assignment #4

CHAPTER 15 Sexually Transmitted Infections

FEATURES

Global Dimensions STIs Around the world
Communication Dimensions Talking with a Partner About STI Prevention
Multicultural Dimensions STIs and Minorities
Ethical Dimensions Notifying Partners About STIs

CHAPTER OBJECTIVES

1 Define STIs and SRDs, describe how are they transmitted, and discuss the reasons for their prevalence.
2 Discuss the bacterially based STIs, including incidence, transmission, symptoms and complications, and diagnosis and treatment.
3 Discuss the virally based STIs, including incidence, transmission, symptoms and complications, and diagnosis and treatment.
4 Discuss the ectoparasitic infestations, including transmission, symptoms and complications, and diagnosis and treatment.
5 Describe ways that STIs and SRDs can be prevented.

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Prevalence of Sexually Transmitted Infections

Bacterial Infections

Viral Infections

INTRODUCTION

Jessica was enrolled in one of our human sexuality classes. One day after class, she asked whether she could stop in during office hours to discuss something “private.” Over the years, we have learned that “private” can mean many things: a student just found out she is pregnant, is being abused by a romantic partner, or is concerned about a sexual disorder. In Jessica’s case, though, it was a concern that she might have an STI.

Jessica went on to describe a sexual encounter with Rodney that culminated in penile-vaginal sex. Shortly afterward, Jessica noticed a rash on her inner thighs and became alarmed. As soon as she described her concern about having contracted an STI, I knew I would have to refer Jessica to a clinician at the campus health center for testing and diagnosis. I am an educator, not a medical doctor, and I know my limitations. Still, I could not refer her immediately for fear that she would think I was uninterested and be disinclined to discuss with me other concerns she might have in the future. Consequently, we discussed the reasons for her concern—the rash appeared, Rodney had not used a condom, they had not employed any other method of birth control, she met Rodney only the week before at a party and she did not really know him well—and we explored any other symptoms she described. Although I did not feel qualified to discuss whether Jessica had an STI, I did take advantage of our private time together to talk about the wisdom of coitus without the use of a condom and/or any other method of birth control and explored with her the decision to engage in coitus with someone she had only recently met.

It turned out that all Jessica had was a rash caused by nylon underpants she wore during her weekly jog. The relief on her face said it all, and I doubt that Jessica forgot that scare the next time she was faced with a decision regarding whether to engage in sex. That is not to say that she will refrain or become abstinent, although those are certainly possibilities and decisions others have made, but rather that she would understand better that any choice to engage in sexual activity is accompanied by both potentially pleasurable and potentially disturbing consequences. Contracting an STI, one of those disturbing consequences, is always a possibility.

Although Jessica did not have an STI, we have encountered other students who did. Fortunately, most of those students were diagnosed early enough and treated successfully. This chapter describes the more common STIs, ways they can be prevented, and ways they are treated when they are not prevented.

What Are Sexually Transmitted Infections?

The term sexually transmitted infections (STIs) describes infections that can be contracted through sexual intimacy. Sexual intimacy includes oral–genital and anal sex, as well as vaginal intercourse. At least 20 STIs have been identified. There are also diseases of the sexual organs referred to as sexually related diseases (SRDs), which are disorders of the reproductive tract that occur in both sexually active and sexually abstinent individuals. These can be caused by organisms that live in the healthy body but under certain conditions, such as stress, diabetes, drug use, and other health-related problems, affect the delicate chemical balance of the body and cause disease conditions of the sexual organs. Some cancers are also considered to be SRDs. A sexually related infection can sometimes be transmitted to a sexual partner, and the conditions under which this occurs are discussed in this chapter.

sexually transmitted infections (STIs)

Infections that are primarily contracted through sexual contact.

sexually related diseases (SRDs)

Diseases of the reproductive system that can occur in either sexually active or sexually inactive individuals.

Whatever the sexual disease, whether contracted during sexual activity or occurring in an abstinent individual, it affects the individual’s feelings about his or her sexuality. Some people feel that anyone with a disease of the sexual organs is unclean, evil, and immoral; that a sexual disease is a punishment for sexual intimacy; and that only those of low socioeconomic and low educational status contract these diseases.

There is no truth to these beliefs. Organisms live in our bodies and can multiply when our resistance is low or, as mentioned earlier, when other conditions exist. Pathogenic organisms can sometimes adjust to their habitat, proliferate, and even change in ways that cause symptoms of disease. Not only can they affect the body of an infected individual, but they are also sometimes transferred to another individual through sexual activity.

Prevalence of Sexually Transmitted Infections

STIs have become quite common, even though we have seen a decline in the rates of some particular STIs. There are many reasons for the prevalence of STIs. For example, whereas most states require physicians to report to health departments HIV and AIDS, chlamydia, gonorrhea, and syphilis cases, this was not always the case. Therefore, to compare current STI rates with periods in which reporting was not required would certainly make it appear that there are more cases; in fact, there may not be. In addition, since the 1960s there has been a change in attitudes about sexual behavior. More frequent sex and earlier sex have meant an increase in the number of people subjected to STIs. Other variables include the following:

1. There is considerable social pressure for social and sexual contact, along with widespread ignorance about sexual health and disease transmission.
2. The traditional restraints on sexual behavior are weakening as families and society in general become more loosely knit. Families are more mobile; relocation can threaten the stability of family members as they move away from the support system offered by the extended family and community. Adolescents and young adults are now reared in an atmosphere favoring more personal freedom and less adult supervision. More and more families have two parents in the workforce; adolescent and young adult family members are frequently employed while attending school; and many more adolescents than in the past are unattended during certain times of the day.

Global DIMENSIONS: STIs Around the World

There are wide variations in STIs around the world. Some countries have a high incidence; others have a lower one. The reasons for these differences may at first appear obvious but on further inspection are extremely complex. For example, it is assumed that lack of education is related to STIs, and, in fact, in some countries that is the case. Better educated people have access to information about STIs, their transmission, and their prevention. Furthermore, better educated people are more likely to have better paying jobs, allowing them to act on their STI knowledge (purchase condoms, for example). Yet, this is not always the case. For example, in the early years of the HIV/AIDS epidemic in sub-Saharan Africa, most HIV infections were among more educated people. Speculated causes for this difference included ideas that individuals with more education were wealthier, more mobile, and had broader networks of sexual partners. However, once educational campaigns were implemented in the region, the HIV rates started to shift, with educated individuals among the first to adopt protective behaviors. This change could be due in part because HIV campaigns were often incorporated into schools, and those who stayed in school longer might have been exposed to more health education messages (Hargreaves & Glynn, 2002). Today, education plays a large role in HIV prevention in Africa, with several studies demonstrating cognitive ability and increased time in school correlated with lower risk levels for HIV (Baker, Collins, & Leon, 2009; Peters et al., 2010).

The reason people contract STIs varies from country to country and even within subpopulations in any one country. The keys to preventing STIs at a policy level are understanding these differences and responding to them systematically.

3. Adolescence is a time of physical, psychological, and biochemical change and development. There is a wide range in the speed of adolescent development. Physiological maturing occurs at a faster rate than do intellectual, social, and emotional maturing. This places young people in a position of biological readiness for activities that have physical and emotional consequences for which they are not prepared. Often they face sexual decisions that affect their interests and they are not able to judge.
4. Current social values have led to widespread expectations of instant gratification. Learning, growing, and achieving goals require persistence; there seems to be a strong sense of urgency to act now, accompanied by a need for immediate satisfaction.
5. An “everybody does it” attitude undermines convictions about individual responsibility. Thus adolescents who feel stifled by external controls and are eager for independence often take actions, frequently sexual in nature, for which they are unprepared.
6. New modes of contraception have not eliminated unwanted pregnancy, but they have all but eliminated the fear of it. In the past this fear effectively inhibited sexual activity among many people of childbearing age.

One result of the combination of these factors has been an increase in sexual activity among most people—not just the young. This increase, in turn, has led to a rise in the incidence of STIs. There is no doubt that the risk of exposure is greater in people who are sexually active, especially with more than one person, because the chance of contracting an STI increases with the number of sexual contacts.

In spite of these social factors, and because of several other variables such as the fear of HIV infection, the rates of several STIs have decreased dramatically. However, accompanying this decrease in rates for some STIs is an increase in rates for others. The rates, signs, symptoms, potential complications, and means of diagnosing and treating the more prevalent STIs are presented in the following sections.

Bacterial Infections

Some STIs are caused by bacteria. Among these are chlamydia, gonorrhea, nongonococcal urethritis, and syphilis. It is not uncommon for these bacterial infections to be transmitted from one partner to the other, and treatment therefore often requires refraining from sexual activity until the bacteria have been eliminated.

Chlamydia

Incidence

Chlamydial infections, caused by the intracellular parasite Chlamydia trachomatis, are the most common reported STIs in the United States today. The Centers for Disease Control and Prevention (CDC) of the Department of Health and Human Services states that because case reporting remains incomplete, estimating the total number of chlamydia cases is extremely difficult. However, in 2010 there were more than 1.3 million chlamydial infections reported (Centers for Disease Control and Prevention, 2011a). There are more than three times more chlamydia cases than gonorrhea cases. From 1990 through 2010, reported cases of chlamydia increased from 160 cases per 100,000 persons to 426 cases per 100,000 (see Figure 15.1). This increase reflects increased screening, recognition of the nature of asymptomatic infection (especially in women), as well as actual increases in the disease.

Chlamydia trachomatis

An intracellular parasite that causes chlamydial infections.

chlamydia

A term that encompasses several major diseases caused by Chlamydia trachomatis, including genitourinary tract infection, a type of conjunctivitis in newborns, a type of pneumonia in infants, lymphogranuloma venereum, and trachoma.

Reported cases of chlamydia in women far exceed reported cases in men (611 cases per 100,000 to 234 per 100,000, respectively). Rates for women are highest in the 15- to 19-year-old age group (3,378 per 100,000 persons) and for 20- to 24-year-olds (3,408 per 100,000) (see Figure 15.2).

Chlamydial infection is an umbrella term that encompasses four major diseases caused by C. trachomatis: (1) a genitourinary tract infection in adults, (2) inclusion conjunctivitis (an acute eye infection) in newborns and chlamydial pneumonia in infants, (3) trachoma (a chronic eye infection), and (4) lymphogranuloma venereum. The two diseases of most concern in the United States are adult genitourinary tract infection and infant conjunctivitis and pneumonia.

Symptoms and Complications

Genitourinary tract chlamydial infection has been called “the silent STI.” Early symptoms of this infection are often mild and therefore unrecognized. Most infected people are asymptomatic. Symptoms, in those who exhibit them, occur 1 to 3 weeks after exposure. In men the most common symptoms include pain or burning on urination and a white, watery discharge from the penis. Women may note painful urination, a vaginal discharge, and abdominal pain. Individuals who engage in receptive anal sex can become infected with chlamydia in the anus. Symptoms can include rectal pain, discharge, or bleeding. For those performing oral sex on an infected partner, chlamydia can also be transmitted to the throat.

Diagnosis

figure 15.1 Chlamydia: rates by sex, United States, 1990–2010.

Source: Reproduced from Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2010. Atlanta: U.S. Department of Health and Human Services, 2011. Available: http://www.cdc.gov/std/stats10/figures/1.htm.

To diagnose chlamydia, a layer of cells is scraped from the infected area or a urine sample can be tested. The type of laboratory test used depends on the collection method, but nucleic acid amplification tests are the most sensitive tests for endocervical specimens and urethral swab and are FDA-cleared for use with urine. Because of the increased sensitivity, it is less likely that a false negative result will be obtained.

figure 15.2 Chlamydia: rates by age and sex, United States, 2010.

Although most samples are collected by a healthcare practitioner, California is trying out a self-service approach in which kiosks allow women to discreetly access testing kits for chlamydia and gonorrhea. One week after the specimens are mailed to the lab, results are available online or via phone with free treatment and follow-up counseling available. The goal of the program is to increase access to testing. On a university campus, a similar program to provide kits for male and female college students to collect a self-obtained sample and then send the kit away to test for chlamydia was unsuccessful. More than 150 individuals were provided with kits, but only 12 returned kits. Another 175 students were directed to an Internet site to request a kit via the mail but only three students internet-requested kits (Jenkins et al., 2012).

Infants born to women with genitourinary chlamydial infections are of risk of acquiring either inclusion conjunctivitis (pink eye) or chlamydial pneumonia during delivery (American Social Health Association, 2012b). In the United States, an estimated 100,000 pregnant women have a chlamydia infection. Because of the magnitude of this health threat, the CDC recommends that all pregnant women be screened for chlamydia at their first prenatal visit, whether or not they exhibit symptoms of infection (Centers for Disease Control and Prevention, 2010c). Additionally, high-risk women should be screened again in their third trimester to prevent complications at birth. Pregnant women should not use doxycycline; erythromycin can be substituted.

Treatment

Chlamydial infections are easily treated in their early stages with antibiotics. The treatment of choice is a single 1-g dosage of azithromycin administered orally or 100 mg of doxycycline administered orally twice a day for 7 days. Alternatively, either erythromycin or ofloxacin may be used. To minimize the risk of reinfection, patients are asked to refer their sexual partners for evaluation, testing, and treatment and to refrain from sexual intercourse with any partners who have not been treated. Reinfection is of prime importance. Many health organizations, including the American Medical Association, the American College of Obstetrics and Gynecologists, the Society for Adolescent Health and Medicine, and the American Academy of Pediatrics, recommend the use of expedited partner therapy (EPT) for chlamydia and gonorrhea in states where the practice is legal. EPT is treating sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his or her partner without the healthcare provider first examining the partner. As of August 2012, EPT is permitted in 32 states, and potentially allowable in an additional 11 as well as the District of Columbia and Puerto Rico. The seven remaining states have statutes that prohibit EPT (Centers for Disease Control and Prevention, 2012d). In states where legality is not clear, the American College of Obstetrics and Gynecologists encourages clinicians to advocate for its legality because there is support that this practice can decrease the risk of reinfection (American College of Obstetrics and Gynecologists, 2011).

Unfortunately, because of the asymptomatic nature of the infection and the similarity of symptoms for chlamydia and gonorrhea, many cases of chlamydia are either improperly treated or untreated. Untreated chlamydia can lead to pelvic inflammatory disease (PID) in women and to epididymitis in men. In both genders the possibility of sterility exists. Because of the high prevalence of chlamydia infections, screening is therefore recommended annually for all sexually active women 25 years of age and younger (Centers for Disease Control and Prevention, 2010c).

Gonorrhea

Incidence

Gonorrhea ranks high on the list of reportable communicable diseases. Only chlamydia is more prevalent. The incidence of gonorrhea declined 74% from 1975–1997 after implementation of a national gonorrhea control program. While the decline halted for several years, gonorrhea rates reached their lowest rate—98.1 per 100,000 individuals—in 2009. The rate increased slightly in 2010 to 100.8 per 100,000 individuals, with 309,341 cases reported in the United States. The increase in gonorrhea rates between 2009 and 2010 was observed among men and women and among all racial/ethnic groups (Centers for Disease Control and Prevention, 2011a) (see Figure 15.3).

gonorrhea

An STI that commonly starts with inflammation of the mucous membrane lining of the openings of the body (mouth, vagina, etc.).

However, rates of gonorrhea are not equal between these groups. Since 2002, rates of gonorrhea have been higher in women than men. In 2010, the gonorrhea rate was 106.5 cases per 100,000 women and 94.1 per 100,000 men. Regarding ethnicity, the 2010 gonorrhea rates remained highest among blacks (432.5 cases per 100,000), which is over 18 times the rate among whites (23.1 per 100,000). Rates among American Indians/Alaska Natives (105.7 per 100,000) were 4.6 times those of whites. Rates among Hispanics (49.9 per 100,000) were 2.2 times those of whites (Centers for Disease Control and Prevention, 2011a) (see Figure 15.4).

It is believed that many other cases of gonorrhea are not reported because of the social stigma still associated with STIs and the reluctance of Americans to address sexual health in an open manner. Because gonorrhea can result in pelvic inflammatory disease, sterility, ectopic pregnancy, and other serious health conditions, the number of Americans subjected to these risks, in spite of the declining rate of gonorrhea, is still disturbing.

Transmission

figure 15.3 Gonorrhea: rates, United States, 1941–2010.

Source: Reproduced from Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2010. Atlanta: U.S. Department of Health and Human Services, 2011. Available: http://www.cdc.gov/std/stats10/figures/14.htm.

Gonorrhea is caused by a bacterium known as Neisseria gonorrhoeae, also called gonococcus. This bacterium grows in the mucous membrane, the moist protective coat that lines all orifices (openings) of the body. The mucous membranes lining the mouth, throat, vagina, cervix, urethra, and anal canal are all very receptive to gonococcus. When contact occurs between the site of gonococcus in one person and the moist membrane of another—as in all forms of sexual activity—bacteria are transferred. Thus oral–vaginal, oral–anal, penile–anal, oral–penile, oral–oral, and genital–genital contact can result in the transmission of the disease from an infected person to the other partner. Outside the body, however, the gonococcus dies in a few seconds, making it next to impossible to transmit the disease via toilet seats, cups, towels, or other articles used by an infected person. Interestingly enough, although bacteria travel from the mucous membrane of the infected partner to that of the uninfected partner, they sometimes die during transfer. Thus exposure does not always result in infection. The risk of transmission from an infected female to a male through vaginal sex is about 20%. This risk increases to 60–80% if there are four or more exposures via vaginal sex. However, for a woman, the risk per episode of vaginal sex for transmission from an infected partner is 50–70%. The difference is because the mucous membrane lining of the vagina, which has a large surface area, is particularly receptive to the bacteria. Any small irritation in the mucous lining can allow the organism rapid entry into the woman’s system. Rates of transmission through anal sex have not been quantified, but it appears to be an efficient mode of transmission; pharyngeal gonorrhea (gonorrhea of the throat) is easily acquired when performing oral sex on a male but transmission to someone performing oral sex on a female is less likely (Centers for Disease Control and Prevention, 2012e).

Neisseria gonorrhoeae

The bacterium that causes gonorrhea; also known as gonococcus. Street names include “clap” and “drip.”

figure 15.4 Gonorrhea: rates by age and sex, United States, 2010.

Symptoms and Complications

Males are more likely than females to exhibit symptoms of gonorrhea, and most males will experience symptoms severe enough to seek treatment. It is estimated that 90% to 95% of men infected with gonorrhea have symptoms (Schwebke, 1991a; Smith, Schoonover, Lauver, & Allen, 1990). The males who exhibit symptoms do so within 1 to 14 days after contact; 2 to 5 days is the most likely interval. The primary sites in males are the urethra and the rectum.

Most males with gonorrhea experience some symptoms, but most females are asymptomatic. For males, the gonorrhea “drip” is a common symptom.

Gonorrhea lesions on the tongue.

Neisseria gonorrhoeae is the cause of gonorrhea.

Symptoms include the sudden onset of frequent, painful urination (dysuria) and a discharge of pus from the urethra. Some males have tenderness in the groin area and noticeable swelling of lymph nodes. In anal gonorrhea, symptoms include membrane irritation, discharge, and painful defecation.

Complications in the male are seen within 2 to 3 weeks without treatment. Infection spreads up the genitourinary tract, the posterior urethra, the prostate, the seminal vesicles, and the epididymis. Sometimes acute inflammation of the prostate occurs, accompanied by pelvic tenderness and pain, fever, and urinary retention. Inflammation of the epididymis may occur; it can be recognized by a feeling of heaviness in the affected testicle, inflammation of the scrotal skin, and sometimes swelling in the lower part of the testicles. If the gonococcal infection spreads to the other testicle, infertility is a possible complication.

Approximately 50% of the females who contract gonorrhea have no symptoms. The cervix is the primary infection site in females, and although it may be inflamed, symptoms may not be evident. Inflammation of the Bartholin’s glands is possible but not common. A yellowish discharge may be present but may remain undetected. In actuality most females do not know they have a gonorrheal infection unless the infected partner tells them or they have a smear and culture done in a routine gynecological examination. This fact alone should encourage sexually active women to ask for a gonorrhea test as part of their regular checkups.

A complication of gonorrhea in women is pelvic inflammatory disease (PID). In PID cases, the most common cause is gonor-rhea. If the gonorrhea goes untreated in a woman, within 2 months the gonococcal organisms may cause an ascending infection into the internal reproductive organs and pelvic cavity. During menstruation and immediately after, the organisms travel rapidly. Symptoms include dyspareunia (painful intercourse), occasional nonmenstrual uterine bleeding, inflammation of the fallopian tubes with subsequent tubal infection, vaginal discharge, general abdominal pain, and fever up to 102°F. PID is a common complication in women. As the body defenses try to wall off the infection, scarring of the fallopian tubes can occur and infertility can result.

pelvic inflammatory disease (PID)

Infection of the reproductive organs, particularly the uterus and fallopian tubes, and the pelvic cavity.

Extragenital complications of gonorrhea (those that occur in areas other than the genitals) include gonococcal arthritis and gonococcal dermatitis. These are sometimes referred to as disseminated gonococcal infection. Gonococcal arthritis affects the hands, wrists, ankles, knees, and elbows. Gonorrhea is the primary cause of arthritis in pregnant women and the most common cause of infectious arthritis in the United States. Gonococcal dermatitis, a rash, is most frequently seen on the hands and lower extremities. White blisters appear and eventually darken, leaving the body without scars. Gonococcal endocarditis, inflammation of the heart valves, is a serious but rare gonorrheal complication. Finally, gonococcal ophthalmic infection can occur in the newborn; that complication has been reduced by treating the eyes of all babies with silver nitrate tetracycline, or penicillin, at birth.

Diagnosis and Treatment

Diagnosing gonorrhea is usually through a urine sample. In some cases, discharge from body sites will be examined. Throat and rectal cultures are taken if the patient’s sexual activity with an infected person involves these body areas. Otherwise, discharge from the urethra in a male and the cervix of a female will be examined. When gonococci are present, approximately 96% of the organism is isolated in these areas.

For many years, the treatment of choice for gonorrhea was penicillin. In 1976, however, a strain of gonococcus resistant to penicillin appeared. This first antibiotic-resistant strain produces a substance that inactivates penicillin. Since then, other antibiotic-resistant strains of gonorrhea have appeared, including those demonstrating resistance to tetracycline and ciprofloxacin. Consequently, only one class of antimicrobials, the cephalosporins, is recommended and available for the treatment of gonorrhea in the United States. Unfortunately, in Japan in 2011 a strain of gonorrhea was found to be resistant to all forms of antibiotics—including all cephalosporin-class drugs (Ohnishi et al., 2011). There are concerns that this gonorrhea strain could spread worldwide in a few decades, especially as the bacteria’s susceptibility to cephalosporins has been decreasing rapidly in the United States as well (Bolan, Sparling, & Wasserheit, 2012).

The current treatment of choice for uncomplicated gonorrhea infections of the cervix, urethra, and rectum consists of an intramuscular injection of the drug ceftriaxone or 400 mg orally of cefixime plus an oral dose of either azithromycin or doxycycline (Centers for Disease Control and Prevention, 2012f). This additional medication is recommended because many individuals with gonorrhea infection have a coexisting chlamydial infection (Centers for Disease Control and Prevention, 2010c). As with all drug regimens, special populations, such as pregnant women, require special precautions and alterations.

Nongonococcal Urethritis

Incidence

Nongonococcal urethritis (NGU) and its potential companion, nongonococcal cervicitis (in females), are STIs characterized by inflammation of the urethra and cervix, respectively. The signs and symptoms of NGU are similar to those of gonorrhea. If there are indications of urethritis and a laboratory test rules out gonor-rhea, NGU is diagnosed.

nongonococcal urethritis (NGU)

Inflammation of the urethra caused by Chlamydia trachomatis, and Ureaplasma urealyticum, Mycoplasma hominis, Trichomonas vaginalis, herpes simplex virus, and unknown organisms.

Before the 1990s this condition was called non-specific urethritis because its causes were unknown. Today, researchers have identified that 15% to 40% of NGU is caused by Chlamydia trachomatis. In most cases of nonchlamydial NGU, no pathogen can be detected, though some research shows that M. genitalium may account for 15–25% of NGU cases (Centers for Disease Control and Prevention, 2010c). Other potential causes of NGU include Ureaplasma urealyticum, adenovirus, Haemophilus vaginalis, Trichomonas vaginalis (rare), and herpes simplex virus (rare) (American Social Health Association, 2012c).

Symptoms

NGU symptoms in males include discharge from the penis and a burning sensation during urination. Women who have NGU-related infection sometimes report a mild vaginal irritation, burning, or discharge. At least 70% of infected women, however, are believed to be asymptomatic. Additionally, 10% of infected men may be asymptomatic. NGU is not a reportable communicable disease, so we have no official count of cases in the United States. It is estimated that cases of NGU equal or surpass those of gonorrhea.

Treatment

Treatment consists of either 100 mg of doxycycline taken twice a day for 7 days or a single dosage of 1 g of azithromycin, both administered orally. Alternatively, erythromycin, levofloxacin, or ofloxacin may be used (Centers for Disease Control and Prevention 2010c).

Syphilis

Incidence

After falling to an all-time low in 2000, the syphilis rate in the United States rose for 9 consecutive years before falling again in 2010 (Centers for Disease Control and Prevention, 2011a). In 2010, 13,774 cases of primary and secondary syphilis were reported, a rate of 4.5 cases per 100,000 people (see Figure 15.5).

Outbreaks of syphilis among men who have sex with men (MSM) are believed to be largely responsible for the increasing syphilis rate. High-risk sexual behaviors and HIV co-infection contribute to the rate among MSM. In 2010, 67% of primary and secondary syphilis cases in the 44 states and the District of Columbia that provided information about sex of sex partners were among MSM (Centers for Disease Control and Prevention, 2011a). One analysis of data reported to the CDC showed that co-infection of HIV and syphilis was present in 53% of MSM, compared to 9% of men who reported having sex only with women and 5% among women (Su & Weinstock, 2011).

Wide disparities exist in the rate of syphilis among racial and ethnic groups. While the rate among blacks decreased from 18.4 to 16.8 cases per 100,000 from 2009 to 2010, this rate is eight times higher than the rate for whites (2.1 cases per 100,000). Rates among Hispanics increased between 2009 and 2010 to a rate two times that of whites (4.6 cases per 100,000). Regarding sex, males contract syphilis at a rate seven times higher than females (Centers for Disease Control and Prevention, 2011a) (see Figure 15.6).

Chancres of primary syphillis on penis.

figure 15.5 Syphilis: reported cases by stage of infection, United States, 1941–2010.

figure 15.6 Primary and secondary syphilis: rates by age and sex, United States, 2010.

Congenital syphilis is still a concern in the United States. Rates declined in the 1990s and early 2000s, but demonstrated an increase between 2006 and 2008. Between 2009 and 2010, the rate of congenital syphilis decreased from 9.9 to 8.7 cases per 100,000 live births, with a total of 377 reported cases in 2010 (Centers for Disease Control and Prevention, 2011a).

Transmission

The cause of syphilis is Treponema pallidum, a spirochete organism that requires a warm, moist area to survive. The spirochete is thin and corkscrew-shaped and is transmitted from the open lesions of the infected person to the mucous membranes or cuts in the skin of the other person. The organism can be transmitted by vaginal, anal, or oral–genital contact. Only a few hours after the time of contact, the spirochete reaches the bloodstream of the newly infected person.

syphilis

An STI caused by the spirochete Treponema pallidum.

spirochete

A spiral-shaped bacterium, one of which, Treponema pallidum, causes syphilis.

The spirochete can also be transmitted by an infected pregnant woman through the placenta to the unborn child. Syphilis bacteria cannot cross the placenta to infect the fetus until after the fourth month of pregnancy because of protection provided by a membrane known as Langhan’s layer. Therefore, if the mother is treated before the fourth month of pregnancy, the baby will be free of the disease. Women should be tested early in pregnancy, and if they suspect exposure at any time during pregnancy, they must be retested. Additionally, high-risk women should be retested in the third trimester (Centers for Disease Control and Prevention, 2010c).

Did You Know . . .

In 1932, the U.S. Public Health Service began a study to determine if syphilis developed differently in African Americans than in whites. The study was conducted in Alabama under the guidance of the Tuskegee Institute, one of the foremost black universities in the United States and, therefore, became known as the Tuskegee Study. The study followed 399 black subjects, all with syphilis—and 201 control subjects who had not contracted the disease—for 40 years.

In 1951, when penicillin became available to treat syphilis, the researchers withheld treatment from the study’s subjects because of concern it would interfere with their results. Even in 1966, when the morality of withholding treatment to subjects of the Tuskegee Study was raised with the director of the U.S. Public Health Service’s Division of Venereal Disease, a committee specifically organized to decide this issue voted to continue the study and continue to withhold treatment from the study’s subjects. Not until a concerned researcher went public in 1972, and another committee chaired by Senator Edward Kennedy in 1973 was formed to study the issue, was a directive ordered to stop the study and treat the remaining subjects. Guidelines were subsequently developed to prevent researchers conducting studies under the aegis of the federal government to ever again behave in such an immoral manner. The remaining subjects of the Tuskegee Study sued the government and eventually settled for $10 million. Unfortunately, a similar study conducted by U.S. researchers in Guatemala in the 1940s was revealed in 2011 in a review of historical documents. In this case, 1,300 Guatemalan patients were intentionally infected with syphilis, gonorrhea, or chancroid (Presidential Commission for the Study of Bioethical Issues, 2011). Because of such incidences, suspicion of researchers, especially among underserved populations, is often prevalent.

A chancre is symptomatic of the primary stage of syphilis. Often, though, the chancre can appear on hidden parts of the female genital areas, making the disease asymptomatic by appearance. A woman who suspects that her partner has syphilis should request a medical exam or test.

Symptoms and Complications

Syphilis has three stages of development: primary, secondary, and latent. Latent infection lacks any clinical symptoms and can be divided into early latent and late latent. Latent syphilis acquired within the last year is referred to as early latent syphilis. Other cases are referred to as either late latent syphilis or latent syphilis of unknown duration. Syphilis is infectious during the primary, secondary, and early latent stages.

Primary syphilis manifests itself by the appearance of a painless lesion, called a chancre. The chancre can appear from 10 to 90 days after exposure; on average, it appears in 21 days. Usually one lesion forms, generally on the glans penis in the male and the cervix in the female; however, the walls of the vagina and the tissues of the labia can also be sites of chancres. Because the lesions occur most frequently on hidden genital areas, they often remain undetected. Lesions can also appear on the nipples, anus, scrotum, or mouth.

primary syphilis

The first stage of syphilis most generally manifested by the appearance of a painless lesion called a chancre.

chancre

A painless lesion that is symptomatic of the primary stage of syphilis and appears at the site of contact.

Unfortunately the chancre disappears with or without treatment within 3 to 6 weeks. A person who suspects that he or she has been exposed to syphilis should have a blood test and not assume that the disappearance of the lesion means absence of the disease. During the primary stage, however, a blood test result may be negative; thus the test should be repeated. If possible, material exuding from a lesion suspected of being syphilitic should be examined under a microscope in what is called the darkfield technique. Sometimes this procedure, too, is repeated.

Secondary syphilis is usually characterized by a generalized rash that appears on the body 6 weeks to several months after initial exposure. The rash does not itch, and it too subsides without treatment. Sometimes in this stage mucous patches are found in the mouth. Other symptoms during secondary syphilis may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue (Centers for Disease Control and Prevention, 2012d). This stage usually lasts from 2 to 6 weeks.

secondary syphilis

The second stage of syphilis, often characterized by a rash.

In the secondary stage of syphilis, a generalized rash can appear on the body 6 weeks to several months after initial exposure. Although the rash disappears within a few weeks, medical treatment should be sought for the underlying syphilis bacteria, Treponema pallidum.

Latent syphilis has no visible symptoms, and this stage may last for years. The early latent period begins when the secondary symptoms disappear and ends 1 to 4 years later. In the late latent period, the disease may remain asymptomatic or symptoms involving the nervous system or cardiovascular system may appear. The disease can cause blindness, paralysis, crippling, brain damage, and possibly death. In the late latent period, blood tests of untreated persons yield positive findings for the spirochete, although the disease is not infectious at this stage (except to a fetus).

latent syphilis

A stage of syphilis that may last for years: early latent (about 1 to 4 years in duration) and late latent (may last for years); it may be symptom free or cause degenerative complications.

Diagnosis and Treatment

As noted, early diagnosis is made through a darkfield microscope examination of the material exuding from the chancre or rash, if possible, and through blood testing. Penicillin G is the current method of choice for all stages of syphilis. The preparation used, the dosage, and the length of treatment all depend on the stage and clinical manifestations of the disease (Centers for Disease Control and Prevention, 2010c).

Viral Infections

Some STIs are caused by viruses. Among these are genital warts, genital herpes, and hepatitis B. Acquired immunodeficiency syndrome (AIDS) is also caused by a virus, the human immunodeficiency virus (HIV). We discuss HIV/AIDS in the next interchapter. These STIs are among the most difficult to eradicate because the viruses that cause them remain in the body even after symptoms subside. However, as we discuss, there are effective treatments for viral STIs.

Human Papillomavirus

Persistent infection with a group of viruses called human papillomavirus (HPV) is associated with the development of cervical cancer and/or genital warts, depending on the type of HPV. Data obtained from the National Health and Nutrition Examination Survey (NHANES) reported overall prevalence of HPV—that associated with cervical cancer and that associated with genital warts—was 42.5% (Centers for Disease Control and Prevention, 2011a). It is estimated that there are more than 20 million people—men and women—who have an HPV infection and that 50% of sexually active individuals will experience an HPV infection at some point in their life. Genital HPV is considered the most common STI in the United States (Centers for Disease Control and Prevention, 2012b).

human papillomavirus (HPV)

A persistent STI caused by any of a group of viruses associated with the development of cervical cancer and/or genital warts.

Genital Warts

Genital warts occur in most areas of the genitals and anus. In females the warts appear on the labia, in the lower area of the vagina, on the cervix, or around the anus. In males they appear on the glans, foreskin, and shaft of the penis; on the scrotum; and in the anal area as well. Genital warts are growths or bumps that vary in appearance; they may be raised or flat, single or multiple, small or large. Usually, they are flesh-colored or whitish in appearance. Typically, warts do not cause itching, burning, or pain. Warts may appear within several weeks after sex with someone infected with a strain of HPV that causes warts, or it may take several months or years to appear. This extended incubation period makes determining the infection date difficult. It is also possible to transmit the virus to sexual partners when no warts are present; however, it is believed that HPV is more likely transmitted when warts are present. Most genital warts are caused by HPV 6 and 11 (American Social Health Association, 2012d).

Communication DIMENSIONS: Talking with a Partner About STI Prevention

Many of our students react incredulously when we suggest they speak with a potential partner about STIs before engaging in sex. “It would ruin the moment,” they argue. In frustration, we sometimes respond, “Contract an STI and then let us know about ruining the moment!” If that were all we offer our students, they would be right to be angry. Instead, we also provide them with suggestions to communicate with a potential sexual partner about preventing STIs:

• Begin the conversation before matters are “hot and heavy.” Once people are sexually excited, it is more difficult for them to make sensible decisions or to participate in meaningful conversation.
• While many STIs are asymptomatic, examining your partner’s genitals can be part of familiarizing yourself for what is normal for your partner. Laughing, soft touch, and expressions of admiration can make the moment enjoyable rather than clinical. Offering to be “examined” first can help reduce your partner’s anxiety about the process.
• Discuss your prior sexual history, as it relates to STI risk, with your partner before asking your partner to share his or her history. Engage in this discussion by disclosing as much detail as you feel comfortable discussing. If expressed in an erotic manner, this discussion can be sexually stimulating as it concurrently accomplishes the purpose of preventing exposure to disease-causing organisms.
• Suggest a “testing” date where you and your partner visit a clinic and get tested together. This can help reduce the pressure or anxiety that you or your partner may feel.
• Demonstrate effective communication skills. Lean forward, nod your head, and look your partner in the eyes to communicate interest. Periodically paraphrase what your partner has said and what you guess he or she is feeling to demonstrate you have been listening. Do not interrupt, raise your voice, or frown in a way that interferes with your partner’s communication.

There are ways to make communicating about STIs less embarrassing, less confrontational, and more effective. Discussing STIs with sexual partners is important. Your health, maybe even your life, may depend on it!

figure 15.7 Genital warts: initial visits to physicians’ offices, United States, 1966–2010.

Data based on the initial visit to a physician indicate that the incidence of genital warts may be increasing (Figure 15.7) (Centers for Disease Control and Prevention, 2010c). In a national study, 5.6% of sexually active 18- to 59-year-olds self-reported a history of genital warts (Dinh et al., 2008), but more recent data collected systematically through clinic diagnoses show ranges for men of up to 12.7%, although results differed based on partner type (men or women) and geographic location (Centers for Disease Control and Prevention, 2010c).

HPV is the most common STI in the United States. Some strains of HPV cause genital warts. Many people who are infected with HPV have a subclinical condition; in other words, the warts are not readily visible. Although the associated symptoms and conditions of HPV are treatable, HPV cannot be cured.

Diagnosis and Treatment of Genital Warts

Genital warts are typically diagnosed through visual exam, although in some cases the warts may be too small to see with the naked eye. A clinician may use acetic acid (vinegar) to “highlight” the warts, because the solution turns warts white. However, because this is not a specific test for HPV, it is not a recommended practice (Centers for Disease Control and Prevention, 2010c).

Treatment of genital warts can vary depending on the size, location, and number of warts; changes in the warts; patient preference; treatment cost; convenience; adverse effects; and a clinician’s experience with the treatments. Some methods occur in a clinician’s office; others are administered at home by the patient. A number of in-office procedures are available. With cryotherapy, the wart is frozen with liquid nitrogen. The tissue then dies and is replaced with healthy normal tissue. Trichloracetic acid is another chemical applied to the surface of the wart by a doctor or a nurse. The warts can also be cut off, which has the advantage of getting rid of warts in a single office visit. With electrocautery, the warts are burned off with an electrical current. Laser therapy uses an intense light to destroy warts. Laser therapy usually is reserved for cases with larger wart clusters, especially those that have not responded well to other treatments. Two prescription creams can also be used at home by the patient to treat warts. Podofilox cream or gel may be less expensive than treatment done in a clinic and is easy to use, but it must be used for about 4 weeks. The other cream, imiquimod cream, is also effective and easy to use. Because this cream boosts the immune system to fight HPV, it may reduce the frequency of recurrences (American Social Health Association, 2012d).

HPV, Cervical Changes, and Cancer

HPV can cause normal cells on infected skin to turn abnormal. As previously discussed, some strains of HPV can cause visible changes in the form of genital warts; other strains may cause cell changes that could be precancerous changes in the cervix or other HPV-related cancers such as cancers of the cervix, vulva, vagina, penis, anus, and oropharynx (back of throat including base of tongue and tonsil).

For precancerous changes in the cervix, in many cases the immune system is able to fight off HPV naturally, and the infected cells return to normal. In other cases, the body is not able to fight the virus and persistent infection, and possible complications result. Most HPV-related cancer is caused by HPV 16 and 18. For men who have sex with men, there is an increased risk of anal cancer due to HPV infection.

Risk of either type of HPV infection increases for people who have unprotected sex, especially at a young age, and have many sex partners. Other factors are related to an increased risk of developing cervical cancer. These include smoking, a weakened immune system, chlamydia infection, a diet low in fruits and vegetables, having three or more full-term pregnancies, having a first pregnancy before age 17, low income, and a family history of cervical cancer (American Cancer Society, 2011).

Diagnosis and Treatment of Cervical Changes

HPV is usually diagnosed as part of a gynecological exam. The Pap test looks for abnormal cells in a woman’s cervix that may be caused by HPV, but it is not a diagnostic test for HPV. Tests are available for women older than 30 years that look for viral DNA or RNA or capsid proteins related to specific HPV strains. These tests are not recommended for women younger than 20 years of age, men, or as a general test for STIs. For women younger than 21 years of age, the rate of spontaneous clearance of HPV is high; therefore limiting HPV screening reduces the possibility of unnecessary treatment. Unfortunately for men, there is no way to diagnose HPV strains related to these cancers before symptoms develop.

For women who are diagnosed with HPV strains related to cancer, the treatment will vary depending on the woman’s age and pregnancy status, the location of the abnormality, and the severity of the cell changes. Because the immune system may be able to combat HPV, in some cases monitoring the cervix and retesting in a few months may be the recommended strategy. In other cases, treatment to remove the affected area may be suggested; this can be done through cryotherapy, Loop Electrosurgical Excision Procedure (LEEP), or a cone biopsy (sometimes called conization) (American Social Health Association, 2012a).

Prevention of HPV

Two vaccines are available in the United States to prevent infection with HPV. Cervarix protects against the two strains of HPV most associated with cervical cancer and has been approved for use in girls and women. Gardasil protects against the four different strains of HPV that are associated with 70% of cervical cancers, 80% of anal cancers (HPV strains 16 and 18), and 90% of genital wart infections (HPV strains 6 and 11). A recent study has shown that Gardasil may provide some protection against anal cancer caused by HPV in MSM (Palefsky et al., 2011). Gardasil has been approved for use in both males and females. Because the vaccine will be most effective when received before becoming sexually active, it is recommended that girls and boys between 11 and 12 years old receive the vaccine (though it can be administered as early as 9 years of age).

Both vaccines are a series of three shots given over a 6-month period, with the second dose 1 to 2 months after the first and the third dose 6 months after the first dose (Centers for Disease Control and Prevention, 2011b). The three doses of the HPV vaccine cost $130 per injection ($390 for the entire series). As a result of the Affordable Care Act, all private insurance must cover the cost of the HPV vaccine. For those without private insurance, the Vaccines for Children (VFC) program provides federal funds to cover the cost of vaccines in children ages 18 and younger who are either Medicaid-eligible, uninsured, American Indian or Alaska Native, or underinsured. Other support options may be available for those who don’t qualify for VFC (Kaiser Family Foundation, 2011).

Whereas health advocates welcome and support the recommendation that all preteens be inoculated, this support is not universal. Some believe that the vaccine encourages sexual behavior, and some parents question the value of vaccinating young children for a sexually transmitted infection. Currently no federal law requires vaccination, and state laws vary regarding requirements of the HPV vaccine for school entry (Kaiser Family Foundation, 2011). In spite of widespread media coverage and financial support, in 2010 only 32% of girls between 13 and 17 received all three doses of an HPV vaccine (Centers for Disease Control and Prevention, 2011e).

Genital Herpes

Incidence

The cause of genital herpes is a virus called herpes simplex virus (HSV), which belongs to a family of more than 70 herpesviruses. Humans play host to four herpesviruses:

genital herpes

An STI characterized by tiny fluid-filled blisters that appear on the genitals and in the genital tract.

herpes simplex virus (HSV)

The virus that causes oral and genital herpes infections.

1. Herpes simplex virus, the agent for fever blisters and genital herpes
2. Cytomegalovirus, a virus that can cause death or retardation if acquired by a fetus
3. Varicella-zoster virus, the agent that causes chickenpox and shingles
4. Epstein-Barr virus, the agent of Burkitt’s lymphoma in humans

In 1961, it was found that two types of HSV exist. Type 1 (HSV-1) is seen more frequently in areas of the body above the waist; type 2 (HSV-2) is seen more frequently below the waist. Although most cases of recurrent genital herpes are caused by HSV-2, rates of genital herpes caused by HSV-1 appear to be increasing, especially among younger heterosexual women and men who have sex with men (Ryder et al., 2009). In addition, genital herpes can appear above the waist. For example, when HSV is transmitted through oral–genital sex, a sore may appear on the mouth.

Most patients who experience a first episode of HSV-2 infection experience recurrent episodes of genital lesions. However, clinical recurrences are much less frequent for HSV-1 infection than for HSV-2 infection. Therefore, identifying the causative agent has implications for treatment and counseling.

Herpes simplex type 1 can manifest itself as a cold sore.

In a nationally representative study, results indicated that about 16.2%, or about 1 in 6, people 14 to 49 years of age has genital HSV-2 infection. Over the past decade, this rate has remained stable. Women are more likely than men to be infected; in opposite-sex sexual experiences, transmission from a male partner to a female partner is more likely than from a female partner to a male partner. There are also racial/ethnic group differences, with black individuals disproportionately at risk for herpes. African Americans have a 39.2% prevalence rate, with black women having a 48.0% prevalence rate (Centers for Disease Control and Prevention, 2010b). Many people—up to 90% of those infected with herpes—do not know they have the virus (American Social Health Association, 2012c). See Figure 15.8 for office visit frequency.

figure 15.8 Genital herpes: initial visits to physicians’ offices, United States, 1966–2010.

Symptoms and Complications

Primary genital herpes corresponds with the time of actual infection by the herpesvirus and the formation of antibodies. A primary (first occurrence) herpes infection can be very painful but can also be completely symptom free. One recent analysis showed that over 80% of individuals who tested positive for HSV-2 infection were asymptomatic or had symptoms that were unrecognized as herpes (Centers for Disease Control and Prevention, 2010b). For many of these infected individuals, they are carriers of HSV, unaware of their infection and pose a potential risk to sexual partners.

primary genital herpes

The first stage of a genital herpes infection; it begins with infection by the herpesvirus and the formation of antibodies. Common symptoms include painful lesions in or around the genital area, a sluggish feeling, fever, and possibly swollen lymph nodes.

The first outbreak usually occurs within 2 weeks after the initial infection, and the sores typically heal within 2 to 4 weeks (Centers for Disease Control and Prevention, 2010b). In women the cervix is the main site of infection, although the vagina and vulva may also be involved. Symptoms include painful lesions, a sluggish feeling, and fever, along with possible lymph-node enlargement. Tiny blisters form, filled with a clear fluid in which the virus thrives. The area may become reddened and infected, and when blisters appear the site is in its most infectious state. The open lesions crust over as healing begins. In men, blisters and ulcers appear on the glans penis and the shaft, and urethritis may also develop. In both genders blisters sometimes appear on the thighs and buttocks. Some people experience itching, tingling, or burning sensations where a lesion will appear, known as the prodrome.

prodrome

Itching, tingling, or burning sensations that occur where a herpes lesion will appear.

Once antibodies are formed, the virus enters the latent genital herpes stage. Antibodies do not protect against reinfection, but they do tend to make any recurrent infection less severe. During the latent stage the herpesvirus travels up the afferent nerve to the sacral ganglion, where it remains inactive (Figure 15.9). At this point in the infection there are no signs and symptoms.

latent genital herpes

The stage of genital herpes characterized by inactivity of the herpesvirus, during which an infected individual is asymptomatic and transmission of the virus is rare.

The virus can become reactivated in the sacral ganglion without producing clinical signs. This occurrence is termed viral shedding. During this stage, the virus is excreted from the body even though the infected individual is experiencing no symptoms. HSV is readily transmitted when blisters or ulcers are present. However, the infection can occur through asymptomatic viral shedding.

viral shedding

HSV is excreted from the body even though an infected individual experiences no signs or symptoms.

Recurrent genital herpes is characterized by reactivation of the virus with clinical manifestations. During this stage the virus travels down the nerve root to the skin, often causing new herpes blisters to erupt. Many individuals experience prodrome symptoms before a recurrence. Symptoms of recurrent infections are usually milder than those of the primary herpes infection and are of shorter duration. The frequency of outbreaks also varies, ranging from one or two recurrences in a lifetime to several outbreaks a month. Researchers have not been able to determine who experiences recurrences or which factors trigger recurrence. It has been suggested that stress, menstruation, or illness may bring on a recurrence; however, more research is needed to clarify the mechanisms at work in the recurrence stage.

recurrent genital herpes

The fourth stage of a genital herpes infection, which is characterized by a reactivation of the virus and the appearance of blisters on the skin. Not all people with herpes have recurrences.

Symptoms of primary genital herpes include painful lesions, a sluggish feeling, and fever, along with lymph-node enlargement.

Recurrences are not always apparent as blisters may appear inside the genital tract where they cannot be seen, or symptoms may be so mild they are unnoticed. Psychological stress increases for many infected with herpes because they are concerned about recurring symptoms. They are also faced with the difficult decision of how to tell new partners that they have had herpes. They may feel vulnerable to rejection and therefore unwilling to share the information, yet they feel guilty if they are not honest. A variety of local groups across the country help herpes sufferers express their feelings about the infection and work through emotional problems.

Diagnosis and Treatment

Traditionally, HSV was diagnosed visually based on symptoms with a culture taken of fluid from the blisters to confirm the diagnosis. While this method is still preferred if genital ulcers are present, the sensitivity of this method is low, especially for recurrent lesions, and declines rapidly as lesions begin to heal. In addition, because an individual’s prognosis and the type of counseling needed depends on whether the genital infection is HSV-1 or HSV-2, clinical diagnosis of genital herpes should be confirmed by laboratory testing that specifies the presence of antibodies for HSV-1 or HSV-2 (Centers for Disease Control and Prevention, 2010c).

Because almost all HSV-2 is sexually transmitted, presence of HSV-2 antibodies implies a genital infection. However, if test results show only HSV-1 antibodies, it is more difficult to interpret. Most persons with HSV-1 antibodies have oral HSV infection acquired during childhood, which might be asymptomatic. At the same time, genital HSV-1 infection appears to be increasing, and genital HSV-1 also can be asymptomatic. Without clinical symptoms, a genital HSV-1 infection may be more difficult to confirm (Centers for Disease Control and Prevention, 2010c).

Treatment for HSV does not remove the virus from the body, but it can help to alleviate symptoms, including outbreaks and viral shedding. Antiviral medication can be used in two primary ways: episodic treatment and suppressive treatment. Episodic treatment is administered during the prodrome or within 1 day of a lesion developing; the goal is to diminish symptom severity and shorten the duration of lesions. Suppressive treatment is usually the treatment option for those with frequent lesion recurrences; it requires a daily dosage of antiviral medication. Studies have shown that suppressive therapy reduces the frequency of genital herpes recurrences by 70–80% in patients who have frequent recurrences, and some have reported no symptomatic outbreaks while being on the therapy (Centers for Disease Control and Prevention, 2010c). Suppression therapy with one type of antiviral (valacyclovir) has also been shown to reduce transmission among serodiscordant heterosexual couples (when one individual has HSV and the other does not). Suppression therapy also reduces the risk of viral shedding (Corey et al., 2004).

figure 15.9 An initial herpes infection takes place when the virus (dots) enters cells of the mucous membranes, eyes, or skin. It reproduces and travels up (arrows) the sensory nerves until it reaches a ganglion (cluster of nerve cell bodies). There it hides, protected from attack by the body’s immune system, which overcomes the infection at the place of entry. Though the entry wound soon heals, when conditions allow, the virus may later travel back down the nerve pathway to reinfect skin cells.

The best treatment for genital herpes is prevention. Some recommended preventive treatment procedures are as follows:

1. Many cases of genital herpes are transmitted by persons who are unaware that they have the infection or are asymptomatic when transmission occurs. Therefore, condom use is strongly recommended during oral, vaginal, and anal sex. Condoms will not eliminate the risk, but they can reduce it.
2. Persons with genital herpes should refrain from sexual activity when lesions or symptoms (prodrome) are present and inform their sexual partners that they have herpes.
3. Because there is a risk of transmitting herpes to a fetus neonatally, childbearing-aged women who have genital herpes should inform their healthcare providers, especially those who care for them during a pregnancy, about the infection.
4. Because stress can induce recurrences, it is advisable for persons with genital herpes to learn stress management techniques and employ them on a regular basis. These include relaxation techniques, such as yoga, meditation autogenics, and progressive relaxation, as means of perceiving events as less stressful (Greenberg, 2009).
5. To help prevent infections in other areas, persons with genital herpes should thoroughly wash their hands after touching their genitals.
6. To help speed the healing process, keep the genital (or other infected) area as clean and as dry as possible. Ensuring the area is exposed to air by wearing loose-fitting cotton underwear can also help.

One rare but serious effect of genital herpes is that it can lead to potentially fatal infections in babies. It is important that women avoid contracting herpes during pregnancy because a newly acquired infection during late pregnancy poses a greater risk of transmission to the baby (Centers for Disease Control and Prevention, 2010c). As already noted, the contagious virus is contained within the lesions. If vaginal lesions leak fluid during childbirth, the virus is transmitted to the infant and can result in encephalitis, brain damage, or both. Though less common, HSV can also be transmitted to a fetus through the placenta, thus causing infection before birth.

At this time it is not considered practical or feasible to test all women for herpes during their pregnancies, but women with a history of herpes definitely should be examined weekly from 32 weeks of gestation until delivery to see whether lesions recur. Any primary genital herpes lesions are likely to be detected in the frequent routine prenatal visits. If genital herpes is present at the time of delivery, the infant should be delivered by cesarean section. If laboratory examinations for active herpesvirus yield negative findings at delivery, the infant can be delivered vaginally with little risk of infection.

Hepatitis

There are five hepatitis viruses: A, B, C, D, and E. In the United States, hepatitis D and E are rare. The other three (A, B, and C) can cause similar symptoms but have different modes of transmission and can affect the liver differently. Hepatitis A is usually associated with oral–fecal contamination of water and food, but transmission through oral–anal contact has been increasingly documented, especially among men who have sex with men (MSM). Hepatitis B is transmitted a variety ways, including sexual contact. Transmission of hepatitis C is usually via blood-to-blood contact through needles or other drug paraphernalia. Hepatitis C can also be spread through sexual contact, although it is unclear how frequently this occurs. Having a sexually transmitted disease or HIV, sex with multiple partners, or rough sex appears to increase a person’s risk for hepatitis C.

In addition to transmission differences, manifestations of the viruses also differ. Hepatitis A appears only as an acute (self-limited) infection and does not become chronic; people infected with hepatitis A usually improve without treatment. Hepatitis B and hepatitis C can also begin as acute infections, but in some people the virus remains in the body, resulting in chronic disease and long-term liver problems. Vaccines are available to prevent hepatitis A and B; however, there is not one for hepatitis C. Because transmission of the hepatitis B virus (HBV) is often sexual, specifically through blood or blood products, semen, vaginal secretions, and saliva, this discussion will focus on that virus.

Hepatitis B Incidence

Did You Know . . .

Individuals infected with an STI are at a higher risk for becoming infected with HIV, the virus that causes AIDS. Researchers believe that the genital lesions characteristic of STIs—such as the blisters associated with herpes infection—provide HIV with an easy entry point to the body. Thus individuals who engage in unsafe sexual practices while an open lesion exists on the genitals lose an important line of defense against infection—unbroken skin.

In 2009, 3,374 cases of acute hepatitis B in the United States were reported to CDC; the overall incidence of reported acute HBV was 1.5 per 100,000 people, the lowest ever recorded. This low level is due to a national effort to eliminate HBV infection, which includes routine vaccination of children born since 1991. However, high-risk adult populations (for example, persons with more than one sex partner in the previous 6 months, MSM, and injecting drug users) are at increased risk (Centers for Disease Control and Prevention, 2012c). In fact, approximately 15–25% of all new HBV infections in the United States are among MSM (Centers for Disease Control and Prevention, 2010c). In the United States, an estimated 800,000 to 1.4 million persons have chronic HBV infection (Centers for Disease Control and Prevention, 2012c).

Photomicrograph of cells infected with the herpes simplex virus.

Hepatitis B Symptoms and Complications

Symptoms of HBV infection vary by age. Most children younger than 5 years and newly infected immune-compromised adults are asymptomatic, whereas 30–50% of persons older than age 5 may experience fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain, or jaundice. Symptoms typically last for several weeks but can persist for up to 6 months (Centers for Disease Control and Prevention, 2012c).

Persons with chronic HBV infection might be asymptomatic, or they may experience more severe conditions such as cirrhosis and liver cancer. In the United States, chronic HBV infection results in 2,000 to 4,000 deaths per year (Centers for Disease Control and Prevention, 2012c).

Hepatitis B Diagnosis, Treatment, and Prevention

Diagnosis of acute or chronic HBV infection requires blood tests for HBV antibodies. Specific antibodies may be present for an acute infection, so clinicians can determine if it is an acute or chronic infection based on the blood tests (Centers for Disease Control and Prevention, 2010c).

No specific therapy is available for persons with acute hepatitis B; treatment is supportive in that it can address any nausea, aches, or other pain. For those with chronic HBV, several antiviral drugs are available. A medical evaluation and regular monitoring should be undertaken to determine whether the disease is progressing and to identify any damage to the liver.

Hepatitis B is diagnosed by a blood test that looks for antibodies or antigens that are present when exposed to the hepatitis B virus.

One of the prime methods of HBV prevention is inoculation with the vaccine. If vaccination has not been undertaken, individuals should consider vaccination and, in the meantime, take steps to reduce their risk. HBV is a highly stable virus that can survive outside the body for at least 7 days and still be infectious (Centers for Disease Control and Prevention, 2012c). Likewise, the HBV is 50 to 100 times more infectious than HIV and is easily transmitted during sexual activity (Centers for Disease Control and Prevention, 2010e), so using a condom to reduce risk is essential. Not handling blood or blood products, semen, and vaginal secretions and not sharing items that might contain blood (such as razors or toothbrushes) are also critical strategies to reduce risk.

Vaginal Infections

One category of infection, vaginitises or vaginal infections, occurs in response to changes in an individual’s own body and has, therefore, been referred to as a sexually related disease (SRD). Two of these vaginitises, trichomoniasis and candidiasis, can also be transmitted from partner to partner and are considered relatively common in women.

Trichomoniasis

Trichomonas vaginalis is a one-celled organism that burrows under the vaginal mucosa to cause trichomoniasis, or trick. A 2007 study showed the estimated prevalence at 3.1% among women age 15–49, which equals 2.3 million cases (Sutton et al., 2007), although some studies show high-risk populations such as adolescents (Krashin et al., 2010) and women entering prison (Sutcliffe et al., 2010) to have much higher rates. The number of clinician visits is significantly less than the estimated rate, possibly because many women (up to 85%) do not have symptoms (Centers for Disease Control and Prevention, 2011f) (see Figure 15.10).

trichomoniasis (trick)

A type of vaginitis that can be an STI or an SRD. Symptoms include a foul-smelling, foamy white or yellow-green discharge that irritates the vagina and vulva. Urethritis may also be present.

The common mode of transmission is through sexual contact with an infected partner; vaginal sex, sharing sex toys, and mutual masturbation can all transmit the one-celled protozoan if fluids from one partner are passed to the genitals of the other. For those women who exhibit symptoms, the main ones are an odorous, foamy, white or yellow-green discharge that irritates the vagina and vulva. Frequent and some painful urination can also occur. Men rarely have symptoms, but if they do occur it is usually a discharge from the urethra or frequent and sometimes painful urination.

Trichomoniasis can be passed back and forth between partners; therefore it is important that all sexual partners of an infected individual receive treatment, especially because of the high rates of asymptomatic infections. Metronidazole (trade name Flagyl) is the drug of choice, although tinidazole has also been used as a treatment. Those undergoing treatment should refrain from alcohol use because of undesirable side effects.

figure 15.10 Trichomoniasis and other vaginal infections: women, initial visits to physicians’ offices, United States, 1966–2010.

Trichomoniasis in pregnant women has been associated with premature rupture of membranes, preterm delivery, and low birth weight. Previous studies identified concerns about treatment during pregnancy, but guidelines today indicate treatment with metronidazole during any stage of pregnancy is acceptable (Centers for Disease Control and Prevention, 2010c). Some studies have shown that infection with trichomoniasis causes an increased risk of HIV infection (McClelland et al., 2007; Van Der Pol et al., 2008).

Micrograph of a vaginal discharge revealing the presence of Trichomonas vaginalis, a common infection. Prolonged, untreated, or inadequately treated trichomoniasis can result in an increased risk of cancer.

Candidiasis

The second most common form of vaginitis, candidiasis, also called moniliasis, Monilia, or yeast infection, is caused by the fungus Candida albicans. This fungus normally lives and grows in the vagina.

candidiasis

A common form of vaginitis, sometimes called a yeast infection, which is caused by the fungus Candida albicans.

It is also known to be present in the mouth and intestine of many men and women. On occasion when the lactobacilli, or Doderlein bacilli, that are necessary for a healthy vaginal condition are reduced in number, the yeast multiply and outgrow other vaginal organisms. Women normally have these lactobacilli in the vagina, where they are necessary to maintain a healthy environment. They protect against a variety of infections, particularly those caused by bacteria in the urinary tract and the colon. The protective lactobacilli can be reduced by general poor health or lowered resistance, by too frequent douching, and by use of antibiotics (which can kill the lactobacilli as well as the bacteria causing the disease for which the antibiotic is prescribed). When the normally acid environment is changed, the yeast multiply and outgrow other vaginal organisms, resulting in a white and curdy discharge. Examination reveals a whitish plaque around the vagina and on its walls. Itching, frequently associated with a rash or redness of the vulva, is common. In advanced cases intercourse is painful, and burning and discomfort occur during urination.

lactobacilli

Bacteria in the vagina that aid in keeping it healthy; also called Doderlein bacilli.

The second most common form of vaginitis is candidiasis, or yeast infection. It can result in white and curdy discharge, as shown here.

Women with compromised immune systems, glucose intolerance, or who are receiving antibiotics may be at increased risk for yeast infections. Prolonged exposure to wet, synthetic material, such as bathing suits, prevent air from circulating around the vulva and keep normal discharges in contact with vaginal tissues, contributing to yeast growth. It is important to keep the area around the vulva as dry as possible. Letting towels dry before reuse and not sharing towels can also help. Avoiding panty hose, tight-fitting clothing, and noncotton underwear are other strategies to decrease risk. In addition, if material from the bowel is carried to the vagina, the person becomes more susceptible to moniliasis, because the bowel harbors the Candida fungus.

A variety of over-the-counter and prescription intravaginal creams and suppositories are available for treatment of yeast infections. A woman should visit a clinician if she has never been diagnosed with a yeast infection before using any over-the-counter treatment. In addition, the creams and suppositories available are oil-based, so pregnancy prevention methods should be considered because they may weaken latex condoms and diaphragms. Because yeast infections in women are not typically transmitted sexually, no data support the need for partner testing or treatment.

Ectoparasitic Infestations

There are two common STIs that are not diseases as such, but rather infestations of parasites. These are pubic lice and scabies. Parasites are found among all socioeconomic classes and are spread by close physical contact.

Pubic Lice

Pubic lice, commonly referred to as crabs, are parasites. Actually there are three different kinds of lice, known as pediculosis lice, and each seems to prefer its own habitat. Pediculus corporis is a body louse; Pediculus capitus is a head louse; and Pediculus pubis is the louse of the pubic area. Pubic lice are usually transmitted from person to person by sexual contact. Infection from infected bedding, clothing, upholstered furniture, and toilet seats is rare. The organism grips the pubic hair and feeds on tiny blood vessels of the skin.

pubic lice

A parasite, commonly referred to as crabs, a louse that grips the pubic hair and feeds on tiny blood vessels of the skin.

pediculosis lice

Also known as crabs, of three common types: Pediculus corporis, a body louse; Pediculus capitis, a head louse; and Pediculus pubis, a pubic louse.

Multicultural DIMENSIONS: STIs and Minorities

Surveillance data show high rates of STIs for some minority racial or ethnic groups compared with rates for whites. Race and ethnicity in the United States are risk markers that correlate with other more fundamental determinants of health status such as poverty, access to high-quality health care, health-care-seeking behavior, illicit drug use, and residence in communities with high prevalence of STIs.

• In 2010, the chlamydia rate among African Americans was more than 8 times that among whites. The chlamydia rate among African American women was more than 7 times higher than the rate among white women. The chlamydia rate among African American men was almost 11 times higher than the rate among white men.
• In 2010, the chlamydia rate among Hispanics was nearly 3 times higher than the rate among whites. The chlamydia rate among American Indians/Alaska Natives was more than 4 times higher than the rate among whites.
• In 2010, approximately 69% of the total number of reported cases of gonorrhea occurred among African Americans. Overall, the rate of gonorrhea among African Americans in the United States was 19 times greater than that among whites. This disparity was higher for African American men (22.2 times higher) than for African American women (16.2 times higher). Among those aged 20 to 24 years, the gonorrhea rate among African Americans was more than 16 times greater than that among whites (1,881.8 versus 116.5 cases per 100,000 population).
• In 2010, the gonorrhea rate among American Indians/Alaska Natives was 125.7 cases per 100,000 population, which was 4.8 times higher than the rate among whites. The gonorrhea rate among Asians/Pacific Islanders was lower than the rate among whites, and the rate among Hispanics was higher than the rate among whites.
• In 2010, 47.4% of all cases of primary and secondary syphilis occurred in African Americans. Compared to whites, the overall 2010 rate of primary and secondary syphilis among African Americans was 8 times higher.
• Compared to whites, the 2010 primary and secondary syphilis rate among American Indians/Alaska Natives was 1.2 times higher, and the rate among Hispanics was 2.2 times higher.

Reducing the prevalence of many of these STIs in minority populations will require a combination of strategies. Of course, education about prevention is important. Still, education will not have a significant effect in minority populations if it is not combined with strategies to reduce poverty, increase access to good-quality health care, decrease drug abuse and the sharing of drug “works,” and create comprehensive sexuality education programs that start in schools at early ages and continue through community agencies into the adult years.

Source: Data from Centers for Disease Control and Prevention. Sexually transmitted diseases surveillance 2010. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, 2011. Available: http://www.cdc.gov/std/stats10/surv2010.pdf.

Pubic lice, commonly called “crabs,” are usually transmitted from person to person by sexual contact. Direct treatment, plus cleaning of clothes and bedding, eliminate the lice.

Female crabs live 1 to 2 months and lay up to 10 eggs a day. As they feed on the human skin and blood, they irritate the skin, causing itching and occasionally swelling of glands in the groin. The nits, or eggs, stick to the pubic hair with a thick substance. Aided by body warmth, the eggs hatch and the new lice perpetuate the cycle of feeding on the human before dropping off. They can live for 1 to 2 days off the body and are visible to the naked eye on clothing and bedsheets. Treatment usually involves a cream rinse applied to the affected area. Reports of resistance to typical treatment methods have been increasing and are widespread. An alternative method is available, though not preferred, because of its strong odor and the longer required application time. And, of course, clothing and bed linen used before treatment should be washed. Fumigation of living areas is not considered necessary.

Scabies

Scabies is caused by a tiny mite that can barely be seen. The organism generally lives for up to 2 months. The female burrows under the skin at night, probably for the warmth of the human host, and the results are intense itching and the formation of pus. There is a characteristic distribution pattern of scabies. It is seen most commonly on the wrists, in the spaces between the fingers, under the breasts, and on the buttocks. Nodular scabies (raised lesions) can last up to 1 year. The mites lay two to three eggs a day, and in 2 or 3 weeks a new cycle begins. Because the incubation period is 4 to 6 weeks for those who have never been infected, one individual can transmit scabies to another before being aware of its existence. Close contact that is usually (but not exclusively) sexual can transmit the mites. Scabies can spread rapidly under crowded conditions where close body and skin contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks. Child care facilities also are a common site of scabies infestations.

scabies

Skin irritation caused by a tiny mite that is transferred from one person to another by close contact, sexual or otherwise.

In addition, a severe form of scabies, called crusted scabies or Norwegian scabies, can occur in persons who are immune-compromised, malnourished, or debilititated. These individuals will have thick crusts of skin that contain large numbers of scabies mites and eggs; they may not show the typical signs and symptoms of scabies and should be considered very contagious.

Diagnosis is usually based on the customary appearance and distribution of the rash and the presence of burrows. However, if possible, the diagnosis should be confirmed by identifying the mite, mite eggs, or mite fecal matter by removing a mite from the end of its burrow using the tip of a needle or by obtaining a skin scraping to examine under a microscope for mites, eggs, or mite fecal matter (Centers for Disease Control and Prevention, 2010a). Typical treatment is application of permethrin cream to all areas of the body (except the head) and washed off after 8 to 14 hours. Lindane (Kwell) is no longer recommended as a primary treatment because of its toxicity; however, if other treatments fail, it can be used under strict guidelines (Centers for Disease Control and Prevention, 2010c). Sexual contacts and those with close personal or household contact within the last month should be examined and treated.

Prevention

On the one hand, STIs are often like other diseases in that, for many, there are effective treatments that result in elimination of the disease. On the other hand, for some STIs, even though there are effective treatments, there are no cures (for example, genital herpes). Still other STIs have only recently had potentially effective treatments developed to treat them and, until then, inevitably led to incapacity and death (for example, syphilis). Even when cured, people who have contracted some STIs can be affected for their entire lives—for example, when the disease results in infertility. STIs, therefore, are serious conditions that we would be best advised to prevent. Fortunately, there are actions we can take to prevent contracting an STI or at least minimize the likelihood of contracting one.

Scabies lesions can last for up to a year and can be transmitted before being aware of its existence.

Ethical DIMENSIONS: Notifying Partners About STIs

There are many reasons why people with STIs choose not to notify their sexual partner(s) about their infection. They may be embarrassed to do so, they may be in a relationship and have contracted the STI from another partner or they may not want anyone to know about their infection for fear they will not be able to get dates or other sexual partners.

Similarly, there are many reasons people with STIs choose to notify their sexual partners. They may believe that all sexual partners, past and present, should be notified of a sexual partner’s STI status. In this way, they can get tested and retested if they are infected. And they can prevent the spread of the infection by refraining from sex with other people until they are disease free.

On the one hand, some people argue that absent any signs or symptoms, notifying a sexual partner might do more harm than good. For example, if the infection was contracted during an extramarital affair, notification might result in divorce. Notification might unduly frighten the unsuspecting partner, causing potentially unhealthy consequences associated with stress.

On the other hand, some people argue that to disclose an STI is consistent with the ethical principles of honesty and nonmaleficence (do no harm). Even if the result of the sexual behavior is accompanied by sanctions (such as divorce), they believe it further compounds the violation of trust to withhold information that a loved one can use to protect his or her health.

What do you think is the ethical thing to do? Does the fact that many STIs are asymptomatic affect your decision?

Abstinence

The most certain way to avoid contracting an STI is to abstain from sexual activity. Because STIs can be contracted through oral sex, anal sex, and skin-to-skin contact, refraining from all penetrative behaviors and contact with the genitals is needed to completely eliminate the risk.

Some may choose abstinence until they are married or until they are in a committed relationship. Others may practice abstinence at different points in their lives, such as after a recent divorce. The option of refraining from sexual activity is available to everyone at all times. However, for many people abstinence is not acceptable for a variety of reasons. Perhaps they have an interest in sex and find it so pleasurable that they are not willing to forgo it. They may have no moral or ethical objections to premarital sex. They may have no intention of marrying in the future, or they may be gay or lesbian and live in a state where legal marriage is unavailable to them. For those not willing to remain abstinent, other strategies to reduce the risk of contracting an STI are available.

Monogamy

If a sexual partner is STI free, and he or she is the only person with whom you engage in sexual activity, then you will not contract an STI. Monogamy with an uninfected partner, though, can be problematic. How are you to be sure your partner is uninfected? How are you to be sure that your partner is also monogamous? Without seeing the STI testing results and following your partner everywhere (which is usually not recommended), you can never really be sure that your partner is STI free and monogamous. And in some cases, like the lack of a test for HPV in men or that herpes infections can go unnoticed and be “discovered” years after an infection, even testing and stalking may not prove adequate. For all of these reasons, relying on monogamy with an uninfected partner as protection against contracting an STI can be risky.

Did You Know . . .

Although it is impossible to determine the exact number of STIs each year, it is agreed that the cost of these diseases is extensive. One estimate is that STI expenditures on direct medical care and related services, as well as the indirect costs associated with the loss of productivity, totaled $15.9 billion in 2008 (Centers for Disease Control and Prevention, 2009). This estimate excludes costs attributed to HIV and AIDS.

If sexually active, the best way to prevent contracting an STI is by maintaining a monogamous relationship in which both partners are STI free.

Myth vs Fact

Myth: If you get syphilis, you will know it because a rash will break out.

Fact: A rash may not appear until secondary syphilis has occurred. Furthermore, although a chancre (a sore) may develop early in the course of the disease, it may not be visible or may be dismissed as inconsequential. Also, in women, the early signs of syphilis may not be readily visible on the genitalia.

Myth: Gonorrhea is no more serious than the common cold and can be cured easily.

Fact: Gonorrhea can cause infertility, arthritis, or endocarditis (inflammation of the heart valves). In addition, certain antibiotic-resistant strains of gonorrhea raise concern about the ability to continue to treat this STI with present medications.

Myth: If you get an STI once, you acquire an immunity to it and cannot contract it a second time.

Fact: You do not have immunity to STIs and can contract them anew each time you have contact with the disease-causing organisms.

Myth: STIs occur only in or on the genital organs.

Fact: You can acquire an STI through oral–genital contact, in which case the signs of the disease would occur in the mouth and on the face. Or, you can have contact with an STI-causing organism by touching an infected area with your fingers, in which case the signs of the infection could appear on other body areas (like eyes and mouth) if you touch those areas.

Reduce the Number of Sexual Partners

If a person is unwilling or unable to maintain a monogamous relationship, decreasing the number of sexual partners lessens his or her odds of contracting an STI. The greater number of sexual partners, the greater the likelihood that one of them will be infected.

Refrain from the Use of Alcohol and Other Drugs

Decisions regarding important aspects of your life deserve thoughtful consideration. What more important decision is there than that concerning whether you will engage in an activity that has the potential of causing serious, sometimes life-threatening illness? Alcohol and other drugs can interfere with decision making by decreasing inhibitions and affecting judgment. Therefore, protection against STIs should include abstention from the use of mind-altering drugs.

Discuss STI Concerns with Potential Sexual Partners

Any new sexual partners should discuss concern about STIs before engaging in sexual activity. Whether they know they are infected, the high-risk behaviors they have engaged in and the results of any medical screenings they have had should be shared. This kind of a conversation can lead to concern about a potential sexual partner and a decision to refrain from sex altogether—or at least until a new medical screening can be obtained.

Be Observant

We used to recommend an examination of your own genitals and your partners’ genitals for any obvious signs of an STI. However, this is no longer recommended because so many STIs are asymptomatic and the “exam” can give individuals a false sense of security that they are infection-free.

At the same time, being familiar with your own body and examining your genitals for any lesions, blisters, or infected sores can help you identify if something abnormal develops. If so, it is important to refrain from sexual activity until you know the cause. If there is any unusual growth or sore or a foul-smelling odor, you need to see a healthcare provider for an exam and possible testing.

You also want to be observant of your partners’ genitals. If you see something that may be a sign of an STI, ask questions and do not continue to engage in any sexual activity until you are certain there is no risk to you. One of us had a student who saw a blister on his partner’s vulva, asked her about it and was informed that “it was a pimple.” When he later contracted genital herpes, he was devastated and wished he had trusted his instinct that it could be a symptom of an STI.

Use Condoms and Other Barriers

Male condom use is something that is often discussed as a prevention strategy for STIs. For all methods that are intended to reduce the risk of STI transmission, accurately estimating the effectiveness is challenging from a research perspective. Measuring consistent and correct use of the method, whether the infection identified is new or preexisting, and how to ensure that the individuals have exposure to the STI of interest during the study all pose challenges.

The research on male latex condoms demonstrates that they protect well against STIs that are transmitted through genital fluids (for example, pre-ejaculate, semen, vaginal secretions). These STIs include HIV, hepatitis B, gonorrhea, chlamydia, and trichomoniasis. The numerous studies on HIV transmission are the most methodologically strong, but there is epidemiological evidence that support prevention of transmission for the other fluid STIs. In all cases, male latex condoms provide a barrier to particles the size of STI pathogens; no “holes” exist in which HIV or virus could penetrate (Centers for Disease Control and Prevention, 2011c).

For infections that are transmitted by skin-to-skin contact, studies have not shown the same level of protection from male condoms. Consistent and correct male condom use can reduce the risk of genital herpes and syphilis only for the covered area. Other studies have shown that condom use may reduce the risk for HPV infection; condom use has also been associated with higher rates of clearance of HPV infection in women and with regression of HPV-lesions on the penis in men. In addition, a few prospective studies have shown condoms as having a protective effect on the acquisition of genital HPV (Centers for Disease Control and Prevention, 2011c).

The male and female condoms prevent STIs by establishing a barrier between the infection-causing organism and the body. This barrier prevents the organism from finding a pathway into the body.

Research is very limited on female condoms, latex dams (used during oral sex on a female or oral–anal contact), gloves, or other latex-protective barriers and the extent these items protect against STIs. In general, female condoms (Centers for Disease Control and Prevention, 2010c) and latex dams are believed to provide protection from fluid-transmitted STIs and from skin-to-skin STIs on the portion of the body covered. Previously, plastic wrap was recommended as an alternative to latex dams, but there is only one research article that suggested potential protection against herpes during oral sex on a female or oral–anal contact, and there are no data on its effectiveness regarding HIV or other STIs (Centers for Disease Control and Prevention, 2009a).

Avoid High-Risk Behaviors

Because organisms that cause STIs are present in semen and vaginal secretions, the goal is to prevent them from being transmitted from an infected person to a person not infected. Penile–vaginal sex without the use of a condom can result in the depositing of semen that includes infection-causing organisms within a partner’s body. So can fellatio without a condom and cunnilingus without a dental dam. Anal sex is a particularly high-risk behavior because the friction creates fissures (tears in the lining) in the anus, allowing easy entrance to infection-causing organisms into the bloodstream. Furthermore, because some organisms that cause STIs reside in the blood, using needles or other products that may contain drops of blood from another person puts one at high risk for disease. Sharing needles is one of the more common ways of contracting HIV in the United States.

Other Protective Measures

Still other behaviors can lessen the likelihood of contracting an STI or increase the likelihood of detecting one at an early stage:

• Wash the genitals before and after sex.
• Obtain regular medical checkups.

figure 15.11 STIs: a fact of life for the sexually active. By “sexually active,” we do not mean having a lot of sex. Instead we are using the term to mean having sex with different people. In general, the fact of life is that, sooner or later, sexually active people will either be exposed to an STI or contract one.

• Inspect the genitalia regularly.
• Do not share razors, hypodermic needles, or scissors.
• Do not handle towels, wet bedding, or undergarments immediately after these have been in contact with another person.

If you suspect you have been exposed to an STI, see a physician or visit a health clinic in your community or on your campus. It is unwise to try to diagnose and treat the condition yourself. It is also extremely important to comply with the treatment regimen, which includes taking all the medication prescribed at the appropriate times and returning for any follow-up visits. Also, if you have an STI, notify your partner(s). Failing to tell a partner of the possibility of infection could result in the spread of the disease, not just to a single individual but possibly to many (see Figure 15.11).

Sexuality Education and STIs

Alarmed at what it called the “hidden epidemic,” the Institute of Medicine (IOM) convened a 15-member expert panel in 1994 to strategize ways to address the STI problem. The IOM concluded that society’s unwillingness to confront sexual issues is the main barrier to responding to STIs (Eng & Butler, 1996). The IOM report went on to explain that this attitude hinders the dissemination of accurate, straightforward information about STIs in educational programs for adolescents and interferes with communication between parents and their children and between sexual partners. Furthermore, this attitude compromises healthcare professionals’ ability to counsel patients, impedes research on sexual behavior, and leads to unbalanced messages being sent via the media. The members of the expert panel noted several studies that found that almost two-thirds of respondents knew little or nothing about STIs other than HIV and AIDS and that most people seriously underestimate their risk of acquiring an STI, as well as its consequences. Not much has changed in the intervening years.

The need for education about STIs is evident, has long been overlooked, and requires the involvement of many different segments of our society, working together to prevent their occurrence and to develop more effective treatments if and when they do occur.

Exploring the Dimensions of: Human Sexuality

Our feelings, attitudes, and beliefs regarding sexuality are influenced by our internal and external environments. Go to go.jblearning.com/dimensions5e to learn more about the biological, psychological, and sociological factors that affect your sexuality.

Case Study

Sexually transmitted infections are quite prevalent, especially among young people. Some STIs and SRDs are curable; some are treatable but chronic. Because many cases are asymptomatic or early symptoms are ignored, treatment does not always occur. The STI can then be transmitted further.

Having a curable STI is, at a minimum, embarrassing. Yet having a chronic STI such as genital herpes or genital warts can have a profound psychological impact on a person’s life. The STI will affect the individual’s sexual activities for an entire lifetime. The fear of rejection after informing a potential sexual partner might cause the individual to say nothing. Self-esteem can diminish.

Socially, race and ethnicity correlate with fundamental determinants of health status such as poverty, access to health care, healthcare-seeking behavior, and residence in areas with a high prevalence of STIs. Thus a higher prevalence of gonorrhea or syphilis among African Americans has social—not biological—underpinnings.

STI risk can be reduced in a number of ways, including abstinence, monogamy, reduction in the number of sexual partners, refraining from alcohol or other drugs, communication with partners, use of latex condoms and other barrier methods, and avoidance of high-risk behaviors. However, if we belong to a community that has high rates of infection, our risk will still be greater unless we practice abstinence from oral sex, vaginal sex, anal sex, and genital contact. Simply engaging in sex with members of our community should not be an increased factor, and society as a whole needs to consider how to address these underlying influences as well as general STI awareness, education, and prevention practices.

Biological Factors

• STIs are contracted primarily through sexual contact.
• SRDs are diseases of the reproductive system that can occur in either sexually active or sexually inactive individuals.
• Individuals with an STI have a higher risk of becoming infected with HIV, possibly because the genital lesions characteristic of STIs give HIV access to the body.
• STIs can be passed to a baby both before and during birth.

Sociocultural Factors

• Society’s unwillingness to confront sexual issues is a major barrier in responding to STIs.
• Some ethnic groups have higher rates of STIs than others. Southern states have higher rates of syphilis than the national average.
• Economically, the cost of treating STIs—and the associated lost productivity—exceeds $15 billion per year.

Psychological Factors

Biological and sociocultural factors combine to influence psychological factors.

• Having an STI affects an individual’s feelings about his or her sexuality.
• Learning later in life that you became sterile due to an undiagnosed STI can have a devastating psychological effect.
• Psychological stress increases for genital herpes sufferers because they are constantly concerned that symptoms will reappear. They must decide whether to tell new partners of their condition, which can lead to rejection.

Summary

• Sexually transmitted infections (STIs) are infections contracted through sexual activities. There are also diseases of the sexual organs referred to as sexually related diseases (SRDs), which can occur in both sexually active and sexually abstinent individuals.
• Chlamydia is the most prevalently reported STI. More than 1.3 million cases were reported in 2010, more than four times the number of gonorrhea cases reported. Symptoms are often asymptomatic, although men may notice pain or burning during urination and women may notice a vaginal discharge and abdominal pain.
• Gonorrhea is the second most reported STI. In 2010, almost 309,000 cases were reported. Males are more likely to experience symptoms from gonorrhea infection than are females. Males may experience frequent and painful urination and a discharge of pus from the urethra. Females are usually asymptomatic, although some may notice a yellowish discharge.
• Syphilis rates declined in 2010, the first time since 2000. Initial symptoms include the development of a lesion (chancre), which disappears in 2 to 4 weeks. Soon afterward, a rash, fever, and some hair loss can occur. If syphilis goes untreated, blindness, paralysis, brain damage, and death are possible.
• Among viral causes of STIs are human papillomavirus (HPV), which is associated with the development of genital warts and cervical cancer. Vaccines are available, and one of them, Gardasil, can prevent as much as 70% of cervical cancers, 80% of anal cancers, and 90% of genital warts caused by HPV. Other viral causes of STIs include herpes simplex virus (HSV), which is associated with the development of genital herpes, and hepatitis B virus (HBV), which is associated with the development of hepatitis B.
• Sexually related diseases include vaginal infections (such as trichomoniasis and candidiasis) and ectoparasitic infections (such as pubic lice and scabies).
• Among the means of preventing or minimizing the risk of developing an STI are sexual abstinence, maintaining a monogamous sexual relationship, reducing the number of sexual partners, refraining from the use of alcohol or other drugs, and using latex condoms.

Discussion Questions

What are STIs, how are they transmitted, and what are the reasons for their prevalence?

What are the bacterially based STIs? Include their incidence, transmission, symptoms and complications, and diagnosis and treatment in your answer.

What are the virally based STIs? Include their incidence, transmission, symptoms and complications, and diagnosis and treatment in your answer.

What are the ectoparasitic infestations? Include their incidence, transmission, symptoms and complications, and diagnosis and treatment in your answer.

List the key ways to prevent STIs, evaluating the theoretical and user effectiveness of each in the real world.

Application Questions

Reread the chapter-opening story and answer the following questions.

Jessica chose to ask her human sexuality professor about her potential STI. Why didn’t she go to the student health clinic or her primary care physician?

The author describes several of the “private” conversations students wish to have with human sexuality professors, concerning pregnancy, abuse, sexual disorders, and STIs. Where on your campus (or in your community) could you go for help for each of these problems? Be specific, creating a list with phone numbers.

Should professors discuss personal sexuality issues with students? Explain why or why not.

Critical Thinking Questions

Applications for marriage licenses in Mississippi require a blood test for syphilis but not for the other STIs. Because many STIs are asymptomatic, should marriage tests require testing for all the major STIs? What difficulties would implementing such a program involve? (Hint: Consider how each disease is diagnosed.)

How can undetected STIs affect fetuses and newborns?

Criminal laws generally provide that someone who deliberately inflicts harm on another person should be punished. Civil laws allow the victim to seek compensation for harm done. Should people who know they are infected with STIs but who have unprotected sex with others and infect them be prosecuted? Should the people they infect be able to sue for physical and psychological damages?

Critical Thinking Case

Most of us believe that STIs afflict young people. But STIs strike people of all ages—including senior citizens. People who are widowed or divorced do not become asexual; rather, they usually begin dating new people. In fact, 90% of postmenopausal women remain sexually active.

Dr. Peter Leone, medical director of the Wake County, North Carolina, STI Clinic, says: “Women who are past menopause often think they can’t get an STI. People link pregnancy and STI risk. But methods to prevent pregnancy aren’t the best ones for preventing STIs. On the other hand, some people think, ‘Why should I use a condom? I can’t get pregnant.’”

Although the STI incidence rates per 100,000 people has remained low for senior citizens, the number of seniors is growing dramatically. So, even if rates remain low, the number will continue to increase. Consequently, in 2009 people 50 years old and older accounted for 22% of the new AIDS cases and 16.5% of the new HIV diagnoses in the United States (Centers for Disease Control and Prevention, 2011d).

Consider your parents or your parents’ friends who are divorced or widowed. How could you, as a student in this class, give them information about taking responsibility for their sexual behavior?

Ironically, it seems that senior citizens share the attitude of young people regarding sexual behavior: It cannot happen to me. Explain this attitude. Do young people and seniors have different reasons for their beliefs?

Exploring Personal Dimensionss

Can You Be Assertive When You Need to Be?

To take the necessary actions to prevent contracting an STI, you will have to be assertive: That is, you will need to resist pressure to engage in sexual activity if you choose not to, and you will need to insist on the use of a condom and other safer sex precautions if you decide to engage in sex. Do you have assertiveness skills? To find out, write an assertive response to each of the situations described.

1. You are on a date and your partner insists on engaging in a sexual activity that you decide is not for you at that time. You say: _____________________________________________ _____________________________________________ _____________________________________________
2. Your partner argues that condoms or latex barriers diminish the sensation. You respond by saying: _____________________________________________ _____________________________________________ _____________________________________________
3. Your partner states that she or he has been tested for STIs and the test result was negative. Therefore, there are no reasons for using safer sex techniques. You respond by saying: _____________________________________________ _____________________________________________ _____________________________________________

To be assertive, you need to:

1. Specify the behavior or situation to which the statement refers.
2. Relate your feelings about that situation.
3. Suggest a remedy or what your preference is.
4. Identify the consequences of the change: what will happen if it occurs and what will happen if it does not occur.

Now check your responses and revise them to be consistent with these assertiveness principles.

Suggested Readings

Grimes, J. Seductive delusions: How everyday people catch STDs. Baltimore, MD: The Johns Hopkins University Press, 2008.

Handsfield, H. H. Color atlas & synopsis of sexually transmitted diseases, 3rd ed. New York: McGraw-Hill Professional, 2011.

Lowy, I. A woman’s disease: The history of cervical cancer. New York: Oxford University Press, 2011.

Nack, A. Damaged goods? Women living with incurable sexually transmitted diseases. Philadelphia, PA: Temple University Press, 2008.

Zenilman, J. M., & Shahmanesh, M. Sexually transmitted infections: Diagnosis, management, and treatment. Sudbury, MA: Jones & Bartlett Learning, 2011.

Web Resourcess

For links to the websites below, visit go.jblearning.com/dimensions5e and click on Resource Links.

Division of STD Prevention

www.cdc.gov/std

This site provides statistics and reports pertaining to STIs. Among the links are those pertaining to bacterial vaginosis, chlamydia, genital herpes, gonorrhea, hepatitis (viral), HIV/AIDS, human papillomavirus infection, pelvic inflammatory disease, pregnancy and STIs, syphilis, trichomoniasis, and general information about STIs.

American Social Health Association

www.ashastd.org

The American Social Health Association develops and delivers accurate, medically reliable information about STIs. ASHA publishes educational pamphlets and books for clients and students. It helps community-based organizations communicate about risk, transmission, prevention, testing, and treatment of STIs. Links to statistics, prevention tips, and information about particular STIs are included on this website.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

www.cdc.gov/nchhstp/

This division of the CDC is responsible for public health surveillance, prevention research, and programs to prevent and control HIV infection and AIDS, other STIs, viral hepatitis, and tuberculosis. The website offers links to reports that include up-to-date information on the above listed topics.

Navigating HPV

www.arhp.org/hpv-tool

This interactive tool allows both males and females to select information on HPV that is appropriate to their age and circumstances. It also offers information on prevention, treatment, and the HPV vaccines.

STD Wizard

www.stdwizard.org

This interactive tool has visitors provide personal information about their sexual health and then creates recommendations for testing and relevant vaccination based on the details provided. While not a substitute for a visit to a healthcare provider, the results can help identify needs and familiarize someone with the questions a health-care provider will ask to assess risk and needed medical attention.

References

American Cancer Society. Cervical Cancer Overview, 2011. Available: http://www.cancer.org/acs/groups/cid/documents/webcontent/003042-pdf.pdf.

American College of Obstetrics and Gynecologists. Committee on Adolescent Health Care and Committee on Gynecologic Practice. Committee Opinion No. 506: Expedited partner therapy in the management of gonorrhea and chlamydia by obstetrician-gynecologists. Obstetrics & Gynecology, 118, no. 3 (2011), 761–766, 2011.

American Social Health Association. Chlamydia, 2012b. Available: http://www.ashastd.org/std-sti/chlamydia.html.

American Social Health Association. Fast Facts, 2012c. Available: http://www.ashastd.org/std-sti/Herpes/learn-about-herpes.html.

American Social Health Association. Genital Warts, 2012d. Available: http://www.ashastd.org/std-sti/hpv/genital-warts.html.

American Social Health Association. Learn about HPV: Cervical dysplasia, 2012a. Available: http://www.ashastd.org/std-sti/hpv/cervical-dysplasia.html.

American Social Health Association. NGU, 2012e. Available: http://www.ashastd.org/std-sti/ngu.html.

Baker, D., Collins, J., & Leon, J. Risk factor or social vaccine? The historical progression of the role of education in HIV/AIDS infection in sub-Saharan Africa. Prospects: Quarterly Review of Comparative Education, 38, no. 4 (2009), 467–486.

Bolan, G. A., Sparling, P. F., & Wasserheit, J. N. The emerging threat of untreatable gonococcal infection. New England Journal of Medicine, 366 (2012), 485–487.

Centers for Disease Control and Prevention. Sexually transmitted diseases surveillance, 2008, 2009. Available: http://www.cdc.gov/STD/stats08/chlamydia.htm.

Centers for Disease Control and Prevention. Oral sex and HIV risk, 2009a. Available: http://www.cdc.gov/hiv/resources/factsheets/oralsex.htm.

Centers for Disease Control and Prevention. Scabies frequently asked questions, 2010a. Available: http://www.cdc.gov/parasites/scabies/gen_info/faqs.html.

Centers for Disease Control and Prevention. Seroprevalence of herpes simplex virus type 2 among persons aged 14–49 years—United States, 2005–2008. Morbidity and Mortality Weekly Review, 59, no. 15 (2010b), 456–459.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2010, 2010c. Available: http://www.cdc.gov/std/stats10/surv2010.pdf.

Centers for Disease Control and Prevention. Syphilis—CDC fact sheet, 2010d. Available: http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm.

Centers for Disease Control and Prevention. Updated to CDC’s Sexually Transmitted Diseases Guidelines, 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections. Morbidity and Mortality Weekly Report, 61, 31 (2012f), 590–594.

Centers for Disease Control and Prevention. Viral hepatitis: Information for gay and bisexual men, 2010e. Available: http://www.cdc.gov/hepatitis/Populations/PDFs/HepGay-FactSheet-BW.pdf.

Centers for Disease Control and Prevention. 2010 sexually transmitted diseases surveillance, 2011a. Available: http://www.cdc.gov/std/stats10/surv2010.pdf.

Centers for Disease Control and Prevention. ACIP recommends all 11- to 12-year-old males get vaccinated against HPV: Press Briefing Transcript, 2011b. Available: http://www.cdc.gov/media/releases/2011/t1025_hpv_12yroldvaccine.html.

Centers for Disease Control and Prevention. Condoms and STDs: Fact sheet for public health personnel, 2011c. Available: http://www.cdc.gov/condomeffectiveness/latex.htm.

Centers for Disease Control and Prevention. HIV surveillance report, 2009; vol. 21, 2011d. Available: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/.

Centers for Disease Control and Prevention. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. Morbidity and Mortality Weekly Report, 60, no. 33 (2011e), 1117–1123.

Centers for Disease Control and Prevention. Trichomoniasis statistics, 2011f. Available: http://www.cdc.gov/std/trichomonas/stats.htm.

Centers for Disease Control and Prevention. Genital herpes—CDC fact sheet, 2012a. Available: http://www.cdc.gov/std/herpes/STDFact-herpes.htm.

Centers for Disease Control and Prevention. Genital HPV infection—fact sheet, 2012b. Available: http://www.cdc.gov/std/HPV/STDFact-HPV.htm.

Centers for Disease Control and Prevention. Hepatitis B FAQs for health professionals, 2012c. Available: http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm.

Centers for Disease Control and Prevention. Legal status of expedited partner therapy (EPT), 2012d. Available: http://www.cdc.gov/std/ept/legal/default.htm.

Centers for Disease Control and Prevention. Ready-to-use STD curriculum for clinical educators: Gonorrhea module, 2012e. Available: http://www2a.cdc.gov/stdtraining/ready-touse/Manuals/Gonorrhea/gonorrhea-notes-8-2012.pdf.

Corey, L., Wald, A., & Patel, R., et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. New England Journal of Medicine, 350 (2004), 11–20.

Greenberg, J. S. Comprehensive stress management, 11th ed. New York: McGraw-Hill Higher Education, 2009.

Hargreaves, J. R., & Glynn, J. R. Educational attainment and HIV-1 infection in developing countries: A systematic review. Tropical Medicine and International Health, 7, no. 6 (2002), 489–498.

Jenkins, W. D., Weis, R., Campbell, P., Barnes, M., Barnes, P., & Gaydos, C. Comparative effectiveness of two self-collected sample kit distribution systems for chlamydia screening on a university campus. Sexually Transmitted Infections, 88 (2012), 363–367. doi: 10.1136/sextrans-2011-050379.

Kaiser Family Foundation. The HPV vaccine: Access and use in the U.S., 2011. Available: http://www.kff.org/womenshealth/upload/7602-03.pdf.

Krashin, J. W., Koumans, E. H., Bradshaw-Sydnor, A. C., Braxton, J. R., Secor, W. E., Sawyer, M. K., & Markowitz, L. E. Trichomonas vaginalis prevalence, incidence, risk factors and antibiotic-resistance in an adolescent population. Sexually Transmitted Diseases, 37, no. 7 (2010), 440–444.

McClelland, R. S., Sangare, L., & Hassan, W. M., et al. Infection with Trichomonas vaginalis increases the risk of HIV-1 acquisition. Journal of Infectious Disease, 195 (2007), 698–702.

Ohnishi, M., Golparian, D., Shimuta, K., Saika, T., Hoshina, S., Iwasaku, K., Nakayama, S., Kitawaki, J., & Unemo, M. Is Neisseria gonorrhoeae initiating a future era of untreatable gonorrhea? Detailed characterization of the first strain with high-level resistance to ceftriaxone. Antimicrobial Agents and Chemotherapy, 55, no. 7 (2011), 3538–3545.

Palefsky, J. M. et al. HPV vaccine against anal HPV infection and anal intraepithelial neoplasia. New England Journal of Medicine, 365 (2011), 1576–1585.

Peters, E., Baker, D., Deickmann, N., Leon, J., & Collins, J. Explaining the education effect on health: A field-study from Ghana. Psychological Science, 21, no. 10 (2010), 1369–1376.

Presidential Commission for the Study of Bioethical Issues. “Ethically Impossible”: STD research in Guatemala from 1946 to 1948, 2011. Available: http://bioethics.gov/cms/sites/default/files/Ethically-Impossible_PCSBI.pdf.

Ryder, N., Jin, F., & McNulty, A. M., et al. Increasing role of herpes simplex virus type 1 in first-episode anogenital herpes in heterosexual women and younger men who have sex with men, 1992–2006. Sexually Transmitted Infections, 85 (2009), 416–419.

Su, J. R., & Weinstock, H. S. Epidemiology of co-infection with HIV and syphilis in 34 states, United States, 2009. Paper presented at the August 2011 National HIV Prevention Conference, Atlanta, GA. Available: http://www.2011nhpc.org/archivepdf/2011%20NHPC%20Final%20Abstract%20Book.pdf.

Sutcliffe, S., Newman, S. B., Hardick, A., & Gaydos, C. A. Prevalence and Correlates of Trichomonas vaginalis infection among female U.S. federal prison inmates. Sexually Transmitted Diseases, 37, no. 9 (2010), 585–590.

Sutton, M., Sternberg, M., Koumans, E. H., McQuillan, G., Berman, S., & Markowitz, L. E. The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001–2004. Clinical Infectious Diseases, 45, no. 10 (2007), 1319–1326.

Van Der Pol B, Kwok C, Pierre-Louis B, et al. Trichomonas vaginalis infection and human immunodeficiency virus acquisition in African women. Journal of Infectious Disease, 197:548–54, 2008.

INTER chapter FOCUS HIV and AIDS

FEATURES

Multicultural Dimensions AIDS Among Asian Americans
Ethical Dimensions Should HIV Testing Be Mandatory for Pregnant Women?
Global Dimensions AIDS in Africa
Gender Dimensions Women and AIDS

CHAPTER OBJECTIVES

1 Describe acquired immunodeficiency syndrome (AIDS), the opportunistic diseases associated with it, and the way in which the human immunodeficiency virus (HIV) invades the body and causes AIDS.
2 Discuss different treatments for HIV infection and AIDS, including how the mortality rate has declined as a result of these treatments.
3 Cite ways in which HIV infection can be prevented.

go.jblearning.com/dimensions5e

Prevention of HIV Infection and AIDS

Global Dimensions: AIDS in Africa

HIV and College Students

Gender Dimensions: Women and AIDS

INTRODUCTION

Tom applied for a graduate assistantship in our department and, because of his impressive academic record and the nature of his experiences, was awarded one. He was a pleasure to have around, always smiling and willing to help in whatever way he could. Because of his personality and his conscientiousness Tom’s graduate assistantship was extended into the next year and several years thereafter.

It was during his fourth year with us that Tom began losing weight and missing some days at school. Attributing it to the flu or a similar condition, no one seemed to take much notice—that is, until Tom started missing even more days and looking emaciated. Before long, the rumor spread that Tom had AIDS and did not have long to live. Unfortunately, the rumor was true and before many more months, Tom died.

With today’s new medications and combination of medications, Tom might be alive today. Or at least he would have lived longer with HIV than he did. Of course, that troubles those of us who knew and cared for Tom. However, other issues are also troubling. Until he told us, we did not even know Tom was gay. He contracted HIV through unprotected sex. Why did he feel the need to hide his identity, and how much torment did that hiding create? More to the point, what did we (the department, the faculty, the university, and the society at large) convey to Tom that led him to conclude we would reject him if we knew about his sexual orientation and HIV status? And how many others are in a situation similar to Tom’s and are in torment as he was?

We hope that this chapter, by presenting information about HIV and AIDS, will help us all become more understanding of those who are wrestling with not only the physical and psychological effects of HIV infection, but also the social consequences.

Acquired Immune Deficiency Syndrome (AIDS)

Acquired immune deficiency syndrome (AIDS), so named because it attacks and slowly destroys the body’s immune system, was first identified by American physicians in mid-1981. At that time, physicians noted the unusual occurrence of five cases of Pneumocystis carinii pneumonia among previously healthy homosexual men in Los Angeles. Soon thereafter, reports surfaced of a rare form of cancer, Kaposi’s sarcoma, also among young homosexual men in New York and California. These observations led to the recognition of AIDS, a disease characterized by opportunistic diseases in an immune-compromised individual. Diseases such as P. carinii pneumonia and Kaposi’s sarcoma are labeled opportunistic because they rarely occur in young healthy individuals, instead relying on the opportunity presented by a depressed immune system. AIDS is considered a syndrome because it is characterized by a range of opportunistic diseases, rather than one particular disease (Table IF4.1).

acquired immune deficiency syndrome (AIDS)

A syndrome caused by the human immunodeficiency virus (HIV), characterized by a depressed immune system and the presence of one or more opportunistic diseases.

opportunistic diseases

A major manifestation of AIDS, diseases that occur in the presence of a suppressed immune system.

Research conducted by Robert Gallo at the National Institutes of Health and by Luc Montagnier and colleagues at the Pasteur Institute in Paris led to the discovery of a new virus believed to cause AIDS. Gallo named the virus human T-lymphotropic virus type III (HTLV-III); Montagnier identified it by the name lymphadenopathy-associated virus (LAV). In May 1986 the International Committee on Taxonomy of Viruses announced its recommendation that the virus be consistently identified by the name human immunodeficiency virus (HIV) (AIDS virus gets new name amid feuding, 1986). Today we know that HIV is the cause of AIDS.

human immunodeficiency virus (HIV)

A retrovirus that causes AIDS.

TABLE IF4.1 AIDS-Defining Conditions*

Cancers

• Invasive cervical cancer
• Kaposi’s sarcoma
• Lymphoma, multiple forms

Fungal Infections

• Candidiasis of bronchi, trachea, esophagus, or lungs
• Cryptococcosis
• Histoplasmosis
• Pneumocystis carinii pneumonia

Protozoan, Spore, and Parasite Infections

• Cryptosporidiosis, chronic intestinal (greater than 1 month’s duration)
• Coccidioidomycosis
• Isosporiasis, chronic intestinal (greater than 1 month’s duration)
• Toxoplasmosis of brain

Viral Infections

• Cytomegalovirus disease (particularly CMV retinitis)
• Herpes simplex: chronic ulcer(s) (greater than 1 month’s duration); or bronchitis, pneumonitis, or esophagitis
• Progressive multifocal leukoencephalopathy

Bacterial Infections

• Mycobacterium avium complex
• Tuberculosis
• Salmonella septicemia, recurrent

Other conditions

• Encephalopathy, HIV-related
• Pneumonia, recurrent
• Wasting syndrome due to HIV

*If someone has HIV and one or more of these opportunistic infections, the person will be diagnosed with AIDS regardless of CD4 count.

Source: Data from Department of Health and Human Services. (2010). Available: http://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/

HIV belongs to a special class of viruses called retro-viruses. Retroviruses consist of a protein shell surrounding the genetic material ribonucleic acid (RNA) (Figure IF4.1). For HIV to attack a human cell, it must first attach itself to a special receptor on the cell’s surface. In humans HIV attaches to CD4 lymphocytes, a type of white blood cell that plays an important role in the immune response to disease. Once attached to the CD4 cell (also called T4), HIV enters the cell and releases its RNA. The RNA is then converted into DNA by an enzyme (reverse transcriptase) also carried by HIV. This HIV DNA combines with the cell’s DNA, causing the cell to reproduce HIV (Figure IF4.2). In essence, HIV converts the cells it attacks into factories producing HIV, which then go on to infect other CD4 cells. As this process progresses, CD4 cells are destroyed and the body becomes unable to defend itself against organisms that would normally be no threat to health. Thus the opportunistic diseases that characterize AIDS infect the individual, usually leading to death.

retroviruses

A group of viruses consisting of ribonucleic acid (RNA) surrounded by a protein coat that can convert their RNA into deoxyribonucleic acid (DNA) once they have invaded a living cell, allowing them to take over the cell and reproduce themselves.

figure IF4.1 HIV consists of an outer shell, or protein envelope, that surrounds a protein core that protects the ribonucleic acid (RNA) and the enzyme reverse transcriptase.

Source: Reproduced from FDA Consumer (October 1987), 10.

figure IF4.2 HIV infection and replication in a human cell. The virus enters the cell and releases RNA, its genetic material. Using the enzyme reverse transcriptase (RT), the virus converts its RNA into deoxyribonucleic acid (DNA), which enters the cell nucleus and combines with the cell DNA. The cell’s altered genetic material then produces messenger RNA (mRNA), which codes for new virus.

Source: Reproduced from FDA Consumer (October 1987), 10.

Incidence of HIV and AIDS

As noted in Table IF4.2, through December 2010, more than 1.1 million adults and adolescents had acquired AIDS in the United States (Centers for Disease Control and Prevention, 2012b). HIV infection disproportionately affects African Americans. Despite representing only 14% of the U.S. population in 2010, African Americans accounted for 46% of all new HIV infections that year. Black men accounted for 70% of the estimated new HIV infections among all blacks, which means that the rate of new HIV infection for black men was more than 7 times as high as that of white men and 2.5 times as high as that of Latino men or black women. Most (88%) black women with HIV acquired HIV through heterosexual sex (Centers for Disease Control and Prevention, 2012b).

TABLE IF4.2 Estimated AIDS Cases by Transmission Category and Sex, 2010 and Cumulative, United States

In the United States, HIV affects different age groups at different rates. In 2010, young people between 15 and 29 years of age accounted for 35% of all new HIV infections, but only accounted for 21% of the U.S. population in 2010. In fact, those aged 20–24 had the highest number and rate of HIV diagnoses of any age group (36.9 new HIV diagnoses per 100,000 people) in 2010 (Centers for Disease Control and Prevention, 2012b).

Although the death rate from HIV infection increased steadily from 6 per 100,000 in 1987 to 17 per 100,000 in 1995, it dropped for the first time to 11.1 per 100,000 in 1996. It has continued to decline ever since (see Figure IF4.3). This drop was primarily a result of new treatments, although education campaigns may have played a part. It is in no small part related to the increased funding for HIV and AIDS research, which increased dramatically over the years.

The global issue of HIV has stabilized in recent years. The annual number of new HIV infections has been declining since the late 1990s, and because of increased access to antiretroviral therapy there are fewer AIDS-related deaths. Although the number of new infections has been decreasing, overall, new infection rates are still high and, with the significant reductions in mortality, the number of people living with HIV in the world has increased (Joint United Nations Programme on HIV/AIDS, 2010).

At the end of 2010, an estimated 34 million individuals were living with HIV infection. Most of these are in sub-Saharan Africa (about 22.9 million), with another 4 million in South and Southeast Asia, 1.5 million in Eastern Europe and Central Asia, 1.5 million in Central and South America, and 200,000 in the Caribbean. In North America, there were approximately 1.3 million people living with HIV in 2010. Worldwide, new infections in 2010 were estimated to be 2.7 million, a decrease from the 3.1 million in 2001. Although this decrease is impressive, it still means that over 7,000 new HIV infections occurred every day in 2010. The number of AIDS-related deaths worldwide remained at 1.8 million in 2010 (the same rate as 2001), but there is great variance between regions. Death rates decreased in most areas, while Eastern Europe, Central Asia, and East Asia experienced an increasing number of HIV-related deaths (Joint United Nations Programme on HIV/AIDS, 2011.)

In contrast to the incidence in the United States, where most of the cases of HIV are the result of same-sex sexual contact among men, the majority of HIV infections in other regions of the world are the result of heterosexual contact.

Transmission

In February 1999, Dr. Beatrice Hahn of the University of Alabama at Birmingham announced that she had tracked HIV’s ancestor to a virus that has long infected Pan troglodytes, a subspecies of African chimpanzees. In an effort to help human HIV patients, researchers are looking into why the monkeys do not appear to become sick from the virus.

HIV is found in large concentrations in two human body fluids: semen and blood. This is related to the large number of white blood cells present in these body fluids. It appears that a concentration of HIV is probably necessary for the transmission of HIV from one individual to another. Thus the most common modes of transmission are those that involve the exchange of semen or blood between individuals. Unprotected penile–vaginal or anal sex with an infected individual is the most common way that infected semen is transmitted. About half of the estimated AIDS cases in the United States involve men who have sex with men (Table IF4.2). While sexual risk—specifically not using a condom during anal sex, and alcohol and drug use that increase this behavior—is the greatest concern, there are other contributing factors. Stigma and homophobia may have a profound impact on the lives of men who have sex with men (MSM) and affect their decision making. Racism, poverty, and lack of access to health care are barriers to HIV prevention services. A CDC study (2012a) found a strong link between socioeconomic status and HIV among MSM: prevalence increased as education and income decreased. In addition, complacency about HIV among young MSM may affect risk-behavior. Given that young MSM did not experience the severity of the early HIV epidemic, some may falsely believe that HIV is no longer a serious health threat because of treatment advances and decreased mortality (Centers for Disease Control and Prevention, 2012a).

figure IF4.3 AIDS diagnoses and deaths of adults and adolescents with AIDS, 1985–2009—United States and dependent areas.

Source: Reproduced from Centers for Disease Control and Prevention. (2012). HIV Surveillance—Epidemiology of HIV Infection (through 2010), Slide 22. Available at: http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm

Multicultural DIMENSIONS: AIDS Among Asian Americans

The incidence of AIDS in the Asian American community is assumed to be small. However, there are problems with this assumption. For example, when Asian Americans are grouped together, diverse ethnic and racial subgroups are ignored. There are 28 Asian subgroups and 20 Pacific Islander subgroups. Chinese and Filipinos make up the two largest Asian subgroups, followed by Japanese, Asian Indians, and Koreans. The result is that certain subgroups actually have a high incidence of HIV infection and others a low incidence. For example, in 2002, 16% of Asian Americans with AIDS were born in the Philippines and 7% in Vietnam, whereas only 2% were born in Cambodia and South Korea, and fewer yet (1%) were born in Laos (Zaidi et al., 2005). Grouping Asian American subgroups together conceals the need for intervention in particular subgroups. In addition, shame often prevents Asian Americans who are infected from revealing that fact to their families and friends, thereby falsely lowering the apparent incidence rate. Furthermore, language barriers sometimes prevent Asian Americans from communicating their HIV status to health providers and authorities who maintain health data.

It is estimated that by the year 2050, the Asian American population will have increased to 8% of the total U.S. population (U.S. Census Bureau, 2008). If this projection is accurate, there will be more than 34 million Asian Americans in the United States by the year 2050. It is time that HIV and AIDS in the Asian American community be studied more systematically and interventions adopted as necessary.

Did You Know . . .

Do mosquitoes transmit HIV? Scientific experiments have shown that HIV does not multiply in insects such as biting flies, mosquitoes, and bedbugs (Centers for Disease Control and Prevention, 2010a). Additionally, it has been noted that the mouths of such insects cannot hold enough blood of one person to be capable of infecting another person. Epidemiological evidence also supports the hypothesis that transmission by insects does not occur.

Of the estimated adult/adolescent AIDS cases in 2010, approximately 30% appear to be related to heterosexual transmission. In the United States, this transmission category includes individuals who reported heterosexual contact with a person known to have, or to be at high risk for, HIV infection. Heterosexual transmission is of particular concern to women—for them, 77% of the 2010 estimated cases were transmitted by heterosexual contact compared to only 14.6% of male cases (Centers for Disease Control and Prevention, 2012b). Many women who become infected with HIV through heterosexual contact have partners who are injecting drug users. Women in this category are not necessarily injecting drug users themselves; they become infected through sexual intercourse with partners who are.

The transmission of HIV related to injecting drug use is also of concern. Through December 2010, injecting drug use was associated with HIV transmission in 13.6% of the estimated AIDS diagnoses. Infection occurs through the sharing of needles contaminated with HIV. Additionally, these injecting drug users can transmit the virus to their sexual partners through penile–vaginal or anal sex and, in the case of female injecting drug users, to their infants prenatally or postnatally.

The efforts of the gay community to garner media attention for the HIV and AIDS crisis brought it to the forefront of the U.S. medical agenda during the 1980s. Because of these efforts, HIV and AIDS research and medical funding garnered a far greater percentage of government spending than it would otherwise have, which resulted in a significant reduction of HIV incidence in the mainstream gay community. Unfortunately, within the gay community, gay men are currently experiencing a resurgence of the HIV and AIDS epidemic. Despite the efforts of both the gay and mainstream communities and tremendous scientific advances in treatments for the virus, this crisis is far from averted.

Between 1979 and mid-1985, HIV transmission through blood transfusions was of great concern to health professionals and the public. In the spring of 1985 an HIV antibody test was approved by the FDA for the purpose of screening blood donations. Antibody tests do an excellent job of protecting the U.S. blood supply from contamination with HIV. There is, however, still a slight risk that the test will miss HIV antibodies (resulting in a false negative test result). Additionally, the test may not detect HIV-infected blood because a person who is infected with HIV may not produce a detectable level of antibodies for up to 3 months after infection. It must be emphasized that this risk is very small. In 1987, the CDC and American Red Cross reported that the risk of contracting HIV through a blood transfusion was 1 in 28,000. Today, more rigorous screening of donors and nucleic acid testing have decreased the risk of contracting HIV through a blood transfusion to 1 in 1.5 million (based on 2007–2008 data) (Zhou et al., 2010). There is no risk of becoming infected with HIV by donating blood.

antibodies

A class of proteins secreted by the immune system that bonds with antigens. Antibodies fight off disease-causing organisms.

The risk of contracting HIV (or other infectious diseases, such as hepatitis B or C) is slightly higher for those receiving an organ donation. Nucleic acid testing (NAT) is often performed for procedures that involve a living donor (such as a kidney transplant). In these cases, it is critical to conduct testing as close as possible to the surgery date to ensure the most accurate results for the recipient. However, there is some debate about the risk and the need for NAT in other circumstances because of a possible loss of donor organs. Evidence suggests a higher false positive rate of NAT when performed under the conditions required for organ donation than reported by the blood donation community, and these organs may then not be used when in reality they represent no risk (Ison & Nalesnik, 2011). The transplant community does not recommend universal prospective screening of organ donors for HIV (or hepatitis C and B) using NAT, but the Centers for Disease Control and Prevention does encourage the use of these tests (Humar et al., 2010; Kuehnert, 2011).

AIDS and the Gay Community

Originally, AIDS was discovered in gay men. Of course, it was soon realized that risky behavior is associated with HIV infection, not one’s sexual identity or one’s country of origin. (For example, Haitians were targeted with discriminatory immigration regulations because of the relatively high incidence of AIDS in Haiti.) However, given the high incidence of HIV infection among men who have sex with men, much effort has been made to educate gay and bisexual men about safer sex practices. Unfortunately, MSM are still disproportionately affected and infected by HIV. While MSM account for 2% of the population, they accounted for 61% of the estimated new HIV infections in 2010 (Centers for Disease Control and Prevention, 2012b).

Not to be overlooked is the effect of the lobbying efforts by the gay community—males and females—for increased funding for AIDS research and more rapid approval of drugs with the potential for treating HIV infection and AIDS. As more and more people, including celebrities (for example, Rock Hudson, Keith Haring, Freddy Mercury, and Greg Louganis) contracted HIV, the alarm was sounded throughout the gay community and beyond. That alarm led the way to successful local and national lobbying efforts. When compared to that for other diseases, funding for AIDS research far exceeds its ranking in terms of deaths or incidence, a direct result of the gay community’s involvement. Imagine what the status of treatment for HIV and AIDS would be today—not to mention the advancements on the horizon—without the gay community’s efforts.

Stages of HIV Infection

Once an individual is infected with HIV, the natural course of the infection progresses in three stages. The first stage is silent infection. This stage is an asymptomatic period during which the only evidence of infection is the presence of HIV antibodies. The development of antibodies takes at least 2 weeks, and it is often 6 to 8 weeks before antibody levels are high enough to be detected by antibody tests.

silent infection

A stage of HIV infection characterized by no symptoms other than the presence of HIV antibodies.

Some infected individuals (it is not known how many) progress to the second stage of infection—symptomatic infection. This stage consists of several general signs and symptoms, the most prominent of which is persistent swelling of the lymph glands, especially in the neck, armpits, and back of the mouth. Other common signs include fatigue, unexplained weight loss, night sweats, persistent fever, and diarrhea. Many infected individuals have no signs or symptoms.

symptomatic infection

The second stage of HIV infection, characterized by HIV antibodies as well as general signs and symptoms such as swollen lymph glands, fatigue, unexplained weight loss, night sweats, persistent fever, and diarrhea.

AIDS is the final stage of HIV infection. People at this stage have badly damaged immune systems. In order for a person to be diagnosed with AIDS, they must have either a CD4 count below 200 cells/mm3 or have one of the opportunistic infections listed in Table IF4.1. A normal CD4 count can range from 500 cells/mm3 to 1,000 cells/mm3. Figure IF4.4 shows the 2010 AIDS diagnosis rates for the states and dependent areas of United States.

Although AIDS is classified as a terminal disease, people now live with AIDS for a long time. Newer medication regimens, accompanied by an enthusiastic research agenda, lead some to conclude that AIDS will be considered a chronic disease (like hypertension and diabetes) that can be controlled, if not eradicated.

Testing for HIV

Several types of HIV tests are available. Traditional testing looks for HIV antibodies in either blood, fluid from the cheek, or urine. The most common screening test is called the EIA (enzyme immunoassay), which identifies the presence of HIV antibodies. If antibodies are present, the person is said to be seropositive. If no antibodies are present, the person is said to be seronegative. However, even though the test results show that HIV antibodies are present, they may be “false positive.” Therefore, once the ELISA finding is positive, a more sensitive, and more expensive, test is administered, the Western blot. If the Western blot result confirms the presence of HIV antibodies, the person can be assured that he or she is infected.

seropositive

The result of a blood test for antibodies to HIV that indicates that such antibodies have been found in the blood.

seronegative

The result of a blood test for antibodies to HIV that indicates no presence of such antibodies.

Some EIA tests use oral fluids and urine to test for HIV antibodies. These oral-fluid tests require a person to place a flat inch-long cotton swab attached to a stick between the gum and cheek for 2 minutes. The swab draws fluid from the mucous membrane, which contains HIV antibodies if the person is infected. This test does not use saliva. A follow-up confirmatory Western blot uses the same oral-fluid sample.

figure IF4.4 Rates of AIDS diagnoses, 2010—United States and dependent areas.

Source: Reproduced from Centers for Disease Control and Prevention. (2012). HIV Surveillance—Epidemiology of HIV Infection (through 2010), Slide 29. Available: http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm.

The sensitivity and accuracy of urine tests for HIV antibodies are less than that of the blood and oral-fluid tests. This EIA antibody test also requires a follow-up confirmatory Western Blot using the same urine sample.

Rapid tests are also available; these are screening procedures that produce results in about 20 minutes. Rapid tests use blood (often from a fingerstick), or oral fluid to look for the presence of antibodies to HIV. As is true for all screening tests, a reactive rapid HIV test result must be confirmed with a follow-up confirmatory test before a final diagnosis of infection is made. These tests have similar accuracy rates as traditional EIA screening tests.

Until 1996, the only way to get tested for HIV was to be tested at a clinic. In 1997, the first home collection kit was approved by the Food and Drug Administration. Today, only two HIV home collection kits are approved and sold legally in the United States (Home Access HIV-1 Test System and Ora-Quick In-Home HIV Test). Although others may advertise and be sold on the Internet, their accuracy cannot be verified. The Home Access kit allows an individual to take a blood sample and send the sample to a laboratory for testing. In July 2012, the Food and Drug Administration approved the first rapid in-home HIV test, OraQuick In-Home HIV Test. The kit tests oral fluid and provides results in 20–40 minutes; there is no need to mail anything. It is approved for sale to individuals 17 years and older. Studies have shown the test to be highly accurate for people who do not have the virus (only 1 false positive result will occur for every 5,000 tests in uninfected individuals). However, the accuracy of this testing mechanism with untrained individuals is lower for individuals who are infected with HIV. There will be 1 false negative result out of every 12 tests performed in HIV-infected individuals (U.S. Food and Drug Administration, 2012b). With both of these tests, a follow-up confirmatory test is needed for any positive results (Centers for Disease Control and Prevention, n.d.).

It should be noted that all of these tests do not directly test for the presence of HIV. Rather, they test for the presence of antibodies produced in response to HIV infection. Thus it is possible that the infection has not yet produced sufficient antibodies to be measured even though the person being tested is infected with HIV. If it is too early for the antibodies to be present in sufficient numbers to be measured, the person can transmit the virus nevertheless.

figure IF4.5 Partner notification programs can be highly productive, as illustrated by results of a South Carolina investigation that began with one HIV-positive man. Of the 19 sexual contacts he named, all but one were tested, and three were seropositive. Those three then named 20 sexual contacts not already identified, leading to the discovery of two more HIV-positive men, who in turn named 24 other previously unidentified contacts, and so forth. When the investigation reached its end point of no new HIV-positive contacts, it had identified a total of 90 persons at risk, tested 68 of them, and found 12 who either were seropositive or seroconverted 6 months after initial testing.

In addition to the tests that detect HIV antibodies, RNA tests are available that look for genetic material of the virus. These tests are used in screening the blood supply and for detection of very early infection cases when antibody tests are unable to detect antibodies to HIV. Because of their high cost, these tests are not commonly used in screening for HIV infection in the United States.

An individual who receives a positive HIV test finding should be given medical and psychological counseling as well as education intended to prevent HIV transmission to others. Additionally, it is important at this time to initiate the process of partner notification. Because treatment for HIV is often more successful when initiated early, informing previous partners of their possible infection can potentially help them manage their infection better and also prevent them from unknowingly spreading the infection to others (Figure IF4.5). However, an HIV-infected person may not feel capable of contacting sexual or needle-sharing partners. Many state and local health departments will notify partners without disclosing the name of the infected individual. In fact, some public health programs are utilizing the Internet and other electronic mediums to facilitate this process (National Coalition of STD Directors, 2008).

Treatment of HIV and AIDS

In 1987 the FDA approved zidovudine (brand name Retrovir; formerly azidothymidine [AZT]) as the first drug licensed in the United States for the treatment of AIDS patients. Zidovudine is an antiviral drug that slows the replication of HIV in human cells. Studies indicate that zidovudine not only slows the progression of HIV infection when given in early stages, but also prolongs survival and decreases the incidence and severity of opportunistic infections in people living with AIDS.

zidovudine

The first drug (brand name Retrovir; also known as AZT) approved by the FDA for the treatment of AIDS. This antiviral drug slows the replication of the AIDS virus, thus slowing the course of the syndrome.

While somewhat effective by itself, zidovudine is no longer the only antiviral medication to combat HIV infection. There are now six classes of antiretroviral drug therapies (U.S. Department of Health and Human Services, 2011):

1. Nucleoside/nucleotide reverse transcriptase inhibitors (for example zidovudine, didanosine, and stavudine): These drugs block the action of reverse transcriptase, thereby preventing HIV RNA from reproducing.
2. Protease inhibitors (for example, indinavir, nelfinavir, ritonavir, and saquinavir): These drugs shut down HIV replication by preventing the viral enzyme protease from cutting other viral protein into shorter pieces needed by HIV to make new viral copies for infecting new CD4 cells.

Ethical DIMENSIONS: Should HIV Testing Be Mandatory for Pregnant Women?

If pregnant women are infected with HIV, they can pass on that infection to their babies in utero. Yet, there is a simple way to prevent many of these babies from being born infected. If a pregnant woman receives anti-retroviral medications, has an elective cesarean section at 38 weeks of pregnancy, and avoids breastfeeding, the risk of perinatal transmission of HIV drops from 15–25% to less than 2%. For this reason, many physicians and legislators advocate that pregnant women be required to be tested for HIV as part of their routine prenatal care. In that way, the danger to the fetus is identified, and treatment can be administered to the women whose fetuses are at risk.

However, this issue is more complicated than it appears at first glance. For example, if women are required to be HIV tested during prenatal care, many may forgo prenatal care to avoid the test and its possible repercussions. These repercussions may include losing one’s job, one’s housing, or one’s partner. In addition, a woman who lives in a rural area may not be able to find a physician willing to manage her pregnancy and help in the delivery of her child. Avoiding prenatal care places the fetus at risk of being born at low birth weight and/or with a variety of birth defects. Opponents of mandatory testing point out that no other segment of society is required to be HIV tested. Therefore, to require this of pregnant women is to discriminate against these women. There is no disagreement that pregnant women ought to be counseled about the risks and benefits of being tested and that there is a treatment to help prevent their babies from being born infected with HIV even if the mother is infected. But, the choice to be tested for HIV should be the woman’s.

Proponents of mandatory HIV testing for pregnant women argue that counseling alone will not persuade enough women to be tested. Too many would choose to avoid testing, and the result would be that too many babies would be born with HIV. To protect the babies, they maintain, women should be required to be tested and their HIV status determined. Only then can pregnant women infected with HIV be administered effective medication, thereby indirectly treating their fetuses. In addition, women who test positive for HIV can be educated about the risk of breastfeeding, another means through which HIV can be transmitted to their babies.

Should the privacy of the mother be protected, or is her privacy less important than the benefits to the fetus? This is not only a policy issue, but also an ethical issue. On which side of this argument do you find yourself?

3. Nonnucleoside reverse transcriptase inhibitors (for example, delavirdine and nevirapine): These drugs block the reverse transcriptase directly.
4. Fusion inhibitors (for example, enfuvirtide): These drugs block HIV from fusing with the CD4 cell.
5. Integrase strand transfer inhibitors (for example, raltegravir): These drugs disable integrase, a protein the HIV uses to insert its viral genetic material into the generic material of an infected cell.
6. CCR5 antagonists (for example, maraviroc): These types of drug block the entry of HIV into the cells.

In addition to the six classes of antiviral medications, some medications are a combination of two or more anti-HIV drugs from one or more classes of drugs. These medications reduce the number of pills an HIV-infected individual needs to take. Whether taken individually or as a combination pill, the therapy used is called combination therapy, or the AIDS cocktail. Combination therapy makes sense because it attacks the virus at different steps in the life cycle rather than at one step.

Studies have reported that combination therapy significantly improves the immune system and its ability to fight off infections, which has resulted in a dramatic decrease in opportunistic infections and deaths in both adults and children (Department of Health and Human Services, 2011; Gona et al., 2006; Nesheim et al., 2007).

Early diagnosis is important so individuals can utilize medications that prevent HIV from destroying the immune system. Previously, treatment started when the CD4 count fell to 350 cells/mm3 or because opportunistic infections began. However, research has shown that it may be easier to maintain higher CD4 counts if HIV treatment is started before the CD4 counts drops that low. Current guidelines recommend antiretroviral treatment if the CD4 count is less than 500 cells/mm3. Some experts also recommend that HIV-infected individuals with CD4 counts above 500 cells/mm3 start therapy, while others consider this optional (Department of Health and Human Services, 2011).

Although these medications allow many HIV-infected individuals to live longer and have fewer complications, there are limitations. Some individuals do not tolerate certain drugs well, and the body can develop resistance to some medications, thus new regimens and medication adjustments are often a component of treatment. In addition, toxicity from the medications can affect other body functions.

From a practical standpoint, many of the drugs are expensive. In 2011, the average cost of medications ranged from $300 to $400 per month for some medications to over $3,000 per month for a fusion inhibitor (Berry, 2011b). The total costs for a year average about $20,000 (Gebo et al., 2010). For HIV-infected individuals with low incomes, government assistance may be available through Medicaid and Medicare. In addition, AIDS Drugs Assistance Programs (ADAP), federal- and state-funded programs, provide medication to about one-third of all individuals in the United States receiving HIV treatment (Berry, 2011a). Unfortunately, many states have waiting lists for these programs, and some individuals do not meet program guidelines. In those cases, many pharmaceutical companies also offer co-pay and patient assistance programs to HIV-infected individuals not eligible or not enrolled in other programs (Berry, 2011a). In spite of these programs, the process of obtaining medications and concern about payment for medications can still be challenging for many HIV-infected individuals in the United States. Individuals in other countries often must rely on government programs or pharmaceutical assistance programs for medication. While usage rates of anti-retroviral medication are increasing, less than half (47%) of those eligible in middle- and low-income countries (an estimated 14.2 million people) were receiving treatment at the end of 2010 (Joint United Nations Programme on HIV/AIDS, 2011).

Prevention of HIV Infection and AIDS

While no cure or vaccine for HIV is currently available, there are both medications and nonmedical strategies for prevention. First, let’s review progress towards a vaccine.

HIV Vaccine

At this time, a vaccine for HIV is not available. Historically, vaccines have virtually eliminated spread of infectious diseases such as smallpox, polio, and measles. Because of the success in controlling these other infections, many believe that an HIV vaccine represents the best long-term strategy for ending the HIV pandemic. However, HIV is different from other infectious diseases; the immune system of the human body does not seem capable of effectively preventing the virus from progressing to disease. The most recent vaccine trials have shown moderate success. The “Thai study” tested two different vaccines together, ALVAC-HIV and AIDSVAX, in a primarily low- or moderate-risk group and showed a short-term protective effect against HIV in about one-third of study participants; however, other analyses were not deemed significant (Rerks-Ngarm et al., 2009). Most researchers consider the study’s success to be limited. However, given the lack of positive movement toward a vaccine, it provides hope and some direction for future studies. For example, in 2011 another vaccine trial with MSM (at that time the largest ongoing study) increased its participant pool in order to look for the protective changes seen in the Thai study whereas previously the study’s primary goal was to determine if the vaccine regimen decreased viral amounts in vaccine recipients who later become infected with HIV (National Institutes of Allergy and Infectious Medicine, 2011).

People with HIV must cope not only with the knowledge of their illness but also with society’s fear of HIV. Support groups offer emotional support and firsthand advice on coping with the illness.

Pre-Exposure Prophylaxis

While the vaccine efforts have not been successful, studies have demonstrated that the use of antiviral medication before exposure can reduce the risk of becoming infected with HIV. Pre-exposure prophylaxis (PrEP), the daily use of a combined pill of emtricitabine and tenofovir (brand name Truvada) has been shown to decrease the risk of HIV infection in high-risk individuals. Studies have specifically looked at MSM in six different countries (on four continents) and heterosexual men and women in African countries with high rates of HIV. In the MSM study, by taking the pill once a day the risk of HIV infection was reduced by 43.8% on average among men and transgender women who have sex with men and by 72.8% among those with 90% self-reported treatment adherence (Grant et al., 2010). In the heterosexual studies, daily oral doses of Truvada reduced risk 62.6% in one study and 73% in another (Centers for Disease Control and Prevention, 2011a). Daily use of Truvada does have side effects such as nausea, vomiting, and dizziness, but for those truly at risk of HIV because of high-risk sexual practices or because of having an HIV-infected partner, the benefit would likely outweigh those risks. In July 2012, the U.S. Food and Drug Administration approved Truvada as a preventive strategy for healthy people at high risk for acquiring HIV (U.S. Food and Drug Administration, 2012a).

Other Prevention Strategies

In addition to these methods, the best strategy to reduce risk is to refrain from oral, anal, or penile–vaginal sex with an HIV-infected partner and to abstain from sharing needles. This is an important message of HIV and AIDS education efforts—especially for adolescents and young adults who are in a developmental stage at which sexual and drug experimentation is common. Today such experimentation carries the risk of HIV and AIDS.

Abstaining from sexual activity throughout one’s life is impractical and undesirable for most people. For those who are uninfected and sexually active, maintaining a mutually faithful monogamous relationship with an uninfected partner prevents the sexual transmission of HIV. Each partner would also need to abstain from sharing needles during drug or steroid use, another high-risk behavior for HIV transmission.

In November 1991, the basketball star Magic Johnson announced that he had acquired HIV infection through unprotected sexual intercourse with an unknown infected woman. Johnson provides living proof of the effectiveness of the AIDS cocktail: The level of HIV in his body has been reduced to an undetectable level.

Did You Know . . .

Approximately 2.7 million new infections of HIV occurred in 2010, according to the UNAIDS. Of those new infections, 390,000 occurred in children younger than 15 years of age. Furthermore, in 2010 1.8 million deaths occurred worldwide as a result of AIDS. The UNAIDS estimates that an additional 2.5 million deaths have been averted in low- and middle-income countries since 1995 due to antiretroviral therapy being introduced.

Many people have previously engaged in behaviors that put them “at high risk” of being infected with HIV. People should be considered at risk if they have shared needles or syringes to inject drugs or steroids; are male and have had anal sex (even once) with another male; have had sex with someone they believe may have been infected with HIV; have had another STI; received blood transfusions or blood products between 1978 and 1985; or have had sex with someone who has any of these risk characteristics. In addition, the more sexual partners a person has had, the greater the chances that person will have had contact with an HIV-infected person. The former basketball player Magic Johnson brought this point home to many people when he announced to the world that he was infected with HIV from unprotected sexual intercourse with a woman he could not identify because of his numerous sexual partners over the years. It is important to remember, however, that unprotected sexual intercourse with just one person is risky if that person is infected with HIV.

If an individual decides to engage in sexual activity with a person who is at risk for or is infected with HIV, public health authorities recommend that a condom be used during oral sex on a male, penile–vaginal sex, and anal sex and that latex barriers be used during oral sex on a female. Latex condoms have been shown to be a highly effective barrier to HIV (Centers for Disease Control and Prevention, 2011b).

Yet, even with all the educational efforts and mass attention directed at the issue of condoms and safer sex, studies indicate that many people do not consistently use condoms during penile–vaginal sex. At the time of publication, the largest nationally representative study of sexual and sexual-health behaviors in the United States ever conducted showed that only 1 of 4 acts of vaginal intercourse are condom protected, with a 1 in 3 rate among single people (Sanders et al., 2010). Rates of unprotected anal sex in MSM remain high. Sometimes MSM engage in serosorting—the practice of trying to limit unprotected anal sex to partners with the same HIV status. However, this is not recommended as a safer sex practice, because many MSM are unaware of their HIV-infection status, assumptions about HIV status may not be accurate, some HIV-infected people may not tell their HIV status, and there is still risk for other STIs. For MSM, the most effective way to prevent HIV and other STIs is to avoid anal sex, or when engaging in anal sex, to always use condoms (Centers for Disease Control and Prevention, 2011f). Even if both partners are HIV-infected, engaging in unprotected anal sex poses risk. One individual could be infected with a drug-resistant strain of HIV and transmit that to his partner.

Regarding condom use among adolescents, a 2006–2010 study (Martinez, Copen, & Abma, 2011) showed that 68% of U.S. adolescent females used condoms during their first act of penile–vaginal sex, with less than half (49%) reporting consistent subsequent condom use. The rate for condom use among first time penile–vaginal sex for males was 8 in 10, and consistent condom use among male adolescents was higher than use by females (68%). All of these rates have increased since 2002 (the last time this study was conducted). There were also ethnic differences; black adolescents report the highest rates of consistent condom use, followed by white teens and then Hispanic teens.

Other safer sex strategies are also recommended. If an individual or a sexual partner is at risk for HIV infection, he or she should avoid mouth contact with the penis, vagina, or rectum. Sex with prostitutes should also be avoided, because both male and female prostitutes are often injecting drug users. The possibility of prostitutes having sexual intercourse with high-risk individuals is also great.

Because the current antibody tests for HIV are not 100% accurate, those who are at high risk of HIV infection and those who are known to be infected are asked not to donate blood. Women infected with HIV should strongly consider using birth control to prevent pregnancy, as HIV can be transmitted to the unborn child (see the Ethical Dimensions box on page 643).

Screening tests for HIV are an important preventive tool as an estimated 20% of HIV-infected individuals do not know their status (Centers for Disease Control and Prevention, 2011e). Current recommendations state that healthcare providers screen for HIV in all patients ages 13–64 unless the patient declines the test. The objective is for all individuals to be screened at least once in their life. Individuals at high risk for HIV infection should be screened at least once a year. In addition, HIV testing is recommended for all pregnant women and for any newborn whose mother’s HIV status is unknown (Branson et al., 2006). The recommendations include an opt-out standard, meaning that once a patient has been told about the test consent is inferred unless specifically declined. While providers may take this opportunity to counsel about prevention and risky behaviors, counseling is no longer required, because it was seen as a barrier to testing for some individuals. Even for those whose results do not show HIV infection, the testing process can provide a valuable “teachable moment.”

HIV infection is determined by a blood test that looks for antibodies produced in response to HIV. Testing may be accompanied by counseling and education to interpret the results and to discuss ways to prevent infection, or to seek treatment if the test is positive.

Of course, among the ways to prevent the spread of HIV are for those who are infected to let their sexual partners know about their HIV status and to take all the necessary precautions to prevent transmission. Unfortunately, many people do not disclose their status to their partners. Overall rates of disclosure are hard to determine, and study results vary, especially between countries (Arnold et al., 2008; Obermeyer, Baijal, & Pegurri, 2011). A review of U.S. studies showed that 56–81% of individuals disclosed their HIV status to sexual partners, but that rate changed significantly for steady partners (74%) compared to casual partners (25%) (Obermeyer et al., 2011). Given that disclosure can lead to stigmatization and other consequences, it is understandable—though not acceptable—that some HIV infected individuals refrain from informing partners or potential partners. All individuals deserve the right to make informed decisions about the risk of their sexual activities and disclosing an HIV infection, or any other type of chronic STI, allows others that opportunity.

HIV and Young Adults

HIV and AIDS are of particular concern for young adults who have a lot of years left to live. Unfortunately, the HIV infection and AIDS rates for young adults is a growing problem. In 2010, young people aged 13–29 accounted for 35% of all new HIV infections (Centers for Disease Control and Prevention, 2012b). This risk is especially notable for gay, bisexual men, and other MSM and all youth of under-served races and ethnicities. A variety of factors place youth at increased risk, including sexual risk, substance use, and lack of awareness.

Early age at sexual initiation, unprotected sex, and older sex partners are all potential risks for HIV. According to the CDC’s 2011 Youth Risk Behavior Survey (YRBS), 47.4% of high school students have had sexual intercourse (YRBS does not specify type of sex), and 6.2% reported first sexual intercourse before the age of 13. Of the 33.7% of students reporting sex during the 3 months before the survey, 39.8% did not use a condom (Centers for Disease Control and Prevention, 2012d). Young people with older sex partners may be at increased risk for HIV because of pressure to not use condoms. CDC data have shown that young gay, bisexual, and other MSM, especially young African American and young Latino MSM, have high rates of new HIV infections. These individuals are less likely to be aware of their HIV infection, and many (approximately 80%) have not received effective HIV interventions or prevention education in the past year. Isolation and lack of support may increase the likelihood of other risk factors, such as risky sexual behaviors (Centers for Disease Control and Prevention, 2011d).

The remarkable AIDS quilt is made up of more than 45,000 panels, each representing a life lost to AIDS. It was created both as a living memorial for those who died and as a brilliant way to help the public visualize the growing toll that AIDS was taking.

Young people in the United States use alcohol, tobacco, and other drugs at high rates. The CDC’s 2011 YRBS found that 21.9% of high school students had consumed five or more drinks of alcohol in a row on at least 1 day during the 30 days before the survey, and 23.1% had used marijuana at least one time during the 30 days before the survey (Centers for Disease Control and Prevention, 2012d). Both casual and chronic substance users are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol. Runaways, homeless young people, and young persons who have become dependent on drugs are at high risk for HIV infection if they exchange sex for drugs, money, or shelter. There is also a lack of awareness regarding the severity of HIV infection. Research has shown that a large proportion of young people are not concerned about becoming infected with HIV. This lack of awareness can translate into not taking measures that could protect their health (Centers for Disease Control and Prevention, 2011d).

While rates of high-risk sexual behavior among youth have declined from the early 1990s, this decline has stabilized with no significant changes since the early part of the 21st century. For example, although the percentage of students overall who had ever had engaged in sex decreased significantly from 54.1% in 1991 to 47.4% in 2011, the prevalence did not change significantly after 2001 (with a rate of 45.6%). Likewise, the percentage of students who had 4 or more sex partners decreased significantly from 18.7% in 1991 to 14.2% in 2001, but there have been no significant changes since then (including the 2011 rate of 15.3%). Condom use at most recent intercourse follows a similar pattern with a significant increase from the 1991 rate of 46.2% to 63.0% in 2003, but no significant changes since then, including the 2011 rate of 60.2% (Centers for Disease Control and Prevention, 2012c).

Global DIMENSIONS: AIDS in Africa

In some areas of Africa, 25% of the population—1 of every 4 people—is infected with HIV. The United Nations reported that at the end of 2010 more than 34 million individuals were HIV-infected and that 68% of those (an estimated 22.9 million) were living in sub-Saharan Africa. Given that this area comprises only 12% of the world’s population, the overall effect is devastating (Joint United Nations Programme on HIV/AIDS, 2011).

On the continent, rates of HIV and AIDS range widely between countries. South Africa’s epidemic remains the largest in the world, with approximately 5.6 million people living with HIV. Swaziland has the highest adult HIV prevalence in the world at 25.9%. In contrast, the HIV prevalence in West and Central Africa remains comparatively low, with the adult HIV prevalence estimated at 2% or under in 12 countries in 2009.

Although the largest epidemics in sub-Saharan Africa (for example, those in Ethiopia, Nigeria, South Africa, Zambia, and Zimbabwe) have either stabilized or are showing signs of decline, the number of deaths in this area is still high, accounting for 72% (1.3 million) of the total HIV-related deaths in 2009. The increasing availability of antiretroviral treatment has had a profound effect; at the end of 2009, 37% of adults and children eligible for antiretroviral therapy in the region were receiving it, compared with only 2% seven years earlier. However, most people receiving antiretroviral therapy in sub-Saharan Africa start treatment late, which limits the overall impact. In addition, the infrastructure, systems, and staff required to properly monitor treatment retention and loss are becoming increasingly inadequate as the number of people receiving medication increases (Joint United Nations Programme on HIV/AIDS, 2010).

In sub-Saharan Africa, women are disproportionately affected. It is estimated that 40% of all HIV-infected women live in sub-Saharan Africa (Joint United Nations Programme on HIV/AIDS, 2010), which can also affect rates among children. For example, approximately 30% of pregnant women in South Africa are infected with HIV (Health Systems Trust, 2011), and the national transmission rate of HIV from mother to child is approximately 11% (Republic of South Africa, 2010). Not only is the child at risk of contracting the virus prenatally, with the mother (and possibly father) being HIV-infected it is highly likely the child is being born into a family that has already experienced other negative effects of HIV on health, income, productivity, and the ability to care for each other. In South Africa, there are an estimated 1.9 million AIDS orphans, with one or both parents deceased (Joint United Nations Programme on HIV/AIDS, 2010). The HIV/AIDS epidemic is estimated to be responsible for half of the country’s orphans (Government of South Africa, 2007) and approximately 70% of the maternal orphans—those who have lost their mother (Budlender et al., 2008).

Theoretically, the rates of HIV infection and death from AIDS should continue to drop as long as there is continued and increased access to antiretroviral medication for those infected or as pre-exposure prophylaxis (PrEP) therapy for those at risk. However, the impact on the family and society of these nations cannot be underestimated.

HIV and College Students

Like adolescents, college students often have the perception that they are not at risk for HIV or other STIs. In reality, some college students are engaging in high-risk behaviors. American College Health Association–National College Health Assessment data from Spring 2011 revealed that 12.4% of male college students and 7.9% of female college students reported having four or more partners in the previous 12 months. For behaviors in the last 30 days, about half of students report engaging in oral (44.9%) or vaginal sex (49.7%) and 5% report engaging in anal sex. Of those engaging in specific behaviors in the previous 30 days, only 5.4% used a condom or latex barrier mostly or always for oral sex, only 51.8% used a condom mostly or always for vaginal sex, and only 31.4% used a condom mostly or always during anal sex. Likewise 16.5% reported having unprotected sex because of alcohol use within the last 12 months (American College Health Association, 2011).

Even more concerning is that individuals who are using condoms may not be doing so correctly. Research has revealed a variety of common condom use errors among adolescents and college students, including inaccurate steps, such as putting the condom on after sex has already started or removing the condom before ending sex; not leaving space at the tip; and placing the condom upside down on the penis and flipping it over (for example Brown et al., 2008; Crosby et al., 2008; Yarber et al., 2007). Error rates vary, with the highest showing that 93.8% of the adults surveyed reported at least one of nine errors assessed (Topping et al., 2011).

As evidenced by these statistics, too many males and females still engage in unhealthy sexual practices that place them at risk of contracting an STI or becoming infected with HIV. Are college students, who are the most educated people in our society, ready to engage in safer sex? A study of 376 university students concluded that they are not (Dahl, Gorn, & Weinberg, 1997). With the rationale that carrying condoms is the one way to ensure that a condom is available when needed, researchers surveyed college students regarding their likelihood of carrying a condom in different situations (a bar, a concert, a party, and a first date). Part of the study involved the researchers interviewing 346 students (137 females and 209 males) at a university bar known for “fun, cheap beer and ... sex.” They offered a five-dollar food coupon for every condom each student possessed. Only 16 students were carrying a condom (less than 5%). What do you think the results of this study would be if conducted today at a bar near your campus?

Bill and Melinda Gates have established a foundation that has donated millions of dollars to combat HIV infection and AIDS, especially on the African continent.

Why do students not use condoms during sexual activities? A variety of reasons for not using condoms have been identified; these include the belief that condoms reduce pleasure; that their partner would not approve of condom use; that condoms are not commonly used in their social group; that condoms are embarrassing, hard to discuss, and hard to use; that condoms cause a loss of erection; and that they do not have a condom when sex happens. In addition to these factors, other studies have shown that college students who did not use condoms had high perceptions of invulnerability and low perception of risk associated with their sexual behavior (Thompson et al., 2006). These students also believed they had the ability to identify a partner’s HIV status.

Gender DIMENSIONS: Women and AIDS

AIDS was originally identified as a disease affecting gay men. However, the face of AIDS has changed. Certainly, gay men are still the largest category of those infected with HIV in the United States. Of the new infections in 2010 in the United States, about 21% were among women (Centers for Disease Control and Prevention, 2012b). The global view of HIV is very different; half of all HIV-infected people in the world are women, and more women than men are affected in sub-Saharan Africa (59% of all people living with HIV in that region) and the Caribbean (53%) (Joint United Nations Programme on HIV/AIDS, 2011).

However, in the United States, women need to be aware of their risk. Of the new HIV infections in women in 2010, almost two-thirds (63.5%) occurred in black women. In fact, in 2010 the rate of new HIV infections among black women was almost 20 times that of white women, and more than 4 times the rate among Hispanic/Latina women (Centers for Disease Control and Prevention, 2012b). The lifetime risks show a disproportionate effect on black and Hispanic women. Overall, 1 in 139 women will be diagnosed with HIV infection, but the rate for black women is 1 in 32. The rate is 1 in 106 for Hispanic/Latina women, 1 in 182 Native Hawaiian/other Pacific Islander women, 1 in 217 American Indian/Alaska Native women, and 1 in 526 for both white and Asian women (Centers for Disease Control and Prevention, 2011c).

Women of color are more likely to contract HIV from a male sexual partner who is infected. Many of these women are also caring for children, which may complicate their treatment. Studies have shown that women infected with HIV are less likely to receive combination therapy and fare more poorly on other access measures than men, often because they have lower incomes, lack transportation, or are too sick to go to the doctor (Kaiser Family Foundation, 2011).

Instituting support groups and community educational campaigns, putting health providers in the community through health clinics and walking of the neighborhoods, and using community health workers to encourage women to seek treatment are ways we can respond to the problem of women and AIDS in the United States.

With so much at stake in terms of one’s health, why do the factors cited seem so insurmountable to many college students and young adults?

Summary

• Acquired immune deficiency syndrome (AIDS) attacks and slowly destroys the immune system, resulting in the development of opportunistic infections such as pneumonia and cancer.
• AIDS is caused by the human immunodefciency virus (HIV), which is transmitted through the transfer of bodily fluids such as semen, vaginal secretions, and blood. HIV infection is contracted primarily through sexual contact such as penile–vaginal sex, oral sex, or anal sex.
• Although AIDS is still considered a terminal illness, the death rate from this cause has steadily declined since 1996. This decline is predominantly due to new medications that seek to transform AIDS into a manageable chronic illness.
• In the United States most AIDS cases occur among men who have sex with men, although the number of women developing AIDS has increased in recent years. Today, over three-quarters of women who contract HIV infection do so through sexual activity with men.
• There are several tests available to diagnose HIV infection and the eventual development of AIDS. Some screening tests employ blood analysis, whereas others test cheek fluid samples. Two home testing kits have been approved by the FDA for the diagnosis of HIV infection.
• AIDS is treated with one of six classes of antiviral medications: nucleoside reverse transcriptase inhibitors, protease inhibitors, non-nucleoside reverse transcriptase inhibitors, fusion inhibitors, integrase inhibitors, and CCR5 antagonists. Each works on a different aspect of HIV infection, such as preventing HIV from reproducing or preventing HIV from invading the cells.
• Among the safer-sex behaviors to prevent HIV infection are remaining sexually abstinent, being in a sexually monogamous relationship, using a condom or dental dam, and avoiding high-risk behaviors such as anal intercourse.
• College students are particularly vulnerable to HIV infection owing to their relatively frequent sexual activity, their feelings of invulnerability, and the fact that they frequently engage in sexual activities without using a condom.

Discussion Questions

Explain the ways HIV is transmitted, the stages of infection, the tests for infection, and how opportunistic diseases occur as a result of AIDS.

Which treatments are available for HIV infection? What limits their worldwide availability?

List the safer-sex practices that reduce the risk of HIV transmission.

Application Questions

Reread the chapter-opening story and answer the following questions.

On June 25, 1998, the Supreme Court ruled that HIV-infected people are protected by a federal ban on discrimination against the disabled—even if they suffer no symptoms of AIDS. If that ruling had been made when Tim was diagnosed with HIV, do you think he might have been more willing to disclose his condition? Why or why not?

Regardless of the law, if you were a professor considering granting a graduate assistantship to a student (or an employer making a hiring decision), would the knowledge that the candidate was infected with HIV make a difference? How about if the person were being treated for cancer? Or heart disease? Why should such information make a difference?

How would you feel if you knew a fellow classmate or employee were HIV infected?

Critical Thinking Questions

Is it fair that the federal government spends a disproportionate share of medical research money on HIV research? Put another way, should federal research money be spent in proportion to the number of people who contract an illness and die of it (such as cancer or heart disease)? Or should the potential threat of a disease becoming more widespread take precedence?

You may remember this gender-related issue from another chapter: Men who carry condoms are considered to be “responsible,” but women who carry condoms are considered “sluts.” Given the need for more condom use to prevent the spread of STIs and HIV, how can this double standard be overcome?

Critical Thinking Cases

Deciding whether to disclose HIV infection is clearly a troubling decision for anyone to make. But do people have an obligation to disclose that information to protect others?

Consider the case of the two-time double-Olympic diving gold medalist Greg Louganis, who was HIV positive during his second Olympics. Louganis did not disclose his HIV status to Olympic officials. During one dive, Louganis hit the diving board with the back of his head and received a wound that bled. A doctor treated him without knowing of the HIV condition—and thus did not take extra precautions. Also, Olympic competitors are required to supply urine samples to test for illegal substances (such as steroids). Because urine would contain HIV, anyone handling Louganis’s sample would have also been at risk unless proper precautions were taken.

Should Louganis have been required to disclose his status before the Olympics? What discrimination may result against an athlete who discloses his or her HIV-infected status? (You may reflect on the problems Magic Johnson faced when he disclosed his status.)

What about typical recreational athletes—people who work out in gyms, play basketball in leagues, fence (saber, epee, or foil), or participate in any recreational activity in which they can be injured accidentally? When do HIV-infected people need to disclose their status?

Exploring Personal Dimensions

Could You Negotiate Safer Sex?

The following items ask you to agree (A) or disagree (D) with the statements presented. Indicate the items about which you are unsure (U) of your response. Compare your responses to those of a friend. Discuss each item about which you said you were unsure of your response. Are there items about which you and a friend disagree? Which changes or adaptations would you or your friend have to make to take on a safer orientation toward sex with a partner?

I believe that . . .

_________ 1. I could use a condom or latex barrier effectively.
_________ 2. I could buy condoms or latex barriers without embarrassment.
_________ 3. If my partner did not want to use a condom or latex barrier during sexual activity, I could convince him or her to do otherwise.
_________ 4. Consumption of alcohol or use of other recreational drugs would in no way affect my determination to use a condom or latex barrier or to convince my partner to respect my wishes.
_________ 5. Having to remember to buy, carry, and use condoms or latex barriers would interfere with sexual spontaneity.
_________ 6. If I suggested using a condom or latex barrier, my partner would think that I must have had many previous sexual partners.
_________ 7. I would feel comfortable insisting on using a condom or latex barrier with a new sexual partner.
_________ 8. I would not feel self-conscious about putting a condom on myself (or on my partner).
_________ 9. I would be able to discuss use of condoms or latex barriers with a partner even before we had any physical intimacy such as touching, caressing, or kissing.
_________ 10. If I suggested using a condom or latex barrier, my partner would think I did not trust him or her.
_________ 11. Using a condom during oral, penile–vaginal, or anal sex would interfere with sexual pleasure or sexual functioning.
_________ 12. Using condoms or latex barriers is an activity primarily for people who have many sexual partners.
_________ 13. Having to use a condom or latex barrier might subsequently prove to be embarrassing to me or my partner if the mechanics of using one resulted in loss of erection.
_________ 14. I could tactfully remove and dispose of a condom after sexual intercourse.
_________ 15. I could convince my partner that use of a condom or latex barrier can be a stimulating part of sexual foreplay

Suggested Readings

Bartlett, J. G., & Finkbeiner, A. K. The guide to living with HIV infection: Developed at the Johns Hopkins AIDS Clinic. Baltimore, MD: Johns Hopkins Press, 2006.

Clark, R. A., Maupin, R. T., & Hayes, J. A woman’s guide to living with HIV infection, 2nd ed. Baltimore, MD: The Johns Hopkins University Press, 2012.

Gallant, J. E. 100 questions & answers about HIV and AIDS, 2nd ed. Burlington, MA: Jones & Bartlett Learning, 2012.

Harden, V. A. AIDS at 30: A history. Dulles, VA: Potomac Books, 2012.

Piot, P. No time to lose: A life in pursuit of deadly viruses. New York: W. W. Norton & Company, 2012.

Skerritt, A. J. Ashamed to die: Silence, denial, and the AIDS epidemic in the South. Chicago: Lawrence Hill Books, 2011.

Volberding, P., Greene, W., Lange, J., Gallant, J. E., & Sewankambo, N. (Eds). Sande’s HIV/AIDS medicine: Medical management of AIDS 2012, 2nd ed. Philadelphia: Saunders, 2012.

Stine, G. AIDS update 2008. New York: McGraw-Hill/Dushkin, 2008.

Web Resources

For links to the websites below, visit go.jblearning.com/dimensions/5e and click on Resource Links.

AIDS.gov

www.aids.gov

This website has three main objectives: (1) to expand visibility of timely and relevant federal HIV policies, programs, and resources to the American public; (2) to increase use of new media tools to extend the reach of HIV programs to communities at greatest risk; and (3) to increase knowledge about HIV and access to HIV services for people most at-risk for, or living with, HIV. The website includes basic HIV information as well as more complex information regarding strategies for those infected with HIV.

Centers for Disease Control and Prevention: HIV/AIDS

www.cdc.gov/hiv

The Division of HIV/AIDS Prevention of the CDC’s National Center for HIV, STD, and TB Prevention maintains this website. It features many differnet resources, including recommendations, guidelines, fact sheets, FAQs, statistics, and materials for prevention and research partners. The CDC also maintains the National Prevention Information Network (CDC NPIN at http://cdcnpin.org/), which features a daily Prevention News Update, reference materials, and referral and distribution services for information on HIV/AIDS, hepatitis, STIs, and tuberculosis.

Henry J. Kaiser Family Foundation: HIV/AIDS

www.kff.org/hivaids/

The Kaiser Family Foundation is dedicated to providing trusted, independent information on the major health issues facing the United States and its people. Its website acts as a clearinghouse of news and information for the health policy community and provides extensive information on both the U.S. and global HIV epidemic, federal actions, and U.S. state HIV/AIDS information.

National Institute of Allergy and Infectious Diseases

www3.niaid.nih.gov

Managed by the federal government, this website presents information pertaining to HIV and AIDS. Links include health and science, research, news and events, the latest news, and research funding.

UNAIDS

www.unaids.org

UNAIDS, the Joint United Nations Programme on HIV/AIDS, works toward achieving universal access to HIV prevention, treatment, care, and support. The website provides country, regional, and global statistics; epidemiological reports; news releases; case studies; and publications on numerous HIV-related topics.

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