Anal sex is a Behavioral Marker for Laboratory-Confirmed STDs and HIV-Associated Risk Among African American Female Adolescents Ralph J. DiClemente, PhD Gina M. Wingood, ScD, MPH Richard A. Crosby, PhD Laura F. Salazar, PhD Sara Head, MPH Eve Rose, MPH Jessica McDermott-Sales, PhD Angela M. Caliendo, MD, PhD

Background Sexually transmitted diseases (STDs) are a significant source of morbidity among adolescents ages 15-24 African-American females in the South are disproportionately affected by the intersecting epidemics of HIV and STDs. One risk behavior that is understudied is anal sex. Anal sex may be a marker for other risks behaviors and STD acquisition A number of sexual behaviors have been identified as influencing African American adolescents’ risk for STD acquisition, including; poor condom use10-13, early sexual debut14, 15, and greater number of male sex partners.14, 16-18 One behavior, however, that is understudied among adolescents is anal sex, particularly in the context of other STD/HIV-associated behaviors19 Anal intercourse, unprotected by condom use, may be a direct risk factor associated with a higher risk for HIV transmission relative to vaginal intercourse20-24 and is also linked to anorectal STDs.25-27 Furthermore, anal sex may be a behavioral marker for other risk behaviors and STD acquisition.28- 30

New AIDS cases across the US, 2005 Here, point out gaps in research: 30 Of the few studies that have examined the association between anal sex and other risk behaviors, these studies have not used a recent measure of anal sex, but instead have included measures of anal sex over broader time periods (e.g., lifetime, past 6 months) from study enrollment. Thus, the temporal association between anal sex and other, current risk behaviors is tenuous. Furthermore, most studies focus on a single risk outcome, with few examining the association of anal sex with a diverse profile of sexual risk behaviors and biological outcomes. Among adolescents, there are a limited number of studies describing the prevalence of anal sex,31-35 and fewer examining the association between anal sex and adverse biological outcomes (i.e., STDs) and other HIV-associated risk behaviors.36 Furthermore, most of these studies have been conducted among older populations and have been geographically limited to California28, 30, 37, 38 or the northeastern U.S.29, 36 No study has been conducted in the Deep South; a region of the U.S. characterized by high rates of STDs and HIV.8, 9, 39 Furthermore, no study has focused exclusively on African American adolescent females nor provides subgroup analyses specifically for African American adolescent females; a subgroup disproportionately adversely impacted by the intersecting STD and HIV epidemics.28-30, 36-38 Try this slide out in Presentation mode – the map shows up first, and then when you click, the red dots appear. The red dots represent all cities / regions where anal sex (and associated behaviors) have been studied. The Brown states are 2.2%-15.0% and the Light Yellow are 0.0%-0.2% FYI: This image comes from avert.org, a website based in the UK. The map (in interactive form) can be found on the Kaiser website at the link cited in the slide. Kaiser got their data directly from: [Table 14, HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2005, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Department of Health and Human Services, 2006. Available at http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/pdf/2005SurveillanceReport.pdf. ] Brown = highest concentration, Light yellow = lowest Source: Statehealthfacts.org (Accessed October 2007) ‘New AIDS Cases, reported in 2005’, The Henry J. Kaiser Family Foundation.

Objective To determine whether among African American adolescent females engaging in penile-anal sex is associated with a profile of other high risk sexual behaviors and laboratory-confirmed STDs

Methods: Sample 715 African-American females Recruitment sites: Urban STD clinic Teen clinic in large hospital Family planning clinic Eligibility: 15-21 years old Sexually active past 60 days

Methods: Data Collection Cross-sectional study Audio-computer assisted self-interview (ACASI) Sexual risk behaviors Anal sex (past 60 days) Self-collected vaginal swab Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Approved by Emory IRB

Methods: Data Analysis Bivariate analyses: prevalence ratios, 95% confidence intervals, P-value; significance was set at α < .05 Hierarchical logistic regression model Conducted to adjust analyses for key covariates: Age Residing with family member Please check the data analysis slides

Results: Sample Characteristics Mean age 17.8 years (+ 1.7) 75.8% reside with family member 65.3% enrolled in school 28.8% positive for 1 of 3 STDs 17.6% C. trachomatis 4.9% N. gonnorhoeae 12.9% T. vaginalis 10.5% prevalence of anal sex (past 60 days)

Results: Bivariate Associations Outcome Anal Sex No Anal Sex PR 95% CI P (n = 75) (n = 640) Positive for at least one STD 40.0% 27.5% 1.46 1.07-1.97 .02 Sexual Risk Profile Any unprotected vaginal sex 78.7% 56.9% 1.38 1.21-1.58 .001 Last vaginal sex was unprotected 77.3% 65.8% 1.41 1.23-1.63 .001 Boyfriend has sex with other females 40.7% 29.0% 1.40 1.00-1.97 .06 Had sex while high or drunk 56.0% 29.5% 1.90 1.50-2.40 .001 Had sex while partner was high or drunk 60.0% 43.1% 1.39 1.13-1.71 .005 Could you please direct me as to how you’d like this displayed? The text will not increase further without bad formatting. I could put it in bullets / text, but you lose the ability to get an overall view. For one of my other presentations, I graphed the four significant variables… but you have nearly 8 significant variables…

Results: Bivariate Associations cont. Outcome Anal Sex No Anal Sex PR 95% CI P (n = 75) (n = 640) Sexual Risk Profile cont. Lifetime # of vaginal sex partners > 4 (58) 77.3 (421) 65.8 1.18 1.03-1.34 .04 Had vaginal sex with 2 or more partners (35) 46.7 (202) 31.6 1.48 1.13-1.93 .009 Had sex with a casual partner (26) 34.7 (199) 31.1 1.12 .80-1.55 .53 Had sex with a partner recently incarcerated (17) 22.7 (105) 16.4 1.38 .88-2.17 .17 Had sex with partner at least 5 years older (19) 25.3 (79) 12.3 2.05 1.32-3.19 .002

Multivariate Analysis

Multivariate Analysis

Limitations Cross-sectional study design Self-reported data for sensitive behaviors, potential recall bias Convenience sample Findings limited to African-American female adolescents Would you like a conclusions slide after this? I inserted one and thought it may be repetitive or put you over your time limit.

Discussion Adolescents reporting recent anal sex had a higher prevalence of STDs and other risk behaviors. Of 10 risk behaviors examined, 6 remained statistically significant after adjustment. Anal sex as a behavioral marker may be useful to facilitate efficient sexual health screening. From a clinical perspective, separating cause and effect as to the temporal association between anal sex and other HIV/STD-associated risk behaviors may be less important than understanding that experiencing anal sex among African American female adolescents is a useful marker for other risk behaviors. Whether anal sex preceded other HIV/STD-associated risk behaviors, co-occurred with other HIV/STD-associated risk behaviors, or is a consequence of one or more of these other risk behaviors is a complex question that awaits additional, more detailed study. Nonetheless, the evidence suggests that many health risk behaviors, sexual risk behaviors being no exception, do not occur in isolation; rather they often cluster with other risk behaviors and adverse health outcomes, as our findings indicate when examining the association between anal sex and other sexual risk indices.45, 46

Implications for Practice Healthcare providers can screen for anal sex as a marker of other risk behaviors Assessing history of anal sex in clinical assessment straightforward allows clinicians to screen adolescents efficiently Pediatricians, adolescent medicine specialists, and family practitioners have an integral role to play in adolescent health promotion47, 48 as they are primarily responsible for providing care to adolescents. Moreover, pediatricians can assess adolescents’ sexual risk behaviors and adverse health outcomes (i.e., STDs) and provide preventive education, risk-reduction counseling, and referral for a more detailed physical and laboratory evaluation and specialized counseling.49–54 Specifically, findings from this study suggest that screening for anal sex is a critically important practice given its relatively high prevalence in a short time period and because anal sex may serve as a useful indicator of other sexual risk and STDs. Assessing a history of anal sex in a clinical assessment during the intake procedure or comprehensive medical history is relatively straightforward, thus allowing clinicians to screen adolescents efficiently in general medical settings.

Acknowledgement This study was supported by a grant from the Center for Mental Health Research on AIDS, National Institute of Mental Health, NIH