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Sexually Transmitted Infections and HIV/AIDS

CHAPTER 15
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SEXUALLY TRANSMITTED INFECTIONS

 Over 19 million STIs reported in U.S. each year,

half of those to people 15-24 years old
 Since many are unreported or undiagnosed,
the actual number is much higher
 Many are unaware of the risks and
consequences of STIs

SEXUALLY TRANSMITTED INFECTIONS (CONT.)

 In the U.S., mandatory reporting applies only to

syphilis, gonorrhea, chlamydia and HIV
 Most effective way of avoiding STIs is to abstain
from oral, vaginal, and anal sex or be in a long-
term, mutually monogamous relationship with
someone free from STIs

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SEXUALLY TRANSMITTED INFECTIONS (CONT.)

 Attitudes About Sexually Transmitted Infections

 High-Risk Groups and STIs
 Birth Control, Pregnancy, and Sexually
Transmitted Infections

ATTITUDES ABOUT SEXUALLY TRANSMITTED

INFECTIONS
 STIs have been viewed as a sign of corrupt
sexuality
 The Punishment Concept of disease – a person
got what he/she deserved
 Negative beliefs and stigma about STIs
currently exist
 These negative attitudes can interfere with
getting tested for an STI

HIGH-RISK GROUPS AND STIS

 Higher rates in racial/ethnic
groups/minorities, men who have sex with
men
 Incidence growing in young adults due to
multiple partners and/or inconsistent
condom use
 Women have more risk of complications
from STIs because vaginal tissue is fragile
 Women more likely to be asymptomatic
 Some infections have properties of latency
(i.e., person has the virus, but no symptoms) 6

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HIGH-RISK GROUPS AND STIS (CONT.)

 African Americans have higher rates of many STIs
than other groups
 The difference is partially explained by differences
in health care clinic reporting methods, access to
health care, ability to seek help, IV drug use,
poverty and sexual practices
 Increases among men who have sex with men
(MSM) due to decreased fear of HIV, increase in
high-risk sexual behaviors, lack of knowledge,
accessing partners via Internet, increased use of
drugs/alcohol

HIGH-RISK GROUPS AND STIS (CONT.)

 Women who have sex with women (WSW) can
acquire bacterial and viral STIs from skin-to-skin
contact, oral sex, vaginal or anal sex using hands,
fingers, shared sex toys and vulva-to-vulva contact
 WSW at higher risk for STIs because less likely to
obtain yearly pelvic exams than heterosexual
women
 STI rates significantly higher in bisexual women
than among women who have sex exclusively with
women

BIRTH CONTROL, PREGNANCY, AND SEXUALLY

TRANSMITTED INFECTIONS
 Barrier methods can decrease the risk of STIs
 Non-oxynol 9 may increase the risk of infection
by irritating the skin
 Condoms are the most effective contraceptive
that reduces the STI risk
 Condoms cannot cover all of the penis, vulva,
or scrotum
 Oral contraceptives may make cervix more
susceptible to infections due to changes in
vaginal discharge.

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BIRTH CONTROL, PREGNANCY, AND SEXUALLY

TRANSMITTED INFECTIONS (CONT.)
 STIs can affect pregnancies – miscarriage,
stillbirth, early onset of labor, mental
retardation, fetal or uterine infection
 30-40% of preterm births and infant deaths are
due to STIs
 Some can cross the placenta (syphilis, HIV)
 Some can infect the newborn during delivery
(chlamydia, gonorrhea, herpes, HIV)
 HIV can be transmitted through breastfeeding
 Antibiotics and C-sections can minimize harm

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ECTOPARASITIC INFECTIONS

 Parasites that live on the skin’s surface

 Two sexually transmitted varieties:
 Pubic Lice
 Scabies

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PUBIC LICE
 Also called “crabs”
 Small, wingless insects difficult to detect on
light-skinned people
 Attach to pubic hair (preferred) by their claws
and drink from tiny blood vessels under the
skin
 Cannot survive more than 24 hours off of the
body; reproduce rapidly and eggs are cemented
to the hair
 Highly contagious

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Pubic lice attach to pubic hair and feed off the tiny blood vessels beneath the skin.

PUBIC LICE (CONT.)

 Incidence: common
 Symptoms: mild to severe itching (particularly
at night) thought to be due to allergic reaction
from their saliva
 Diagnosis: lice and eggs are visible
 Treatment: kill eggs and lice with Kwell
ointment (shampoo, cream); clothing and
sheets dry cleaned, boiled or washed in hot
water

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SCABIES

 Mite Sarcoptes scabiei

 Spread via any skin-to-skin contact

 Mites can live up to 48 hours off of the body

 Not visible to naked eye

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SCABIES (CONT.)
 Incidence: millions worldwide among all ethnic
groups, races and social classes
 Symptoms: rash and severe itching
 Diagnosis: examination of the rash and a skin
scraping can confirm diagnosis; immediate
diagnosis and treatment necessary
 Typically less than 10 mites on the body during
an infection
 Treatment: topical creams; clothing and sheets
washed in hot water

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BACTERIAL INFECTIONS: GONORRHEA,

SYPHILIS, CHLAMYDIA, AND MORE
 Gonorrhea
 Syphilis

 Chlamydia

 Chancroid

 Vaginal Infections

 Pelvic Inflammatory Disease

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GONORRHEA

 Also called the “clap” or “drip”

 Bacterium Neisseria gonorrhoeae

 Survives only in mucous membranes, such as

the cervix, mouth, urethra, rectum, throat, eyes
 Transmitted when mucous membranes contact
each other

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The majority of men infected with gonorrhea experience symptoms and will seek out treatment.
However, this may not happen until they have already infected others.

GONORRHEA (CONT.)
 Incidence: In 2009 301,174 reported cases in U.S.
(actual number closer to 700,000)
 Highest rates among
 Those aged 15-24
 African American Males (26x higher than in white males
in 2009
 African American Females (17x higher than in white
females
 Highest rates in the South and Midwest; lowest in the
West and Northeast

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GONORRHEA (CONT.)

 Symptoms:
 Men: most have symptoms; epididymitis, urethral
discharge, painful, frequent and urgent urination
 Women: most are asymptomatic; cervix is most
common infection site; urinary frequency, abnormal
bleeding, PID
 Swelling, pain and pus in the joints

 Rectal gonorrhea: bloody stools and pus

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GONORRHEA (CONT.)

 Diagnosis: examine for bacteria in a sample of

the discharge
 Treatment: antibiotics (usually injection of
Ceftriaxone or other antibiotic combination)
 Patients often co-infected with other STIs
 All sexual partners should also be tested

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SYPHILIS
 Bacterium Treponema pallidum
 Live in the mucous membranes
 Typically first infects the cervix, anus, penis,
lips or nipples
 Congenital syphilis can transmit through
placenta during first or second trimester
 Incidence: 13,997 cases reported in 2009
 High rates in the South, low rates in the Midwest
 Highest among young people, men, and Black
men
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SYPHILIS (CONT.)

 Symptoms: 3 stages
 Stage 1: primary/early syphilis 10-90 days after
infection
 Chancres (small, round, red-brown, painless sores with a
hard raised edge & sunken center) may appear on the
vulva, penis, vagina, cervix, anus, mouth, lips

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Typical syphilis chancre on a woman’s labia.

SYPHILIS (CONT.)

 Symptoms (Cont.)
 Stage 2: secondary syphilis after chancres
disappear (3-6 weeks after chancre has healed)
 Syphilis invades the central nervous system
 Reddish patches on the skin, possible wart-like growths
in area of infection
 Lymph glands enlarge and are tender
 Headaches, fever, anorexia, flu-like symptoms, fatigue

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A secondary syphilis infection produces rashes on the palms or soles, as well as a generalized body rash.

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SYPHILIS (CONT.)

 Symptoms (Cont.)
 Stage 3: tertiary/late syphilis
 Stage of remission and a person feels fine, though able
to transmit the disease for 1 year
 If not treated, this stage can cause neurological,
muscular, sensory & psychological difficulties and is
eventually fatal

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SYPHILIS (CONT.)

 Diagnosis: culture taken from a lesion; blood

tests
 Treatment: If person has been infected for less
than a year, a single injection of antibiotics is
the treatment. If progresses to later stages, not
treatable and often fatal.

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CHLAMYDIA
 Bacterium Chlamydia trachomatis
 Transmitted through vaginal intercourse, oral and
anal sex; mother can infect newborn during
childbirth
 Incidence: most commonly reported infectious
disease in the U.S.; 1,244,189 cases in U.S. in
2009
 Highest in
 Men and women under age 25
 Black men (12x higher than in White men)
 Women (3x higher than in men)

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CHLAMYDIA (CONT.)
 Symptoms: many people are asymptomatic; a
“silent disease”
 Female symptoms: burning while urinating, painful
intercourse, pain in lower abdomen,
bleeding/spotting
 Male symptoms: penile discharge, burning while
urinating, burning and itching at penile opening,
pain or swelling of testicle
 Bacteria that causes chlamydia may also cause
epididymitis and nongonococcal urethritis in
men

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CHLAMYDIA (CONT.)
 Diagnosis: culture cervical discharge for
women, blood test, urine test for men; yearly
screening recommended for sexually active
women under 25 and older women with risk
factors
 Treatment: antibiotics for 7-10 days; some
cases have become drug-resistant
 Chlamydia is highly contagious; leading cause
of pelvic inflammatory disease, infertility, and
ectopic pregnancies

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CHANCROID
 Bacterium Hemophilus ducreyi
 Different from a syphilis chancre as it has soft
edges
 Incidence: relatively rare in the U.S., though
underreported
7 million cases per year worldwide
 Prevalent in poor countries
 Associated with HIV transmission and common in
areas with high rates of HIV

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VAGINAL INFECTIONS

 Characterized by a discharge, itching and/or

odor
 Bacterial vaginosis
 Trichomoniasis

 Vulvovaginal candiasis

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BACTERIAL VAGINOSIS
 Most common vaginal infection in women of
childbearing age; half are asymptomatic
 Increased susceptibility with: multiple partners,
douching, low concentrations of beneficial
vaginal bacteria, women having sex with
women
 Increased risk of PID and endometriosis
 Treatment: metronidazole or clindamycin (orally
or vaginally)

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TRICHOMONIASIS
 Trichomonas vaginalis
 Female symptoms 3-28 days after infection:
increase in yellowish, frothy and foul-smelling
vaginal discharge; burning/itching in vagina;
some are asymptomatic
 Male symptoms: urethra, asymptomatic,
discharge at tip of penis, burning while
urinating or ejaculating, mild discharge
 Treatment: metronidazole (Flagyl™)

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VULVOVAGINAL CANDIDIASIS
 Vulvovaginal candiasis; yeast infection
 Caused by a variety of fungi, most commonly
Candida albicans
 40-45% of women will have two or more
episodes in their lifetime
 Fungi normally common in vagina, but will
multiply when the pH balance is disturbed
 pH changes due to: pregnancy, oral
contraceptives, douching, antibiotics, diabetes,
fecal material contacting the vagina

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VULVOVAGINAL CANDIDIASIS (CONT.)

 Symptoms: burning, itching, and increase in
vaginal discharge that may be thin, white,
watery and include white chunks
 Recurrences are common
 Treatment: antifungal prescription or over-the-
counter drugs (cream is topical or inserted into
the vagina); misuse of over-the-counter drugs
contributes to medication-resistant strains of
yeast; plain yogurt

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PELVIC INFLAMMATORY DISEASE

 Infection of the female genital tract, including
endometrium, fallopian tubes and lining of
pelvic area
 Most often caused by chlamydia and gonorrhea
 PID can cause long-term complications such as
ectopic and tubal pregnancies, chronic pelvic
pain, infertility
 Estimated 750,000 women in U.S. experience
acute PID each year

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PELVIC INFLAMMATORY DISEASE (CONT.)

 Characteristics of a typical PID sufferer: young,

unmarried, multiple partners, had an STI, early
age at first intercourse, minority, use douches
 Symptoms: acute pelvic pain, high fever, painful
urination, abnormal vaginal discharge or
bleeding; some women asymptomatic
 Treatment: variety of approaches, usually with
antibiotics

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VIRAL INFECTIONS: HERPES, HUMAN

PAPILLOMAVIRUS, AND HEPATITIS
 Once a virus enters a body, it can reproduce
and the person will have it for the rest of
his/her life
 Although they may not experience symptoms while
the virus lies dormant, they are still infected
 Herpes
 Human Papillomavirus
 Viral Hepatitis

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HERPES
 Infection with herpes simplex virus (HSV)
 The virus prefers the mouth and face (herpes
simplex I) or the genitals (herpes simplex II)
 The symptoms may be less severe if the virus
infects a less-preferred site
 The virus exists in the sores, as well as from
the infected skin without the sores present
(viral shedding)
 HSV can be spread without active symptoms

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This is a typical patch of HSV-1 blisters, which often appear on the lips or mouth.

HERPES (CONT.)

 A person can re-infect themselves on another

body part (auto inoculate)
 Incidence: one of the most common STIs in the
U.S.; 1 out of every 5 Americans is infected with
HSV-2
 Majority of people with HSV-2 infections have never
been diagnosed; are infected by someone that
doesn’t even know they have it

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HSV-2 infection in women can cause blisters on the vulva, vagina, or any place the virus entered the
body.

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HERPES (CONT.)
 Symptoms: sores that last 8-10 days,
tingling/burning feeling, itching & red swollen
genitals, painful urination, blisters with pus, fever,
headaches, pain, itching, discharge, fatigue;
symptoms peak within 4 days of blisters
appearance
 Severity and frequency of recurrent episodes
depend on amount of infectious agent, severity of
infection, type of herpes and timing of treatment
 Psychological reactions: guilt, anger, anxiety,
helplessness, frustration, depression, lowered self-
esteem

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Here HSV-2 blisters appear on the penis.

HERPES (CONT.)
 Diagnosis: blood tests, presence of blisters,
often a scraping of the blister
 Treatment: no cure; therapy with antiviral drugs
(topical, oral, injected) to decrease outbreaks,
prevent complications and reduce viral
shedding; ice pack; cooling or drying agent; L-
lysine; decrease sugar and nuts
 No medications have been found to effectively
reduce viral shedding

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HUMAN PAPILLOMAVIRUS
 Over 40 types of HPV
 Almost all cervical cancers can be attributed to
HPV and HPV can also cause genital warts
 Transmitted through intercourse, oral sex,
vulva-to-vulva sex, anal sex
 Incidence: estimated 6 million Americans
infected each year
 Half of
sexually active men and women will get HPV
at some point
 Common in both WSW and MSM

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HUMAN PAPILLOMAVIRUS (CONT.)

 Symptoms: asymptomatic; genital warts; foul-
smelling discharge; itching & pain
 Women: vagina, vulva, cervix; Men: penile shaft, head,
and scrotum
 Diagnosis: visual inspection of warts, biopsies, Pap
test
 high-risk HPV DNA testing is available for women
 Treatment: chemical topical solutions, cryotherapy,
electrosurgical interventions, laser surgery
 May resolve itself or need many treatments

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HUMAN PAPILLOMAVIRUS (CONT.)

 Treatment: Gardasil, first vaccine developed to

prevent certain types of HPV that have been
found to cause cervical cancer and genital
warts (types 6,11,16, and 18)
 Approved for women ages 9-26
 Given in 3 doses over 6 months
 Protects boys and men against most genital warts

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Warts that appear on the penis are usually flesh-colored and may have a bumpy appearance.

Here genital warts appear on the outside of the vulva.

VIRAL HEPATITIS

 3 types and their transmission routes:

 Hepatitis A (HAV) – fecal-oral contact; vaccine-
preventable
 Hepatitis B (HBV) – high-risk sexual behaviors

 Hepatitis C (HCV) – sexual behavior, drug use,

unscreened blood transfusion

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VIRAL HEPATITIS (CONT.)

 Incidence:
 HAV: 22,000 cases in the U.S. (decreased since
1995 HAV vaccine)
 HBV: 38,000 in the U.S. 350 million worldwide

 HCV: 3.2 million in the U.S.

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VIRAL HEPATITIS (CONT.)

 Symptoms:
 HAV: fatigue, abdominal pain, loss of appetite,
diarrhea
 HBV: asymptomatic, nausea, vomiting, headaches,
jaundice, fever, fatigue, darkened urine, liver
enlargement, chronic liver disease
 HCV: asymptomatic, mild illness, chronic liver
infection

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VIRAL HEPATITIS (CONT.)

 Diagnosis: blood test

 Treatment: 3 drugs that interfere with the life
cycle of the virus and induces an immune
response
 Vaccines are available for HAV and HBV
 Recommended for high risk individuals

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HUMAN IMMUNODEFICIENCY VIRUS AND

ACQUIRED IMMUNE DEFICIENCY SYNDROME
 AIDS is caused by HIV
 HIV is transmitted through bodily fluids (semen,
vaginal fluid, blood) during vaginal and anal
intercourse or by sharing needles
 The virus may remain dormant; however, it is
often fatal if untreated
 Origin of HIV is unknown

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HUMAN IMMUNODEFICIENCY VIRUS &

ACQUIRED IMMUNE DEFICIENCY SYNDROME
(CONT.)

 HIV attacks T-lymphocytes (T-helper cells) in the

blood, lowering the body’s ability to fight
infections
 Immune system releases antibodies & many
white blood cells to fight the HIV infection
 The lowered immune system response means
many opportunistic diseases infect people with
AIDS that a healthy person can easily fight

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HUMAN IMMUNODEFICIENCY VIRUS &

ACQUIRED IMMUNE DEFICIENCY SYNDROME
(CONT.)

 Incidence
 Knowledge and Attitudes about AIDS

 Symptoms

 Diagnosis

 Treatment

 Prevention

 Families and HIV

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INCIDENCE

 Approximately1.1 million Americans are living

with HIV
 Rate of HIV in females decreased from 2006-
2009, rates in males remained stable
 IN 2009, majority of people infected were MSM
(57%), followed by heterosexuals (31%)
 Can be transmitted to a baby during pregnancy,
labor, delivery and breastfeeding

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Figure 15.9 HIV and AIDS in the United States, 1977-2005.

Figure 15.10 Diagnoses of HIV Infection by Race and Ethnicity, 2009.

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Figure 15.11 HIV transmission categories in the United States, 2009.

KNOWLEDGE AND ATTITUDES ABOUT AIDS

 More knowledge about AIDS in the U.S. has not

been correlated with practice of safer sex or
behavior changes
 AIDS remains stigmatized in the U.S.

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SYMPTOMS

 Decline in T-helper cells takes 3 years if

depressed, and 5+ years if not depressed
 AIDS develops within 8-10 years without
treatment
 Early symptoms are flu-like (fever, headaches,
fatigue, sore throat, swollen lymph nodes)

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SYMPTOMS (CONT.)

 Later symptoms: weight loss, severe diarrhea,

night sweats, oral candidiasis, gingivitis, oral
ulcers, fever, dizziness, confusion, blurred
vision or hearing
 Opportunistic diseases: pneumonia,
toxoplasmosis, cryptococcosis,
cytomegalovirus, Kaposi’s sarcoma

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DIAGNOSIS

 Tests typically look for antibodies that fight HIV,

though some may look for HIV in blood
 Antibody tests (can require 2 weeks for the
result):
 ELISA (enzyme-linked immunoabsorbent assay)
 Western Blot

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DIAGNOSIS (CONT.)

 OraQuick Rapid HIV Antibody test uses a drop

of blood & gives results in 20 minutes
 OraQuick Advance Antibody Device uses blood
from mucous membranes in the mouth
 Rapid tests are less effective

 False negative and false positive results are

possible with all tests

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TREATMENT

 Before treatment, a viral load test and CD4+ T

cell count are taken to determine how much
HIV is in the system and to provide a baseline
to assess the effectiveness of treatment
 HAART – highly active antiretroviral therapy
 Blend of 3+ HIV drugs (drug cocktails)
 Mid-1990s involved taking 25+ pills a day at
different times on a strict schedule
 Now fewer pills (3-pill-a-day treatment)

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TREATMENT (CONT.)

 HAART side effects: fatigue, fever, rashes,

nightmares, headaches, nausea, diarrhea,
increased cholesterol, diabetes, lowered bone
density, liver problems
 Psychological counseling is important

 Social support is more likely received from

friends than family

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PREVENTION
 Requires behavior change
 Many schools now include AIDS education
 HAART has been related to an increase in high risk
sexual practices in homosexual men, but not
among heterosexuals
 If infected, inform past partners that they should
be tested
 Research into high risk behaviors is needed
 First AIDS vaccine was found ineffective

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FAMILIES AND AIDS

 Due to the social stigma, caretakers often have

no one to turn to
 Adolescents that were told their parents had
AIDS had more emotional distress and engaged
in more high risk sexual practices

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GLOBAL ASPECTS OF AIDS

 Between 2001-2009, the HIV incidence around
the world fell by more than 25%
 AIDS has largely affected children
 Areas throughout the world:
 Asia
 Eastern Europe and Central Asia
 North America and Western and Central Europe
 Sub-Saharan Africa
 The Caribbean
 The Middle East

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ASIA

 Over 5 million with HIV in 2009

 Main mode transmission unprotected sex with
intimate partner and sex workers
 Rates have decreased in India, Nepal, Thailand,
Malaysia and Sri Lanka
 Rates have increased in Bangladesh and the
Philippines

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EASTERN EUROPE AND CENTRAL ASIA

 1.4 million people living with HIV

 Mostly transmitted by MSM, heterosexual
intercourse, injecting drug use, and paid sex

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SUB-SAHARAN AFRICA

 Most of the people with HIV live in Africa

 68% of HIV-positive people live in sub-Saharan
Africa
 In sub-Sahara, 90% of children younger 15 are
estimated to be HIV-positive
 Most people are not receiving HAART therapy
due to costs; they are also not being treated for
opportunistic diseases

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THE CARIBBEAN

 240,000 living with HIV

 Transmission primarily through unprotected
heterosexual sexual behavior, especially paid
sex

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THE MIDDLE EAST

 460,000 people living with HIV

 Primary transmission was unprotected paid
sex, MSM and injecting drug use

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PREVENTING STIS AND AIDS

 Some believe money should be spent on

providing HAART therapy
 Many poor countries lack expertise in administering
the drugs
 Others believe it would be better spent on AIDS
education and prevention

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PREVENTING STIS AND AIDS (CONT.)

 If sexually active, you should get tested
 Have partner tested if in a sexual relationship
 Carefully choose partners
 Use barrier methods, such as condoms
 Avoid high-risk sexual behaviors if not in a
monogamous relationship
 Early detection & treatment is important
 Notify your sexual partners
 Talking about STIs – honesty and trust

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