The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic has surpassed forty years with many medical advancements in prevention and treatment. Often believed to be at negligible or low risk by society at large, sexual minority women have remained understudied regarding their risk of HIV and other sexually transmitted infections (STIs), leaving their sexual health inadequately understood and supported in healthcare and social services. The sexual health of young South Asian sexual minority women, who are multiply minoritized due to their intersecting identities, has been entirely overlooked. This qualitative study aimed to understand the knowledge, attitudes, and practices of young South Asian sexual minority women as it pertains to their HIV/STI risk. Barriers and facilitators to accessing community-based sexual health supports and services were also investigated. A community-engaged approach was taken to develop this study in partnership with the Alliance for South Asian AIDS Prevention to investigate the HIV/STI risk context and sexual health needs of this group residing in the Greater Toronto Area. A maximum variation sampling strategy was used to recruit six young South Asian sexual minority women and semi-structured in-depth interviews were conducted to collect narrative data. Narrative analysis of the data found socio-cultural and structural influences which guide the HIV/STI risk context for this group. The participants illuminated an inadequate understanding of sexual health when engaging in sex with women, an overall low HIV/STI risk perception, barriers to adequate sexual healthcare and health promotion resources, and multiple minority stressors which impacted their access to safe sex. These findings have major implications for school-based sexual health education, medical training for healthcare practitioners, and sexual health support and services provided by community-based sexual health organizations in the Greater Toronto Area. / Thesis / Master of Public Health (MPH)

PROBLEM STATEMENT: Globally, 70% of more than three million new curable sexually transmitted infections (STI) are among 15-24 year olds, with young people in developing countries bearing the highest burden. Chlamydia Trachomatis prevalence, for example, is 15.4% and 20.5% in young women and men attending STD clinics in the U.S. However, Caribbean STI data for young men are particularly scarce and inconsistent and cases are under-reported due to poor health seeking behavior. In Guyana, 42% of the STI cases from 2010 -2014 occurred in young people, aged 15- 24. Moreover, few programs and policies focus specifically on the sexual and reproductive health (SRH) needs of young men. This dissertation explores the contextual and behavioral factors that cause young men’s vulnerability to STI and proposes recommendations for the national response in Guyana. METHODS: Research methods included: 9 focus group discussions (FGDs) with young men, aged 15-18, mothers and fathers and 25 in-depth interviews with representatives from government, community, faith-based and donor organizations. Interviews and FGDs were audiotaped, transcribed, and analyzed for major themes among and across each stakeholder group. Analysis was guided by a socio-ecologic framework and resulted in program and policy recommendations to address vulnerability to STI and augment protective factors against STI in young men in Guyana. RESULTS: Salient overarching themes include: Poverty and Disenfranchisement “Yes, this is a Man”: Early Sex, Fast Money, and Risk”, “The Empty Room: Young Men without Male Roles Models”, “Sex in a violent society”, “Stigma, Discrimination, and Shame: Road blocks to young men’s sexual health” and Young men’s Sexual and Reproductive Health: Young men’s Sexual and Reproductive Health: It all depends on family, religion, education, music and media (or not). Participants highlighted a lack of SRH awareness and health care seeking resulting from insufficient male SRH promotion and services. Parental engagement, school attendance, supportive peers, religious commitment and internet use for SRH information were described as protective factors. CONTRIBUTION: A socio-ecological model helped to comprehensively identify and organize broad social determinants of SRH and high risk sexual behaviors for young men. The resulting program and policy recommendations are proposed for implementation in Georgetown, Guyana. / 2018-11-08T00:00:00Z

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Background: Selected factors place Dominican female adolescent and adults at risk for sexually transmitted infections (STIs) such as Chlamydia, causative organism Chlamydia trachomatis, and Gonorrhea, causative organism Neisseria gonorrhoeae. The purpose of this study was to determine the prevalence of Chlamydia and Gonorrhea among adolescent and adult females that utilize the clinic in Veron, Dominican Republic. Clinical standards of care for these STIs and educational programs for prevention were developed from the data gathered from this study. Significance at 0.05 ά of the relationship of educational level, management of risk factors and other selected independent variables on prevalence rate of Chlamydia and Gonorrhea in the clinic population of Veron, Dominican Republic were determined. The objectives of the study were to 1) determine the prevalence of adolescent and young adult females diagnosed with Gonorrhea and Chlamydia who visit the clinic for prenatal visits, annual pap smear exams and gynecological complaints; 2) determine the extent to which educational level is a predictor of positive diagnosis or risk for infection of Chlamydia and Gonorrhea and; 3) determine which selected demographic and risk factors are associated with positive test results for Gonorrhea and Chlamydia. Methods: All adolescent and adult females ages 15 years and older visiting the clinic in Veron for prenatal exams, pap smear exams and gynecological complaints between January 28, 2008 – March 3, 2008 were invited to participate in this prevalence study. Of the 90 invited, the accepting sample was 90 who signed an informed consent form. Prior to STI testing each patient completed a verbal interview and questionnaire on sociodemographic characteristics as well as knowledge, attitudes, and beliefs related to Chlamydia and gonorrhea, sexual experiences and behaviors and illicit drugs use. Specimens collected from the endocervical canal of each female were tested and results provided within two hours, followed by immediate treatment by a licensed Dominican physician and follow-up care based on the guidelines and standards of care. The data were analyzed using descriptive statistics, chi square, t-test and logistic regression. Results: A total of ninety women participated in the study. Chlamydia was detected in 6.7% of the patient population and Gonorrhea was detected in 22.2% of the patient population. Co-infection of both Chlamydia and Gonorrhea was present in 2 cases. Among the positive Chlamydia tests results, 50% had less than a six-year education and 50% had more then six years of education. In addition, 83.3% of the patients with positive Chlamydia results answered "yes", they could read and 16.6% stated they could not read, while 83.3% of the patients with positive Chlamydia results stated they could write and 16.6% stated they could not write (P>0.05). Among the patients that tested positive for Gonorrhea, 55% stated they had less than six years of formal education and 45% had more than six years of formal education (P>0.05). There were 75% of the patients that tested positive for Gonorrhea that stated they could read and 25% who stated they could not read (P>0.05); while 85% of the patients with positive Gonorrhea results stated they could write and 15% stated they could not write (P> 0.05). Conclusion: Educational level and other selected demographic characteristics and risk factors in this study are not a significant predictor of positive diagnosis or risk of infection for Chlamydia or Gonorrhea. We cannot conclude that specific risk factors are associated with positive test results for Gonorrhea and Chlamydia. For the physicians involved in the clinical decision-making regarding the female patients at the Veron clinic, more data are needed to determine appropriate populations for screening of Gonorrhea and Chlamydia as well as appropriate educational tools on sexually transmitted infections. / Ph. D.

Thesis advisor: Christopher S. Lee / Background: Genital hair removal is a popular practice in Westernized cultures and has been associated with the belief that removal is necessary for hygiene. A body of literature exists that has found that genital hair removal is associated with adverse health outcomes, including sexually transmitted infections (STIs). This dissertation aims to detail the history of the practice, why the hygiene belief exists, and to systematically review the existing literature that assesses genital hair removal and STIs. Methods: Historical, socio-cultural analysis from the feminist perspective was performed on the literature to outline why genital hair removal was adopted at a population level. The STI/genital hair removal literature was systematically reviewed and analyzed utilizing PRISMA guidelines. The data generated did not support meta-analysis. Results: Genital hygiene removal has been normalized in Westernized culture as a compulsory component of genital hygiene, particularly for women. Genital hair removal decreases pubic lice infestations. Genital hair removal increases the incidence of gonorrhea and chlamydia infections in women. The data does not support that genital hair removal is necessary for genital hygiene and may be harmful to genital health. Conclusions: Healthcare providers should ask about genital hair and genital hygiene practices when taking a sexual health or preventative care history. Health care providers can educate patients that genital hair removal is not necessary for genital health. New research inquiries on this topic must account for the normalization of the genital hygiene belief. / Thesis (PhD) — Boston College, 2024. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Background: Sexually transmitted infection (STI) rates represent a significant health disparity among young adult African American women. A major factor contributing to this issue is inconsistent condom use. This is especially a challenge for the state of Georgia, which has a high incidence of STI among the southern states. STI prevention counseling delivery through primary care providers is the primary recommendation from the Centers for Disease Control and Prevention and U.S. Preventive Services Taskforce. However, knowledge, attitudes, and practices of STI prevention counseling by advanced practice registered nurses (APRN) who care for young adult African American women are unknown in Georgia.Purpose: This doctor of nursing practice project investigated knowledge, attitudes, and practices of STI prevention by Georgia APRNs caring for young adult African American women on an outpatient basis and determined congruency of their counseling with primary prevention guide-lines. Methods: The design was descriptive cross-sectional. An online survey using Qualtrics software was distributed via professional listservs and postal mail to eligible Georgia APRNs currently in practice. Participants' knowledge of STI, STI prevention, and current practice guidelines and recommendations were assessed using knowledge questionnaires including true/false and multiple choice questions. Participants' attitudes regarding STI prevention counseling with young African American women and current APRN behaviors, in relation to current practice guidelines, were measured using Likert-type scales. Outcomes: The final sample size included 22 participants. Forty initiated the survey, ten did not meet eligibility criteria, six ended the survey during eligibility screening, and two ended the survey after completing less than seven percent of it. In general, participants were knowledgeable of STI and the majority of participants were knowledgeable of the CDC and USPSTF guidelines. The majority of participants felt comfortable discussing sexual practices with patients and providing feedback and advice on reducing STI risk behavior. However, the majority of participants did not believe that their current practice setting actively supported their delivery of STI prevention counseling. Overall, participants' practices were more congruent with the CDC guidelines compared to the USPSTF guidelines. This was reflected in knowledge and practice behaviors, specifically assessing for STI, providing feedback on risk behavior, and advising on behavior change with STI-infected patients and those at risk for STI. Fewer chose the USPSTF as their established practice guideline. This was revealed in practice behaviors pertaining to 'high-risk' counseling, as few tended to set goals for STI risk behavior change, document behavior goals, refer to STI resources, or follow up with referrals made to other STI risk reduction programs. Practice implications: Although overall APRN knowledge of STI was high, there were some knowledge deficits relating to appropriate barrier methods for viral-based STI and high-risk sexual behaviors associated with HBV. There was also a lack of knowledge and practice behaviors of the USPSTF STI prevention counseling guidelines. Therefore, future studies and interventions should aim to educate APRNs about these knowledge and practice insufficiencies.

Background: Adverse childhood experiences (ACEs) are a major public health problem in the US, and have been linked to risky sexual behavior and psychopathology. However, studies examining the link between the wide range of ACEs and sexual health outcomes and behaviors, and the associated mediational role of psychopathology are lacking. Objectives: The main objectives of this dissertation project were: 1) To determine the association between ACEs and sexual health outcomes and behaviors (early sexual debut, intimate partner violence (IPV) perpetration, and HIV/STIs); 2) To examine the disparities among selected populations; and 3) To assess the mediational role of psychopathology in the association between ACEs and sexual health. Methods: Data were obtained from Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic and linear regression models were used to determine the association between ACEs (neglect, physical/psychological abuse, sexual abuse, witnessing parental violence, and parental incarceration/psychopathology) and early age at sexual debut by sex and sexual orientation. Structural equation modeling (SEM) was used to determine the mediational role of psychopathology (PTSD, substance abuse, and depression) in the association between ACE constructs and IPV perpetration, and the role of psychopathology, early sexual debut and IPV perpetration in the association between ACEs and HIV/STIs. Results: The association between ACEs and early sexual debut was generally stronger for women and sexual minorities. Among men, PTSD mediated the association between sexual abuse and IPV perpetration (z=0.004, p = 0.018). However, among men and women, substance abuse mediated the association between physical/psychological abuse and IPV perpetration: z=0.011, p=0.036 and z=0.008, p=0.049, respectively. Among men, PTSD mediated abuse (physical/psychological, and sexual) and parental incarceration/psychopathology; substance abuse mediated abuse and neglect; depression and early sexual debut mediated abuse; and IPV perpetration mediated sexual abuse, and HIV/STIs. Among women, substance abuse mediated neglect and physical/psychological abuse, and depression mediated physical/psychological abuse and HIV/STIs. Conclusions: Intervention and prevention programs geared towards preventing sexual health outcomes and behaviors should employ a life course approach and address ACEs. Treatment components addressing PTSD, substance abuse, and depression should also be added to IPV perpetration and HIV/STI prevention programs.

Considerando as situações de vulnerabilidades individuais, sociais e programáticas presentes nos cotidianos de vida adolescentes perante as Infecções Sexualmente Transmissíveis (IST), avaliadas atualmente como principal fator facilitador da transmissão sexual do Vírus da Imunodeficiência Humana (HIV) e Síndrome da Imunodeficiência Adquirida (AIDS), este estudo objetivou conhecer os elementos que constituem as vulnerabilidades na prevenção das IST/HIV/AIDS de um grupo de adolescentes e identificar suas demandas de cuidado à saúde com base no Modelo Bioecológico do desenvolvimento humano. É um estudo qualitativo, conduzido pelo método Photovoice de Caroline C. Wang, usado parcialmente para coleta de informações. O estudo ocorreu em uma Organização Não Governamental (ONG) situada em um município do oeste de Santa Catarina com a participação de dez adolescentes de ambos os sexos, com idades entre 12 e 18 anos. A pesquisa foi aprovada pelo Comitê de Ética em Pesquisa da Universidade do Estado de Santa Catarina, sob o número 1.267.706. As informações foram interpretadas à luz da Hermenêutica proposta por Paul Ricouer, com suporte no referencial da Vulnerabilidade e do Modelo Bioecológico, emergindo dois temas principais: percepções dos adolescentes perante a prevenção das IST/HIV/AIDS e demandas de cuidado perante a prevenção das IST/HIV/AIDS dos adolescentes. Os resultados sinalizam que o microssistema, ou sistema familiar, é o alicerce do cuidado à saúde sexual dos adolescentes: mesmo que existam constrangimentos e conhecimento incipiente, o que ela ensina repercute em seus comportamentos. O mesossistema, isto é, as vivências com vizinhos e amigos, oportuniza aprendizados; já o exossistema, por meio da ONG, influencia seus crescimentos e desenvolvimento saudáveis; o cronossistema compõe suas histórias de vida, contribuindo com o somatório de conhecimentos que adquirem, enquanto o macrossistema envolve a cultura, as políticas e as ações programáticas de saúde, inseridas nos seus convívios sociais que os fazem perceber a necessidade de autocuidado. Identificou-se que os adolescentes são carentes de informações sobre as IST/HIV/AIDS, sobressaindo o sentimento de vergonha, problemática que também favorece as dificuldades de acesso aos bens e serviços disponibilizados gratuitamente. As demandas de cuidado na saúde sexual englobam o desejo de informações/educação sobre as IST/HIV/AIDS, visitas domiciliares, promoção de campanhas, distribuição de folders e panfletos para despertar nas pessoas a necessidade da prevenção às doenças sexuais. A proposta é empoderar a família porque, como a formadora das bases dos conhecimentos dos adolescentes, poderá contribuir para o não fortalecimento das vulnerabilidades individuais, sociais e programáticas, como também o não favorecimento de ambientes suscetíveis à possibilidade de adoecimento. Acredita-se que os resultados deste estudo fornecem subsídios para o cuidado de enfermagem porque, no âmbito das vulnerabilidades e dos ambientes bioecológicos em que vivem os adolescentes, destacam pontos importantes possíveis de serem incluídos nas estratégias de cuidado à saúde dos mesmos. / Considering situations of individual, social and programmatic vulnerabilities present in the daily lives of adolescents, against Sexually Transmissible Infections (IST), currently evaluated as the main facilitator of sexual transmission of Human Immunodeficiency Virus (HIV) and Syndrome Immunodeficiency Acquired (SIDA). This study aimed to know the elements that constitute vulnerabilities in the prevention of IST/HIV/SIDA of a group of adolescents and to identify their health care demands based on the Bioecological Model of human development. It is a qualitative study, driven by the Photovoice method of Caroline C. Wang, used partially for information gathering. The study was carried out at a non-governmental organization (ONG) located in a municipality in the west of Santa Catarina with the participation of ten adolescents of both sexes, aged between 12 and 18 years. The research was approved by the Research Ethics Committee of the State University of Santa Catarina, under the number 1,267,706. The information was interpreted in the light of the hermeneutics proposed by Paul Ricouer, supported by the Vulnerability and Bioecological Model, with two main themes emerging: adolescents' perceptions regarding IST/HIV/SIDA prevention and care demands for prevention IST/HIV/SIDA of adolescents. The results indicate that the microsystem, or family system, is the foundation of adolescent sexual health care: even if there are constraints and incipient knowledge, what it teaches has repercussions on their behaviors. The mesosystem, that is, the experiences with neighbors and friends opportunize learning; already, the exosystem, through the ONG, influences its healthy growth and development. The chronosystem composes their life histories and thus contributes with the sum of knowledge they acquire, while the macro system involves the culture, the policies and the programmatic actions of health, inserted in their social relations that make them realize the necessity of self-care. It was identified that adolescents lack information about IST/HIV/SIDA, with a feeling of shame, a problem that also favors the difficulties of access to the goods and services available free of charge. The demands for sexual health care include the desire for information / education about IST/HIV/SIDA, home visits, promotion of campaigns, distribution of folders and leaflets to awaken in people the need to prevent sexual diseases. The proposal is to empower the family because, as the founder of the knowledge bases of adolescents, it can contribute to the non-strengthening of individual, social and programmatic vulnerabilities, and the non-favoring of environments susceptible to the possibility of becoming ill. It is believed that the results of this study provide subsidies for nursing care, since, within the scope of the bioecological vulnerabilities and environments in which adolescents live, highlights important and possible points to be included in the health care strategies of the same.

Neisseria gonorrhoeae is an obligate human pathogen that causes the common STI gonorrhea, which presents a growing threat to global health. The WHO estimated 78 million new cases of gonorrhea worldwide in 2017, with estimates of 820,000 new cases in the United States alone according to the CDC. High-frequency phase and antigenic variation inherent in N. gonorrhoeae, coupled with its natural ability to rapidly acquire and stably integrate antimicrobial resistance factors into its genome, have culminated in an infection against which there is no effective vaccine, and for which the list of viable therapeutic options is quickly shrinking. Moreover, no protective immunity against subsequent infections is elicited upon exposure to N. gonorrhoeae, which highlights the need for research of novel antimicrobial and vaccination strategies. Within the human host, N. gonorrhoeae utilizes a unique strategy to overcome host sequestration of essential nutrients – termed nutritional immunity (NI) – such as ions of trace metals. The pathogen produces a family of outer membrane proteins called TonB-dependent transporters (TdTs) capable of binding to host NI factors and stripping them of their nutritional cargo for use by the pathogen. Importantly, these TdTs are very highly conserved and expressed among Neisseria species. TbpA is a well-characterized TdT that allows N. gonorrhoeae to acquire iron from human transferrin, and recent studies from our lab have shown that TdfH is capable of binding to a zinc-sequestering S100 protein called calprotectin and stripping it of its zinc ion. The S100 proteins are EF-hand calcium-binding proteins that naturally play an integral role in Ca2+ homeostasis, but due to their ability to bind transition metals, they have also demonstrated an innate immunity role by participating in nutrient sequestration. The S100 proteins are expressed in all human cells, and all are capable of binding transition metals including zinc, manganese, and cobalt. Calprotectin, S100A7, and S100A12 have demonstrated an ability to hinder the infection potential of pathogenic E. coli, S. aureus, C. albicans, and various other pathogens via zinc sequestration. Herein, we demonstrate that N. gonorrhoeae is able to overcome this phenomenon and actually utilize these proteins as a zinc source in vitro. Furthermore, we identify S100A7 as the specific ligand for TdfJ, which utilizes this ligand to internalize zinc during infection. S100A7 growth support in vitro is dependent upon a functional TonB, TdfJ, and the cognate ABC transport system ZnuABC, and isogenic mutants incapable of producing znuA or tdfJ recover S100A7 utilization by complementation. Whole-cell binding assays and affinity pulldowns show that S100A7 binds specifically to both gonococcal and recombinant TdfJ, and growth and binding experiments show that these described phenomena are specific to human and not mouse S100A7. Finally, we show that a His-Asn double mutant S100A7 that is incapable of binding zinc cannot be utilized for growth by gonococci. These data illustrate the unique nature of the gonococcus’ ability to co-opt host defense strategies for its own purposes, and further identify the TdTs as promising targets for strategies to combat and prevent gonococcal infection.

Sexually transmitted infection (STI) prevalence rates are increasing in the United States and globally. Education has been found to be an important strategy for increasing STI testing and treatment rates among sexually active young adults. The goal of this project was to develop an interactive educational game suitable for young adults to decrease the social and economic burden of STIs. The health belief model informed the project. A moderated usability evaluation was conducted using the concurrent think-aloud technique. The participants (N = 5) were a purposive sample of professionals who played the interactive game and then completed Schnall, Cho, and Lie’s Health-Information Technology Usability Evaluation Scale instrument. The findings revealed the necessity of (a) an introduction screen, (b) a reward system for correct answers, and (c) avatars, while also highlighting that (d) the effect on indicator value bars is difficult to understand and (e) the timer led to a feeling of being rushed. The Cronbach’s alpha for the participant group was 0.798, the subscale “Perceived Ease of Use” achieved an alpha level of 0.815, and the subscale “Perceived Usefulness,” 0.762. Refinements to the game based on these data might help to ensure that use of the interactive game contributes to social change by increasing knowledge of STIs in the young adult population.