STI Update: Epidemiology, Prevention and Treatment

STI Update: Epidemiology, Prevention and Treatment Gary Rogers MBBS, MGPPsych, PhD Associate Professor of Medical Education School of Medicine Griffith University Queensland Australia

Brainstorm • What are the most common sexually transmissible infections in the Pacific Islands currently? • What are the most significant sexually transmissible infections in the Pacific Islands currently?

Most common? • Human papilloma virus infection • Syphilis • Genital herpes • Genital chlamydiosis • HIV • Gonorrhoea • Hepatitis B • Trichomoniasis

Prevalence in Pacific • Goodman MT et al. Prevalence, Acquisition, and Clearance of Cervical Human Papillomavirus Infection among Women with Normal Cytology: Hawaii Human Papillomavirus Cohort Study. Cancer Res 68(21):8813-24, 2008. • CliffeSJet al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis35(9):801-6, 2008 • HaddowLJet al. Herpes Simplex Virus Type 2 (HSV-2) Infection in Women Attending an Antenatal Clinic in the South Pacific Island Nation of Vanuatu. Sex Trans Dis34(5):258-61 • Suligoi B et al. Infection with human immunodeficiency virus, herpes simplex virus type 2, and human herpes virus 8 in remote villages of southwestern Papua New Guinea. Am J Trop Med Hyg. 72(1): 33–6, 2005. • SPC. Cumulative reported HIV, AIDS and AIDS deaths: cases, incidence rates and gender, plus cases with missing details, 2007

Prevalence in Pacific • Goodman MT et al. Prevalence, Acquisition, and Clearance of Cervical Human Papillomavirus Infection among Women with Normal Cytology: Hawaii Human Papillomavirus Cohort Study. Cancer Res 68(21):8813-24, 2008. • Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008 • Haddow LJ et al. Herpes Simplex Virus Type 2 (HSV-2) Infection in Women Attending an Antenatal Clinic in the South Pacific Island Nation of Vanuatu. Sex Trans Dis 34(5):258-61 • Suligoi B et al. Infection with human immunodeficiency virus, herpes simplex virus type 2, and human herpes virus 8 in remote villages of southwestern Papua New Guinea. Am J Trop Med Hyg. 72(1): 33–6, 2005. • SPC. Cumulative reported HIV, AIDS and AIDS deaths: cases, incidence rates and gender, plus cases with missing details to 2007, 2009.

Prevalence in Pacific • CliffeSJet al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis35(9):801-6, 2008 • Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008. • Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008 • Fotinatos N et al. Trichomonasvaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.

Prevalence in Pacific • Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008 • Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008. • Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008 • Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.

Most significant? • Human papilloma virus infection • Syphilis • Genital herpes • Genital chlamydiosis • HIV • Gonorrhoea • Hepatitis B • Trichomoniasis

Significance • In relation to the health of the population of a country or territory in general ... • ... or of particular populations • Determined by a range of factors: • Prevalence • Severity of acute symptomatology • Transmissibility – preventability • Curability • Long term consequences or complications

Human Papilloma Virus Ho GY et al. Natural history of cervicovaginal papilloma virus infection in young women. N Engl J Med 338(7):423-8, 1998 • Non-enveloped DNA virus • Replicates exclusively in epithelial cells • Transmitted by skin to skin contact with microabrasions • Enters cell and modifies cell cycle to maxmise further transmissibility • Naturally cleared in months to years • Median duration of infection 8 months, 9% persistent after 2 years1 • Persistence related to: • Infection with multiple types • Infection with high risk types

HPV associated disease >100 genetically related types Different types adapted for different skin areas Types 16 & 18 (and others) strongly associated with cervical carcinoma Types 6 & 11 (and others) associated with visible anogenital warts Some types also associated with anal, penile and oral cancers Islands’ experience of cancer of cervix and anogenital warts

HPV: genital warts

Genital warts: diagnosis

Genital warts: treatment • Lots of different approaches – nothing is perfect! • Most treatment is cosmetic not curative • Very high recurrence rates • Imiquimod cream (Aldara®) • Induces local immune response • 5% cream applied 3x/week for up to 16 wks • Response is delayed • Lower recurrence rate • Contraindicated in pregnancy • Expensive!

First line treatment in your centre? Podophylotoxin Diathermy Cryotherapy Imiquimod Surgical excision Nothing Something else

My favourite treatment

HPV: Cervical cancer

HPV: Cervical cancer Gleize L et al. Cancer registry of French Polynesia: Results for the 1990±1995 period among native and immigrant population. European Journal of Epidemiology 16: 661-7, 2000. Frish M, Goodman MT. Human Papillomavirus-Associated Carcinomas in Hawaii and the Mainland U.S. Cancer 88(6):1464-9, 2000. GLOBOCAN database.

HPV: Cervical cancer Gleize L et al. Cancer registry of French Polynesia: Results for the 1990±1995 period among native and immigrant population. European Journal of Epidemiology 16: 661-7, 2000. Frish M, Goodman MT. Human Papillomavirus-Associated Carcinomas in Hawaii and the Mainland U.S. Cancer 88(6):1464-9, 2000. GLOBOCAN database. Importance of screening programs Potential impact of HPV vaccines Islands experience with Ca cervix, screening programs and HPV vaccines (Gardasil, Cervarix)

Genital herpes • Caused by two types of DNA viruses herpes simplex 1 & 2 (HSV 1 & 2 = HHV 1 & 2) • Other herpesviruses that cause human diseases : • HHV3 (Varicella zoster) Chickenpox/shingles • HHV4 (Ebstein-Barr virus) infectious mononucleosis • HHV5 (Cytomegalovirus) • HHV6 & 7 (Roseolainfantum) • HHV8 (Kaposi’s sarcoma)

Genital herpes • HSV spread by skin to skin or mucosa to mucosa contact with friction • Primary infection at site of entry then lifelong infection of sensory dorsal ganglia supplying infected skin/mucosa • ‘Originally’ • HSV1 – oral ‘cold sores’ • HSV2 – genital herpes • Now primary HSV1 is common cause of genital herpes in developed countries

Genital herpes 1 – 26 days (usually 6 – 8 days) after first acquisition – primary infection Complications of primary infection include urinary retention, aseptic meningitis and rarely transverse myelitis First clinical episode is not always primary infection

Genital herpes

Clinical course of episode Prodromal tingling  vesicles  ulcers  crusts  healing All takes 5 – 7 days but activeHSV infection is the first 48 hours – after that it is just healing Need to treat episode within first 48 hours or not worth it (except in people with HIV)

Genital herpes

Genital herpes & HIV Relative risk of acquiring HIV based on HSV2 serology, adjusted for age and sexual behavior Freeman EE et al. Herpes simplex virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies. AIDS 20(1) :73–83, 2006

Genital herpes & HIV HSV ulcers often coalesce and persist in people with HIV

Genital herpes treatment

Genital herpes treatment • Some evidence of survival benefit in people with HIV who have HSV if HSV treated • Continuous suppressive therapy certainly worthwhile if symptomatic

Take a break!

Syphilis • Caused by a spirochaete (spiral bacterium): Treponemapallidum • Transmitted by skin to skin or mucous membrane contact with abrasion • Four classical stages: • Primary • Secondary • Latent • Tertiary • Early syphilis is not always classical

Primary syphilis 9 – 90 days after exposure Appearance of chancre at site of exposure Usually single, painless, indurated, sharply defined edges Can often be missed (if not penile!) Disappears in 3 to 6 weeks if not treated

Chancres

Secondary syphilis 6 weeks to 6 months after primary infection In ~1/3rd chancre will still be present Fever, malaise, headache, myalgia Rash in 80-90% Classically dark pink macules ‘The great mimic’ Can affect palms and soles Transient or can last weeks

STI Update: Epidemiology, Prevention and Treatment