The Issue:

Women are disproportionately affected by sexually transmitted diseases and their consequences as is illustrated by the following:

• In the United States, chlamydia, which infects 4 million people annually, and gonorrhea, which infects 800,000 people annually, are responsible for the majority of pelvic inflammatory disease (PID).¹ PID is the leading cause of preventable infertility, potentially fatal ectopic (tubal) pregnancy, and chronic pelvic pain. Ectopic pregnancy is the leading cause of first-trimester pregnancy-related deaths in African American women. Yet, approximately 70 percent of chlamydia-infected women and 50 percent of gonorrhea-infected women have no symptoms, leaving many women untreated.² Though asymptomatic infection is much less common in men, it is a serious concern because asymptomatic men are an important source of infection transmission to women.
• Human papillomavirus (HPV) which causes genital warts infects approximately 500,000 to 1 million persons every year, but because it is an incurable viral disease, has a prevalence of approximately 24 million.³ HPV infection is the single most important risk factor for cervical cancer, the fourth most common malignancy diagnosed in women of all ages. Death rates from cervical cancer for African American women are 6.5 per 100,000 women of child bearing age and 2.6 for white women.⁴
• Sexually transmitted diseases may be one of the most important preventable causes of adverse outcomes of pregnancy, including low birth weight/prematurity, congenital infection, stillbirth, and postpartum infection. For example, in 1994, 2,200 babies were born with syphilis⁵, a condition that can be prevented with appropriate diagnosis and treatment during prenatal care. Also, there is a high risk of neonatal morbidity or mortality in infants exposed to primary genital herpes infection at the time of delivery. There is also now evidence that providing AZT to HIV positive pregnant women can prevent approximately two-thirds of transmission of HIV from an infected mother to her fetus.⁶

Opportunities:

1. Female condom. The development of the female condom offers a new option for female controlled STD and HIV prevention.
2. Safe, effective vaginal microbicides. Increasing interest in women's reproductive health has resulted in a number of initiatives by organizations such as WHO, Rockefeller Foundation and the Population Council to develop safe and effective vaginal microbicides to prevent HIV and other STDs.
3. Non-invasive diagnostic tests. The advent new tests for chlamydia and gonorrhea that do not require a speculum examination will greatly facilitate STD diagnosis and treatment in women.
4. The link between STD prevention and other factors in women's lives. There is growing appreciation of the links for women between effective sexual negotiation for STD prevention and factors such as self-esteem, domestic violence, communication skills, and self-efficacy.
5. Increasing condom use on high-risk populations. Successful efforts to increase condom use among commercial sex workers (e.g., prostitutes) suggest that sexual relations carried out for money are more amenable to "negotiation" than sex in socially close relationships.
6. Focus on infertility prevention nationwide. Efforts to establish a national STD-related infertility prevention program present a major opportunity to focus the impact of STD prevention on women.

Challenges:

1. Women are more likely than men to acquire STDs. Most STDs including HIV, are transmitted more efficiently from a male to a female than from a female to a male.
2. Women often have fewer options than men to protect themselves from STDs. Compared with men, women more frequently perceive that they have limited control over when, where, or with whom they have sex. Few female-controlled technologies have demonstrated efficacy in prevention of STDs. The anatomy of the vagina facilitates prolonged exposure to infected secretions following intercourse.
3. Women are less likely than men to seek care for STDs. In contrast to men, the majority of STD-infected women are asymptomatic and, therefore, do not realize that they need treatment. Furthermore, in many communities, seeking care for STDs remains far more stigmatizing for women than for men.
4. STDs in women are more difficult to diagnose than those in men. The low sensitivity and specificity of clinical signs and symptoms of STDs in women necessitate use of laboratory tests that have traditionally required speculum examinations and expensive, technically sophisticated diagnostic procedures. Accurate diagnosis of STDs in men, on the other hand, is usually relatively simple and inexpensive.
5. Women suffer more frequent and severe consequences from STDs than men. Many of the factors highlighted above, as well as biological differences between women and men contribute to the higher incidence of severe STD complications among women. STDs also increase the risk of HIV transmission, especially in heterosexual sex. Finally, the psychological and social consequences for women of STDs and complications such as infertility or adverse outcomes of pregnancy are just beginning to be appreciated.

Recommendations:

1. STD prevention services should be incorporated into medical care wherever women receive family planning or prenatal care services. This includes not only family planning clinics, where many do provide STD prevention services, but also prenatal care and primary care clinics. Such services should be provided with cultural competency appropriate to the particular women being served.
2. Organizations that serve women, such as youth-serving and social services organizations, should routinely provide information and assistance in accessing STD-related care.
3. As women have few options for protecting themselves against STDs, research on STD microbicides (agents that kill bacteria) should be encouraged and supported.
4. Providers who see women for health care, especially managed care providers, should receive STD-related training that addresses the unique aspects of these serious health threats for women.

The STD Prevention Partnership is a group of national organizations with shared concern about the continuing spread of STDs, including HIV. Its mission is to support and encourage partnerships among the private, voluntary, and public sectors in developing and implementing strategies to reduce the incidence and impact of STDs.

This statement was adopted by the STD Prevention Partnership at their biannual meeting, February 28, 1996. Membership in the STD Prevention Partnership does not necessarily imply endorsement of this statement by each individual organization participating in the Partnership.

For more information about the STD Prevention Partnership, write to:

STD Prevention Partnership
c/o CERO
DSTDP/NCHSTP
1600 Clifton Rd., NE, MS E-02
Atlanta, GA 30333

¹Division of STD/HIV Prevention, DSTDP 1994 Annual Report, CDC, Atlanta, 1995.

²Division of STD Prevention, Sexually Transmitted Disease Surveillance 1994, CDC, Atlanta, 1995.

³Division of STD/HIV Prevention, DSTDP 1994 Annual Report, CDC, Atlanta, 1995.

⁴American Cancer Society Department of Epidemiology and Surveillance, Atlanta, GA, October 1994, based on data from the Division of Vital Statistics, the National Center for Health Statistics, CDC.

⁵Division of STD Prevention, Sexually Transmitted Disease Surveillance 1994, CDC, Atlanta, 1995.

⁶CDC, "Recommendations of the U.S. Public Health Service task force on the use of zidovudine to reduce perinatal transmission of human immunodeficiency virus," Morbidity & Mortality Weekly Report, 43 [No. RR-11], 1994.