Public Health (2005) 119, 825–836 Prevention and control of sexually transmitted infections among adolescents: the importance of a socio-ecological perspective—a commentary R.J. DiClementea,b,c,*, L.F. Salazara,c, R.A. Crosbya,c, S.L. Rosenthald a Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Room 554, 1518 Clifton Road 30322 Atlanta, GA, USA b Department of Pediatrics, Division of Infectious Diseases, Epidemiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA c Emory Center for AIDS Research, Atlanta, GA, USA d Department of Pediatrics, Division of Adolescent and Behavioral Health, University of Texas Medical Branch, Galveston, TX, USA Received 13 April 2004; received in revised form 1 September 2004; accepted 22 October 2004 Available online 23 May 2005 KEYWORDS Adolescents; Sexually transmitted infections; Human immunodeficiency virus; Socio-ecological perspective; Prevention Summary The sexually transmitted infection (STI) epidemic among adolescents in the USA is inextricably tied to individual, psychosocial and cultural phenomena. Reconceptualizing the epidemic within an expanded socio-ecological framework may provide an opportunity to better confront its challenges. In this article, we use a socio-ecological framework to identify determinants of adolescents’ sexual risk and protective behaviours as well as antecedents of their STI acquisition. The goal is to provide a synthesis of several discrete categories of research. Subsequently, we propose an integrated strategy that addresses the STI epidemic among adolescents by promoting a socio-ecological perspective in both basic research and intervention design. This approach may expand the knowledge base and facilitate the development of a broader array of intervention strategies, such as communitylevel interventions, policy initiatives, institutionally based programmes, and macro-level societal changes. Although there are inherent challenges associated with such an approach, the end result may have reciprocal and re-inforcing effects designed to enhance the adoption and maintenance of STI-preventive practices among adolescents, and further reduce the rate of STIs. Q 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. Introduction * Corresponding author. Tel.: C1 404 255 0038; fax: C1 404 727 1369. E-mail address: rdiclem@sph.emory.edu (R.J. DiClemente). In the USA, sexually transmitted infections (STIs) affect adolescents disproportionately, and prevalence rates among some subgroups have reached epidemic proportions.1 In general, the 0033-3506/$ - see front matter Q 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2004.10.015 826 sustainability of the STI epidemic can be characterized as a function of the reproductive rate of the epidemic. This rate is driven by three discrete factors: the infectivity of the pathogen, the rate of sexual partner changes in a given population, and the duration of infection.2 Each of these factors is amenable to modification; however, the complexity in modifying these inter-related factors among adolescents has proven to be a formidable challenge. Historically, the STI epidemic has been viewed largely as an individual-level phenomenon where much effort has been focused on understanding intrapsychic influences that affect adolescents’ sexual decision-making. Consequently, many intervention efforts target adolescents’ pertinent intrapsychic influences, with the goal of eliminating or reducing specific STI-associated risk behaviours. Unfortunately, these intervention programmes have often been designed without understanding or addressing pervasive contextual influences that directly and indirectly influence STI acquisition. Moreover, although there is evidence to suggest that many of these individual-level interventions are effective, 3,4 individual-level interventions may not be sufficient to sustain newly adopted STI-preventive behavioural changes over protracted periods of time or in the presence of countervailing influences. Finally, only addressing behavioural change at the individual level may lack sufficient breadth to reach large segments of the at-risk adolescent population.5 Thus, there is a need to modify the current STI prevention and control paradigm for adolescents. Over the past few years, researchers and practitioners in diverse fields of public health have begun to recognize the value of adopting a socio-ecological perspective.6 A socio-ecological perspective involves examining the behaviours of individuals within the context of their social and physical environment. Socio-ecological factors include cultural influences, familial influences, and societal and peer influences.7 The model presented in Fig. 1 is an adaptation of Bronfenbrenner’s ecological model.7 It depicts five concentric spheres of influence that correspond to varying levels of analysis. The innermost sphere represents the individual and includes psychological characteristics and behaviours. The family, relational and community spheres suggest that interactions between adolescents and family members, intimate partners and peers have a strong influence on adolescents’ behaviours. The outermost sphere indicates that characteristics of the society at large (e.g. socio-economic status, healthcare policies, media, gender and racial/ R.J. DiClemente et al. Figure 1 A socio-ecological model of STD risk and protective factors for adolescents. ethnic discrimination) provide a broader context in which adolescents, institutions and communities are embedded and, thus, may have a potent effect on adolescents’ behaviour. The multiplicity of influences among spheres ultimately shape adolescents’ behaviour. In this commentary, we highlight research that encompasses an array of risk and protective factors pertaining to sexual risk behaviour and STI acquisition among adolescents residing in the USA. Our commentary was assembled based on evidence from each level of Bronfenbrenner’s model. The goal was to synthesize findings derived from these discrete, albeit related, levels of research. Subsequently, we articulate directions for future research to address gaps in the literature, while proposing an integrated strategy that targets the social ecology of the STI epidemic among US adolescents. Sti risk and protective factors Numerous empirical studies have identified the determinants of adolescents’ STI-associated risk behaviours, while markedly fewer studies have identified determinants of STI acquisition. Factors related to both STI-associated risk behaviours and STI acquisition range from individual characteristics and aspects of social interactions to characteristics of school, community and society. Viewed together, this range of factors represents Prevention and control of STIs among adolescents the socio-ecological perspective adolescents’ sexual health. underlying Individual characteristics Studies suggest that adolescents who perceive that they are at risk for pregnancy and STIs tend to engage in less risky sexual behaviours than those who do not have these perceptions.8–10 Furthermore, adolescents who feel confident in using condoms,9,11–14 in their ability to negotiate condom use with their partners,14,15 in their ability to say ‘no’ to sexual intercourse not protected by a condom,13 and in their ability to discuss sexual matters (i.e. previous partners, sexual histories)9, 15,16 tend to use condoms more often and have lower rates of STIs.17 Adolescents with high levels of impulsivity, or who have a proclivity for sensation-seeking behaviour, may place themselves at greater risk for STI acquisition18–21 because they tend to engage in more sexual risk behaviours.22 Kahn et al. found that greater impulsivity was associated with a greater frequency of sexual risk behaviour and a history of chlamydia infection among a sample of adolescent females.19 Other individual characteristics such as low self-esteem, psychological distress and depression also place many adolescents at risk for engaging in STI-associated sexual behaviours.20,23–26 Depression has been shown to predict STI diagnosis in a recent prospective study,25 and self-esteem has been found to distinguish between positive and negative STI diagnoses among female adolescent clinic attendees.27 Adolescents who engage in unprotected intercourse tend to perceive more barriers towards condom use,9,28 believe that using condoms results in less pleasure,9,12,29 hold more negative attitudes towards using condoms,30, 31 and perceive low susceptibility to STI and human immunodeficiency virus (HIV) infection.10,29 Other types of risk behaviour tend to co-occur with risky sexual behaviours where research has revealed significant associations between adolescents’ sexual risk behaviours and alcohol or drug use,9,32–34 antisocial behaviours32 and current pregnancy.35 Moreover, many of these same factors are related to STI acquisition,8,9,24,25,33,34,36–39 as well as having multiple sexual partners.8,33,40–43 Family characteristics The roles of parents and family are critical in keeping adolescents safe. Perceived family support, parent–family connectedness, family 827 structure, family cohesiveness, parental monitoring and parent–adolescent communication about sex help to prevent adolescents from engaging in many risky sexual behaviours.44–56 Parental monitoring is a particularly important familial factor. Emerging evidence suggests that adolescents who perceive that their parents (or parent figure) know where they are and who they are with outside of school or work are substantially less likely to engage in sexual risk behaviours or to have an STI.32,46,55,57–59 Moreover, parents’ influence can also buffer adolescents’ against the influence of negative peer norms that encourage risky sexual behaviours.60 Relational characteristics Relationship characteristics also play a pivotal role in influencing adolescents’ risky behaviour and their likelihood of acquiring an STI. Although commonalities occur across gender, some differences also exist. Among adolescent females, lack of relationship control,28 longer length of relationship,28,61,62 fear of condom use negotiation,14 less frequent partner communication about sexually related topics,9,63,64 and having older sexual partners 64–66 have been associated with greater likelihood of engaging in STI risk behaviours or acquiring STIs. Other relational risk factors include perceptions of partner control over STI acquisition,67 perception of low partner support of condoms,68 being a date rape victim,69 and being a victim of dating violence.69–71 Similar associations have been found for having a new partner72 and having a risky partner.73 For males, partner communication about sexually related topics,74,75 belief in male responsibility for contraception,74 being in an early stage of relationship,74,76 and perceptions of partners’ sexual inexperience76 have been associated with increased condom use. Furthermore, suspicion of partners’ high risk for an STI,76 perceived partners’ negative attitude towards condom use,77 and being a victim of dating violence69 have been related to unprotected intercourse and an increased number of sexual partners. Although all of these findings are intriguing, the cognitive and relational processes that underlie each are largely unexplored. For example, it is not known why suspicion of a partner as ‘high risk for an STI’ would be associated with lack of condom use. However, the socio-ecological framework advocated in this commentary remains quite useful despite these types of quandaries because it necessitates (in this example) that relational 828 aspects be understood and addressed in STI interventions for adolescents. The framework thus guides population-specific investigations that will ultimately lead to tailored, socio-ecological interventions. Peer and community characteristics Another developmental aspect of adolescence is the increasing importance of peer influences. Peer pressure to smoke, drink alcohol and engage in sexual intercourse increases with age.78 Although it has been shown that parents have more influence on adolescent decisions to engage in risk behaviours than peers,79 perceived peer norms surrounding sexual behaviours and condom use have been shown to be important influencers of risky sexual behaviour. If adolescents and young adults perceive that their friends are having unprotected sex and engaging in other types of risky sex, they may be more likely to adopt their friends’ behaviours. 8,28,32,33,80 In contrast, perceived peer norms supportive of STI-protective behaviours can have a significant influence on the adoption and maintenance of preventive behaviours.8,28,32,33 Community characteristics can also influence adolescents’ adoption of STI-protective behaviours. Adolescents’ affiliations with social organizations,81 adolescents who perceive that they have higher levels of social support,82 and positive school environments may serve as protective factors. For example, among a nationally representative sample of adolescents, a sense of belonging to a school was associated with delaying sexual intercourse.54 Schools may also play a role in reducing sexual risk-taking by making condoms available. Adolescents who have better accessibility and availability of condoms tend to have higher rates of condom use84,85 without an increase in overall rates of sexual activity.84–86 The link between better accessibility and availability and increased condom use may be explained by related research which showed that those who carry condoms are more likely to use condoms than those who do not always carry condoms.29,87 On the other hand, other studies have found no effect of condom availability or condom carrying on adolescents’ use of condoms.88,89 One possible explanation for these mixed results is that many of these studies failed to examine other possible mediating factors that could explain the relationships. An emerging line of inquiry suggests that social capital, another community characteristic, may also influence adolescents’ risk behaviours. Social R.J. DiClemente et al. capital is an index comprised of trust, reciprocity and co-operation among members of a social network.90 A recent study demonstrated that social capital was inversely correlated with acquired immunodeficiency syndrome case rates as well as the incidence of chlamydia, gonorrhoea and syphilis among adults.91 More recent research has shown that adolescents residing in states with greater levels of social capital were less likely to engage in selected sexual risk behaviours.92 Greater levels of social capital, however, may not be protective for adolescents if the social network involved is antisocial in nature, such as a gang. It has been suggested that gangs are a community problem with underlying neighbourhood factors such as the need for protection from crime and/or abusive families, peer pressures and lack of money-making opportunities serving as major risk factors for gang involvement.93,94 When adolescents choose to join a gang, they put themselves at greater risk for engaging in a diverse array of health-compromising behaviours such as violence, risky sexual behaviours, antisocial behaviours and alcohol/drug use.95–98 These risks are not unique to males. One study of high-risk African American adolescent females found gang involvement to be related to school expulsion, binge drinking, using marijuana, engaging in physical fights, and positive diagnoses of Trichomonas vaginalis and Neisseria gonorrhoeae.99 Other aspects of communities may also affect adolescents’ risk of STI acquisition. Communities that have high rates of STIs among adults may pose a heightened risk for adolescents. Recent research suggests that the disproportionate incidence of STIs among African American adolescents may be a consequence of residing in communities that have high rates of STIs rather than adolescents’ behavioural characteristics.100,101 For example, a national survey of 14–21-year-olds observed that African Americans were more than 3.5 times as likely to report a history of STI infection compared with adolescents of a different racial/ ethnic background; a difference that was not attributable to measurable sexual risk behaviour or sociodemographic factors. Understanding how these community characteristics affect adolescents’ sexual behaviour and risk for STIs is one of many challenges currently confronting the field of STI prevention. Societal characteristics A societal characteristic that plays a distinct role in shaping cultural norms and influencing Prevention and control of STIs among adolescents behaviours is the media.102 The media, therefore, may be an important influence on the sexual health of adolescents. Whether they are seeking information (e.g. internet) or entertainment, the media plays a significant role in the socialization of adolescents.103 Implicit and explicit sexual imagery coupled with situations depicting unprotected intercourse are ubiquitous. Furthermore, violence and aggression towards females are woven into many of these sexual themes. This is especially true of music videos. For example, in a recent study, adolescent females with greater exposure to rap music videos were significantly more likely to hit a teacher, to have been arrested, to have multiple sexual partners, to use drugs, and to test positive for an STI.104 Furthermore, there is evidence of an association between exposure to X-rated movies and negative condom attitudes, having multiple sexual partners, more frequent sexual intercourse, not using contraception during last intercourse, and testing positive for chlamydia.105 Unfortunately, little is known about the psychosocial mechanisms that might explain observed associations between the media and adolescents’ STI-related risk behaviour. Thus, a more in-depth look at this general observation is required. However, an important counter-perspective is that the general observation is sufficient in its own right to warrant a focus on this form of societal influence when developing STI interventions for defined populations of adolescents. It should also be noted that what constitutes ‘media’ will naturally vary within and across different populations of adolescents. Sociological constructs of race and gender are influences of adolescents’ sexual health and have been consistently associated with STI infection. Surveillance data indicate that adolescents of African American race and female gender experience disproportionate rates of STIs relative to other racial/ethnic groups and males.106 The apparent influences of race/ethnicity may be confounded by a host of environmental factors. For example, poverty may be a risk factor where its direct association with race/ethnicity exerts an indirect influence on STI rates.107,108 It has been suggested, therefore, that African American adolescents’ higher STI rates can be traced to a greater proportion of African Americans living in geographic clusters characterized by poverty, low educational attainment, compromised family structures and lower socio-economic status.109 829 Intervention approaches Levels of change Individual level To date, many programmes have been developed that address both prevention and control of STIs through individual-level behavioural change programmes. It is beyond the scope of this article to provide a review of them; however, key review articles describing prevention programmes are readily available.4,110,111 Nevertheless, in general, underlying most individual-level sexual risk-reduction interventions is a common core of activities: emphasize motivational factors; provide skills training, including partner communication, sexual negotiation, resistance skills and condom application; and attempt to modify peer norms.112,113 Given recent advances in biomedical technologies, however, a number of strategies may enhance the effectiveness of current individual-level approaches. For example, enhanced screening can identify a greater proportion of infected adolescents, particularly those who are asymptomatic; however, many clinicians are not screening adolescents adequately for STIs. 114 Recent advances in rapid testing technology and the advent of non-invasive specimen collection that uses nucleic acid amplification assays for chlamydia and gonorrhoea may facilitate increased acceptance of STI testing, including HIV testing, among adolescents, and may also increase screening practices among clinicians. The adoption of intensified screening practices and strategies to motivate adolescents’ STI testing, coupled with the availability of effective orally administered single-dose therapy for the non-viral STIs, may help to reduce the STI epidemic by shortening the duration of infection, thereby reducing the potential for transmission. Relational level This strategy directly addresses salient relational influences associated with STI risk and protective behaviours while also transferring the burden to initiate STI-protective behaviours from one person to the dyad. This is particularly important for adolescent females who are in power-imbalanced relationships with their male partners.64,65,100,114 Additionally, this type of intervention holds great promise for enhancing not only the adoption of STI-preventive behaviours by the dyad, but also, in the event of dissolution, the generalization of recently adopted STI-preventive behaviours to new relationships. 830 In the same vein, existing strategies often fail to recognize the unique dilemmas that adolescents confront when disclosing positive STI diagnoses to sexual partners. Thus, ‘adolescent-friendly’ partner services represent an approach that may promote disclosure and care-seeking behaviour of partners. Specifically, ‘adolescent friendly’ signifies an approach that is developmentally appropriate and incorporates activities designed to teach adolescents how to effectively communicate positive diagnoses to sexual partners and promote care-seeking among those partners.115 The use of partner-delivered medication for treating STIs could also be used as an adjunct to the adolescent-friendly services, thereby preventing subsequent re-infection and transmission.116 Family level Emerging evidence suggests that several familylevel interventions may be effective at reducing adolescents’ STI-associated risk behaviours.117–120 Family-level interventions typically promote increased communication between adolescents and parents about STI prevention.21 These interventions may also attempt to increase parental monitoring of adolescents and adolescents’ perceptions of enhanced parental monitoring, as well as foster a sense of increased family support. Acknowledging the importance of family-level interventions, the National Institute of Mental Health has established a consortium of family grants specifically designed to enhance parent–adolescent interactions surrounding STI/HIV prevention.122 Community level Programmes implemented within the community are an important STI prevention and control strategy. A main goal of many of these programmes is to create social norms that promote safer sex practices. By evoking change within the community in which adolescents are embedded, STI-preventive behaviours may be magnified. One example of this type of approach is the Prevention Marketing Initiative (PMI).123 PMI targeted adolescents less than 20 years old with the goals of increasing adolescents’ awareness of STI prevalence, influencing preventive behaviours (i.e. condoms and abstinence), promoting parent–adolescent discussions, providing information about STIrelated prevention services, and changing adolescents’ perceptions of norms supportive of STI-preventive behaviours. A recent evaluation of the programme conducted in five sites demonstrated increases in STI-preventive behaviour.123 The primary benefit of community-level programmes such as PMI is the ability to reach R.J. DiClemente et al. large numbers of adolescents as opposed to reaching only a few high-risk adolescents. Clinic- and school-based screening programmes are also a community-level approach to STI prevention and control. Recent studies have demonstrated that repeated STI screening and treatment in these settings effectively reduced gonorrhoea and chlamydia incidence rates among adolescents124,125; however, screening programmes are only effective if they are reaching a substantial percentage of sexually active adolescents. Another community-level approach that could prove to be effective is the use of adolescents’ sexual networks as a venue for preventing and controlling STIs.126 The ability to prevent STI transmission may be hobbled unless clinic services can be brought into adolescents’ neighbourhoods and/or schools. These services include screening and treatment for STIs as well as counselling and education. A sexual network approach is also unique in that it increases case findings through ‘contact tracing’ using developmentally appropriate techniques. For example, interviewing one adolescent who tests positive for an STI can serve as the starting point for locating, interviewing and screening other adolescents within the same network.127 This approach also provides an opportunity to promote safer sex behaviours through the education of key members of these sexual networks. Promoting, enhancing or creating social capital is another community-based approach that has yet to be implemented, but one that could have an impact on STI risk behaviours and incidence. As discussed previously, social capital, defined as the levels of trust, reciprocity and connectedness to a social network, has been shown to be a protective factor for preventing STIs among adults,91 and also for preventing adolescents from engaging in sexual risk behaviours.92 Traditionally, social capital has been viewed as a predictor variable where the majority of the research has examined different health outcomes that have been associated with varying levels of social capital. To influence or effect social capital and view it as a dependent variable would be innovative. Although a challenge, a promising strategy to help reduce STIs including HIV among adolescents would be to try and influence the positive social networks so that adolescents feel more connected, more supported, and are provided access to necessary resources such as extracurricular activities, condoms and sexual education through these enhanced support networks. Societal level Societal-level interventions have great potential to reach a large audience. For example, mass media Prevention and control of STIs among adolescents campaigns can be an effective tool for reaching adolescents who may not otherwise be exposed to interventions. A nationwide mass media campaign implemented in Norway was evaluated and revealed that the campaign was effective in reaching a substantial proportion of a national probability sample of adolescents. Results also showed positive changes in attitudes and practices relevant to safer sex behaviours.128 In addition, trend analyses of ongoing evaluations of media-based interventions in Switzerland have observed marked reductions in risk behaviours.129 For example, between 1987 and 1991, an aggressive marketing campaign aimed at 21–30-year-olds observed an increase in condom use with casual sexual partners from 8 to 50%. Among a younger subgroup (17–20-year-olds), effects were even more striking; condom use increased from 19 to 73%. Equally important from a health policy perspective, the Swiss study found that rates of sexual activity remained unchanged over the time period during implementation of the media campaign.129 Societal-level changes can also promote increased accessibility to and acceptability of STI prevention and control services for adolescents. For example, managed care organizations that provide time and incentives for clinicians to screen, counsel and educate adolescents at risk for, or diagnosed with, an STI could have a tremendous impact on the reproductive rate of the STI epidemic.130,131 Affecting change to existing policies or creating new policies also has potential for ameliorating the STI epidemic. For example, healthcare policy should ensure that adolescents receive services for STI prevention, testing and treatment despite income disparities. These types of policies should exempt adolescents from obtaining parental consent for treatment. Implementing policy initiatives such as adolescent partner notification and partnerdelivered treatment may also be critically important. Furthermore, policies should support the clinical use of new technologies such as rapid testing and nucleic acid amplification assays, both of which require less invasive specimen collection techniques and are more sensitive relative to culture, and the use of single-dose orally administered therapy, which can reduce adherence problems. A socio-ecological approach The central premise of the proposed socioecological model is that none of its levels should 831 function in isolation from the others. Indeed, we suggest that designing effective STI prevention and control programmes can best be achieved by taking full advantage of the ‘synergy’ among the five levels that comprise the model. Preventive synergy is the cumulative re-inforcement of messages using co-ordinated, diverse intervention channels and resources. This synergy can amplify and complement isolated approaches, thereby optimizing and sustaining favourable effects. Thus, although this approach requires intensified efforts and resources, its returns warrant implementation. However, it is critical to note that implementation of this framework necessitates the ability to influence policies at several levels. Indeed, it should be noted that policy could be considered as the cornerstone of a socio-ecological approach. In essence, a need exists to link STI-prevention resources into an efficient network. This network, for example, would consist of the community, schools, health providers, local government agencies and non-governmental agencies or community-based organizations. The role of this network would be to link resources thereby enhancing preventive services. For example, multiple access points (i.e. recreation centres, after-school programmes and physicians’ offices) could be used as opportunity sites for providing STI-prevention information and motivating adolescents to adopt relevant health-promotion skills. A key related question is how to go about this in a cost-effective way while determining which programmes work best for various populations of adolescents. Additionally, it is important to note that a socioecological approach is pro-active. To create ‘prevention synergy’, the approach necessitates an augmentation of the medical model of STI prevention and control to include theory-guided practice grounded within the developmental context of adolescents’ lives. Moreover, adolescents’ STI-associated risk behaviour should be viewed as a reflection of relational, familial, community and societal environments rather than a reflection of individual deficits. Recognizing these realities provides health professionals with the impetus for several forms of broad-based action: (1) linking STI treatment to intensified prevention efforts; (2) targeting social support structures that may foster responsible sexual behaviour; (3) revealing appropriate channels to affect change to underlying social norms and related policies; and (4) integrating effective behavioural approaches with STI-associated biomedical advances. Finally, it is important to note that this commentary has been based on evidence from 832 adolescent populations residing in the USA. Clearly, extrapolation to adolescents in other developed nations or those residing in developing countries may be problematic. Nonetheless, it is important to note that similar commentaries have been provided based on the STI prevention needs of adolescents in diverse parts of the world.132–134 Conclusion Our examination of research pertaining to the prevention and control of STIs among adolescents residing in the USA suggests that the majority of effort has been dedicated to identifying individuallevel risk and protective factors. This suggests that the field regards the STI epidemic among adolescents as an individual and not a socio-ecological phenomenon. Thus, if research continues its focus at the individual level, it will not make the substantial changes to families, institutions, communities or society that could promote STI prevention and control efforts. Integrated interventions, which traverse multiple levels of causation in the socio-ecological model, can marshal new kinds of data, ask new and broader questions regarding the range of influences that affect risk of STIs, and, most important, create new and promising options for STI prevention. If we are to confront the challenge of STIs among adolescents, prevention programmes targeting social change will play a major role. For the science of STI prevention and control to progress more rapidly, with respect to theory and behavioural change strategies, a comprehensive and coordinated infrastructure to conceptualize, stimulate and support STI intervention research is of critical importance. References 1. Eng TR, Butler WT. The hidden epidemic: confronting sexually transmitted diseases. Washington, DC: National Academy Press; 1997. 2. May RM, Anderson RM. Transmission dynamics of HIV infection. Nature 1987;326:137–42. 3. Centers for Disease Control and Prevention. 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