STDs and HIV

HIV Counselor Perspectives
V3, N1, Feb 1993

Research Update

Each year in the United States an estimated 12 million people are infected with STDs; two-thirds of these people are under age 25. [1]

More than 50 organisms and syndromes are recognized as being sexually transmitted. STDs are caused by a variety of agents, including bacterial and viral ones. Bacterial STDs include gonorrhea and syphilis. Medications can be used a preventive therapy as well as to treat and cure bacterial STDs.

Viral STDs include HIV, genital herpes, hepatitis B, and human papillomavirus (HPV). Viral STDs can be transmitted through sexual and non-sexual routes. While treatable, viral STDs are not curable, and therefore they can recur or they can progress. Fungal and parasitic agents, including trichomoniasis, can also be transmitted sexually.

STD symptoms typically include one or more of the following: buring or pain during urination and defecation; itching or burning around the genitals; mucous discharge or bleeding from the genitals; ulceration or blistering; rashes on the body; and flu-like symptoms. STD infections lead to a variety of illnesses, including pelvic inflammatory disease (PID) and non-gonococcal ufethritis.

After being infected with most STDs, people may remain asymptomatic, or free of symptoms, for extended periods ranging from days to several months. During this period, however, people can transmit the infection to others.

Symptoms related to bacterial or viral STDs often dissipate and recur. Because of long periods in which an infection may not produce symptoms, public health and medical experts recommend that people at risk for STDs seek an STD risk assessment, a physical examination based on syptoms, and laboratory tests to detect infections that may be asymptomatic.

Relationship between HIV and Other STDs

HIV and other STDs are related in several ways. They are transmitted through similar routes and they respond to similar prevention messages. [2,3]

Researchers have identified a complex relationship between HIV and other STDs that results in a synergistic interaction -- that is, the presence of HIV with another STD produces a result affecting the course of HIV disease that would not be produced if the STD was absent. [4] Of the major STDs, syphilis, chlamydia, gonorrhea, genital herpes, trichomoniasis, genital warts, and hepatitis B have been investigated for their impact on HIV.

Researchers have demonstrated that the presence of STDs, both ulcerative and non-ulcerative, increases the risk of HIV transmission about 3- to 5-fold. [4] STDs appear to promot HIV transmission by causing inflammation and lesions of the genital tract, thus creating an accessible place of entry for HIV. Ulcerations, which are caused by syphilis and genital herpes, have been related to increased susceptibility for HIV transmission. Increased risk of HIV transmission can also be attributed to non-ulcerative STDs such as chlamydia, gonorrhea and trichomoniases, which weaken the body's defenses against disease. However, research related to the relationship between non-uncerative STDs and HIV is more limited. [4]

Researchers suggest that the debilitating effects of STDs may accelerate progression of HIV for someone who is infected with HIV. In addition, for someone with HIV, it appears that the suppressive effects of HIV on the immune system worsen the symptoms of other STDs and decrease the healing effects of STD therapies. [4]

It is also possible that the course of an STD may be altered by HIV. For example, genital herpes ulcers normally heal within two to three weeks but persist much longer in people with HIV. Similarly, syphilis treatments sometimes fail or the disease develops more severely in people with HIV. [5]

Facts about STDs

Syphilis is a bacterial STD that produces ulcers in the genitals, throat and rectum. Effective treatment with penicillin is widely available; without treatment, heart disease, brain damage, blindness and death can result. Although the rate of syphilis infection has declined steadily in the last 50 years, sporadic outbreaks occurred during the 1980s in some urban areas. The occurrence was most common among African-American men and women in urban communities with high HIV incidence. [2] In 1990, 134,000 syphilis cases were reported nationally.

Affecting as many as one million people each year in this country, gonorrhea is a bacterial infection that causes inflammation of the urethra and rectum in men. In women, it causes inflammation of the cervix, and infections of the uterus, fallopian tubes and pelvic organs -- leading to PID. Symptoms include pain during urination or defecation and discharge from the vagina or penis.

While penicillin historically has been the most widely used treatment to cure gonorrhea, strains resistant to penicillin have developed in recent years. [5] Therefore, suspected gonorrhea cases are now treated with other medicines, even though these are often many times more expensive than penicillin. [1]

Chlamydia, like gonorrhea, causes inflammation of the urethra, cervix and prostate, and can cause PID and genital ulcers. Manifestations of chlamydia have both bacterial and viral characteristics. In women, chlamydia can lead to premature birth, ectopic pregnancy and sterility. During ectopic, or tubal, pregnancy, the fetus develops outside the uterus in the fallopian tubes.

Nationally, as many as four million people across all ethnic groups may be infected with chlamydia. A person with this STD can remain asymptomatic for long periods. Accurate and affordable diagnostic tests have only recently become widely available. When diagnosed, infections can be cured by taking tetracycline or other antibiotics. [6] Several studies from Africa clearly indicate that women with cervical chlamydial infection are at increased risk of being infected with HIV through unsafe sexual intercourse. [5]

Thrichomoniasis, a parasitic condition estimated to affect three million people in the United States, has not been thoroughly studied for its relationship to HIV. Those with the disease may be asymptomatic for extended periods. In women, trichomoniasis may cause severe vaginitis, and in men, painful swelling of the penis as well as epididymitis. Treatment regimens usually involve the drugs flagyl or metronidaole.

Genital Herpes (herpes simplex virus types 1 and 2)
Genital herpes, a viral infection, is an uclerative disease that causes painful blisters on the genitals, mouth, anus, and other mucous membranes, and sometimes on the skin of other areas of the body. Men and women infected with genital herpes are often asymptomatic for long periods. Women can have a longer asymptomatic period and a more sever initial manifestation of disease than men, and women can transmit the virus during pregnancy and childbirth. Recurrent episodes are common, but are usually less severe over time. Acyclovir is the standard treatment for genital herpes.

Various studies estimate that 25% to 50% of all people in this country are infected with a herpes virus. [1] Studies have found infection rates two to three times higher among African Americans and highest among African-American women. Infection rates are disporportionately higher among poorer people living in inner city areas. [5]

Human papillomavirus (HPV)
There are more than 60 types of HPV, and millions of sexualy active people are known to be infected with the virus. Some types of HPV cause genital infection, and a small number produce benign genital warts, which are non-ulcerative and frequently recur. Certain types of HPV are linked to pre-cancerous lesions or cancer of the cervix, vulva, penis, anus and throat. HPV cannot be eradicated; treatment usually involves removal of warts by cold-based therapies such as liquid nitrogen, or through laser therapy.

While there are no well-designed, prospective studies of HPV's effects on HIV, it seems clear that the immunosuppression caused by HIV affects the course of HPV. A recent study confirmed that gay men with HIV are at increased risk for HPV infection. [7] In the presence of HIV, a broader variety of HPV infections tends to occur, infections often worsen and larger lesions appear. In people with HIV, HPV infections typically do not respond as well to therapy.

Hepatitus B virus
People infected with hepatitis B may develop cirrhosis, carcinomas and chronic active hepatitis. While a vaccine was introduced 10 years ago, and it is considered effective, incidence has remained unchanged since then. [8] No special treatments are recommended for active infection.

In addition to sexual routes of transmission, hepatitis B may be transmitted to a fetus during pregnancy or to a child at birth, as well as through injection drug use. It is estimated that up to half of all hepatitis B infections are sexually transmitted. [9] The proportion of hepatitis B cases attributed to sexual contact between men has declined in recent years, while the proportion attributed to heterosexual contact and injection drug use has increased. Multiple sex partners and high-risk sex practices, especially receptive anal intercourse, place both gay men and heterosexuals at increased risk for hepatitis B transmission. [9]

HIV Counselor Perspectives, V3N1, 2/93 (Thu Sep 1 20:40:09 1994)