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Sexually Transmitted Diseases and HIV/AIDS

1 st Advanced Course: “Health on the move” Migrants’ and displaced populations’ health. Sexually Transmitted Diseases and HIV/AIDS. Evangelos Vryonis MD, MSc. Athens , January 14 & 15 2012 . Sexually Transmitted Infections or STI’s.

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Sexually Transmitted Diseases and HIV/AIDS

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  1. 1st Advanced Course: “Health on the move” Migrants’ and displaced populations’ health Sexually Transmitted Diseases and HIV/AIDS Evangelos Vryonis MD, MSc Athens , January 14 & 15 2012

  2. Sexually Transmitted Infections or STI’s • STI’s are infections that are spread primarily through person-to-person sexual contact. • There are more than 30 different sexually transmissible bacteria, viruses and parasites. • Several, in particular HIV and syphilis, can also be transmitted from mother to child during pregnancy and childbirth, and through blood products and tissue transfer.

  3. Background Information Knowledge About STDs Among Americans Source: Kaiser Family Foundation, 1996

  4. Background Information Percent of Women Who Said Topic Was Discussed During First Visit With New Gynecological or Obstetrical Doctor/Health Care Professional Percentages may not total to 100% because of rounding or respondents answering “Don’t know” to the question “Who initiated this conversation?” Source: Kaiser Family Foundation/Glamour National Survey on STDs, 1997

  5. Background Information Sexually transmitted infections (STIs) are a public health issue • >448 million new infections of curable sexually transmitted (syphilis, gonorrhoea, chlamydia and trichomoniasis) infections occur yearly. • Some STIs exist without symptoms • In pregnant women with untreated early syphilis, 25% of pregnancies result in stillbirth and 14% in neonatal death. • Sexually transmitted infections are the main preventable cause of infertility, particularly in women. • Regional distribution (The largest number of new infections occurs in the region of South and Southeast Asia, followed by sub-Saharan Africa, Latin America, and the Caribbean) • In low-income countries, STIs rank in the top five disease categories for which adults seek health care. • 1 in 4 sexually active teens has an STI. WHO, Fact sheet N°110, August 2011

  6. Common pathogens Bacterial infections Viral infections Human immunodeficiency virus (causes AIDS) Herpes simplex virus type 2 (causes genital herpes) Human papillomavirus(causes genital warts and certain subtypes lead to cervical cancer in women) Hepatitis B virus (causes hepatitis and chronic cases may lead to cancer of the liver) Cytomegalovirus (causes inflammation in a number of organs including the brain, the eye, and the bowel). • Neisseriagonorrhoeae(causes gonorrhoea or gonococcal infection) • Chlamydia trachomatis(causes chlamydial infections) • Treponema pallidum(causes syphilis) • Haemophilusducreyi(causes chancroid) • Klebsiellagranulomatis(previously known as Calymmatobacteriumgranulomatis causes granulomainguinale or donovanosis). • Parasites • Trichomonasvaginalis(causes vaginal trichomoniasis) • Candida albicans(causes vulvovaginitis in women; inflammation of the glans penis and foreskin [balano-posthitis] in men).

  7. ..WHO recommends a syndromic approach to diagnosis and management of sexually transmitted infections… Although many different pathogens cause STIs, some display similar or overlapping signs and symptoms. Some of these signs and symptoms are easily recognizable, giving what is known as a syndrome that signals the presence of one or a number of pathogens. For example, a discharge from the urethra in men can be caused by gonorrhoea alone, chlamydia alone or both together. The main syndromes of common STIs are: • urethral discharge • genital ulcers • inguinal swellings (bubo, which is a swelling in the groin) • scrotal swelling • vaginal discharge • lower abdominal pain • neonatal eye infections (conjunctivitis of the newborn).

  8. Discharge syndromes Discharge syndromes-“Drips” • Discharge syndromes . Urethral/vaginal discharge and dysuria are the hallmarks of • Gonorrhea, • Chlamydia, • Trichomoniasis, • Bacterial vaginosis, • Candidiasis • Mycoplasmagenitalium infections are increasingly recognized as causes of sexually transmitted discharge syndromes in adolescents and young adults. • …genital herpes ?(sometimes associated with dysuria and a scant, mucoid urethral discharge, but nearly always in association with other genital lesions) • Characteristics of the discharge, such as color (eg, clear, mucoid, yellow, green) are unreliable indicators of the etiology.

  9. Discharge syndromes Gonorrhea • Urethritis - male • Incubation: 1-14 d (usually 2-5 d) • Sx: Dysuria and urethral discharge (5% asymptomatic) • Dx: Gram stain urethral smear (+) > 98% culture • Complications • Urogenital infection - female • Endocervical canal primary site • 70-90% also colonize urethra • Incubation: unclear; sx usually in l0 d • Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain • Dx: Gram stain smear (+) 50-70% culture • Complications Gonorrhoea world map Neisseriagonorrhoeae Gram-negative diplococci

  10. Discharge syndromes NongonococcalUrethritis • Chlamydia trachomatis • More than 3 million new cases annually in US • Responsible for causing • Cervicitis • Urethritis • Proctitis • Lymphogranulomavenereum • Pelvic Inflammatory Disease • Direct and indirect cost of chlamydial infections run into billions of dollars • Potential to transmit to newborn during delivery • Conjunctivitis • Pneumonia • Etiology: • 20-40% C. trachomatis • 20-30% genital mycoplasmas (Ureaplasmaurealyticum, Mycoplasmagenitalium) • Occasional Trichomonasvaginalis, 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 (+)

  11. Discharge syndromes Normal Cervix Chlamydia Cervicitis

  12. Genital ulcer syndrome (GUS)- “Sores” • Primary syphilis -important diagnostic consideration, especially in the setting of commercial or high-risk sexual networks ± drug use • Genital Herpes -US most common (HSV-2, HSV-1) • Chancroid(Hemophilusducreyi) • Lymphogranulomavenereum(Chlamydia trachomatis) • Granulomainguinale (Calymmatobacteriumgranulomatis)

  13. Genital ulcer syndrome Does It Hurt? • Painless • Syphilis • Lymphogranulomavenereum • Granulomainguinale • Painful • Genital herpes simplex • Chancroid

  14. Genital ulcer syndrome Primary Syphilis Age-standardised disability-adjusted life year (DALY) rates from Syphilis by country. WHO 2009 • Incubation: 10-90 days (average 3 weeks) • Chancre • Early: macule/papule erodes • Late: clean based, painless, indurated ulcer with smooth firm borders • Resolves in 1-5 weeks • Unnoticed in 15-30% of patients • HIGHLY INFECTIOUS Treponema pallidum

  15. Genital ulcer syndrome Secondary Syphilis • Represents hematogenous dissemination of spirochetes • Usually 2-8 weeks after chancre appears • Findings: • rash - whole body (includes palms/soles) • mucous patches • condylomatalata - HIGHLY INFECTIOUS • constitutional symptoms • Sn/Sx resolve in 2-10 weeks

  16. Genital ulcer syndrome

  17. Genital ulcer syndrome Portrait of Gerard de Lairesseby Rembrandt van Rijn, ca. 1665 oil on canvas. De Lairesse, himself a painter and art theorist, suffered from congenital syphilis that severely deformed his face and eventually blinded him Posthumous portrait of Christopher Columbus (1451 – 1506) by Sebastiano del Piombo.

  18. Genital ulcer syndrome Treponema pallidum DISEASE Smallpox Influenza Typhus Measles Malaria Diphtheria Whooping Cough (Pertussis)

  19. Genital ulcer syndrome Genital Herpes • 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% (majority of infections in some regions) • Most cases subclinical • Transmission primarily from subclinical infection • Complications: neonatal transmission, enhanced HIV transmission, psychosocial issues • Vesicles  painful ulcerations  crusting • Recurrence a potential • Diagnosis: • Culture • Serology (Western blot) • PCR

  20. Pelvic Inflammatory Disease (PID) • Common sequela of genital gonorrhea and chlamydia infections (l0%-20%) • In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID • Douching may increase the risk of developing PID, especially when performed frequently • CDC minimal criteria • uterine adnexal tenderness, cervical motion tenderness • Other symptoms include • endocervical discharge, fever, lower abd. pain • Complications: • Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia • 7X risk of ectopic pregnancy with 1 episode PID • chronic pelvic pain in 18%

  21. Dermatologic syndromes • The most common STD with primarily dermatologic presentation is genital warts (condylomaacuminata) caused by HPV • Secondary Syphilis- Skin rash Condylomalata • Gonococcal infection- Skin rash is also a common manifestation of disseminated disease

  22. Human papillomavirus-HPV • Infection is generally indicated by the detection of HPV DNA • HPV infection is causally associated with cancer • Over 99% of cervical cancers have HPV DNA detected within the tumor • Routine Pap smear screening ensures early detection (and treatment) of pre-cancerous lesions

  23. HIV/AIDS HUMAN IMMUNODEFICIENCY VIRUS HIV ACQUIRED IMMUNODEFICIENCY SYNDROME AIDS Acquired Immunodeficiency Syndrome (AIDS) is a disease of the human immune system caused by the human immunodeficiency virus (HIV). The illness interferes with the immune system making people with AIDS much more likely to get infections, including opportunistic infections and tumors that do not affect people with working immune systems. This susceptibility gets worse as the disease continues. • Modes of transmission of HIV varies in different countries. • In resource-limited areas • vaginal sex 70-80% percent of AIDS • perinatal transmission 5-10% • injection drug use 5-10% percent • In contrast in USA, male-to-male sexual contact and IDU accounted for about one-half of cases

  24. Natural History and Progression of HIV DiseaseA generalized graph of the relationship between HIV copies (viral load) and CD4 counts over the average course of untreated HIV infection; any particular individual's disease course may vary considerably. HIV-1 infection is divided into stages of primary infection with seroconversion, clinical latency, early symptomatic disease, and AIDS

  25. Age-standardised disability-adjusted life year (DALY) rates from HIV/AIDS by country (per 100,000 inhabitants).

  26. The amplifying effect of STDs in HIV transmission • At least 2 to 5-fold increased risk of HIV seroconversionconfirmed by data from 4 continents • Greater infectiousness because of prevalence & magnitude of HIV shedding increased by STDs; • STD treatment reduces HIV shedding to baseline levels • 40% reduction in HIV incidence achieved in randomized trial of treatment of symptomatic STDs in Tanzania

  27. Despite common occurance of conflicts between old and new establishments, migratory flows have contributed significantly to human development >130 million people living in foreign countries >4 million people cross the boundaries >23 million refugees worldwide ?? numbers of clandestines 2-3% of the world population

  28. migration flow map

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