STD Case Studies: Case #1.

How to identify an STD

As a part of a community service requirement you are volunteering at the local clinic for
sexually transmitted diseases (STDs). At the clinic you are responsible for conducting intake
interviews. When patients arrive, they fill out a questionnaire and then you take them to an
office to go over their answers with them.
Your first patient is a 22-year-old woman. On the questionnaire, she lists her chief
complaint as “pain in her belly.” You wonder why she has come to the STD clinic for belly pain
and speculate it is because this clinic is the only one in town that is free. You excuse yourself
and ask the head nurse if it okay to continue with this client’s questionnaire. “Why wouldn’t it
be?” is his answer. You say you don’t think belly pain points to a sexually transmitted disease.
The nurse chuckles and says it is one of the most frequent complaints they have in this clinic.

1. What is the association between belly pain and STDs?

2. Pelvic inflammatory disease is usually cased by Chlamydia or Gonorrhea, if left untreated

what are the possible health consequences for this woman?

3. You look further down the questionnaire and see there is a question about the client’s recent
sex partners. She answered that she has had relations only with her boyfriend during the past 12
months. Does the boyfriend need information or treatment? Explain.

4. What type of treatment will this couple receive?

STD Case Studies: Case #2. A case of infidelity?

You met your wife Becky at the local hospital where you are a nurse and she works in
medical records. You were married 18 months ago and now she discovers she is pregnant. You
are both extremely happy and you go together to the obstetrician for here first prenatal visit.
Everything looks good: she is seven weeks into a normal pregnancy. About 10 days later you
come home from work and she is waiting for you in the kitchen, looking very upset. She tells
you that the obstetrician’s office called this afternoon with the news that she has tested positive
for gonorrhea.
She says it must mean that you have been unfaithful to her, since she knows for sure that
she has had no relations with anyone else since you were married. She is so distraught that she
will not listen to what you have to say. She packs a suitcase and drives to here mother’s house
across town.
You believe Becky without question. At the same time, you know that you have also
been faithful.

1. How is this infection possible if both of you have been monogamous for at least two years?

2. What about the immediate problem? Should Becky be treated, even though she is pregnant?
Discuss.

3. What are the risks to the fetus if treated? if untreated?

4. Once these facts are explained to Becky, she calms down. You still wonder if she doubts
your fidelity. You wonder how other couples fare- particularly those who may have less trust in
one another, or who don’t know how to access information about STDs. Speculate about why
Becky’s physician did not explain all the possibilities.
STD Case Studies: Case #3. Poor Jack

Your best friend, Jack (a 30-year-old investment banker), has had a steady girlfriend for
the past six months. He has avoided having sex with her because she told him she has genital
herpes. You remember the day that she told Jack about it; he came over to your house very upset
and the two of you talked for hours about what that meant for Jack. He thought about breaking
up with her because he couldn’t see how they could have a long-term, intimate relationship.
Finally he decided that he did love her and they would figure something out.
Now she wants to take the relationship to the next level, a level that includes sexual
relations. She told Jack that they would do this only if she were lesion-free and that if he wore
wear a condom, they would be fine.
Jack is skeptical. He comes to you for advice.

1. Are they safe if she does not have lesions at the time of their intercourse? Why or why not?

2. Whether Jack’s girlfriend has lesions or not, if he uses a condom will he be protected?

3. If Jack had herpes and his girlfriend was uninfected, would his use of a condom completely
protect her? Explain.

4. What about those new drugs Jack has heard about on TV? Can his girlfriend take those and
cure herself? Or at least avoid infecting him? Give some details.
STD Case Studies: Case #4. Teen Pledges Barely Cut STD Rates

By Ceci Connolly, Washington Post Staff Writer, Saturday, March 19, 2005; Page A03

Teenagers who take virginity pledges -- public declarations to abstain from sex -- are almost as likely to be infected
with a sexually transmitted disease as those who never made the pledge, an eight-year study released yesterday
found.

Although young people who sign a virginity pledge delay the initiation of sexual activity, marry at younger ages and
have fewer sexual partners, they are also less likely to use condoms and more likely to experiment with oral and anal
sex, said the researchers from Yale and Columbia universities.

"The sad story is that kids who are trying to preserve their technical virginity are, in some cases, engaging in much
riskier behavior," said lead author Peter S. Bearman, a professor at Columbia's Institute for Social and Economic
Research and Policy. "From a public health point of view, an abstinence movement that encourages no vaginal sex
may inadvertently encourage other forms of alternative sex that are at higher risk of STDs."

Rates of Disease

The findings are based on the federally funded National Longitudinal Study of Adolescent Health, a survey begun in
1995 that tracked 20,000 young people from high school to young adulthood. At the start of the project, the students
were 12 to 18 years old and agreed to detailed, sexually explicit interviews. They were re-interviewed in 1997 and
again in 2002, when 11,500 also provided urine samples.

Virginity pledges emerged in the early 1990s based on the theory that young people would remain chaste if they had
stronger community support -- or pressure -- to remain abstinent. Programs vary, but in most cases teenagers
voluntarily sign a pledge or publicly announce their intention to abstain from sex. Often pledgers receive a pin or
ring to symbolize the promise and team up with an "accountability partner."

Since it was founded in 1993, the virginity group True Love Waits claims 2.4 million youths have signed a card
stating: "Believing that true love waits, I make a commitment to God, myself, my family, those I date, and my future
mate to be sexually pure until the day I enter marriage."

The study, published in the Journal of Adolescent Health, found that 20 percent of those surveyed said they had
taken a virginity pledge. Bearman and co-author Hannah Bruckner broke them into two categories -- "inconsistent
pledgers" and "consistent pledgers" -- to reflect the fact that some changed their status or their responses between
interviews. Among those youngsters, 61 percent of the consistent pledgers and 79 percent of the inconsistent
pledgers reported having intercourse before marrying or prior to 2002 interviews.

Almost 7 percent of the students who did not make a pledge were diagnosed with an STD, compared with 6.4
percent of the "inconsistent pledgers" and 4.6 percent of the "consistent pledgers." Bearman said those differences
were not "statistically significant," although Robert Rector, who studies domestic policy issues at the conservative
Heritage Institute, said he interpreted the data to mean that young people committed to the abstinence pledge were
less likely to become infected.

The study did not detect major geographic differences but found that minorities were far more likely to have an
STD. About one quarter of African American girls in the survey tested positive for at least one STD in 2002.

In terms of high-risk behavior, the raw numbers were small, but the gap was statistically significant, Bearman said.
Just 2 percent of youth who never took a pledge said they had had anal or oral sex but not intercourse, compared
with 13 percent of "consistent pledgers."

Debate on Abstinence
The report sparked an immediate, bitter debate over the wisdom of teaching premarital abstinence.

Deborah Roffman, an educator and author of "Sex and Sensibility: The Thinking Parent's Guide to Talking Sense
About Sex," said youths who take virginity pledges are often undereducated about sexual health. "Kids who are
engaging in oral sex or anal sex will tell you they are practicing abstinence because they haven't had 'real sex' yet,"
she said.

Ralph DiClemente, a professor at Emory University's School of Public Health in Atlanta, compared virginity
pledges to adults' efforts to make New Year's resolutions.

"I wish it was that easy. We'd all be a lot healthier," he said. "If we can't do it as adults, why would we expect kids to
be able to handle those issues?"

But Joe S. McIlhaney Jr., chairman of the Medical Institute for Sexual Health, said the study offers an incomplete
picture because it could not say whether sexually active teens who did not take a pledge had been pregnant or treated
for an STD before the 2002 testing. The analysis "doesn't prove or disprove" assertions that virginity pledges are
flawed, he said.

On the other hand, Bill Smith, public policy vice president for the Sexuality Information and Education Council of
the United States, said, "Not only do virginity pledges not work to keep our young people safe, they are causing
harm by undermining condom use, contraception and medical treatment."

Conservative academics said the paper overlooked earlier important findings about adolescents who take virginity
pledges, most notably that they have fewer pregnancies and out-of-wedlock births.

"It's hugely successful on those variables," Rector said. "Bearman has focused in on the one variable he thinks can
show they [pledgers] don't do better."

President Bush has requested $206 million in federal funding for abstinence-only programs this year.

Several True Love Waits officials were unavailable Friday, according to a receptionist. Telephone calls to another
virginity group, the Silver Ring Thing, were not returned.

Questions

1. What do you think are the benefits and limitations of an “abstinence-only” sex-education program for high school
students?

2. Based on the article, do you think that virginity pledges for high school students is a good public health
intervention? Why or Why not?

3. What do you think should be included in high school sex-ed classes?

STD Case Studies: Case Study #5. A fatal STD

Janice, a 20 year old college student, came back from her annual doctor’s appointment upset. The results
from her pap smear were “abnormal” and she would need a biopsy to rule out cervical cancer. She had
heard about cervical cancer but didn’t think it could happen to someone her age so she looked for some
information on the internet. What she found surprised and worried her. She learned that each year
approximately 13,000 new cases of cervical cancer are found and that over 4,000 women die of the
disease. This is twice as many as die of HIV/AIDS. She also learned that 93% of cervical cancers are
caused by a virus.

1. What virus is the most common cause of cervical cancer?

2. Janice has only had sexual relationships with two men. With her first boyfriend they always used
condoms, but with the second they were less than perfect. Could she have contracted this virus from
either of the men?

3. Neither of her boyfriends showed any signs of infection, but she still contracted the virus. Explain
how this is possible.

A few weeks later Janice received the results of her biopsy. Fortunately it turned out negative for cervical
cancer although it did indicate she was infected with HPV. She learned that most cases of the virus clear
on their own without treatment, within about 2 years. She vowed to be safer in the future. However,
unless she enters a stable monogamous relationship, explain why she is at risk for infection again (Hint:
approximately what % of the population have this virus).

4. Recently a vaccination for this virus has become available. It is being recommended for girls/women
between 11-26. Why do you think it is targeted to such young women?
STD Case Studies: Case #6. An AIDS outbreak traced to a single infected male

As of July 1997, six sexually transmitted infections in young women who reported sexual contact with the
same man (index patient) were detected at health service clinics in a rural county in upstate New York.
During the next several months, other sexual contacts of the man were discovered by public health
officials. For this investigation, female sex partners of the index case individual were considered primary
contact, and male sex partners of the primary contacts were considered secondary contacts. Blood
specimens from consenting persons were forwarded to CDC for identification and DNA sequence
analysis.

Here is some of the data:

Primary contacts (all women):
Identified: 47
Number tested: 42
Number of HIV positive: 13

The ages of the infected and uninfected women were about the same.
Infected women had more encounters (2-6) with the index patient than the uninfected
women (1-2).

Secondary contacts (partners of the 13 positive primary contacts – all men)

Identified: 84
Number tested: 50
Number of HIV positive: 1 (may have been exposed elsewhere)

Three infants were born to HIV infected mothers, one was born HIV positive.

None of the sexual relationships were same-sex, and there was no needle-sharing.

Questions:
1. What is the rate of HIV infection in the primary contacts of the index patient?

2. Based on the data what can you tell about the likelihood of contracting HIV in men and women?

3. The primary contacts were identified when they began to show symptoms, what types of
symptoms were they likely having?

4. Should the index patient be identified and informed of his status? Should he be legally
prosecuted if he continues to have unprotected sex?