideal form of protection against STDs since they do not require a voluntary change in behavior or sexual practices and their effects are long lasting. All that is required is a simple injection that contains a non-infectious form of the disease organism. The introduction of this harmless variant into the body allows the immune system to prepare defenses against the particular germ, so that the real germ can be successfully fought off if it is encountered years or even decades in the future.

Although vaccines have been developed and proven effective against many dangerous epidemic diseases such as smallpox and polio, the only successful vaccine against STDs is that developed for hepatitis B. The hepatitis B vaccine is now offered among other standard childhood immunizations and gives close to 100 percent protection against the disease. The vaccine may also be given to adults and is strongly recommended for sexually active adolescents, health care workers, homosexual men, and people whose sexual partners are infected with the virus.

Successful vaccines against other STDs are not yet available. However, recent breakthroughs have been made in preventing the transmission of HIV using new antiviral drugs. These drugs reduce the number of viral particles in the bloodstream to undetectable levels. This not only substantially increases the life span of people who are already infected with HIV but also reduces the chance of transmission of HIV to others during sexual activity and from infected pregnant women to their babies because so few viral particles are present. Some evidence even suggests that immediate dosage of antiviral drugs following initial exposure to HIV can perhaps prevent HIV infection from taking hold. Because such potent antiviral drugs have serious side effects, however, they are not suitable for widespread prescription to healthy people as a prevention measure.

Prevention Requires Changing Behavior

No matter what prevention strategy is adopted, all require the individual to take voluntary, responsible action. Regardless of whether the action involves the purchase and use of condoms, submitting to screening tests, taking medications or getting vaccinated, or abstaining from sex altogether, remaining STD-free is not a passive exercise.

Taking a proactive role in preventing STD transmission is hard simply because changing behavior is hard. Taking individual action is complicated by social, cultural, and even religious barriers that interfere with prevention strategies. For example, some cultures that do not approve of artificial contraception discourage the use of condoms, which prevent pregnancy as well as STDs. Traditional social perceptions that people who use condoms are sexually promiscuous, and therefore held up to criticism or ridicule, are also hard to change. And many people find it all too easy to decide that condoms are a nuisance to use and reduce pleasurable sensation during sex and so choose not to use them.

Major well-funded efforts promoting the use of condoms and other methods of STD prevention have changed anticondom attitudes to some degree, but such programs are somewhat undermined by the powerful influence of the mass media and its popular portrayal of sexual intercourse as an exciting and worry-free activity. According to former U.S. surgeon general David Satcher, "Media programming rarely depicts sexual behavior in the context of a long-term relationship, use of contraceptives, or the potentially negative consequences of sexual behavior."¹³ Despite the media's damaging reinforcement of high-risk sexual behavior, Satcher is quick to note that the media has an equally potent ability to promote safe sexual practices. This is supported by a recent national survey in which teenagers rated magazines and television as among the top five ways that they learned about STDs and ways to prevent them.

Young People Are the Least Likely to Take Precautions Against STDs

Reports about STDs by the media have been particularly prolific since the emergence of HIV/AIDS. This, together with the emergence of the Internet, means that people are experiencing unprecedented access to information about STDs and ways to prevent them. Yet awareness of STDs and safe sexual practices is far from complete, and many people, especially young people, fail to put their knowledge regarding STD protection into practice. A January 2003 briefing by the Association of American Colleges and Universities notes that 50 percent of fifteen- to twenty-four-year-olds in key developing countries in the Caribbean, Central Asia, Eastern Europe, and East Asia have never heard of HIV or AIDS. It comes as no coincidence that this age group has the highest incidence of STDs.

Ignorance is not the only reason young people do not adopt prevention methods. Peer pressure can work against prevention by discouraging instead of promoting abstinence, the only guaranteed method of STD prevention. Katie, seventeen, from Oregon says, "Sooo many people feel like all their friends are doing it and they're left out. It just ends up that no one wants to be the last person to have sex."¹⁴ Many young people cope with this pressure by not talking about their choice to be celibate, while others, like Thom Pasculli, eighteen, are vocal about their decision. Thom says, "Believe it or not, I have no problem admitting that I'm a virgin. I don't need a support group, and I don't care what other people think (although everyone I've told has expressed respect)."¹⁵

Denial also plays a potent role in the failure of people to protect themselves against these diseases. Young people, in particular, are prone to dismiss the consequences of high-risk activities. According to high school junior Alison Forbes, seventeen, many of her peers are more worried about how sex will affect their relationship than whether it will put them at risk for catching an STD. Alison says, "People don't like to think about [catching STDs]."¹⁶ Heidi Chuckel, who is eighteen years old and a high school senior, says, "They don't consider what could happen. It's not a lack of knowledge; it's a lack of understanding. We know the facts. It's just that people, especially those in their youth, think they are untouchable."¹⁷ A national survey by the Kaiser Family Foundation, MTV, and Teen People in 1999 concurs with these opinions showing that only one-fifth of those between fifteen and seventeen years of age believe there is a risk of contracting an STD with a single sexual encounter.

The current increase in unprotected sex among young male homosexuals is another example of rational decisions taking a back seat to impulsive, high-risk behavior. Although educational campaigns within the gay community were highly effective at promoting safe sexual practices early in the AIDS epidemic, many men are now choosing to ignore these messages and engage in high-risk sexual activity. Tim Alderman, who is forty-seven years old and a member of the gay community in Sydney, Australia, says:

It is interesting to note that there is a current rise in the rate of infections from 'old-fashioned' STD's in the gay community at the moment, especially [gonorrhea]. I feel that HIV has become a 'generational' thing [i.e., a product of my generation], and that the young ones think they are immune. This is the problem with a disease becoming unfashionable—no one takes it seriously anymore. The youngsters on the scene see HIV and the safe-sex lifestyle as something they are immune from. It cropped up in my generation, we suffered all the problems caused by it, we solved a lot of the problems and biases, and now it is in the past. They think it will never happen to them (ah, the innocence of youth); therefore they are no longer practicing safe sex, and think they will never get HIV. Consequently, STD's are back.¹⁸

Failure to Communicate Helps to Spread STDs

The tendency to ignore messages about safe sex is accompanied by widespread reluctance between sexual partners to talk about STDs with each other. The national survey by the Kaiser Family Foundation, MTV, and Teen People found that talking about STDs, even with friends, was something most people would rather avoid. Over 70 percent of Americans ranked this topic of conversation as anxiety-provoking, and discussion of STDs with a sexual partner was viewed as awkward by nearly 40 percent. Less talk about STDs means less action, in terms of prevention. People are not as informed, less aware, and more likely to contract an STD than they would be if the topic was easily discussed over the dinner table.

While the lack of communication about STDs detracts from promoting the message of safe sex as a whole, the real problem arises when those who have been diagnosed with an STD fail to tell their previous and current sexual partners about their disease. According to Connie, "People think that if they have an STD they will be judged by others as sexually promiscuous and morally loose. The unfortunate result of this attitude is that it can prevent people [diagnosed with an STD] from telling their sexual partners that they should come in and get tested. It really is a huge problem for stopping the spread of these diseases."¹⁹ The Kaiser survey supports that viewpoint in reporting that 82 percent of teenagers say telling a sexual partner about a positive result for an STD test would be uncomfortable and 52 percent say it would be very uncomfortable. Although the majority of people in all age groups viewed notification of a sexual partner as an obligation, a sizable minority did not hold this belief. Teenagers in particular indicated that the need to notify a partner that they were infected with an STD infection could be dismissed if condoms were always used or if sexual activity occurred only when no symptoms were apparent.

Official intervention to selectively screen all previous and current sexual partners of people who have been diagnosed with an STD is one way to get around relying on the infected individual to communicate information. It has been argued that diagnosis and treatment of STDs within this high-risk population would be an efficient means to short-circuit the spread of these diseases and would go a long way toward gaining control of the epidemic. This approach is theoretical, however, because several problems make its practical application unlikely. First, it is not always possible to identify all sexual partners of a person who has been diagnosed with an STD. Even when sexual partners can be identified, the obligation of doctors to keep the details of their patient's health confidential prevents notification of partners without the patient's permission. More often than not, the potentially touchy situation of informing sexual partners that they may have contracted an STD is left to the patient. Alerting sexual partners that they may have an STD is only the first step in the process. There is no guarantee that those who are notified will present themselves for testing and treatment. Denial, embarrassment, and a simple reluctance to go to a doctor or clinic for testing can undermine the most persistent attempts to treat the partners of people with STDs. To overcome this hurdle, a pilot project is currently being run in the United States to test the effectiveness of sending positively diagnosed patients home with medication for their sexual partners as well as themselves. It is hoped that this may prevent inertia or embarrassment from being a stumbling block to receiving treatment.

STD Education in Schools: A Controversial Issue

Education has long been viewed as the most important factor in counteracting the ignorance, denial, and stigma that fuel the STD epidemic. STD hotlines, the Internet websites, and government-issued pamphlets at clinics and doctors' offices have all been helpful in providing up-to-date information about STDs and ways to prevent them. Yet these avenues for education are only partially effective as they mainly reach those who already have some awareness of or curiosity about STDs. Getting the message across to those with little or no knowledge of STDs poses a greater challenge but is critical for stemming the tide of new infections.

The high prevalence of STDs among teenagers has made this group one of the primary targets for educational campaigns about STDs. While there is a general consensus that alerting teens to the dangers of STDs is necessary, opinions are divided on how best to accomplish this. Parents and educators disagree about whom to teach, what information to present, and when educational programs should be offered. Traditionally the responsibility for discussing STDs, and sexuality in general, with children has been left to parents. The danger of this status quo is that not all parents are able, willing, or well enough informed to teach their children about STDs. Even when parents make the attempt to talk about STDs with their children, the effectiveness of discussions may be compromised by the parent-child relationship. Kathy, a high school student, says, "Both of my parents spoke to me about sex. I think they were mostly worried that I would become pregnant or get a disease, like AIDS. Even though I knew that what they were talking about was important and I wanted to know more, I felt uncomfortable about asking questions. I was worried that they might think that I was already having sex if I seemed too interested."²⁰ The fact is that while some teens may learn about STD prevention from their parents or doctors, most people in this age group say their school health programs are their primary source of information.

There is little question that school health-education programs are ideal for reaching the majority of teens, but accommodating the diverse personal and cultural values of all students is difficult at best. One of the central issues is whether school programs should provide students with information about all forms of STD prevention or only cover the option of sexual abstinence. Programs that teach abstinence, outside of marriage, as the only acceptable means of STD prevention have been heavily promoted by thefederal government over the past few years, with half a billion dollars allocated by Congress since 1998 and an expected increase to $133 million per year in 2003. In contrast, no federal funds are currently being put toward programs that teach comprehensive methods of STD prevention. As such, the number of schools teaching sexual abstinence as the only form of prevention has risen from 2 percent to 28 percent over the last decade.

Driving this push to limit preventive methods in schools to sexual abstinence is the belief that teaching teens about other forms of protection encourages sexual activity. Yet findings from several recent studies dispute this viewpoint, showing that students who were provided with comprehensive information about other forms of prevention were not any more likely to become sexually active than those who were taught only about abstinence. Furthermore, students who were already sexually active did not seek additional partners or have sex more frequently after attending comprehensive programs, and in some cases even became less sexually active. On the other side of the debate, abstinence-only programs that encourage teens to make pledges to abstain from sexual intercourse until marriage have had some success, delaying intiation of intercourse by some students for up to eighteen months. However, these programs were found to have dangerous long-term repercussions in that students who took part in them, rather than programs with comprehensive information, were a third less likely to protect themselves against STDs once they became sexually active. In addition, abstinence-only programs have also been criticized because they fail to address the situation of homosexual students, who may never marry, or students who are already sexually active. A recent medical journal commentary by Leslie Kantor and William Bacon states:

The [abstinence-only] programs clearly fail to meet the needs of the 50% of US teens who are sexually active, and they leave all teens vunerable to unintended pregnancy and STDs. In addition, premarital intercourse is the norm in American society, as it has been for decades [90% of Americans engage in premarital sex]. No evidence suggests that this 80-year trend is likely to be reversed by any educational intervention.²¹

The movement in support of comprehensive sex education is growing. Despite lack of federal funding, several states have introduced laws that require schools to provide up-to-date, judgment-free information about STDs and methods of prevention. Most parents seem to support this movement, according to a Kaiser Family Foundation survey showing that 85 percent of parents want schools to teach their children how to use condoms. The survey also found that although 33 percent of parents want schools to promote the message of sexual abstinence until marriage, many of these same parents want schools to include comprehensive methods of STD prevention in their programs. Tina Hoft, director of public health for the Kaiser foundation says, "What comes across in this study is that parents look to schools to prepare their children for real life. Their concerns are practical, not political."²²

Education Is Essential

In the absence of cures for serious STDs, education is the main hope for arresting the STD epidemic. According to Debra Haffner, the president of the Sexuality Information and Education Council of the United States, "Abstinence and monogamy are 100% effective if they are practiced. But we know that [they] are not always practiced, even by people who say they are practicing them.… There are lots of studies that show that if you give people good education, they will protect themselves."²³