Sexually Transmitted
Diseases
Los Angeles County Department of Health
Services
Sexually Transmitted Disease Program
Reportable STDs in LAC
• Chlamydia
• Gonorrhea
• Syphilis
• Chancroid
• PID
• NGU
Other STDs -- Viral
• HSV
• HPV
• HIV
3
Reported Sexually Transmitted Diseases
United States, 2002
19
351,852
9
2098
15,291
67
312,133
412
Source: CDC Sexually Transmitted Disease Report, Year 2002
834,555
Chlamydia trachomatis
• Most common bacterial STD in US
• Chlamydial infections can cause PID, ectopic
pregnancy, infertility and pregnancy
complications
• Up to 70% of sexually active women have
asymptomatic chlamydial infections
• ~15-30% women re-infected by 6 -12
months
• Asymptomatic rectal infections in MSM
Chlamydia — Rates: United States, 1984–2002
Potential reasons for continuing increase:
1. More complete national reporting
2. Improvement in information systems
for reporting
Rate (per 100,000 population) 3. Use of more sensitive diagnostic tests
300
4. Expansion of screening services
297
240
180
120
51
60
0
1984
86
88
90
92
94
96
98
2000
02
Chlamydia Rates by Gender: United States, 1984–2002
Potential reasons for gender differential:
1. Greater number of women screened
Rate (per 100,000 population)
500
455
2. Sex partners of women not diagnosed
or reported
400
300
Men
Women
200
130
100
Urine screening*
0
1984
86
88
90
92
94
96
98
2000
*55% increase (males): 84-130 cases per 100,000; 20% increase (females): 381 to 455 cases per 100,000 from 1998 to 2002
02
Chlamydia — Age- and sex-specific rates: United States,
2002
Men
3,000
Rate (per 100,000 population)
2,400
1,800
1,200
600
0
10.2
408.4
691.5
331.6
163.2
82.1
46.0
19.7
6.4
2.1
130.4
Age
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-54
55-64
65+
Total
Women
0
600
1,200
1,800
2,400
3,000
142.1
2,619.1
2,570.1
875.8
328.7
123.9
55.5
20.8
5.6
2.5
456.5
Chlamydia — Rates by State: United States and outlying
areas, 2002
253.4
274.3
141.6
195.6
204.9
205.4
193.4
316.9
293.4
191.2
269.4
324.7
211.7
258.9
279.3
297.1
387.3 281.2
158.5
325.6
326.1
291.8
407.7
252.3
313.1
335.0
136.3 261.6
289.2
216.6
273.5
356.8
Guam 355.3
351.0
Rate per 100,000
population
415.3
333.4
412.7
607.1
156.7
126.0
171.9
270.1
288.0
168.3
338.1
318.9
307.2
282.0
414.8
VT
NH
MA
RI
CT
NJ
DE
MD
263.2
<=150.0
(n= 4)
150.1-300.0 (n= 29)
>300.0
(n= 20)
373.2
Puerto Rico 78.7
Note: The total rate of chlamydia for the United States and outlying areas
(Guam, Puerto Rico and Virgin Islands) was 293.6 per 100,000 population.
Virgin Is. 190.6
Reported Sexually Transmitted Diseases, Los Angeles County,
2003
NGU, 1,393
PID, 82
Gonorrhea, 8,008
Chlamydia
Congenital Syphilis
Early Syphilis, 807
AIDS
Early Syphilis
AIDS, 935
Congenital Syphilis, 31
Gonorrhea
NGU
PID
Chlamydia, 36,555
Los Angeles County Chlamydia Rates
1991-2003
Per 100,000 population
450
Urine
screening
400
386 389
350
300
250
200
276
301 313
332
265
252
216
231
196
193
215
150
100
50
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Los Angeles County Chlamydia Rates by
Gender
1991-2003
Introduction of nucleic
amplification tests
600
526
500
460
400
469
428
401 410
390
344
547 546
461
414
Male
356
Female
300
200
100
75
77
77
81
81
99
118 116
132
160
184
218 226
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Per 100,000 population
Los Angeles County Chlamydia Rates by Age
and Gender, 2003
3000
Male
Female
2500
2000
1500
1000
500
0
0-14 15-19 20-24 25-29 30-34 35-44 45-54 55-64 65+
Per 100,000 population
Los Angeles County Chlamydia
Rates by Race/Ethnicity, 2003
1000
864.7
800
600
334.6
400
200
99.2
100.1
0
White
Black
Hispanic
Race/Ethnicity
Rate per 100,000 pop.
Asian/PI
Chlamydia take home points
• Epidemic particularly among young women in
Los Angeles County
• Often asymptomatic
• Serious sequelae, particularly with repeat
infections & co-factor for HIV infection
• Need novel strategies for control
• Expanded screening
• Patient Delivered Partner Therapy
• Field Delivered Partner Therapy
• Need testing technology to screen MSM for
rectal infections
Gonorrhea
• Second most common bacterial STD in US
• Usually symptomatic in males, often
asymptomatic in women
• Can cause PID, infertility, ectopic pregnancy,
and complications in pregnancy in women
• High prevalences reported from non-genital sites
among MSM (oropharynx & rectum)
• Fluoroquinolone resistance
Gonorrhea — Rates by state: United States and
outlying areas, 2002
49.6
13.6
11.1
11.2
26.6
62.0
7.3
118.2
34.8
13.2
115.1
50.6
108.2
91.4
99.5
81.6
74.0
193.8
193.5 121.6
16.7
72.6
80.4
102.1
135.1
53.9
160.0
147.8
93.3
171.5
228.1
241.7
227.5
16.1
9.7
51.1
85.9
95.2
93.8
201.1
176.6
192.9
164.3
Guam 31.7
Rate per 100,000
population
224.6
129.4
254.8
102.2
VT
NH
MA
RI
CT
NJ
DE
MD
148.6
133.6
<=19.0
(n= 9)
19.1-100.0 (n= 20)
>100.0
(n= 24)
61.1
Puerto Rico 10.8
Virgin Is. 45.1
Note: The total rate of gonorrhea for the United States and outlying areas
(Guam, Puerto Rico and Virgin Islands) was 123.4 per 100,000 population.
The Healthy People 2010 objective is 19.0 cases per 100,000 population.
Gonorrhea — Rates: United States,
1970–2002 and the Healthy People 2010
objective
Rate (per 100,000 population)
500
Gonorrhea
2010 Objective
400
300
200
100
Reasons for decline in gonorrhea rates:
1. Increased screening
2. Increase use of sensitive diagnostic
tests
3. Improved reporting and casefinding
0
1970
73
76
79
82
85
88
91
94
Note: The Healthy People 2010 objective for gonorrhea is 19.0 cases per
100,000 population.
97
2000
Gonorrhea — Age- and sex-specific
rates: United States, 2002
Men
750
Rate (per 100,000 population)
600
450
300
150
0
7.4
287.9
538.1
320.4
199.2
131.4
92.1
48.1
17.3
4.4
124.5
Age
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-54
55-64
65+
Total
0
Women
150
300
450
600
750
46.6
675.6
650.3
251.4
113.1
57.4
31.3
10.6
2.1
0.8
125.5
Gonorrhea Rates by Gender,
California, 1993–2002
125
Rate per 100,000 population
600
Rate per 100,000 population
Gonorrhea
2010 Objective
400
100
200
0
1970
1974
1978
1982
1986
1990
1994
1998
2002
75
50
25
0
1993
1994
1995
1996
1997
Male
Note:
1998
1999
2000
2001
2002
Female
Gender "Not Specified" accounted for less than 0.6% of all cases.
Source: California Department of Health Services, STD Control Branch, 02/2003 Provisional Data
Gonorrhea Rates*
Los Angeles County, 1990-2003
200
182
180
160
140
Introduction of nucleic
amplification tests
163
149
129
120
104
100
89
80
65
60
64
66
66
73
79
84
85
40
Healthy People 2010 Objective
20
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
*Per 100,000 population
Year
Gonorrhea Rates* by Age and Gender
Los Angeles County, 2003
350
Male
Female
300
250
200
150
100
50
*Per 100,000 LA County population
Age Group
65
+
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-4
4
45
-5
4
55
-6
4
014
0
Gonorrhea Rates by Race/Ethnicity
Los Angeles County, 2003
400
357.7
300
200
100
37
36.4
13.4
0
White
Rate per 100,000 pop.
Black
Hispanic
Asian/PI
Fluoroquinolone Resistant GC
(QRNG)
• Widespread in parts of Asia, the
Pacific, Hawaii. Many cases reported
in CA.
• Culture with antibiotic sensitivities
recommended.
• Avoid treatment with fluoroquinolones
Gonococcal Isolate Surveillance Project (GISP) — Location
of participating clinics and regional laboratories: United
States, 2002
Seattle
Portland
Minneapolis
Cleveland
Philadelphia
Chicago
San Francisco
Cincinnati
Las Vegas
Baltimore
Denver
St. Louis
Greensboro
Ft. Bragg
Long Beach
Orange Co.
San Diego
Phoenix
Albuquerque
Birmingham
Atlanta
Dallas
New Orleans
Anchorage
Tripler AMC
Honolulu
STD Clinics
Laboratories
Miami
Gonococcal Isolate Surveillance Project (GISP) — Percent
of Neisseria gonorrhoeae isolates with resistance or
intermediate resistance to ciprofloxacin, 1990–2002
Percent
4.0
Resistance
3.2
Intermediate resistance
2.4
1.6
0.8
0.0
1990
91
92
93
94
95
96
97
98
99
2000
Note: Resistant isolates have ciprofloxacin MICs > 1 g/ml. Isolates with
intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 g/ml.
Susceptibility to ciprofloxacin was first measured in GISP in 1990.
01
02
Prevalence of quinolone-resistant Neisseria
gonorrhoeae (QRNG)* among tested
gonococcal isolates, and gonorrhea rate,
California, 1993-2002
10
100
Gonorrhea rate per 100,000 population
75
8
6
50
4
25
2
0
Gonorrhea rate per
100,000 population
% of gonococcal isolates
with QRNG
% of gonococcal isolates with QRNG
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
*QRNG is defined as N. gonorrhoeae, resistant to ciprofloxacin [minimal inhibitory concentration (MIC) >1.0 g/mL by
agar dilution or disk diffusion zone size <27 mm] or ofloxacin (disk diffusion zone size 24 mm) by the National
Committee on Clinical Laboratory Standards.
Cultures Processed and
Gonoccocal Isolates Recovered
Los Anegeles Sentinel Site
March 2003 – September 2004
605
238
Cultures Processed
N=843
288
South HC
(47.6%)
129
GLC (54.2%)
Isolates Recovered
N=417 (49.5%)
Ciprofloxacin Resistant Isolates Los Angeles Sentinel Site
232
South HC (9.1%)
31
GLC (25.8%)
120
Positive Cultures
March 2003 – July 2004 N=352
21
Resistant Isolates (14.8%)
Gonorrhea Treatment in
California
Uncomplicated Genital/Rectal Infections
• Avoid fluoroquinolones (ciprofloxacin,
ofloxacin, and levofloxacin) to treat gonorrhea in
California
• Recommended regimens for uncomplicated
gonococcal infections of the cervix, urethra, and
rectum:
Ceftriaxone 125 mg intramuscularly in a
single dose OR
Cefixime 400 mg orally in a single dose
• Co-treatment of chlamydia is recommended
unless chlamydia infection has been ruled out
Gonorrhea take home points
• Overall increase in rates in California
• Fluoroquinolone resistance increasing
• Limited first line therapies:
• Ceftriaxone (IM)
• Cefpodoxime
• Cefixime (still limited availability)
Syphilis
(Treponema pallidum)
Primary and secondary syphilis — Rates by
sex: United States, 1981–2002 and the
Healthy People 2010 objective
Rate (per 100,000 population)
25
Male
Female
2010 Objective
20
15
10
5
0
1981
83
85
87
89
91
93
95
97
99
2001
Primary & Secondary Syphilis Cases by Gender,
California, 1996–2002
1,000
ALL MALE
P&S Syphilis Rates 1940-2002, California
75
Rate per 100,000
Rate
50
Number of Cases
800
25
0
1940
1950
1960
1970
1980
1990
2000
Year
600
known MSM
400
200
FEMALE
0
1996
1997
1998
1999
2000
2001
02/2003 Provisional Data - CA DHS STD Control Branch
2002
Primary & Secondary Syphilis, Rates by Gender and Age Group,
California, 2002
Male
14
Rate per 100,000
12
10
8
6
4
2
0.1
0.7
10-14
15-19
20-24
5.4
25-29
9.2
13.0
14.7
3.6
5.6
Source:
0
0
Female
2
4
6
8
10
12
14
0.0
0.5
0.2
0.7
30-34
0.4
35-44
0.4
45+
0.1
Total
0.2
California Department of Health Services, STD Control Branch
Provisional Data 03/18/2002
Number of MSM P&S Syphilis Cases by Region and Year
20
Northern Region
15
10
5
120
100
80
60
40
20
0
0
Bay Area Region
1999
2000
2001
2002
Central Region
25
20
15
10
1999 2000 2001 2002
5
0
San Francisco
1999
250
200
150
2000
2001
2002
Southern Region
150
120
90
60
30
0
100
50
0
1999
2000
2001
2002
1999
Los Angeles
2000
2001
2002
250
200
150
100
50
0
1999
2000
2001
2002
3/03 Provisional Data - CA DHS STD Control Branch
Early Syphilis, Los Angeles
County, 2001-2003
Los Angeles County Early Syphilis
By SPA Of Residence
2003
(n=389)
2002
(n=371)
2001
(n=198)
250
200
Cases
150
100
50
0
SPA 1 SPA 2 SPA 3 ANTELOPE
SAN
SAN
VALLEY FERNANDO GABRIEL
VALLEY
SPA 4 METRO
SPA 5 WEST
SPA 6 SOUTH
SPA 7 EAST
SPA 8 SOUTH
BAY
Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003
UNKNOWN
SPA
Early Syphilis Cases By Age & Sexual
Orientation, Los Angeles County, 2003
Age Group
Sexual Orientation
30%
100%
25%
80%
22
20%
16.9
15%
60.7
60%
16
40%
12
8.5
10%
9.5 9.6
20%
9.6
16.8
5.1
6.9
0%
5% 2.2
e
om
H
al
xu
A
se
/N tero
K
e
D
H
e
al
al
m
xu al
Fe
se
xu
Bi
e
se
o
al
er
l
M
et
ua
H
ex
os
al
M
e
+
50
9
-4
45
4
-4
40
9
-3
35
4
-3
30
9
-2
25
4
-2
20
20
<
Source: Early Syphilis Surveillance Summary, Aug. 2004
al
M
0%
Primary & Secondary Syphilis by
Race/Ethnicity among MSM and NonMSM
MSM & MSM/W
MSW
All Female
Other/Unk/Ref
160
140
120
Cases
100
80
60
40
20
0
White
Afr.-Amer.
Latina/o
Asian/ Pac. Is.
Am.Ind/
Alas.Nat.
Unknow n
Ethnicity/Race
Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003
MSM1 Early Syphilis Cases by
Race/Ethnicity, 2003
Other/
Unknown
2%
White
53%
API
3%
Latino
33%
MSM includes MSM, MSM/W, and male
to female TG or men or women who
have sex with M to F transgenders
Black
9%
HIV Serostatus of LA County
MSM Early Syphilis Cases
2003, n=466
Unknown
11%
HIV32%
HIV+
57%
Early Syphilis Cases By HIV Serostatus
& Sexual Orientation, 2001 – 2003
(n=724)
Posititive
Negative
Unknown
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
MSM & MSM/W
MSW
All Female
Other/Unk/Ref
Sexual Orientation
Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003
The Impact of STDs on Sexual
Transmission of HIV
Types of evidence
•
Studies on the biological plausibility and
potential pathogenic mechanisms
•
Cohort studies of HIV seroconversion
associated with specific STDs
•
Community level interventions assessing the
impact of STD treatment on HIV incidence
44
STDs and HIV Transmission
Pathogenic/Biologic Mechanisms
• Transmission:
• Inflammatory conditions increase viral load in
secretions
• Virus can be cultured from genital ulcers
• Susceptibility:
• Breaks in epithelial barrier allow viral access
• Inflammation increases number and/or
receptivity of target cells
• Enhancement of viral survival
45
Urethritis and HIV Transmission
• HIV+ men with urethritis had HIV RNA
levels in seminal plasma 8x > controls
• Levels highest with GC
• Levels returned to baseline within two
weeks of treatment of urethritis
• No change in serum viral loads
Cohen et al. Lancet 1997, 349:1868-73
46
Impact of STDs on Sexual
Transmission of HIV
Problems in Study Design/Interpretation
• Must control for sexual behavior
• Studies should be prospective to document the
temporal sequence of events
• HIV increases the expression of certain STDs
• Coinfections make interpretation difficult
• Must stratify by gender and sexual preference
47
Effect of STD on HIV Susceptibility
Estimates (ORs) from Cohort Studies
STD
M to F
F to M
Syphilis
2.1
2.5
Gonorrhea
2.6
3.9
Chlamydia
2.8
ns
HSV
insuff data
2.7
GUD
2.8
4.4
Rottingen et al STD 2001
49
Behavioral Risk Factors
for MSM Syphilis Cases
50
Sexual Encounter Venues Among MSM Early
Syphilis Cases, Los Angeles, 2001-2003 (YTD)
Internet (n=830)
Bars/Clubs (n=852)
55%
Don't
Frequent
22%
Use
45%
Frequent
78%
Don't Use
CSVs (n=869)
28%
Attend
72%
Don't
Attend
Source: Epidemiology Unit, STD Program, 2003.
51
HIV Sero-status Among MSM Early
Syphilis Cases Attending CSVs, Los
Angeles County 2001-2003 (YTD)
Attend CSVs (n=230)
Don't Attend CSVs (n=585)
Not HIV
Infected
29%
HIV
Infected
71%
HIV
Infected
38%
Not HIV
Infected
62%
Source: Epidemiology Unit, STD Program; n=815
52
MSM Early Syphilis Cases & Specific CSV’s
Mentioned for Sexual Encounters, 20002003 (YTD)
N
(%)
• 9 Bathhouses
• Club 1350
•
•
•
•
•
•
•
Flex
Hollywood Spa
KLYT
Melrose Spa
Midtowne Spa
North Hollywood Spa
Roman Holiday Spa/II1
4
2
32
59
1
22
35
1
5
15
28
0.5
10
17
0.5
2
-35
-17
• 3 Sex clubs
• MB Club
• Slammer
53
Multivariate Analysis for Predictors of CSV
Attendance, 2001 – 2003 (YTD), N=997
• Variables in model:
•
Age
•
Race/Ethnicity
•
HIV Status
•
Behavioral Risk Factors (anal insertive, anal
receptive, oral, history of anonymous
partners, condom use, past incarceration,
IDU, non-IDU)
54
Multivariate Analysis for Predictors of
CSV Attendance, 2001 – 2003 (YTD),
N=997
• Significant predictors of CSV
attendance: HIV status and multiple
anonymous partners.
• MSM with syphilis:
• Twice as likely to be HIV positive
(OR=1.77, 95% CI 1.13 – 2.77).
• Six times as likely to have multiple
anonymous partners (OR=6.53, 95%
CI 3.04 – 14.05).
55
Background and Context
• Bathhouses were never forced to close in LA
• Conditions of operation: provide condoms and
safer sex messages to patrons
• Previous surveys indicated 10-11%
unprotected anal sex among patrons (Van
Beneden, 2002, Richwald, et al. 1988)
• Anecdotal evidence of waning safer sex
behaviors (HAART era) and 2000 syphilis
outbreak
56
Formative Research
Interview topics
• Typical bathhouse visit
• Sexual behavior and condom use
• Sexual communication
• HIV serostatus disclosure & assumptions
• Alcohol and drug use
• Attitudes & beliefs about testing clinic
57
Formative Research
HIV Status Assumptions
• 85% never discuss HIV status with
partners before sex
• Healthy-looking men assumed HIV• “Bottoms” assumed HIV+
• “Tops” assumed HIV-
58
Epidemiologic Research
Sample
8% 3%
• 916 tests 5/01 - 12/02
27%
• 278 (30%) tests from
BH #2
• 676 (74%) completed
detailed questionnaire
46%
White
A/PI
16%
Black
Other
Latino
59
Epidemiologic Research (n=676)
Reasons for going to BH
• 91% -- for the sex
• 71% -- specifically for anon. sex
• 50% -- to see or be seen
• 49% -- because of boredom
• 26% -- to blow off steam
• 26% -- out of habit
• 20% -- to see friends
62
Bathhouse visits (n=676)
How often and how risky?
• 38% visit more than twice per month
Compared to other places they have sex…
• 35% say sex habits in BH are higher risk
• 49% same level of risk
• 12% less risk
• 39% somewhat concerned about getting HIV
• 49% very concerned
63
Epidemiologic Research (n=676)
Reported Risks (last visit)
Behavior
Number
%
Substance use
Group sex
231
111
34
16
Oral w/o condom
493
73
Insertive anal sex
315
47
w/o condom
47
7
Receptive anal sex
w/o condom
169
28
25
4
64
Epidemiologic Research (n=676)
In and Out of the Bathhouse
Oral or anal sex in the past 6 months
Total male partners
mean 31, median 15
Males inside BH
mean 25, median 8
Males outside BH
mean 9, median 3
Female partners
16% of patrons (med.=2)
65
Epidemiologic Research (n=676)
Other places patrons go for sex
(past 6 months)
• 48% Go To Other Venues For Sex
– 20% visit sex clubs
– 28% bookstores/video arcades
– 14% public parks
– 6% public restrooms
– 5% circuit parties
66
Epidemiologic Research
Syphilis and HIV screening
791 syphilis screening tests
18 reactive RPR (titer 4+) = 2.2%
8 reported previous infection
910 HIV-antibody tests
102 (11%) HIV-positive results
67
Epidemiologic Research (n=896)
HIV Prevalence by Race/ethnicity
20
16
%
12
8
4
0
A/PI
Black
Latino
White
Other
68
Epidemiologic Research
STARHS testing
• 102 HIV+ specimens
• 60/102 consented to storage of
remnant sera for “future” HIV tests
• 50/60 were serum specimens
• 40/50 were tested with LS-EIA (10
mistakenly discarded in lab)
• 11/40 were “recent” infections
69
Epidemiologic Research
STARHS HIV Incidence Results
• Proportion recently infected:
27.5% of HIV+ clients showed
evidence of recent infection
• HIV incidence “rate”:
8.7 per 100 person-years
(95% CI: 4.7, 15)
70
Regulation of CSVs
• Environmental regulations for pools etc
• No formal regulation regarding safer sex
practices, drug use
• Ongoing collaboration with
owners/operators, CBO (APLA) and LAC
PH programs to develop guidelines
71
Proposed Guidelines
• 1. Condoms, lube available on site
• 2. Safer sex and risk reduction guidelines
posted
• 3. Display of educational materials
• 4. Provision of space for onsite health
education services.
• 5. Provision of training and periodic
updates for staff
72
Proposed Guidelines, cont
• 6. Consumption of ETOH and drugs per
•
•
•
•
applicable laws
7. Solicitation of patron agreement to adhere to
house rules upon entry
8. Adherences to local ordinances regarding
public assembly and fire codes
9. Provision of wash up facilities with soap and
water
10. House rules enforced through periodic
monitoring by trained staff.
73
Other Control Measures
Social Marketing –Media Campaign
74
Stop the Sores Syphilis
Campaign for MSM
Background
• Funded by LA County Board of
Supervisors and overseen by the STD
Program, Department of Health Services
• Coordinated by Aids HealthCare
Foundation in collaboration with 5 other
community agencies serving MSM in LA
County
75
Stop the Sores Syphilis
Campaign for MSM
Objective
• Increase awareness of syphilis among the
MSM population and promote testing
Activities
• Print, outdoor and Internet ads geared
towards MSM
• Palm cards, stress grips and posters for
venues and outreach activities
• Campaign Web Site Stop the Sores
76
Healthy
Penis Media
Campaign
San
Francisco
Print Ad
77
Healthy
Penis Media
Campaign
San
Francisco
Print Ad
78
Herpes Simplex Virus (HSV):
Overview
• Types: HSV 1 & HSV 2
• HSV 1: orolabial herpes
• HSV 2: genital herpes
• Both symptomatic & asymptomatic
infections are common
• Can cause serious complications
80
Genital Herpes in the U.S.
 Estimated annual incidence: 600,000 to 1
million cases
 NHANES studies (1976 and 1988) showed
32% increase in prevalence by serology
testing
 Approximately two-thirds are unaware of
infection
 Most genital and perianal cases are caused
by HSV-2, but 10-50% of first episodes are
due to HSV-1
81
Genital Herpes
NHANES* II (1976–1980) and NHANES III (1988–1994)
Percent
40
32
24
16
NHANES II
NHANES III
8
0
12-19
20-29
30-39
40-49
50-59
60-69
70+
Age Group
Note: Bars indicate 95% confidence intervals.
*National Health and Nutrition Examination Survey
82
HSV-2 Seropositivity
Epidemiology in the U.S.
• Prevalence: over 40 million adults in U.S.
•
•
•
•
(22%)
Among blacks, 35% of men and 55% of
women are seropositive
Among whites, 15% of men and 20% of
women are seropositive
Seropositivity increases with age
Rates are higher in HIV infected persons and
adults of lower socioeconomic status
83
Genital Herpes
Transmission
 Major routes: sexual & vertical
 Most sexual transmission probably
occurs when index case is
asymptomatic
 Efficiency is greater from men to women
than women to men
 Mertz, et al: 144 serodiscordant couples
 Almost 17% man-to-woman transmission
 Almost 4% woman-to-man transmission
Mertz et al, Annals of Internal Medicine, Feb., 1992
87
Genital Herpes
Local Symptoms of Primary Herpes
 Pain
95%
 Vaginal discharge
85%
 Inguinal adenopathy 80%
 Cervicitis
70%
 Itching & dysuria
68%
 Urethral discharge
30%
88
Genital Herpes
Spectrum of Presentations
Recognized
Symptoms
20%
Asymptomatic
20%
Unrecognized
Symptoms
60%
89
Genital Herpes
Established (Chronic) Infection
• Establishes latent infection in paraspinous
ganglia
• Infection persists despite host immune
response
• Virus may remain latent indefinitely or
reactivation can occur
93
Genital Herpes
Primary Infection
• First infection ever with either HSV-1 or
HSV-2
• No serum antibody is present when
symptoms appear, then rises in
convalescence
• Symptoms are usually more severe
than in non-primary or recurrent disease
• Average incubation period: 2-12 days
97
Genital Herpes
Subclinical/Asymptomatic Infection
• Serum antibody is present
• Patient has never noticed symptoms
• Most probably have mild, unrecognized
disease
• Probably all shed virus from the genital
area intermittently
• Thought to account for much of
transmission
100
Genital Herpes
Patient’s Perception of Etiology
Women
Men
• Yeast infection
• Folliculitis
• Vaginitis
• Jock itch
• UTI
• “Normal” itch
• Menstrual complaint
• Zipper burns
• Hemorrhoids
• Hemorrhoids
• Allergies (condoms,
• Allergy to condom
sperm, spermicide,
pantyhose
• Rash from sex, shaving,
bike seat
• Irritation from tight jeans,
sex, bike seat
• Insect bite
Koutsky, NEJM, 1992
102
Questions?