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ABC’s of Sexual Transmission of Hepatitis: Newborns to Nineties

Trudy Larson, MD University of Nevada School of Medicine. ABC’s of Sexual Transmission of Hepatitis: Newborns to Nineties. Sexually Transmitted Infections. General concepts The earlier the onset of sexual activity the more lifetime sexual partners

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ABC’s of Sexual Transmission of Hepatitis: Newborns to Nineties

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  1. Trudy Larson, MD University of Nevada School of Medicine ABC’s of Sexual Transmission of Hepatitis: Newborns to Nineties

  2. Sexually Transmitted Infections • General concepts • The earlier the onset of sexual activity the more lifetime sexual partners • The more lifetime sexual partners the greater the likelihood of becoming infected with a STI • Where there is one STI there is often another • Many STIs remain asymptomatic, especially in women

  3. STIs and Substance Abuse: Behavioral Risk Drug effect and sexual risk taking • Impaired judgement • Promiscuous sexual activity • Lack of safe sex protection

  4. Prevention and Control of STDs • Education and counseling of those at risk on ways to reduce risk of STDs (Risk assessments) • Detection of asymptomatically infected persons and those symptomatic but unlikely to seek diagnostic and treatment services • Effective diagnosis and treatment of infected persons • Where there is one, there may be others • Evaluation, treatment, and counseling of sex partners of persons with STDs • Pre-exposure vaccination of persons at risk for vaccine preventable STDs

  5. What teens know about STIs:National Survey of Youth Ages 15-17, 1998 • 82% of teens stated they knew a lot or a fair amount about STIs However... • 74% did not know that chlamydia is curable • 54% did not know that herpes is not curable • 40% did not know that STIs cause long term problems for women Kaiser Family Foundation-MTV-Teen People, 1998 (N=400)

  6. Sexually experienced teens’ perception of STI risk • 67% did not perceive themselves at risk for STIs However... • 43% did not regularly use condoms • 70% had never been tested for STIs • 55% had not discussed STIs with any sexual partner • 57% had never discussed STIs with their medical provider Kaiser Family Foundation-MTV-Teen People, 1998

  7. But that doesn’t count as sex… • 56-63% of teens do not consider oral sex as “SEX” and • 18-21% do not consider anal sex “SEX” Coincidentally… • Oral sex is increasing among teens and • Up to 15% of teen girls and 22% of teen boys have engaged in anal sex JAMA 1999; Schuster et al. AJPH 1996

  8. STD Dilemmas • Most STDs are asymptomatic in both men and women • GC and Chlamydia no sx. in >70% of women • HSV often undiagnosed except by HSV antibody • HIV has no symptoms for an average of 10 years • HPV may be unrecognized if flat or internal • Syphilis can be easily mistaken as “sore” • Even though these may have no symptoms, they are infectious

  9. Background Estimated Burden of STD in U.S. - 2003 Source: The Tip of the Iceberg: How Big Is the STD Epidemic in the U.S.? Kaiser Family Foundation 1998

  10. Chlamydia Chlamydia — Age- and sex-specific rates: United States, 2003 Source: CDC/NCHSTP 2003 STD Surveillance Report

  11. HIV/AIDS Estimated Incidence of AIDS and Death of Adults with AIDS*, United States, January 1985 – June 2003 Note: Adjusted for reporting delays Source: CDC/NCHSTP 2003 HIV/AIDS Surveillance Report

  12. HIV/AIDS Proportion of Adult/Adolescent AIDS Cases by Transmission Category and Year Diagnosis, United States, 1985-2003 Note: Data adjusted for reporting delays and estimated proportional redistribution of cases reported reported without an identified risk factor Source: CDC/NCHSTP 2003 HIV/AIDS Surveillance Report

  13. HIV/AIDS Estimated AIDS Incidence* among Adults/ Adolescents, Diagnosed by Sex and Exposure Category, United States, 2003 • Data adjusted for reporting delays and estimated proportional redistribution of cases initially reported without risk. • Source: CDC/NCHSTP 2003 HIV/AIDS Surveillance Report

  14. Diagnosis and Treatment of STDs • Ask appropriate questions to define risk and symptoms • Are you having sex? With men/women or both? What types of sex do you have? • Screening necessary with positive sexual activity “where there is one STD there may be others” • Need careful PE to distinguish any signs

  15. Diagnosis and Treatment of STDs • Screening tests include: • Chlamydia/GC from a urine specimen • Uses nucleic acid detection for diagnosis • VDRL and Hep B on serum specimen • Now add HIV routinely to test • Pap smear for evidence of HPV

  16. Diagnosis and Treatment of STDs • Specific tests may include: • HSV culture of lesions • HPV acetic acid wash of cervix or penis; may include biopsy of more advanced • Various office tests of vaginal discharge • Microscopy for candida, trichomonas, bacterial vaginosis (clue cells) • Hep C screening if risk assessment postive

  17. Hepatitis A: Epidemiology of Transmission • In developed countries sexual contact and household contact have a greater role in transmission • 28-36% prevalence anti-HAV among MSM • Seattle STD clinic 30% MSM anti-HAV+ (12% non-MSM) • Anti-HAV + persons reported more frequent oral-anal contact, greater number of sex partners, longer duration of MSM activity

  18. Hepatitis A Risk Factors 1990-2000

  19. Hepatitis A: Epidemiology • Fecal-oral spread is dominant • Concentration of Hepatitis A virus is greatest in feces (>108), then serum (>104), then saliva (>103) • No transmission documented from saliva • Requires close personal contact (household, sexual, childcare) or contact with contaminated food or water (infected food handler, raw shellfish) • Blood exposure rare

  20. Hepatitis A Prevention • Measures typically used to prevent the transmission of other STDs (e.g., use of condoms) do not prevent HAV • Efforts to promote good personal hygiene have not been successful in interrupting outbreaks of hepatitis A. • Vaccination is the most effective means of preventing HAV transmission among persons at risk for infection, many of whom might seek services in STD clinics.

  21. Hepatitis A Prevention • Hepatitis A vaccine • Two doses 6 months apart highly effective • Currently recommended for children (school) • Recommended for adults with risk (IDU, MSM) • Post exposure prevention • Immune globulin is highly effective in preventing Hep A infection if given within 14 days • Recommended for close contacts including sexual partners, needle using partners

  22. Hepatitis B: Epidemiology of Transmission • Sexual activity accounts for the most transmission in the US • Risks include: • Multiple sex partners • History of STD • MSM: unprotected anal receptive sexual activity • MSM-Young Men’s Survey showed evidence of HBV infection in 2% of 15 y/o to 17% of 22 y/o • 9% evidence of immunity by vaccination

  23. Hepatitis B Risk 1991-1997

  24. Hepatitis B Epidemiology of Transmission • Parenteral through • Injection drug use • Occupational exposure with hollow needle • Household exposures with razors, nail files, toothbrushes • May occur from contaminated instruments in tatooing/body piercing if not sterile

  25. Hepatitis B Epidemiology of Transmission • Perinatal from infected mother to infant from exposure during labor • Accounts for most transmission in developing countries • Neonates born to HBsAg+ mothers • Maternal HBeAg results in higher infectivity • Horizontal • Child to child in areas with high infection rates through biting, skin lesions

  26. Concentrations of Hepatitis B in Body Fluids

  27. Hepatitis B Prevention • Among adults seeking treatment in STD clinics, as many as 10%–40% have evidence of past or current hepatitis B virus (HBV) infection. • Many of these infections could have been prevented through universal vaccination during delivery of STD prevention or treatment services. • A study of adults diagnosed with acute hepatitis B found that 39% had sought care or been screened for an STD before they were infected with HBV, indicating a significant missed opportunity to vaccinate at-risk persons when they first access STD prevention or treatment services.

  28. Combined Hep A and Hep B Vaccine • Twinrix is FDA approved for persons >18 years of age • Vaccination schedule: 0,1,6 months • Useful for pre-exposure prophylaxis for MSM, IDU who need both Hep A and B vaccines • Hep B now required for school entry; Hep A either required or recommended • May have cohort getting into sexually active years who are already protected (adolescents)

  29. Hepatitis B Prevention • Primary Hepatitis B Vaccine • Highly protective with the 3 dose series • Still no booster recommended • Recommended for sexual contacts of carriers, MSM, multiple sex partners, history of STD, IDU, infants born to carriers mothers (along with HBIG), all those going to STD clinics, etc. • Recommended for all adolescents (age 11-18) who have not already been immunized with the infant series

  30. Hepatitis B Post-exposure Prophylaxis • HBIG (Hep B Immune Globulin) and first dose of Hep B vaccine • Perinatal exposure (infant born to HBsAg+ mother) within 12 hours of birth • Sex exposure to acute Hep B within 14 days of not previously vaccinated • Household, sex, IDU contacts to chronic Hep B carrier need vaccine only

  31. Hepatitis C Epidemiology • Injecting drug use approximately 60% of new infections despite decline in cases among IDUs • Prevalence after initiating IDU: approx 30% after 3 years, >50% after 5 years • Post transfusion hepatitis 90% Hep C before screening • Percutaneous most efficient spread • Permucosal less efficient route for transmission • Perinatal and sexual

  32. Sources of Infection for Persons with Hepatitis C

  33. Hepatitis C Sexual Transmission • Permucosal: sexual transmission (15% HCV risk) • Low efficiency (much less then HBV) • Cumulative incidence of HCV seroconversion 2.5% vs. 26% for HBV • Controversial due to conflicting studies; existing studies suggest association with: • Exposure to HCV+ sex partner • Mutiple partners • Failure to use a condom • Other STDs • Sexual activities involving trauma

  34. Hepatitis C Perinatal Transmission • Risk of transmission: • 2% if mother is anti-HCV + • 4-7% if mother has detectable HCV RNA at delivery • Up to 20% if HIV co-infected mother • Role of viral titer unclear at delivery • Limited studies to confirm if high viral titer assoc with risk of transmission to neonate • IDU may be associated with higher transmission risk to neonate • No data if C-section is beneficial

  35. Hepatitis C Sexual Transmission • Persons engaging in high risk sex have higher prevalence of HCV + (avg US 4-6%) • Commercial sex workers 6% avg, range 1-9% • Persons with multiple sex partners and STD clinic attendees 4% avg, 1-10% range • Some studies show male to female transmission to be more efficient • MSM have no higher risk then hetersexuals

  36. Hepatitis C Sexual Transmission • Rare but not absent for long term partners of patients with HCV (estimated prevalence 1.5%) • Transmission risk unknown (more virus?) • Risk of transmission approximately 0-0.6%/ year • HIV co-infection may increase risk for male to female transmission • One study detected HCV in semen of infected mend

  37. Screening for HCV • All HIV infected persons • 25-35% of HIV+ patients are HCV+ • Persons with IVD or ever injected drugs • Persons with transfusion before 1992 or on chronic hemodialysis • With specific risks consider: • Pregnant women • Household contacts (non-sexual) • Uncertain need for screening in steady partners of HCV+ persons or if sexually active with multiple partners

  38. Recommended HIV/AIDS, Sexually Transmitted Disease (STD), and Viral Hepatitis Prevention Services, by Risk Population Risk population Recommended services High-risk heterosexuals Persons seeking STD evaluation Hepatitis B vaccination Testing for HIV infection Testing for syphilis, gonorrhea, and chlamydia Sexually active men not in a long-term, mutually monogamous relationship Hepatitis B vaccination Annual testing for HIV infection Sexually active women not in a long-term, mutually monogamous relationship Hepatitis B vaccination Annual testing for HIV infection Annual testing for chlamydia (Note: also recommended for all sexually active females aged <25 yrs)

  39. Recommended HIV/AIDS, Sexually Transmitted Disease (STD), and Viral Hepatitis Prevention Services, by Risk Population Risk populationRecommended services Men who have sex with men (MSM) All MSM Hepatitis A vaccination Hepatitis B vaccination Sexually active MSM not in a long-term, mutually monogamous relationship Hepatitis A vaccination Hepatitis B vaccination Annual testing for HIV infection Annual testing for syphilis, gonnorhea, and chlamydia Injection-drug users Hepatitis A vaccination Hepatitis B vaccination Testing for hepatitis C virus Annual testing for HIV infection Substance-abuse treatment

  40. Last Messages • There has been no consistently effective behavioral intervention to reduce STDs except: • Condom use all the time • Monogamy with uninfected partners • Abstinence • Preventive vaccines • Need to appreciate human behavior and always ask the difficult questions!!!

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