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DOD initiatives address the sexual health of our military

Image of a bacterium. Click to open a larger version of the image. What looks like a Kraken rising from the ocean’s depths is actually - Treponema pallidum, the spirochete (spiral-shaped) bacterium that causes syphilis. (Photo by Dr. David Cox, Centers for Diseases Control and Prevention.)

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Armed Forces Health Surveillance Division | Health Readiness | Medical and Dental Preventive Care Fitness | Men's Health | Women's Health | Sexually Transmitted Infection Prevention

When it comes to sexual health statistics and the military, there is promising news – and concerning news. However, the Department of Defense has initiatives in place to address the concerning news with broad efforts to promote sexual health among all personnel.

“Rates of viral infections like human papillomavirus [HPV] and genital herpes have been trending down in recent years,” explained Dr. Jose Sanchez, deputy chief of the Defense Health Agency's Armed Forces Health Surveillance Division, about the promising news.

Sanchez noted that from 2011 to 2019, the incidence of HPV infection decreased by almost 50 percent among all active component service members, likely as a result of the introduction of the HPV vaccine. Although the vaccine can be started as young as age 9, it’s typically recommended for children between 11 or 12 and everyone through age 26. In 2018, the U.S. Food and Drug Administration approved the vaccine for men and women up to age 45, based on their risk of infection.

In the military, the HPV vaccine is encouraged and recommended, but not mandatory. Sanchez said the percentage of eligible service men who initiated the HPV vaccine increased to about 3.1% in 2017 from almost zero in 2010. But the percentage of eligible service women who initiated the HPV vaccine declined over that same time – to 5.7% from 10.3%, he said.

“This could be due to more women receiving the HPV vaccine prior to military service,” Sanchez said. “But if fewer service women are initiating and completing the HPV vaccine prior to and during military service, this could result in a resurgence of infections.”

Another good news story is that the incidence of human immunodeficiency virus infection among service members has remained low in recent years, at around 2 per 10,000 tested, Sanchez said. This might be due in part to DHA’s initiatives to provide information and promote sexual health among all service members through their different clinical communities.

The concerning news is that rates of chlamydia and gonorrhea have generally been on the rise in the U.S. military. According to the Armed Forces Health Surveillance Branch’s Medical Surveillance Medical Report from March 2019, the incident rates of infection of chlamydia and gonorrhea among active U.S. military members between 2010 and 2018 showed an increase among both males and females in the latter half of the surveillance period.

“But at least rates in the military recently leveled off or decreased between 2018 and 2019, which is promising,” Sanchez said.

Military health personnel preparing tools for a medial procedure
Angelica Lopez, a medical assistant assigned to Naval Medical Center San Diego’s OB-GYN, prepares for a contraception procedure at the hospital Sept. 14. (Photo by Navy Seaman Luke Cunningham, Naval Medical Center San Diego.)

Sanchez said sexual health is highly relevant to the military because service members tend to be young – the most likely to be affected by sexually-transmitted infections. However, STIs are not unique to a specific age group or gender.

“STIs are increasing in older populations, when risk of pregnancy is gone, but the knowledge of safer sexual practices may not be as well known,” said Army Lt. Col. (Dr.) Erin Keyser, the Army representative for DHA’s Woman and Infant Clinical Community (WICC) at Brooke Army Medical Center, in San Antonio. “Education and screening related to STIs should occur across all the years of sexual activity.”

STIs are important to identify and treat because they can impact service members’ health and readiness, as well as their ability to perform their duties. DHA’s clinical communities work together to provide outreach, information, and educational material about common health concerns – such as STIs and overall sexual health – to ensure everyone gets the same message.

For example, the Military Specific Clinical Community, the Primary Care Clinical Community, and WICC work in partnership to share leading practices and standardized practice models on health issues common to all service members, such as sexual health. PCCC – with a mission to support routine and required screening of health care effective measures – identifies and treats STIs, including HIV, hepatitis C, and HPV, explained Keyser.

WICC leverages technology to provide information resources to beneficiaries more broadly. The Deployment Readiness Education for Service Women mobile application and handbook, anticipated for release in the fall, will make DRES content applicable to all services on Android and Apple platforms.

“The DRES app is designed to enhance the knowledge of women’s health and provide education on topics throughout the female lifespan, to include sexual health and safe sex practices for all types of couples,” said Keyser.

WICC has also partnered with the DHA Connected Health Branch to create a series of podcasts on women’s health issues to be released in the spring.

“The podcasts target providers taking care of active-duty female service members and female beneficiaries and focus on clinical and deployment readiness, including information on the HPV vaccine, female deployment, breastfeeding, postpartum depression, and infertility, among others,” said Keyser.

WICC’s focus is mainly for female beneficiaries, with an emphasis on empowering women through knowledge. “When we teach women and empower them about sexual health, women can then share and discuss this knowledge with all those around them including their partners, friends, colleagues, and communities,” said Air Force Lt. Col. (Dr.) Larissa Weir, Air Force representative for WICC at BAMC.

“Sexual health is an individual responsibility and a shared responsibility within a couple. Empowering both partners expands knowledge and healthy behaviors,” added Weir.

Community-based care

To make this knowledge available to all MHS beneficiaries, there are over 30 DOD walk-in contraception clinics across MHS. These provide STI screening and treatment as well as allow women immediate access to a full spectrum of contraception.

Additionally, many of the military treatment facilities provide local sexual health awareness and services. At Naval Medical Center Camp Lejeune, in Camp Lejeune, North Carolina, the Community Health Clinic (CHC) provides STI testing, treatment, and prevention services, including medication such as HIV Pre-Exposure Prophylaxis for active-duty service members at moderate to high risk, said Navy Petty Officer 2nd Class Kameron Jacobs, hospital corpsman at the clinic who leads the command’s Sexual Health Awareness and Responsibility Program.

Image of a stack of IUDs in round containers
An intrauterine device, shown at Naval Medical Center San Diego. There are more than 30 DOD walk-in contraception clinics across Military Health System that provide STI screening and treatment as well as allow women immediate access to a full spectrum of contraception. (Photo by Navy Seaman Luke Cunningham, Naval Medical Center San Diego.)

“This walk-in clinic has provided high-quality disease intervention and care to over 6,000 patients since its opening in April of 2019,” said Jacobs. “Additionally, SHARP regularly conducts trainings for health care providers and others to ensure medical teams are proficient and equitable in their practice.”

Following the Center for Disease Control and Prevention’s “Talk. Test. Treat.” campaign for decreasing instances of STIs, the CHC offers tailored in-person preventive counseling and education to each patient who walks in the door, preventive “conscious checks” or screening testing for active-duty service members to check-up on their sexual health, and highly effective treatment as soon as possible to significantly reduce their chance of spreading STIs and preventing chronic, irreversible conditions from developing.

“Taking the time to talk with service members about their sexual health and identifying areas where risk can be reduced is an essential step in disease prevention,” said Jacobs. “Service members come from all over the United States with a variety of sexual health education backgrounds. Establishing a baseline of knowledge and encouraging safer goal behaviors continues to be the primary mission of community health at both the personal and enterprise level.”

MARSH Study

For Air Force Maj. (Dr.) Ryan Landoll, assistant dean for preclinical sciences at the Uniformed Services University for Health Sciences and principal investigator of the Military Active-duty Reproductive & Sexual Health (MARSH) research program, inclusivity is another important aspect.

“It’s very important that we think of comprehensive sexual and reproductive health that is considerate of all our service members,” said Landoll. “The focus is on total force health.”

The MARSH study broadly focuses on working to decrease STIs and unplanned pregnancies using a mobile health intervention application to target health risky sexual behaviors. Landoll and his team developed the innovative Mission Wellness mobile app to provide all service members an array of interactive educational tools and information on sexual health with a focus on motivation and behavioral skills, such as future-oriented thinking.

The app includes narrative videos and interactive activities to facilitate difficult conversations surrounding sexual health with a partner, a supervisor, or a health care provider and to spur users to think about the consequences that unhealthy sexual behaviors today could have on their lives and careers. While the app is only available for download for participants in the MARSH study, the hope upon completion is that it will serve as an equitable resource where all service members can anonymously and in their own time advocate for their own sexual health.

“The user has the ability to design their own avatar to walk through the app with, and all the education elements have been designed with a very intentional focus on inclusivity,” said Landoll. “Our app is always focused on behaviors, understanding that there are risky behaviors, not risky identities or individuals.”

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