Sexually Transmitted Infections (STIs) Dr. Assad Rahhal National AIDS Program

Infections—Generally Speaking What are they? Overgrowths of bacteria, viruses, fungus (yeast), or protozoal pathogens How are they spread? Inhalation of infected air, contact with infected body fluids, contact with infected skin (rashes, lesions) How can they be prevented? Avoiding contact with infected air, fluids, and skin

Sexually Transmissible Infections (STIs) Also known as Sexually Transmitted Diseases (STDs) Venereal Diseases What are your risks?

Sexually Transmissible Infections Bacterial Infections Chlamydia Gonorrhea Syphilis Viral Infections Herpes Hepatitis B Molluscum contagiosum HIV Human papillomavirus

Common STIs Human Papillomavirus (HPV) (virus) Chlamydia (bacteria) Warts on genitals and anus (men and women) Warts and pre-cancers on cervix (women) Often asymptomatic, presenting no visible symptoms Communicable or non-communicable when asymptomatic Chlamydia (bacteria) Infected cervix, tubes, epididymis Sometimes no symptoms at all

Common STIs Herpes (HSV I & II) (virus) Molluscum Contagiosum (virus) Painful ulcers Often no symptoms at all Molluscum Contagiosum (virus) Pimple-like lesions Often confused with pimples or folliculitis

“Risky Contact” for the Spread of STIs You don’t have to have sexual intercourse to contract an STI Many STIs are spread by direct skin contact Everyone who has “risky contact” is at risk Teens and young adults are more “at risk” than other populations

“Risky Contact” for the Spread of STIs Condoms do NOT completely protect from infections spread by skin contact, because they do not cover all infected areas of the skin Infection with these organisms does not require penetration during intercourse if there is other “risky contact.” HPV Herpes Molluscum

“Risky Contact” for the Spread of STIs Avoid “risky contact,” which is any contact with skin or fluids that may contain the viruses and bacteria that cause STIs Don’t share intimate apparel such as swimwear or underwear

Who gets STIs? Anyone who has “risky contact” with a person with an STI One contact might be all it takes to get an STI The more contacts, the greater the risk

STI Prevention Abstinence works best Avoid genital touching Many teens and young adults are now choosing abstinence Abstinence reflects feelings of self worth and self esteem Not everyone is “doing it” Sexual activity is NOT a requirement for friendship or social acceptance

The Most Prevalent STIs Chlamydia Women: infects urethra, cervix Often no symptoms Sometimes pain with urination or lower abdominal pain Infection can spread to tubes and ovaries Can cause infertility Men: infects urethra, epididymis Can cause pain with urination Swelling and pain of the testicles Spread by body fluids Semen Vaginal Anal

Epididymitis due to Chlamydia - the swelling of this infection is seen above the right testicle

Hydrosalpinx resulting from Chlamydia - closed, swollen and water-filled left tube in a young woman

The Most Prevalent STIs Genital herpes Men and women: genital skin Extremely painful lesions Often no symptoms Women: cervix Abnormal vaginal discharge May infect newborns during delivery Spread by skin contact Genital-Genital Hand-Genital Oral-Genital

Penis with vesicles (blisters) from genital herpes

External genital skin of female with herpes ulcers

The Most Prevalent STIs Molluscum Can appear anywhere on the skin Bumps that look like pimples Can become infected with bacteria Spread by body skin contact Genital-Genital Hand-Genital Oral-Genital

Molluscums of lower abdomen

External genital skin of female with huge molluscums

Human Papillomavirus (HPV) Over 100 types of HPV More than 20 types of HPV can infect genital skin Men and women: genital and anal warts Women: lesions on the cervix and vagina Spread by skin contact Genital-Genital Hand-Genital Oral-Genital

Human Papillomavirus (HPV) HPV: Genital Warts Men and women: external genital skin, anus, in urethra Women: cervix, vaginal walls Condoms offer some protection, but don’t cover all of the skin that can be infected

Papillary genital warts of female

Papillary genital warts of female

Flat genital warts of male

Papillary genital warts of male

Papillary genital warts of male

Papillary genital warts of male anus

HPV and Pre-Cancers Cervix and anus: some HPV types cause lesions that can be pre-cancers If not treated, they can eventually become cancers The Pap smear detects lesions on cervix Cells scraped from cervix are examined under a microscope If they have ever had sexual contact, women need yearly Paps

Genital warts on cervix of female

Pre-cancer changes on cervix

If you think you have an STI See a health care professional Be honest about your sexual behavior Ask for explanations If you do have an STI, notify your partner

Remember: Abstinence works best Avoid genital touching Many teens and young adults are choosing abstinence for now Abstinence reflects feelings of self worth and self esteem Not everyone is “doing it” Sexual activity is NOT a requirement for friendship or social acceptance

STI Prevention Alcohol and Drugs contribute to becoming infected with an STI Combined with sexual activity, the use of alcohol and other drugs is strongly associated with: Sexual activity when you are not really ready The spread of STIs Unwanted/unplanned pregnancy

The Connection Between STDs and HIV

Three Main Points There is a causal link between infection with STDs and increased transmission of HIV Preventing and treating STDs will reduce the number of new HIV infections You can make a difference by helping people prevent, identify and treat STDs

What is the STD-HIV Connection? Similar behaviors put people at risk of both STDs and HIV A current STD can increase risk of getting HIV by 2-5 times People with both HIV infection and another STD have increased HIV viral loads and can more easily infect others with HIV People with HIV can have more serious complications of other STDs

Many STDs Have No Symptoms In women: over 50% with gonorrhea and 70% with Chlamydia had no symptoms In men: 68-92% with gonorrhea and 92% with Chlamydia reported no symptoms

Epidemiologic Evidence Researchers have observed a strong association between having STDs and HIV in a number of studies. The association is termed “epidemiological synergy” 2-5 fold increased risk for HIV infection among persons who have other STDs.

Why the Increased Risk Ulcers and inflamed areas provide an easy portal of entry STDs attract T-helper cells to the infected area Even asymptomatic STDs can cause abnormal cellular changes that allow easier passage of infectious agents. Some STDs increase viral load and shedding of HIV

Recommendations Use condoms with all new sexual partners Reduce the number of new sexual partners Identify and treat new STDs Know that most STDs do not produce symptoms People already infected with HIV should be screened routinely for STDs

Recommendations (Continued) Regular screening for those at risk of STDs Those particularly at risk: sexually active young adults, especially those with multiple partners, those who exchange sex for drugs or money, and young men who have sex with men Easy access for all to STD care and treatment Education that douching (vaginal or anal) may increase the risk of acquiring HIV or another STD

Conclusions There is a direct link between other STDs and HIV transmission Early identification and treatment of STDs will reduce HIV transmission You can make a difference by helping people know these facts and working with those at risk to get screened and treated

Thank You

HPV Treatments Treatments for External Genital Warts Patient-applied prescription remedies Aldara™ (imiquimod) Cream, 5% Condylox™ gel 0.5% (podofilox) Procedures performed in the doctor’s office Freezing–cryoprobe or liquid nitrogen Caustic chemicals–TCA, BCA, podophyllin Laser

HPV—Treatments of the Cervix and Anus Cervix: destruction of lesion by freezing, laser, loop excision These treatments are about 90% successful Anus: similar to external genital warts Aldara™, Condylox™, freezing, caustic chemicals, laser

HPV Protection Consistent condom use can cut down, but not eliminate, the transmission of HPV Many HPV-associated lesions resolve spontaneously, but they may return Warts can be treated and removed, but the virus may remain in latent form See your health care provider for an accurate diagnosis and appropriate treatment

Testing for STIs There is no single test that detects all STIs No test is perfect (every test can fail to detect an infection) Screening tests (used when no symptoms are present) HPV (visual examination; Pap smear tests the cervix only) Chlamydia, gonorrhea (tests of genital secretions or urine) HIV, syphilis (specific blood tests) There is no reliable test for herpes when symptoms are absent