Advancing Sexual and Reproductive Health and Rights
 
Perspectives on Sexual and Reproductive Health
Volume 36, Number 1, January/February 2004
FYI


SITCOM AS SEX EDUCATOR?

Entertainment television, especially when supplemented by parental discussion, can be "a positive force in the sex education of youth."1 In 2001, a character on the sitcom Friends had an unintended pregnancy after a single act of intercourse with an ex-boyfriend; during one episode, a conversation between the couple revealed that they had used a condom, but they acknowledged an awareness that condoms are only 97% effective. What messages did the episode's 1.7 million 12-17-year-old viewers take away? One-third of a sample of 323 youngsters surveyed 3-4 weeks after the episode aired recalled that the characters had used a condom; 15% remembered hearing that condoms were more than 95% but less than totally effective. One in 10 young viewers said they had learned something about condoms from the episode, but six in 10 understood the message to be that condoms often do not prevent pregnancy. Sixteen percent had discussed the episode with an adult, and these teenagers were more likely than others to have talked with an adult about condom effectiveness or unintended pregnancy. At a six-month follow-up interview, 24% gave correct estimates of condom effectiveness—about the same proportion as found among teenagers who had not seen the Friends episode. The researchers comment that although the episode did not present an unambiguous message, it taught or reminded "potentially huge numbers of adolescents...of the risks accompanying sexual activity."

1. Collins RL et al., Entertainment television as a healthy sex educator: the impact of condom-efficacy information in an episode of Friends, Pediatrics, 2003, 112(5): 1115-1121.

OVER-THE-HILL CHILDBEARING

Childbearing is possible for some women aged 50 and older, but it is associated with risks for both the mother and her infant that exceed those of younger women.1 Analyses of data on all U.S. births from 1997 to 1999 show that rates of several maternal complications—cardiac disease, diabetes, chronic hypertension, eclampsia and placental problems—rise steadily with age. The likelihood that a singleton infant will be low-birth-weight, preterm, very preterm or small for gestational age is significantly higher if the mother is 50 or older than if she is 20-29 years old (odds ratios from analyses controlling for risk-related factors, 1.7-3.0); the odds of fetal death also are elevated if a woman is 50 or older when she conceives (2.2). For all of these outcomes except fetal death, the risks are raised in multiple births, but the differentials are smaller (odds ratios, 1.5-1.6). Notably, the risks of poor outcomes for infants and, to a lesser extent, of maternal complications are markedly higher if the pregnancy occurs at age 50 or later than if a woman conceives in her 40s. Thus, the analysts conclude that pregnancy among older women may entail a distinct pattern of risks that calls for "special counseling both before and after conception."

1. Salihu HM et al., Childbearing beyond maternal age 50 and fetal outcomes in the United States, Obstetrics & Gynecology, 2003, 102(5, part 1): 1006-1014.

TESTING, TESTING...

HIV testing methods that are less invasive or yield more rapid results than standard laboratory tests could help increase testing among people at risk of infection, but results of a seven-state survey conducted in 2000-2001 suggest that individuals at risk often do not know of these methods or are unwilling to use them.1 In a sample comprising 2,836 men who have sex with men, injection-drug users and patients at sexually transmitted disease clinics, only 54% of respondents knew about kits for collecting a blood sample at home and sending it to a laboratory for testing, 42% knew about an oral test and 13% knew of tests that produce rapid results. The proportions who had used these methods were low—4%, 35% and 14%, respectively, of those who were aware of them. With some exceptions, levels of both awareness and use were highest among men who have sex with men. In all three subsamples, regardless of whether respondents had had an HIV test, the predominant reasons for not having used an alternative test were a preference for a "standard test" and concerns about privacy and accuracy. Citing research demonstrating that people who are educated about alternative HIV tests often prefer them, the investigators urge promotion of these tests, accompanied by education for both providers and people at risk of infection.

1. Greensides DR et al., Alternative HIV testing methods among populations at high risk for HIV infection, Public Health Reports, 2003, 118(6):531-539.

THE MORE THINGS CHANGE...

Americans' views about teenage sexual activity were largely constant between 2001 and 2003, but some fairly dramatic changes occurred, according to results of the National Campaign to Prevent Teen Pregnancy's third annual survey exploring the subject.1 One striking change was a drop from 63% to 43% since 2001 in the proportion of adults aged 20 and older who said that teenagers are getting a clear message that adolescent pregnancy is wrong. Between 2002 and 2003 alone, the proportion of 12-19-year-olds who said that young people are embarrassed to admit their sexual inexperience to their friends rose from 19% to 26%, and the proportion who said that it would be easier to postpone sex and prevent pregnancy if teenagers could have more open, honest conversations with parents about these topics shot up from 69% to 88%. As in previous years, the majority of both adults and teenagers in the nationally representative sample believed that society should send a strong abstinence message to teenagers, that this message should be accompanied by information about contraception and that the emphasis on both does not confuse the message.

1. National Campaign to Prevent Teen Pregnancy, America's Adults and Teens Sound Off About Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2003.

PARTNER SERVICES HELP DETECT HIV

As a result of state-sponsored counseling and referral services for partners of persons with newly diagnosed HIV infection, 610 people in North Carolina underwent HIV testing in 2001; 21% tested positive.1 Through voluntary, confidential interviews with 1,379 people with newly reported infection (87% of the state's total), disease intervention specialists identified 1,532 sex or needle-sharing partners, who had potentially been exposed to the virus. After receiving counseling, 488 partners who had never had an HIV test and 122 who had previously tested negative agreed to be tested; 22% and 14%, respectively, were infected. The proportion counseled was significantly higher among partners of whites (90%) than among partners of blacks (84%) and Hispanics (74%), but the proportion tested was lowest among partners of whites (55% vs. 65-93%). Compared with partners of people whose infection was diagnosed at a private facility, partners of those whose HIV had been detected at a public clinic had higher rates of counseling (88% vs. 83%) and testing (68% vs. 61%). Local and state health departments, the analysts conclude, "should consider [partner counseling and referral services] an essential component of any comprehensive HIV-prevention program."

1. Foust E et al., Partner counseling and referral services to identify persons with undiagnosed HIV—North Carolina, 2001, Morbidity and Mortality Weekly Report, 2003, 52(48):1181- 1184.

COCKEYED OPTIMISTS

Although their general profile suggested high risk, most teenagers interviewed at clinics in Connecticut in 1998-2000 did not consider themselves likely to acquire a sexually transmitted disease (STD) in the near future.1 On average, the 209 pregnant, sexually active 14-19-year-olds had initiated sex before the age of 15; half had had unprotected intercourse in the month before the interview. Three in 10 of the young women had had an STD, and four in 10 of these had had more than one. Nevertheless, when asked to rate their chance of acquiring an STD within a year, 89% of those interviewed put it at little or none—including at least 80% of those who had an STD history, those with current symptoms of infection, those reporting recent unprotected sex and those who had had four or more sexual partners. Overall, 21% tested positive for chlamydia or gonorrhea at the time of the interview or within the next 12 months; 81% of this group had considered themselves to have little or no risk of infection. Given the apparent "mismatch between evidence and perceptions of risk," the researchers stress that "more work is necessary to help young women to accurately assess their risk for infection."

1. Ethier KA et al., Adolescent women underestimate their susceptibility to sexually transmitted infections, Sexually Transmitted Infections, 2003, 79(5): 408- 411.

TWO BIRDS WITH ONE STONE

Substituting a vaccine that is active against both hepatitis A and hepatitis B for the hepatitis B vaccine that many public sexually transmitted disease (STD) clinics routinely offer clients would prevent a substantial amount of illness, and would do so cost-effectively.1 Results of an analysis based on a hypothetical cohort of one million adults receiving services at public clinics in 2002 suggest that use of the combined vaccine would be associated with a 22% reduction in the number of overt hepatitis A infections over the next 50 years, and with 17-20% reductions in hospitalizations, liver transplants and deaths resulting from the disease. The $6.2 million added cost of combined immunization would be somewhat offset by $2.5 million in savings owing to declines in costs related to treating hepatitis A. Moreover, according to the analysts, the costs per life-year saved ($20,892) and per quality-adjusted life-year gained ($13,397) meet accepted standards of cost-effectiveness. Use of the combined vaccine would be at least as cost-effective as common STD clinic interventions, including testing HIV-positive women for human papillomavirus.

1. Jacobs RJ and Meyerhoff AS, Cost-effectiveness of hepatitis A/B vaccine versus hepatitis B vaccine in public sexually transmitted disease clinics, Sexually Transmitted Diseases, 2003, 30(11):859-865.

FINE-TUNING CESAREAN RISK

The risk that a woman will require a cesarean the first time she gives birth varies widely, but some measures that are easily assessed early in labor may be key factors.1 In a case-control study of 325 nullip-arous women who delivered in a Colorado hospital in 1998-2001, five factors that were known within two hours of admission were independently associated with the risk of cesarean: A woman's likelihood of having a cesarean increased with her weight (odds ratio, 1.02) and with gestational age (1.1), and was sharply elevated if she had preeclampsia (5.8); the more the cervix dilated and the more progress the fetus made along the birth canal in two hours, the lower the likelihood of this outcome (0.5 and 0.6, respectively). The researchers divided the women into five groups of equal size on the basis of scores calculated from these results; they found that only 5% of women in the group with the lowest scores had cesareans, compared with 86% of those in the highest-scoring group. As the researchers acknowledge, the predictive ability of their model needs to be confirmed. However, they add, if it is validated, the model "would be easy to use during labor and delivery," and could help "avoid the pitfall of proceeding with a long labor or a failed operative vaginal delivery" among women with the greatest risk of requiring a cesarean.

1. Wilkes PT et al., Risk factors for cesarean delivery at presentation of nulliparous patients in labor, Obstetrics & Gynecology, 2003, 102(6):1352-1357.