21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile chapter yar35317_ch15_481-517.indd Page 481 15 Sexually Transmitted Infections MAIN TOPICS The STI Epidemic 483 Principal Bacterial STIs 493 Principal Viral STIs 500 Vaginal Infections 506 Other STIs 508 Ectoparasitic Infestations 509 STIs and Women 510 Preventing STIs 511 481 yar35317_ch15_481-517.indd Page 482 21/07/12 8:32 AM user-f502 “Up to this date, I have slept with about thirteen men. My most recent ‘wake-up call’ was from a threat from a prospective partner and from a Student human sexuality Voices course. I took a test for HIV; the result was negative. However, I did get infected and passed on genital warts to my ex-boyfriend. I simply pretended that I had never slept with anyone else and that if anyone had cheated it was him. It never fazed me that I was at such a risk for contracting HIV. My new resolutions are to educate my family, friends, and peers about sex, take a proactive approach toward sex with prospective partners, and discuss sex openly and honestly with my mother.” —23-year-old female “My partner and I want to use a condom to protect ourselves from STIs. But I feel inadequate when we are intimate and he cannot keep an erection to put a condom on. I feel too embarrassed for him to discuss the situation. So, we both walk away a T O rose, thou art sick! The invisible worm “ That flies in the night, In the howling storm, Has found thy bed Of crimson joy, And his dark secret love Does thy life destroy. —William Blake (1757–1827) 482 • Chapter 15 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile bit disappointed—him because he could not stay erect and me because I did not take the time or have the courage to help him. I think if he masturbated with a condom on it would help him with his performance anxiety problem.” —22-year-old female “STIs and HIV are precisely the reason I exercise caution when engaging in sexual activity. I don’t want to ever get an STI, and I’d rather never have sex again than have HIV.” —24-year-old male “Why do males often convince women to have sex without proper protection? I don’t understand this because there is always a risk of getting an STI. I know that women think about this just as often as men do, but why is it that men do not seem to care?” —21-year-old female “I am usually very careful when it comes to my sexual relations and protecting myself from STIs, but there have been a couple of times when I’ve drunk a lot and have not practiced safe sex. It scares me that I have done things like that and have tried to make sure it doesn’t happen again. STIs are just a very uncomfortable subject.” —27-year-old male he term “sexually transmitted infections” (STIs) refers to more than 25 infectious organisms passed from person to person primarily through sexual contact. STIs were once called venereal diseases (VDs), a term derived from Venus, the Roman goddess of love. More recently, the term “sexually transmitted diseases” (STDs) replaced “venereal diseases.” Actually, many health professionals continue to use “STD.” However, some believe that “STI” is a more accurate and less judgmental term. That is, a person can be infected with an STI organism but not have developed the illness or disease associated with the organism. So, in this book, we use “STI,” although “STD” may appear when other sources are cited. There are two general types of STIs: (1) those that are bacterial and curable, such as chlamydia and gonorrhea, and (2) those that are viral and incurable— but treatable—such as HIV infection and genital herpes. STIs are a serious health problem in our country, resulting in considerable human suffering. In this chapter and the next, we discuss the incidence (number of new cases) and prevalence (total number of cases) of STIs in our country particularly among youth, the disparate impact of STIs on certain population groups, the factors that contribute to the STI epidemic, and the consequences of STIs. We also discuss the incidence, transmission, symptoms, and treatment of the principal STIs that affect Americans, with the exception of HIV/AIDS, which is the subject of Chapter 16. The prevention of STIs, including protective health behaviors, safer sex practices, and communication skills, is also addressed in this chapter. Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 483 • 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile The STI Epidemic The federal Institute of Medicine (IOM) characterizes STIs as “hidden epidemics of tremendous health and economic consequences in the United States,” adding that “STDs represent a growing threat to the nation’s health and national action is urgently needed.” The IOM notes that STIs are a challenging public health problem because of their “hidden” nature. The IOM adds that “the sociocultural taboos related to sexuality are a barrier to STD prevention” (Eng & Butler, 1997). The “silent” infections of STIs make them a serious public threat requiring greater personal attention and increased health-care resources. STIs: The Most Common Reportable Infectious Diseases STIs are common in the United States, but identifying exactly how many cases there are is impossible, and even estimating the total number is difficult. Often, an STI is “silent”—that is, it goes undiagnosed because it has no early symptoms or the symptoms are ignored and untreated, especially among people with limited access to health care. Asymptomatic infections can be diagnosed through testing, but routine screening programs are not widespread, and social stigmas and the lack of public awareness about STIs may result in no testing during visits to health-care professionals. And even when STIs are diagnosed, reporting regulations vary. Only a few STIs—gonorrhea, syphilis, chlamydia, hepatitis A and B, HIV/AIDS, and chancroid—must be reported by health-care providers to local or state health departments and to the federal Centers for Disease Control and Prevention (CDC). But no such reporting requirement exists for other common STIs, such as genital herpes, human papillomavirus (HPV), and trichomoniasis. In addition, the reporting of STI diagnoses is inconsistent. For example, some private physicians do not report STI cases to their state health departments (American Social Health Association [ASHA], 2006a; CDC, 2011f). In spite of the underreporting and undiagnosed cases, several significant indicators illustrate the STI problem in the United States: ■ STIs are the most common reported infectious diseases in the United ■ ■ ■ ■ ■ States. In 2008, STIs represented four of the five most frequently reported infectious diseases (CDC, 2010d) (see Figure 15.1). An estimated 19 million new STI cases occur each year (CDC, 2011g). STIs negatively impact the lives of more than 65 million Americans (CDC, 2008g). By age 25, 1 in 2 young persons will acquire an STI (Cates, Herndon, Schulz, & Darroch, 2004). More than one half of sexually active men and women will become infected with an STI at some point in their lives (CDC, 2011f ). One in four teenage girls (3.2 million) in the United States is infected with at least one of the most common STIs: HPV, chlamydia, genital herpes, or trichomoniasis (CDC, 2008h). Who Is Affected: Disparities Among Groups Anyone, regardless of gender, race/ethnicity, social status, or sexual orientation, can get an STI. What people do—not who they are—exposes them to the organisms that cause STIs. Nevertheless, some population groups are disproportionately The STI Epidemic • 483 yar35317_ch15_481-517.indd Page 484 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile • FIGURE 15.1 Selected Notifiable Diseases, United States, 2008. (Source: Centers for Disease Control and Prevention, 2010d.) 1,210,523 Chlamydia Gonorrhea 336,742 Salmonellosis* 51,040 Syphilis 46,277 AIDS 39,202 0 300,000 600,000 900,000 1,000,000 1,300,000 Number of cases, 2008 *Infection with the Salmonella bacterium that causes diarrheal illness. affected by STIs; this disparity reflects gender, age, and racial and ethnic differences (CDC, 2011g). Gender Disparities Overall, the consequences of STIs for women often are more serious than those for men. Generally, women contract STIs more easily than men and suffer greater damage to their health and reproductive functioning. STIs often are transmitted more easily from a man to a woman than vice versa. Women’s increased likelihood of having an asymptomatic infection results in a delay in diagnosis and treatment (ASHA, 1998a; CDC, 2011f). A kind of “biological sexism” means that women are biologically more susceptible to infection than men when exposed to an STI organism (Hatcher et al., 2007). A woman’s anatomy may increase her susceptibility to STIs. The warm, moist interior of the vagina and uterus is an ideal environment for many organisms. The thin, sensitive skin inside the labia and the mucous membranes lining the vagina may also be more receptive to infectious organisms than the skin covering a man’s genitals. The symptoms of STIs in women are often very mild or absent, and STIs are more difficult to diagnose in women due to the physiology of the female reproductive system. The long-term effects of STIs for women may include pelvic inflammatory disease (PID), ectopic pregnancy, infertility, cervical cancer, and chronic pelvic pain, as well as possible severe damage to a fetus or newborn, including spontaneous abortion, stillbirth, low birth weight, neurological damage, and death (CDC, 2011f ). Lesbian and bisexual women may also be at risk for STIs. A nationally representative study found the rates of self-reported genital herpes and genital warts to be 15–17% among self-identified bisexual women and 2–7% among selfidentified lesbian women (Tao, 2008), both groups aged 15–44. Another study of lesbian and bisexual women found that many underestimated their risk for STIs, had limited knowledge of potential STI transmission, and reported little use of preventive behaviors with female partners, such as washing hands, using rubber gloves, and cleaning sex toys (Marrazzo, Coffey, & Bingham, 2005). According to a study conducted in Sydney, Australia, women who had sex with other women had a higher rate of bacterial vaginosis (BV) than heterosexual women. Among the women who had sex with other women, 93% reported 484 • Chapter 15 Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 485 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile previous sexual contact with men; they had a median (the numerical value in the middle of the upper half and lower half of a group of numbers) of 12 lifetime male sexual partners, compared with 6 lifetime partners for the heterosexual women. Thus, lesbian women may not be free of STI risk because many women who have sex with other women and self-identify as lesbian also have sex with men during their lifetime (Fetters, Marks, Mindel, & Estcourt, 2000). A study of 35 lesbian and bisexual women aged 16–35 found that BV was associated with reporting a partner with BV, vaginal lubricant use, and the sharing of sex toys (Marrazzo, Thomas, Agnew, & Ringwood, 2010). Studies have found that women who had sex with both men and women had greater odds of having acquired a bacterial STI and had more HIV/STI behavioral risk factors than women who had sex only with men (Bauer, Jairam, & Baidoobonso, 2010; Kaestle & Waller, 2011; Mercer et al., 2007; Scheer et al., 2002). A case study found that femaleto-female transmission of syphilis occurred through oral sex (Campos-Outcalt & Hurwitz, 2002). Surveillance data on several STIs suggest that an increasing number of men who have sex with men (MSM) are acquiring STIs. For example, in recent years, MSM have accounted for an increasing number of estimated syphilis cases in the United States. In 2010, 67% of syphilis cases in the U.S. were among MSM (CDC, 2011f ). (HIV/AIDS data for men who have sex with men will be presented in Chapter 16.) Age Disparities Compared to older adults, sexually active young adolescents, 12 to 19 years old, and young adults, 20 to 24 years of age, are at higher risk for acquiring an STI. About one half of new STI cases are among individuals aged 15–24 although they comprise only about one quarter of the sexually active population (CDC, 2011f; Weinstock, Berman, & Cates, 2004). Young people are at greater risk because they are, for example, more likely to have multiple sexual partners, to engage in risky behavior, to select higher-risk partners, and face barriers to accessing quality STI prevention products and services (CDC, 2007e, 2011f ). Racial and Ethnic Disparities Race and ethnicity in the United States are Rate (per 100,000 population) STI risk markers that correlate with other basic determinants of health status, such as poverty, access to quality health care, health-care-seeking behavior, illegal drug use, and communities with high prevalence of STIs. STI rates are higher among racial and ethnic minorities. (See Figures 15.2 and 15.3 for rates of two STIs—chlamydia and gonorrhea—by race/ethnicity, 2000–2009.) Social factors, 2,000 1,500 • FIGURE 15.2 American Indians/Alaska Natives Asians/Pacific Islanders Blacks Hispanics Whites Rates of Chlamydia by Race/ Ethnicity, United States, 2000–2009. (Source: CDC, 2010e.) 1,000 500 0 2000 2001 2002 2003 2004 Year 2005 2006 2007 2008 2009 The STI Epidemic • 485 • FIGURE 15.3 Rates of Gonorrhea by Race/ Ethnicity, United States, 2000–2009. (Source: CDC, 2010e.) 21/07/12 Rate (per 100,000 population) yar35317_ch15_481-517.indd Page 486 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile 800 700 600 500 400 300 200 American Indians/Alaska Natives Asians/Pacific Islanders Blacks Hispanics Whites 100 0 2000 2001 2002 2003 2004 2005 Year 2006 2007 2008 2009 such as poverty and lack of access to health care, in contrast to inherent factors, account for this discrepancy. Factors Contributing to the Spread of STIs According to the Institute of Medicine, “STDs are behavioral-linked diseases that result from unprotected sex,” and behavioral, social, and biological factors contribute to their spread (Eng & Butler, 1997). These factors are obstacles to the control of STIs in the United States. Behavioral Factors Early Initiation of Intimate Sexual Activity People who are sexually active at an early age are at greater risk for STIs because this early initiation increases the total time they are sexually active and because they are more likely to have nonvoluntary intercourse, to have a greater number of sexual partners, and to use condoms less consistently (Manlove, Ryan, & Franzetta, 2003). For example, a nationally representative sample of 9,844 respondents found that the odds of contracting an STI for an 18-year-old who first had intercourse at age 13 were more than twice those of an 18-year-old who first had intercourse at age 17 (Kaestle, Halpern, Miller, & Ford, 2005). The more exclusive sexual partners an individual has over a period of time (called serial monogamy), the greater the chance of acquiring an STI. (For a discussion of serial monogamy, see Chapter 7.) For example, according to one national study, 1% of respondents with 1 sexual partner within the past year, 4.5% of those with 2–4 partners, and 5.9% of those with 5 or more partners reported that they had become infected with an STI (Laumann, Gagnon, Michael, & Michaels, 1994). In addition, the more sexual partners respondents had, the more likely it was that each of those partners was unfamiliar and nonexclusive. Being unfamiliar with partners, especially knowing the person for less than 1 month before first having sex, and having nonexclusive partners were both strongly associated with higher STI incidence. Data from the National Survey of Men and the National Survey of Women discovered that the likelihood of contracting an STI increased with an increase in the number of lifetime sexual partners: Compared to persons with 1 partner, those reporting 2 or 3 partners have 5 times the likelihood of having an STI, and the odds were as high as 31 to 1 for those Sequential Sexual Relationships 486 • Chapter 15 Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 487 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile reporting 16 or more lifetime partners (Tanfer, Cubbins, & Billy, 1995). A study found that 34% of sexually active women aged 15–44 were at risk for STIs because either they had more than 1 sexual partner (21%) or their partners had 2 or more partners (23%). Interestingly, 20% of the women whose partners had multiple sexual partners thought that they were in mutually exclusive sexual relationships. Among men aged 18–24, 24% were at risk for STIs because of having 2 or more sexual partners (Finer, Darroch, & Singh, 1999). Concurrent Sexual Relationships Having concurrent sexual relationships— overlapping sexual partnerships—facilitates the spread of STIs. Research has shown that sexual concurrency is associated with individual STI risk (Manhart, Aral, Holmes, & Foxman, 2002). This risk is especially true during acute HIV infection, when transmission is greatest. A nationally representative study of men found that 11% reported concurrent sexual relationships in the past year, mostly involving women. These men were less likely to use a condom during their last sexual encounter; were less likely (than those not reporting concurrent sexual partners) to be married; and were more likely to report several risk factors including drug or alcohol intoxication during sexual intercourse, nonmonogamous female and male partners, and sexual intercourse with men (Adimora & Schoenbach, 2007; Doherty, Schoenbach, & Adimora, 2009). Among women in a nationally representative study, the prevalence of reported concurrent sexual relationships was 12%, with lowest concurrency being among those currently married (Adimora et al., 2002). A study of STI clinic patients—one half reporting concurrent sexual partners in the past 3 months—found that both men and women believed that having concurrent partners was normal. They thought that no one was exclusive and that, based on previous relationships with nonexclusive partners, they found it difficult to trust their partners and be emotionally invested in the relationship. Most of the study participants, particularly the women, were looking for exclusive sexual relationships (Senn, Scott-Sheldon, Seward, Wright, & Carey, 2011). Having sex with a person who has had many partners increases the risk of acquiring an STI. One example of this is a female who has a bisexual male partner. Often, the female does not know that her male partner also has sex with men. Another example is when an older, sexually experienced person has sex with a younger and less experienced partner (Boyer et al., 2000; Thurman, Holden, Shain, & Perdue, 2009). Also, a survey of 1,515 men aged 18–35 attending health centers found that those who had purchased sex were twice as likely to be infected with an STI than those who had not purchased sex (Decker, Raj, Gupta, & Silverman, 2008). People often select new sexual partners from their social network. If a person acquires an STI, then the social network could be considered a high-prevalence group, thus increasing a person’s chance of future STI infections. Research has shown that selecting new partners from outside one’s social network is associated with reduced risk for repeat STIs (Ellen et al., 2006). High-Risk Sexual Partners Certain sexual behaviors with a partner put individuals at higher risk for acquiring an STI than other behaviors. For example, a study of 1,084 heterosexual men and women patients at an STI clinic found that individuals who had ever engaged in anal intercourse were more likely to report a history of having had an STI (Gorbach et al., 2009). A study High-Risk Sexual Behavior The STI Epidemic • 487 yar35317_ch15_481-517.indd Page 488 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile of women in the rural southern U.S. found that those who reported engaging in more high-risk behaviors in the past 12 months were more likely to report having an STI during that same time (Yarber, Crosby, & Sanders, 2000). Inconsistent and Incorrect Condom Use Correctly using a latex male condom during each sexual encounter and at any time the penis comes into contact with the partner significantly reduces the risk of STIs. Several studies have shown that both correct and consistent condom use is associated with lower STI rates in both men and women and lower rates of PID outcomes in women (Grimley, Annang, Houser, & Chen, 2005; Hutchinson, Kip, & Ness, 2007; Nielson et al., 2010; Paz-Bailey et al., 2005; Shlay, McClung, Patnaik, & Douglas, 2004; Wald et al., 2005). (See the box “‘Do You Know What You Are Doing?’ Common Condom-Use Mistakes Among College Students” in Chapter 16 for a review of recent studies of college students and condom-use errors and problems.) The abuse of alcohol and drugs is associated with high-risk sexual behavior, although researchers are not certain if there is a cause-and-effect relationship between alcohol/drug use and risky sexual behavior. Substances may affect cognitive and negotiating skills before and during sex, lowering the likelihood that partners will protect themselves from STIs and pregnancy (U.S. Department of Health and Human Services, 2011a). A review of 11 studies of problem drinking and STIs showed an overall association between problematic alcohol use and STI infection (Cook & Clark, 2005). Substance Abuse Sexual Coercion Not all people enter sexual relationships as willing partners, particularly women. The 2009 Youth Risk Behavior Survey (CDC, 2010a) revealed that 8% of the adolescents surveyed had experienced forced sexual intercourse, with a greater percentage of females (11%) being coerced than males (6%). Individuals experiencing violence are less able to protect themselves from STIs. Lack of Knowledge of and Concern About STIs It is important for persons who are sexually active with partners to have knowledge about the wide range of STIs and the ways they are transmitted and prevented. With increased STI information on the Internet and in school health classes, most persons have some fundamental knowledge of STIs and the potential for acquiring an STI through risk behavior. Yet, there are gaps in knowledge among some persons. For example, a study of 393 adolescents found that their specific knowledge about non-HIV STIs was only cursory, despite their reports of having received education about STIs (Clark, Jackson, & Allen-Taylor, 2002). A study of 300 sexually active adolescent females, some of whom had received an STI diagnosis and were recruited from health-care sites, concluded that they knew more about their previous STI than about other STIs, including ones they had unknowingly contracted. That is, they appeared to learn about STIs mainly after an STI diagnosis, too late for effective prevention behavior, early medical detection, or prompt disease treatment (Downs, de Bruin, Murray, & Fischhoff, 2006). Lastly, focus groups of lesbian and bisexual women revealed that the knowledge of the potential for STI transmission between women and of bacterial vaginosis was limited (Marrazzo, Coffey, & Bingham, 2005). A study of 1,101 women aged 18–25 found that 75% believed they were at low risk of acquiring an STI in 488 • Chapter 15 Sexually Transmitted Infections practically speaking Preventing STIs: The Role of Male Condoms and Female Condoms For decades, the male condom has been promoted by public health officials as an important STI prevention device for sexually active individuals. However, there has been much discussion about how effective condoms really are in preventing HIV and other STIs. Some skeptics argue that condoms fail too often and that claims of condom effectiveness are misleading and exaggerated. Interestingly, despite these claims and denunciations by skeptics, a random telephone survey of 517 Indiana residents found that nearly 92% considered condoms at least somewhat effective in preventing HIV and STIs (Yarber, Milhausen, Crosby, & Torabi, 2005). The Centers for Disease Control and Prevention (CDC) has issued statements and recommendations on male condoms, female condoms, and STI prevention for public health personnel. Male Condoms The CDC’s (2007f, 2009b) recommendations about the male latex condom and the prevention of STIs, including HIV, are based on information about the ways the various STIs are transmitted, the physical nature of condoms, the coverage or protection that condoms provide, and epidemiological studies of condom use and STIs. About STI prevention and condoms, the CDC has this to say: For persons whose sexual behaviors place them at risk for STDs, correct and consistent use of the male latex condom can reduce the risk of STD transmission. However, no protective method is 100 percent effective, and condom use cannot guarantee absolute protection against any STD. Furthermore, condoms lubricated with spermicides are no more effective than other lubricated condoms in protecting against the transmission of HIV and other STDs. In order to achieve the protective effect of condoms, they must be used correctly and consistently. Incorrect use can lead to condom slippage or breakage, thus diminishing their protective effect. Inconsistent use (e.g., failure to use condoms with every act of intercourse) can lead to STD transmission because transmission can occur with a single act of intercourse. In addressing specific STIs, the CDC has stated that latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV and reduce the risk of transmission of gonorrhea, chlamydia, and trichomoniasis. Correct and consistent use of latex condoms reduces the risk of genital herpes, syphilis, and chancroid only when the infected area or site of potential exposure is protected. Genital ulcer diseases and human papillomavirus (HPV) infections can occur in both male and female genital areas that are covered or protected by a latex condom, as well as areas that are not covered. Condom use may reduce the risk for HPV infection and HPVassociated diseases such as genital warts and cervical cancer. Two other nonlatex condoms are available. The first type is made of polyurethane or other synthetic materials and provides protection against STIs. It can be substituted for a latex condom for persons with latex allergies. The other type is natural membrane condoms, which are not recommended for protection against STIs (CDC, 2011f, 2011i). Female Condoms Research has shown that female condoms, when used properly, are as effective as barriers to semen during intercourse as male condoms (Macaluso et al., 2007). When used consistently and correctly, the female condom might substantially reduce the risk for STIs including HIV. The CDC recommends that when a male condom cannot be used properly, sexual partners should consider using a female condom. The female condom has also been used for STI/HIV protection during receptive anal intercourse (Gross et al., 1999). SOURCES: Centers for Disease Control and Prevention. (2007). Male latex condoms and sexually transmitted diseases. Available: http://www.cdc.gov/ condomeffectivness/latex.htm (Last visited 10/12/08); Centers for Disease Control and Prevention. (2010). Sexually transmitted diseases treatment guidelines, 2010. Morbidity and Mortality Weekly Report, 59 (No. RR-12); Yarber, W. L., Milhausen, R. R., Crosby, R. A., & Torabi, M. R. (2005). Public opinion about condoms for HIV and STD prevention: A midwestern state telephone survey. Perspectives on Sexual and Reproductive Health, 37, 148–154; Centers for Disease Control and Prevention. (2011). Condoms and STDs: Fact sheet for public health personnel. Available: http://www.cdc.gov/condomeffectiveness/ latex.htm (Last visited 11/16/11). Gross, M., et al. (1999). Use of Reality “female condoms” for anal sex by US men who have sex with men. American Journal of Public Health, 89, 1739–1741; Zimmerman, R. (2002, September 25). Some makers, vendors drop N-9 spermicide on HIV risk. The Wall Street Journal Online. The STI Epidemic • 489 yar35317_ch15_481-517.indd Page 490 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile the next year even though most were having unprotected sex. Some of the women did not perceive STIs as a “big deal” and were desensitized to the risk of contracting STIs (Yarnall et al., 2003). Erroneous Perception of Partner’s STI Status People also often do not have an adequate perception of whether or not their sexual partner has been diagnosed with an STI. In one study of STI clinic patients in Southern California, participants indicated that they did not use condoms when they perceived new sexual partners to be STI-free. Instead of directly discussing their partners’ sexual history, they relied on both visual and verbal cues to judge whether their partners were disease-free. This assessment reflected serious error in judgment because most of the study participants had, in fact, contracted an STI (Hoffman & Cohen, 1999). A recent study of heterosexual couples attending outpatient clinics found that 10% of women and 12% of men were unaware that their partner had recently received an STI diagnosis. Two percent of women and 4% of men were unaware that their partner is HIV-positive (Witte, El-Bassel, Gilbert, Wu, & Chang, 2010). This kind of information underscores the need for communication and honesty as part of STI prevention. Social Factors Poverty and Marginalization Individuals in lower socioeconomic groups and those in social networks in which high-risk behavior is common and access to health care is limited are disproportionately affected by STIs. These groups include sex workers (people who exchange sex for money, drugs, or other goods), adolescents, persons living in poverty, migrant workers, and incarcerated individuals. STIs, substance abuse, and sex work are closely connected (Eng & Butler, 1997; U.S. Department of Health and Human Services, 2000b). Analysis of nationally representative data of adults aged 18–27 found that contextual conditions were associated with prevalence and recent contraction of STIs. As the number of contextual conditions increased, STI prevalence similarly increased. Conditions associated with STI included housing insecurity, exposure to crime, having been arrested, gang participation, childhood sexual abuse, frequent alcohol use, and depression (Buffardi, Thomas, Holmes, & Manhart, 2008). Access to high-quality and culturally sensitive health care is imperative for early detection, treatment, and prevention counseling for STIs. Unfortunately, health services for STIs are limited in many low-income areas where STIs are common, and funds for public health programs are scarce. Without such programs, many people in highrisk social networks have no access to STI care. Access to Health Care One factor that separates the United States from other countries with lower rates of STIs is the cultural stigma associated with STIs and our general discomfort with sexuality issues. (For further discussion about stigma, see the box “The Stigmatization of HIV and Other STIs” in Chapter 16.) Historically, a moralistic, judgmental stance on STIs has hindered public health efforts to control STIs. For example, significant funding for AIDS research did not begin until it was clear that heterosexual individuals as well as gay men were threatened (Altman, 1985; Shilts, 1987). Secrecy and Moral Conflict About Sexuality It is important for persons who are sexually active to have knowledge about the wide range of STIs and the ways they are transmitted and prevented. 490 • Chapter 15 Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 491 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile Biological Factors Asymptomatic Nature of STIs Most STIs either do not produce any symptoms or cause symptoms so mild that they go unnoticed or disregarded. A long time lag—sometimes years—often exists between the contracting of an STI and the onset of significant health problems. During the time in which the STI is asymptomatic, a person can unknowingly infect others. The individual may not seek treatment, allowing the STI to damage the reproductive system. Resistance to Treatment or Lack of a Cure Because resistant strains of viruses, bacteria, and other pathogens are continually developing, antibiotics that have worked in the past may no longer be effective in treating STIs. Infected people may continue to transmit the STI, either because they believe they have been cured or because they currently show no symptoms. And some STIs, such as genital herpes, genital warts, and HIV, cannot be cured. The individual who has any of these viruses is always theoretically able to transmit them to others. Susceptibility in Women Adolescent women are highly susceptible to acquiring chlamydia and gonorrhea because of an immature cervix (ASHA, 1998c). Women who practice vaginal douching are also at greater risk for PID and STIs (National Women’s Health Information Center, 2002b). For many STIs, most scientific literature appears to support the preventive value of circumcision; however, other studies refute these findings. A circumcised penis has been linked to reduced risk of STIs such as HPV, gonorrhea, HIV, genital herpes, and syphilis (Bailey et al., 2007; Gray, 2009; National Institutes of Health, 2011; Weiss, Thomas, Munabi, & Hayes, 2006), and one study found reduced risk of HPV for female partners of circumcised males (Wawer et al., 2011). Other studies found that circumcision was not related to reduced syphilis and genital herpes prevalence (National Institutes of Health, 2011; Xu, Markowitz, Sternberg, & Aral, 2007), and one study found that early childhood circumcision does not markedly reduce the risk of genital herpes in the general population (Dickson, van Roode, Herbison, & Paul, 2008). Further, research on male circumcision and STI infection in women found that women with circumcised partners had similar risk of chlamydia, gonorrhea, and trichomoniasis (Turner et al., 2008). Male circumcision has been associated with lower risk of HIV infection in international observational studies and clinical trials in Africa. From these studies, the World Health Organization (WHO) states that “there is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%” (WHO, 2011c). The WHO continues to state that it and the Joint United Nations Programme on HIV/ AIDS recommend that male circumcision should be considered as an effective intervention for HIV prevention in countries and world regions with heterosexually-acquired HIV epidemics, high HIV prevalence, and low male circumcision prevalence. The groups also note that male circumcision provides only partial protection as one element in a comprehensive HIV prevention program that includes HIV testing and counseling, STI treatment, promotion of safer sex behavior, and provision of male and female condoms and promotion of their correct and consistent use. The U.S. Centers for Disease Control and Prevention (CDC) states that it has not yet determined if male circumcision Other Biological Factors The STI Epidemic • 491 yar35317_ch15_481-517.indd Page 492 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile practically speaking STI Attitude Scale T his scale was developed by William L. Yarber, Mohammad Torabi, and C. Harold Veenker to measure the attitudes of young adults to determine whether they may be predisposed to high or low risk for contracting a sexually transmitted infection. The scale presented here is an updated version of the originally published scale. Follow the directions, and mark your responses to the statements below. Then calculate your risk as indicated. 15. I would feel that I should take my sexual partner with me to a clinic if I thought I had an STI. 16. It would be embarrassing to discuss STIs with my sexual partner if I were sexually active. 17. If I were to have sex, the chance of getting an STI makes me uneasy about having sex with more than one partner. 18. I like the idea of sexual abstinence (not having sex) as the best way of avoiding STIs. Directions 19. If I had an STI, I would cooperate with public health people to find the source of my infection. Read each statement carefully. Indicate your first reaction by writing the letter that corresponds to your answer. 20. If I had an STI, I would avoid exposing others while I was being treated. Key 21. I would have regular STI checkups if I were having sex with more than one partner. 22. I intend to look for STI signs before deciding to have sex with anyone. SA ⫽ Strongly agree A ⫽ Agree U ⫽ Undecided D ⫽ Disagree SD ⫽ Strongly disagree 23. I will limit my sexual activity to just one partner because of the chances of getting an STI. 1. How I express my sexuality has nothing to do with STIs. 24. I will avoid sexual contact any time I think there is even a slight chance of getting an STI. 2. It is easy to use the prevention methods that reduce my chances of getting an STI. 25. The chance of getting an STI will not stop me from having sex. 3. Responsible sex is one of the best ways of reducing the risk of STIs. 26. If I had a chance, I would support community efforts to control STIs. 4. Getting early medical care is the main key to preventing the harmful effects of STIs. 27. I would be willing to work with others to make people aware of STI problems in my town. 5. Choosing the right sexual partner is important in reducing my risk of getting an STI. Scoring 6. A high prevalence of STIs should be a concern for all people. Calculate points as follows: 7. If I have an STI, I have a duty to get my sexual partners to seek medical treatment. 8. The best way to get my sexual partner to STI treatment is to take him or her to the doctor with me. 9. Changing my sexual behaviors is necessary once the presence of an STI is known. Items 1, 10–14, 16, and 25: Strongly agree ⫽ 5, Agree ⫽ 4, Undecided ⫽ 3, Disagree ⫽ 2, Strongly disagree ⫽ 1 Items 2–9, 15, 17–24, 26, and 27: Strongly Agree ⫽ 1, Agree ⫽ 2, Undecided ⫽ 3, Disagree ⫽ 4, Strongly disagree ⫽ 5 11. If I were sexually active, I would feel uneasy doing things before and after sex to prevent getting an STI. The higher the score, the stronger the attitude that may predispose a person toward risky sexual behaviors. You may also calculate your points within three subscales: items 1–9 represent the “belief subscale,” items 10–18 the “feeling subscale,” and items 19–27 the “intention to act” subscale. 12. If I were sexually active, it would be insulting if a sexual partner suggested we use a condom to avoid getting an STI. SOURCE: Adapted from Yarber, W. L., Torabi, M. R., & Veenker, C. H. (1989). 10. I would dislike having to follow the medical steps for treating an STI. 13. I dislike talking about STIs with my peers. 14. I would be uncertain about going to the doctor unless I was sure I really had an STI. 492 • Chapter 15 Sexually Transmitted Infections Development of a three-component sexually transmitted diseases attitude scale. Journal of Sex Education and Therapy, 15, 36–49. With permission from the authors. yar35317_ch15_481-517.indd Page 493 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile should be recommended for any population in the United States. The CDC (2009c) declares that the implementation of any male circumcision recommendation would be voluntary and that the ultimate decision rests with individuals and parents. For men who have sex with men, little evidence supports circumcision for HIV/STI prevention. A review of 15 studies involving 53,567 gay and bisexual men in eight countries failed to show any benefit for HIV protection for those who were circumcised (Millett, Flores, Marks, Reed, & Herbert, 2008). Whether male circumcision should be routinely done as an HIV/STI prevention strategy is still debated and remains controversial at the time of the printing of this book. On a side note, some males worry that being circumcised will decrease their sexual pleasure; most studies have found little difference in sexual sensation and sexual function between those circumcised and those not (CDC, 2008c; Kigozi et al., 2008). Consequences of STIs The list of problems caused by STIs seems almost endless. Women and infants suffer more serious health damage than men from all STIs. Without medical attention, some STIs can lead to blindness, cancer, heart disease, infertility, ectopic pregnancy, miscarriage, and even death (CDC, 2007g, 2010d; Yarber, 2003). A serious outcome of STI infection is that the presence of other STIs increases the likelihood of both transmitting and acquiring HIV. When someone who is infected with another STI is exposed to HIV through sexual contact, the likelihood of acquiring HIV infection is at least 2–5 times higher than when he or she is not infected with an STI. Research has also shown that if an HIV-infected individual is also infected with another STI, that person is more likely to transmit HIV through sexual contact than HIV-infected persons not infected with another STI (CDC, 2010g; U.S. Department of Health and Human Services, 2000b). Besides having human costs, the estimated cost of STI treatment within the U.S. health-care system was $16.9 billion in 2010. This cost does not include indirect, nonmedical costs such as lost wages and productivity due to illness, out-of-pocket expenses, and costs related to STI transmission to infants (Chesson et al., 2011). • Principal Bacterial STIs In this section we discuss chlamydia, gonorrhea, urinary tract infections, and syphilis, the major bacterial STIs. As indicated earlier, bacterial STIs are curable. Table 15.1 summarizes information about all of the principal STIs, including bacterial STIs, viral STIs, vaginal infections, other STIs, and ectoparasitic infestations (parasites that live on the outer skin surfaces). Chlamydia The most common bacterial STI and most commonly reported infectious disease (see Figure 15.1) in the United States is caused by an organism called Chlamydia trachomatis, commonly known as chlamydia. In 2010, 1,307,893 cases of chlamydia were reported to the CDC, representing a rate increase of about 5% over the 2009 rate. The 2010 national rate of chlamydia was Principal Bacterial STIs • 493 yar35317_ch15_481-517.indd Page 494 TABLE 15.1 • STI and Infecting Organism 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile Principal Sexually Transmitted Infections Symptoms Time from Exposure to Occurrence Medical Treatment Comments Bacterial STIs Chlamydia (Chlamydia trachomatis) Women: 75% asymptomatic; others may have abnormal vaginal discharge or pain with urination. Men: About one half asymptomatic; others may have discharge from penis, burning or itching around urethral opening, or persistent low fever. 7–21 days. Antibiotics If untreated, may lead to pelvic inflammatory disease (PID) and subsequent infertility in women. Sexually active females aged 25 and younger need testing every year. Gonorrhea (Neisseria gonorrhoeae) Women: Up to 80% asymptomatic; others may have symptoms similar to those of chlamydia. Men: Some asymptomatic; others may have itching, burning or pain with, urination discharge from penis (“drip”). Women: Often no noticeable symptoms. Men: Usually 2–5 days, but possibly 30 days or more. Antibiotics If untreated, may lead to pelvic inflammatory disease (PID) and subsequent infertility in women. People with gonorrhea can more easily contract HIV. Urethritis (various organisms) Painful and/or frequent urination; discharge from penis; women may be asymptomatic. Can have discharge from vagina and painful urination. 1–3 weeks. Antibiotics Laboratory testing is important to determine appropriate treatment. Syphilis (Treponema pallidum) Stage 1: Red, painless sore (chancre) at bacterium’s point of entry. Stage 2: Skin rash over body, including palms of hands and soles of feet. Stage 1: 10–90 days (average 21 days). Antibiotics Easily cured, but untreated syphilis can lead to damage of internal organs. There is a two- to fivefold increase of acquiring HIV when already infected with syphilis. Possible flulike symptoms but often no symptoms during early phase. Variety of later symptoms, including weight loss, persistent fever, night sweats, diarrhea, swollen lymph nodes, bruiselike rash, persistent cough. Several months to several years. No cure available, although new treatment drugs have improved the health and lengthened the lives of many HIVinfected individuals. HIV infection is usually diagnosed by tests for antibodies against HIV. One in five people living with it are unaware of their infections. Stage 2: 6 weeks after chancre appears. Viral STIs HIV infection and AIDS (human immunodeficiency virus)* *HIV infection and AIDS are discussed in detail in Chapter 16. 426 cases per 100,000. An estimated 2.8 million individuals are infected annually with chlamydia. Rates of reported chlamydia infections have been increasing annually since 1990, and adolescent and young women remain the population most affected by chlamydia (see Figure 15.4) (CDC, 2011f, 2011i; Satterwhite, Tian, Braxton, & Weinstock, 2010). 494 • Chapter 15 Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 495 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile STI and Infecting Organism Time from Exposure to Occurrence Symptoms Genital herpes (herpes simplex virus) Small sore or itchy bumps on genitals or rectum, becoming blisters that may rupture, forming painful sores; flulike symptoms with first outbreak. Within 2 weeks No cure, although antiviral medications can relieve pain, shorten and prevent outbreaks, and reduce transmission to partners when medication is taken. Virus remains in body, and outbreaks of contagious sores may recur. Most people diagnosed with first episode have four to five symptomatic recurrences a year, although recurrences are most noticeable in first year and decrease in frequency over time. Genital human papillomavirus infection (group of viruses) Over 40 HPV types, including genital warts, infect the genitals; rectum, mouth, and throat. Most people with genital HPV infection do not know they are infected; some get visible genital warts. In 90% of cases, the body clears HPV naturally within 2 years. Visible genital warts can be removed by patient or healthcare provider with prescribed medication. Some HPV types can cause cervical cancer. HPV usually disappears on its own without causing health problems Most people who have sex acquire HPV at some time in their lifetime. Vaccines protect girls and women against genital warts and cervical, anal, vaginal and vulvar cancers and boys and men against genital warts and anal cancers. Viral hepatitis (hepatitis A or B virus) Fatigue, diarrhea, nausea, abdominal pain, jaundice, darkened urine due to impaired liver function. 1–4 months No medical treatment available; rest and fluids are prescribed until disease runs its course. Hepatitis B is more commonly spread through sexual contact. Both A and B can be prevented by vaccinations. Within a few days up to 4 weeks. Depends on organism; oral, topical, and vaginal medications are available. Not always acquired sexually. Other causes include stress, birth control pills, pregnancy, tight pants or underwear, antibiotics, douching, vaginal products, and poor diet. Hatching of eggs in 6–10 days. Creams, lotions, or shampoos—both over-the-counter and prescription. Avoid sexual contact with people having unusual spots or insects or nits in the genital area. Also avoid contaminated clothing, sheets, and towels. Medical Treatment Comments Vaginal Infections Vaginitis (Gardnerella vaginalis, Trichomonas vaginalis, or Candida albicans) Intense itching of vagina and/or vulva, unusual discharge with foul or fishy odor, painful intercourse. Men who carry organisms may be asymptomatic. Ectoparasitic Infestations Pubic lice, crabs (Pediculosis pubis) Itching, blue and gray spots, and insects or nits (eggs) in pubic area; some people may have no symptoms. Chlamydia is so common in young women that, by age 30, 50% of sexually experienced women show evidence that they had chlamydia sometime during their lives (CDC, 2001). Women who develop the infection 3 or more times have as great as a 75% chance of becoming infertile. Pelvic inflammatory disease (PID) occurs in 10–15% of women with untreated chlamydia. Also, research Principal Bacterial STIs • 495 • FIGURE 15.4 Rates of Chlamydia by Sex, United States, 1990–2010. (Source: CDC, 2011f.) 21/07/12 Rate (per 100,000 population) yar35317_ch15_481-517.indd Page 496 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile 750 625 500 Men Women Total 375 250 125 0 1990 1992 1994 1996 1998 2000 Year 2002 2004 2006 2008 2010 shows that women infected with chlamydia have a 5 times greater chance of acquiring HIV if exposed (CDC, 2011i). Untreated chlamydia can be quite painful and can lead to conditions requiring hospitalization, including acute arthritis. Infants of mothers infected with chlamydia may develop dangerous eye, ear, and lung infections. Any sexually active person can become infected with chlamydia. This is particularly true for adolescent girls and young women since their cervix is not fully matured and is probably more susceptible to infection. Chlamydia can be transmitted during vaginal, anal, or oral sex and from an infected mother to her baby during vaginal childbirth. Men who have sex with men are at risk for chlamydial infections since chlamydia can be transmitted during oral or anal sex. Chlamydia is known as a “silent” disease; about three fourths of infected women and about one half of infected men have no symptoms. If symptoms do occur, they usually appear within 1–3 weeks after exposure. When early symptoms occur in women, they are likely to include unusual vaginal discharge, a burning sensation when urinating and frequent urination, and unexplained vaginal bleeding between menstrual periods. Later symptoms, when the infection spreads from the cervix to the fallopian tubes, are low abdominal pain, lower back pain, bleeding between menstrual periods, a lowgrade fever, and pain during intercourse. One third to one half of men are asymptomatic when first infected. Men’s symptoms may include unusual discharge from the penis, a burning sensation when urinating, itching and burning around the urethral opening (urethritis), pain and swelling of the testicles, and a low-grade fever. The last two symptoms may indicate the presence of chlamydia-related epididymitis, inflammation of the epididymis. Untreated epididymitis can lead to infertility. Chlamydia responds well to antibiotic therapy. Rectal pain, discharge, or bleeding may occur in men or women who acquired chlamydia during receptive anal intercourse. A study of 3,076 men who have sex with men that was conducted in London HIV clinics found that the prevalence of chlamydia in the rectum was 8% and in the urethra 5%. HIV and rectal chlamydia coinfection was 38%. Most of the rectal infections (69%) were asymptomatic and would not have been found if screening had not been conducted (Annan et al., 2009). Chlamydia can also be found in the throats of men and women engaging in oral sex with an infected person (CDC, 2011f, 2011j). 496 • Chapter 15 Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 497 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile The CDC recommends yearly chlamydia testing for all sexually active women aged 25 and younger, older women with risk factors (new sex partner or multiple sex partners), and all pregnant women. Two types of laboratory tests can be used to detect chlamydia. One kind tests a urine sample; another tests fluid from a man’s penis or a woman’s cervix. A Pap smear does not test for chlamydia (CDC, 2011j). Gonorrhea Gonorrhea is the second most commonly reported notifiable disease in the United States, where the highest reported rates of infection are among sexually active teenagers, young adults, and African Americans. The CDC estimates that more than 700,000 persons in the United States become infected with gonorrhea each year. Less than half of these infections are reported to the CDC. In 2010, 309,341 cases of gonorrhea in the U.S. were reported to the CDC, a rate of 101 per 100,000 (CDC, 2011f, 2011k). Popularly referred to as “the clap” or “the drip,” gonorrhea is caused by the Neisseria gonorrhoeae bacterium. The organism thrives in the warm, moist environment provided by the mucous membranes lining the mouth, throat, vagina, cervix, urethra, and rectum. Gonorrhea is transmitted during vaginal, anal, or oral sex with an infected person. Ejaculation does not have to occur for gonorrhea to be transmitted or acquired. Men tend to experience the symptoms of gonorrhea more readily than women, notably as a watery discharge (“drip”) from the penis, the first sign of urethritis. (“Gonorrhea” is from the Greek, meaning “flow of seed.”) Some men infected with gonorrhea may have no symptoms at all. Other men have signs and symptoms that appear 2–5 days after infection. But symptoms can take as long as 30 days to appear (CDC, 2011k). Besides a watery discharge, symptoms in men may include itching or burning at the urethral opening and pain when urinating. If untreated, the disease soon produces other symptoms, such as thick yellow or greenish discharge, increasing discomfort or pain with urination, and painful or swollen testicles. Up to 80% of women with gonorrhea show no symptoms or very mild symptoms, which they tend to ignore. Because untreated gonorrhea, like untreated chlamydia, can lead to PID, it is important for women to be on guard for symptoms and to be treated if they think they may have been exposed to gonorrhea (e.g., if they have had numerous sexual partners). Symptoms a woman may experience include thick yellow or white vaginal discharge that might be bloody, a burning sensation when urinating, unusual pain during menstruation, and severe lower abdominal pain. Both females and males may have mucous discharge from the anus, blood and pus in feces, irritation of the anus, and mild sore throat. Gonorrhea is curable with several antibiotics. However, drug-resistant strains of gonorrhea are increasing in many parts of the United States and the world, making successful treatment more difficult. Persons with gonorrhea should be tested for other STIs. Untreated gonorrhea can cause sterility in both sexes, ectopic pregnancy, prostate damage, epididymitis, scarring of the urethra in men, and testicular pain. Gonorrhea may be passed to an infant during childbirth, causing conjunctivitis (an eye infection) and even blindness if not treated. People with gonorrhea can more easily contract HIV. People with HIV infection and gonorrhea are more likely than people with HIV infection alone to transmit HIV to others (CDC, 2008j, 2011k). Gonorrhea infection in men is often characterized by a discharge from the penis. Principal Bacterial STIs • 497 yar35317_ch15_481-517.indd Page 498 I had the honor “ To receive, worse luck! From a certain empress A boiling hot piss. —Frederick the Great (1712–1786) And he died in the year fourteen-twenty. “ Of the syphilis, which he had a-plenty. —François Rabelais (1490–1553) 498 • Chapter 15 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile Urinary Tract Infections Urethritis, the inflammation of the urethra, can result from sexual exposure and noninfectious conditions. Among the several organisms that cause these infections, the most common and most serious is chlamydia. Urinary tract infections are sometimes referred to as nongonococcal urethritis (NGU). The diagnosis of NGU occurs more frequently in men, largely due to their anatomy. In men, urethritis may produce a burning sensation when urinating, burning or itching around the opening of the penis, white or yellowish discharge from the penis, and underwear stain. Women are likely to be asymptomatic. They may not realize they are infected until a male partner is diagnosed. If a woman does have symptoms, they are likely to include itching or burning while urinating and unusual vaginal discharge. It is important to have a laboratory test for an unusual discharge from the penis or vagina so that the appropriate antibiotic can be prescribed. Antibiotics are usually effective against NGU. Untreated NGU may result in permanent damage to the reproductive organs of both men and women and problems in pregnancy. The organisms that cause NGU in men may cause other infections in women, such as cervicitis, which is discussed later in this chapter (ASHA, 2008, 2011a; CDC, 2011f ). The most common urinary tract infection among women, cystitis, is briefly discussed later in this chapter. Syphilis Syphilis, a genital ulcerative disease, is caused by the bacterium Treponema pallidum. In the United States, health officials reported 45,834 cases of syphilis in 2010, including 13,774 cases of primary and secondary syphilis (see below for explanation of primary and secondary syphilis). Most syphilis cases in 2011 occurred in individuals aged 20–36. Although syphilis rates decreased steadily in the United States during 1900–2000, the rate increased annually during 2001–2009 before decreasing in 2010 to 4.5 cases per 100,000 in the population. Syphilis continues to be a serious problem in the south and in urban areas in other parts of the U.S. and among MSM (CDC, 2011f; Su, Beltrami, Zaidi, & Weinstock, 2011). In 2010, 67% of the reported primary and secondary (P&S) syphilis cases were among MSM, largely because of high rates of HIV coinfection and high-risk sexual behavior. Treponema pallidum is a spiral-shaped bacterium (a spirochete) that requires a warm, moist environment such as the genitals or the mucous membranes inside the mouth to survive. It is spread by direct contact with a syphilis sore during vaginal, anal, and oral sexual behavior. Syphilis cannot be spread through contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils. The syphilis bacterium of an infected mother can infect the baby during the pregnancy. Depending on how long the woman has been infected, she may have a high risk of having a stillborn baby or giving birth to a baby who dies soon after birth. An infected baby may be born and not have any signs or symptoms, but if not treated immediately, the baby may develop serious health problems within a few weeks. Untreated infants may become developmentally delayed, have seizures, or die. Untreated syphilis in adults may lead to brain damage, heart disease, blindness, and death. Syphilis has often been called “the great imitator” since many of its signs and symptoms are indistinguishable from those of other diseases. Yet, many people infected with syphilis do not have any symptoms for years but remain at risk for complications if they are not treated. Although transmission occurs Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 499 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile The first symptom of syphilis is a red, pea-sized bump called a chancre at the site where the bacterium originally entered the body. from individuals with sores who are in the primary and secondary stages, many of these sores are unrecognized or hidden. Thus, transmission may occur from people who are unaware of their infection. Syphilis progresses through three discrete stages, although it is most often treated during the first two: ■ Stage 1: Primary syphilis. The first symptom of syphilis appears from 10 to 90 days (average 21 days) after contact with an infected partner. It is a small, red, pea-sized bump that soon develops into a round, painless sore called a chancre (SHANK-er). The person’s lymph nodes may also be swollen. The chancre may appear on the labia, the shaft of the penis, the testicles, or the rectum; within the vagina; within the mouth; or on the lips. Unless it is in a visible area, it may not be noticed. Without treatment, it will disappear in 3–6 weeks, but the bacterium remains in the body, and the person is still highly contagious. ■ Stage 2: Secondary syphilis. Untreated primary syphilis develops into secondary syphilis about 6 weeks after the chancre has disappeared. The principal symptom at this stage is a skin rash that neither itches nor hurts. The rash is likely to occur on the palms of the hands and the soles of the feet, as well as on other areas of the body. The individual may also experience fever, swollen lymph nodes, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The rash or other symptoms may be very mild or may pass unnoticed. The person is still contagious. ■ Stage 3: Latency. If secondary syphilis is not treated, the symptoms disappear within 2–6 weeks, and the latent stage begins. The infected person may experience no further symptoms for years or perhaps never. After about a year, the bacterium can no longer be spread to sex partners, although a pregnant woman can still transmit the disease to her fetus. The late stages of syphilis can develop in about 15% of people who have not been treated for syphilis and can appear 10–20 years after infection was acquired. In the late stages, damage may occur many years later in internal organs, such as the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Damage could also include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, dementia, and even death. Principal Bacterial STIs • 499 yar35317_ch15_481-517.indd Page 500 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile think about it The Tuskegee Syphilis Study: A Tragedy of Race and Medicine In 1932 in Macon County, Alabama, the U.S. Public Health Service, with the assistance of the Tuskegee Institute, a prestigious Black college, recruited 600 African American men to participate in an experiment involving the effects of untreated syphilis on Blacks. Of this group, 399 men had been diagnosed with syphilis and 201 were controls. The study was originally meant to last 6–9 months, but “the drive to satisfy scientific curiosity resulted in a 40-year experiment that followed the men to ‘end point’ (autopsy)” (Thomas & Quinn, 1991). The history of this experiment—the racial biases that created it, the cynicism that fueled it, and the callousness that allowed it to continue—is chillingly chronicled by James Jones (1993) in Bad Blood: The Tuskegee Syphilis Experiment and Susan Reverby (2009) in Examining Tuskegee: The Infamous Syphilis Study and Its Legacy. The purpose of the study was to determine if there were racial differences in the developmental course of syphilis. The racial prejudice behind this motivation may seem hard to fathom today, yet, as we shall see, the repercussions still reverberate strongly through African American communities (Ross, Essien, & Torres, 2006). Much of the original funding for the study came from the Julius Rosenwald Foundation (a philanthropic organization dedicated to improving conditions within African American communities), with the understanding that treatment was to be a part of the study. Although Alabama law required prompt treatment of diagnosed venereal diseases, the state Public Health Service managed to ensure that treatment was withheld from the participants. Even after 1951, when penicillin became the standard treatment for syphilis, the Public Health Service refused to treat the Tuskegee “subjects” on the grounds that the experiment was a “never-again-to-be-repeated opportunity” (Jones, 1993). The Tuskegee participants were never informed that they had syphilis. The Public Health Service, assuming they would not understand medical terminology, referred to it as “bad blood,” a term used to describe a variety of ailments in the rural South. The participants were not told their disease was sexually transmitted, nor were they told it could be passed from mother to fetus. It was not until 1966 that anyone within the public health system expressed any moral concern over the study. A congressional subcommittee headed by Senator Edward Kennedy began hearings in 1973. The results included the rewriting of the Department of Health, Education, and Welfare’s regulations on the use of human subjects in scientific experiments. A $1.8-billion class-action suit was filed on behalf of the Tuskegee participants and their heirs. A settlement of $10 million was reached out of court. Each survivor received $37,500 in damages, and the heirs of the deceased each received $15,000. Also, a congressionally mandated program, the Tuskegee Health Benefit Program, provides comprehensive lifetime medical benefits to the affected widows and offspring of participants in the Tuskegee syphilis study (Reverby, 2009). Current public health efforts to control the spread of HIV infection, AIDS, and other STIs raise the specter of genocide and beliefs of conspiracy among many members of the African American community. Research on African American people living in the United States has found that a significant proportion of respondents endorsed HIV/AIDS conspiracy beliefs; that is, HIV/AIDS was created by the federal government to kill and wipe out African Americans. Among African American men, stronger conspiracy beliefs were significantly associated with negative attitudes about condoms and lower likelihood of condom use (Bogart, Galvan, Wagner, & Klein, 2011; Bogart & Thornton, 2005; Hutchinson et al., 2007; Ross, Essien, & Torres, 2006). In the primary, secondary, and early latent stages, syphilis can be successfully treated with antibiotics. There is an estimated two- to fivefold increase in the chances of acquiring HIV if exposed to that infection when syphilis is present (CDC, 2008k, 2011l). • Principal Viral STIs Four principal viral STIs—HIV and AIDS, genital human papillomavirus infection, genital herpes, and hepatitis—are discussed here. Recall that diseases caused by viruses are treatable, but not curable. 500 • Chapter 15 Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 501 21/07/12 8:32 AM user-f502 Many of the current beliefs of African American people about HIV/AIDS as a form of genocide are attributed to the Tuskegee syphilis study. On both physiological and psychological levels, there is much healing to be done. Even though it is unthinkable that such a study would be done today, efforts must still be made to ensure that all people are protected against such tragedies. For reflections on the legacy of the Tuskegee study, see Caplan, 1992; Jones, 1993; King, 1992; and Reverby, 2009). Several Internet sites provide further information about this terrible experiment, including the transcript of President Clinton’s 1997 formal apology to study participants. /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile Think Critically 1. Is it possible for another medical experiment like the Tuskegee syphilis study to happen in America today? Explain your view. 2. What can be done to prevent another Tuskegee syphilis study? 3. What can the medical and scientific community do to gain the trust of all Americans? AUTH © 1972 The Philadelphia Inquirer. Reprinted with permission of UNIVERSAL PRESS SYNDICATE. All rights reserved. HIV and AIDS On June 5, 1981, the U.S. government published a report warning about a rare disease, eventually named as acquired immunodeficiency syndrome, or AIDS (CDC, 1981). Since that time, this disease has become an enormous public health challenge nationally and globally. Human immunodeficiency virus (HIV)—the virus that causes AIDS—and AIDS have claimed millions of lives worldwide, becoming one of the deadliest epidemics in human history. Despite advances in medical testing and treatment and prevention efforts, HIV/AIDS remains a significant public health problem. Because of its major global impact and continued medical and prevention Principal Viral STIs • 501 yar35317_ch15_481-517.indd Page 502 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile challenge, we have decided to devote an entire chapter to HIV and AIDS, which follows this chapter. Genital Human Papillomavirus Infection Genital human papillomavirus infection, or genital HPV, is a group of viruses that includes more than 100 different strains; over 40 are sexually transmitted and can infect the genitals, rectum, mouth, and throat. Currently, at least 20 million people in the U.S. are infected with HPV, with 6 million new infections reported each year, accounting for one third of all new STIs. HPV is the most common STI among young, sexually active people, particularly women. At least one half of sexually experienced men and women acquire genital HPV infection at some point in their lives. By age 50, at least 80% of women will have acquired genital HPV infection (ASHA, 2011b; CDC, 2008l, 2011h). The type of HPV that infects the genital area is spread primarily through sexual contact with an infected person. In rare instances, a pregnant woman can pass HPV to her baby during vaginal delivery. The incubation period (the period between the time a person is first exposed to a disease and the time the symptoms appear) is usually 6 weeks to 8 months. You cannot see HPV. Most people who have a genital HPV infection do not know they are infected, and most infections are temporary. Sometimes, certain types of HPV can cause genital warts in men and women. Other HPV types can cause cervical cancer and less common cancers of the vulva, vagina, anus, and penis. The types of HPV that can cause genital warts are not the same as the types that can cause cancer. HPV types are referred to as “low risk” (wart causing) or “high risk” (cancer causing). In 90% of the cases, the body’s immune system clears the HPV—both high-risk and low-risk types—naturally within 2 years. If a high-risk HPV infection is not cleared by the immune system, it can linger for many years and turn abnormal cells into cancer over time. About 10% of women with high-risk HPV on their cervix will develop long-lasting HPV infections that will put them at risk for cervical cancer (CDC, 2008l, 2011h). The Pap test can identify abnormal or precancerous tissue in the cervix so that it can be removed before cancer develops. An HPV DNA test, which can find high-risk HPV on a women’s cervix, may also be used with a Pap test in certain cases. There is no general test for men and women to check one’s overall “HPV status,” nor is there an approved HPV test to find HPV on the genitals or in the mouth or throat. HPV usually goes away on its own, without causing health problems. So an HPV infection that is found today will most likely not be there a year or two from now. Hence, there is no reason to be tested just to find out if you have HPV now. But you should get tested for signs of diseases that HPV can cause, such as cervical cancer (CDC, 2008l, 2011h). (See Chapter 13 for recommendations about frequency of pap smears.) The genital-wart history of a national sample of 8,849 men and women found that 7% of women and 4% of men reported ever being diagnosed with genital warts (Dinh, Sternberg, Dunne, & Markowitz, 2008). About 1% of sexually active adults in the U.S. have genital warts at some point in their lives. Genital warts usually appear as soft, moist, pink, or flesh-colored swellings, usually in the genital area. They can also be flat, single or multiple, small or large, and sometimes cauliflower shaped. They can appear on the penis or scrotum, in or around the vagina or anus, on the cervix, or on the groin or 502 • Chapter 15 Sexually Transmitted Infections thigh. Visible genital warts can be removed by the patient him- or herself with prescribed medications or treated by a health-care provider. Some people choose not to treat warts but see if they disappear on their own. No one treatment is better than another. If the warts cause discomfort or problems (such as interfering with urination), they can be removed by cryosurgery (freezing) or laser surgery. Removal of the warts does not eliminate HPV from the person’s system. Because the virus can lie dormant in the cells, in some cases warts can return months or even years after treatment. The extent to which a person can still transmit HPV after the visible warts have been removed is unknown. In recent years, a major medical breakthrough has occurred in protecting thousands of females and males against the health-impairing outcomes of HPV infection. Two HPV vaccines have been developed, and the U.S. Department of Health and Human Services highly recommends their use. In June 2006, the U.S. Food and Drug Administration approved the HPV vaccine Gardasil (Merck) for use by females aged 9–26; in October 2009, this vaccine was also licensed for use in males aged 9–26. Gardasil protects against HPV types 6 and 11 (the cause of 90% of genital warts) and types 16 and 18 (the cause of 70% of cervical cancer). Gardasil also prevents HPV associated with anal, vulvar and vaginal cancers. In 2009, another HPV vaccine, Cervarix (GlaxoSmithKline), was approved for types 16 and 18. Both of these vaccines are given in three shots over 6 months (ASHA, 2011a; CDC, 2011f, 2011m). One study found that since the Gardasil HPV vaccination began in 2007 in Australia, the number of women seeking treatment for genital warts decreased 59% (Donovan et al., 2011). Despite its significant health value, the effort to vaccinate all young people has faced difficulties. For example, nationally representative data have shown that only one third of girls aged 13–17 have been vaccinated (Pruitt & Schootman, 2010). Studies have shown that some girls taking the HPV vaccine did not complete the vaccine series in the 6-month time period or did not complete the series (Widdice, Bernstein, Leonard, Marsolo, & Kahn, 2011) or would not take the vaccine even if it was free (Crosby, Casey, Vanderpool, Collins, & Moore, 2011). In addition, parental acceptance of the HPV vaccine has been mixed (Dempsey, Butchart, Singer, Clark, & Davis, 2011; Milhausen, Crosby & Yaber, 2008). Although many parents accept HPV vaccination, some parents believe that vaccinating girls against HPV condones premarital/teen sex. Further educational efforts to promote the value of HPV vaccines, particularly to parents, need to occur. The American Social Health Association (ASHA) has developed a support service for people with HPV called the HPV and Cervical Cancer Prevention Resource Center (http://www.ashastd.org). It provides information about HPV and its link to cervical cancer, support groups for emotional issues surrounding HPV, and an e-mail address (mystory@ashastd.org) where people share their experiences with HPV, which are posted on the ASHA website. If you have HPV, don’t blame your current sexual partner or assume that your partner is not sexually exclusive with you. Remember, most people who have sex will have HPV at some time in their lives, and they may have HPV for a very long time before it is detected. Most people do not realize they are infected or that they are passing on the virus to a sexual partner. Sexual partners usually share HPV, particularly those who are together for a long time. There should be no shame or blame involved with having genital HPV; the virus is very common. Genital warts appear in a variety of forms. Principal Viral STIs • 503 yar35317_ch15_481-517.indd Page 504 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile Genital Herpes Genital herpes is an STI caused by the herpes simplex virus (HSV) type 1 (HSV-1) and type 2 (HSV-2). Most genital herpes is caused by HSV-2. Nationally representative data show that genital herpes infection occurs commonly in the United States, with 16.2% of people aged 14–49, or about 1 in 6 persons in that age group, having a genital HSV-2 infection. Over the past decade, the percentage of Americans with genital herpes in the United States has remained stable. Genital HSV-2 infection is more common in women (about 1 in 5 women aged 14–49) than men (about 1 in 9 men aged 14–49). This may be due to male-to-female transmission being more likely than female-to-male transmission. Herpes can make people more susceptible to HIV infection, and it can make HIV-infected individuals more infectious (CDC, 2010h). Actually, many HIV-infected persons are coinfected with HSV-2 (Romanowski et al., 2009). HSV-1 and HSV-2 can be found and released from the sores that the viruses cause, but also can be released between outbreaks from skin that does not appear to be broken or have a sore (Tronstein, 2011). Generally, a person can get HSV-2 infection only during sexual contact with someone who has a genital HSV-2 infection. It is important to know that transmission can occur from an infected partner who does not have a visible sore and may not know that he or she is infected. HSV-1 can cause genital herpes, but it more often causes infections of the mouth and lips, so-called fever blisters. HSV-1 infection of the genitals can be caused by oral-genital or genital-genital contact with a person infected with HSV-1. Genital HSV-1 outbreaks recur less regularly than genital HSV-2 outbreaks. Most infected people have no or minimal signs or symptoms from HSV-1 and HSV-2 infection. When signs appear, they typically occur within 2 weeks after the virus is transmitted and appear as one or more blisters on or around the genitals or rectum. The blister breaks, leaving tender ulcers (sores) that may take 2–4 weeks to heal the first time they occur. Most people diagnosed with a first episode of genital herpes can expect to have several (typically four or five) outbreaks within a year, but they are almost always less severe and shorter than the first outbreak. Even though the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over a period of years (CDC, 2008m, 2010a). There is no cure for herpes, but there are medications that can help to keep the virus in check (Handsfield, Warren, Werner, & Phillips, 2007). Antiviral medications can relieve pain, shorten the duration of sores, prevent bacterial infections at the open sores, and prevent outbreaks while the person is taking the medications. Other actions that may be useful in preventing, shortening the duration of, or lessening the severity of recurrent outbreaks include getting plenty of rest, maintaining a balanced diet, avoiding tight clothes, keeping the area cool and dry, taking aspirin or other painkillers, and reducing stress. Individuals with herpes should inform their partners and together decide what precautions are right for them. Because having sex during a recognized outbreak or when other symptoms are present (e.g., flulike symptoms, swollen glands, fever) puts an uninfected partner at risk, people should abstain from sex when signs and symptoms of either oral or genital herpes are present. The male latex condom can help prevent infections, but only when the condom covers the ulcer. Condoms should be used between outbreaks of the ulcers. Managing HSV 504 • Chapter 15 Sexually Transmitted Infections Herpes lesions may develop on the penis, perineum, anus, vulva, or within the vagina. Also, daily suppressive therapy for symptomatic herpes can reduce transmission to partners. Pregnant women or their partners who have HSV should be sure to discuss precautionary procedures with their medical practitioners. Genital herpes often causes psychological distress in people who know they are infected. ASHA has developed a support service for people with herpes infections called the Herpes Resource Center (http://www.ashastd.org). It provides accurate and current information about herpes, such as the STI Resource Center Hotline (919-361-8488), and referrals to local support groups. Viral Hepatitis Hepatitis is a viral disease meaning inflammation of the liver. The most common types of the virus that can be sexually transmitted are hepatitis A and hepatitis B. A third type, hepatitis C, is a common virus passed on primarily through contact with infected blood; risk of transmittal from sexual partners or from mothers to newborns during birth is low. Hepatitis A is transmitted primarily through oral contact with contaminated food or water or through sexual contact, especially oral-anal sex. In the United States, there were an estimated 21,000 new hepatitis A infections in 2009, a decrease from 56,000 estimated new infections in 2004. A highly effective vaccine, which is routinely given to all children, travelers to certain countries, and persons at risk for the disease, can prevent hepatitis A. Although the symptoms of hepatitis A are similar to those of hepatitis B, the disease is not considered as dangerous. Individuals infected with hepatitis A usually experience shortterm illness, recover completely, and develop immunity against reinfection (CDC, 2009d, 2011n). Hepatitis B is 50–100 times more infectious than HIV. It is commonly spread through sexual contact, in blood, semen, saliva, vaginal secretions, and urine. In the United States, two thirds of acute hepatitis cases resulted from sexual contact with the virus. It can also be contracted by using contaminated needles and syringes, including those used in ear piercing, acupuncture, and tattooing, and by sharing the toothbrush or razor of an infected person. Unlike hepatitis A, hepatitis B is not spread routinely through food or water. It is not spread by sharing eating utensils, breastfeeding, hugging, kissing, holding hands, coughing, or sneezing. An estimated 700,000 to 1.4 million Americans are chronically infected with hepatitis B. The number of new infections per year has declined dramatically from an average of 260,000 per year in the 1980s to about 38,000 in 2009 (CDC, 2009e, 2011n). Anyone can get hepatitis B, Principal Viral STIs • 505 yar35317_ch15_481-517.indd Page 506 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile but individuals in their teens and twenties are at greater risk. Because hepatitis B spreads “silently”—that is, without easily noticeable symptoms—many people are not aware it is in their communities. Chronic hepatitis B is a serious disease that can result in long-term health problems and even death. About 2,000 to 4,000 people die every year from hepatitis B–related liver disease (CDC, 2009e). Hepatitis B can be prevented by a simple, widely available vaccine. The CDC (2009e) recommends routine vaccination for those most at risk, including sexually active people not in a long-term, exclusive relationship, men who have sex with men, people who share drug-injection equipment, people whose sexual partner has hepatitis B, and people with HIV. Screening for hepatitis B is also recommended for pregnant women so that their newborns can be immediately vaccinated if necessary. Usually given as three or four shots over a 6-month period, the vaccine is safe and effective and provides lasting protection. Tattoos and body piercings should be done at parlors that thoroughly sterilize the instruments used to penetrate the skin. In 2009, there were an estimated 16,000 new hepatitis C virus infections in the United States. An estimated 3.2 million individuals in the U.S. have chronic hepatitis C, and about 75–85% of people who become infected with hepatitis C will develop a chronic infection. About 8,000 to 10,000 people die every year from hepatitis C–related liver disease (CDC, 2009f, 2011n). Risk of infection from sexual activity is low unless it involves blood contact; numerous sexual partners, failure to use condoms, a history of STIs, and sexual activities involving trauma (e.g., “rough” sex) increase the risk. About 50–90% of HIVinfected persons who use injection drugs are also infected with hepatitis C. Most cases of hepatitis C can be traced to blood transfusions before 1992, the sharing of needles during injection drug use, and accidental needle-sticks. Known as the “silent epidemic,” hepatitis C damages the liver over the course of many years, and even decades, before symptoms appear. The symptoms of all forms of hepatitis include fatigue, diarrhea, nausea, abdominal pain, jaundice, darkened urine, and an enlarged liver. About 15–25% of people who get hepatitis C will clear the virus from their bodies without treatment and will not get a chronic infection. There is no medical treatment nor vaccine for hepatitis C. Occasionally, serious liver damage or death results. • Vaginal Infections Vaginal infections, or vaginitis, affect 3 out of 4 women at least once in their lives. These infections are often, though not always, sexually transmitted. They may also be induced by an upset in the normal balance of vaginal organisms by such things as stress, birth control pills, antibiotics, nylon panty hose, and douching. The three principal types of vaginitis are bacterial vaginosis, candidiasis, and trichomoniasis. Bacterial Vaginosis Bacterial vaginal infections, referred to as bacterial vaginosis (BV), may be caused by a number of different organisms, most commonly Gardnerella vaginalis, often a normal inhabitant of the healthy vagina. An overabundance of Gardnerella, however, can result in vaginal discharge, odor, pain, itching, or burning. Bacterial vaginosis is the most common vaginal infection in women 506 • Chapter 15 Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 507 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile of childbearing age and, in the United States, is common among pregnant women. An estimated 29% of American women (21 million) aged 14–49 have BV now, but the vast majority do not report symptoms to their health-care provider (CDC, 2008q, 2010i; Koumans et al., 2007). Not much is known about how women get bacterial vaginosis, and there are many unanswered questions about the role that harmful bacteria play in causing it and what role sexual activity plays in its development. Any woman can get BV, although some activities can upset the normal balance of bacteria in the vagina and put women at risk, including having a new sexual partner or numerous partners and douching. Research has shown that douching at least once a month is associated with BV but that most female hygienic behaviors, such as type of underwear, menstrual protection, or hygienic spray or towelettes, were found not to be related to BV (Hutchinson, Kip, & Ness, 2007; Klebanoff et al., 2010). Bacterial vaginosis may also be spread between female sex partners (Bailey, Farquhar, & Owen, 2004). Women who never had sexual intercourse may get BV (Tabrizi, Fairley, Bradshaw, & Garland, 2006). Most often this infection causes no complications, although having it can increase a woman’s susceptibility to HIV infection and other STIs such as chlamydia and gonorrhea and can increase the chances that an HIV-infected woman can pass HIV to her sexual partner. BV may also put a woman at increased risk for some complications during pregnancy. Even though bacterial vaginosis sometimes clears up without treatment, all women with symptoms of BV should be treated with antibiotics so that the bacteria that cause BV do not infect the uterus and fallopian tubes, an infection called pelvic inflammatory disease, or PID. Male partners generally do not need to be treated (CDC, 2010d). A study of women at high risk for STI found that consistent condom users had a 45% decreased risk for BV than women not using condoms consistently (Hutchinson et al., 2007). Genital Candidiasis Genital candidiasis, also known as a “yeast infection,” is a common fungal infection that occurs when there is an overgrowth of the fungus called Candida albicans. Candida is always present in the body (e.g., vagina, mouth, gastrointestinal tract) in a small amount; however, when an imbalance occurs, such as when the normal acidity of the vagina changes or when hormonal balance changes, Candida can multiply. Women with a vaginal yeast infection usually experience itching or burning, with or without a “cottage cheese–like” vaginal discharge. Males with genital candidiasis, which occurs on rare occasions, may have an itchy rash on the penis. Nearly 75% of all adult women have had at least one vaginal yeast infection in their lifetime. Vaginal yeast infections are rarely transmitted during sexual activity. While most cases are caused by the person’s own Candida organisms, the use of birth control pills or antibiotics, frequent douching, pregnancy, and diabetes can promote yeast infections. Genital candidiasis occurs more often and with more severe symptoms in people with weakened immune systems. Antifungal drugs, taken orally, applied directly to the affected area, or used vaginally, are the drug of choice for vaginal yeast infections and are effective 80–90% of the time. Because over-the-counter (OTC) treatments are becoming more available, more women are diagnosing themselves with vaginal yeast infections and using one of a family of drugs called “azoles” for therapy. However, “Sex is a pleasurable exercise in “ plumbing, but be careful or you’ll get yeast in your drainpipe. —Rita Mae Brown (1944–) Vaginal Infections • 507 yar35317_ch15_481-517.indd Page 508 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile personal misdiagnosis is common and studies show that as many as two thirds of OTC drugs sold to treat vaginal yeast infections are used by women without the disease, which may lead to resistant infections. Resistant infections are very difficult to treat with currently available medications. Therefore, it is important to be sure of the diagnosis before treating with OTC or other antifungal medications (CDC, 2010j). Trichomoniasis Trichomoniasis is caused by a single-celled protozoan parasite, Trichomonas vaginalis. Trichomoniasis is the most common curable STI in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men (CDC, 2007i). One study of 1,209 women attending three STI clinics found that trichomoniasis, unlike other STIs, was found more often in older compared to younger women (Helms et al., 2008). In women, the vagina is the most common site of infection; in men, it is the urethra. The parasite is sexually transmitted during penile-vagina intercourse or vulva-to-vulva contact with an infected person. Women can acquire the disease from infected men or women, but men usually contract it only from infected women. Symptoms are more common in women than men, although up to one half of infected women are asymptomatic. Some women have signs and symptoms usually within 5–28 days after exposure, which include frothy, yellow-green vaginal discharge with a strong odor. The infection may also cause discomfort during intercourse and urination, as well as itching and irritation of the female genital area, and, rarely, lower abdominal pain. Some men may temporarily have an irritation inside the penis, mild discharge, or slight burning after urination or ejaculation. For both women and men, a physical examination and a laboratory test are used to diagnose trichomoniasis, although it is harder to detect in men (CDC, 2007i). Prescription drugs are effective in treating trichomoniasis. To prevent reinfection, both partners must be treated, even if the partner is asymptomatic. • Other STIs A number of other STIs appear in the United States, but with less frequency than they do in some developing countries. Among these other STIs are the following: ■ Chancroid is a painful sore or group of sores on the penis, caused by the bacterium Hemophilus ducreyi. Women may carry the bacterium but are generally asymptomatic for chancroid. ■ Cytomegalovirus (CMV) is a virus of the herpes group that affects people with depressed immune systems. A fetus may be infected with CMV in the uterus. ■ Enteric infections are intestinal infections caused by bacteria, viruses, protozoans, or other organisms that are normally carried in the intestinal tract. Amebiasis, giardiasis, and shigellosis are typical enteric infections. They often result from anal sex or oral-anal contact. ■ Granuloma inguinale appears as single or multiple nodules, usually on the genitals, that become lumpy but painless ulcers that bleed on contact. 508 • Chapter 15 Sexually Transmitted Infections yar35317_ch15_481-517.indd Page 509 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile ■ Lymphogranuloma venereum (LGV) begins as a small, painless lesion at the site of infection and then develops into a painful abscess, accompanied by pain and swelling in the groin. ■ Molluscum contagiosum, caused by a virus, is characterized by smooth, round, shiny lesions that appear on the trunk, on the genitals, or around the anus. • Ectoparasitic Infestations Although they are not infections per se, parasites such as scabies and pubic lice can be spread by sexual contact. Scabies and pubic lice are considered ectoparasitic parasites or infestations since they live on the outer surfaces of the skin. Scabies The red, intensely itchy rash caused by the barely visible mite Sarcoptes scabiei is called scabies. It usually appears on the genitals, buttocks, feet, wrists, knuckles, abdomen, armpits, or scalp as a result of the mites’ tunneling beneath the skin to lay their eggs and the baby mites’ making their way back to the surface. Typically, fewer than 10 to 15 mites can be present on the entire body of an infested person. On a person, scabie mites can live as long as 1–2 months, but off a person they usually do not survive more than 48–72 hours. It is highly contagious and spreads quickly among people who have close contact, both sexual and nonsexual. The mites can also be transferred during prolonged contact with infested linens, furniture, or clothing. Scabies is usually treated with a prescribed lotion, applied at bedtime and washed off in the morning. Clothing, towels, and bedding of people who have scabies should be disinfected by washing in hot water and drying in high heat or by dry cleaning (CDC, 2010k). Pubic Lice The tiny Phthirus pubis, commonly known as a “crab,” moves easily from the hair of one person to that of another (probably along with several of its relatives). Pubic lice usually are found in the genital area on pubic hair, although they can be found on other coarse body hair such as hair on the legs, armpits, mustache, and beard. To live, lice must feed on blood. When pubic lice mate, the male and female grasp adjacent hairs; the female soon begins producing eggs (nits), which she attaches to the hairs at the rate of about three eggs a day for 7–10 days. The nits hatch within 6–10 days and begin reproducing in about 2–3 weeks, creating a very ticklish (or itchy) situation. Although pubic lice and nits can be large enough to be seen with the naked eye, a magnifying lens may be necessary to find lice or eggs. Pubic lice can be transmitted during sexual contact with a person who has crabs, moving from the pubic hair of one person to the pubic hair of another. They may fall into underwear, sheets, or towels, where they can survive up to a day and lay eggs that hatch in about a week. Thus, it is possible to get crabs simply by sleeping in an infected person’s bed, wearing his or her clothes, or sharing a towel. People can usually tell when they have pubic lice. There is intense itching, and upon inspection, they discover a tiny, pale, crablike louse or its minuscule, pearly nits attached near the base of a pubic hair. There are both prescription Pubic lice, or “crabs,” are easily spread during intimate contact; they may also be transmitted via bedding, towels, or underwear. Ectoparasitic Infestations • 509 yar35317_ch15_481-517.indd Page 510 21/07/12 8:32 AM user-f502 /Volume/207/es/MH01875/yar35317_disk1of1/0078035317/yar35317_pagefile and over-the-counter treatments for pubic lice. An infested person does not have to shave off his or her pubic hair to get rid of crabs. In addition to killing all the lice and nits on the body, infested individuals must wash all linen and clothing in hot water and dry it in high heat, or the crabs may survive (ASHA, 2011d; CDC, 2010l). • STIs and Women In addition to the direct effects that STIs have on the body, women are vulnerable to complications from STIs that threaten their fertility. These are related to the biological factors, discussed earlier, that make women more susceptible to STIs and make STIs more difficult to detect in women than in men. Pelvic Inflammatory Disease (PID) As discussed in Chapter 12, pelvic inflammatory disease (PID), also known as salpingitis, is one of the leading causes of female infertility. Up to 750,000 women experience an episode of acute PID annually, resulting in 10–15% of these women becoming infertile each year due to the consequences of PID. PID occurs when bacteria move upward from a woman’s vagina or cervix into her uterus, fallopian tubes, and other reproductive organs. Several organisms can cause PID, but many cases are associated with gonorrhea and chlamydia. A prior episode of PID increases the risk of another episode because the reproductive organs may have been damaged during the initial episode. Sexually active women in their childbearing years are at most risk, and those under age 25 are more likely to develop PID than those older than 25. Because the cervix of teenage girls and yo...
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