Download STD`s AT SMU - Alabama – North Carolina STD | HIV Prevention

STDs/STIs: Old
Behaviors, New
Challenges
Rick Meriwether
UAB Department of Medicine
STD Program
[email protected]
Common STDs
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Chlamydia
Gonorrhea
Genital Herpes (HSV-2)
Genital Warts (HPV)
Hepatitis B
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HIV
Pubic Lice
Syphilis
Trichomoniasis
STD Risk Factors
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Sexual activity
Early age of sexual initiation
Increased number of partners
Use of drugs or alcohol
Belief in invulnerability--”It doesn’t happen
to people like me”
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Why are teens at higher risk?
Cervix of younger women more prone to getting infected with
certain STD
Multiple partners
Unprotected intercourse
Pool of disease in age group
Lack of Knowledge/Uncomfortable talking about sex
Abstinence Programming Limitations (Bearman et al, 2004)
Alcohol & drug use
Lack of insurance or other ability to pay for services,
transportation, discomfort with facilities, confidentiality
HIV and Youth, National
Estimates
• Youth under age 25
• One-third of US population
• About half of all new US HIV
infections
• Sexual contact leading cause of infection
National Teen Sexual Health Data
• 1 of every 10 female and 1 of every 20 male high school
students have been forced to have sex
• 1 of every 5 sexually active teen female will get pregnant
this year.
– 3 of every 4 teen pregnancies are unplanned.
• At least one-half of all new HIV infections in the U.S. are
estimated to be among those under 25.
• Two U.S. teens are infected with HIV every hour of every
day.
The Good News…
• Among teens who are sexually active, condom use has
increased from 46% in 1991 to 63% in 2003.
• The number of teens who are sexually active has
declined from 54% in 1991 to 47% in 2003.
• The teen pregnancy rate has decreased nationwide from
56.0 (per 1,000) in 1995 to 41.6 in 2003
Source: CDC Youth Risk Behavior Surveillance (YRBS) 2003 and Health, US 2005
Risk behaviors contributing to major
morbidity (STD/HIV, pregnancy) in
adolescents
u 57% of Alabama 9-12th graders ever had sexual intercourse
(47 % U.S.)
u 42% had intercourse in past 3 months (34% U.S.)
u 21% had four or more sex partners (14% U.S.)
37% of Alabama sexually active teens did not use
a condom at last sexual intercourse (38% U.S.)
u10% of Alabama teens reported ever experiencing
forced sexual behavior (9% U.S.)
u
2003 Youth Risk Behavior Survey
•It is estimated that 20 percent of all Americans age
12 and older are infected with genital herpes.
•It is estimated that there are more than 68 million
current STD infections among Americans. Each year,
15.3 million new STD infections occur, including over
3 million infections in teens. The two most common
STDs, herpes and human papilloma virus (HPV),
account for 65 of the 68 million current infections.
•Source: American Social Health Association. Sexually Transmitted Disease
in America: How Many Cases and at What Cost? Menlo Park, Calif.: Kaiser
Family Foundation; 1998.
•Pregnant teen girls are carrying on average 2.3
sexually transmitted diseases.
•Each day 33, 000 Americans become infected
with an STD.
•Today 12 thousand teenagers will contract a
sexually transmitted disease
•In l980, four million people were reported to have
been infected with an STD. By 1990 that number
tripled with 12 million people reported to have a new
STD infection that year.
•Today, one in every five Americans between ages 15
and 55 is infected with at least one sexually
transmitted disease.
•The Centers for Disease Control reports there are
now more than 50 known STDs. Some STDs can
make you sterile. Some are incurable.
Alabama Law
for HIV/STI Testing
• Requires informed consent (22-11A-51)
• No premarital testing requirement
• Prenatal testing is required (420-4-1-14)
• School notification not required for positive
staff or students (universal precautions)
Alabama Law
for HIV/STI Testing (cont.)
• Allows testing of individuals:
– 12 years of age or older without parental
consent (22-11A-19)
– Mandatory testing for prison inmates Court
ordered testing for defendants charged with a
sex offense as defined in
the Code of Alabama and the Administrative
Alabama Code (22-11A-17)
Genital Warts
• Caused by Human Papilloma Virus (HPV)
• Sexually active persons who have had > 3
partners or whose partners have had > 3
partners have a 75 % chance of being
infected with virus.
• Over 80% of sexually active students will
contract and transmit HPV by the time they
graduate from college.
Intercourse vs.. Outercourse
“Rub a dub dub”
• Penile – Vaginal penetration is not required
to contract HPV.
• Genital contact or hand/oral
manipulation may result in HPV
infection.
• “Virgins” (no vaginal penetration by
penis) can and do still contract HPV.
Human Papillomavirus
• > 100 types of HPV with > 30 types
infecting genital tract
– Type that causes genital warts not same as
types that cause cervical cancer
• 20 million infected with HPV in U.S.
• 6 million new infections each year
• 50% of people will become infected at
some point in life
HPV: Diagnosis &
Treatment
• Dx: HPV DNA - detection • Vaccines protect females
of viral nucleic acid
against HPV types that
cause most cervical cancers
• Used in conjunction with
Pap test
• One available vaccine also
provides protection against
most genital warts
• Screening without Pap
test not recommended
• No treatment for virus
(treat cancer & warts)
• Recommended for females:
– 11-12 years
– 13-26 years
Condyloma acuminata, penile
Condyloma acuminata, vulva
Clinical Manifestations
Intrameatal Wart
Source: Cincinnati STD/HIV Prevention Training Center
Clinical Manifestations
Perianal Warts
Source: Seattle STD/HIV Prevention Training Center at the University of
Washington/ UW HSCER Slide Bank
HPV
Perianal Wart
Source: Cincinnati STD/HIV Prevention Training Center
HPV infection in the throat
Normal larynx
HPV infected larynx
exhaling
STIs: HPV
Herpes Simplex Virus (HSV)
• Prevalent among college students
• Type 1 - Oral (Freshmen: 37%
Seniors: 46%)
• Type 2 - Genital (Freshmen: 0.4%
Seniors: 4%)
• Types 1 & 2 found in genital lesions
• Diagnosed by examination and cultures
• Can be transmitted even without visible
lesions
Herpes
• Herpes simplex virus (HSV-1 & HSV-2)
– Majority of recurrent genital herpes caused by
HSV-2
• At least 50 million people in U.S. have
genital HSV infection  more common in
females
• Majority of infections transmitted by
people unaware of infection or
asymptomatic  transmission can occur
without visible lesions
Herpes: Signs &
Symptoms
• First outbreak can occur within 2 weeks
after exposure
– Blisters in genital area  eventually break
leaving painful ulcers/sores  2-4 weeks to
heal
• Can be weeks or months for another
outbreak
– Usually less severe & shorter duration
– Number of outbreaks tend to decrease over
years
Herpes: Diagnosis
• Dx: Virologic & Type-specific serologic
testing
– Virologic  HSV culture for visible lesions
only
– Type-specific serologic testing  looks for
HSV antibodies
– HSV-1
– HSV-2
– HSV 1 & 2
Herpes
Herpes in a Man
Source: Cincinnati STD/HIV Prevention Training Center
Primary herpes, female
Same patient, four days later
Herpes
You can get herpes anywhere . . .
Source: Cincinnati STD/HIV Prevention Training Center
Herpes Simplex Virus (HSV)
Management
• Can be controlled but not cured
• Acyclovir for primary outbreak and flares
• Recurrent flares in 80% of infected
individuals exacerbated by:
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Stress
Heat
Menstruation
Trauma
Herpes: Treatment
• 1st Episode:
• Episodic Therapy:
(7-10 day course)
– Acyclovir 400 mg TID
or
– Famciclovir 250 mg
TID
or
– Valacyclovir 1 gm BID
– Acyclovir 400 mg TID x 5d
or
– Acyclovir 800 mg BID x 5d
or
– Acyclovir 800 mg BID x 2d
or
– Famciclovir 125 mg BID x 5d
or
– Famciclovir 1 gm BID x 1d
or
– Valacyclovir 500 mg BID x 35d or
– Valacyclovir 1 gm QD x 5d
Chlamydia
• 5% of college students infected
• Frequent association with other STD’s
• Symptoms
• Often no symptoms
• Women: discharge, painful urination, pain with sex,
heavy and irregular menstrual periods
• Men: discharge, epididymitis (painful scrotum)
• Can cause PID and infertility
Untreated chlamydia in infants may lead:
•Blindness
•Complications of pneumonia, which can include death
Chlamydia: Diagnosis
• Annual screening recommended for:
– All sexually active females < 25 years old
– Older females with risk factors (new or
multiple partners)
• Screen all pregnant women
• Dx: Nucleic Acid Amplification Testing
(NAAT)
– Urine
– Swab
Chlamydia: Treatment
Non-Pregnant:
• Azithromycin 1
gm x 1
or
• Doxycycline 100
mg BID x 7 days
Source: CDC 2006 STD Treatment Guidelines
Pregnant:
Doxycycline
contraindicated
• Azithromycin 1
gm x 1
or
• Amoxicillin 500
mg TID x 7 days
Chlamydia:
Treatment
• Empiric treatment should be provided for:
– Anyone with risk factors
– If follow-up cannot be ensured
• All partners need evaluation/treatment to prevent
reinfection
• Abstain from sex during treatment & for 7 days
after everyone has finished treatment
• Repeat testing (3-4 weeks after completing
therapy) recommended in pregnant women or
anyone with questionable treatment compliance
Chlamydia:
Complications
• 10-15% develop PID
•  risk of HIV infection
• Perinatal exposure  leading cause of
early infant pneumonia and conjunctivitis
in newborns
Gonorrhea: Signs &
Symptoms
• Bacteria: Neisseria gonorrhoeae
• Second most commonly reported infectious
disease in the U.S.  2008: 336,742 cases
reported
• Many asymptomatic (50%) & undiagnosed 
actually 600,000 new cases each year
• Symptoms usually appear 2-5 days after
exposure & are non-specific
– Vaginal discharge
– Dysuria
Gonorrhea: Diagnosis
• Screening recommended for:
– All sexually active women at increased risk for
infection
– All pregnant women
• Dx: Nucleic Acid Amplification Testing
– Urine
– Specimen
*Culture & susceptibility testing for persistent infection after
treatment
Gonorrhea: Treatment
• Same treatment for non-pregnant &
pregnant:
– Ceftriaxone 125 mg IM x 1
or
– Cefixime 400 mg x 1
– PLUS treatment for chlamydia if not ruled ou
*Fluoroquinolones (ciprofloxacin/ofloxacin/levofloxacin)
no longer recommended for treatment due to widespread
fluoroquinolone-resistant gonorrhea in U.S. – MMWR
April 13, 2007
Source: 2006 CDC STD Treatment Guidelines
Gonorrhea: Treatment
• Empiric treatment should be provided:
– Anyone with risk factors
– If follow-up cannot be ensured
• All partners need evaluation/treatment to
prevent reinfection
• Abstain from sex during treatment & for 7
days after everyone has finished treatment
• Test of cure is not recommended
– Due to high prevalence consider re-testing 3
months after treatment
Gonorrhea:
Complications
• 10-20% develop PID
•  risk of HIV infection
• Perinatal exposure:
• Blindness
• Joint infections
• Life-threatening septicemia
Pelvic Inflammatory Disease
(PID)
• Infection spreads
upward from cervix to
uterus, Fallopian
tubes, ovaries &
surrounding
structures
• Often have more than
one infection 
chlamydia &/or
gonorrhea
• Affects > 750,000
females in the U.S.
each year
• Most common cause
of female infertility &
ectopic pregnancy
• Non-specific
symptoms:
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Chronic pelvic pain
Fever
Nausea/vomiting
Pain during sex
Irregular bleeding
Cervical motion
tenderness
– Tender adnexal mass (or
Gonorrhea
Swollen or Tender Testicles
(Epididymitis)
Source: Health Awareness Connection, http://www.healthac.org/images.html
Syphillis
• Rates increasing among youth/young adults
• Progressive disease
• Primary phase: single genital chancre (ulcer),
swollen lymph nodes
• Secondary phase: more sores, usually on genitals
• Late phase: involvement of multiple organs
• Curable with antibiotics
Syphilis
• Bacteria: Treponema • Progresses through
pallidum
stages if left
• Re-emerged as public
untreated:
health threat in 2001
Primary
& rates steadily
Secondary
increasing
• “The Great Imitator”
Tertiary
– has variety of
• 2008: 13,500
clinical
reported cases of
manifestations
primary/ secondary
syphilis
Syphilis: Diagnosis
• Screening recommended for:
– Anyone with a genital lesion
– All pregnant women upon entry into prenatal care
• Repeat testing twice in third trimester in areas of high
prevalence or those at high risk
– Between 28-32 weeks
– At delivery
• Dx: RPR (rapid plasma reagin) – looks for
nonspecific antibodies
– Fluorescent treponemal antibody absorbed (FTAABS) test used to confirm (+) RPR  looks for
antibodies specific to T. pallidum
Syphilis - Treponema pallidum
on darkfield
Primary syphilis - chancre
STIs: Primary Syphilis
Laura Bachman, MD
Secondary syphilis papulosquamous rash
Syphilis: Treatment
• No recommendations for annual screening
except during pregnancy
• Partners need to be evaluated & treated
• Clinical & serologic follow up should be
done 6 & 12 months after treatment
• HIV testing should be done on anyone
with syphilis & if (-) repeat 3 months later
in high prevalence areas
Syphilis: Treatment
• Penicillin G preferred treatment for all stages –
dosage & length of treatment depends on disease
stage & clinical manifestations
• Same treatment for non-pregnant &
pregnant:
PCN 2.4 million units IM x 1
• PCN allergy alternatives for non-pregnant  doxycycline or
tetracycline (compliance?)
• Jarisch-Herxheimer reaction – acute febrile with
headache/myalgias that can occur within first 24 hours after
treatment
Source: CDC 2006 STD Treatment Guidelines
Syphilis: Complications
• Disease progresses - damages CNS, eyes,
heart, blood vessels, liver, bones, joints &
can cause death
•   risk of HIV infection
• Perinatal exposure:
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Miscarriage
Premature delivery
Stillbirths (40%)
Death of infant (12%)
Congenital syphilis (40-70%) – infected in utero/at birth
• Untreated  deformities, delays in development, seizures
Vaginitis and Cervicitis
• Symptoms: discharge, lower abdominal
pain, abnormal menstrual bleeding, pain
with urination, frequent urination
• Sexually transmitted: trichomonas, bacterial
vaginosis, yeast
• Non-sexually transmitted: bacterial
vaginosis, yeast, soap or spermicide
allergies, perfumes, foreign bodies (e.g.
forgotten tampons)
Trichomoniasis
• Parasite: Trichomonas vaginalis
• 7.4 million new cases each year in the U.S.
• Symptoms develop 5-28 days after
exposure
– Frothy, yellow-green vaginal discharge with
strong odor
– Dysuria
– Pain during sex
– Genital irritation/itching
Trichomoniasis: Diagnosis &
Treatment
• Dx: Wet Prep – microscopic examination
of discharge  motile trichomonads
• Same treatment for non-pregnant &
pregnant: Metronidazole 2 gm x 1
– Treat partners
– Abstain from sex until asymptomatic
• Perinatal exposure:
• Premature ROM
• Preterm labor
• Low birth weight
Source:CDC 2006 STD Treatment Guidelines
Other Genital Disorders
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Yeast infections (Candida Albicans)
Scabies
Pubic lice
Molluscom contagiosum
Tinea cruris (jock itch)
Folliculitis (infected hair follicles)
Bacterial Vaginosis
Bacterial
Vaginosis
• Clinical
syndrome - normal
balance of bacteria
disrupted (usually Gardnerella)
• Most common cause of vaginal infection in
women of childbearing age
• Some activities increase risk  douching, bubble
baths, new/multiple partners
• Usually asymptomatic but if present:
– Thin, white/gray discharge with unpleasant odor
– Pain during sex
– Dysuria
– Genital itching
Bacterial Vaginosis:
Treatment
• Same treatment for non-pregnant & pregnant:
Metronidazole 500 mg BID x 7 days
• Response to therapy/recurrence not affected by
treatment of partner(s) so routine treatment not
recommended
• Perinatal exposure:
– Premature ROM
– Chorioamnionitis
– Preterm labor/delivery
– Postpartum endometritis
Female Crab Louse
Information Alone is Not Enough
• Primary prevention of STDs is about
teaching youth knowledge and skills they
need before risky behaviors begin
“Programs that combine a focus on youth development
(including involvement in activities such as educational
mentoring, employment, sports, or the performing arts)
with sex education can have a strong impact on
frequency of sex as well as pregnancies and births …”
Protective Factors for HIV, STDs,
and Unintended Pregnancy
• Internal Protective Factors
• Connectedness to parents, family, school,
community, culture
• Positive values, sense of purpose, hope for future,
and resiliency
• Social and cultural competency
• Self-esteem, self-efficacy, self-reliance and autonomy
• Critical thinking, decision-making, and problemsolving skills
• Communication, negotiation, and refusal skills
continued …
• External Protective Factors
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Adult role models/mentors
Opportunities for preparation
After school activities
Communities that value youth
Viral Hepatitis
• The only infectious form of hepatitis
• Currently 6 different forms (A,B,C,D,E,
&G)
• 4 forms (B,C,D, and G) are blood borne
while 2 (A & E) forms are oral-fecal
• Hepatitis D is typically a co-infection with
Hepatitis B and Hepatitis G is typically a
co-infection with Hepatitis C
Viral Hepatitis cont’d
• All forms of viral hepatitis have the similar signs
and symptoms: jaundice, fatigue, abdominal pain,
loss of appetite, nausea,& vomiting
• Signs and symptoms of hep B & C also include
joint pain and dark urine
• IDU’s are at high risk for contacting either
Hepatitis B or C
• It is estimated that 50%-90% of IDUs with HIV
also have Hep C
HEPATITIS B (HBV)
• Hepatitis B virus
infection
– Of the total number of
those infected, a small
percentage die from
cirrhosis (top picture)
and primary liver
cancer (bottom picture)
WHAT IS CIRRHOSIS ?
• Scarring of the liver
with loss of function
• Liver function tests
may be normal due
to a decrease in the
number of normal
liver cells
NORMAL BIOPSY
BIOPSY OF CIRRHOSIS
PATIENT WITH END-STAGE LIVER FAILURE DUE TO CIRRHOSIS
Transmission
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For both Hep B & C transmission occurs when infected blood enters the body
of a person who is not infected
Hep B is most frequently transmitted through unprotected sex, shared needles
and works, and from mother to child during birth
Hep C is most frequently transmitted through sharing needles and works, and
from mother to child during birth. Hep C has a lowest risk of sexual
transmission among the hep viruses
Hep B & C are acquired rapidly among IDU’s. Within 5 years of beginning
injection drub use 50%-70% of IDUs become infected with Hep B and 50%80% become infected with Hep C
• Blood exposure is most efficient method of transmission
• Large number of individuals with the disease equally large numbers
of potential transmission
• High rate of sharing among IDUs: drugs, solutions, works, needles,
syringes, etc.
Huge Sale! Buy Crystal, Get HIV
Free!
• Biochemical effects:
– Reduce inhibitions
– increases sexual desire and
– feelings of invincibility
• Powerful drug in terms of initiating,
enhancing and prolonging sexual activity
(Horn, 2005)
METH
• Users are motivated by feelings of invincibility, and
energy (especially men with HIV because it negates
both emotional and physical pain)
• Sex occurs without guilt and mental distractions of
shame and embarrassment
• Inhibitions are lowered resulting in more
anonymous sex
• Users report more “hard core” sex
• Meth users average more incidents of unsafe sex
compared to cocaine users
(Huff, 2005)
What Meth Can Do For You:
• Permanently damage nerve cells
• Meth + Viagra+ Poppers = high risk of Heart
Attack
• Suppress the immune system
• Cause long term “crystal dick” (limp)
• Increase the risk of contracting HIV
• Contribute to psychotic episodes
• Rapidly increase the progression of HIV
(Cascade AIDS Project)
Other infectious complications in intravenous
drug users:
• Skin and soft-tissue infections
– Common in the intravenous drug user (IDU)
– Frequent injections, nonsterile technique, sharing equipment and
skin popping all predispose the addict to soft-tissue infection.
– Cellulitis, skin abscesses, thrombophlebitis (vein inflammation due
to blood clot), necrotizing fasciitis (flesh-eating bacteria),
pyomyocisitis (abscess found in a muscle), gangrene
– Besides causing abscesses at an infected injection site, needle use
can also inject bits of foreign matter into the bloodstream that can
lodge in the spine, brain, heart, lungs, or eyes and cause an
embolism or other problems.
Other infectious complications:
• MRSA (methicillin-resistant staphylococcus aureus)
– IDUs have higher carriage rates of staphylococcal and streptococcal
organisms than general population.
– As many as 60% of intravenous drug users may be taking antibiotics sold
on the street, often supplied by the intravenous drug supplier.
– One result is the emergence of MRSA, methicillin-resistant
staphylococcus aureus.
• Endocarditis
– A common, but potentially fatal condition caused by bacteria that lodge
and grow in the valves of the heart.
– IV cocaine users have a higher rate of endocarditis, perhaps because the
ups and downs of cocaine require more injections than heroin or
methamphetamines.
Other infectious complications:
• Tetanus
– There have been many reports of increased incidence of tetanus among
IDUs.
– An acute, sometimes fatal disease caused by exotoxin produced by
Clostridium tetani (C. tetani). Potential sources of tetanus in IDUs include
contamination of drugs, adulterants, paraphernalia and skin.
– Heroin is frequently cut with quinine, which causes favorable conditions
for C. tetani growth.
– Skin popping increases superficial skin infections and growth potential for
C. tetani.
• Cotton fever
– The symptoms are similar to those of a very bad case of the flu.
– A very common disease, caused by bits of cotton used to filter a drug or
by infections carried into the body by cotton fibers injected into the blood.
Other infectious complications:
•
Skeletal infections
– Septic arthritis (infection of a joint which leads to destruction if untreated) and
osteomyelitis (acute infection of the bone) may occur as a result of a blood spread
from a distant site, most commonly endocarditis
– These infections are generally confined to immunocompromised patients or those
with chronic debilitating illnesses. However, in the IDU, skeletal infections are
often in a young, otherwise healthy individual.
• Most frequent site of osteomyelitis infection is the vertebral column, especially the
lumbar spine; and, infectious arthritis usually involves the knee or hip
•
Nervous system infections
– Most common nervous system infections in IDUs include meningitis, epidural
abscess, and brain abscess
– Extensions of bone infections (osteomyelitis) and embolic complications of
endocarditis may be the source of nervous system infections.
Other infectious complications:
• Alcohol
– Infectious disease also linked to excessive
drinking because it can disrupt white blood
cells and in other ways weaken the immune
system, thus resulting in greater susceptibility
to infections.
The Good News
• HIV education is increasing awareness of
HIV and other STDs
• Studies show modest but significant
decrease in recent sexual activity
• Use of condoms is increasing
• Research has brought new and better
therapies for many STDs in recent years
Making Sex Safer
• ABSTAIN from sexual intercourse until you
are in a long-term, committed relationship
• Experiment with non-sexual ways to
express affection
• Communicate with your partner about sex