William E. Lafferty

Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy

PURPOSE The role that sex education plays in the initiation of sexual activity and risk of teen pregnancy and sexually transmitted disease (STD) is controversial in the United States. Despite several systematic reviews, few epidemiologic evaluations of the effectiveness of these programs on a population level have been conducted. METHODS Among never-married heterosexual adolescents, aged 15-19 years, who participated in Cycle 6 (2002) of the National Survey of Family Growth and reported on formal sex education received before their first sexual intercourse (n = 1719), we compared the sexual health risks of adolescents who received abstinence-only and comprehensive sex education to those of adolescents who received no formal sex education. Weighted multivariate logistic regression generated population-based estimates. RESULTS Adolescents who received comprehensive sex education were significantly less likely to report teen pregnancy (OR(adj) = .4, 95% CI = .22- .69, p = .001) than those who received no formal sex education, whereas there was no significant effect of abstinence-only education (OR(adj) = .7, 95% CI = .38-1.45, p = .38). Abstinence-only education did not reduce the likelihood of engaging in vaginal intercourse (OR(adj) = .8, 95% CI = .51-1.31, p = .40), but comprehensive sex education was marginally associated with a lower likelihood of reporting having engaged in vaginal intercourse (OR(adj) = .7, 95% CI = .49-1.02, p = .06). Neither abstinence-only nor comprehensive sex education significantly reduced the likelihood of reported STD diagnoses (OR(adj) = 1.7, 95% CI = .57-34.76, p = .36 and OR(adj) = 1.8, 95% CI = .67-5.00, p = .24 respectively). CONCLUSIONS Teaching about contraception was not associated with increased risk of adolescent sexual activity or STD. Adolescents who received comprehensive sex education had a lower risk of pregnancy than adolescents who received abstinence-only or no sex education.

Recurrences after oral and genital herpes simplex virus infection. Influence of site of infection and viral type

We prospectively followed 39 adults with concurrent primary herpes simplex virus (HSV) infection (12 with HSV type 1 and 27 with HSV type 2) of the oropharynx and genitalia, caused by the same virus in each person, to evaluate the influence of viral type (HSV-1 vs. HSV-2) and site of infection (oropharyngeal vs. genital) on the frequency of recurrence. The subsequent recurrence patterns of HSV infection differed markedly according to viral type and anatomical site. Oral-labial recurrences developed in 5 of 12 patients with HSV-1 and 1 of 27 patients with HSV-2 (P less than 0.001). Conversely, genital recurrences developed in 24 of 27 patients with HSV-2 and 3 of 12 patients with HSV-1 (P less than 0.01). The mean rate of subsequent genital recurrences (due to HSV-1 and HSV-2) was 0.23 per month, whereas the mean rate of oral-labial recurrences was only 0.04 per month (P less than 0.001). The mean monthly frequencies of recurrence were, in order, genital HSV-2 infections, 0.33 per month; oral-labial HSV-1 infections, 0.12 per month; genital HSV-1 infections, 0.020 per month; and oral HSV-2 infections, 0.001 per month (P less than 0.01 for each comparison). We conclude that the likelihood of reactivation of HSV infection differs between HSV-1 and HSV-2 infections and between the sacral and trigeminal anatomical sites. The sixfold more frequent clinical recurrence rate of genital HSV infections as compared with oral-labial HSV infections may account for the relatively rapid increase in the prevalence of clinically recognized genital herpes in recent years.

Herpes Simplex Virus Type 1 as a Cause of Genital Herpes: Impact on Surveillance and Prevention

This study compared characteristics of patients who had herpes simplex virus (HSV) type 1 with characteristics of patients who had HSV-2, by use of data from a cross-sectional analysis. Data were collected in an urban sexually transmitted diseases clinic from patients who had positive genital HSV cultures. Overall, 17.1% (95% confidence interval [CI], 14.9%-19.3%) of 1145 genital HSV isolates obtained during 1993-1997 were HSV-1. The proportion of HSV-1 among initial genital herpes infections was higher among men who had sex with men (46.9%) than among women (21.4%) and was lowest among heterosexual men (14.6%). White race (odds ratio [OR], 3.7; 95% CI, 2.3-5.9) and receptive oral sex in the preceding 2 months (OR, 2.8; 95% CI, 1.9-4.3) significantly increased the odds that initial infections were HSV-1 rather than HSV-2. Genital HSV-1 may often be acquired through contact with a partners mouth. These data suggest that seroprevalence studies based solely on HSV-2 type-specific assays underestimate overall prevalence of genital HSV infection.

Sexually transmitted diseases in men who have sex with men. Acquisition of gonorrhea and nongonococcal urethritis by fellatio and implications for STD/HIV prevention.

Background and Objectives: Despite trends toward safer sex practices in homosexually active men, some such people remain at high risk for acquiring sexually transmitted diseases (STD). This study was designed to assess behavioral and demographic determinants of STD acquisition in men who have sex with men (MSM), to guide prevention interventions. Study Design: A cross‐sectional medical record review was undertaken of MSM who attended an urban STD clinic from January, 1993 through December, 1994. Gonorrhea, chlamydial infection, Chlamydia‐negative nongonococcal urethritis (NGU), and newly documented human immunodeficiency virus (HIV) infection were analyzed in relation to demographic and behavioral variables. Results: Among 1,253 MSM, 196 (15.6%) had nonchlamydial NGU, 105 (8.4%) had gonorrhea, 31 (2.5%) had chlamydial infection, and 162 (12.9%) had known or newly documented HIV infection. Known HIV infection was an independent predictor of urethral gonorrhea (odds ratio [OR] 2.3, 95% confidence interval [CI95] 1.2–4.8). Oral insertive intercourse was independently associated with urethral gonorrhea (OR 4.4, CI95 1.4–13.4) and nonchlamydial NGU (OR 2.2, CI95 1.3–3.7), and receptive anal intercourse was associated with newly documented HIV infection (OR 2.6, CI95 1.3–4.9). Neither number of sex partners nor condom use was associated with any incident STD outcome, including new HIV infection. Conclusions: MSM who attend STD clinics represent a subgroup of homosexually active men who remain at high risk for STDs, including HIV infection. Fellatio, commonly thought to be a “safe” sexual practice, is an independent risk factor for urethral gonorrhea and nonchlamydial NGU. A history of consistent condom use or of few sex partners should not dissuade clinicians from performing screening tests for HIV and other STDs. Repeated STD screening and counseling about safer sex are indicated for many HIV‐infected MSM.

Potential Interactions Between Complementary/Alternative Products and Conventional Medicines in a Medicare Population

Background: Despite the high prevalence of complementary and alternative medicine (CAM) product use among the elderly, little is known about the extent of concurrent CAM-conventional medicine use and the potential for adverse reactions. Objective: To determine the prevalence of CAM product use concurrent with conventional medications, prescription and nonprescription, in a Medicare population and assess the risk for adverse interactions. Methods: Retrospective analysis was performed on Cardiovascular Health Study interview data from 1994, 1995, 1997, and 1999. The prevalence of concurrent combinations of CAM products and conventional drugs was tabulated. The adverse interaction risks were categorized as unknown, theoretical, and significant. Results: Of 5052 participants, the median age was 75, 60.2% were female, 16.6% were African American, and 83.4% were white. The percent using CAM products during the 4 time periods was 6.3%, 6.7%, 12.8%, and 15.1 %, The percent using both CAM products and conventional drugs was 6.0%. 6.2%. 11.7%, and 14.4%, Of these, 294 (5.8%) individuals took combinations considered to have a significant risk for an adverse interaction. Combinations with risk were observed on 393 separate interviews. Most (379) involved a risk of bleeding due to use of ginkgo, garlic, or ginseng together with aspirin, warfarin, ticlopidine, or pentoxifylline. An additional 786 observations of combinations were considered to have some, albeit theoretical or uncertain, risk (or an adverse interaction. Conclusions: Concurrent use of CAM products and conventional medicines in a Medicare population was found to be common. Research to define the risks of combining ginkgo and garlic supplements with aspirin should be of high priority.

The role of alternative medical providers for the outpatient treatment of insured patients with back pain.

Study Design. Analysis of health insurance claims from 2 large Washington State companies. Objective. To evaluate the prevalence and cost of complementary and alternative medicine (CAM) provider use for back pain treatment. Summary of Background Data. Washington State requires all commercial insurance to cover licensed CAM providers. Methods. Outpatient claims for the treatment of back pain were analyzed by the International Classification of Disease-9 codes and provider type. The number of visits and expenditures associated with different forms of treatments were calculated. Results. Back pain accounted for 15% of all outpatient visits, and these companies spent more than

Challenges of Using Medical Insurance Claims Data for Utilization Analysis

52 million on 652,593 claims submitted by 104,358 adults. Most people used only CAM (43%) or only conventional providers (45%) for back pain treatment, with merely 12% using both. Patients who saw only CAM providers had fewer comorbidities than the other 2 groups and made approximately twice as many visits as “conventional only” users (median 4 vs. 2). Average amount allowed per outpatient low back pain claim was lower for CAM visits (mean

The association of complementary and alternative medicine use and health care expenditures for back and neck problems

50, SD

Quality of life at the end of life

28) than for conventional visits (mean

Preventive Screening of Women Who Use Complementary and Alternative Medicine Providers

128, SD