1. Sexually Transmitted Diseases and HIV/AIDS Evangelos Vryonis MD, MSc 1 st Advanced Course: “Health on the move” Migrants’ and displaced populations’ health Athens, January 14 & 15 2012

2. Sexually Transmitted Infections or STI’s STI’s are infections that are spread primarily through person-to-person sexual contact. There are more than 30 different sexually transmissible bacteria, viruses and parasites. Several, in particular HIV and syphilis, can also be transmitted from mother to child during pregnancy and childbirth, and through blood products and tissue transfer.

3. Background Information Knowledge About STDs Among Americans Source: Kaiser Family Foundation, 1996

4. Percent of Women Who Said Topic Was Discussed During First Visit With New Gynecological or Obstetrical Doctor/Health Care Professional Percentages may not total to 100% because of rounding or respondents answering “Don’t know” to the question “Who initiated this conversation?” Source: Kaiser Family Foundation/Glamour National Survey on STDs, 1997 Background Information

5. Sexually transmitted infections (STIs) are a public health issue > 448 million new infections of curable sexually transmitted (syphilis, gonorrhoea, chlamydia and trichomoniasis) infections occur yearly. Some STIs exist without symptoms In pregnant women with untreated early syphilis, 25% of pregnancies result in stillbirth and 14% in neonatal death. Sexually transmitted infections are the main preventable cause of infertility, particularly in women. Regional distribution (The largest number of new infections occurs in the region of South and Southeast Asia, followed by sub-Saharan Africa, Latin America, and the Caribbean) In low-income countries, STIs rank in the top five disease categories for which adults seek health care. 1 in 4 sexually active teens has an STI. WHO, Fact sheet N°110, August 2011 Background Information

6. Common pathogens Bacterial infections Neisseria gonorrhoeae (causes gonorrhoea or gonococcal infection) Chlamydia trachomatis (causes chlamydial infections) Treponema pallidum (causes syphilis) Haemophilus ducreyi (causes chancroid) Klebsiella granulomatis (previously known as Calymmatobacterium granulomatis causes granuloma inguinale or donovanosis). Viral infections Human immunodeficiency virus (causes AIDS) Herpes simplex virus type 2 (causes genital herpes) Human papillomavirus (causes genital warts and certain subtypes lead to cervical cancer in women) Hepatitis B virus (causes hepatitis and chronic cases may lead to cancer of the liver) Cytomegalovirus (causes inflammation in a number of organs including the brain, the eye, and the bowel). Parasites Trichomonas vaginalis (causes vaginal trichomoniasis) Candida albicans (causes vulvovaginitis in women; inflammation of the glans penis and foreskin [balano-posthitis] in men).

7. ..WHO recommends a syndromic approach to diagnosis and management of sexually transmitted infections… Although many different pathogens cause STIs, some display similar or overlapping signs and symptoms. Some of these signs and symptoms are easily recognizable, giving what is known as a syndrome that signals the presence of one or a number of pathogens. For example, a discharge from the urethra in men can be caused by gonorrhoea alone, chlamydia alone or both together. The main syndromes of common STIs are: urethral discharge genital ulcers inguinal swellings (bubo, which is a swelling in the groin) scrotal swelling vaginal discharge lower abdominal pain neonatal eye infections (conjunctivitis of the newborn).

8. Discharge syndromes-“Drips” Discharge syndromes. Urethral/vaginal discharge and dysuria are the hallmarks of – Gonorrhea, – Chlamydia, – Trichomoniasis, – Bacterial vaginosis, – Candidiasis – Mycoplasma genitalium infections are increasingly recognized as causes of sexually transmitted discharge syndromes in adolescents and young adults. – …genital herpes ?(sometimes associated with dysuria and a scant, mucoid urethral discharge, but nearly always in association with other genital lesions) Characteristics of the discharge, such as color (eg, clear, mucoid, yellow, green) are unreliable indicators of the etiology. Discharge syndromes

9. Gonorrhea Neisseria gonorrhoeae Gram-negative diplococci Urethritis - male – Incubation: 1-14 d (usually 2-5 d) – Sx: Dysuria and urethral discharge (5% asymptomatic) – Dx: Gram stain urethral smear (+) > 98% culture – Complications Urogenital infection - female – Endocervical canal primary site – 70-90% also colonize urethra – Incubation: unclear; sx usually in l0 d – Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain – Dx: Gram stain smear (+) 50-70% culture – Complications Gonorrhoea world map Discharge syndromes

10. Nongonococcal Urethritis Etiology: – 20-40% C. trachomatis – 20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium) – Occasional Trichomonas vaginalis, HSV – Unknown in ~50% cases Sx: Mild dysuria, mucoid discharge Dx: Urethral smear  5 PMNs (usually  15)/OI field Urine microscopic  10 PMNs/HPF Leukocyte esterase (+) Chlamydia trachomatis More than 3 million new cases annually in US Responsible for causing Cervicitis Urethritis Proctitis Lymphogranuloma venereum Pelvic Inflammatory Disease Direct and indirect cost of chlamydial infections run into billions of dollars Potential to transmit to newborn during delivery Conjunctivitis Pneumonia Discharge syndromes

11. Normal CervixChlamydia Cervicitis Discharge syndromes

12. Genital ulcer syndrome (GUS)- “Sores” – Primary syphilis - important diagnostic consideration, especially in the setting of commercial or high-risk sexual networks ± drug use – Genital Herpes -US most common (HSV-2, HSV-1) – Chancroid (Hemophilus ducreyi) – Lymphogranuloma venereum (Chlamydia trachomatis) – Granuloma inguinale (Calymmatobacterium granulomatis)

13. Does It Hurt? Painless – Syphilis – Lymphogranuloma venereum – Granuloma inguinale Painful – Genital herpes simplex – Chancroid Genital ulcer syndrome

14. Primary Syphilis Treponema pallidum Age-standardised disability-adjusted life year (DALY) rates from Syphilis by country. WHO 2009 Incubation: 10-90 days (average 3 weeks) Chancre – Early: macule/papule erodes – Late: clean based, painless, indurated ulcer with smooth firm borders – Resolves in 1-5 weeks – Unnoticed in 15-30% of patients – HIGHLY INFECTIOUS Genital ulcer syndrome

15. Secondary Syphilis Represents hematogenous dissemination of spirochetes Usually 2-8 weeks after chancre appears Findings: – rash - whole body (includes palms/soles) – mucous patches – condylomata lata - HIGHLY INFECTIOUS – constitutional symptoms Sn/Sx resolve in 2-10 weeks Genital ulcer syndrome

17. Portrait of Gerard de Lairesse by Rembrandt van Rijn, ca. 1665 oil on canvas. De Lairesse, himself a painter and art theorist, suffered from congenital syphilis that severely deformed his face and eventually blinded him Posthumous portrait of Christopher Columbus (1451 – 1506) by Sebastiano del Piombo. Genital ulcer syndrome

18. DISEASE Smallpox Influenza Typhus Measles Malaria Diphtheria Whooping Cough (Pertussis) DISEASE Smallpox Influenza Typhus Measles Malaria Diphtheria Whooping Cough (Pertussis) Treponema pallidum Genital ulcer syndrome

19. Genital Herpes One of the 3 most common STDs, increased 30% from late 70s to early 90s 25% of US population by age 35 HSV-2: 80-90%, HSV-1: 10-20% (majority of infections in some regions) Most cases subclinical Transmission primarily from subclinical infection Complications: neonatal transmission, enhanced HIV transmission, psychosocial issues Vesicles  painful ulcerations  crusting Recurrence a potential Diagnosis: – Culture – Serology (Western blot) – PCR Genital ulcer syndrome

20. Pelvic Inflammatory Disease (PID) Common sequela of genital gonorrhea and chlamydia infections (l0%-20%) In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID Douching may increase the risk of developing PID, especially when performed frequently CDC minimal criteria – uterine adnexal tenderness, cervical motion tenderness Other symptoms include – endocervical discharge, fever, lower abd. pain Complications: – Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia – 7X risk of ectopic pregnancy with 1 episode PID – chronic pelvic pain in 18%

21. Dermatologic syndromes The most common STD with primarily dermatologic presentation is genital warts (condyloma acuminata) caused by HPV Secondary Syphilis- Skin rash Condyloma lata Gonococcal infection- Skin rash is also a common manifestation of disseminated disease

22. Human papillomavirus- HPV Infection is generally indicated by the detection of HPV DNA HPV infection is causally associated with cancer Over 99% of cervical cancers have HPV DNA detected within the tumor Routine Pap smear screening ensures early detection (and treatment) of pre- cancerous lesions

23. HIV/AIDS HIV HUMAN IMMUNODEFICIENCY VIRUS AIDS ACQUIRED IMMUNODEFICIENCY SYNDROME Acquired Immunodeficiency Syndrome (AIDS) is a disease of the human immune system caused by the human immunodeficiency virus (HIV). The illness interferes with the immune system making people with AIDS much more likely to get infections, including opportunistic infections and tumors that do not affect people with working immune systems. This susceptibility gets worse as the disease continues. Modes of transmission of HIV varies in different countries. In resource-limited areas vaginal sex 70-80% percent of AIDS perinatal transmission 5-10% injection drug use 5-10% percent In contrast in USA, male-to-male sexual contact and IDU accounted for about one-half of cases

25. Natural History and Progression of HIV Disease A generalized graph of the relationship between HIV copies (viral load) and CD4 counts over the average course of untreated HIV infection; any particular individual's disease course may vary considerably. HIV-1 infection is divided into stages of primary infection with seroconversion, clinical latency, early symptomatic disease, and AIDS

27. Age-standardised disability-adjusted life year (DALY) rates from HIV/AIDS by country (per 100,000 inhabitants).

28. The amplifying effect of STDs in HIV transmission At least 2 to 5-fold increased risk of HIV seroconversion confirmed by data from 4 continents Greater infectiousness because of prevalence & magnitude of HIV shedding increased by STDs; STD treatment reduces HIV shedding to baseline levels 40% reduction in HIV incidence achieved in randomized trial of treatment of symptomatic STDs in Tanzania

29. 2-3% of the world population Despite common occurance of conflicts between old and new establishments, migratory flows have contributed significantly to human development >130 million people living in foreign countries >4 million people cross the boundaries >23 million refugees worldwide ?? numbers of clandestines

30. migration flow map