Common Sexually Transmitted Diseases

Topics

Background Information
Genital ulcerative disease

Diseases presenting with discharge

Role of STDs in HIV Transmission

Background

Where Do People Go for STD Treatment?

Population-based estimates from National Health and Social Life Survey Private provider 59% Other clinic 15% Emergency room 10% STD clinic 9% Family planning clinic 7%

Source: Brackbill et al. Where do people go for treatment of sexually transmitted diseases? Family Planning Perspectives. 31(1):10-5, 1999
3

Background

Percent of Women Who Said Topic Was Discussed During First Visit With New ObGyn Doctor/Health Care Professional

Source: Kaiser Family Foundation/Glamour National Survey on STDs, 1997

4

Background

Estimated Burden of STD in US - 1996

STD Chlamydia Incidence 3 million Prevalence 2 million

Gonorrhea
Syphilis Trichomoniasis

650,000
70,000 5 million

-------

HSV
HPV Hepatitis B

1 million
5.5 million 77,000

45 million
20 million 750,000

HIV

20,000
5

560,000

Source: The Tip of the Iceberg: How Big Is the STD Epidemic in the U.S.? Kaiser Family Foundation 1998

Proportion of Adult/Adolescent AIDS Cases by Transmission and Year - US 1985-2003

HIV/AIDS

Note: Data adjusted for reporting delays and estimated proportional redistribution of cases reported reported without an identified risk factor 6 Source: CDC/NCHSTP 2003 HIV/AIDS Surveillance Report

HIV/AIDS

AIDS Incidence among Adults/ Adolescents by Sex and Exposure - US 2003

Data adjusted for reporting delays and estimated proportional redistribution of cases initially reported without risk. 7 Source: CDC/NCHSTP 2003 HIV/AIDS Surveillance Report

HIV/AIDS

Proportion of AIDS Cases by Race/Ethnicity and Year US 1985-2003

Note: Adjusted for reporting delays Source: CDC/NCHSTP 2003 HIV/AIDS Surveillance Report
8

Acute HIV

Background

STDs - Genital ulcers disease

Syphilis Genital herpes (HSV-2, HSV-1) Others uncommon in the U.S.

Lymphogranuloma venereum (Chlamydia trachomatis L1, L2, L3) Chancroid (Haemophilus ducreyi) Granuloma inguinale (Donovanosis)
10

Background

STDs - Associated with discharges

Gonorrhea Chlamydia Nongonococcal urethritis /

Trichomonas vaginitis / urethritis Candidiasis (vulvovaginal)
11

mucopurulent cervicitis

STDs - Other

Genital HPV (especially type 16,

18) and Cervical Cancer

Background

Bacterial Vaginosis

Controversy: STD - yes or no Need for treatment

1980: only if patient complains 2002: increased risk of:

Preterm birth / premature rupture of membranes Amniotic fluid infection Chorioamnionitis / Postpartum endometritis PID Cervical intraepithelial neoplasia Mucopurulent cervicitis Acquisition of HIV infection
13

Genital Ulcerative Disease

Syphilis HSV-2, HSV-1 Lymphogranuloma venereum Chancroid Granuloma inguinale
14

Sores

Genital Ulcer Diseases

Painful Chancroid HSV Painless Syphilis Lymphogranuloma venereum Granuloma inguinale

15

Sores

Epidemiology of Genital HSV

One of the 3 most common STDs, increased 30% from late 70s to early 90s 25% of US population by age 35 HSV-2: 80-90%, HSV-1: 10-20% Most cases subclinical Transmission primarily from subclinical infection Complications: neonatal transmission, enhanced HIV transmission, psychosocial issues
16

Sores

Genital HSV Clinical Manifestations

Direct contact may be with asymptomatic shedding

Primary infection commonly asymptomatic; symptomatic cases sometimes severe, prolonged, systemic Vesicles painful ulcerations crusting Recurrence

Diagnosis:
Culture Serology (Western blot) PCR
17

Sores

Underdiagnosis of Genital HSV

779 women attending STD clinic Of the 372 diagnosed with genital herpes
82 (22%) symptomatic 14 (4%) viral shedding without symptoms 60 (14%) history of symptoms 216 (58%) HSV-2 antibody without viral shedding or history of symptoms
18

Sores

Genital Herpes Simplex

Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 19

Sores

Genital Herpes Simplex

20 Source: CDC/NCHSTP/Division of STD, STD Clinical Slides

Sores

Genital Herpes Simplex

Source: Centers for Disease Control and Prevention 21

Sores

Genital Herpes Simplex

Source: Florida STD/HIV Prevention Training Center 22

Chancroid
(Haemophilus ducreyi)

Syphilis Cases by stage of illness United States, 19412003

Syphilis

Source: CDC/NCHSTP 2003 STD Surveillance Report 24

Syphilis

Primary and Secondary Syphilis by race and ethnicity - US 1981-2003

Source: CDC/NCHSTP 2003 STD Surveillance Report 25

Syphilis

Primary and Secondary Syphilis Age- and gender-specific rates - US, 2003

Source: CDC/NCHSTP 2003 STD Surveillance Report 26

Sores

Primary Syphilis Clinical Manifestations

Incubation: 10-90 days (average 3 weeks) Chancre

Early: macule/papule erodes Late: clean based, painless, indurated ulcer with smooth firm borders Unnoticed in 15-30% of patients Resolves in 1-5 weeks HIGHLY INFECTIOUS
27

Sores

Primary Syphilis Chancre

Source: Florida STD/HIV Prevention Training Center 28

Sores

Primary Syphilis

Source: Centers for Disease Control and Prevention 29

Sores

Secondary Syphilis Clinical Manifestations

Represents hematogenous dissemination of spirochetes Usually 2-8 weeks after chancre appears Findings:

rash - whole body (includes palms/soles) mucous patches condylomata lata - HIGHLY INFECTIOUS constitutional symptoms
30

Sn/Sx resolve in 2-10 weeks

Secondary Syphilis Rash

Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides 31

Secondary Syphilis Rash

Source: Florida STD/HIV Prevention Training Center 32

Sores

Secondary Syphilis Rash

Source: Florida STD/HIV Prevention Training Center 33

Sores

Secondary Syphilis Rash

Source: Cincinnati STD/HIV Prevention Training Center 35

Sores

Secondary Syphilis

Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 36

Condylomata Lata

37

Florida STD/HIV Prevention Training Center

Tertiary Syphilis

Gummas CNS Periph NS CV

Granuloma Inguinale
(Donovanosis) (Klebsiella granulomatosis)

STDs with discharges

Gonorrhea
Nongonococcal urethritis Chlamydia

Mucopurulent cervicitis
Trichomonas vaginitis and urethritis Candidiasis
40

Gonorrhea

Gonorrhea Rates by gender United States, 19812003

Source: CDC/NCHSTP 2003 STD Surveillance Report 41

Gonorrhea

Gonorrhea by race and ethnicity US, 19812003

Source: CDC/NCHSTP 2003 STD Surveillance Report 42

Gonorrhea Age- and gender-specific rates US, 2003

Gonorrhea

Source: CDC/NCHSTP 2003 STD Surveillance Report 43

Gonorrhea - Clinical Manifestations

Urethritis - men

Incubation: 1-14 d (usually 2-5 d) Sx: Dysuria and urethral discharge (5% asymptomatic) Dx: Gram stain urethral smear (+) > 98% culture

Urogenital infection - women

Endocervical canal primary site

70-90% also colonize urethra

Incubation: unclear; sx usually in l0 d Sx: majority asymptomatic; may have vaginal discharge, dysuria, labial pain/swelling, abd. pain

Other sx: pharyngitis, migratory polyarthritis, tenosynovitis

Dx: Gram stain (intracellular diplococci) 50-70% culture
44

Gonorrhea

Source: Florida STD/HIV Prevention Training Center 45

Gonorrhea

Percent of GC isolates with resistance to ciprofloxacin, 19902003

Note: Resistant isolates have ciprofloxacin MICs >1 mg/mL. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 mg/mL. Susceptibility to ciprofloxacin was first measured in GISP in 1990. Source: CDC/NCHSTP 2003 STD Surveillance Report
46

Nongonococcal Urethritis

Etiology:
20-40% C. trachomatis 20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium) Occasional Trichomonas vaginalis, HSV Unknown in ~50% cases

Sx: Mild dysuria, mucoid discharge Dx: Urethral smear 5 PMNs (usually 15)/OI field Urine microscopic 10 PMNs/HPF Leukocyte esterase (+) 47

Chlamydia Rates by gender United States, 19842003

Chlamydia

Source: CDC/NCHSTP 2003 STD Surveillance Report 48

Chlamydia Chlamydia Age- and sex-specific rates United States, 2003

Source: CDC/NCHSTP 2003 STD Surveillance Report 49

Chlamydia trachomatis

More than 3 million new cases annually Causes cervicitis, urethritis, proctitis, lymphogranuloma venereum, PID Direct and indirect cost of chlamydial infections run into billions of dollars Potential to transmit to newborn during delivery

Conjunctivitis, pneumonia
50

Normal Cervix

Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center 51

Chlamydia Cervicitis

Source: St. Louis STD/HIV Prevention Training Center 52

Mucopurulent Cervicitis

Source: Seattle STD/HIV Prevention Training Center 53

Laboratory Tests for Chlamydia

Tissue culture = standard

Specificity approaching 100% Sensitivity ranges from 60% to 90%

Non-amplified tests
Enzyme Immunoassay (EIA) Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2
sensitivities 75-100%; specificities > 95% able to detect gonorrhea and chlamydia from one swab

DNA amplification assays: PCR

Sensitivity 95%; specificity ~100%
54

Pelvic Inflammatory Disease (PID)

Develops in l0-20% women with GC C. trachomatis >> GC in symptomatic women

CDC minimal criteria

uterine adnexal tenderness, cervical motion tenderness

Other symptoms
endocervical discharge, fever, lower abd pain

Complications:
Infertility: 15-24% with 1 episode (GC or chlamydia) 7x increased risk of ectopic pregnancy with 1 episode chronic pelvic pain 18%
55

HPV and Cervical Cancer

57

HPV and Cervical Cancer

HPV infection

~ 75% sexually active adults infected with genital HPV over their lifetime Causally associated with cervical cancer and probably other anogenital SCC (anal, penile, vulvar, vaginal) > 99% cervical cancers have HPV DNA within tumor Routine Pap smear screening ensures early detection (and tx) of pre-cancerous lesions
58

HPV and Cervical Cancer

HPV-Associated Cancers

Cervical cancer:

In the U.S., an estimated 14,000 Worldwide, an estimated 450,000

cases and 200,000 deaths
59

cases and 5,000 deaths

HPV and Cervical Cancer

Cervical Cancer Incidence by Year: US 19731999

Source: Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK (eds). SEER Cancer Statistics Review, 1973-1999, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1973_1999/, 60 2002.

HPV and Cervical Cancer

Cervical Cancer Incidence by Year of Dx and Race

61

Invasive Cervical Cancer Incidence and Mortality Rates by Race/Ethnicity U.S., 1998-2002
Incidence Mortality
White
Hispanic

HPV

Black
Asian/Pacific Islander

American Indian/ Alaskan Native

80 70 60 50 40 30 20 10 0 10 20 30 40

Note: Rates are expressed as cases per 100,000. Source: Statistics generated from data provided by the US National Center for Health Statistics, and provided by the SEER Program for research purposes only. 62

HPV and Cervical Cancer

Perianal Wart

Source: Cincinnati STD/HIV Prevention Training Center 63

HPV and Cervical Cancer

HPV Penile Warts

64 Source: Cincinnati STD/HIV Prevention Training Center

HPV and Cervical Cancer

HPV Warts on the Thigh

Source: Cincinnati STD/HIV Prevention Training Center

65

HPV and Cervical Cancer

Possible HPV on the Tongue

Source: Cincinnati STD/HIV Prevention Training Center

66

Role of STDs in HIV Transmission

67

STDs and HIV

Role of STDs in HIV Transmission

At least 2-5x increased risk of HIV seroconversion

Attributable risk of STDs for HIV transmission substantial in some populations

HIV susceptibility likely increased through

endocervical CD4 recruitment (any STD) portal of entry created by ulcers
68

STDs and HIV

Role of STDs in HIV Transmission

Greater infectiousness due to HIV shedding increased by STDs

STD treatment
reduces shedding to baseline level 40% reduction in HIV incidence achieved in RCT of tx of symptomatic STDs in Tanzania No reduction of HIV incidence demonstrated with STD mass tx Q10mo (RCT in Uganda)

69

STD/HIV Inter-Relationships

Influence of Treatment and Cure of Gonorrhea on Urethral HIV DNA Detection

No gonorrhea Gonorrhea (before Rx)

6/35 (17%)

21/48 (44%) P=0.02

Gonorrhea (after Rx)

10/48 (21%)

Source: Moss GB, Overbaugh J, Welch M, et al. (1995).

70

STDs and HIV

STD Treatment for HIV Prevention in the US - Where Do We Start?

Access to & quality of STD clinical services

Early & effective STD-related health care

behaviors
Surveillance systems to monitor STD/HIV trends & interrelationships
71

STDs and HIV

STD Treatment for HIV Prevention Access to Quality Clinical Services

Public & private settings serving HIVinfected or high-risk persons

Timely access to quality STD diagnosis &

treatment for symptomatic people at high risk (e.g., HIV C/T sites, schools, drug treatment centers, jails)

Training for clinicians & program managers

72

STD Treatment for HIV Prevention Early, Effective Health Care Behavior

STDs and HIV

Sexual risk reduction counseling PLUS

Messages for at-risk persons & providers Other STDs increase HIV spread Recognize & act on symptoms/sign

Most STDs asymptomatic; regular screening critical

Specific information on sources of care

73