Sexually Transmitted Diseases

1. Sexually Transmitted Diseases Los Angeles County Department of Health Services Sexually Transmitted Disease Program

2. Reportable STDs in LAC • Chlamydia • Gonorrhea • Syphilis • Chancroid • PID • NGU

3. Other STDs -- Viral • HSV • HPV • HIV

4. Reported Sexually Transmitted Diseases United States, 2002 Source: CDC Sexually Transmitted Disease Report, Year 2002

5. Chlamydia trachomatis • Most common bacterial STD in US • Chlamydial infections can cause PID, ectopic pregnancy, infertility and pregnancy complications • Up to 70% of sexually active women have asymptomatic chlamydial infections • ~15-30% women re-infected by 6 -12 months • Asymptomatic rectal infections in MSM

6. Rate (per 100,000 population) 300 240 180 120 60 0 1984 86 88 90 92 94 96 98 2000 02 Chlamydia — Rates: United States, 1984–2002 • Potential reasons for continuing increase: • More complete national reporting • Improvement in information systems for reporting • Use of more sensitive diagnostic tests • Expansion of screening services 297 51

7. Chlamydia Rates by Gender: United States, 1984–2002 Potential reasons for gender differential: 1. Greater number of women screened 2. Sex partners of women not diagnosed or reported 455 130 Urine screening* *55% increase (males): 84-130 cases per 100,000; 20% increase (females): 381 to 455 cases per 100,000 from 1998 to 2002

8. Chlamydia — Age- and sex-specific rates: United States, 2002

9. Chlamydia — Rates by State: United States and outlying areas, 2002 Note: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 293.6 per 100,000 population.

10. Reported Sexually Transmitted Diseases, Los Angeles County, 2003

11. Los Angeles County Chlamydia Rates 1991-2003 Per 100,000 population Urine screening

12. Los Angeles County Chlamydia Rates by Gender 1991-2003 Introduction of nucleic amplification tests Per 100,000 population

13. Los Angeles County Chlamydia Rates by Age and Gender, 2003 Per 100,000 population

14. Los Angeles County Chlamydia Rates by Race/Ethnicity, 2003 Rate per 100,000 pop.

15. Chlamydia take home points • Epidemic particularly among young women in Los Angeles County • Often asymptomatic • Serious sequelae, particularly with repeat infections & co-factor for HIV infection • Need novel strategies for control • Expanded screening • Patient Delivered Partner Therapy • Field Delivered Partner Therapy • Need testing technology to screen MSM for rectal infections

16. Gonorrhea • Second most common bacterial STD in US • Usually symptomatic in males, often asymptomatic in women • Can cause PID, infertility, ectopic pregnancy, and complications in pregnancy in women • High prevalences reported from non-genital sites among MSM (oropharynx & rectum) • Fluoroquinolone resistance

17. Gonorrhea — Rates by state: United States and outlying areas, 2002 Note: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 123.4 per 100,000 population. The Healthy People 2010 objective is 19.0 cases per 100,000 population.

18. Gonorrhea — Rates: United States, 1970–2002 and the Healthy People 2010 objective Reasons for decline in gonorrhea rates: 1. Increasedscreening 2. Increase use of sensitive diagnostic tests 3. Improved reporting and casefinding Note: The Healthy People 2010 objective for gonorrhea is 19.0 cases per 100,000 population.

19. Gonorrhea — Age- and sex-specific rates: United States, 2002

20. Gonorrhea Rates by Gender,California, 1993–2002 Note: Gender "Not Specified" accounted for less than 0.6% of all cases. Source: California Department of Health Services, STD Control Branch, 02/2003 Provisional Data

21. Gonorrhea Rates* Los Angeles County, 1990-2003 Introduction of nucleic amplification tests Healthy People 2010 Objective Year *Per 100,000 population

22. Gonorrhea Rates* by Age and Gender Los Angeles County, 2003 Age Group *Per 100,000 LA County population

23. Gonorrhea Rates by Race/Ethnicity Los Angeles County, 2003 Rate per 100,000 pop.

24. Fluoroquinolone Resistant GC (QRNG) • Widespread in parts of Asia, the Pacific, Hawaii. Many cases reported in CA. • Culture with antibiotic sensitivities recommended. • Avoid treatment with fluoroquinolones

25. Gonococcal Isolate Surveillance Project (GISP) — Location of participating clinics and regional laboratories: United States, 2002

26. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2002 Note: Resistant isolates have ciprofloxacin MICs > 1 g/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 g/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

27. Prevalence of quinolone-resistant Neisseria gonorrhoeae (QRNG)* among tested gonococcal isolates, and gonorrhea rate, California, 1993-2002 *QRNG is defined as N. gonorrhoeae, resistant to ciprofloxacin [minimal inhibitory concentration (MIC) >1.0 g/mL by agar dilution or disk diffusion zone size <27 mm] or ofloxacin (disk diffusion zone size 24 mm) by the National Committee on Clinical Laboratory Standards.

28. March 2003 – September 2004 South HC (47.6%) GLC (54.2%) Cultures Processed N=843 Isolates Recovered N=417 (49.5%)

29. Ciprofloxacin Resistant Isolates Los Angeles Sentinel Site South HC (9.1%) GLC (25.8%) Positive Cultures Resistant Isolates (14.8%) March 2003 – July 2004 N=352

30. Gonorrhea Treatment in CaliforniaUncomplicated Genital/Rectal Infections • Avoid fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin) to treat gonorrhea in California • Recommended regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum: • Ceftriaxone 125 mg intramuscularly in a single dose OR • Cefixime 400 mg orally in a single dose • Co-treatment of chlamydia is recommended unless chlamydia infection has been ruled out

31. Gonorrhea take home points • Overall increase in rates in California • Fluoroquinolone resistance increasing • Limited first line therapies: • Ceftriaxone (IM) • Cefpodoxime • Cefixime (still limited availability)

32. Syphilis(Treponema pallidum)

33. Primary and secondary syphilis — Rates by sex: United States, 1981–2002 and the Healthy People 2010 objective

34. Primary & Secondary Syphilis Cases by Gender, California, 1996–2002 ALL MALE Rate per 100,000 known MSM FEMALE 02/2003 Provisional Data - CA DHS STD Control Branch

35. Primary & Secondary Syphilis, Rates by Gender and Age Group, California, 2002 Male Rate per 100,000 Female Source: California Department of Health Services, STD Control Branch Provisional Data 03/18/2002

36. Number of MSM P&S Syphilis Cases by Region and Year 3/03 Provisional Data - CA DHS STD Control Branch

37. Early Syphilis, Los Angeles County, 2001-2003

38. Los Angeles County Early Syphilis By SPA Of Residence (n=389) (n=371) (n=198) Cases Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003

39. Early Syphilis Cases By Age & Sexual Orientation, Los Angeles County, 2003 Age Group Sexual Orientation Source: Early Syphilis Surveillance Summary, Aug. 2004

40. Primary & Secondary Syphilis by Race/Ethnicity among MSM and Non-MSM Cases Ethnicity/Race Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003

41. MSM1 Early Syphilis Cases by Race/Ethnicity, 2003 MSM includes MSM, MSM/W, and male to female TG or men or women who have sex with M to F transgenders

42. HIV Serostatus of LA County MSM Early Syphilis Cases 2003, n=466

43. Early Syphilis Cases By HIV Serostatus & Sexual Orientation, 2001 – 2003(n=724) Sexual Orientation Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003

44. The Impact of STDs on Sexual Transmission of HIV Types of evidence • Studies on the biological plausibility and potential pathogenic mechanisms • Cohort studies of HIV seroconversion associated with specific STDs • Community level interventions assessing the impact of STD treatment on HIV incidence

45. STDs and HIV TransmissionPathogenic/Biologic Mechanisms • Transmission: • Inflammatory conditions increase viral load in secretions • Virus can be cultured from genital ulcers • Susceptibility: • Breaks in epithelial barrier allow viral access • Inflammation increases number and/or receptivity of target cells • Enhancement of viral survival

46. Urethritis and HIV Transmission • HIV+ men with urethritis had HIV RNA levels in seminal plasma 8x > controls • Levels highest with GC • Levels returned to baseline within two weeks of treatment of urethritis • No change in serum viral loads Cohen et al. Lancet 1997, 349:1868-73

47. Impact of STDs on Sexual Transmission of HIVProblems in Study Design/Interpretation • Must control for sexual behavior • Studies should be prospective to document the temporal sequence of events • HIV increases the expression of certain STDs • Coinfections make interpretation difficult • Must stratify by gender and sexual preference

48. Effect of STD on HIV SusceptibilityEstimates (ORs) from Cohort Studies Rottingen et al STD 2001

49. Behavioral Risk Factors for MSM Syphilis Cases

50. Sexual Encounter Venues Among MSM Early Syphilis Cases, Los Angeles, 2001-2003 (YTD) Internet (n=830) Bars/Clubs (n=852) CSVs (n=869) Source: Epidemiology Unit, STD Program, 2003.