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The STD/HIV Connection

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  1. The STD/HIV Connection Tanya Zangaglia, MD Medical Director, Project Streetbeat Curriculum Coordinator, New York/Virgin Islands AIDS Education and Training Center The Joseph L. Mailman School of Public Health, Columbia University

  2. SEXUALLY TRANSMITTED DISEASES (STDs) The United States has the highest rates of STD infection among industrialized nations in the world, with 12-15 million new cases each year

  3. STI Rates in The Developed WorldGonorrhea (Cases per 100,000/per year) Canada 18.6 Australia 18.1 Denmark 5.5 Germany 4.9 Sweden 3 US 149.5 England 34.1 Source: The Hidden Epidemic, IOM, 1997

  4. SEXUALLY TRANSMITTED DISEASES (STDs) The cost to the health care system approaches $20 billion dollars (approximately $10 billion for STDs other than HIV)

  5. SEXUALLY TRANSMITTED DISEASES (STDs) • STDs are more easily transmitted from males to females • Women tend not to have symptoms and hence usually have more serious complications of STDs

  6. Of 236 adolescents treated for chlamydia, gonorrhoeae or trichomonas, 41% were infected again within 12 months of treatment for the initial STD HIV AND STDS Sex. Transm. Dis. 26(1):26-32, 1999

  7. SEXUALLY TRANSMITTED DISEASES (STDs) • Chlamydia trachomatis has surpassed syphilis and gonorrhea in prevalence • Viral STDs though remain the major burden in terms of actual numbers of individuals infected with STDs • Genital herpes • Human papillomavirus • Hepatitis B infection

  8. SEXUALLY TRANSMITTED DISEASES (STDs) STDs which are undiagnosed, untreated and uncared for enhance HIV Transmission

  9. The Mwanza Study • First randomized community-based study showing that comprehensive STD control can significantly reduce HIV transmission Lancet Aug 26, 1995; 346: 530-36

  10. The Mwanza Study • Objectives: • To improve the diagnosis and treatment of STDs in the general population • To measure the impact of this intervention on the incidence of HIV infection and on the prevalence/incidence of STDs Lancet Aug 26, 1995; 346: 530-36

  11. The Mwanza Study: Results • HIV transmission in the community reduced by 40% over a 2 year period • There was no concurrent change in behavior which lead to this reduction Lancet Aug 26, 1995; 346: 530-36

  12. The Mwanza Study: Cost Effectiveness • Cost of STD clinical services: $64,000/year • Cost per capita: $0.45/year • Cost per case of HIV infection prevented: $250 (254 HIV infections) Gilson, L, Mkanje, R, et al. Cost effectiveness of improved STD treatment services as a preventive intervention against HIV in Mwanza region. XI Int’l Conf. on AIDS (abstract MoC444)

  13. GONORRHEA

  14. GONORRHEA • Gram-negative diplococcus (Neisseria gonorrhoeae) • Causes a variety of illnesses and is usually transmitted through sexual intercourse • Vertical transmission is uncommon • Risk of transmission is higher from males to females (50% per contact)

  15. GONORRHEA • The rate of gonorrheal disease in the U.S. peaked in 1975 • Adolescents account for the majority of cases • Disease rates are also higher in lower socioeconomic communities

  16. GONORRHEA Manifestations MANIFESTATIONS • Cervicitis • Urethritis • Anorectal infection • Pharyngeal Gonococcal Infection • Pelvic Inflammatory Disease • Ocular Autoinfection • Perihepatitis (Fitz-Hugh-Curtis Syndrome)

  17. GONORRHEA

  18. GONORRHEA MANIFESTATIONS Manifestations • Disseminated Gonococcal Infection (occurs in 1% to 2% of patients) • Arthralgias • Asymmetric polyarthritis • Dermatitis

  19. GONORRHEA • N. gonorrhoeae infects columnar or cubodial epithelium • It attaches via pili and penetrates within 1-2 days • There is a neutrophilic response which creates a purulent discharge

  20. GONORRHEA CERVICITIS • Females infected with gonorrhea are usually symptomatic • Symptoms usually include: • Increased vaginal discharge • Dysuria • Variable amount of vaginal bleeding • The classic sign of Mucopurulent Cervicitis is not always present… if present it is usually similar to that caused by other genitourinary pathogens

  21. GONORRHEA ANORECTAL • Symptoms include: • Anal pain and pruritus • Tenesmus • Purulent discharge • Rectal bleeding • More common among men but occurs in up to 40% of women who have endocervical disease

  22. GONORRHEA PHARYNGEAL GONOCOCCAL INFECTION • Usually contracted by fellatio • Typically asymptomatic • May resolve spontaneously

  23. GONORRHEA PELVIC INFLAMMATORY DISEASE • Present in 10%-20% of gonococcal infections in women • Risk factors for ascending infection include • Age <20 yrs • Prior PID • Vaginal douching • Bacterial vaginosis • Symptoms range from: • Minimal (lower abdominal tenderness) to • Severe Pain

  24. GONORRHEA DIAGNOSIS • Culture of endocervical region • Gold standard, used in all medico legal arenas • Specimen acquisition is the key • Swab should have a wire shaft and a synthetic fiber tip • Avoid swabs with wooden shafts or cotton tips because they may be toxic to N. gonorrhoeae

  25. GONORRHEA DIAGNOSIS • Gram Stain • Highly specific, less costly, quick • Diagnostic if gram negative diplococci are seen within polymorphonuclear leukocytes

  26. GONORRHEA DIAGNOSIS • DNA probes • High sensitivity and specificity • Concurrently test for N. gonorrhea and C. trachomatis with a single specimen • More widely used than cultures… and cost is similar

  27. GONORRHEA DIAGNOSIS • Ligase chain reaction (LCR) assays • More expensive but also more convenient • Can perform on urine samples or vaginal swabs • Sensitivity of 95% and specificity of 98%-100% • Tests’ performance in asymptomatic, low prevalence setting, is unknown • Not to be used as a test of cure (Will identify nonviable gonococcal nucleic acid)

  28. GONORRHEA

  29. GONORRHEA

  30. GONORRHEA

  31. GONORRHEA

  32. GONORRHEA TREATMENT • All recommended therapies are given as a single dose • Should be given to symptomatic patients at the time of testing • Enhances compliance profoundly: • Reduces further transmission • Reduces resistance

  33. GONORRHEA FOLLOW-UP • Tests of cure are not needed for uncomplicated gonococcal infections • If patient fails to improve, a culture is required for antimicrobial susceptibility testing • Infections identified after completion of treatment are said to be due to reinfection rather than treatment failure

  34. GONORRHEA FOLLOW-UP • Some experts advocate the testing of all sexually active teenagers twice a year (this is based on the frequent reinfection rates in this age group)

  35. GONORRHEA FOLLOW-UP • Patients should be encouraged to refer their sexual partners for testing and treatment • Patients should be advised to abstain from sexual intercourse until they have fully completed therapy and are asymptomatic

  36. GONORRHEA PREVENTION • Condoms are effective in preventing the transmission of N. gonorrhoeae • Diaphragms in combination with vaginal spermicides also reduce the risk of gonococcal transmission (no impact on HIV risk) • Female condoms ????

  37. High-gonorrhea, high poverty neighborhood, New Orleans, LA The American Journal of Public Health - June 1999 Broken Windows and Rising Rates of Gonococcal Infection

  38. Low-gonorrhea, high poverty neighborhood, New Orleans, LA The American Journal of Public Health - June 1999 Broken Windows and Rising Rates of Gonococcal Infection

  39. SYPHILIS

  40. SYPHILIS • Causative agent is the spirochete (Treponema pallidum) • Although the incidence of the disease has markedly declined in the U.S. over the past decade, recent peaks in the South, Midwest and the Northeast point to the need for continued vigilance

  41. Syphilis • In Indianapolis there has been a 475% increase in rates from 1997 to 1999 • The following cities lead the nation in reported rates of syphilis and gonorrhea • Altlanta • Baltimore • Chicago • Detroit • Indianapolis • Memphis • New Orleans • Newark • Norfolk • Richmond • St. Louis • Washington, D.C.

  42. SYPHILIS • Syphilis should always be considered in any patient who is found to have an ulcerative lesion in the genital region

  43. Primary Chancre of the Penile Shaft

  44. SYPHILIS • Patients in the later stages of syphilis can present with a variety of systemic manifestations • This is especially true in women who are asymptomatic in the primary phase and therefore often go untreated for a longer period of time