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An Epidemic No One Wants to Talk About

By Robert E. Fullilove, Adaora Adimora and Peter Leone
Friday, March 21, 2008

A much-publicized study from the Centers for Disease Control and Prevention this month highlighted the high rates of sexually transmitted diseases among teenage Americans. But for those of us who work in public health, this "news" is already old.

A decade ago, the National Academy of Sciences' Institute of Medicine published a landmark report, "The Hidden Epidemic," examining sexually transmitted diseases in the United States. In 1995, the report noted, STDs accounted for 87 percent of cases of the 10 most frequently reported diseases in the nation. Despite the huge costs that such infections imposed on our health-care system, awareness of their importance was all but absent from the public consciousness. We fear that this latest study will have its 15 minutes in the spotlight and also fade from view.

Sadly, our national silence may be related to our difficulty discussing the roles that race and poverty play in these trends. In 2005, for example, the rate of gonorrhea (a curable STD) among African Americans was 18 times greater than the rate among whites. The contrast in rates for HIV-AIDS, syphilis and chlamydial infection among blacks and whites is only slightly less dramatic. These diseases cost tens of billions of dollars each year, but with the exception of HIV infection, STDs remain the elephant in the room when it comes to the national conversation about health and health care.

One obvious reason is that conversations about sexual behavior, race and sexually transmitted infections remain taboo. Another is that the incidence of many STDs, particularly HIV, is concentrated in poor, segregated neighborhoods that are characterized by high rates of incarceration. Inner-city populations of African Americans and Latinos account for almost two-thirds of the 2.2 million Americans in prison nationwide, and two disturbing trends are increasingly present in these communities.

One is the shift in the patterns of marriage and courtship that result when so many men are removed from a community. The other is an increase in the number of "multiple concurrent sexual partnerships," in which individuals are engaged in sexual relationships with more than one person at a time. In many communities, when one sexual partner is imprisoned, the person left behind chooses another partner. When widespread, this behavior creates an efficient, effective pattern for introducing and maintaining an STD through a network of sexual relationships.

Concurrent sexual partnerships, our research indicates, are a more effective engine for transmitting STDs than sequential partnerships. In the latter case, an infected individual is more likely to be diagnosed before a new partner is infected. In the former, an individual infected by one partner can immediately pass the infection on to another, potentially spreading it quickly through the network. As people move in and out of relationships and in and out of communities, such infections become almost impossible to treat efficiently. Movement in and out of prison aggravates these trends.

We can no longer have effective STD prevention campaigns in poor communities of color if they treat one person at a time or ignore the social conditions underpinning high rates of HIV and other STDs. For one thing, women in poor African American communities who engage in the lowest levels of risk behavior are dramatically more likely to acquire STDs than higher-risk women in communities with low background rates of infection. Where you live and choose sexual partners has an enormous impact on your risk, particularly if it is in a community with high incarceration rates. Imprisonment changes community male-female ratios, and these unbalanced numbers contribute to low marriage rates, a reluctance to negotiate "safe sex," formation of concurrent partnerships and the maintenance of STDs within the networks in which members choose partners.

Simply put, we will never rid the United States of HIV and other STDs if our only weapon is medical treatment. And if we are unable to engage in a national dialogue about the sexual health of our youths and the social dynamics that drive STDs, this epidemic will go largely ignored, and many more lives will be lost.

Robert E. Fullilove is associate dean of Columbia University's Mailman School of Public Health. Adaora A. Adimora is an associate professor of medicine at the University of North Carolina at Chapel Hill. Peter Leone is medical director of the HIV/STD Prevention and Care Branch of the North Carolina Division of Public Health. The authors were members of a panel convened by the Centers for Disease Control and Prevention in June 2007 to examine HIV and STD trends. The opinions presented here are their own.

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