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Sexually Transmitted Diseases. Los Angeles County Department of Health Services Sexually Transmitted Disease Program. Reportable STDs in LAC. Chlamydia Gonorrhea Syphilis Chancroid PID NGU. Other STDs -- Viral. HSV HPV HIV. Reported Sexually Transmitted Diseases United States, 2002.

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sexually transmitted diseases

Sexually Transmitted Diseases

Los Angeles County Department of Health Services

Sexually Transmitted Disease Program

reportable stds in lac
Reportable STDs in LAC
  • Chlamydia
  • Gonorrhea
  • Syphilis
  • Chancroid
  • PID
  • NGU
reported sexually transmitted diseases united states 2002
Reported Sexually Transmitted Diseases United States, 2002

Source: CDC Sexually Transmitted Disease Report, Year 2002

chlamydia trachomatis
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
chlamydia rates united states 1984 2002

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

chlamydia rates by gender united states 1984 2002
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

chlamydia rates by state united states and outlying areas 2002
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.

los angeles county chlamydia rates 1991 2003
Los Angeles County Chlamydia Rates 1991-2003

Per 100,000 population

Urine

screening

los angeles county chlamydia rates by gender 1991 2003
Los Angeles County Chlamydia Rates by Gender 1991-2003

Introduction of nucleic

amplification tests

Per 100,000 population

chlamydia take home points
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
gonorrhea
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
gonorrhea rates by state united states and outlying areas 2002
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.

gonorrhea rates united states 1970 2002 and the healthy people 2010 objective
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.

gonorrhea rates by gender california 1993 2002
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

gonorrhea rates los angeles county 1990 2003
Gonorrhea Rates* Los Angeles County, 1990-2003

Introduction of nucleic

amplification tests

Healthy People 2010 Objective

Year

*Per 100,000 population

gonorrhea rates by age and gender los angeles county 2003
Gonorrhea Rates* by Age and Gender Los Angeles County, 2003

Age Group

*Per 100,000 LA County population

fluoroquinolone resistant gc qrng
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
slide25
Gonococcal Isolate Surveillance Project (GISP) — Location of participating clinics and regional laboratories: United States, 2002
slide26

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.

slide27

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.

slide28

March 2003 – September 2004

South HC (47.6%)

GLC (54.2%)

Cultures Processed N=843

Isolates Recovered N=417 (49.5%)

slide29

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

gonorrhea treatment in california uncomplicated genital rectal infections
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
gonorrhea take home points
Gonorrhea take home points
  • Overall increase in rates in California
  • Fluoroquinolone resistance increasing
  • Limited first line therapies:
    • Ceftriaxone (IM)
    • Cefpodoxime
    • Cefixime (still limited availability)
slide33
Primary and secondary syphilis — Rates by sex: United States, 1981–2002 and the Healthy People 2010 objective
primary secondary syphilis cases by gender california 1996 2002
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

primary secondary syphilis rates by gender and age group california 2002
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

slide36

Number of MSM P&S Syphilis Cases by Region and Year

3/03 Provisional Data - CA DHS STD Control Branch

los angeles county early syphilis by spa of residence
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

early syphilis cases by age sexual orientation los angeles county 2003
Early Syphilis Cases By Age & Sexual Orientation, Los Angeles County, 2003

Age Group

Sexual Orientation

Source: Early Syphilis Surveillance Summary, Aug. 2004

primary secondary syphilis by race ethnicity among msm and non msm
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

msm 1 early syphilis cases by race ethnicity 2003
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

early syphilis cases by hiv serostatus sexual orientation 2001 2003 n 724
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

the impact of stds on sexual transmission of hiv
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
stds and hiv transmission pathogenic biologic mechanisms
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
urethritis and hiv transmission
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

impact of stds on sexual transmission of hiv problems in study design interpretation
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
effect of std on hiv susceptibility estimates ors from cohort studies
Effect of STD on HIV SusceptibilityEstimates (ORs) from Cohort Studies

Rottingen et al STD 2001

sexual encounter venues among msm early syphilis cases los angeles 2001 2003 ytd
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.

hiv sero status among msm early syphilis cases attending csvs los angeles county 2001 2003 ytd
HIV Sero-status Among MSM Early Syphilis Cases Attending CSVs, Los Angeles County 2001-2003 (YTD)

Source: Epidemiology Unit, STD Program; n=815

msm early syphilis cases specific csv s mentioned for sexual encounters 2000 2003 ytd
MSM Early Syphilis Cases & Specific CSV’s Mentioned for Sexual Encounters, 2000-2003 (YTD)

N(%)

  • 9 Bathhouses
    • Club 1350 4 2
    • Flex 32 15
    • Hollywood Spa 59 28
    • KLYT 1 0.5
    • Melrose Spa 22 10
    • Midtowne Spa 35 17
    • North Hollywood Spa 1 0.5
    • Roman Holiday Spa/II1 5 2
  • 3 Sex clubs
    • MB Club -- --
    • Slammer 35 17
    • The Zone 17 8

1. Roman Holliday Spa and Roman Holiday II combined.

multivariate analysis for predictors of csv attendance 2001 2003 ytd n 997
Multivariate Analysis for Predictors of CSV Attendance, 2001 – 2003 (YTD), N=997
  • Variables in model:
    • Age
    • Race/Ethnicity
    • HIV Status
    • Behavioral Risk Factors (anal insertive, anal receptive, oral, history of anonymous partners, condom use, past incarceration, IDU, non-IDU)
multivariate analysis for predictors of csv attendance 2001 2003 ytd n 99754
Multivariate Analysis for Predictors of CSV Attendance, 2001 – 2003 (YTD), N=997
  • Significant predictors of CSV attendance: HIV status and multiple anonymous partners.
  • MSM with syphilis:
  • Twice as likely to be HIV positive (OR=1.77, 95% CI 1.13 – 2.77).
  • Six times as likely to have multiple anonymous partners (OR=6.53, 95% CI 3.04 – 14.05).
regulation of csvs
Regulation of CSVs
  • Environmental regulations for pools etc
  • No formal regulation regarding safer sex practices, drug use
  • Ongoing collaboration with owners/operators, CBO (APLA) and LAC PH programs to develop guidelines
proposed guidelines
Proposed Guidelines
  • 1. Condoms, lube available on site
  • 2. Safer sex and risk reduction guidelines posted
  • 3. Display of educational materials
  • 4. Provision of space for onsite health education services.
  • 5. Provision of training and periodic updates for staff
proposed guidelines cont
Proposed Guidelines, cont
  • 6. Consumption of ETOH and drugs per applicable laws
  • 7. Solicitation of patron agreement to adhere to house rules upon entry
  • 8. Adherences to local ordinances regarding public assembly and fire codes
  • 9. Provision of wash up facilities with soap and water
  • 10. House rules enforced through periodic monitoring by trained staff.
other control measures
Other Control Measures

Social Marketing –Media Campaign

stop the sores syphilis campaign for msm
Stop the Sores Syphilis Campaign for MSM

Background

  • Funded by LA County Board of Supervisors and overseen by the STD Program, Department of Health Services
  • Coordinated by Aids HealthCare Foundation in collaboration with 5 other community agencies serving MSM in LA County
stop the sores syphilis campaign for msm73
Stop the Sores Syphilis Campaign for MSM

Objective

  • Increase awareness of syphilis among the MSM population and promote testing

Activities

  • Print, outdoor and Internet ads geared towards MSM
  • Palm cards, stress grips and posters for venues and outreach activities
  • Campaign Web Site Stop the Sores
slide74

Healthy Penis Media Campaign

San Francisco

Print Ad

slide75

Healthy Penis Media Campaign

San Francisco

Print Ad

herpes simplex virus hsv overview
Herpes Simplex Virus (HSV): Overview
  • Types: HSV 1 & HSV 2
    • HSV 1: orolabial herpes
    • HSV 2: genital herpes
  • Both symptomatic & asymptomatic infections are common
  • Can cause serious complications
genital herpes in the u s
Genital Herpes in the U.S.
  • Estimated annual incidence: 600,000 to 1 million cases
  • NHANES studies (1976 and 1988) showed 32% increase in prevalence by serology testing
  • Approximately two-thirds are unaware of infection
  • Most genital and perianal cases are caused by HSV-2, but 10-50% of first episodes are due to HSV-1
genital herpes nhanes ii 1976 1980 and nhanes iii 1988 1994
Genital HerpesNHANES* II (1976–1980) and NHANES III (1988–1994)

Note: Bars indicate 95% confidence intervals.

*National Health and Nutrition Examination Survey

hsv 2 seropositivity epidemiology in the u s
HSV-2 SeropositivityEpidemiology in the U.S.
  • Prevalence: over 40 million adults in U.S. (22%)
  • Among blacks, 35% of men and 55% of women are seropositive
  • Among whites, 15% of men and 20% of women are seropositive
  • Seropositivity increases with age
  • Rates are higher in HIV infected persons and adults of lower socioeconomic status
genital herpes transmission
Genital HerpesTransmission
  • Major routes: sexual & vertical
  • Most sexual transmission probably occurs when index case is asymptomatic
  • Efficiency is greater from men to women than women to men
    • Mertz, et al: 144 serodiscordant couples
    • Almost 17% man-to-woman transmission
    • Almost 4% woman-to-man transmission

Mertz et al, Annals of Internal Medicine, Feb., 1992

genital herpes local symptoms of primary herpes
Genital HerpesLocal Symptoms of Primary Herpes
  • Pain 95%
  • Vaginal discharge 85%
  • Inguinal adenopathy 80%
  • Cervicitis 70%
  • Itching & dysuria 68%
  • Urethral discharge 30%
genital herpes established chronic infection
Genital HerpesEstablished (Chronic) Infection
  • Establisheslatent infection in paraspinous ganglia
  • Infection persists despite host immune response
  • Virus may remain latent indefinitely or reactivation can occur
genital herpes primary infection
Genital HerpesPrimary Infection
  • First infection ever with either HSV-1 or HSV-2
  • No serum antibody is present when symptoms appear, then rises in convalescence
  • Symptoms are usually more severe than in non-primary or recurrent disease
  • Average incubation period: 2-12 days
genital herpes subclinical asymptomatic infection
Genital HerpesSubclinical/Asymptomatic Infection
  • Serum antibody is present
  • Patient has never noticed symptoms
  • Most probably have mild, unrecognized disease
  • Probably all shed virus from the genital area intermittently
  • Thought to account for much of transmission
genital herpes patient s perception of etiology
Women

Yeast infection

Vaginitis

UTI

Menstrual complaint

Hemorrhoids

Allergies (condoms, sperm, spermicide, pantyhose

Rash from sex, shaving, bike seat

Men

Folliculitis

Jock itch

“Normal” itch

Zipper burns

Hemorrhoids

Allergy to condom

Irritation from tight jeans, sex, bike seat

Insect bite

Koutsky, NEJM, 1992

Genital HerpesPatient’s Perception of Etiology