1. Wisconsin Department of Health Services January 2014 P-00522N Healthiest Wisconsin 2020 Baseline and Health Disparities Report Reproductive and Sexual Health

2. REPRODUCTIVE AND SEXUAL HEALTH Background Overview of Healthiest Wisconsin 2020 Baseline and Health Disparities Report Healthiest Wisconsin 2020 objectives and indicators Rationale Key points Data Births to teens Sexually transmitted diseases HIV Sexual risk behaviors among youth References Links to additional reports and resources Contacts Chapter Outline 2 Chapter outline

3. REPRODUCTIVE AND SEXUAL HEALTH Report Overview This chapter is part of a larger report created by the Wisconsin Department of Health Services to track progress on the objectives of Healthiest Wisconsin 2020 (HW2020) and identify health disparities in the state. The full report is available at: http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf The report is designed to address the Health Focus Areas in HW2020. Where direct measures exist, data are presented; where direct measures are not available, related information may be included. Information about populations experiencing health disparities is provided in the Health Focus Area chapters and is summarized in separate chapters devoted to specific populations. Technical notes are available at: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf Report overview 3

4. REPRODUCTIVE AND SEXUAL HEALTH Report Format Full Report Format: PDF Intended use: reference document Chapters Format: Annotated PowerPoint slide set Intended uses: presentations to –Decision-makers –Service providers –Community leaders –The public Sample annotated slide Report overview 4

5. REPRODUCTIVE AND SEXUAL HEALTH Report Outline Executive Summary Section 1: Introduction Section 2: Demographic overview Section 3: Health focus areas Section 4: Infrastructure focus areas Section 5: Data summaries by population Section 6: Technical notes Report overview 5

6. REPRODUCTIVE AND SEXUAL HEALTH Report Outline: Detail Section 3: Health focus areas Alcohol and other drug use Chronic disease prevention and management Communicable diseases Environmental and occupational health Healthy growth and development Injury and violence Mental health Nutrition and healthy foods Oral health Physical activity Reproductive and sexual health Tobacco use and exposure Section 4: Infrastructure focus areas Access to health care Report overview 6

7. REPRODUCTIVE AND SEXUAL HEALTH Report Outline: Detail Section 5: Data summaries by population  Racial/ethnic minority populations o American Indians o Asians o Blacks o Hispanics  People of lower socioeconomic status  People with disabilities  Lesbian, gay, bisexual, and transgender populations  Geography Report overview 7

8. REPRODUCTIVE AND SEXUAL HEALTH Data notes Please refer to the Technical Notes chapter for a more detailed description of limitations and methods: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf The 95% confidence intervals are denoted by error bars. Where confidence intervals do not overlap, as shown in the example on the right, differences are statistically significant. Larger confidence intervals may indicate less reliable estimates that should be interpreted with caution. Population estimates that are considered unreliable are excluded. Misclassification of racial/ethnic groups may affect the accuracy of rates. Unless otherwise indicated, the Hispanic population may include people of various races; Whites, Blacks, Asians, and American Indians are non- Hispanic. Report overview 8

9. REPRODUCTIVE AND SEXUAL HEALTH Factors that influence health Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, http://www.countyhealthrankings.org/our-approach Report overview 9

10. REPRODUCTIVE AND SEXUAL HEALTH Healthiest Wisconsin 2020 objectives and indicators Objective 1 By 2020, establish a norm of sexual health and reproductive justice across the life span as fundamental to the health of the public. Objective 1 Indicators Percentage of sexually active high school students who reported that they or their partner had used a condom during last sexual intercourse. Unintended pregnancy rates. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Reproductive and Sexual Health Focus Area Profile. 10 HW2020 objectives

11. REPRODUCTIVE AND SEXUAL HEALTH Objective 2 By 2020, establish social, economic and health policies that improve equity in sexual health and reproductive justice. Objective 2 Indicators Periodic inventory of state policies and funding targeted to achieving this objective. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Reproductive and Sexual Health Focus Area Profile. 11 HW2020 objectives Healthiest Wisconsin 2020 objectives and indicators

12. REPRODUCTIVE AND SEXUAL HEALTH Healthiest Wisconsin 2020 objectives and indicators Objective 3 By 2020, reduce the disparities in reproductive and sexual health experienced among populations of differing races, ethnicities, sexual identities and orientations, gender identities, and educational or economic status. Objective 3 Indicators Racial and ethnic disparities in births to teens, unintended pregnancies, and STD and HIV rates. HIV prevalence for men who have sex with men and others by race and ethnicity. Education and income disparities in sexual behavior indicators. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Reproductive and Sexual Health Focus Area Profile. 12 HW2020 objectives

13. REPRODUCTIVE AND SEXUAL HEALTH Rationale Reproductive and sexual health includes the factors that affect physical, emotional, mental, and social well-being related to reproduction and sexual health across the life span. Unintended pregnancies, sexually transmitted diseases (STDs), and HIV result in significant health and economic consequences for individuals and society. A woman with an unintended pregnancy is less likely to seek early prenatal care and is more likely to expose the fetus to harmful substances, such as tobacco or alcohol. STDs and HIV may result in serious outcomes including cancers, infertility, ectopic pregnancy, miscarriages, stillbirth, low birthweight, neurologic damage, and death. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Reproductive and Sexual Health Focus Area Profile 13 Rationale

14. REPRODUCTIVE AND SEXUAL HEALTH Key points Milwaukee ranks second among large cities in the United States for rates of chlamydia and gonorrhea and sixth for the percent of births that are to teens. Rates of teen birth, STDs, and HIV are significantly higher in Milwaukee than in the rest of Wisconsin. Teen birth rates declined for all racial/ethnic groups from 2001 to 2010, while Chlamydia rates increased. Blacks have significantly higher rates of births to teens, STDs, and HIV compared to Whites. Teen birth rates are also high among American Indians and Hispanics. 14 Key points

15. REPRODUCTIVE AND SEXUAL HEALTH Key points Sexual minority youth have higher rates of sexual risk behaviors compared to sexual majority youth. One-third of Wisconsin adults report having had an HIV test and 4% have been in an HIV risk situation in the past year. Rates for both these measures are higher among: –Milwaukee residents –Blacks compared to other racial/ethnic groups –Low-income residents –People with a disability –Men who have sex with men (MSM) For both men and women, HIV rates are highest among Blacks. In Wisconsin in 2011, nearly one in four Black MSM was estimated to be HIV-positive, compared to 7% of Hispanic and 3% of White MSM. 15 Key points

16. REPRODUCTIVE AND SEXUAL HEALTH Births to teens 16

17. REPRODUCTIVE AND SEXUAL HEALTH Births to teens by race/ethnicity, ages 15-19, rate per 1,000, Wisconsin, 2000-2010 Source: Wisconsin Department of Health Services, Division of Public Health, Office of Health Informatics, Births to Teens in Wisconsin, 2010. Births to teens 17

18. REPRODUCTIVE AND SEXUAL HEALTH Births to teens ages 15-19, as a percent of all births, by race/ethnicity, Wisconsin, 2000-2010 Percent of all births Source: Wisconsin Department of Health Services, Division of Public Health, Office of Health Informatics: Births to Teens in Wisconsin, 2010. January 2012. Births to teens 18

19. REPRODUCTIVE AND SEXUAL HEALTH Sexually transmitted diseases 19

20. REPRODUCTIVE AND SEXUAL HEALTH Reported cases of chlamydia, rate per 100,000, Milwaukee County and Wisconsin excluding Milwaukee County, 2001-2010 Source: Wisconsin Department of Health Services, Sexually Transmitted Disease Program. Sexually transmitted diseases 20

21. REPRODUCTIVE AND SEXUAL HEALTH Reported cases of chlamydia by age group, rate per 100,000, Milwaukee County and Wisconsin excluding Milwaukee County, 2010 Source: Wisconsin Department of Health Services, Sexually Transmitted Disease Program. Sexually transmitted diseases 21

22. REPRODUCTIVE AND SEXUAL HEALTH Reported cases of syphilis, rate per 100,000, Milwaukee County and Wisconsin excluding Milwaukee County, 2001-2010 Source: Wisconsin Department of Health Services, Sexually Transmitted Disease Program. Sexually transmitted diseases 22

23. REPRODUCTIVE AND SEXUAL HEALTH Reported cases of selected sexually transmitted diseases, rate per 100,000, by race/ethnicity, Wisconsin, 2010 White Black Hispanic Asian American Indian Source: Wisconsin Department of Health Services, Sexually Transmitted Diseases Program. 23 Sexually transmitted diseases

24. REPRODUCTIVE AND SEXUAL HEALTH HIV 24

25. REPRODUCTIVE AND SEXUAL HEALTH Reported cases of HIV, rate per 100,000, Milwaukee County and Wisconsin excluding Milwaukee County, 2002-2011 Source: Wisconsin HIV Surveillance System. HIV 25

26. REPRODUCTIVE AND SEXUAL HEALTH Reported cases of HIV by age group, rate per 100,000, Milwaukee County and Wisconsin excluding Milwaukee County, 2011 Source: Wisconsin HIV Surveillance System. HIV 26

27. REPRODUCTIVE AND SEXUAL HEALTH Reported cases of HIV (ages 15-59) by race and ethnicity, rate per 100,000, Wisconsin, 2007-2011 Source: Wisconsin HIV Surveillance System. Note: Hispanic population may include individuals of various races. 27 HIV

28. REPRODUCTIVE AND SEXUAL HEALTH Less than 1.5% Estimated HIV prevalence within demographic group Demographic Group Estimated prevalence of HIV in selected demographic groups, ages 15- 59, by race/ethnicity, Wisconsin, as of December 31, 2012 Source: Wisconsin Department of Health Services, Wisconsin HIV Surveillance System. Note: MSM = Men who have sex with men. The estimated prevalence is adjusted to account for the CDC’s estimate that 18% of HIV-infected persons are unaware of their infection and therefore not reported. The MSM population for each racial/ethnic group uses the CDC’s estimate that 4% of adult males are MSM 28 HIV

29. REPRODUCTIVE AND SEXUAL HEALTH Rates of HIV testing and risk among Wisconsin adults, by sex, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 combined landline-cell dataset. HIV 29

30. REPRODUCTIVE AND SEXUAL HEALTH Rates of HIV testing and risk among Wisconsin adults, by age, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 combined landline-cell dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. HIV 30

31. REPRODUCTIVE AND SEXUAL HEALTH Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Testing rates are not age-adjusted; rates of exposure to high-risk situations are age-adjusted. Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Rates of HIV testing and age-adjusted risk behaviors among Wisconsin adults, by race/ethnicity, 2008-2011 31 HIV

32. REPRODUCTIVE AND SEXUAL HEALTH Rates of HIV testing and age-adjusted risk behaviors among Wisconsin adults, by household income, 2008-2011 HIV Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Testing rates are not age-adjusted; rates of exposure to high-risk situations are age-adjusted. 32

33. REPRODUCTIVE AND SEXUAL HEALTH Rates of HIV testing and age-adjusted risk behaviors among Wisconsin adults, by level of urbanization, 2008-2011 HIV Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Testing rates are not age-adjusted; rates of exposure to high-risk situations are age-adjusted. 33

34. REPRODUCTIVE AND SEXUAL HEALTH Rates of HIV testing and risk among Wisconsin adult ages 18-64, by disability status, 2008-2011 HIV Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. 34

35. REPRODUCTIVE AND SEXUAL HEALTH Rates of HIV testing and risk among Wisconsin men, by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. 35 HIV

36. REPRODUCTIVE AND SEXUAL HEALTH Sexual risk behaviors among youth 36

37. REPRODUCTIVE AND SEXUAL HEALTH Estimated prevalence of sexual risk behaviors among Wisconsin high school students by race/ethnicity, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. 37 Sexual risk behaviors among youth

38. REPRODUCTIVE AND SEXUAL HEALTH Estimated prevalence of sexual risk behaviors among Wisconsin high school students by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. 38 Sexual risk behaviors among youth

39. REPRODUCTIVE AND SEXUAL HEALTH References 1.University of Wisconsin Population Health Institute. County Health Rankings, 2013. http://www.countyhealthrankings.org/our-approach http://www.countyhealthrankings.org/our-approach 2.Center for Urban Population Health. Milwaukee Health Report, 2011. http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf 3.LaVeist TA, Gaskin DA, Richard P (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf 4.Thomas JC, Sage M, Dillenberg J, Guillory VJ (2002). A Code of Ethics for Public Health. Am Journal of Public Health. 92(7):1057–1059. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ 5.Wisconsin Department of Health Services (DHS). Healthiest Wisconsin 2020. http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf 6.Centers for Disease Control and Prevention (CDC). Birth Rates for the United States: Teenagers Reach Historic Lows for All Age and Ethnic Groups. http://www.cdc.gov/nchs/data/databriefs/db89.pdf http://www.cdc.gov/nchs/data/databriefs/db89.pdf 7.National Center for Health Statistics. Child Trends analysis of 1990-2009 Natality microdata files from Centers for Disease Control and Prevention. http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?loct=3&by=v&order =d&ind=4&dtm=252&tf=38 http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?loct=3&by=v&order =d&ind=4&dtm=252&tf=38 39 References

40. REPRODUCTIVE AND SEXUAL HEALTH 8.Wisconsin Department of Health Services (DHS). Sexually Transmitted Diseases in Wisconsin, 2010. http://www.dhs.wisconsin.gov/communicable/std/Statistics/AnnualData/2010data/201 0WisconsinSummaryReport.pdf http://www.dhs.wisconsin.gov/communicable/std/Statistics/AnnualData/2010data/201 0WisconsinSummaryReport.pdf 9.CDC. 2010 Sexually Transmitted Diseases Surveillance. Cases of Sexually Transmitted Diseases Reported by State Health Departments and Rates per 100,000 Population, United States, 1941-2010. http://www.cdc.gov/std/stats10/tables/1.htmhttp://www.cdc.gov/std/stats10/tables/1.htm 10.CDC. 2010 Sexually Transmitted Diseases Surveillance. National Profiles – Chlamydia. http://www.cdc.gov/std/stats10/chlamydia.htmhttp://www.cdc.gov/std/stats10/chlamydia.htm 11.CDC. 2010 Sexually Transmitted Diseases Surveillance. National Profiles – Gonorrhea. http://www.cdc.gov/std/stats10/gonorrhea.htmhttp://www.cdc.gov/std/stats10/gonorrhea.htm 12.Wisconsin DHS. Sexually Transmitted Disease Surveillance. http://www.dhs.wisconsin.gov/communicable/STD/Statistics/Index.htm http://www.dhs.wisconsin.gov/communicable/STD/Statistics/Index.htm 13.Wisconsin DHS. Syphilis Fact Sheet. http://www.dhs.wisconsin.gov/publications/p4/p42095.pdf http://www.dhs.wisconsin.gov/publications/p4/p42095.pdf 14.CDC. 2010 Sexually Transmitted Diseases Surveillance. National Profiles – Syphilis. http://www.cdc.gov/std/stats10/syphilis.htm http://www.cdc.gov/std/stats10/syphilis.htm 40 References

41. REPRODUCTIVE AND SEXUAL HEALTH 15.Wisconsin AIDS/HIV Surveillance Data Update. Milwaukee County, 2010: http://www.dhs.wisconsin.gov/aids- hiv/Stats/MilwaukeeReports/ExecSumMKECounty2010.pdf http://www.dhs.wisconsin.gov/aids- hiv/Stats/MilwaukeeReports/ExecSumMKECounty2010.pdf 16.Lieb S. et al. Statewide estimation of populations of MSM in the United States. Public Health Reports 2011;126(1):60–72. 17.CDC. HIV in the United States: At A Glance, 2013. http://www.cdc.gov/hiv/resources/factsheets/PDF/stats_basics_factsheet.pdf http://www.cdc.gov/hiv/resources/factsheets/PDF/stats_basics_factsheet.pdf 18.CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm 19.CDC. Sexual and Reproductive Health of Persons Aged 10–24 Years. http://www.cdc.gov/healthyyouth/sexualbehaviors/srh.htm http://www.cdc.gov/healthyyouth/sexualbehaviors/srh.htm 41

42. REPRODUCTIVE AND SEXUAL HEALTH Links to additional reports and resources Births to Teens in Wisconsin, 2010: http://www.dhs.wisconsin.gov/publications/P4/P45365-10.pdf http://www.dhs.wisconsin.gov/publications/P4/P45365-10.pdf Sexually Transmitted Diseases in Wisconsin, Statistics and Reports: http://www.dhs.wisconsin.gov/communicable/STD/Statistics/Index.htm http://www.dhs.wisconsin.gov/communicable/STD/Statistics/Index.htm Wisconsin AIDS/HIV Program, Statistics and Reports: http://www.dhs.wisconsin.gov/aids-hiv/ http://www.dhs.wisconsin.gov/aids-hiv/ Wisconsin Youth Sexual Behavior and Outcomes: http://www.dhs.wisconsin.gov/lgbthealth/HealthReports/index.htm http://www.dhs.wisconsin.gov/lgbthealth/HealthReports/index.htm Wisconsin YRBS and Sexual Minority Youth: http://www.dhs.wisconsin.gov/lgbthealth/HealthReports/index.htm http://www.dhs.wisconsin.gov/lgbthealth/HealthReports/index.htm Lesbian, Gay, Bisexual, Transgender Health in Wisconsin: http://www.dhs.wisconsin.gov/lgbthealth/ http://www.dhs.wisconsin.gov/lgbthealth/ Centers for Disease Control and Prevention (CDC). Sexual Health. http://www.cdc.gov/sexualhealth/ http://www.cdc.gov/sexualhealth/ 42 Links

43. REPRODUCTIVE AND SEXUAL HEALTH Contacts Division of Public Health Wisconsin Department of Health Services Births to Teens Katherine Kvale, PhD Maternal and Child Health Epidemiologist Bureau of Community Health Promotion Email: Katherine.Kvale@dhs.wisconsin.govKatherine.Kvale@dhs.wisconsin.gov Sexually Transmitted Diseases Brandon Kufalk Disease Intervention Specialist/Surveillance Coordinator Wisconsin Sexually Transmitted Disease Section Bureau of Communicable Diseases and Emergency Response Email: Brandon.Kufalk@dhs.wisconsin.govBrandon.Kufalk@dhs.wisconsin.gov AIDS/HIV Mari Gasiorowicz, MS HIV and Health Disparities Epidemiologist AIDS/HIV Program Bureau of Communicable Diseases and Emergency Response Email: Mari.Gasiorowicz@dhs.wisconsin.govMari.Gasiorowicz@dhs.wisconsin.gov 43 Contacts