Author Insights: Time to Take Sex Ed Online

A pair of JAMA authors argue that online sex education will help kids get good information when and where they need it. Image: © iStock.com/gloch

A pair of JAMA authors argue that online sex education will help teens get good information when and where they need it. Image: © iStock.com/gloch

It’s time for evidence-based sexual education to meet teens where they are—online, argue a pair of authors in a JAMA Viewpoint today.

Providing adolescents with factual information about sexual health in public schools, particularly information about contraception, remains controversial in the United States—a situation reflected in the larger ongoing debate in US society about public policy and contraception.

This debate is a long-standing one. A 1966 JAMA editorial (reprinted in JAMA Revisited), noted that the American Medical Association took a stand to support the provision of contraception as an essential part of comprehensive health care, noting that some legal barriers to contraceptive access had been removed and that certain religious groups had softened their position on contraception. Last week, nearly a half century later, the US Supreme Court’s rule to affirm the right of certain employers to forgo providing health coverage for contraception based on religious grounds set off renewed debate about the intersection of public policy, sexual health, and religious convictions.

One way that educators and public health organizations can sidestep the controversy and educate teens about sexual health is to leverage digital tools to make comprehensive sex education (including information about contraception) available online, argue Victor C. Strasburger, MD, of the department of pediatrics at the University of New Mexico School of Medicine and Sarah S. Brown, MSPH, of the National Campaign to Prevent Teen and Unplanned Pregnancy.

 Victor C. Strasburger, MD, of the University of New Mexico School of Medicine and Sarah S. Brown, MSPH, of the National Campaign to Prevent Teen and Unplanned Pregnancy, make a case for online sex education in JAMA. Image: University of New Mexico.


Victor C. Strasburger, MD, of the University of New Mexico School of Medicine and Sarah S. Brown, MSPH, of the National Campaign to Prevent Teen and Unplanned Pregnancy, make a case for online sex education in JAMA. Image: University of New Mexico.

Strasburger discussed the issue with news@JAMA.

news@JAMA: What is the current state of sex education in the United States?

Dr Strasburger: Sex education has been controversial since I was a teen, and it really shouldn’t be. We really do a terrible job of educating kids about sex. Every other western country knows that teaching kids about sex makes them more knowledgeable. Some people think teaching them comprehensively will make them more sexually active, which isn’t true.

Teens get a lot of sex “education” from the media, which doesn’t provide good information about preventing pregnancy and the spread of sexually transmitted disease. It’s foolish to think 1 semester in middle school or high school can counteract the 15 000 sexual references they will see in the media each year.

We’ve come a long way with drug abuse prevention and bullying. But we haven’t made a lot of progress with sex education since I was growing up in the ’60s and ’70s.

news@JAMA: What are the advantages of online sex ed?

Dr Strasburger: The primary advantage is you don’t have to go through a conservative school board to get it implemented. The Internet offers free access to all. It’s also there 24/7. Teens need constant access to information about sexual health. They have questions that develop as situations arise. The Internet is always there. It’s a major resource that we have yet to use appropriately.

news@JAMA: What are the downsides?

Dr Strasburger: There’s a lot of bad information and pornography online. It’s unregulated. We worry that if health professionals create websites, they might be seen [by teens] as too totalitarian. You need teens involved in creating websites that are appealing. You can’t put a textbook online and expect it to be effective.

news@JAMA: How might local programs leverage online materials?

Dr Strasburger: We both feel the good will outweigh the bad if more people join in. It will give local communities more control. Communities vary in how conservative they are in their thinking. Communities can set up their own websites or text answer services.

The Internet can be a useful adjunct to traditional sex education. MTV has an app to identify the nearest place to find condoms. There is a website called bedsider.org that has good information and very funny videos. It takes the stigma out of teaching kids about sex.

news@JAMA: What’s your take-home message?

Dr Strasburger: Kids are getting a lot of sex education now, but it’s the wrong kind. We can use new technology wisely and in ways they will enjoy.

The controversy that exists around sex education is unnecessary and unscientific. There is no evidence that making kids smarter about sex makes them sexually active at a younger age. It’s time for the controversy to end.

Only 10% With Chronic Hepatitis C Complete Successful Treatment

Only 10% of the estimated 3.5 million US residents with chronic hepatitis C are successfully treated to achieve undetectable viral load. (Image:©/IvelinRadkov)

Only 9% of the estimated 3.5 million US residents with chronic hepatitis C are successfully treated to achieve undetectable viral load. (Image:©/IvelinRadkov)

Fewer than 10% of US residents with chronic hepatitis C virus (HCV) infection know of their illness, have access to health care, and have been treated successfully with antiviral therapy, according to a new study.

The finding comes 2 years after the Centers for Disease Control and Prevention recommended 1-time testing for the baby boom generation born between 1945 and 1965, which accounts for about 75% of all HCV infections in the United States. The study’s lead author, Baligh Yehia, MD, MPP, MSHP, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, said the new data provide a baseline of hepatitis C care that health experts can use to monitor the effect and success of screening such a large population.

Reporting today in the journal PLOS ONE, Yehia and his colleagues conducted a meta-analysis to accurately estimate how many US residents with chronic HCV infection have completed the continuum of care from initial infection and diagnosis to treatment that achieves undetectable viral load. The researchers focused on 10 studies published from 2003 to 2013 from among the 10 000 they screened.

Their analysis showed that in the general US population, an estimated 3.5 million people have chronic HCV infection. About half have been diagnosed and are aware of their illness. Of the entire 3.5 million with chronic infection, some 43% had access to outpatient health care, 27% had their diagnosis confirmed with a hepatitis C virus RNA test, 17% had a liver biopsy to stage their disease, 16% had antiviral treatment prescribed, and about 9% achieved an undetectable viral load.

Last month, the Centers for Medicare & Medicaid Services began reimbursing for hepatitis C virus screening for baby boomers and those in high-risk groups. Six months earlier, the US Food and Drug Administration approved sofosbuvir, an oral medication that in clinical trials produced high rates of sustained viral suppression with fewer adverse effects than current treatments.

“The advent of new antiviral agents for hepatitis C will shorten treatment duration, likely increasing the number of people offered treatment, and improving cure rates,” Yehia said in a statement. “However, educating [health professionals] and the general public about prevention, care, and treatment; ensuring access to skilled treatment of hepatitis C; and addressing the high cost of these agents will be critical to maximizing the benefits of these new therapies.”

 

Author Insights: Two Doses of HPV Vaccine Reduce Genital Wart Risk

Lisen Arnheim-Dahlström, PhD, of the Karolinska Institutet in Stockholm, Sweden, and her colleagues provide evidence that 1 or 2 doses of the human papillomavirus vaccine may provide some protection against the development of genital warts. Image: Karolinska Institutet

Lisen Arnheim-Dahlström, PhD, of the Karolinska Institutet, and her colleagues found that 1 or 2 doses of the human papillomavirus vaccine provide some protection against genital warts. Image: Karolinska Institutet

Just 2 doses of the human papillomavirus (HPV) vaccine reduced the risk of young women developing genital warts, although 3 doses provided even greater protection, according to a study published in JAMA today.

A 3-dose regimen of HPV vaccine is recommended for girls and young women in the United States and many other countries to reduce their risk of developing cervical cancer and other HPV-related conditions, such as genital warts. But the multiple-dose regimen, costs, and other concerns have dampened HPV vaccine’s uptake. According to the US Centers for Disease Control and Prevention, in 2012 only one-third of US teens received all 3 doses of the vaccine and a little more than half received at least 1 dose.

Some previous studies have suggested that fewer than 3 doses of the HPV vaccine may also reduce the effects of the virus to some extent. Now, Lisen Arnheim-Dahlström, PhD, of the Karolinska Institutet in Stockholm, Sweden, and her colleagues provide evidence that 1 or 2 doses may provide some protection against the development of genital warts, or condylomas.

The researchers followed a cohort of more than 1 million Swedish females between the ages of 10 and 24 years between 2006 and 2010. They identified 20 383 new cases of genital warts, including 322 that occurred among individuals who received at least 1 dose of the HPV vaccine. The most protection was offered by the 3-dose regimen, which was associated with incidence of 459 fewer cases of genital warts per 100 000 person-years. A 2-dose regimen was slightly less effective, reducing cases by 400 per 100 000 person-years. Receiving 1 dose of HPV vaccine reduced cases by 384 per 100 000 person-years.

Dr Arnheim-Dahlström spoke with news@JAMA about the results.

news@JAMA: Why did you decide to look at genital warts as an end point?

Dr Arnheim-Dahlström: Condyloma represents the earliest measurable disease outcome for the HPV vaccine, as the incubation time for condyloma is much shorter than for precancerous lesions of the cervix or cervical cancer.

news@JAMA: Do you think your findings strengthen the case that 2 doses might be enough to protect against HPV-related disease?

Dr Arnheim-Dahlström: The immunogenicity trials show that 2 doses mount high antibody responses against HPV types in the vaccine, and our study shows that receiving 2 doses was associated with substantial risk reduction. However, it is important to further evaluate this finding with cervical cancer as the end point.

news@JAMA: Are your results generalizable to the United States?

Dr Arnheim-Dahlström: Approximately 30% of the targeted population [adolescent girls aged 13-17 years] were vaccinated, which I think is comparable to the US vaccination rates. The result from our study is probably generalizable to the situation in the United States.

news@JAMA: Could HPV infections contracted before vaccination have affected your findings?

Dr Arnheim-Dahlström: It may be so that some study participants had an infection prior to vaccination. We do not know this because we could not measure HPV status in this study. However, we included into our statistical model buffer periods to account for [prior] infections.

news@JAMA: What questions remain to be answered?

Dr Arnheim-Dahlström: Will 3 doses still offer protection when measured with longer follow-up time? Will the results be different or the same when we study girls who received the vaccine when they are younger, 10 to 12 years? What about when higher vaccination coverage and herd immunity may be achieved? Further, what will the result be when we study outcomes such as precancerous lesions of the cervix.

news@JAMA: What would you say is the main take-home message?

Dr Arnheim-Dahlström: There are several important messages. This study is an important complement to the clinical trials, as they have data only on immunogenicity by dose level and not disease outcomes. Further, our population-based study may also be more generalizable to the more diverse populations actually getting vaccinated.

Still, the most important outcomes—precancerous lesions and cervical cancer—need to be studied as well. Clinicians and patients should stick to the recommended dose schedule until new recommendations are made.

Newly Discovered Protein Helps Mycoplasma Evade Immune Response

Protein M binds with myriad antibodies, potentially helping bacteria establish chronic infection. (Image: Christina Corbaci and Rajesh K. Grover)

Protein M binds with myriad antibodies, potentially helping bacteria establish chronic infection. (Image: Christina Corbaci and Rajesh K. Grover)

Researchers have discovered a new bacterial protein with a unique structure that shields antigens from antibodies poised to attack. Dubbed Protein M, the molecule could have implications for developing new antibacterial treatments.

Investigators at the Scripps Research Institute in La Jolla, California, and several other institutions made the discovery while studying multiple myeloma, a B-cell cancer that can result from chronic infection with certain pathogens including Escherichia coli and hepatitis C virus. Their study, published online today in Science, focused on experiments with Mycoplasma, a bacterial parasite that causes chronic infection.

Using samples of antibodies taken from 20 patients with multiple myeloma, the research team found that every antibody sample they tested reacted to a protein produced by Mycoplasma genitalium, which causes human sexually transmitted disease. Protein M, as they named it, didn’t react only with antibodies specifically programmed to fight M genitalium. Protein M could bind to any of the antibodies it encountered, making it a kind of universal decoy that could neutralize the entire antibody response.

The investigators suspect that Protein M evolved to help M genitalium, which has a tiny bacterial genome, survive by fooling the body’s immune response. “The smallest parasitic bacteria on planet Earth seems to have evolved the most sophisticated” evasive mechanism, lead author Rajesh Grover, PhD, of Scripps, said in a statement.

Grover said Protein M’s distinct structure extends “like a tail, over the antibody’s main antigen-binding region.” A search of thousands of known structures in the Protein Data Bank, a worldwide database, came up with none other like it.

“Protein M may be particularly important for large-scale purification of therapeutic antibodies,” Grover and his collaborators wrote. It could also become a target for new drugs aimed at chronic infection with M genitalium and other microbes that can contribute to cancer and inflammatory diseases.

New Assay Developed for Rapid Chlamydia Diagnosis

A new assay can detect Chlamydia trachomatis from a urine sample in less than 20 minutes, according to a new study. (Image: chemicalbilly/iStock.com)

A new assay can detect Chlamydia trachomatis from a urine sample in less than 20 minutes, according to a new study. (Image: chemicalbilly/iStock.com)

A sensitive new assay that detects Chlamydia trachomatis in less than 20 minutes may help many more patients in clinics and other point-of-care settings learn they have the bacterial infection and receive prompt treatment to prevent severe complications.

The assay uses recombinase polymerase amplification (RPA), a nucleic acid amplification technique that identifies C trachomatis directly from urine samples. Other nucleic acid amplification methods such as polymerase chain reaction are highly sensitive, but they’re time-consuming and require trained personnel and costly automated equipment to produce test results.

Having a rapid assay for use in sexually transmitted disease clinics and other point-of-care settings is important because the infection often is asymptomatic and therefore goes undiagnosed. Studies also show that among patients who are tested for C trachomatis, up to 50% never return for their test results or recommended treatment.

The infection may cause nongonococcal urethritis in men and a number of reproductive tract infections in women, including cervicitis and pelvic inflammatory disease. Left untreated, C trachomatis infection increases the risk of ectopic pregnancy and is a leading cause of infertility worldwide. About 5% to 10% of the population has the infection.

In their study appearing online today in the Journal of Molecular Diagnostics, researchers in Estonia reported results using the RPA assay to test urine samples from 70 patients—51 women and 19 men, all aged 18 to 25 years. C trachomatis infection is particularly prevalent among young adults up to age 25 years.

Test results showed the assay had a specificity of 100% and a sensitivity of 83%, meaning that it correctly identified negative test results 100% of the time and accurately detected positive results 83% of the time.

The researchers noted that other existing point-of-care tests for C trachomatis are 96% to 99% specific but sensitivity is only 10% to 40%. Such performance “has limited their wider use, and there is a clear requirement for more sensitive and cost-effective diagnostic platforms,” they wrote. The RPA assay, they concluded, “takes only 15 to 20 minutes and does not require expensive machinery, which makes it potentially applicable in point-of-care settings.”

Latent HIV Reservoir May Be Larger Than Previous Estimates

The latent HIV reservoir in people who are infected could be 60 times larger than previously estimated, according to a new study. Image:  JAMA, ©AMA

The latent HIV reservoir in people who are infected could be 60 times larger than previously estimated, according to a new study. Image: JAMA, ©AMA

The sleeping giant of HIV infection—a reservoir of viral DNA that lies dormant in human immune cells—could be far larger than previously believed.

A study published today in the journal Cell shows that the reservoir, consisting of proviruses integrated into resting CD4 immune cells, may be 60 times larger than scientists had estimated. Antiretroviral therapy (ART) kills replicating HIV but not the latent proviruses, which pose a major barrier to eradicating the virus from the body and curing infection.

Recent research had indicated that fewer than 1% of proviruses become infectious when resting CD4 cells are activated in a test tube. Without activation, proviruses can’t replicate. The proviruses that don’t cause infection have been considered defective, but investigators hadn’t described specifics about the deficiencies.

In the new study, a team of investigators used a more detailed method to study proviruses that didn’t switch on and become infectious when the resting CD4 cells they inhabited were activated in the laboratory. They cloned the genomes of 213 inactive proviruses from 8 HIV-infected patients treated with ART for more than 6 months. Their genetic analyses showed that about 88% of proviruses that didn’t turn on had obvious defects that prevented them from replicating. But nearly 12%—a far greater percentage than previously estimated—were capable of replicating and causing infection.

The investigators said their study suggests that there are enough proviruses that don’t turn on but are capable of replicating to boost the size of the latent reservoir by 60-fold. “These results indicate an increased barrier to cure, as all intact noninduced proviruses need to be eradicated,” senior author Robert Siliciano, MD, PhD, of Johns Hopkins University School of Medicine in Baltimore, said in a statement.

“We would like to use these findings by developing better ways to measure the size of the latent reservoir in patients who are participating in future trials of potentially curative strategies,” Siliciano added. “In this way, we think our analysis will contribute to HIV eradication efforts.”

Unintended Consequences: Improved Living Conditions and Safer Sex May Be Putting Teens at Higher Risk for Genital Herpes

A lack of childhood exposure to herpes simplex virus type 1 puts teens at higher risk of developing genital herpes, a new study suggests. (Image: diane39/iStockphoto.com)

A lack of childhood exposure to herpes simplex virus type 1 puts teens at higher risk of developing genital herpes, a new study suggests. (Image: diane39/iStockphoto.com)

A new study suggests fewer US teens have been exposed in their childhood to herpes simplex virus type 1 (HSV-1), a common cause of cold sores. And although that sounds like a positive trend, it may not be, because these teens then lack antibodies to prevent genital herpes when they become sexually active. The study appears online today in The Journal of Infectious Diseases.

The study authors, researchers with the US Centers for Disease Control and Prevention and Emory University School of Medicine in Atlanta, estimated that among adolescents aged 14 to 19 years assessed with blood tests from 2005 through 2010, about 30% had antibodies produced by exposure to HSV-1, a 23% decrease from the 39% of adolescents with HSV-1 antibodies in 1999 through 2004. The authors said such a decline in HSV-1 seroprevalence has occurred in other industrialized countries over the past 20 years, which suggests that improvements in living conditions, better hygiene, and less crowding are likely reasons for the decline in childhood-acquired HSV-1.

While prevalence of childhood-acquired HSV-1 (which is usually contracted through skin-to-skin contact with an infected adult) has declined, other studies have found the proportion of genital herpes caused by HSV-1 compared with HSV-2 (which is usually transmitted through sexual contact) has increased. “Declines in early childhood acquisition of HSV-1 mean more young people are susceptible to genital HSV-1 infection, and symptomatic HSV-2 disease is more likely among persons lacking HSV-1 antibodies,” the authors wrote.

In an accompanying editorial commentary, the author noted that promotion of “safe sex” to decrease risk of acquiring HIV and to prevent pregnancy has led to an increase in oral sex, which could greatly increase the chances of acquiring HSV-1 during adolescence or early adulthood and greatly increase the number of people able to transmit the virus. “We saw an epidemic of genital herpes caused by HSV-2 in the 1980s when 15%-20% of the population had HSV-2 infections. Imagine the consequences with >50% of the population intermittently shedding virus orally and also engaging in oral sex practices with sero-negative partners,” the editorial author wrote.

The editorial author added that the most serious consequence of genital herpes is transmission of HSV to an infant at the time of delivery because infants lack a mature immune system to battle the virus. Up to 30% infants with the most severe form of HSV disease (disseminated disease) die.