Common Sexually Transmitted Diseases: STD 101 for Clinicians

1
Common Sexually Transmitted Diseases STD 101
for Clinicians

• John F. Toney, M.D.
• Professor of Medicine
• Univ. of South Florida College of Medicine
• Medical Director, Southeast STD/HIV Prevention
  Training Center
• CDC National Network of STD/HIV Prevention
  Training Centers

2
Disclosure of Financial Relationships Dr. Toney
has the following significant financial
relationships with commercial entities to
disclose

• Speakers bureau Glaxo SmithKline, Merck
• Research grants Merck

This slide set has been peer-reviewed to ensure
that there are no conflicts of interest
represented in the presentation.
3
Topics

• Background Information
• Sores
• Drips
• Role of STDs in HIV Transmission

4
Audience Question 1

• In a Kaiser survey, what percent of individuals
  were unaware that STDs increase the risk of HIV
  infection?
• 16
• 26
• 56
• 76
• 96

5
Background Information
6
Knowledge About STDs Among Americans
Background
Source Kaiser Family Foundation, 1996
7
Where Do People Go for STD Treatment?
Background

• Population-based estimates from National Health
  and Social Life Survey
• Private provider 59
• Other clinic 15
• Emergency room 10
• STD clinic 9
• Family planning clinic 7

Source Brackbill et al. Where do people go for
treatment of sexually transmitted diseases?
Family Planning Perspectives. 31(1)10-5, 1999
8
Audience Question 2

• In a Kaiser/Glamour magazine survey, what of
  women said the topic of STDs (other than
  HIV/AIDS) was discussed during their first visit
  with new OB-GYN doctor/health care professional?
• 15
• 25
• 35
• 55
• 85

9
Percent of Women Who Said Topic Was Discussed
During First Visit With New Gynecological or
Obstetrical Doctor/Health Care Professional
Background
Percentages may not total to 100 because of
rounding or respondents answering Dont know to
the question Who initiated this
conversation? Source Kaiser Family
Foundation/Glamour National Survey on STDs, 1997
10
Audience Question 3

• What is the number of new STD cases of that occur
  per year in the US?
• 500,000
• 1.5 million
• 6.7 million
• 15 million
• 50 million

11
Estimated Burden of STD in U.S. - 1996
Background
Source The Tip of the Iceberg How Big Is the
STD Epidemic in the U.S.? Kaiser Family
Foundation 1998
12
...the scope and impact of the STD epidemic are
under-appreciated and the STD epidemic is largely
hidden from public discourse.
Background
IOM Report 1997
13
STDs of Concern
Background

• Actually, all of them
• Sores (ulcers)
• Syphilis
• Genital herpes (HSV-2, HSV-1)
• Others uncommon in the U.S.
• Lymphogranuloma venereum
• Chancroid
• Granuloma inguinale

14
STDs of Concern (continued)
Background

• Drips (discharges)
• Gonorrhea
• Chlamydia
• Nongonococcal urethritis / mucopurulent
  cervicitis
• Trichomonas vaginitis / urethritis
• Candidiasis (vulvovaginal, less problems in men)
• Other major concerns
• Genital HPV and Cervical Cancer

15
Sores

• Syphilis
• Genital Herpes (HSV-2, HSV-1)

16
Genital Ulcer Diseases Does It Hurt?
Sores

• Painful
• Chancroid
• Genital herpes simplex
• Painless
• Syphilis
• Lymphogranuloma venereum
• Granuloma inguinale

17
Primary Syphilis Clinical Manifestations
Sores

• Incubation 10-90 days (average 3 weeks)
• Chancre
• Early macule/papule ? erodes
• Late clean based, painless, indurated ulcer
  with smooth firm borders
• Unnoticed in 15-30 of patients
• Resolves in 1-5 weeks
• HIGHLY INFECTIOUS

18
Primary Syphilis Chancre
Sores
Source Southeast STD/HIV Prevention Training
Center
19
Primary Syphilis
Sores
Source Centers for Disease Control and Prevention
20
Secondary Syphilis Clinical Manifestations
Sores

• Represents hematogenous dissemination of
  spirochetes
• Usually 2-8 weeks after chancre appears
• Findings
• rash - whole body (includes palms/soles)
• mucous patches
• condylomata lata - HIGHLY INFECTIOUS
• constitutional symptoms
• Sn/Sx resolve in 2-10 weeks

21
Secondary Syphilis Rash
Sores
Source Southeast (Florida) STD/HIV Prevention
Training Center
22
Secondary Syphilis Generalized Body Rash
Sores
Source CDC/NCHSTP/Division of STD Prevention,
STD Clinical Slides
23
Secondary Syphilis Rash
Sores
Source Southeast (Florida) STD/HIV Prevention
Training Center
24
Secondary Syphilis Rash
Sores
Source Cincinnati STD/HIV Prevention Training
Center
25
Secondary Syphilis
Sores
Source Diepgen TL, Yihune G et al. Dermatology
Online Atlas
26
Secondary Syphilis Condylomata Lata
Sores
Source Florida STD/HIV Prevention Training Center
27
Audience Question 4

• What of individuals who are found to be HSV-2
  antibody () have typical manifestations of
  genital HSV? (vesicles ? ulcers ? crusts)
• 10
• 25
• 50
• 75
• 95

28
Genital Herpes Simplex Clinical Manifestations
Sores

• Direct contact may be with asymptomatic
  shedding
• Primary infection commonly asymptomatic
  symptomatic cases sometimes severe, prolonged,
  systemic manifestations
• Classic (10 of cases)Vesicles ? painful
  ulcerations ? crusting
• Recurrence a potential
• Diagnosis
• Culture
• Serology (Western blot)
• PCR

29
Epidemiology of Genital Herpes
Sores

• One of the 3 most common STDs, increased 30 from
  late 70s to early 90s
• 25 of US population by age 35
• HSV-2 80-90, HSV-1 10-20 (majority of
  infections in some regions)
• Most cases subclinical
• Transmission primarily from subclinical infection
• Complications neonatal transmission, enhanced
  HIV transmission, psychosocial issues

30
Underdiagnosis of Genital Herpes
Sores

• 779 women attending STD clinic
• 372 (48) genital herpes diagnosis
• 363 HSV-2 antibody positive
• 9 HSV-1 culture positive lesions
• Of the 372 diagnosed with genital herpes
• 82 (22) symptomatic
• 14 (4) viral shedding without symptoms
• 60 (14) history of symptoms
• 216 (58) HSV-2 antibody without viral shedding
  or history of symptoms

31
Do my patients have genital herpes?
32
Seroprevalence of HSV-2 in Suburban Primary Care
Practices

• Background
• HSV-2 seroprevalence is high nationwide
• Many primary care providers believe genital
  herpes is not seen in their patient population
• Study Objectives
• Determine the seroprevalence of HSV-2 in suburban
  practices

Leone P. Sex Transm Dis. 200431(5)311-316.
33
Study Design
Six US Communities
Boston, MA
Chicago, IL
Denver, CO
Baltimore, MD
Atlanta, GA
Six Clinics per Community 6 clinics X 6
communities 36 sites
Dallas, TX
Age (years) 18-59 Malefemale ratio 11 Consent
before study initiation
150 Patients per Clinic 150 patients x 36 clinics
5,400 patients
Leone P. Sex Transm Dis. 200431(5)311-316.
34
Patient Demographics
Married
N5,428
Caucasian
N5,432
Employed
N5,433
Some College, Professional or Technical Education
N5,432
Household income ?60,000/year
N5,334
Private/Employer Provided Insurance
N5,400
Leone P. Sex Transm Dis. 200431(5)311-316.
35
1 in 4 Adults in the Suburbs was infected with GH
Leone P. Sex Transm Dis. 200431(5)311-316.
36
9 Out of 10 Did Not Know They Had GH
12 reported having GH
88 did NOT know they had GH
Leone P. Sex Transm Dis. 200431(5)311-316.
37
Do Patients Want to Know?
Sores

• 92.4 wanted to know if they were infected
• 90.8 wanted to know if their partners were
  infected
• 65 expected the test as part of STD screening

Source International Herpes Management Forum,
1999
38
Genital Herpes Simplex
Sores
Source Diepgen TL, Yihune G et al. Dermatology
Online Atlas
39
Genital Herpes Simplex
Sores
Source CDC/NCHSTP/Division of STD, STD Clinical
Slides
40
Genital Herpes Simplex in Females
Sores
Source Centers for Disease Control and
Prevention
41
Genital Herpes Simplex
Sores
Source Southeast (Florida) STD/HIV Prevention
Training Center
42
Drips

• Gonorrhea
• Nongonococcal urethritis
• Chlamydia
• Mucopurulent cervicitis
• Trichomonas vaginitis and urethritis
• Candidiasis

43
Gonorrhea - Clinical Manifestations
Drips

• Urethritis - male
• Incubation 1-14 d (usually 2-5 d)
• Sx Dysuria and urethral discharge (5-15
  asymptomatic)
• Dx Gram stain urethral smear () 98 culture
• Complications
• Urogenital infection - female
• Endocervical canal primary site
• 70-90 also colonize urethra
• Incubation unclear sx usually in l0 d
• Sx majority asymptomatic may have vaginal
  discharge, dysuria, urination, labial
  pain/swelling, abd. pain
• Dx Gram stain smear () 50-70 culture
• Complications

44
Gonorrhea
Drips
Source Southest (Florida) STD/HIV Prevention
Training Center
45
Gonorrhea Gram Stain
Drips
Source Cincinnati STD/HIV Prevention Training
Center
46
Nongonococcal Urethritis
Drips
Source Diepgen TL, Yihune G et al. Dermatology
Online Atlas
47
Nongonococcal Urethritis
Drips

• Etiology
• 20-40 C. trachomatis
• 20-30 genital mycoplasmas (Ureaplasma
  urealyticum, Mycoplasma genitalium)
• Occasional Trichomonas vaginalis, HSV
• Unknown in 50 cases
• Sx Mild dysuria, mucoid discharge
• Dx Urethral smear ? 5 PMNs (usually ?15)/OI
  field Urine microscopic ? 10 PMNs/HPF
  Leukocyte esterase ()

48
Chlamydia Life Cycle
Drips
Source California STD/HIV Prevention Training
Center
49
Chlamydia trachomatis
Drips

• More than three million new cases annually
• Responsible for causing cervicitis, urethritis,
  proctitis, lymphogranuloma venereum (L
  serotypes), and pelvic inflammatory disease
• Direct and indirect cost of chlamydial infections
  run into billions of dollars
• Potential to transmit to newborn during delivery
• Conjunctivitis, pneumonia

50
Normal Cervix
Drips
Source Claire E. Stevens, Seattle STD/HIV
Prevention Training Center
51
Chlamydia Cervicitis
Drips
Source St. Louis STD/HIV Prevention Training
Center
52
Laboratory Tests for Chlamydia
Drips

• Tissue culture has been the standard
• Specificity approaching 100
• Sensitivity ranges from 60 to 90
• Non-amplified tests
• Enzyme Immunoassay (EIA), e.g. Chlamydiazyme
• sensitivity and specificity of 85 and 97
  respectively
• useful for high volume screening
• false positives
• Nucleic Acid Hybridization (NA Probe), e.g.
  Gen-Probe Pace-2
• sensitivities ranging from 75 to 100
  specificities greater than 95
• detects chlamydial ribosomal RNA
• able to detect gonorrhea and chlamydia from one
  swab
• need for large amounts of sample DNA

53
Laboratory Tests for Chlamydia (continued)
Drips

• DNA amplification assays (e.g. Gen-Probe Aptima
  2)
• PCR, TMA, SDA, LCR
• Sensitivities 95 and 85-98 specificity
  approaches 100
• Detect chlamydia in first void urine

54
Pelvic Inflammatory Disease (PID)
Drips

• l0-20 women with GC develop PID
• In Europe and North America, higher proportion of
  C. trachomatis than N. gonorrhoeae in women with
  symptoms of PID
• CDC minimal criteria
• Uterine / adnexal tenderness, cervical motion
  tenderness
• Other symptoms include
• endocervical discharge, fever, lower abd. pain
• Complications
• Infertility 15-24 with 1 episode PID secondary
  to GC or chlamydia
• 7X risk of ectopic pregnancy with 1 episode PID
• chronic pelvic pain in 18

55
Pelvic Inflammatory Disease
Drips
Source Cincinnati STD/HIV Prevention Training
Center
56
C. trachomatis Infection (PID)
Drips
Normal Human Fallopian Tube Tissue
PID Infection
Source Patton, D.L. University of Washington,
Seattle, Washington
57
HPV and Cervical Cancer
58
US HPV Statistics

• Lifetime risk for sexually active men and women
  is at least 50.1
• By 50 years of age, at least 80 of women will
  have acquired genital HPV infection.1
• Estimated incidence 6.2 million per year1
• Estimated prevalence 20 million2
• In sexually active individuals 1524 years of
  age, 9.2 million are currently infected.3
• An estimated 74 of new HPV infections occur in
  this age group.3
• In studies of women rates ranged from 28 to 46.4,5

1. Centers for Disease Control and Prevention.
Rockville, Md CDC National Prevention
Information Network 2004. 2. Cates W Jr, and
the American Social Health Association Panel. Sex
Transm Dis. 199926(suppl)S2S7. 3. Weinstock H,
Berman S, Cates W Jr. Perspect Sex Reprod Health.
200436610. 4. Burk RD, Ho GYF, Beardsley L,
Lempa M, Peters M, Bierman R. J Infect Dis.
1996174679689. 5. Bauer HM, Ting Y, Greer CE,
et al. JAMA. 1991265472477.
59
Estimated Annual Incidence of HPV Cervical
Infection/Dysplasia1

• Virtually all cases of cervical cancer come from
  high-grade dysplasias.

1. World Health Organization. Geneva,
Switzerland World Health Organization 1999122.
60
Audience Question 5

• Which of the following is are HPV types
  associated with genital cancers?
• 1 and 4
• 6 and 11
• 16 and 18
• All of the above
• None of the above

61
Oncogenic HPV Types Are a Necessary Cause of
Cervical Cancer

• Infection with oncogenic HPV types is the most
  significant risk factor in cervical cancer
  etiology.1
• Analysis of 932 specimens from women in 22
  countries indicated prevalence of HPV DNA in
  cervical cancers worldwide 99.7.1
• Specific oncogenic HPV types (16, 18, 31, 33, and
  45) have been detected in 6397 of invasive
  cervical cancer cases worldwide.2

1. Walboomers JM, Jacobs MV, Manos MM, et al. J
Pathol. 19991891219. 2. Clifford GM, Smith JS,
Plummer M, Muñoz N, Franceschi S. Br J Cancer.
2003886373.
62
Invasive Cervical Cancer 2001 US Incidence and
Mortality1

• In 2003, US cases of cervical cancer 12,200
  deaths 4,1002

1. National Cancer Institute. Bethesda, Md
National Cancer Institute 2004. 2. American
Cancer Society. Atlanta, Ga American Cancer
Society 2003148.
63
Risk Factors for HPV Infection

• Women
• Young age (peak age group 2024 years of age)1
• Lifetime number of sex partners2
• Early age of first sexual intercourse3
• Male partner sexual behavior3
• Smoking4
• Oral contraceptive use4
• Uncircumcised male partners5

• Men
• Young age (peak age group 2529 years of age)1
• Lifetime number of sex partners6
• Being uncircumcised6

1. Insinga RP, Dasbach EF, Myers ER. Clin Infect
Dis. 20033613971403. 2. Burk RD, Ho GYF,
Beardsley L, Lempa M, Peters M, Bierman R. J
Infect Dis. 1996174679689. 3. Murthy NS,
Mathew A. Eur J Cancer Prev. 20009514. 4.
Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB,
Koutsky LA. Am J Epidemiol. 2003157218226. 5.
Schiffman M, Castle PE. Arch Pathol Lab Med.
2003127930934. 6. Svare EI, Kjaer SK, Worm AM,
Osterlind A, Meijer CJLM, van den Brule AJ. Sex
Transm Infect. 200278215218.
64
Infection From Time of First Sexual Intercourse
Study of female college students (N603)
From Winer RL, Lee S-K, Hughes JP, Adam DE,
Kiviat NB, Koutsky LA. Genital human
papillomavirus infection Incidence and risk
factors in a cohort of female university
students. Am J Epidemiol. 2003157218226, by
permission of Oxford University Press.
65
Perianal Wart
HPV and Cervical Cancer
Source Cincinnati STD/HIV Prevention Training
Center
66
HPV Penile Warts
HPV and Cervical Cancer
Source Cincinnati STD/HIV Prevention Training
Center
67
Intrameatal Wart of the Penis(and Gonorrhea)
HPV and Cervical Cancer
Source Southeast (Florida) STD/HIV Prevention
Training Center
68
HPV Cervical Warts
HPV and Cervical Cancer
Source Cincinnati STD/HIV Prevention Training
Center
69
STD Treatment for HIV Prevention in the US -
Where Do We Start?
STDs and HIV

• Access to quality of STD clinical services
• Early effective STD-related health care
  behaviors
• Surveillance systems to monitor STD/HIV trends
  interrelationships

70
STD Treatment for HIV Prevention Access to
Quality Clinical Services
STDs and HIV

• Public private settings serving HIV-infected or
  high-risk persons
• Timely access to quality STD diagnosis
  treatment for symptomatic people at high risk
  (e.g., HIV C/T sites, schools, drug treatment
  centers, jails)
• Training for clinicians program managers

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Improved prevention of STDs should be an
essential component off a national strategy for
preventing sexually transmitted HIV infection.
STDs and HIV

• The Hidden Epidemic Confronting STDs Institute
  of Medicine, 1997