Transcript Document

UNITED NATIONS POPULATION FUND
ความก้าวหน้ าทางวิทยาศาสตร์ การแพทย์
ด้ านสุ ขภาพทางเพศและอนามัยการเจริญพันธุ์
นายแพทย์ทวีทรัพย์ ศิรประภาศิริ
กองทุนประชากรแห่งสหประชาชาติ
Scope of presentation
Sexual behavior
 Contraception
 HIV prevention technologies

Microbicides
 Preand post exposure prophylaxis
 Vaccine
 Circumcision


STI related vaccine and treatment
Reproductive Health อนามัยการเจริ ญพันธุ์

a state of complete physical, mental and social
well being and not merely the absence of
disease or infirmity, in all matters relating to
the reproductive system and its function and
process
 Reproductive health therefore implies that
people are able to have satisfying and safe
sex life and that they have the capability to
reproduce and the freedom to decide if, when
and how often to do so
Sexual Health สุ ขภาพทางเพศ


the integration of the somatic, emotional, intellectual
and social aspects of sexual being in ways that are
positively enriching and that enhance personality,
communication and love
a state of physical, emotional, mental, and social well
being in relation to sexuality; it is not merely the
absence of disease, dysfunction or informality. Sexual
health requires a positive and respectful approach to
sexuality and sexual relationships, as well as the
possibility of having pleasurable and safe sexual
experiences, free of coercion, discrimination and
violence
Fertile Years Prior to Marriage
Increasing
1890
Marriage
Menarche
7.2 years
10
14.8
14.8
30
22.0
22.0
Age
1988
Menarche
Marriage
11.8 years
10
12.5
Age
Source: U.S. data: adapted from Alan Guttmacher Institute, 1995.
24.3
30
Average Age at First Intercourse for
Unmarried, Sexually Active Youth
Average age
25
20
15
10
Latin
Age at America
first
Asia
Age at first North America
Age at
intercourse,
males
intercourse,
females
Source: CDC Surveys; WHO, 1997; AGI, 1995.
marriage
females
Reproductive Health Risks and
Consequences for Young Adults
Risks:
 Unintended and too-early pregnancy
 STIs, including HIV/AIDS
 Unsafe abortion
Consequences:
 Sexual violence
 Medical
and unwanted
 Psychological
sexual activity
 Social
 Economic
Contraceptive Options for Young Adults
Contraceptive methods
 Emergency contraception
 Dual method use
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Young Adults and Contraceptive Use
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Few married youth use contraceptives before first
birth
After becoming sexually active, unmarried youth
delay use of contraceptives about a year
Common reasons for non-use of contraceptives
among unmarried youth:
 did not expect to have sex
 lacked information about contraception
 lacked access to contraceptives
Limited Contraceptive Use:
Characteristics of Youth

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Tend not to plan ahead or anticipate
consequences
Think they are not at risk
Feel invulnerable
Lack confidence or motivation to use
Embarrassed or not assertive
Lack power and skill to negotiate use
Social or cultural expectations or beliefs
Limited Contraceptive Use:
Barriers to Access
Lack of access to services or methods:
 Clinics not designed to be inviting to youth
 Providers reluctant to serve unmarried youth
 Laws/policy may prohibit provision to unmarried youth
Youth may:
 Lack transportation to clinic or money for contraceptives or
services
 Fear judgment or discovery
 Be concerned about having pelvic exam
Contraceptive Issues for Young Adults
Non-medical issues:
 High-risk behavior
 Lack of accurate information
 May not use methods consistently and correctly
 Have unplanned and sporadic sexual activity
 Lack of knowledge or access to emergency
contraception
Complete Abstinence

Most effective way (in theory)
to prevent pregnancy and STIs

No sexual intercourse

May include other forms of
sexual expression

Option for all youth, including
those who have begun sexual
activity

Requires high motivation, selfcontrol, communication and
social support
Traditional Methods
Periodic abstinence and withdrawal:
 Always available
 Can promote reproductive health awareness
 High pregnancy rates in typical use
 No STI protection
 Require considerable motivation
 Periodic abstinence is difficult for young
women with irregular menstrual cycles
 Training about fertility awareness essential
Barrier Methods
Includes male and female condoms, spermicides,
diaphragms and cervical caps
 Are most effective when used consistently and
correctly
 Pregnancy rates in typical use
range from 12 percent for condoms
to 21 percent for spermicides
 Safe, with no systemic effects
Male, Female Condom : Advantages
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Male condom is the most effective method for
STI/HIV prevention
Female condom is an alternative to male condom
Dual protection (pregnancy and HIV/STI)
Most methods are accessible and available
Good for infrequent sexual activity
User-controlled
Easily initiated and discontinued
How to use FC
Oral Contraceptives
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Very safe and effective when used
consistently and correctly
Many non-contraceptive health benefits
Rapid return to fertility
Use independent of sexual intercourse
Can be used without partner’s knowledge
Usually requires visit to clinic or other trained
provider
No STI protection
Oral Contraceptives: Counseling
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Contraceptive benefit wears off quickly
Pills must be taken daily
Possible side effects include nausea or
breakthrough bleeding
Link pill-taking to a daily routine
Encourage use of condoms for backup if pills not
taken correctly or if at risk for STIs
แผ่ นแปะผิวหนัง คุมกาเนิด
(สั ปดาห์ ละ ๑ แผ่น ใช้ ๓ สั ปดาห์
เว้ น ๑ สั ปดาห์ )
Injectables and Implants
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Very effective against pregnancy
Non-contraceptive health benefits
No daily action required or supplies
needed at home
Use independent of sexual intercourse and
can be used without partner knowledge
Require clinic visit
No STI protection
Injectables and Implants: Counseling
Progestin-only injectables and implants:
 Bleeding irregularities likely
 Return to fertility
delayed with injectables
immediate upon removal of implants
Use condoms if at risk for STIs
Implants:
 Appropriate for those wanting long-term method
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Intrauterine Devices (IUDs)
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Very effective at pregnancy prevention
Use independent of intercourse
Quick return to fertility
Requires clinic visit for insertion and removal
No STI protection
Intrauterine Devices (IUDs): Counseling
Eligibility:
 Not usually recommended for young women at
increased risk for STIs
 Not recommended for those with recent or current STIs
 Under age 20 and nulliparous women may have
increase risk of expulsion
Counseling messages:
 IUDs are not appropriate for those with high-risk
behavior
 Important to check for signs of expulsion
Emergency Contraception

Prevents pregnancy after unprotected intercourse
 Not meant to be a regular method
 After use, a regular method should be initiated or
resumed
 Can be used at any time during cycle
 Does not protect against STIs
 Most effective when used early after unprotected
intercourse
 Method options:
 combined oral contraceptive pills
 progestin-only contraceptive pills
Emergency Contraception:
Combined Oral Contraceptives
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Prevents 75% of expected
pregnancies
Requires 2 doses,
12 hours apart
Each dose contains at least
100 mcg of ethinyl estradiol
and 500 mcg of
levonorgestrel
May cause nausea and
vomiting
Pill Regimens
within 72 hours after
unprotected intercourse
low-dose
pills
high-dose
pills
12 hours
12 hours
repeat dose
repeat dose
Emergency Contraception:
Progestin-Only Oral Contraceptives
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
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More effective than
combined pills for
emergency contraception
Requires 2 doses, 12 hours
apart
Each dose contains 750
mcg levonorgestrel
Much less likely to cause
nausea and vomiting than
combined pills
Pill Regimen
within 72 hours
after unprotected
intercourse
first dose
750
750mcg
mcglevonorgestrel
levonorgestrel
12 hours
repeat dose
750
750mcg
mcglevonorgestrel
levonorgestrel
ประสิ ทธิผลของการใช้ยาเม็ดคุมกาเนิดฉุกเฉิ น 2 วิธี
LNG
อัตราการตัง้ ครรภ ์
Yuzpe regimen
1.1
3.2
อาการขางเคี
ยง (%)
้
คลืน
่ ไส้
อาเจียน
23.1
5.6
50.5
18.8
เวียนศี รษะ
ออนเพลี
ย
่
11.2
16.9
16.7
28.5
เกิน 72 ชัว่ โมง แต่ไม่เกิน 120 ชัว่ โมง
ใช้ levonorgestrel 750 g ( 1 เม็ด + 1 เม็ด)
อัตราการตั้งครรภ์
เพิม่ จาก 1.69 % เป็ น 2.44 %
Dual Protection: Pregnancy and
STIs
Dual method use:
Primary method for
pregnancy prevention
Condoms added
for STI
prevention
Other option for dual protection:
Condom as primary
method for
pregnancy and
STI prevention
Emergency
contraceptive pills
if condoms not used,
or if they break or slip
Summary of Contraceptive Options for Youth
Age and Parity
Barrier Methods,
OCs, Implants,
Traditional, LAM
Progestin-only
Injectables
Nulliparous
Under 18
No restriction
18-19
20 and over
Source: WHO, 2004.
Can generally
use
IUDs
New Technology in contraception
Spray-on contraceptives
 Male hormonal contraception
 RISUG: Injected Gel Blocks Sperm
 Intra Vas Device: Two implanted Plugs
Block Sperm

Summary and Next Steps
Young adults face high risks of pregnancy and STIs
To address this:
Young adults need information,
skills, and access to services
Policy-makers and providers need
to know how and where to reach
youth, and what contraceptive and
STI/HIV services are needed
การยุติการตั้งครรภ์
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Surgical
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IUD within 5 days after sexual intercourse
Suction
Curettage
Medical
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Mifepristone (RU486) 200 mg orally followed by
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Misoprotol (Cytotec) 0.8 mg vaginally
Success rate is 99% up to 63 days of pregnancy
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What Is a Microbicides?

Microbicides are new technologies being
developed in the form of gels, creams, tablets,
or rings to help prevent sexually transmitted
infections, most critically, but not entirely,
HIV/AIDS.
 In addition, researchers are investigating
the use of oral antiretroviral drugs for preexposure prophylaxis (PrEP) to prevent HIV
infection.
Microbicides
Pre exposure prophylaxis of HIV
Pre exposure prophylaxis of HIV
Post exposure prophylaxis of HIV
Service is available only for occupational
exposure and sexual assault victims
 A 28 days of ART course is provided for
persons seeking care less than 72 hours
 Problem with tolerability of side effects
 Consideration of concurrent prevention
of Hepatitis B, C and pregnancy

Estimated per-act risk for acquisition of HIV,
by exposure route (per 10,000 exposure)

Blood transfusion
 Needle sharing injection-drug use
 Receptive anal intercourse
 Percutaneous needle stick
 Receptive penile-vaginal intercourse
 Insertive anal intercourse
 Insertive penile-vaginal intercourse
 Receptive oral intercourse
 Insertive oral intercourse
9,000
67
50
30
10
6.5
5
1
0.5
Vaccine trial
UNFPA CST Bangkok
UNFPA CST Bangkok
Male Circumcision (MC) and HIV

MC reduces risk of HIV acquisition by men
during penile-vaginal sex by 50-60%
 Lack of MC is associated with STI ulcer
diseases, chlamydia, infant urinary tract
infection, penile cancer and cervical cancer
 Complication of infant circumcision ranged
from 0.2-2% in US (minor bleeding, infection)
 Adverse events of adult circumcision ranged
from 2-8% in Africa (pain, mild bleeding)
STI/HIV Risk Higher in Young Adults
Behavioral susceptibility:
Youth feel invulnerable, don’t believe it could
happen
to them
 Condoms not used consistently or correctly
 Have multiple partners, or partners with multiple
partners
 Other factors such as drug and alcohol use
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Biological susceptibility in young women:
 Cervical ectopy
Annual incidence of STIs
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Curable
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Gonorrhoea 62 million
Chlamydia 92 million
Syphilis 12 million
Trichomonas 174 million
Non curable
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Herpes
Human Papilloma Virus (HPV)
Hepatitis B
HIV (3-5 million)
Curable STIs
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Curable with antibiotics
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Access to treatment services
important opportunity
Often asymptomatic and
hard to diagnose

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Can lead to PID and infertility

Some can be transmitted
during childbirth or result in
adverse pregnancy outcomes
Increases risk of HIV
transmission

Other Viral STIs
Human papilloma virus (HPV):
 Causes genital warts
 Highly associated with
cervical cancer
Hepatitis B:
 Causes liver damage
 Vaccine available
Herpes:
 Symptomatic or asymptomatic
 Widespread among young adults
Most Common Curable STIs
Trichomoniasis:
 Estimated to be most common STI globally
 Associated with adverse pregnancy outcomes
Chlamydia and gonorrhea:
 High rates in young adults
 May lead to PID
 Can infect newborn during childbirth
Syphilis:
 High risk of congenital infection
Update on STI prevention and
treatment
Reemerge of STI incidence
 No longer use of certain drugs in GC
treatment due to the widespread of drug
resistance
 HPV vaccine is available
 Suppressive therapy of HSV may reduce
HIV transmission
