Sexual Health and Responsibility Program (SHARP): Preventing HIV, STIs, and Unplanned Pregnancies in the Navy and Marine Corps

Abstract

In 1999, the Navy and Marine Corps Public Health Center converted an HIV train-the-trainer program into a broader effort of preventing not just HIV, but also other sexually transmitted infections (STIs) and unplanned pregnancies. The premise for this broader approach was that a more comprehensive sexual health promotion message of STI, HIV, and unplanned pregnancy prevention is more likely to include at least one personally relevant concern for any given individual and is, therefore, more likely to be internalized and acted upon by the greatest number of individuals, and that risk reduction for any one of these consequences of sexual activity may reduce risk for all. This new effort was labeled the Sexual Health and Responsibility Program (SHARP). Within the Navy and Marine Corps, SHARP has become a focal and trusted source of sexual health promotion products, consultative services, and training, as well as a conduit for multidisciplinary collaboration and coordination. The existence of this central sexual health program normalizes integrated and comprehensive sexual health messages, enables efficiencies, promotes program and policy uniformity, and provides a forum for cross-organizational collaboration and continuous improvement.

Active-duty sailors and Marines acquire preventable sexually transmitted infections (STIs) and experience high rates of unintended pregnancy. Each year from 1999 to 2011, 85 to 100 active-duty sailors and Marines were newly diagnosed with the human immunodeficiency virus (HIV). From 1985 through 2011, at least 5,800 active-duty sailors and Marines were infected with HIV.¹ Health-care costs and lost-duty days for periodic evaluations and care for military members infected with HIV have not been calculated. In 2011, more than 5,000 cases of chlamydia, gonorrhea, or syphilis were diagnosed among active-duty sailors and Marines.² The incidence of other STIs, including human papillomavirus (HPV, which can cause genital warts as well as cervical and other cancers), genital herpes, pelvic inflammatory disease, and trichomoniasis, are not tracked and costs are unknown.

Unplanned pregnancies among active-duty sailors continue to be a concern. In 2010, only 36% of pregnancies among surveyed enlisted female sailors were intended, with the highest rates observed among married women aged 21–25 years.³ The national Healthy People 2020 objective is to increase the proportion of pregnancies that are intended to at least 56%. Lost-duty days for unintended pregnancy health care, post-delivery convalescence, and separations due to pregnancy have not been calculated. The presumably stressful impact of single parenthood on active-duty members, families, and Navy and Marine Corps units has not been quantified.

In 2008, only half of unmarried active-duty male sailors and Marines used a condom the last time they had sex. Among unmarried active-duty female sailors and Marines, only one of three reported using a condom.⁴ STI and HIV infections, as well as unintended pregnancies, occur among members both in garrisons and during deployments. The consequences of sexual risk-taking for the individual sailor or Marine may include pain and suffering, embarrassment, lifelong health implications, and other effects on career, family, relationships, and personal finances. For the Department of the Navy, the negative consequences may include lost-duty days, early separations from service, direct medical care costs, and an erosion of the Navy's image.

HISTORY OF THE NAVY'S SEXUAL HEALTH AND RESPONSIBILITY PROGRAM

In 1998, the Navy and Marine Corps Public Health Center (NMCPHC), an organization directly subordinate to the Navy Bureau of Medicine and Surgery (BUMED, the Navy's medical headquarters), was tasked and funded with three full-time-equivalent positions to take over an existing HIV train-the-trainer program from BUMED. This new opportunity was instead used by NMCPHC to embark on a larger vision of preventing not just HIV, but also other STIs and unplanned pregnancies. The premise for this broader approach was that a more comprehensive sexual health promotion message of STI, HIV, and unplanned pregnancy prevention is more likely to include at least one personally relevant concern for any given individual and is, therefore, more likely to be internalized and acted upon by the greatest number of individuals, and that risk reduction for any one of these consequences of sexual activity may reduce risk for all.

This new effort was labeled the Sexual Health and Responsibility Program (SHARP) with the motto, “Chart a Safe Course.” This motto affirms that individuals have both the right and responsibility to make choices about their health, and that sexual health decision-making is a lifelong and dynamic process because a person's life circumstances and relationships may change over time. The SHARP vision is defined as follows: “A Department of Navy cultural norm in which sexual responsibility and safety are encouraged, supported, and expected, and a population in which all pregnancies are planned, syphilis is eliminated, and other sexually transmitted infections, including HIV, are prevented.” This vision was intended to inspire, unite, and engender the collaboration of Navy and Marine Corps leaders, researchers, public health advocates, health promoters, faith-based professionals, alcohol-abuse and sexual assault prevention specialists, women's health advocates, and health-care providers. The SHARP goal is to reduce the incidence of STIs, including HIV, and unplanned pregnancies among active-duty sailors, Marines, and families. A logo was created to brand this new effort (Figure 1). Three full-time people initially staffed SHARP, with that number declining to two people in 2001 and one person since 2004, as NMCPHC received new tasks in other preventive health realms and priorities shifted.

Figure 1.

SHARP logo created to brand the SHARP program and its goal of reducing the incidence of STIs, including HIV, and unplanned pregnancies among active-duty sailors, Marines, and families

SHARP = Sexual Health and Responsibility Program

STI = sexually transmitted infection

HIV = human immunodeficiency virus

In 1999, SHARP recognized early that institutionalized, coordinated, and long-term success would require (1) multidisciplinary involvement of many stakeholders, (2) written policies, and (3) measurable outcomes that are valued by leaders and funders. To be successful, the effort had to encompass a wide array of activities including surveillance, research, individual sexual health education, condom and contraception access, professional medical education, and health-care practices. But, being an advisory organization only, NMCPHC controlled none of the Navy or Marine Corps training curricula, conducted no pure research, collected no data on HIV or unplanned pregnancy, conducted no surveillance of sexual risk behavior, and was not empowered to direct any health-care policies or practices.

Because of these limitations, SHARP adopted a strategy to become the central sexual health promotion advocate, a collaborative partner, and a provider of products and training needed by partners and customers. This strategy is guided by a few central tenants: (1) keep the program focused to prevent mission drift; (2) rely on medical accuracy and scientific evidence to ensure positive outcomes and counter stigma and resistance; (3) motivate partners by offering to assist them, rigorously respecting their turf, and remembering that trust is the most precious commodity; and (4) write programs into policy.

PARTNERSHIPS AND COLLABORATIVE EFFORTS

Since 1999, SHARP has established itself within the Navy as a conduit for multidisciplinary collaboration and coordination for the creation of sexual health policy, outcome objectives, products, and training. SHARP strives to ensure that the products, services, and policies it develops or advocates are culturally competent, technically accurate, and evidence-based. SHARP pursues this goal by diligently and respectfully consulting all stakeholders, such as the primary user of a product, the primary owner of a training course, or the primary agency with management responsibility for a given policy. SHARP also collaborates with subject-matter experts such as the Navy specialty leaders for women's health, preventive medicine, and HIV care regarding technical details, surveillance objectives and systems, and priority outcome objectives. Additionally, SHARP consults national-level experts such as the Centers for Disease Control and Prevention (CDC), national women's health organizations, and national unplanned pregnancy prevention associations regarding scientific evidence of effectiveness and replicable models. This robust commitment to collaboration not only increases the likelihood of getting it right, but also promotes buy-in among partners.

The key organizations that SHARP sought out for collaboration were those that control Navy medical-training schools, Navy preventive medicine programs, Navy women's health policies, Navy health promotion programs, Marine Corps health promotion programs, Navy HIV-treatment centers, Navy and Marine Corps boot camps (the initial training program for sailors and Marines), and the Navy's sailor training agency, which owned the curriculum for mandatory annual training for all sailors.

SHARP has established fruitful relationships and collaborative projects with each of these organizations. Many new products and services have been developed and launched by SHARP and its valued partners. SHARP advocated for the improvement of the sexual health questions in two previously existing Navy-wide surveys to better assess sexual risk among military members. These two existing surveys about parenting and pregnancy (managed by the Navy's personnel management headquarters) and health-related behaviors (managed by the Department of Defense Assistant Secretary of Defense for Health Affairs) now include more sexual health questions and more descriptive ranges of possible responses. Also, two sexual health questions were added to a new workplace-centric, self-administered, anonymous health risk assessment managed by NMCPHC, which was completed by more than 77,000 sailors and Marines in 2011.⁵ These three improved, ongoing surveys have significantly improved our understanding of and capacity to monitor sexual risk behaviors and attitudes within our population.

SHARP advocated and BUMED established the first Navy HIV risk behavior surveillance system for newly diagnosed active-duty sailors and Marines, mirroring the national surveillance system.⁶ SHARP advocated, designed, and partnered with the manager of the Navy-wide STI surveillance system at NMCPHC on the establishment of a first-ever Navy and Marine Corps STI (other than HIV) risk behavior surveillance mechanism within a new Web-based STI reporting system. The U.S. Army subsequently adopted this system. SHARP also collaborated with this surveillance system manager and the manager of the Navy's preventive medicine program to increase use of this STI reporting system, increase reporting accuracy, and improve monthly data analysis.

Since 1999, SHARP has advocated and BUMED has established new Navy sexual health policies on emergency contraception access, sexual risk assessment in primary care, HPV vaccination, chlamydia screening, HIV and STI sexual partner referral services, and condom access. New training courses designed and advocated by SHARP have been institutionalized for HIV-STI prevention counseling, partner services, community-level sexual health promotion, sexual risk assessment, and STI 101 for non-clinicians. For example, in 2000, having explored and discovered a gap in Navy training, SHARP negotiated with the Navy School of Health Sciences to insert into the curriculum for Navy preventive medicine technicians (the disease intervention specialists for the Navy and Marine Corps) three days of SHARP training on the RESPECT model for HIV-STI prevention counseling (the CDC-recommended, evidence-based, six-step model for working with patients to reduce sexual risk behavior),⁷ and a newly created SHARP course on sexual partner services. Since then, each of the 1,200 preventive medicine school graduates has received this evidence-based training. In 2003, SHARP negotiated with the Navy's Surface Warfare Medical Institute and, since then, the 400 medical officers who attended their 30-day orientation for medical officers newly assigned to sea duty have received a SHARP lecture on promoting the sexual health of sailors on ships. In 2001, SHARP was able to insert sexual health lectures and skills-building courses on community-level sexual health promotion into the Navy's annual public health conference and the Navy's biennial Health Promotion and Wellness Program Manager's course. These lectures have been delivered to more than 500 Navy health educators. These are examples of institutionalized sexual health education programs for Navy health-care providers, which have and will continue to contribute to a more capable medical workforce.

SHARP has also been successful at securing invitations for its staff to speak about sexual health at annual conferences for Navy Flight Surgeons and Navy Independent Duty Corpsmen; General Medical Officer intern courses; 25 Navy and Air Force medical treatment facilities and Marine Corps wellness centers in Asia, Europe, the Caribbean, and the U.S.; and many other venues. SHARP has also delivered many sexual health lectures directly to sailors and Marines on ships and in the field. SHARP advocated for the integration of an evidence-based risk-reduction intervention for people living with HIV into the care program delivered at the three Navy HIV treatment centers and arranged for CDC to train the staff in these treatment centers.

In the past decade, SHARP discovered a wide variety of educational, training, and informational products in use that were outdated, inaccurate, or otherwise suboptimal, and worked with multiple organizations to improve these products or simply replace them with new SHARP-developed or other products. These suboptimal training products were typically developed in isolation by well-intended authors and were offered by well-intended leaders, but suffered from incomplete and sometimes outdated information. For example, most addressed STIs only. Rarely could one find information on HIV or unplanned pregnancy, even though these issues are perhaps much more impactful to sailors and Marines and the Navy and Marine Corps. These training products typically focused on the scary outcomes of sex, using clinical slides of genital lesions and discharges, but failed to deliver messages about individual risk-reduction options. Speakers assigned to use these products often had little baseline training on the topics. Meanwhile, SHARP discovered three very good Navy films, developed in the mid-1990s, of which potential users were completely unaware. The Navy's health research center had developed two of the films and the Navy's training center had developed the third. SHARP has subsequently marketed and distributed these films to potential users, reviewed and improved training products developed by other Navy and Marine Corps users, and developed new products to fill gaps. The new SHARP products include posters, fact sheets, program guidelines, and group interventions covering prevention of HIV, other STIs, and unplanned pregnancy. New films were produced on contraception, STI prevention, HIV prevention, and HIV prevention for HIV-positive members. New courses and lectures were also developed for health-care and public health professionals. Examples of these prevention products are listed in Figure 2.

Figure 2.

Selected Navy and Marine SHARP products developed since 1999 and currently in use

^aCenters for Disease Control and Prevention (US). Project RESPECT [cited 2012 Oct 23]. Available from: URL: http://www.cdc.gov/hiv/topics /research/respect/index.htm

SHARP = Sexual Health and Responsibility Program

HIV = human immunodeficiency virus

STI = sexually transmitted infection

SHARP-developed and SHARP-edited products are now used in many Navy schools, boot camps, ships, workplaces, and medical treatment facilities. These products are also marketed and distributed on a SHARP Toolbox DVD and a robust website. Additionally, sexual health has been integrated into the Navy Surgeon General's workplace-centric health promotion and wellness award program (known as the Blue H), wherein Navy ships and workplaces receive points for conducting activities and enacting policies regarding the prevention of sexual assault, HIV, and other STIs, as well as family planning (Figure 3).

Figure 3.

Sample SHARP poster focusing on Navy women as well as men who have sex with men

SHARP = Sexual Health and Responsibility Program

OUTCOMES AND EVALUATION

Beginning in 2000 and evolving over time, sexual health goals and metrics were chosen and partners were engaged to strengthen or establish surveillance mechanisms. SHARP proposed these metrics using nationally recognized objectives such as those in Healthy People 2020 as a point of departure, based on their applicability to the active-duty sailors and Marines, their perceived impact on the health of these military personnel, their perceived achievability, and their measurability. These metrics were discussed with Navy subject-matter experts in women's health, HIV care, and preventive medicine, and with the agencies responsible for recurring health surveys and health surveillance. These metrics have been updated each year under the supervision of the NMCPHC leaders. The 2012 SHARP priority objectives are listed in Figure 4. Each objective is now measurable via standing periodic Navy surveys or surveillance systems. Measuring population-level health and outcomes over time is a difficult proposition in a mobile population such as the Navy and Marine Corps, where perhaps 20% of the population turns over each year. Some sexual health outcomes have improved over time, while others have been more intractable. In general, the unplanned pregnancy rate has been steady for the past two decades and does not yet meet the target rate. The HIV seroconversion rate among sailors declined each year from 2008 through 2011, after nine years of steady increases, but still exceeds the target rate. The HIV rate among Marines has been flat and significantly lower than the rate among sailors, but has not met the target rate since 1998. HIV among female sailors and Marines is extremely rare. Gonorrhea rates among male and female sailors and Marines are low and declining, and now meet or exceed the target rates. Syphilis case numbers are small, but have been rising since 2009. Chlamydia preventive screening rates are high and exceed the target rate.

Figure 4.

Navy and Marine SHARP metrics as of August 2012

SHARP = Sexual Health and Responsibility Program

HIV = human immunodeficiency virus

Because rigorous evaluation has been absent and NMCPHC lacks the funding and tasking to conduct pure research, there are insufficient data to specifically demonstrate that any specific SHARP action has directly affected the incidence of STIs, HIV, or unplanned pregnancies among sailors and Marines. Instead, SHARP has advocated for the adoption into Navy processes of evidence-based interventions and policies that have the greatest likelihood of efficacy. What can be said is that many of the developments described in this article would not have occurred at all without SHARP advocacy, action, and collaboration, demonstrating the utility of SHARP as an essential connector.

CURRENT PRIORITIES AND TARGETS

More remains to be done. For example, unplanned pregnancy rates are high among Navy and Marine Corps women aged 21–25 years, both single and married. Among the women in this group who experienced an unplanned pregnancy, about half used birth control pills and about half were using no form of contraception when the pregnancy occurred. The use of -long-acting reversible contraceptives (LARC), including intrauterine devices and hormonal implants, which are much more effective than oral contraceptive pills, was very low in this group. Therefore, SHARP, in collaboration with BUMED Women's Health, boot camp clinics, the Navy training establishment, and other partners, is presently conducting a LARC promotion effort to reduce misinformation about LARC and increase LARC access.

Another current priority is addressing the rising proportion of HIV in the U.S. attributable to sex between men, a key goal of the U.S. National HIV Prevention Strategy.⁸ The 2011 repeal of the Department of Defense “Don't Ask Don't Tell” policy is a new opportunity to more openly address issues of HIV risk among gay and bisexual men in uniform. The challenge for SHARP and Navy partners currently engaged in collaborative focus groups is to reach these men with relevant and effective health messages, while avoiding the creation or exacerbation of stigma. An additional and continuing SHARP challenge is posed by the general stigma and silence surrounding sexual behavior. Certainly, these phenomena affect the attitudes of people in uniform just as they do the general U.S. population, and challenges remain. Also, sexual health is only one of many other high-priority health concerns within the Navy and Marine Corps, and SHARP must continuously compete for limited resources.

CONCLUSION

SHARP is a low-cost effort that has provided a focal and trusted source of sexual health advocacy, educational products, consultative services, and training. SHARP is now specifically cited as the source of sexual health information in the Navy-wide policies governing HIV management, STI prevention, and workplace health promotion, and SHARP-provided training is specifically required in the formal curriculum for Navy preventive medicine technicians. SHARP also serves as a conduit for multidisciplinary collaboration and coordination. The mere existence of a central sexual health program normalizes integrated and comprehensive sexual health messages, enables efficiencies (such as training product development), promotes program and policy uniformity, and provides a forum for cross-organizational collaboration and continuous improvement.