Sexually Transmitted Infections

1. Sexually Transmitted Infections Cathlene Hardy Hansen and Pat Nagel--Health Educator

2. IU Health Center Services Massage: $33 with paid health fee Nutrition: 1 session free/semester Tobacco Cessation: Free, including cessation products CAPS therapy sessions: 2 free semester Sexual Assault Counseling: free, unlimited sessions Gynecological exams: free (tests, pay)

3. INTRODUCTION • “This is a hidden and silent epidemic. Normally an epidemic of this proportion would have attracted more attention.” 1996, Chancellor of Baylor College of Medicine Refers to the 12 million new STI cases/year in 1996; now estimated to be 15 million/year (increase due to higher numbers and better testing) http://www.medicinenet.com/stds_pictures_slideshow/article.htm

4. INTRODUCTION • Hidden – 2 meanings • 1. taboo subject of sex; not talked about publicly in a serious way • 2. most Americans not aware of this epidemic • Silent – 3 meanings • 1. some STIs have no symptoms • 2. lack of communication between individuals and their health care providers • 3. lack of communication between sexual partners

5. STI vs. STD • STI • Someone who is an infectedperson • ASYMPTOMATIC may not have any symptoms, • Could be unaware that they are even sick. • STD • A disease is any abnormal condition • of the body or mind with some type of symptom, • in other words your body tells you that you are unwell.

6. BACTERIA VIRUS • Living organism • May be stopped with appropriate antibiotic • Mild Severe • Not “alive;” lives on host • No known cures • Controlled by vaccine • Mild  Severe

7. IMPACT ON WOMEN • Lack of symptoms; more difficult to diagnose until serious problems develop • 150,000 (estimate) women become infertile each year due to PID (pelvic inflammatory disease)as a result of an STI • 15-30% (estimate) of the 2.3 million US couples who are infertile may by result of an STI

8. RISK FACTORS • Most STIs more easily transmitted to women than to men • Co-factor: infected with an STI makes one more likely to contract another STI, including HIV, after unprotected sexual contact with an infected partner • Multiple sex partners increase risk of exposure over one’s lifetime

9. Viral • Viral: • Herpes • HPV • HIV • Hepatitis B

10. HERPES GENITALIS • Caused by: Herpes Simplex Virus (HSV); • Type 1: 50-80% exposure rate; prefers facial area; • Type 2: 20% exposure rate; prefers genital areas; • Once in body, migrates to a nerve cluster (ganglia) and goes dormant; evades detection from body’s immune system; probably not contagious at this time. • May stay dormant forever or may migrate back to its first entry point on skin (active phase); it infects healthy cells, making new viruses. The immune system attacks and destroys infected cells; this “battle” is a herpes “outbreak.”

11. Herpes - symptoms • Incubation period: 1-12 days after sex with an infected person; may not appear for months or years • Duration: may last 12 days; flu-like symptoms; average of 4-5 outbreaks per year; • Sores: single or multiple fluid-filled blisters; painful; some outbreaks are mild and go unnoticed, especially in men • Outbreaks: not known for sure what causes successive outbreaks; they seem to occur more often when a person is rundown, under extreme stress, sick or sunburned, when the body is weak, in some way. • Future outbreaks? Duration, frequency and severity depend on: 1. is virus in preferred site (HSV-1 on genitals recurs less often than HSV-2; HSV-2 can be transmitted to the mouth, although rare); 2. each individual’s immune system; 3. how long person has had the virus.

12. Herpes - transmission • Skin to skin contact with infected person; includes oral, anal and vaginal sex; most contagious when sores are present; • Asymptomatic viral shedding (virus on skin surface but no symptoms); probably most common way virus is transmitted; approximately 80-90% of those with genital HSV do not know they’re infected; viral shedding most significant in year following first outbreak; • Viral shedding continues about 5-10% of each year; days can’t be predicted; • No documented cases of transmission from inanimate object such as toilet seat

13. Genital Herpes - Penis Genital Herpes - Vulva Picture Credits: University of Erlangen, Department of Dermatology and American College Health Association

14. Human Papilloma Virus • Caused by: • Human papilloma virus (HPV) on genitals (vagina, cervix, urethra, penis, anus) • Over 100 types of HPV, 30-40 of which can infect genitals • Mode of Transmission: • Skin-to-skin contact with an infected person; penetration not needed; could happen during anal, vaginal and oral sex • Virus can be transmitted when no warts or symptoms are present • Symptoms: • Dry, painless, firm, rough warts – may be large or small, multiple or single. May itch or cause irritated area (only small percentage will have warts) • Cervical changes detected on Pap test • HPV may be present without visible warts or cervical changes • http://www.youtube.com/watch?v=RjBpLeBzkng

15. Genital Warts Penis Genital Warts (HPV) Vulva Picture Credits: University of Erlangen, Department of Dermatology and Health Awareness Connection

16. Human Papilloma Virus (Cont.) • Diagnosis: • Clinical observation of genital warts. Symptoms may appear 1-8 months or longer after exposure. • Colposcopy - a procedure in which a colposcope (a lighted magnifying device) is used to identify the area of HPV infection on the cervix. • Pap test which detects cervical cell changes and HPV typing (determines high or low risk) • When an HPV test is positive, it does not mean that the virus is new or that a partner has been unfaithful. HPV can persist in cells for decades. • No diagnosis for asymptomatic males • Treatment: • Removal of warts by caustic chemical treatment, cryosurgery (freezing), laser treatment, electrocautery, or surgical removal of genital warts. • Careful follow-up of abnormal Pap test • May be transient infection. Immune system may clear HPV from the body over time or suppress the virus. Contagious? Probably not.

17. Human Papilloma Virus (Cont.) • Potential Complications: • Several strains, 23 types of HPV, are associated with an increased risk of cervical cancer (These strains generally do not cause visible warts.) Persistent infection with high risk type increases risk for cervical cancer. • Less common, but also reported, are increased risk of cancer of the vagina, penis, and anus as well as mouth cancers. • Transmission rate to newborn is unknown, but thought to be low. • VACCINE is now available; Gardasil is for females AND males ages 9-26; works against 2 strains most often implicated in cervical cancer and 2 strains that cause about 90% of genital warts; series of 3 shots ($155/shot at HC); • http://www.youtube.com/watch?v=DXST0MITOFE • NEW VACCINE just FDA approved: Cervarix; only for females and only protects against the 2 most common strains related to cancer • pap test for women still necessary due to 30% of cervical cancers caused by other strains. • Women age 27+ may obtain shot from HC; must see dr. or NP first, sign consent form. May not be as effective as compared to younger women.

18. Human Papilloma Virus (Cont.) • Comments: • 5.5 million new cases are diagnosed yearly; numbers are probably higher • Most common STI in the U.S. • Recent study reports: more than ½ of young adults in a new sexual relationship were infected with HPV; among those infected, nearly ½ were from an HPV type that causes cancer. Take away message? All young people should expect to be exposed to HPV. • HPV is the leading cause of cervical cancer • Condoms may help but may not cover all areas

19. Hepatitis B • Caused by: • Hepatitis B virus • Mode of Transmission: • Unprotected anal, oral, or vaginal sex with an individual infected with Hep B • Sharing Hep B contaminated needles and syringes • Mother-to-child transmission during breastfeeding or childbirth

20. Hepatitis B (Cont.) • Diagnosis: • Blood test for Hep B • Treatment: • No specific treatment • Supportive care is given • Nutritious diet is important • Alpha interferon for treatment of chronic Hep B infection • Vaccination available • Potential Complications: • Chronic Hep B infection increases risk of liver disease, liver cancer, death • 5-10% of adults and adolescents become chronic carriers

21. HIV Infection • Caused by: • Human Immunodeficiency Virus • Mode of transmission: • SEX: Unprotected anal, oral, or vaginal sex with an individual infected with HIV/AIDS • BLOOD: Sharing contaminated needles and syringes with an HIV positive individual • BIRTH: Mother-to-child via breastfeeding or childbirth

22. HIV Infection (Cont.) • Symptoms: • Flu-like symptoms – usually 2-4 weeks; up to 12 weeks • Antibodies usually develop within three months, but can take up to six months • Asymptomatic (No symptoms) • Symptomatic HIV disease – average 8-11 years between exposure to virus and symptoms appear. May be longer with treatment • AIDS: Specific diseases, opportunistic infections. Weakened immune system - < 200 T-cell; the virus works by invading specific immune system cells, makes more copies of itself so that immune system is unable to fight off infections.

23. HIV Infection (Cont.) • Diagnosis: • HIV antibody test, accurate at 3-6 months after exposure to virus. • Two ways of being tested: • 1. anonymous: no identifying information associated with your test results; • 2. confidential: test results put into your medical records. • Newer form of testing that does not require a blood sample; a sample of mouth cells is used; Positive link offers anonymous and confidential testing with Oraquick, results available in approximately 20-40 minutes; cost

25. Prevention – What can you do? • Abstain from risky sexual behaviors • Be sexually monogamous with an uninfected partner • Communicate with a sexual partner; self-esteem issues • Needle Exchange program • AZT Medications

26. Do condoms work all the time? Effectiveness: 95-98% when used correctly and consistently Heterosexual couple study – 1994 256 discordant couples (163 HIV+ M; 93 HIV+ F) ½ couples reported condom use every time (vaginal or anal intercourse); no HIV+ conversions Of the 121 couples reporting inconsistent or never using condoms, 12 HIV+ conversions

27. Bacterial • Bacterial: • Chlamydia • Gonorrhea • Syphillis • Vaginitis

28. Chlamydia • Caused by: • Chlamydia trachomatis bacteria • Prevalence: 4 million new cases per year • http://www.youtube.com/watch?v=CO9okOAlij4&NR=1 • Mode of transmission: • Unprotected oral, vaginal, or anal sex with an infected person in which there is an exchange of vaginal or cervical secretions or semen • Mother-to-infant during childbirth

29. Chlamydia (Cont.) • Symptoms: Symptoms may appear 1-3 weeks after sex with an infected partner (incubation period) Men • Discharge from urethra • Painful urination • 20-40% of men have no symptoms of infection Women • Vaginal discharge • Burning and bleeding with intercourse • Fever • Abdominal pain • Swollen lymph glands • 60-80% of women have no symptoms of infection

30. Chlamydia (Cont.) • Diagnosis: • Cell culture • Microscopic examination of discharge • Urine test for men • Treatment: • Specific antibiotic regimen such as doxycycline, zithromax, or tetracycline • Those infected and their partners should be treated at the same time to prevent the passing of infection back and forth between partners.

31. Gonorrhea • Caused by: • Neisseria gonorrhea bacteria • Mode of transmission: • Unprotected oral, vaginal, or anal sex with an infected person in which there is an exchange of vaginal or cervical secretions or semen • Mother-to-infant during childbirth

32. Gonorrhea (Cont.) • Symptoms: • Symptoms may appear 2-10 days after sex with infected partner • Men • Discharge from urethra • Increased frequency and pain during urination • 25% of men have no symptoms • Women • Vaginal discharge • Abnormal menses • Painful urination • 80% of women have no symptoms

33. Syphilis (Cont). • Symptoms: • Primary • 1-12 weeks after sex with infected partner, painless sore on genitals (chancre) • Secondary • 2 weeks to 6 ½ months after exposure, a skin rash (on entire body, hands or soles of feet) and flu-link symptoms may develop • Latent • Patients are without clinical signs of infection – not contagious and no symptoms • Late (Tertiary) • 1/3 of persons not treated will develop complications such as damage to the heart, brain, eyes, nervous system, bones, and joints

34. Primary Syphillis (sore on penis) Secondary Syphillis (rash on hands) Picture Credits: University of Erlangen, Department of Dermatology

35. Syphilis (Cont.) • Diagnosis: • Serologic (blood) test for syphilis • Treatment: • Penicillin by injection or other antibiotic • Potential complications: • If left untreated – blindness, heart disease, brain damage, death • Comments: • Rare

36. Vaginitis • Caused by: • Trichomonas vaginitis – protozoan: women will most likely be symptomatic while most men will be asymptomatic • Bacterial vaginosis – bacteria • Yeast (candida) – fungus • Mode of transmission: • Unprotected oral, anal, or vaginal intercourse • Not always sexually transmitted

37. Vaginitis (Cont.) • Symptoms: • Men • If symptomatic, inflammation of the urethra • Skin irritation of the penis • Women • Swelling • Itching or pain of the external genitalia • Discharge is excessive or malodorous • Diagnosis: • Microscopic examination of discharge

38. Vaginitis (Cont.) • Treatment: • Trichomonas • Metronidazole – partner also treated to prevent reinfection • Bacterial vaginosis • Metronidazole or clindamycin • Yeast (Candida) • Miconazole nitrate or clotrimazole • Potential complications: • Recurrent infections are common

39. Other STIs

40. Pubic Lice (Crabs) • Cause: • Lice that infect the genital region in both men and women • Phthirus pubis • Mode of Transmission: • Skin-to-skin contact with someone who is infected • Contact with bedding or clothing of some who is infected • Symptoms: • For some, there is noticeable itching • Individuals may notice nits – tiny white specks on hair follicles • May take a few days to a month to develop symptoms Picture Credits: http://naturalginesis.com/index.htm

41. Pubic Lice (Crabs) Cont. • Diagnosis: • Usually only a visual exam of the genitalia is needed to diagnose pubic lice • Medial providers may also look at nits and lice under a microscope • Treatment: • Usually treated with a medicated shampoo • Those infected do not necessarily have to shave pubic hair • Important also to wash clothing, bedding etc. with which the infected individual has had contact • Comments: • May be transmitted from an inanimate object like a toilet seat.

42. Scabies • Cause: • A skin mite • Sarcopetesscabei • Mode of Transmission: • Skin-to-skin contact with someone who is infected • Contact with bedding or clothing of some who is infected • Symptoms: • A rash that appears about 2-4 weeks after infection usually on the hands, wrists, and genitals • Itching – more prominent at night and after showers Picture Credit: http://web.ukonline.co.uk/ruth.livingstone/little/scabies2.htm

43. Scabies (Cont.) • Diagnosis: • A visual exam of the genitals may be all that is needed • It is possible for the symptoms of scabies to be confused with the symptoms of other skin conditions • Medical provider may choose to scrape a lesion and examine using using magnification. • Treatment: • Usually a cream is applied topically to the skin from the neck down. • Important also to wash clothing, bedding etc. with which the infected individual has had contact

44. Bloomington Men’s S.T.R.O.N.G. Project • Men between 17-24 • patnagel@indiana.edu • Free STD testing (812) 266-1978 • Chlamydia • Gonorrhea • Trichomonas • $20 gift card • Confidential and voluntary

45. WEB SITES • American Social Health Association: www.ashastd.org and www.iwannaknow.org (for teens) • Centers for Disease Control:www.cdc.gov/health/std.htm • IUHC lab: http://healthcenter.indiana.edu/departments/laboratory/stdtest.html • Columbia University Health Educationwww.goaskalice.columbia.edu • Kinsey Institute Sexuality Information Service for Students www.indiana.edu/~kisiss • Gay and Lesbian Medical Associationwww.glma.org • Gay Men’s Health Crisis: www.gmhc.org • Planned Parenthood: www.ppfa.org PP for teens: www.teenwire.org • Advocates for Youth: www.advocateforyouth.com • www.itsyoursexlife.com • www.prevent.org/NCC: chlamydia

46. Women & HIV/AIDS Overview and statistics http://www.youtube.com/watch?v=NNJIzhJGxjE&NR=1 “Today the HIV/AIDS epidemic represents a growing and persistent health threat to women in the US, especially young women of color.” (CDC - 2005)

47. Cumulative Effects Women make up an increasing part of the epidemic. Increased from only 8% (in 1985 ) to 14% (1992) to 23% (1995) to 26% of new HIV/AIDS diagnoses in 2007. http://www.youtube.com/watch?v=OS93UvqfAPg&feature=related Of the approximately 1 million people living with HIV in the US, between 120,000-160,000 women have HIV. Nearly ¼ of these women don’t know they’re infected; this puts them at high risk of passing the virus to their babies. http://www.youtube.com/watch?v=7Mpw80ApTuo&feature=related Annual number of AIDS diagnoses increased 15% among women compared to 1% for men .

48. CumulativeEffects (continued) According to a recent CDC study of more than 19,000 patients in 10 US cities, HIV+ women were slightly less likely than infected men to receive prescriptions for the most effective treatments for HIV infection. In 2005, an estimated 4,128 women with AIDS died, representing 25% of the 16,316 persons with AIDS who died in the 50 states and the District of Columbia

49. Cumulative Effects (continued) Of the women given an HIV or AIDS diagnosis in 2007, high risk heterosexual contact was the source for almost 83% of these infections; IDU in 16% of infections; 1% not identified. (CDC reported from 34 states) Most women with HIV/AIDS receiving medical care had children under age 18 living at home (76%); child care may compromise a woman’s ability to manage her own illness

50. Cumulative Effects (continued) • Geography: HIV in some states more likely to have a woman’s face; • 1/3 of those estimated to be living with AIDS in Maryland, Connecticut, NJ are female • (compared to 23% nationally) • New AIDS cases in women highest: • northeast • south • Women with HIV disproportionately low-income; • 64% had annual income below $10,000 • compared to 41% for HIV infected males