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433
Bacterial Infections
Why do health authorities now consider chlamydia infections a
major health problem?
What kinds of complications can accompany gonorrhea?
Why are health authorities concerned about syphilis in the United
States?
Viral Infections
Can the herpes virus be transmitted if an open sore is not present?
Why do health practitioners consider genital warts a serious
problem?
Can both hepatitis A and hepatitis B be transmitted sexually? What
symptoms are associated with hepatitis?
Common Vaginal Infections
What is a male partner’s role in transmitting bacterial vaginosis?
What factors are associated with the development of candidiasis,
and how is this infection treated?
How common is trichomoniasis, and what possible complications
are associated with this infection?
Ectoparasitic Infections
Can pubic lice be transmitted by ways other than sexual
interaction?
How contagious is scabies, what are its symptoms, and how is it
treated?
Acquired Immunodeciency Syndrome (AIDS)
How is HIV transmitted, and what behaviors put one at risk for
becoming infected with HIV?
Among what portions of the population is AIDS increasing most
rapidly?
Has there been signicant progress in the search for either an
effective treatment or a cure for this disease?
Preventing Sexually Transmitted Infections
What are some effective methods of preventing STIs or reducing
the likelihood of contracting one?
433
Copyright © David Young-Wolff / Photo Edit
15
Sexually Transmitted
Infections
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434 CHAPTER 15
The possibility of getting a sexually transmitted infection has caused me to be
extremely cautious and selective about whom I choose to be sexual with. It
also makes every decision in a sexual relationship so critical and has made me
much more careful in the choices I make. (Authors’ files)
In this chapter, we discuss a variety of sexually transmitted infections (STIs)*—
that is, infections that can be transmitted through sexual interaction.
Table 15.1 sum-
marizes the STIs described in this chapter. Some of these infections are curable; others
are not. As we will see, the consequences of STIs—such as compromised health, pain
and discomfort, infertility, and even death—can adversely aect the quality of our lives.
Our purpose in including a chapter on STIs is not to discourage you from exploring
the joys of sexuality. Rather, we wish to help you make good decisions by presenting a
realistic picture of what STIs are, how to recognize them, what should be done to treat
them, and what measures can be taken to avoid contracting or transmitting them. We
believe that this information is especially relevant to our college-age readers. e trans-
mission of STIs on American college campuses continues to pose signicant health con-
cerns (Williams et al., 2008). Moreover, it is estimated that about half the STIs diagnosed
annually in the United States occur among 15- to 24-year-olds, although that population
constitutes only one quarter of the overall sexually active population in the United States
(Dariotis et al., 2011). Furthermore, most HIV infections in America occur among
young people under the age of 30 (Barnard, 2011; Crosby & Danner, 2008).
You may wonder why we postpone our discussion of HIV/AIDS until later in this
chapter. Certainly AIDS has received far more attention in the media than any of the
other infections discussed in this chapter. is emphasis on AIDS, although understand-
able in view of the continuing worldwide spread of this deadly ailment, tends to obscure
the fact that many other STIs are substantially more prevalent. Furthermore, many of
these commonly occurring STIs, such as chlamydia and genital warts, pose major health
risks that are escalating in proportion to the increasing incidence of these infections.
Many factors contribute to the epidemic of STIs in the United States. Engaging in
risky sexual behavior, such as having multiple sexual partners and unprotected (condom-
less) sex, is a prime reason for the high incidence of STIs. Such behavior is especially
prevalent during adolescence and early adulthood, when the incidence of STIs is the high-
est (Workowski et al., 2010). It is also believed that increased use of oral contraceptives
has contributed to the epidemic of STIs—both by increasing susceptibility of women to
some STIs and by reducing the use of condoms, a contraceptive method known to oer
protection against many infections. Lack of adequate public health measures and lim-
ited access to eective systems for prevention and treatment of STIs also contribute to
this ongoing epidemic. In addition, many health-care providers in the United States are
reluctant to ask questions about their patients sexual behaviors, thus missing opportuni-
ties for STI-related counseling, diagnosis, and treatment. Moreover, a number of stud-
ies indicate that many college students do not receive adequate STI-related information
from their college or university health service (Williams et al., 2008).
e spread of STIs is facilitated by the unfortunate fact that many of these infections
do not produce obvious symptoms. In some cases, particularly among women, there
may be no outward signs at all. Under these circumstances, people may unknowingly
infect others. In addition, feelings of guilt and embarrassment that often accompany
having an STI may prevent people from seeking adequate treatment or from informing
their sexual partners. In the Let’s Talk About It box, Telling a Partner, we explore why
informing sexual partners is important and suggest ways to do so more easily.
*Some health professionals prefer to call these conditions sexually transmitted diseases, or STDs.
sexually transmitted infections
(STIs)
Infections that are transmitted by
sexual contact.
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Sexually Transmitted Infections435 435
In the following sections, we focus on the most common STIs. We also provide an
expanded discussion of AIDS and the progress being made in treating this dreadful
malady. e Centers for Disease Control and Prevention (CDC) periodically provides
updated guidelines for treating STIs. e most recent guidelines, published at the end
of 2010 (Workowski et al., 2010), are the basis for most of the treatment information
provided for the infections discussed in this chapter.
At a Glance
TABLE 15.1 Common Sexually Transmitted Infections: Transmission, Symptoms, and Treatment
STI Transmission Symptoms Treatment(s)
Chlamydia The Chlamydia trachomatis
bacterium is passed through
sexual contact.
Infection can spread from
one body site to another via
ngers.
Women:
Pelvic inammatory disease, disrupted
menstruation, pelvic pain, raised temperature,
nausea, vomiting, headache, infertility, and ecto-
pic pregnancy.
Men: Urethra infection; discharge and burning
during urination; with epididymitis, heaviness in
and painful swelling at bottom of affected testis,
inammation of scrotum.
Doxycycline by mouth
for several days, or one
dose of azithromycin.
Gonorrhea The Neisseria gonorrhoeae
bacterium is passed through
penile–vaginal, oral–genital,
oral–anal, or genital–anal
contact.
Women: Green or yellowish discharge (usually
remains undetected); pelvic inammatory disease
may develop.
Men: Cloudy discharge from penis and burning
during urination; complications include painful
swelling at bottom of affected testis and inam-
mation of scrotum.
Dual therapy of one dose
of a cephalosporin medi-
cation (e.g., ceftriaxone),
plus one dose of azithro-
mycin (or doxycycline for
7 days).
Nongono-
coccal
urethritis
(NGU)
Primarily caused by various
bacteria transmitted through
coitus.
Some NGU results from aller-
gic reactions or from Tricho-
monas infection.
Women: Mild discharge of pus from vagina (often
remains undetected).
Men: Discharge from penis and irritation during
urination.
One dose of azithromy-
cin, or doxycycline for 7
days.
Syphilis The Treponema pallidum
bacterium is passed from open
lesions during penile–vaginal,
oral–genital, oral–anal, or geni-
tal–anal contact.
Primary Stage:
Painless chancre at site where
bacterium entered body.
Secondary Stage: Chancre disappears, and gener-
alized skin rash appears.
Latent Stage: There may be no visible symptoms.
Tertiary Stage: Heart failure, blindness, mental
disturbance, and more; death may result.
Benzathine penicillin G,
doxycycline, tetracycline,
or ceftriaxone.
Herpes HSV-2 (genital herpes virus)
passed primarily through
penile–vaginal, oral–genital,
oral–anal, or genital–anal
contact.
HSV-1 (oral herpes) passed by
kissing or oral–genital contact.
Small, painful, red bumps appear in the genital
region or mouth.
Bumps become painful blisters and eventually
rupture to form wet, open sores.
No known cure.
A variety of treatments
can reduce symptoms.
Oral acyclovir, valacy-
clovir, or famciclovir
promote healing and
suppress recurrent
outbreaks.
Genital
warts
Human papillomavirus (HPV)
is passed primarily through
penile–vaginal, oral–genital,
oral–anal, or genital–anal
contact.
Hard and yellow-gray growths on dry skin areas.
Soft, pinkish-red, and cauliower-like growths on
moist areas.
Freezing, application of
topical agents, cauteriza-
tion, surgical removal, or
vaporization by carbon
dioxide laser.
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436 CHAPTER 15
STI Transmission Symptoms Treatment(s)
Viral
hepatitis
Hepatitis B virus can be passed
through blood, semen, vaginal
secretions, and saliva. Man-
ual, oral, or penile stimulation
of anus is strongly associated
with spread of hepatitis B.
Hepatitis A is spread by means
of oral–anal contact, especially
when the mouth encounters
fecal matter.
Hepatitis C is spread through
intravenous drug use and less
frequently through contami-
nated blood products, sexual
contact, or mother-to-fetus or
mother-to-infant contact.
Varies from no symptoms to mild, ulike symp-
toms to an incapacitating illness characterized by
high fever, vomiting, and severe abdominal pain.
No specic treatment for
hepatitis A and B.
Bed rest and adequate
uid intake.
Combination therapy
with antiviral drugs may
be effective against hepa-
titis C.
Bacterial
vaginosis
Different types of bacterial
microorganisms are passed
through coitus.
Women: Fishy- or musty-smelling, light-gray, thin
discharge (consistency of our paste).
Men: Usually asymptomatic.
Metronidazole (Flagyl) by
mouth.
Intravaginal applications
of topical metronidazole
gel or clindamycin cream.
Candi-
diasis (yeast
infection)
The fungus Candida albicans
accelerates growth when
normal chemical balance of
the vagina is disturbed. Can
be passed through sexual
interaction.
Women: White, “cheesy” discharge, irritation of
vaginal and vulval tissues.
Men: Usually asymptomatic but may have itching
or reddening of the penis and burning during
urination.
Vaginal suppositories
or topical cream, such
as clotrimazole and
miconazole.
Oral uoconazole or
itraconazole.
Trichomo-
niasis
The protozoan parasite Tricho-
monas vaginalis is usually
passed through sexual contact.
Women: White or yellow vaginal discharge with
unpleasant odor; vulva is sore and irritated.
Men: Usually asymptomatic but may have
urethral discharge, urge to urinate frequently, or
painful urination.
One dose of metronida-
zole (Flagyl or tinidazole)
for women and men.
Pubic lice
(“crabs”)
Pubic louse is spread through
body contact or through
shared clothing or bedding.
Persistent itching.
Lice are visible and can be located in pubic or
other body hair.
Prescription or over-the-
counter medications
(lotions or creams) applied
to all affected areas.
Scabies Highly contagious.
Can be passed by close
physical contact (sexual and
nonsexual).
Small bumps and a red rash that itch intensely
(especially at night).
Topical scabicide applied
from neck down to toes.
Acquired
immuno-
deciency
syndrome
(AIDS)
Blood, semen, and vaginal u-
ids are the major vehicles for
transmitting HIV (which attacks
the immune system).
Passed primarily through
penile–vaginal, oral–genital,
oral–anal, or genital–anal
contact or by needle sharing
among injection drug users.
Varies with the types of opportunistic infections or
cancers that can afict an infected person.
Common symptoms include fever, night sweats,
weight loss, chronic fatigue, swollen lymph
nodes, diarrhea and/or bloody stool, atypical
bruising or bleeding, skin rashes, headache,
chronic cough, and a whitish coating on the
tongue or throat.
Commence treatment
with a combination of
three or more antiret-
roviral drugs (HAART)
when CD4 count is sig-
nicantly low.
Specic treatments may
be necessary to treat
opportunistic infections
and tumors.
TABLE 15.1 Common Sexually Transmitted Infections: Transmission, Symptoms, and Treatment (continued)
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Sexually Transmitted Infections437 437
If you want more information, we recommend that you contact your county health
service, an STI/STD clinic, or a Planned Parenthood clinic, or that you call the National
STI Resource Center.* ese services can answer questions, send free literature, and,
most important, give you the name and phone number of a local physician or public
clinic that will treat STIs for free or at minimal cost.
Bacterial Infections
A variety of STIs are caused by bacterial agents. We begin this section with a discussion
of chlamydia, one of the most prevalent and damaging of all STIs. The other bacterial
infections we describe are gonorrhea, nongonococcal urethritis, and syphilis. We discuss
bacterial vaginosis, a common vaginal infection, in a later section of this chapter.
SEXUALHEALTH
Telling a Partner
LET’S TALK
ABOUT IT
Most of us would nd it difcult to discuss with our lover(s)
the possibility that we have transmitted an infection to her
or him during sexual activity. Because of the stigma often
associated with STIs, it can be bad enough admitting to your-
self that you have one of these infections. The need to tell
others that they might have “caught” something from you
may seem like a formidable task. You might fear that such a
revelation will jeopardize a valued relationship, or you might
worry that you will be considered “dirty.” In relationships pre-
sumed to be monogamous, you might fear that telling your
partner about an STI will threaten mutual trust. At the same
time, however, concealing a sex-related illness places a good
deal more at risk in the long run. Moreover, a recent study
found that people who had disclosed their STI to their part-
ners “had signicantly more positive feelings about aspects
of their sexual self-concept than those who had not disclosed
their STI to their partners” (Newton & McCabe, 2008, p. 187).
Most important, not disclosing the existence of an STI
risks the health of your partner(s). Many people may not
have symptoms and thus may not become aware that they
have contracted an infection until they discover it for them-
selves, perhaps only after they have developed serious
complications. Furthermore, if a lover remains untreated,
she or he may reinfect you even after you have been cured.
Unlike some diseases (such as measles and chicken pox),
STIs do not provide immunity against future infections. You
can get one, give it to your lover, be cured, and then get it
back again if he or she remains untreated.
The following suggestions provide some guidelines
for telling a partner about your STI.
Remember, these
are only suggestions that have worked for some people;
they may need to be modied to t your particular
circumstances. This sensitive issue requires thoughtful
consideration and planning.
1. Be honest. There is nothing to be gained by downplaying
the potential risks associated with STIs. If you tell a part-
ner, “I have this little drip, but it probably means noth-
ing,” you may regret it. Be sure your partner understands
the importance of obtaining a medical evaluation.
2. Even if you suspect that your partner may have been
the source of your infection, there is little to be gained
by blaming him or her. Instead, you may wish simply
to acknowledge that you have an infection and are con-
cerned that your partner gets proper medical attention.
3. Your attitude may have a considerable effect on how
your partner receives the news. If you display high levels
of anxiety, guilt, fear, or disgust, your partner may reect
these feelings in her or his response. Try to present the
facts in as clear and calm a fashion as you can manage.
4. Be sensitive to your partners feelings. Be prepared for
reactions of anger or resentment. These are understand-
able initial responses. Being supportive and demonstrat-
ing a willingness to listen without becoming defensive
may be the best tactics for diffusing negative responses.
5. Engaging in sexual intimacies after you become aware of
your condition and before you obtain medical assurances
that you are no longer contagious is clearly inappropriate.
Discuss with your partner that abstinence from sexual
intercourse is crucial for persons who are being treated
for an STI or whose partners are undergoing treatment.
6. Medical examinations and treatments for STIs, when
necessary, can be a financial burden. Offering to pay
for some or all of these expenses may help to maintain
(or reestablish) goodwill in your relationship.
*The American Social Health Associations STI Resource Center can be dialed toll-free from
8:00 a.m. to 8:00 p.m. on weekdays and from 10:00 a.m. to 6:00 p.m. on weekends, Pacific
time. The number is (800) 227-8922.
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438 CHAPTER 15
Chlamydia Infection
Chlamydia (cluh-MID-ee-uh) is caused by Chlamydia trachomatis, a bacterial micro-
organism that grows in body cells. This organism is now recognized as the cause of a
diverse group of genital infections and is a common cause of preventable blindness.
Incidence and Transmission
Chlamydia is the most frequently reported infectious disease in the United States
(Powers et al., 2011; Workowski et al., 2010). Sexually active teenagers, especially
females, have higher infection rates than any other age group (Powers et al., 2011). It
appears that teenage girls and young women in their early 20s are especially susceptible
to chlamydia infection, largely because their cervixes have not fully matured (Centers
for Disease Control, 2009b).
Chlamydia infection is transmitted primarily through vaginal, anal, or oral sexual
contact. It can also be spread by ngers from one body site to another, such as from the
genitals to the eyes.
Symptoms and Complications
Two general types of genital chlamydia infections affect females. The first of these,
infection of the mucosa of the lower reproductive tract, commonly takes the form of
an inflammation of the urethral tube or an infection of the cervix. In both cases women
experience few or no symptoms (Centers for Disease Control, 2009b). When symp-
toms do occur, they include a mild irritation or itching of the genital tissues, a burning
sensation during urination, and a slight vaginal discharge.
e second type of genital chlamydia infection in women is invasive infection of the
upper reproductive tract, expressed as pelvic inflammatory disease (PID). PID typi-
cally occurs when bacteria that cause chlamydia or gonorrhea spread from the cervix
upward, infecting the lining of the uterus (endometritis), the fallopian tubes (salpingitis),
and possibly the ovaries and other adjacent abdominal structures (Gottlieb et al., 2011;
Wendling, 2011). An estimated 40% of women with untreated chlamydia will develop
PID (Centers for Disease Control, 2009b).
PID resulting from chlamydia infection often produces a variety of symptoms,
which can include disrupted menstrual periods, chronic pelvic pain, lower back pain,
fever, nausea, vomiting, and headache. Salpingitis caused by chlamydia infection is the
primary preventable cause of female infertility and ectopic pregnancy (Gottlieb et al.,
2011). Even after PID has been eectively treated, residual scar tissue in the fallopian
tubes can leave some women sterile.
A woman who has had PID should be cautioned about the use of the IUD as a
method of contraception. An IUD does not prevent fertilization (see Chapter 10 for an
explanation of how the IUD prevents pregnancy); thus a tiny sperm cell could negotiate
a partially blocked area of a scarred fallopian tube and fertilize an ovum that, because of
its larger size, subsequently becomes lodged in the scarred tube. e result is an ectopic
pregnancy, a serious hazard to the woman. e incidence of ectopic pregnancies in the
United States has increased dramatically in the last two decades, largely because of an
escalation in the occurrence of chlamydia infections. Chlamydia also often reduces fer-
tility in women without detectable fallopian tube damage (Coppus et al., 2011).
In men, untreated chlamydia may result in a variety of symptoms, including a dis-
charge from the penis and/or a burning sensation during urination, itching around the
opening of the penis, and, less commonly, pain and swelling in the testicles (Centers for
Disease Control, 2009b).
One of the most disheartening aspects of chlamydia is that symptoms are either
minimal or nonexistent in a majority of infected women and about half of infected men
chlamydia
Urogenital infection caused by the
bacterium Chlamydia trachomatis.
pelvic inammatory disease (PID)
An infection in the uterus and pelvic
cavity.
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Sexually Transmitted Infections439 439
(Centers for Disease Control, 2009b). Most women and
men with rectal chlamydia infections also manifest few
or no symptoms (Kent et al., 2005).
Another complication associated with Chlamydia
trachomatis is trachoma (truh-KOH-muh), a chronic,
contagious form of conjunctivitis (kun-junk-ti-VIE-
tus) (inammation of the mucous membrane that lines
the inner surface of the eyelid and the exposed surface of
the eyeball) (Kari et al., 2011). Trachoma is the world’s
leading cause of preventable blindness; it is particularly
prevalent in Asia and Africa (Karpecki & Shechtman,
2008). Chlamydia trachomatis is a common cause of
eye infections (conjunctivitis) in newborns, who can
become infected as they pass through the birth canal
(Workowski et al., 2010). In addition, many babies of
infected mothers will develop pneumonia caused by
chlamydia infection (Workowski et al., 2010). Chla-
mydia infection in pregnant women can also lead to
premature delivery (Ball, 2011; H. Johnson et al., 2011). e CDC recommends that
pregnant women be tested for chlamydia during their rst prenatal visit.
e Centers for Disease Control (2009b) estimates that women infected with chla-
mydia are up to ve times more likely to become infected with HIV (the virus that
causes AIDS) if exposed to it.
Treatment
CDC guidelines suggest treating uncomplicated chlamydia infections with a 7-day reg-
imen of doxycycline taken by mouth or a single 1-gram dose of azithromycin. All sexual
partners exposed to chlamydia should be examined for STIs and treated if necessary.
Gonorrhea
Gonorrhea (gah-nuh-REE-uh), known in street language as the clap, is an STI
caused by the bacterium Neisseria gonorrhoeae (also called gonococcus).
Incidence and Transmission
Gonorrhea is the second most reported infectious condition in the United States,
trailing only chlamydia (Workowski et al., 2010). The CDC estimates that there are
more than 700,000 new cases of gonorrhea each year (Bolan et al., 2012). Unfortu-
nately, after declining or remaining stable for many years, national rates of gonorrhea
increased slightly in recent years, and the incidence of gonorrhea remains exception-
ally high among teenagers and young adults, especially in lower-socioeconomic ethnic-
minority communities (Bolan et al., 2012; Bradley et al., 2012).
e gonococcus bacterium thrives in the warm mucous membrane tissues of the geni-
tals, anus, and throat. Its mode of transmission is by sexual contact—penile–vaginal,
oral–genital, oral–anal, or genital–anal.
Symptoms and Complications
Early symptoms of gonorrhea infection are more likely to be evident in men than in women
(Centers for Disease Control, 2009c). Most men who experience gonococcal urethritis
have some symptoms, ranging from mild to pronounced. However, it is not uncommon
for men with this type of infection to have no symptoms and yet be potentially infectious.
Chlamydia conjunctivitis in a newborn, acquired from an infected
mother during birth.
© Western Ophthalmic Hospital/Science Photo Library/Custom Medical Stock Photo
trachoma
A chronic, contagious form of con-
junctivitis caused by chlamydia
infections.
conjunctivitis
Inammation of the mucous mem-
brane that lines the inner surface of
the eyelid and the exposed surface of
the eyeball.
gonorrhea
A sexually transmitted infection
that initially causes inammation of
mucous membranes.
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440 CHAPTER 15
Early Symptoms in the Male In men early symptoms typically appear 2–5 days after
sexual contact with an infected person. However, symptoms can show up as late as 30
days after contact or, in a small number of cases, may not appear at all. The two most
common signs of infection are a bad-smelling, cloudy discharge from the penis (see
Figure 15.1) and a burning sensation during urination. Some infected men also have
swollen and tender lymph glands in the groin. These early symptoms sometimes clear
up on their own without treatment. However, this is no guarantee that the infection has
been eradicated by the body’s immune system. The bacteria may still be present, and a
man may still be able to infect a partner.
Complications in the Male If the infection continues without treatment for 2 to 3 weeks,
it can spread up the genitourinary tract. Here, it can involve the prostate, bladder, kidneys,
and testes. Most men who continue to harbor gonococcus have only periodic flare-ups of the
minor symptoms of discharge and a burning sensation during urination. In a small number
of men, however, abscesses form in the prostate. These can result in fever, painful bowel
movements, difficulty urinating, and general discomfort. In approximately 1 out of 5 men
who remain untreated for longer than a month, the bacteria move down the vas deferens to
infect one or both of the epididymal structures that lie along the back of each testis. In gen-
eral, only one side is infected initially, usually the left. Even after successful treatment, gono-
coccal epididymitis leaves scar tissue, which can block the flow of sperm from the affected
testis. Sterility does not usually result, because this complication typically affects only one
testis. However, if treatment is still not carried out after epididymitis has occurred on one
side, the infection can spread to the other testis, causing permanent sterility.
Early Symptoms in the Female Most women infected with gonorrhea are unaware
of the early symptoms of this infection. The primary site of infection, the cervix,
can become inflamed without producing any observable symptoms. Symptoms
that may occur include a painful or burning sensation when urinating and/or
increased vaginal discharge. However, because this discharge is rarely heavy, it com-
monly goes unnoticed. A woman who is aware of her vaginal secretions is more
likely to note the infection during these early stages. Sometimes the discharge is
irritating to the vulval tissues. However, when a woman seeks medical attention
for an irritating discharge, her physician may fail to consider gonorrhea because
many other infectious organisms produce this symptom. Also, many women who
have gonorrhea also have trichomoniasis (discussed later in this chapter), and this
condition can mask the presence of gonorrhea. Consequently, it is essential for
any woman who thinks she may have gonorrhea to make certain that she is tested
for the infection when she is examined. (A Pap smear is not a test for gonorrhea.)
Complications in the Female Serious complications result from the spread of this infec-
tion to the upper reproductive tract, where it often causes PID (Centers for Disease Con-
trol, 2009c). The symptoms of PID, discussed in the section on chlamydia infection, are
often more severe when the infecting organism is gonococcus rather than Chlamydia tracho-
matis. Sterility and ectopic pregnancy are serious consequences occasionally associated with
gonococcal PID. Another serious complication that can result from PID is the development
of tough bands of scar tissue adhesions that may link several pelvic cavity structures (fal-
lopian tubes, ovaries, uterus, etc.) to each other, to the abdominal walls, or to both. These
adhesions can cause severe pain during coitus or when a woman is standing or walking.
Other Complications in Both Sexes In about 2% of adult men and women with gonor-
rhea, the bacteria enter the bloodstream and spread throughout the body to produce a
variety of symptoms, including chills, fever, loss of appetite, skin lesions, and arthritic
Figure 15.1 A cloudy discharge symptomatic
of gonorrhea infection.
© Lester V. Bergman/CORBIS
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Sexually Transmitted Infections441 441
pain in the joints (Centers for Disease Control, 2009c; Martin et al., 2008). If arthritic
symptoms develop, quick treatment is essential to avoid permanent joint damage. In
rare cases the gonococcus organism can invade the heart, liver, spinal cord, and brain.
An infant can develop a gonococcal eye infection after passing through the birth
canal of an infected woman (Workowski et al., 2010). In a few rare cases, adults have
transmitted the bacteria to their own eyes by touching this region immediately after
handling their genitals—one reason why it is important to wash with soap and water
immediately after self-examination.
Oral contact with infected genitals can result in infection of the throat. Although
this form of gonorrhea can cause a sore throat, most people experience no symptoms.
Rectal gonorrhea can be caused by anal intercourse or, in a woman, by transmission of
the bacteria from the vagina to the anal opening by means of menstrual blood or vaginal
discharge. Rectal gonorrhea is often asymptomatic, particularly in females, but it might
be accompanied by itching, bleeding, rectal discharge, and painful bowel movements.
Treatment
Because gonorrhea is often confused with other ailments, it is important to make the
correct diagnosis. Because coexisting chlamydia infections often accompany gonorrhea,
health practitioners often use a treatment strategy that is effective against both. For a
number of years the treatment regimen recommended by the CDC involved the dual
therapy of a single dose of a fluoroquinolone antibiotic, such as ciprofloxacin, plus a sin-
gle dose of azithromycin (or doxycycline for 7 days). Unfortunately, in recent years there
has been an alarming worldwide increase in strains of gonorrhea resistant to fluoroqui-
nolone antibiotics (Dowell et al., 2012). Consequently, the CDC now recommends that
health professionals stop using fluoroquinolones and substitute a cephalosporin medi-
cation (a different class of antibiotics, such as ceftriaxone) to treat gonorrhea infections.
Recent research has identied a new mutated strain of the gonococcus bacterium,
HO41, that causes an infection that cannot be treated by available antibiotics, including
cephalosporin-class antibiotics (Unemo et al., 2011). is alarming discovery suggests
that a once easily treatable infection may become a global public health threat if this new
drug-resistant strain becomes widespread (Bolan et al., 2012).
It is quite common for sexual partners of infected individuals to have also contracted
gonorrhea. Consequently, all sexual partners exposed to a person with diagnosed gonor-
rhea should be examined, cultured, and, if necessary, treated with a drug regimen that
covers both gonococcal and chlamydia infections (Katz, 2011).
Nongonococcal Urethritis
Any inflammation of the urethra that is not caused by gonorrhea is called nongono-
coccal urethritis (NGU). It is believed that three microscopic bacterial organisms—
Chlamydia trachomatis, Ureaplasma urealyticum, and Mycoplasma genitaliumare
primary causes of NGU (Centers for Disease Control, 2009d). NGU can also result
from invasion by other infectious agents, allergic reactions to vaginal secretions, or
irritation from soaps, vaginal contraceptives, or deodorant sprays.
Incidence and Transmission
NGU is quite common among men: In the United States NGU occurs more frequently
than gonorrhea. Although NGU generally produces urinary tract symptoms only in
men, there is evidence that women harbor the organisms that can cause NGU. The
most common forms of NGU are generally transmitted through coitus. That NGU
rarely occurs in men who are not involved in sexual interaction supports this contention.
SEXUALHEALTH
nongonococcal urethritis (NGU)
An inammation of the urethral tube
caused by organisms other than
gonococcus.
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442 CHAPTER 15
Symptoms and Complications
Men who contract NGU often manifest symptoms similar to those of gonorrhea infec-
tion, including discharge from the penis and a mild burning sensation during urina-
tion. Often the discharge is less pronounced than with gonorrhea; it may be evident
only in the morning before urinating.
Women with NGU are generally unaware of the infection until they are informed
that it has been diagnosed in a male partner. ey frequently show no symptoms,
although there may be some itching, a burning sensation during urination, and a mild
discharge of pus from the vagina. A woman may unknowingly have the infection for a
long time, during which she may pass it to sexual partners.
e symptoms of NGU generally disappear after 2 to 3 months without treatment.
However, the infection may still be present. If left untreated in women, it can result in
cervical inammation or PID; in men it can spread to the prostate, epididymis, or both.
In rare cases NGU can produce a form of arthritis.
Treatment
A single dose of azithromycin or a regimen of doxycycline for 7 days usually clears up
NGU. All sexual partners of individuals diagnosed with NGU should be examined for
the presence of an STI and treated if necessary.
Syphilis
Syphilis (SIH-fuh-lus) is an STI caused by a thin, corkscrewlike bacterium called
Treponema pallidum (also commonly called a spirochete).
Incidence and Transmission
Syphilis rates declined steadily in the United States throughout the 1990s (Rosen,
2006). Unfortunately, syphilis rates have recently risen. This overall increased inci-
dence of syphilis was largely attributable to an increase among men who have sex with
men (MSM) (Mayer & Mimiaga, 2011).
Treponema pallidum requires a warm, moist environment for survival. It is trans-
mitted almost exclusively from open lesions of infected individuals to the mucous
membranes or skin abrasions of sexual partners through penile–vaginal, oral–genital,
oral–anal, or genital–anal contacts.
An infected pregnant woman can also transmit Treponema pallidum to her unborn
child through the placental blood system. e resulting infection can cause miscarriage,
stillbirth, or congenital syphilis, which can result in death or extreme damage to infected
newborns (Centers for Disease Control, 2010a; Hawkes et al., 2011). Worldwide more
than 2 million pregnant women have active syphilis (Hawkes et al., 2011), and every
year at least 500,000 children are born aicted with congenital syphilis (Ramiandrisoa
et al., 2011). If syphilis is successfully treated before the 4th month of pregnancy, the
fetus will not be aected. erefore pregnant women should be tested for syphilis some-
time during their rst 3 months of pregnancy. e CDC recommends that all pregnant
women be tested for syphilis at the rst prenatal visit.
Symptoms and Complications
If untreated, syphilis can progress through the primary, secondary, latent, and tertiary
phases of development. We provide a brief description of each phase in the following
paragraphs.
Primary Syphilis In its initial or primary phase, syphilis is generally manifested in the
form of a single, painless sore called a chancre (SHANG-kur), which usually appears
syphilis
A sexually transmitted infection
caused by a bacterium called Trepo-
nema pallidum.
chancre
A raised, red, painless sore that is
symptomatic of the primary phase of
syphilis.
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Sexually Transmitted Infections443 443
about 3 weeks after initial infection at the site where the spirochete organism entered
the body (see
Figure 15.2). In women this sore most commonly appears on the inner
vaginal walls or cervix. It can also appear on the external genitals, particularly the labia.
In men the chancre most often occurs on the glans of the penis, but it can also show up
on the penile shaft or on the scrotum. Although most chancres are genital, the sores can
occur in the mouth or rectum or on the anus or breast. People who have had oral sex
with an infected individual might develop a sore on the lips or tongue. Anal intercourse
can result in chancres appearing in the rectum or around the anus.
Since the chancre is typically painless, it often goes undiscovered when it occurs on
internal structures, such as the rectum, vagina, or cervix. (Occasionally, chancres may be
painful, and they may occur in multiple sites.) Even when the chancre is noticed, some
people do not seek treatment. Unfortunately (from the long-term perspective), the chancre
generally heals without treatment 3 to 6 weeks after it rst appears. For the next few weeks,
the infected person usually has no symptoms but can infect an unsuspecting partner. After
about 6 weeks (although sometimes after as little as 2 weeks or as many as 6 months), the
infection often progresses to the secondary stage in people with untreated primary syphilis.
Secondary Syphilis In the secondary phase, which usually emerges 2 to 8 weeks after
exposure, a skin rash appears on the body, often on the palms of the hands and soles
of the feet (see
Figure 15.3). The rash can vary from barely noticeable to severe, with
raised bumps that have a rubbery, hard consistency. Although the rash may look terrible,
it typically does not hurt or itch. Besides a generalized rash, a person may experience
flulike symptoms, such as fever, swollen lymph glands, fatigue, weight loss, and joint or
bone pain. Even when not treated, these symptoms usually subside within a few weeks.
Rather than being eliminated, however, the infection can then enter the potentially
more dangerous latent phase (Centers for Disease Control, 2009e).
Latent Syphilis The latent stage can last for several years, during which time there may be
no observable symptoms (Centers for Disease Control, 2009e). Nevertheless, the infecting
organisms continue to multiply, preparing for the final stage of syphilitic infection. After 1
year of the latent stage, the infected individual is no longer contagious to sexual partners.
However, a pregnant woman with syphilis in any stage can pass the infection to her fetus.
Tertiary Syphilis Approximately 15% of individuals who do not obtain effective treat-
ment during the first three stages of syphilis enter the tertiary stage later in life (Centers
Figure 15.2 The first stage of syphi-
lis. A syphilitic chancre as it appears
on (a) the penis and (b) the labia.
© Lester V. Bergman/CORBIS
© Centers for Disease Control, Atlanta, GA
(a)
(b)
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444 CHAPTER 15
for Disease Control, 2009e). The final manifestations of syphilis can be
severe, often resulting in death. They usually occur anywhere from 10 to
20 years after initial infection and include such conditions as heart failure,
blindness, ruptured blood vessels, paralysis, skin ulcers, liver damage, and
severe mental disturbance (Centers for Disease Control, 2009e). Treat-
ment even at this late stage can be beneficial.
Genital sores (chancres) associated with the primary phase of syphi-
lis infections increase the possibility of either transmitting or acquiring
HIV infection through sexual activity. It is estimated that there is a two-
to vefold increased risk of becoming infected with HIV if exposed to
this infectious virus when syphilitic sores are present (Centers for Dis-
ease Control, 2009e). Any sores, ulcers, or breaks in the skin (conditions
that often accompany STIs) increase the possibility of either transmitting
or becoming infected with HIV. Ulcerative sores bleed easily (blood is a
major reservoir for HIV), and when they come into contact with genital,
oral, or rectal mucosa during sexual activity there is a resulting increase in
both the infectiousness of and susceptibility to HIV.
Treatment
Primary, secondary, or latent syphilis of less than 1 years duration can be
effectively treated with intramuscular injections of benzathine penicillin
G. People who are allergic to penicillin can be treated with doxycycline,
tetracycline, or ceftriaxone. Syphilis of more than 1 years duration is
treated with intramuscular injections of benzathine penicillin G once a
week for 3 successive weeks. The CDC recommends follow-up at 6 and
12 months after initial diagnosis to determine the effectiveness of treat-
ment. Recent research reveals significant risk factors for repeat syphilis
infection, especially among MSM (Cohen et al., 2012).
All sex partners who have been exposed to a person with infectious
syphilis should be tested and treated if necessary.
Viral Infections
Viruses are the cause of several common STIs. A virus is an organism that
invades, reproduces, and lives within a cell, thereby disrupting normal cel-
lular activity. Most viruses are transmitted through direct contact with
infectious blood or other body fluids. We begin our discussion with her-
pes, the most common viral STI. Next, we describe genital warts caused by
several varieties of viruses that have reached epidemic proportions in the
U.S. population. We conclude with some information about viral hepatitis.
AIDS, caused by HIV infection, is described in detail later in this chapter.
Herpes
Herpes is caused by the Herpes simplex virus (HSV). Eight different herpes viruses
infect humans, the most common being the varicella-zoster virus (VZV) that causes
chicken pox, followed in frequency by Herpes simplex virus type 1 (HSV-1) and Herpes
simplex virus type 2 (HSV-2). In the following discussion we confine our attention to
HSV-1 and HSV-2 because these are the two herpes viruses that are widely transmit-
ted through sexual contact. HSV-1 typically manifests itself as lesions or sores—called
Figure 15.3 In the secondary phase of syphilis,
a skin rash appears on the body, often on (a) the
palms and (b) the feet.
Southern Illinois University/Photo Researchers, Inc.© Biophoto Associates/Photo Researchers, Inc.
(a)
(b)
herpes
An infection characterized by blis-
ters on the skin in the regions of the
genitals or mouth. It is caused by the
Herpes simplex virus and is easily
transmitted through sexual contact.
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Sexually Transmitted Infections445 445
cold sores or fever blisters—in the mouth or on the lips (oral herpes). HSV-2 generally
causes lesions on and around the genital areas (genital herpes).
Although genital and oral herpes are usually associated with dierent herpes viruses,
oral–genital transmission is possible. HSV-1 can aect the genital area, and, conversely,
HSV-2 can produce a sore in the mouth (Centers for Disease Control, 2009f). How-
ever, most infections of the genitals are of the HSV-2 variety, and most mouth infec-
tions are HSV-1 (Centers for Disease Control, 2009f; Looker et al., 2008).
Incidence and Transmission
Current estimates indicate that more than 100 million Americans have oral herpes,
and at least 50 million (1 in 5 people over age 12) have genital herpes (Workowski et
al., 2010). Worldwide genital herpes cases number in the hundreds of millions, and
24–25 million people are newly infected each year (Looker et al., 2008). Genital her-
pes infections in the United States are more common in women than in men, which
may indicate that male-to-female transmission is more likely than female-to-male
transmission (Centers for Disease Control, 2009f).
Genital herpes appears to be transmitted primarily by penile–vaginal, oral–genital,
genital–anal, or oral–anal contact. Oral herpes can be transmitted by kissing or through
oral–genital contact. A person who receives oral sex from a partner who has herpes in
the mouth region can develop either type 1 or type 2 genital herpes.
When any herpes sores are present, the infected person is highly contagious. It is
extremely important to avoid bringing the lesions into contact with someone elses body
through touching, sexual interaction, or kissing.
Although it was once believed that herpes could be transmitted only when lesions
were present, we now know that HSV can be transmitted even when there are no symp-
toms (Workowski et al., 2010). In fact, research strongly indicates that asymptomatic
“viral shedding (the emission of viable HSV onto body surfaces) is likely to occur
at least some of the time in many people infected with HSV (Tronstein et al., 2011;
Worcester, 2012). is asymptomatic viral shedding can result in transmission of the
virus despite the absence of symptoms that suggest active infection. Many people who
are infected with HSV are unaware of their infection, and the majority of infections are
transmitted by these individuals (Mark et al., 2008).
Research has shown that herpes viruses do not pass through latex condoms. us
condoms are eective in preventing transmission from a male whose only lesions occur
on the glans or shaft of the penis. Condoms are helpful but less eective in preventing
transmission from a female to a male, because vaginal secretions containing the virus
can wash over the males scrotal area. Nevertheless, using condoms consistently and cor-
rectly can minimize the risk of either acquiring or transmitting genital herpes.
What can infected people do to reduce the risk that they will transmit the virus to
a sexual partner? Clearly, when lesions are present, individuals should avoid any kind of
intimate or sexual activity that will expose a partner’s body to viral shedding of HSV.
However, as previously described, even when no sores or other symptoms are present,
infected individuals are at risk for shedding the virus. e best strategy for people who
are either infected themselves or involved with an infected partner is to consistently and
correctly use condoms even when they or their partners are asymptomatic.
Symptoms and Complications
The symptoms associated with HSV-1 and HSV-2 infections are quite similar.
Genital Herpes (Type 2) Symptoms The incubation period of genital herpes is 2 to 14
days, and the symptoms usually last 2 to 4 weeks (Centers for Disease Control, 2009f;
SEXUALHEALTH
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446 CHAPTER 15
Looker et al., 2008). However, many individuals with genital herpes experience minimal
or no recognizable symptoms (Centers for Disease Control, 2009f). When symptoms are
present, they consist of one or more small painful red bumps, called papules, that usually
appear in the genital region. In women the areas most commonly infected are the labia. The
mons veneris, clitoris, vaginal opening, inner vaginal walls, and cervix can also be affected. In
men the infected site is typically the glans or shaft of the penis. Men and women who have
engaged in anal intercourse can develop eruptions in and around the anus.
Soon after their initial appearance, papules rapidly develop into tiny painful blis-
ters lled with a clear uid containing highly infectious virus particles. e body then
attacks the virus with white blood cells, causing the blisters to ll with pus (see
Figure
15.4). Soon the blisters rupture to form wet, painful open sores surrounded by a red
ring (health practitioners refer to this as the period of viral shedding). A person is highly
contagious during this time. About 10 days after the rst appearance of a papule, the
open sore forms a crust and begins to heal—a process that can take as long as 10 more
days. Sores on the cervix can continue to produce infectious material for as long as 10
days after labial sores have completely healed. Consequently, it is wise to avoid coitus for
a 10-day period after all external sores have healed.
Other symptoms can accompany genital herpes, including swollen lymph nodes in
the groin, fever, muscle aches, and headaches. In addition, urination may be accompa-
nied by a burning sensation, and women may experience increased vaginal discharge.
Oral Herpes (Type 1) Symptoms Oral herpes is characterized by the formation of pap-
ules on the lips and sometimes on the inside of the mouth, on the tongue, and on the
throat. These blisters tend to crust over and heal in 10 to 16 days. Other symptoms
include fever, general muscle aches, swollen lymph nodes in the neck, flulike symptoms,
increased salivation, and sometimes bleeding in the mouth.
Recurrence Even after complete healing, lesions can recur. Unfortunately, the herpes
virus does not typically go away; instead, it retreats up the nerve fibers leading from the
infected site (Colgan et al., 2003). Ultimately, the genital herpes virus finds a resting
place in nerve cells adjacent to the lower spinal column, whereas the oral herpes virus
becomes lodged in nerve cells in the back of the neck. The virus can remain dormant in
these cells, without causing any apparent damage, perhaps for a persons entire lifetime.
However, in many cases there will be periodic flare-ups as the virus retraces its path
back down the nerve fibers leading to the genitals or lips.
Many individuals with genital herpes who
have rare outbreaks of the infection worry
about being rejected by prospective sexual
partners if they disclose their condition.
Do you believe that people who carefully
monitor their health and take reasonable
precautions can ethically enter into sexual
relationships without revealing that they
have genital herpes? Why or why not?
Critical Thinking Question
Figure 15.4 Genital herpes blisters as they appear on (a) the labia and (b) the penis.
© Centers for Disease Control, Atlanta, GA
© Centers for Disease Control, Atlanta, GA
(a) (b)
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Sexually Transmitted Infections447 447
Although some people never experience a recurrence of herpes following the initial
or primary infection, research suggests that most people who have undergone a primary
episode of genital herpes infection experience at least one recurrence. Individuals who
experience recurrences may do so frequently or only occasionally. Symptoms associated
with recurrent attacks tend to be milder than primary episodes, and the infection tends
to run its course more quickly.
Most people prone to recurrent herpes outbreaks experience some type of prodro-
mal symptoms that warn of an impending eruption. ese indications include itch-
ing, burning, throbbing, or “pins-and-needles tingling at the sites commonly infected by
herpes blisters, and sometimes pain in the legs, thighs, groin, or buttocks. Many health
authorities believe that a persons degree of infectiousness increases during this stage
and that it further escalates when the lesions appear. Consequently, a person should be
particularly careful to avoid direct contact from the time he or she rst experiences pro-
dromal symptoms until the sores have completely healed. Even during an outbreak, it is
possible to continue sexual intimacies with a partner, as long as infected skin does not
come into contact with healthy skin. During this time, partners may wish to experiment
with other kinds of sensual pleasuring, such as sensate focus (see Chapter 14), hugging,
or manual stimulation.
A variety of factors can trigger reactivation of the herpes virus, including emotional
stress, anxiety, depression, acidic food, ultraviolet light, fever, menstruation, poor nutri-
tion, being overtired or run-down, and trauma to the aected skin region. Because
triggering factors vary so widely, it is often dicult to associate a specic event with a
recurrent herpes outbreak.
Some people may not experience a relapse of genital herpes until several years after
the initial infection. erefore, if you have been in what you believe is a sexually exclu-
sive relationship and your partner shows symptoms or transmits the virus to you, it does
not necessarily mean that she or he contracted the infection from someone else during
the course of your relationship. Furthermore, as stated earlier, many people with genital
herpes infections are asymptomatic or have mild symptoms that are often unrecogniz-
able. us a rst episode of symptomatic genital herpes may not be due to recent sexual
contact with an infected person (Centers for Disease Control, 2009f ).
Other Complications Although the sores are painful and bothersome, it is unlikely that
men will experience major physical complications of herpes. Women, however, face two
serious, although quite uncommon, complications: cancer of the cervix and infection
of a newborn. Evidence suggests that the risk of developing cervical cancer is some-
what higher among women who have had genital herpes (Centers for Disease Control,
2006b). However, the role of genital herpes in cervical cancer is at most that of a cofac-
tor, not that of a direct causative agent (Centers for Disease Control, 2006b). Fortu-
nately, the great majority of women infected with herpes will never develop cancer of
the cervix. Nonetheless, it is advisable for all women, particularly those who have had
genital herpes, to obtain an annual cervical Pap smear. Some authorities recommend
that women with genital herpes should have this test every 6 months.
A newborn can be infected with genital herpes while passing through the birth canal,
and such an infection can cause severe damage or death (Looker et al., 2008; Workowski
et al., 2010). It is believed that viral shedding from the cervix, vagina, or vulva plays the
primary role in transmitting the infection perinatally from mother to infant. e risk
of a pregnant mother transmitting genital herpes to her newborn is highest for women
who are rst infected during late pregnancy (Workowski et al., 2010). e CDC recom-
mends that these women should consult with an infectious disease specialist to deter-
mine how to manage the impending birth.
prodromal symptoms
Symptoms that warn of an impending
herpes eruption.
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448 CHAPTER 15
e presence of a genital herpes infection is associated with a two- to threefold
increased risk of acquiring an HIV infection when exposed to HIV through sexual activity
(Looker et al., 2008). e risk of transmission of HIV by a person infected with both HIV
and HSV is estimated to increase vefold on a per-sexual-act basis (Looker et al., 2008).
One additional serious complication can occur when a person transfers the virus to
an eye after touching a virus-shedding sore. is can lead to a severe eye infection known
as ocular herpes (Karpecki & Shechtman, 2011). e best way to prevent this complica-
tion is to avoid touching herpes sores. If you cannot avoid contact, thoroughly wash your
hands with hot water and soap immediately after touching the lesions. ere are eective
treatments for ocular herpes, but they must be started quickly to avoid eye damage.
Many people who have recurrent herpes outbreaks are troubled with mild to severe
psychological distress (Barnack-Tavlaris, 2011; Merin & Pachankis, 2011). In view of
the physical discomfort associated with the infection, the unpredictability of recurrent
outbreaks, and the lack of an eective cure (see next section), it is no small wonder that
people who have herpes undergo considerable stress. We believe that becoming better
informed about herpes may help to alleviate some of these emotional diculties. In
addition, talking with supportive partners might ease a persons psychological adjust-
ment to recurrent genital herpes infections. Certainly, herpes is not the dread infection
that some people believe it to be. In fact, many individuals have learned to cope eec-
tively with it, as did the person in the following account:
When I first discovered I had herpes several years ago, my first reaction was,
Oh no, my sex life is destroyed!” I was really depressed and angry with the
person who gave me the infection. However, with time I learned I could live
with it, and I even began to gain some control over it. Now, on those infrequent
occasions when I have an outbreak, I know what to do to hurry up the healing
process. (Authors’ files)
Treatment
At the time of this writing, no medical treatment has been proven effective in curing
either oral or genital herpes. However, medical researchers are pursuing an effective
treatment on many fronts, with mounting optimism. Recent research suggests that
efforts to develop a herpes vaccine may yield positive results sometime in the future
(Belshe et al., 2012). Current treatment strategies are designed to prevent outbreaks or
to reduce discomfort and to speed healing during an outbreak.
ree separate antiviral drugs are often highly eective in the management of herpes.
Oral acyclovir taken several times daily is a common drug treatment for genital herpes.
Two other antiviral agents, valacyclovir (Valtrex) and famciclovir (Famvir), taken orally,
have also proven eective for management of genital herpes (Workowski et al., 2010).
Two antiviral treatment strategies are used to manage recurrent genital herpes infec-
tions. In suppressive therapy medication is taken daily to prevent recurrent outbreaks.
Suppressive therapy often prevents HSV reactivation and development of herpes
lesions (Workowski et al., 2010). Suppressive therapy also reduces asymptomatic viral
shedding between outbreaks and decreases the risk of sexual transmission of HSV
infections (Workowski et al., 2010). Episodic treatment involves treating herpes out-
breaks when they occur with an antiviral agent. Episodic treatment has been shown
to reduce the duration and severity of lesion pain and the time needed for total healing
(Worcester, 2010). However, episodic treatment does not reduce the risk for transmit-
ting HSV to a sexual partner (Workowski et al., 2010).
SEXUALHEALTH
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Sexually Transmitted Infections449 449
A number of other measures can provide relief from the discomfort associated with
herpes. e following suggestions can be helpful. Because the eectiveness of these
measures varies from person to person, we encourage people to experiment to nd an
approach that best meets their needs.
1. Keeping herpes blisters clean and dry will lessen the possibility of secondary
infections, signicantly shorten the period of viral shedding, and reduce the total
time of lesion healing. Washing the area with warm water and soap two to three
times daily is adequate for cleaning. After bathing, dry the area thoroughly by
patting it gently with a soft cotton towel or by blowing it with a hair dryer set
on cool. Because the moisture that occurs naturally in the genital area can slow
the healing process, sprinkling the dried area liberally with cornstarch or baby
powder can help. It is desirable to wear loose cotton clothing that does not trap
moisture (cotton underwear absorbs moisture, but nylon traps it).
2. Two aspirin every 3 to 4 hours might help to reduce the pain and itching. Appli-
cation of a local anesthetic, such as lidocaine jelly, can also help to reduce sore-
ness. Ice packs applied directly to the lesions can also provide temporary relief
(but avoid wetting the lesions as the ice melts). Keeping the area liberally pow-
dered can also alleviate itching.
3. Some people have an intense burning sensation when they urinate if the urine
comes into contact with herpes lesions. This discomfort can be reduced by pouring
water over the genitals while voiding or by urinating in a bathtub filled with water.
It might help to dilute the acid in the urine by drinking lots of fluids (but avoid
liquids that make the urine more acidic, such as cranberry juice).
4. Because stress has been implicated as a triggering event in recurrent herpes, it is
a good idea to try to reduce this negative influence. A variety of approaches may
help reduce stress. These include relaxation techniques, yoga or meditation, and
counseling about ways to cope with daily pressures.
5. If you are prone to repeated relapses of herpes, try recording events that occur
immediately before an outbreak (either after the fact or as part of an ongoing jour-
nal). You may be able to recognize common precipitating events, such as fatigue,
stress, or excessive sunlight, which you can then avoid in the future.
Genital Warts
Genital warts are caused by a virus called the human papillomavirus (HPV). Applica-
tion of recently developed technology has led to the identification of more than 100
types of HPV, about half of which cause genital infections (Workowski et al., 2010).
Incidence and Transmission
The incidence of HPV infections has been increasing so rapidly in both sexes that
this infection has reached epidemic proportions in recent years. HPV is now the most
common viral STI in the United States (Navas, 2010). It is estimated that at least 15%
of people in the United States are infected with HPV (Centers for Disease Control,
2009g). At least 50% of sexually active people will acquire an HPV infection at some
point in their lives (Centers for Disease Control, 2009g).
HPV is primarily transmitted through vaginal, anal, oral, or oral–genital sexual inter-
action. Transmission of HPV between the hands and genitals may also occur (Hernandez
et al., 2008). Condoms, which signicantly reduce transmission of many bacterial and
viral infections, provide some protection but are far from an ideal preventive measure for
HPV because the virus is often present on skin not covered by a condom (omas, 2008).
SEXUALHEALTH
genital warts
Viral warts that appear on the genitals
and are primarily transmitted sexually.
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450 CHAPTER 15
HPV passed during oral sex is a common cause of throat cancer among American
men (Girshman, 2011). About 60% of throat cancers in the United States are attributed
to this virus, and the recent rise in the incidence of this cancer has occurred predomi-
nantly among men (Gillison, 2012; Girshman, 2011).
Subclinical or asymptomatic infections with HPV are common, and viral shedding
and transmission of the virus can occur during asymptomatic periods of infection. In
fact, HPV is most commonly transmitted by asymptomatic individuals who do not
realize that they are infected (Centers for Disease Control, 2009g).
Symptoms and Complications
Most people who have genital HPV infections do not develop visible symptoms and
thus are unaware that they are infected (Centers for Disease Control, 2009g). Visible
warts, which have an average incubation period of about 3 months, may appear within
weeks or months after sexual contact with an infected person.
In women genital warts most commonly appear on the bottom part of the vaginal
opening. ey can also occur on the perineum, the labia, the inner walls of the vagina,
and the cervix. In men genital warts commonly occur on the glans, foreskin, or shaft
of the penis (see
Figure 15.5). Genital warts can also occur in the anus of either sex
(Wieland, 2012). In moist areas (such as the vaginal opening and under the foreskin),
genital warts are pink or red and soft, with a cauliower-like appearance. On dry skin
areas they are generally hard and yellow-gray.
If left untreated, genital warts may disappear, remain unchanged, or increase in size
and number (Centers for Disease Control, 2009g). A healthy immune system often
suppresses the virus, and most infected people with an eective immune response will
become HPV-negative in 6–24 months after the initial positive test for the virus.
Genital warts are sometimes associated with serious complications. ey can invade
the urethra, causing urinary obstruction and bleeding. Research has also revealed an
association between HPV infection and cancers of the cervix, vagina, vulva, urethra,
penis, and anus (Giuliano et al., 2011; Kim, 2011). e types of HPV that cause genital
warts are not the same as the types that can cause cancer (Centers for Disease Con-
trol, 2009g). Recent evidence indicates that HPV infections account for 85–90% of
the attributable risk for the development of cervical cancer, which is the second most
common cancer diagnosed in women worldwide and the leading cause of death from
Figure 15.5 Genital warts on the penis.
© Science Visuals Unlimited/Visuals Unlimited
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Sexually Transmitted Infections451 451
cancer among women in developing nations, where it kills about 250,000 women each
year (Centers for Disease Control, 2009g; McNeil, 2011). However, there is actually
little risk that a woman infected with HPV will develop cervical cancer unless the virus
remains undetected and untreated (Centers for Disease Control, 2009g). is is the
reason that regular Pap testing and appropriate follow-up treatment for precancer-
ous lesions are essential to prevent most women from getting cervical cancer (Kahn &
Hillard, 2006). A spokeswoman for the CDC recently stated that physicians often test
young women for strains of HPV that are not associated with cervical cancer and thus
needlessly subject women to unnecessary invasive tests (Saraiya in Neergaard, 2011).
Another rare but serious complication of HPV is that pregnant women infected
with the virus can transmit it to their babies during birth (Rintala et al., 2005). Infected
infants can develop a condition known as respiratory papillomatosis, which results from
HPV infection of their upper respiratory tracts. Respiratory papillomatosis can have
serious health consequences that produce lifelong distress and require multiple surgeries.
Treatment
No single treatment has been shown to be uniformly effective in removing warts or in
preventing them from recurring. Current CDC guidelines suggest several fairly con-
servative approaches to HPV management that focus on the removal of visible warts.
The most widely used treatments include cryotherapy (freezing) with liquid nitrogen
or cryoprobe and topical applications of podofilox, imiquimod cream, or trichloroace-
tic acid. For large or persistent warts, cauterization by electric needle, vaporization by
carbon dioxide laser, or surgical removal may be necessary. However, these more radi-
cal treatments can cause severe side effects. Even though there is no cure for HPV
infections, genital warts often disappear on their own without treatment (Centers for
Disease Control, 2009g). Consequently, some people elect to adopt a “wait and see
approach in lieu of immediate treatment.
In June 2006 Merck & Co., developer of a vaccine against four HPV types respon-
sible for the majority of genital warts and cancers associated with HPV, obtained Food
and Drug Administration (FDA) approval for their product Gardasil. In the same
month, the Advisory Committee of Immunization Practices, appointed by the U.S.
Department of Health and Human Services, voted unanimously that females ages
11–26 should be vaccinated with Gardasil (women older than 26 were not included in
clinical trials) and that the vaccine should be available to girls as young as 9. Gardasil
protects vaccine recipients against HPV types 16 and 18, two high-risk strains associ-
ated with the development of about 70% of cervical cancer cases (Centers for Disease
Control, 2010d). e vaccine also blocks infection by two other strains of HPV (types
6 and 11), which are responsible for 90% of genital warts (Giuliano et al., 2011; Moon,
2011). Recent evidence also suggests that Gardasil could help reduce the incidence of
oral cancer (cancer of the mouth or throat) caused by HPV, especially type 16 (Zelkow-
itz, 2009). e rate of oral cancer has risen steadily since 1973, and many health experts
believe that this increase is related to the transmission of HPV via oral–genital contact
(Zelkowitz, 2009).
In October 2009 the FDA licensed another HPV vaccine for use in females ages
9–26—Cervarix, produced by GlaxoSmithKline. is vaccine has also proven to be an
eective prevention tool (Centers for Disease Control, 2010c). e Advisory Commit-
tee on Immunization Practices now recommends routine vaccination for females in the
appropriate age range with either Gardasil or Cervarix.
Recently, the FDA also approved the use of Gardasil to prevent anal cancer in both
males and females, ages 9–26 (Kuehn, 2011). In October 2009 the FDA licensed Gar-
dasil as a tool for preventing HPV infections in males ages 9–26. A number of studies
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452 CHAPTER 15
have demonstrated the eectiveness of Gardasil in males without accompanying serious
adverse side eects (Giuliano et al., 2011; Kim, 2011).
Mandatory HPV vaccination for youth, especially for girls, has been the target of
resistance from vocal political and religious organizations that oppose providing an
STI prevention vaccine to teenagers and preteens. is is yet another example of how
activist groups politicize public health issues related to sexual behavior, regardless of
the harmful consequences of their actions, in seeking to exert control over our sexual-
ity. e opposition to an HPV vaccine is mounted by the same groups that oppose
over-the-counter sale of emergency contraception and comprehensive sex education in
public schools because of the erroneous assumption that denying young people access
to sexuality information, health protection, and birth control will prevent them from
experiencing sexual intercourse before marriage.
e arguments for and against mandatory vaccination of American youth pose
issues widely debated in both professional and nonprofessional circles. ese view-
points are outlined in the Sex and Politics box, Arguments Against and For Mandatory
HPV Vaccination.
Viral Hepatitis
Viral hepatitis (heh-puh-TIE-tus) is a disease in which liver function is impaired by
a viral infection. There are three major types of viral hepatitis: hepatitis A, hepatitis
B, and hepatitis C. Each of these forms of viral hepatitis is caused by a different virus.
Incidence and Transmission
As reflected in the annual rate of new hepatitis infections, hepatitis B is the most com-
mon form of viral hepatitis in the United States, followed in order of frequency by
hepatitis A and hepatitis C (Centers for Disease Control, 2009h). Each of these three
varieties of hepatitis infection has declined substantially in incidence over the last
20 years (Holtzman, 2008). Although all three types of hepatitis can be transmitted
through sexual contact, types A and B are more likely to be transmitted sexually than
type C. Hepatitis B is transmitted more often through sexual activity than is hepati-
tis A. Sexual transmission among adults accounts for most hepatitis B infections in
the United States (Centers for Disease Control, 2009h). Hepatitis A is a relatively
common infection of young homosexual men, especially those who have multiple sex
partners and those who engage in anal intercourse or oral–anal contact (Centers for
Disease Control, 2009h; Des Jarlais et al., 2003). Furthermore, both hepatitis A and
hepatitis B are often transmitted by means of needle sharing among injection drug
users (Centers for Disease Control, 2009h).
Hepatitis B can be transmitted through blood or blood products, semen, vaginal
secretions, and saliva (Torpy et al., 2011). An infected mother can transmit a hepatitis
B infection to her baby at birth (Centers for Disease Control, 2009h). e CDC rec-
ommends that pregnant women be tested for hepatitis B. Manual, oral, or penile stimu-
lation of the anus is strongly associated with the spread of this viral agent. Hepatitis
A seems to be spread primarily through the fecal–oral route. Consequently, epidemics
often occur when infected handlers of food do not wash their hands properly after using
the bathroom. Oral–anal sexual contact seems to be a primary mode for sexual trans-
mission of hepatitis A (Centers for Disease Control, 2009h).
Recently, health ocials in the United States have focused considerable atten-
tion on the most health-threatening of the hepatitis viruses, hepatitis C, which is an
emerging communicable disease of epidemic proportions (Centers for Disease Control,
2010b; Edlin, 2011). Over the last few years, hepatitis C has become a major global
Should government agencies have the option
of denying teenage women access to an
HPV vaccine? Why or why not? What are
the implications for society of politicizing
and possibly blocking a chance to prevent
cervical cancer?
Critical Thinking Question
viral hepatitis
An ailment in which liver function is
impaired by a viral infection.
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Sexually Transmitted Infections453 453
Arguments Against and for Mandatory HPV Vaccinations
sex &
politics
The controversy surrounding possible implementation of
mandatory HPV vaccination for middle-school girls in the
United States is grounded in political, religious, moral,
economic, and sociocultural arguments (Gostin, 2011). One
leading expert on the legality of mandatory HPV vaccina-
tion recently concluded that states have the constitutional
authority to mandate such vaccinations (Dowling, 2008).
Whether such laws will be adopted depends largely on the
persuasiveness of nonlegal arguments.
Arguments Against Mandatory HPV Vaccination
Opponents of mandatory HPV vaccinations in public
schools argue that parents, not government or school of-
cials, should decide what is best for the protection of their
children (Gostin, 2011). Why, they ask, should government
be allowed to force people to undergo a medical solution
to a potential health problem when HPV infection can be
avoided through behavioral control?
Other arguments against mandatory HPV vaccination
are based on medical evidence and economic factors. Gar-
dasil protects against four types of HPV, “which together
affect only about 3.5% of the female population” (Dowl-
ing, 2008, p. 74). This fact calls into question the practical-
ity and necessity of requiring a costly vaccination that
will benet only a small number of women. The total cost
of one vaccination series (3 shots given over a 6-month
period) exceeds $300. Moreover, protection fades after 5 to
8 years, necessitating additional costly vaccination series
(Tomljenovic & Shaw, 2012). The fact that Gardasil protects
only against strains of HPV associated with 70% of cervical
cancer cases suggests that the risk of developing this form
of cancer later in life may not be proportional to the costs
of required vaccination of all middle-school girls.
Other medically based arguments against mandatory
HPV vaccination include concern that Gardasil has not been
adequately tested to determine its long-term safety and
efcacy and that HPV is not a highly contagious infection,
like measles or chicken pox, that can be spread by casual
contact. The majority of mandated vaccines in the United
States protect against highly contagious diseases that
cause serious and potentially widespread health problems.
Some health ofcials suggest that at present it is not clear
whether the risk of HPV-caused cervical cancer ts into this
category. Gardasil has also been linked with a number of
adverse side effects. However, health ofcials maintain that
this vaccine is safe and appropriate for widespread use.
Arguments for Mandatory HPV Vaccination
Perhaps the most persuasive argument for manda-
tory HPV vaccination is clear evidence that the Gardasil
vaccine is an important medical achievement that, if
widely implemented, will result in a signicant decrease
in adverse health consequences, including death, for
millions of American women (and men). Medical experts
estimate that the economic burden of HPV infections
and their consequences cost[s] $5 billion per year in the
United States alone” (Vamos et al., 2008, p. 305). Beyond
the obvious monetary benets of mandatory HPV vac-
cination, there are signicant emotional and physical
benets associated with preventing the need for women
to undergo invasive procedures to remove precancerous
and cancerous cervical lesions, as well as the psychologi-
cal stress women experience upon receiving word of an
abnormal Pap smear. Moreover, a combination of HPV
vaccination with routine Pap smear screening has the
potential to largely eradicate cervical cancer in American
women.
Mandatory HPV immunization for girls and perhaps for
boys as well, at an age prior to the onset of sexual activity,
is an ideal method for rapid and widespread implementa-
tion of a preventive health strategy for children regardless
of socioeconomic status or race/ethnicity. Proponents of
mandatory vaccination maintain that there can be little
argument with the viewpoint that cervical cancer and other
HPV-caused diseases are a signicant enough health threat
to classify a preventive measure effective against this
threat as a public health necessity.
Medical and social scientists argue that while Gardasil
has been shown to be safe in a well-designed clinical trial,
there are widely publicized controversies surrounding
HPV vaccination. These may prove benecial to parent–
child relationships by motivating parents to become more
involved with their children regarding health decisions
(Kowalczyk et al., 2012; London, 2011). Furthermore,
recent research indicates that girls receiving HPV vaccina-
tions continue to perceive a need for safer sexual behav-
iors after vaccination (Kowalczyk et al., 2012). Regardless
of what actions parents advocate for their children
(participating in or opting out of a school vaccination pro-
gram or seeking immunization via a health-care provider
outside the school setting), “[p]arents must assume a
proactive posture with respect to their child’s health care,
an action for which parents or policy makers would be
hard pressed to nd a negative consequence” (Vamos et
al., 2008, p. 307).
Arguments both against and in favor of mandatory HPV
vaccinations have been voiced by activist groups, medical
experts, and parents. Only time will tell how these argu-
ments inuence future decisions about implementing a
mandatory HPV vaccination program in America’s schools.
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454 CHAPTER 15
health problem, and it is now one of the most common chronic viral infections in North
America. It is estimated that approximately 200 million people in the world have chronic
hepatitis C infections—5 million of whom are in the United States (Centers for Disease
Control, 2010b; Gravitz, 2011). People whose immune systems are decient, such as
HIV-infected individuals, are especially vulnerable to hepatitis C infections, which cause
12,000 deaths each year in the United States (Centers for Disease Control, 2010b).
Hepatitis C is transmitted most commonly through blood-contaminated needles
shared by injection drug users (Centers for Disease Control, 2011b; Gravitz, 2011).
Other, less common modes of transmission include transfusion of contaminated blood
products, sexual contact, and perinatal transmission from an infected mother to her
fetus or infant (Centers for Disease Control, 2009h). Whether transmission of hepatitis
C through unprotected sexual intercourse is a signicant factor in the spread of hepa-
titis C is debatable, but evidence indicates that some hepatitis C infections are sexu-
ally transmitted, especially among HIV-infected MSM (Centers for Disease Control,
2009h; Fierer et al., 2011; Montoya-Ferrer et al., 2011).
Symptoms and Complications
Symptoms of viral hepatitis vary from nonexistent to mild flulike symptoms (poor
appetite, upset stomach, diarrhea, sore muscles, fatigue, headache) to an incapacitating
illness characterized by high fever, vomiting, and severe abdominal pain. One of the
most notable signs of viral hepatitis is a yellowing of the whites of the eyes; the skin of
light-complexioned people can also take on a yellow, or jaundiced, look. Hospitalization
is required only in severe cases. Chronic infections with hepatitis B or C are a major risk
factor for developing liver cirrhosis, end-stage liver disease, and cancer of the liver, one
of the most common cancers in the world (Centers for Disease Control, 2012c; Torpy
et al., 2011).
Treatment
No specific therapy is known to be effective against hepatitis A. Treatment generally
consists of bed rest and adequate fluid intake to prevent dehydration. The disease
generally runs its course in a few weeks, although complete recovery can take several
months in cases of severe infection. Infection with hepatitis B is typically treated in
the same manner as hepatitis A, and it also generally runs its course in a few weeks.
However, sometimes hepatitis B infections become chronic and persist for more than
6 months. An estimated 800,000 to 1.4 million Americans have a chronic hepatitis
B infection (Centers for Disease Control, 2009h). These chronic infections can be
treated with several antiviral drugs (Quan, 2008; Shamliyan et al., 2009).
Hepatitis C presents a more serious treatment problem. For most of the estimated
5 million Americans who have a hepatitis C infection, the disease is relatively mild, remains
stable over several decades, and does not signicantly erode the persons health (Centers
for Disease Control, 2009h; Edlin, 2011). However, for about one quarter of those who
develop the progressive form of the disease, active treatment is essential to avert severe
complications and/or death (Centers for Disease Control, 2009h). By 2007 hepatitis C
had superseded AIDS as a cause of death in the United States (Ly et al., 2012). Hepatitis
C causes half of all liver cancers and is the most prevalent reason for liver transplants in the
United States (Chung, 2012; Schlutter, 2011). A combination therapy with the antiviral
drugs peglated interferon and ribavirin has been shown to be relatively eective in control-
ling some cases of chronic hepatitis C infection (Chung, 2008; Rodriguez-Torres et al.,
2009). Recent research indicates that adding either of the drugs teleprevir or boceprevir
to the peglated interferon/ribavirin protocol may signicantly reduce the time necessary
to successfully treat a chronic hepatitis C infection (Alter & Liang, 2012; Liu et al., 2012).
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Sexually Transmitted Infections455 455
An eective and safe vaccine to prevent hepatitis B infection has been available since
1982, and in 1995 the U.S. Food and Drug Administration approved an eective and
safe hepatitis A vaccine. Since the development and implementation of vaccinations for
hepatitis A and B, the incidence of these infections in the United States has fallen dra-
matically to historic lows (Centers for Disease Control, 2010e; Ward, 2008). Unfor-
tunately, no eective vaccine for hepatitis C exists, although eorts are under way to
develop this prevention tool (Eisenstein, 2011).
Common Vaginal Infections
Several kinds of vaginal infections can be transmitted through sexual interaction. The
infections we discuss in this section are also frequently contracted through nonsexual
means. Vaginitis and leukorrhea are general terms applied to a variety of vaginal infec-
tions characterized by a whitish discharge. The secretion can also be yellow or green
because of the presence of pus cells, and it often has a disagreeable odor. Additional
symptoms of vaginitis include irritation and itching of the genital tissue, burning sen-
sation during urination, and pain around the vaginal opening during intercourse.
Vaginal infections are common. Practically every woman experiences one or more
of these infections during her lifetime. In fact, vaginitis is one of the most common rea-
sons women consult health-care providers (Head, 2008). Under typical circumstances
many of the organisms that cause vaginal infections are relatively harmless. In fact, some
routinely live in the vagina and cause no trouble unless something alters the normal
vaginal environment and allows them to overgrow. e vagina normally houses bacteria
(lactobacilli) that help maintain a healthy vaginal environment. e pH of the vagina is
usually suciently acidic to ward o most infections. However, certain conditions can
alter the pH toward the alkaline side, which can leave a woman vulnerable to infection.
Some factors that increase the likelihood of vaginal infection include antibiotic ther-
apy, use of contraceptive pills, menstruation, pregnancy, wearing pantyhose and nylon
underwear, and lowered resistance from stress or lack of sleep. Douching also increases
the risk of vaginal infections, especially bacterial vaginosis (Centers for Disease Control,
2009i; Cottrell & Close, 2008). In spite of the negative health consequences associated
with douching, evidence indicates that almost 36% of women of childbearing age in the
United States engage in douching (Cottrell & Close, 2008).
Most women with vaginitis have an infection diagnosed as bacterial vaginosis, can-
didiasis, or trichomoniasis. Bacterial vaginosis is the most common of these infections.
Bacterial Vaginosis
Bacterial vaginosis (BV) is a vaginal infection caused by a replacement of the normal
vaginal lactobacilli by an overgrowth of microorganisms, which can include anaerobic
bacteria, Mycoplasma bacteria, and a bacterium known as Gardnerella vaginalis.
Incidence and Transmission
The presence of moderate levels of bacterial microorganisms in the vaginal environ-
ment is normal. However, under conditions of decreased levels of beneficial lactobacilli,
an overgrowth of other vaginal microorganisms occurs. This can result in high concen-
trations of one or more of the bacterial microorganisms associated with BV (Marrazzo
et al., 2011). BV is the most common vaginal infection in U.S. women (Centers for
Disease Control, 2009i). Although the role of sexual transmission in BV is not fully
understood, it is believed that coitus often provides a mode of transmission for the
bacterial vaginosis (BV)
A vaginal infection caused by bacte-
rial microorganisms; it is the most
common form of vaginitis among U.S.
women.
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456 CHAPTER 15
infection. BV occurs more frequently among sexually active women than among sexu-
ally inactive women (Doskoch, 2005). Furthermore, although BV is common among
women in general, it is even more common among women with female sex partners
(Gorgos et al., 2011). However, BV is not necessarily sexually transmitted, because
this infection has been diagnosed in teenagers and women who have not experienced
sexual intercourse (Coco & Vandenbosche, 2000).
Symptoms and Complications
Most women who are infected with BV manifest no overt symptoms of this infec-
tion (Centers for Disease Control, 2009i). However, when present, the most common
symptom of bacterial vaginosis in women is a foul-smelling, thin discharge that resem-
bles flour paste in consistency. The discharge is usually gray or white, but it can also
be yellow or green. The disagreeable odor, often noticed first by an infected womans
sexual partner, is typically described as fishy or musty. This smell may be particularly
noticeable after coitus because the alkaline seminal fluid reacts with the bacteria, caus-
ing the release of the chemicals that produce the smell. A small number of infected
women experience irritation of the genital tissues and a mild burning sensation during
urination. Recent evidence suggests a link between bacterial vaginosis and both PID
and adverse pregnancy outcomes, including premature rupture of the amniotic sac and
preterm labor (Centers for Disease Control, 2009i; Marrazzo et al., 2011).
Having a BV infection can both increase a womans susceptibility to HIV infection
if she is exposed to this virus and increase the probability that an HIV-infected woman
will transmit HIV to her sexual partner(s) (Centers for Disease Control, 2009i).
Men may also harbor the infectious organisms that cause BV, often without mani-
festing detectable symptoms. However, some infected males develop inammation of
the foreskin and glans of the penis, urethritis (inammation of the urethral tube), and
cystitis (bladder infection).
Treatment
For many years the treatment of choice for bacterial vaginosis has been metronidazole
(Flagyl) taken by mouth for 7 days. However, recent research indicates that intravaginal
application of topical metronidazole gel or clindamycin cream is as effective as oral met-
ronidazole (Workowski et al., 2010). Studies indicate that there is little or no proven
benefit in treating male sex partners of women diagnosed with BV (Centers for Disease
Control, 2009i). Female sex partners should be evaluated and treated if necessary.
Candidiasis
Candidiasis (kan-duh-DIE-uh-sus), also commonly referred to as a yeast infection, is
primarily caused by a yeastlike fungus called Candida albicans.
Incidence and Transmission
Candidiasis is the second most common vaginal infection in North America. An esti-
mated 75% of women will have at least one genital candidiasis infection in their lifetime
(Workowski et al., 2010). The microscopic Candida albicans organism is normally present
in the vagina of many women; it also inhabits the mouth and large intestine of a large
number of women and men. A disease state results only when certain conditions allow the
yeast to overgrow in the vagina. This accelerated growth can result from pregnancy, use of
oral contraceptives, or diabetes—conditions that increase the amount of sugar stored in
vaginal cells (Candida albicans thrives in the presence of sugar) (Centers for Disease Con-
trol, 2009j). Another factor is the use of oral antibiotics or spermicidal jellies or creams,
urethritis
An inammation of the urethral tube.
cystitis
An infection of the bladder.
candidiasis
An inammatory infection of the vagi-
nal tissues caused by the yeastlike
fungus Candida albicans.
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Sexually Transmitted Infections457 457
which reduce the number of lactobacilli (mentioned earlier as important for a healthy vagi-
nal environment). This reduction permits Candida albicans to multiply rapidly.
If the yeast organism is not already present in the womans vagina, it can be transmit-
ted to this area in a variety of ways. It can be conveyed from the anus by wiping back to
front or on the surface of a menstrual pad, or it can be transmitted through sexual inter-
action, because the organism can be harbored in various reservoirs in the male body, espe-
cially under the foreskin of an uncircumcised man (Ringdahl, 2000). e organism can
also be passed from a partner’s mouth to a womans vagina during oral sex (Greer, 1998).
Symptoms
A woman with a yeast infection may notice that she has a white, clumpy discharge that
looks something like cottage cheese. In addition, candidiasis is often associated with intense
itching and soreness of the vaginal and vulval tissues, which typically become red and dry.
Treatment
A variety of treatments have proved effective in combating yeast infections. Traditional
treatment strategies consist of vaginal suppositories or topical creams, such as clotrim-
azole, miconazole, butoconazole, or terconazole. Over-the-counter intravaginal prepa-
rations of clotrimazole and miconazole are now available for treatment of candidiasis;
however, these medications are recommended only for women who have previously
been medically diagnosed and treated and who have a recurrence of symptoms.
Two drugs taken by mouth, uconazole and itraconazole, have also proven eective
in treating candidiasis (Pitsouni et al., 2008). Because Candida albicans is a hardy organ-
ism, treatment should be continued for the prescribed length of time (usually several
days to 2 weeks), even though the symptoms may disappear in 2 days.
Practical tips to help women reduce the risk of a yeast infection include decreasing
sugar intake, adding yogurt or a daily lactobacillus acidophilus supplement to their diet,
and avoiding glycerin-based lubricants that can fuel a yeast infection (Fink, 2006).
Trichomoniasis
Trichomoniasis (trih-kuh-muh-NIE-uh-sus) is caused by a one-celled protozoan
parasite called Trichomonas vaginalis.
Incidence and Transmission
Trichomoniasis is a common STI in both women and men. Between 7 and 8 million
new cases of trichomoniasis occur each year in the United States (Centers for Disease
Control, 2009k). The primary mode of transmission of this infection is through sexual
contact. Women can acquire it from infected men via penile–vaginal intercourse and
from infected women via vulva-to-vulva contact; however, men usually contract tricho-
moniasis only from infected women via coitus (Centers for Disease Control, 2009k).
Symptoms and Complications
The most common symptom of trichomoniasis infection in women is an abundant,
frothy, white or yellow-green vaginal discharge with an unpleasant odor. The discharge
can irritate the tissues of the vagina and vulva, causing them to become inflamed, itchy,
and sore (Centers for Disease Control, 2009k). The infection is usually limited to the
vagina and sometimes the cervix, but occasionally the organism invades the urethra,
bladder, or Bartholins glands. Inflammation of genital tissues caused by trichomonia-
sis can increase a womans susceptibility to HIV infection and increase the probability
that an HIV-infected woman will transmit HIV to her sex partner(s) (Centers for
trichomoniasis
A form of vaginitis caused by the
one-celled protozoan Trichomonas
vaginalis.
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458 CHAPTER 15
Disease Control, 2009k). Untreated trichomoniasis infection in pregnant women is
associated with premature rupture of the amniotic sac and preterm delivery (Centers
for Disease Control, 2009k; Huppert, 2006). Trichomoniasis infections in men, usu-
ally asymptomatic, may be associated with an urge to urinate frequently, painful urina-
tion, or a slight urethral discharge.
Treatment
To avoid passing the protozoan back and forth, it is important that the sex partner(s)
of an infected woman be treated, even if they are asymptomatic. If a male partner is
not treated, the couple should use condoms to prevent reinfection. The recommended
drug regimen for both sexes is a single 2-gram dose of metronidazole (Flagyl) or tini-
dazole taken by mouth.
Ectoparasitic Infections
Ectoparasites are parasitic organisms that live on the outer skin surfaces of humans
and other animals (ecto means outer”). Two relatively common STIs are caused by
ectoparasites: pubic lice and scabies.
Pubic Lice
Pubic lice, more commonly called crabs, belong to a group of parasitic insects called bit-
ing lice. They are known technically as Phthirus pubis. Although tiny, adult lice are visible
to the naked eye. They are yellowish-gray and under magnification resemble crabs, as
Figure 15.6 shows. A pubic louse (the singular of lice) generally grips a pubic hair with
its claws and sticks its head into the skin, where it feeds on blood from tiny blood vessels.
Incidence and Transmission
Pubic lice are quite common and are seen frequently in public health clinics and by pri-
vate physicians. Pubic lice are especially prevalent among young (15- to 25-year-old) single
people and are frequently associated with the presence of other sexually transmitted infec-
tions. Pubic lice are often transmitted during sexual contact when two people bring their
pubic areas together (Centers for Disease Control, 2009b). The lice can live away from the
body for 1 to 2 days, particularly if their stomachs are full of blood. They may drop off onto
underclothes, bedsheets, sleeping bags, and so forth. Eggs deposited by the female louse on
clothing or bedsheets can survive for several days. Thus it is possible to get pubic lice by
sleeping in someone elses bed or by wearing his or her clothes. Furthermore, a successfully
treated person can be reinfected by being exposed to her or his own unwashed sheets or
underclothes. Pubic lice do not necessarily limit themselves to the genital areas. They
can be transmitted, usually by the fingers, to the armpits or scalp.
Symptoms
Most people begin to suspect something is amiss when they start itching. Suspi-
cions become stronger when scratching brings no relief. However, a few people
seem to have great tolerance for the bite of a louse, experiencing little if any dis-
comfort. Self-diagnosis is possible simply by locating a louse on a pubic hair.
Treatment
Both prescription and over-the-counter medications (lotions and creams) are
available for treatment of pubic lice (Centers for Disease Control, 2009b). These
SEXUALHEALTH
Figure 15.6 A pubic louse, or “crab.
© E. Gray/SPL/Photo Researchers, Inc.
ectoparasites
Parasitic organisms that live on the
outer skin surfaces.
pubic lice
Lice that primarily infest the pubic
hair and are transmitted by sexual
contact.
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Sexually Transmitted Infections459 459
medications should be applied to all affected areas and washed off after a few minutes.
It is advisable to apply the lotion or cream to all areas where there are concentrations of
body hair—the genitals, armpits, scalp, and even eyebrows. These treatments should be
repeated 7 to 10 days later if lice are still present. Be sure to wash all clothes and sheets
that were used before treatment.
Scabies
Scabies is caused by a tortoise-shaped parasitic mite with four stubby legs called Sar-
coptes scabiei. Unlike pubic lice, mites are too tiny to be seen by the naked eye. Scabies
infestations are initiated by the female mite; after mating, she burrows beneath the skin
to lay her eggs, which hatch shortly thereafter. Each hatched egg becomes a full-grown
adult in 10 to 20 days. The adult mite forages for nourishment in the host’s skin that is
adjacent to the site of the original burrow. The average person with scabies is infested
with 5 to 15 live adult female mites (Centers for Disease Control, 2009m).
Incidence and Transmission
Although scabies is not among the infectious conditions reported to health organizations in
the United States and elsewhere, the worldwide prevalence of this infection is estimated at
about 300 million annual cases (Chosidow, 2006). Scabies is a highly contagious condition
that can be transmitted by close physical contact, both sexual and nonsexual. The mites can
also be transferred on clothing or bedding, where they can remain viable for up to 72 hours
(Centers for Disease Control, 2009m). In addition to sexually active people, schoolchildren,
nursing home residents, and indigent people are especially at risk for scabies infestations.
Symptoms
Symptoms of first-time scabies infections may not appear for up to 2 months after the per-
son has been infested by the mites (Centers for Disease Control, 2009m). Small vesicles or
pimplelike bumps occur in the area where the female mite tunnels into the skin. A red rash
around the primary lesion indicates the area where hatched adult mites are feeding. Areas
of infestation itch intensely, especially at night. Favorite sites of infestation typically include
the webs and sides of fingers, wrists, abdomen, genitals, buttocks, and female breasts.
Treatment
Scabies is treated with a topical scabicide (lotion or cream product used to kill scabies)
that is applied from the neck down to the toes. Several prescription scabicides are available;
they are applied at bedtime and left on for 8 hours, then washed off with soap and water. A
single application is usually effective, although some physicians advocate a second applica-
tion 7–10 days later. It is recommended that all household members and close contacts of
an infested person, including asymptomatic ones, be treated simultaneously. In addition, all
clothing and bedding used by treated people should be washed in hot water or dry cleaned.
Acquired Immunodeciency Syndrome
(AIDS)
The acquired immunodeficiency syndrome (AIDS) epidemic is now recognized as
the most serious disease pandemic of our time. An all-out research assault on this
deadly disease, unprecedented in scope and extent, is being conducted throughout the
world, and new findings are surfacing with startling rapidity.
scabies
An ectoparasitic infestation of tiny
mites.
acquired immunodeciency syn-
drome (AIDS)
A catastrophic illness in which a
virus (HIV) invades and destroys the
ability of the immune system to ght
disease.
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460 CHAPTER 15
At the end of the three decades since AIDS was rst identied, researchers world-
wide are pursuing ways to improve prevention and treatment of this disease while con-
tinuing to seek a cure (Dieenbach & Fauci, 2011). We address these unprecedented
eorts in the following pages.
AIDS results from infection with the human immunodeficiency virus (HIV).
HIV falls into a special category of viruses called retroviruses, so named because they
reverse the usual order of reproduction within cells they infect, a process called reverse
transcription.
Two forms of HIV have been linked with the development of AIDS: HIV-1 and HIV-
2. HIV-1 was the rst human immunodeciency virus to be identied and is the one that
causes the greatest number of AIDS cases in the United States and throughout the world
(De Cock et al., 2011). HIV-2 occurs in some African countries along with HIV-1. HIV-
1, the more virulent of the two forms, is a formidable enemy because it is constantly mutat-
ing and is present in multiple strains or subtypes (Osborn, 2008; Taylor et al., 2008). To
simplify our discussion of AIDS, we refer to the infective agent simply as HIV.
A great deal of speculation about the origin of AIDS has occurred since the emer-
gence of the global pandemic. It has been variously proposed that HIV came from resi-
dents of Africa or Haiti, mosquitoes, monkeys, pigs, or even from early testing of a polio
vaccine in Africa in the 1950s. Recently published research appears to have solved the
riddle of the origin of HIV/AIDS. Persuasive evidence that HIV was introduced to
humans from chimpanzees was obtained by two international teams of scientists who
traced the roots of HIV to a related virus in a subspecies of chimpanzees that reside in
central and southwestern Africa (Gao et al., 1999; Keele et al., 2006). Genetic analysis
revealed that this subspecies, Pan troglodytes troglodytes, harbors a simian immunode-
ciency virus (SIV) that is the origin of HIV-1. Evidence suggests that SIV is quite
ancient, at least 32,000 years old (Worobey et al., 2010). Scientists believe that SIV
genetically converted to HIV either while it was still in a chimpanzee or after a human
contracted SIV, perhaps through exposure to chimpanzee blood from hunting or han-
dling the meat during food preparation (De Cock et al., 2011).
Armed with evidence implicating a specic subspecies of chimpanzees in the origin
of HIV, another research team conducted tests that allowed them to estimate that HIV
rst evolved from the SIV carried by these chimpanzees sometime between 1915 and
1941, with 1931 being the most likely year (Korber et al., 2000). With such an early
date of origin, why was HIV not identied as the AIDS-causing virus until 1983? Sci-
entists believe that when SIV turned into a human killer, probably in the early 1930s, it
likely remained conned to a small population in an isolated area, such as a village, until
migration into large cities and jet travel spread the virus worldwide. Evidence that HIV
existed well before its identication was provided by discovery of HIV in a frozen blood
sample collected in 1959 from an adult male residing in Africa (De Cock et al., 2011;
Zhu et al., 1998). us it now appears likely that HIV originated early in the 20th
century by means of cross-species transmission from a subspecies of chimpanzees to
humans, and then was spread worldwide much later, when Africa became less isolated.
HIV specically targets and destroys the body’s CD4 lymphocytes, also called
T-helper cells or helper T-4 cells. In healthy people these cells coordinate the immune
systems response to disease. e impairment of the immune system resulting from
HIV infections leaves the body vulnerable to a variety of cancers and opportunistic
infections (infections that take hold because of the reduced eectiveness of the immune
system). Initially, HIV infection was diagnosed as AIDS only when the immune system
became so seriously impaired that the person developed one or more severe, debilitat-
ing diseases, such as cancer or an unusual form of pneumonia caused by the protozoan
Pneumocystis carinii. However, eective January 1, 1993, the CDC broadened this de-
nition of AIDS to include any HIV infection in which the immune system is severely
human immunodeciency virus
(HIV)
The immune-system-destroying virus
that causes AIDS.
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Sexually Transmitted Infections461 461
impaired. Now anyone who is infected with HIV and has a CD4 count of 200 cells or
less per microliter of blood is considered to have AIDS, regardless of other symptoms.
(Normal CD4 counts in healthy people not infected with HIV range from 600 to 1,200
cells per microliter of blood.)
Incidence
By January 2011 well over 1 million cumulative cases of AIDS had been reported
in the United States, and almost 600,000 people had died of the disease since it was
first diagnosed in 1981. The number of people in the United States living with HIV,
approximately 1.2 million, continues to increase (Tasker, 2011; Torian et al., 2011).
About 20% of people in the United States living with HIV are unaware of their HIV
status (Centers for Disease Control, 2011f).
Each year about 2.6 million new HIV infections occur globally and almost 34 mil-
lion people worldwide are infected (Dieenbach & Fauci, 2011; Kelland, 2011). Before
2007, United Nations ocials estimated that each year about 5 million new HIV infec-
tions occurred worldwide and that a total of about 40 million people were infected
(UNAIDS, 2006). Recently, lower estimates of global HIV infection rates have been
made based on a more accurate method for assessing worldwide HIV infection preva-
lence (Cheng, 2007). While the decline in global infection rates is due largely to revised
numbers reecting better methodology, there is mounting evidence that the HIV/
AIDS pandemic is losing some of its global momentum (Brown, 2010). By the end
of the rst decade of the 21st century, the number of new HIV infections worldwide
was nearly 20% lower than a decade earlier (Brown, 2010). e downward trend in the
number of global HIV infections is the result of many inuences, including a reduction
of risky sexual behaviors, lower infectious risk among people undergoing antiretroviral
drug treatment, and signicant success in preventing mother-to-child HIV transmis-
sion (Brown, 2010). e decline in HIV/AIDS may also reect the epidemics natural
history, in which the annual number of new infections peaks and then declines as the
disease saturates high-risk groups in the population (Brown, 2010, p. 9).
In sub-Saharan Africa, national epidemics have stabilized or even declined slightly
in several countries (Steinbrook, 2008). Nevertheless, in spite of these encouraging
signs, we cannot lose sight of the fact that the pandemic continues to rage. To date, more
than 25 million people worldwide have already died of AIDS, and the disease claims
about 2 million lives each year (Friedrich, 2011a; Kelland, 2011). Global annual death
rates caused by AIDS peaked in 2005 and decreased over the next several years, due in
part to wider availability of antiretroviral drug therapy (Brown, 2010; Jae, 2008). Sub-
Saharan Africa is estimated to be home to roughly two thirds of all people living with
AIDS. e hardest hit nation, South Africa, is home to about one sixth of the world’s
HIV-infected people (De Cock et al., 2011).
e number of new AIDS cases reported annually in the United States grew rapidly
throughout the early 1980s, increasing by about 85% each year, and reached a peak rate in
the middle of the decade. Until recently, the CDC estimated that approximately 40,000
new HIV infections have occurred annually in the United States since the early 1990s
through 2007. However, recent evidence indicates that federal ocials have been underes-
timating the number of new HIV infections for more than a decade (Maugh, 2008). New
laboratory-based procedures, which make possible improved estimation of HIV infection
incidence, indicate that approximately 50,000 to 56,000 new infections have occurred each
year during this period (Centers for Disease Control, 2010h; McNeil, 2011). Although
the overall incidence of new HIV infections in the U.S. population has been stable for
several years, the number of new cases among teenagers, women, and racial and ethnic
minorities continues to rise (Guilamo-Ramos et al., 2011; Timpson et al., 2010).
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462 CHAPTER 15
Many people with AIDS were infected during their adolescent years (Balaji et al.,
2008). Unfortunately, it is very uncommon for American adolescents to be tested for
HIV. A recent nationwide survey found that only 12.7% of teenagers have been tested,
with more females (14.7%) than males (10.9%) having had an HIV test (Centers for
Disease Control, 2010h). e growing problem of HIV infection among adolescents
has been attributed to a number of factors, including the following:
Many teenagers have multiple sexual partners, increasing their exposure to
infection.
Many adolescents engage in sexual activity without using condoms.
Access to condoms is generally more dicult for adolescents than for other age
groups.
Many adolescents do not use condoms correctly and consistently as revealed by
the NSSHB (Reece et al., 2010b).
Teenagers have high rates of other STIs, which are often associated with HIV
infection.
Substance abuse, which often increases risky behavior, is relatively widespread
among adolescents (Freeman et al., 2011).
Teenagers tend to be especially likely as a group to have feelings of invulnerability
(see Chapter 12).
On the other hand, a signicant number of teenagers, nearly 15% according to a
recent study, take chances and engage in risky behavior because of a strong sense
of fatalism or belief they will die young (Borowsky et al., 2009).
Homeless youth often engage in risky sexual behavior that increases their vulner-
ability to HIV infection (Rice et al., 2012).
MSM (men who have sex with men) and ethnic and racial minority groups in the
United States account for a majority of the total number of AIDS cases reported since
1981 (Centers for Disease Control, 2011a; McCree et al., 2010). e higher AIDS rates
among ethnic and racial minority groups might reect, among other factors, (1) reduced
access to health care, associated with disadvantaged socioeconomic status, (2) cultural or
language barriers that limit access to information about strategies for preventing STIs,
and (3) dierences in HIV risk behaviors, especially higher rates of injection drug use.
Since AIDS rst appeared in the United States, most cases have been directly or indi-
rectly related to two risk-exposure categories: MSM and injection drug users. e preva-
lence of HIV infection in the United States remains highest among MSM, who account
for 53–59% of HIV infections in the United States (Centers for Disease Control, 2011d;
Oster et al., 2011). Reported AIDS cases among MSM declined sharply and then lev-
eled o between the mid-1980s and the late 1990s (Adams et al., 2005). Unfortunately,
the incidence rates of HIV infection among MSM are again moving upward (Centers
for Disease Control, 2011d, 2011e; D. Smith et al., 2011). is resurgence of the HIV
epidemic among MSM is especially prevalent among young MSM and among MSM of
color (K. Jones et al., 2008; Oster et al., 2011; Mustanski, Newcomb et al., 2011).
In recent years an HIV/AIDS epidemic has emerged among MSM in countries in the
Middle East and North Africa, especially Egypt, Sudan, and Tunisia (Friedrich, 2011a).
e number of HIV infections attributed to injection drug use has declined in
recent years but still remains high at roughly 9% of new HIV infections occurring annu-
ally in the United States (Centers for Disease Control, 2012a).
In the United States about a third of all AIDS cases are attributable to heterosexual
transmission (Maugh, 2008). Heterosexual contact has always been the primary form
of HIV transmission worldwide, especially in Africa and Asia (Harris & Bolus, 2008;
UNAIDS, 2006).
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Sexually Transmitted Infections463 463
Over the last few years the number of women infected with HIV has steadily
increased in the United States and worldwide (Harris & Bolus, 2008). In sub-Saharan
Africa, women ages 15 to 24 are three to four times more likely to be infected with HIV
than are young men their age (Underwood et al., 2011).
Research indicates that HIV is not as easily transmitted from women to men as
it is from men to women (Shapiro & Ray, 2007). us the risk of becoming infected
through heterosexual intercourse appears to be much greater for a female with an HIV-
infected male partner than for a male with an infected female partner. One explanation
for womens greater risk during heterosexual intercourse is that semen contains a higher
concentration of HIV than vaginal uids do, and the female mucosal surface is exposed
to HIV in the ejaculate for a considerably longer time than a males penis is exposed to
HIV in vaginal secretions (Lamptey et al., 2006; Shapiro & Ray, 2007). In addition,
a larger area of mucosal surface is exposed on the vulva and in the vagina than on the
penis, and the female mucosal surface is subjected to greater potential trauma than is
typically the case with the penis (Lamptey et al., 2006). Furthermore, some women
engage in unprotected anal intercourse, a high-risk behavior because HIV transmission
from an infected man to an uninfected woman is thought to be 10 times as likely with
anal intercourse as with vaginal intercourse (Shapiro & Ray, 2007). In fact, receptive
unprotected anal intercourse has been shown to be associated with the highest risk of
HIV infection through sexual activity for both men and women (Jenness et al., 2011;
Shapiro & Ray, 2007). Finally, adolescent women are especially biologically vulnerable
to HIV infection because their immature reproductive tracts, especially the cervix, are
highly susceptible to infection by STIs (Lamptey et al., 2006; Shapiro & Ray, 2007).
e global proportionate incidence of HIV/AIDS among women is considerably
greater in Africa, Asia, and the Caribbean than in the United States. In sub-Saharan
Africa—the epicenter of HIV/AIDS—about 57% of HIV infections among adults
occur in women (Yount & Abraham, 2007). About 75–80% of HIV infections among
African youth are of females (Tenkorang & Matick-Tyndale, 2008). It is estimated that
among the 800,000 children infected with HIV each year (most in sub-Saharan African
countries), about 90% of the infections result from mother-to-child transmission (Har-
ris & Bolus, 2008; Stringer et al., 2008).
In developing nations, especially those in Africa, a majority of new HIV infections
occur among 15- to 24-year-olds (Kim & Free, 2008). e terrible plight of Africa dur-
ing these plague years is described in the following Sexuality and Diversity discussion.
SEXUALITY and DIVERSITY
AIDS in Africa: Death and Hope on a Ravaged Continent
To date, the vast majority of AIDS deaths have occurred in Africa, primarily in sub-
Saharan nations, which contain about 10% of the global population but are home to
approximately 70% of all people who are living with HIV/AIDS (Kelland, 2011). Of
the millions of global AIDS orphans—children who have lost their parents to the dis-
ease—more than 90% reside in sub-Saharan Africa. Children in sub-Saharan African
nations also often serve as the primary caregivers for parents living with HIV/AIDS
(Skovdal, 2011).
For many years scientists and health professionals mistakenly assumed that the
explosive spread of the pandemic in Africa, where HIV is transmitted primarily through
heterosexual sex, was largely a function of risky sexual behavior reected in a propensity
of Africans to have sex at an early age and with a large number of partners. e false-
ness of this stereotypical notion about sexual behavior in Africa is revealed by numerous
surveys indicating that sexual debut in Africa tends to occur in the late teens, just as it
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464 CHAPTER 15
does in Europe and the United States, and that African men and women report similar,
if not fewer, numbers of lifetime sexual partners than do heterosexuals in many Western
nations (Epstein, 2007; Stephenson, 2010; Wellings et al., 2006). Why, then, are HIV
infection rates so much higher in parts of Africa than in Western nations?
e answer to this question is perhaps best presented in a recent book written by
Helen Epstein titled e Invisible Cure: Africa, the West, and the Fight Against AIDS
(2007). Epstein, a molecular biologist, spent many years in Africa investigating the sky-
high HIV infection rates in some regions of that continent. In her book she focuses on
multiple, concurrent partnerships as the primary contributing factor to Africas HIV/
AIDS pandemic. In sub-Saharan African nations, a relatively high proportion of men
and women are involved in simultaneous ongoing relationships with a small number of
people—perhaps two or three—and these concurrent relationships might overlap for
months or years. is pattern diers from the serial monogamy that is more common in
Western cultures, and these concurrent or simultaneous sexual partnerships are more
dangerous than serial monogamy, because they link people up in a giant web of sexual
relationships that creates ideal conditions for the rapid spread of HIV (p. 55).
While relationship concurrency is clearly a major contributor to the HIV pandemic
in sub-Saharan Africa, other factors also play an important role, not the least of which is
a marked inclination among African youth to avoid using condoms during sexual inter-
course. As pointed out elsewhere in this chapter, condoms are an important component
of eorts to slow the HIV/AIDS pandemic in Africa. However, in many sub-Saharan
nations, where young people account for about half of all new HIV infections, reported
condom use among them remains low (Winskell et al., 2011).
e spread of HIV/AIDS in Africa is also strongly inuenced by extremely limited
health resources and government inaction (Dugger, 2008; Nullis, 2007). e absence
of ecient health infrastructures has created major barriers to eective administration
of antiretroviral drug treatment programs. is serious problem is further complicated
by the reluctance of many African governments to recognize the seriousness of this
pandemic and to mobilize whatever limited health resources are available to combat
it. An especially disheartening example of government inaction or outright opposi-
tion to HIV/AIDS programs is provided by the nation of South Africa. For many
years ocials in this government, including former president abo Mbeki, refused to
acknowledge that HIV causes AIDS (De Cock et al., 2011). Only recently, under a new
government, has this nation nally begun to mobilize eorts to combat a disease that
claims over 350,000 South African lives each year.
Cultural factors also play a signicant role in perpetuating the African AIDS plague.
African nations are male-dominated societies in which most women nd themselves in
relationships of economic dependency and sociocultural subordination to men (Hig-
gins & Hirsch, 2007; Hindin & Muntifering, 2011). Womens lack of rights within rela-
tionships and their diculties in negotiating safer sex with partners who dislike using
condoms and typically refuse to acknowledge and discuss their other concurrent sexual
relationships result in elevated vulnerability to HIV infection (Heisea et al., 2011;
Onoya et al., 2011). Recent research conducted in 13 sub-Saharan African countries
revealed that condom use by married couples is relatively uncommon (de Walgue &
Kline, 2011). It is not uncommon for married African women, who are not engaged in
extramarital sex, to be infected by their husbands, who are engaging in unprotected sex
in outside relationships (Stephenson, 2010). Furthermore, the combination of poverty,
economic inequity, and relationship power imbalances experienced by many African
women often leads them to exchange sex for money, alcohol, gifts, and goods, a practice
that signicantly increases their risk of acquiring an HIV infection (Higgins & Hirsch,
2007; Watt et al., 2012). Research in Africa indicates that transactional sex can increase
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Sexually Transmitted Infections465 465
the risk of HIV infection in both sexes via involvement with multiple partners and
inconsistent condom use (Watt et al., 2012).
Another cultural contributor to the spread of HIV in Africa is the practice of female
genital cutting described in Chapter 3. e increased HIV risk associated with this
practice is related to several factors, including possible HIV-tainted-blood contamina-
tion of cutting tools, increased risk among cut women of genital infections associated
with increased susceptibility to HIV infection, and a stronger inclination to engage in
anal intercourse, a high-risk behavior for acquiring HIV (Yount & Abraham, 2007).
Against such a grim background, can there be any hope for Africas future? e
answer is a cautious yes. Many government and nongovernment organizations (NGOs)
are ooding Africa with disease specialists, nancial resources, and aordable drugs to
treat AIDS. Drug treatment–based programs have beneted from a dramatic decrease
in the cost of antiretroviral drugs in recent years. e availability of generic versions of
these medications, coupled with the willingness of Western pharmaceutical companies
to provide them at not for prot” prices, has, for example, dropped the cost of one widely
used multiple-drug treatment regimen to 25 cents per day. In contrast, antiretroviral
drugs can cost $20,000 or more a year for infected people in the United States (Tasker,
2011). While this increase in the aordability of treatment drugs in African nations is a
marvelous improvement in the battle against HIV/AIDS, it is far from a panacea. For
example, in Botswana, where antiretroviral drugs are widely available and where infec-
tion rates have stabilized and even declined slightly among some populations, the overall
incidence of HIV infection is still astonishingly high (J. Cohen, 2008).
In recent years a number of educational programs focused on reducing HIV risk
behaviors have been designed and implemented in developing countries, especially
those located in sub-Saharan Africa. ese innovative intervention methods use trained
community members as peer educators to reach out in a grassroots educational eort
that includes providing information and resources, a format for talking openly about
sexual issues, and a supportive context for positive behavior changes. A major advantage
of peer education is that this method places health-related knowledge in the hands of
ordinary people, who act not only as peer educators but also as role models for posi-
tive behavior change. A number of studies have demonstrated that such grassroots pro-
grams increase the likelihood that people will engage in health-promoting behaviors
(Campbell & Mzaidume, 2001; Crooks & Tucker, 2006; Wheeler, 2003).
A peer-educator–based HIV/AIDS intervention program was established some
years ago in the Makindu region of southeastern Kenya, with planning and guidance
provided by Bob Crooks and his wife, Sami Tucker, in collaboration with a number of
Kenyan citizens and with the assistance of a German NGO. is program, partially
funded by royalty revenues from this textbook, is described at the website www.ithelps.
org. e involvement of Crooks and Tucker includes developing a research strategy to
evaluate the impact of this grassroots program, designing and implementing a peer-
educator–based educational strategy, and conducting 2-week training sessions for peer
educator sta. Research evidence obtained via administration of anonymous pre- and
postworkshop questionnaires has revealed improved awareness of HIV/AIDS risk
behaviors and prevention strategies and signicant increases in safer sexual behaviors
among all categories of participants as a direct result of the Makindu program (Crooks
& Tucker, 2006). In the fall of 2009 Crooks and Tucker launched a similar program in
the South Coast region of Kenya.
Perhaps the best hope for Africa lies in the development of the ultimate weapon
against any virus—an eective preventive vaccine. However, as discussed elsewhere in
this chapter, progress on this front has been slow, and the likelihood of having such a
vaccine soon is slight at best.
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466 CHAPTER 15
Transmission
HIV has been found in the semen, blood, vaginal secretions, saliva, urine, and breast
milk of infected individuals. It also can occur in any other bodily fluids that contain
blood, including cerebrospinal fluid and amniotic fluid. Blood, semen, and vaginal
secretions are the three bodily fluids that most consistently contain high concentra-
tions of the virus in infected people. Most commonly, HIV enters the body when
bodily fluids are exchanged during unprotected vaginal or anal intercourse with an
infected person. Transmission of HIV through sexual contact is estimated to be the
cause of about 80% of worldwide HIV infections. HIV is also readily transmitted by
means of blood-contaminated needles shared by injection drug users.
e virus can also be passed perinatally from an infected woman to her fetus before
birth, to her infant during birth, or to her baby after birth through breast-feeding
(Kumwenda et al., 2008; Osborn, 2008). Mother-to-child transmission (MTCT) is
the primary way that children are infected with HIV.
e likelihood of transmitting HIV during sexual contact depends on both the viral
dose and the route of HIV exposure. Viral dose is a direct eect of the viral load
how much virus is present in an infected persons blood. e viral load measurement
widely used is the number of individual viruses in a milliliter of blood. In general, the
greater the viral load, the higher the chance of transmitting the infection. As common
sense would suggest, when a person is in a late stage of HIV/AIDS disease, with more
advanced infection and thus greater viral load, he or she is highly infectious. However,
many readers might be surprised to learn that evidence strongly indicates that in the
initial period between exposure to HIV and the appearance of HIV antibodies in the
blood—a period called primary infection, which usually lasts a few months—viral load
can be extremely high, creating a state of heightened infectiousness (Harris & Bolus,
2008; Shapiro & Ray, 2007). is relatively brief peak in the transmissibility of HIV
soon after a person is infected is especially troubling because most infected people are
likely to remain unaware during these few months that they have been invaded by HIV.
Some experts believe that transmission during primary infection accounts for a large
portion of HIV infections worldwide (Cohen & Pilcher, 2005; Wawer et al., 2005).
e likelihood of infection during sexual activity is greater when HIV is transmit-
ted directly into the blood (e.g., through small tears in the rectal tissues or vaginal walls)
rather than onto a mucous membrane. Researchers have become increasingly aware that
circumcision status aects a mans risk for contracting HIV. e foreskin of the uncir-
cumcised penis is soft and prone to tiny lacerations that may allow HIV to enter the
bloodstream more easily. In addition, the foreskin has high concentrations of CD4 and
Langerhans cells, the immune cells typically targeted by HIV (Reynolds et al., 2004;
Seppa, 2005). While health-care providers continue to debate the practice of circumci-
sion on medical and ethical grounds, the case for circumcision as a means for reducing
HIV transmission is building. Evidence supporting this position is discussed in the
Spotlight on Research box, “Circumcision as a Strategy for Preventing HIV Infection.
Research also suggests that HIV can be transmitted during oral sex when the virus
present in semen or vaginal secretions comes into contact with mucous membrane tis-
sues in the mouth. Unfortunately, many people mistakenly consider oral sex to be a safe
practice (Kaestle & Halpern, 2007). Current CDC recommendations for preventing
HIV transmission call for using a condom during mouth-to-penis contact. However,
it is rare for people to use condoms during oral sex (Torassa, 2000). If you engage in
unprotected oral sex with partners whose HIV status is unknown, it would be wise to
take certain precautions: Make sure that your gums are in good shape (oral sores or
breaks in gum tissue provide HIV easier access to blood), avoid ossing immediately
before or after sex (ossing can damage oral tissue and cause bleeding), and avoid taking
SEXUALHEALTH
viral load
The amount of HIV present in an
infected person’s blood.
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Sexually Transmitted Infections467 467
ejaculated semen into your mouth. Furthermore, in light of the often substantial con-
centration of HIV in vaginal uids, you might also be cautious about engaging in cun-
nilingus with a female partner who has not tested negative for HIV. Finally, even though
there is some risk of HIV transmission via oral sex, the current consensus of experts is
that unprotected oral sex is an eective risk reduction strategy compared to unprotected
vaginal or anal penetration (Shapiro & Ray, 2007).
In the early 1980s, before the U.S. government required screening of donated blood for
HIV, contaminated blood and blood products infected an estimated 25,000 transfusion
recipients and people with blood-clotting disorders (such as hemophilia) in the United
States (Graham, 1997). However, since early 1985, donated blood and blood products
have been screened with extensive laboratory testing for the presence of HIV antibod-
ies. “e risk of transfusion transmitted HIV infections has been almost eliminated by
A number of health professionals and researchers have
suggested that circumcision may signicantly reduce the
risk of HIV infection by removing an entry point for the
virus—the thin foreskin with its high concentrations of cells
that are easily infected by HIV. This contention is supported
by several observational studies revealing that HIV infection
is less prevalent in circumcised men than in uncircumcised
men (
Reynolds et al., 2004; WHO/UNAIDS, 2007). There is
also strong empirical evidence from experimental clinical
trials that circumcision provides some protection against
HIV infection (Heisea et al., 2011). Three well-designed inves-
tigations, conducted in South Africa, Kenya, and Uganda,
demonstrated that study participants who underwent
circumcision experienced a 60%, 53%, and 51% reduc-
tion, respectively, in their risk of acquiring an HIV infection
(Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007).
It is important to emphasize that circumcision does
not in any way provide complete protection against HIV.
Rather, it is best viewed as an additional strategy in the
arsenal of tools used to prevent heterosexually acquired
HIV infection in men (WHO/UNAIDS, 2007). Recent research
indicates that circumcision may not provide protection
from HIV transmission that occurs during insertive anal
sex (Sanchez et al., 2011). Moreover, it appears that male
circumcision may have no effect on the transmission of HIV
from men to women (Berer, 2007; WHO/UNAIDS, 2007).
Studies conducted in Uganda and Zimbabwe found no
signicant association between women’s risk of acquir-
ing an HIV infection and the circumcision status of their
primary sexual partner (Turner et al., 2007). In addition,
these investigations found no association between male
circumcision and women’s risk of acquiring chlamydia,
gonorrhea, or trichomonal infections (Turner et al., 2007).
There is, however, evidence that men who are circumcised
are less vulnerable than uncircumcised men to infection by
H
PV (Auvert et al., 2008). A recent study of over 5,000 men
found that circumcision signicantly reduced the incidence
of HPV and genital herpes infections as well as providing
protection against HIV infection (Tobian et al., 2011).
The clear evidence that male circumcision for HIV
prevention provides partial protection for HIV-negative men
but not for their female partner(s) is highly problematic,
as recently described by Marge Berer (2008), an expert in
women’s sexual and reproductive health and rights. Berer
points out that while partners of circumcised men have an
equal right to protection against HIV, the circumcised status
of their male partners may in fact increase their vulner-
ability to HIV infection. For example, a circumcised man,
falsely believing that he is not at risk for HIV infection, may
choose not to practice safer sex, such as using condoms,
thereby subjecting his partner to greater risk of infection. If
a circumcised man “thinks he is protected, and he contin-
ues depositing semen in his partner’s body unimpeded
every time they have sex, then as I see it, his partner is
in a worse position than before” (Berer, 2008, p. 172). A
man who elects to be circumcised is able to achieve some
protection for himself without any changes in his behavior.
But for his sex partner(s) to achieve protection, safer sex is
necessary. Thus, equity for partners of circumcised men is
an issue that will be discussed and debated concurrently
with the implementation of male circumcision programs in
African nations in coming years.
Finally, two studies revealed potential obstacles to
large-scale circumcision programs in Africa. In one study
about one third of 1,007 young Kenyan men experienced
complications (lacerations, scarring, etc.) after being cir-
cumcised (Bailey et al., 2008). The second study revealed
that circumcision of all HIV-negative men in sub-Saharan
Africa would be markedly less cost-effective than distribut-
ing free condoms to men who need them (McAllister et al.,
2008). The authors of this report concluded that prevent-
ing one HIV infection via circumcision would cost almost
$6,000—more than 100 times the cost of preventing a
single infection with condoms.
RESEARCH
SPOTLIGHT ON
Circumcision as a Strategy for Preventing HIV Infection
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468 CHAPTER 15
the use of questionnaires to exclude donors at higher risk for HIV infection and the use
of highly sensitive laboratory screening to identify infected blood donations (Centers
for Disease Control, 2010f, p. 1335). ere is no danger of being infected as a result
of donating blood. Blood banks, the Red Cross, and other blood-collection centers use
sterile equipment and a new disposable needle for each donor. Unfortunately, U.S. pro-
cedures for safeguarding the blood supply are not widely practiced globally. is problem
is especially acute in some of the world’s poorest nations, which also have high rates of
blood-transmitted diseases, such as HIV and viral hepatitis (Lamptey et al., 2006).
Research indicates that a small percentage of people appear to be resistant to HIV
infection and that about 1 in 300 untreated HIV-infected people do not progress to
AIDS (Collins & Fauci, 2010; Lok, 2011). Evidence suggests that in some individu-
als this resistance has a genetic basis. Research in the laboratory of Stephen O’Brien
(2003), a respected medical geneticist, has indicated that people who inherit two cop-
ies of a gene labeled CCR5-32, one from each parent, are resistant to HIV infection.
CCR5 is a protein receptor on the surface of CD4 cells that acts as a docking station for
HIV. People who are homozygous for the CCR5-32 gene—about 1% of White Ameri-
cans—lack this docking station (HIVs doorway to cellular infection) and therefore are
resistant to infection. is gene is much less common among African Americans, and
the few copies of CCR5-32 among this population derive exclusively from Caucasian
gene ow to the African slaves and their descendants since their transport to America
(O’Brien, 2003, p. 215). is protective gene is completely absent in native African and
native East Asian ethnic groups.
It is believed that the risk of transmitting HIV through saliva, tears, and urine is
extremely low. Furthermore, no evidence indicates that the virus can be transmitted
by casual contact, such as hugging, shaking hands, cooking or eating together, or other
forms of casual contact with an infected person. All the research to date conrms that it
is sexual contact with an infected person or sharing contaminated needles that places an
individual at risk for HIV infection. Furthermore, certain high-risk behaviors increase
the chance of infection. ese behaviors include having multiple sexual part-
ners, engaging in unprotected sex, having sexual contact with people known
to be at high risk (such as injection drug users, sex workers, and people with
multiple sexual partners), sharing drug injection equipment, and using non-
injected drugs such as cocaine, marijuana, and alcohol, which can impair good
decision making.
Symptoms and Complications
As with many other viruses, HIV often causes a brief flulike illness within a
few weeks of initial infection. Symptoms include fevers, headaches, muscle
aches, skin rashes, loss of appetite, diarrhea, fatigue, and swollen lymph
glands (Harris & Bolus, 2008; Mosack et al., 2009). These initial reactions,
which represent the body’s defenses at work, tend to fade fairly rapidly.
However, as the virus continues to deplete the immune system, other symp-
toms can occur, such as persistent or periodically repeating fevers, night
sweats, weight loss, chronic fatigue, persistent diarrhea or bloody stools,
easy bruising, persistent headaches, a chronic dry cough, and oral candidia-
sis. Candidiasis of the mouth and throat is the most common infection in
HIV-infected people. Many of these physical manifestations also indicate
common, everyday ailments that are by no means life threatening. However,
observing that you have one or more of these symptoms that are persistent
can alert you to seek a medical diagnosis of your ailment.
The late tennis great Arthur Ashe at a news
conference announcing that he had AIDS as a
result of receiving an HIV-tainted blood transfusion.
© Bettmann/CORBIS
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Sexually Transmitted Infections469 469
HIV Antibody Tests
Within a few months of being infected with HIV, most people develop antibodies to
the virus, in a process called seroconversion. Seroconversion typically occurs sometime
between 25 days and 6 months after initial infection. HIV infection can be detected
by standard blood tests for blood serum antibodies to HIV. Most HIV tests are
now performed with a simplified diagnostic test kit that uses a finger-stick sample
of blood and provides results that are 99.6% accurate in as little as 20 minutes. HIV
antibodies can also be detected with a high degree of accuracy in urine and saliva
samples (Wright & Katz, 2006). A survey of 128 U.S. college health centers found
that HIV tests are widely available at campus clinics (Smith & Roberts, 2009). For
more information about HIV tests and test sites, contact the CDC National Hot-
line at 1-800-232-4636 or go online to the website of the American Social Health
Association.
Home testing for HIV, via the OraQuick HIV test, may soon be available. In May
2012, this test was approved by a 17-member FDA panel. e test, which utilizes a
mouth swab, appears to be slightly less accurate than a professionally administered HIV
test (Bacon, 2012).
Although quite uncommon, silent” HIV infections can be present in some individu-
als for 3 years or more before being detected by standard serum antibody tests. More
costly and more labor-intensive tests for the virus itself can be performed to detect a
silent or latent infection. Once infected with HIV, a person should be considered con-
tagious and capable of infecting others indenitely, regardless of whether clinical signs
of disease are present.
Many public health ocials are advocating for greater use of a new blood test for
genetic traces of HIV. e advantage of this procedure, compared to standard HIV
tests, is that it can detect an HIV infection within 7 to 10 days of occurrence (Tuller,
2009). Identifying new HIV infections sooner may encourage infected people to seek
counseling that will help them avoid transmitting the virus to other people, especially
during the period of primary infection when they are highly infectious.
e development of better treatment strategies oers compelling reasons for people
at risk to discover their HIV status as soon as possible. Presumably, once people become
aware of their HIV-positive status, they will be much less likely to pass the infection
on to others. is assumption was supported by a study which found that, of 615 men
and women diagnosed with HIV infection, most adopted safer sexual behaviors after
diagnosis, including regular use of condoms, less frequent or no sex, or engaging only
in oral sex (Centers for Disease Control, 2000a). Another study found that a substan-
tial majority of 1,363 HIV-infected men and women were using condoms during vagi-
nal or anal intercourse with partners known to be HIV-negative and with partners of
unknown HIV status (Centers for Disease Control, 2003).
Most HIV-infected people in the United States are not tested for HIV until they
develop symptoms of disease, and most HIV infections are transmitted by people who
are unaware of their status (Bowling, 2011; Koo et al., 2006). ese alarming facts
prompted the CDC to recommend, in September 2006, expanding HIV testing in the
United States by including HIV screening in routine health-care services for people
ages 13 to 64 and all pregnant women unless individuals specically opt out (Bartlett
et al., 2008; Bayer & Oppenheimer, 2011). e underlying goal of this recommenda-
tion is to promote early entry into medical care for HIV-infected people and facilitate
behavior changes that inhibit transmission of the virus to others (Bartlett et al., 2008).
e percentage of U.S. citizens ages 18 to 64 ever tested for HIV remained stable at
approximately 40% from 2001 to 2006 and increased to 45% in 2009 (Centers for Dis-
ease Control, 2010h).
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470 CHAPTER 15
As discussed near the end of this chapter, we believe that all couples poised on the
brink of a new sexual relationship should seriously consider undergoing medical exami-
nations and laboratory testing designed to rule out HIV and other STIs before begin-
ning any sexual activity that might put them at risk for infection. e following account
expresses one mans experience in this matter:
In the early stages of dating and getting to know one another, my future wife
and I candidly discussed our prior relationship histories. Neither of us had been
sexual with another for over a year, and we were both confident that we were
free of diseases transmitted during sex. But since we were aware that the AIDS
virus in an infected person’s body may go undetected for years, we decided
to be tested for the virus. We had our blood samples drawn at the same time,
in the same room, and later shared our respective lab reports. Thankfully, as
expected, we both tested negative. This process, while clearly reassuring, was
also helpful in contributing to a sense of mutual trust and respect that has con-
tinued into our married years. (Authors’ files)
Development of AIDS
As HIV continues to proliferate and invade healthy cells in an infected persons body,
the immune system loses its capacity to defend the body against opportunistic infec-
tions. The incubation period for AIDS (i.e., the time between HIV infection and the
onset of one or more severe, debilitating diseases associated with extreme impairment
of the immune system) typically ranges from 8 to 10 years in adults. However, a small
percentage of people infected with HIV remain symptom-free for much longer periods.
Furthermore, as we will see, powerful new treatment strategies can dramatically slow
the progress of HIV/AIDS in individuals who have access to these costly treatments.
People who experience progression to AIDS can develop a range of life-threatening
complications. A common severe disease among HIV-infected people, and one that
accounts for many AIDS deaths, is pneumonia caused by overgrowth of the proto-
zoan Pneumocystis carinii, which normally inhabits the lungs of healthy people. Other
opportunistic infections associated with HIV include tuberculosis, encephalitis (viral
infection of the brain), severe fungal infections that cause a type of meningitis, salmo-
nella illnesses (bacterial diseases), and toxoplasmosis (caused by a protozoan). Africa is
currently plagued with an escalating tuberculosis epidemic fueled largely by the HIV/
AIDS pandemic (Karim et al., 2011; Lawn, 2012). Worldwide tuberculosis is the most
common infectious cause of death in HIV-infected people, and of the approximately 2
million annual deaths worldwide attributable to AIDS, about 25% are associated with
this disease (Friedrich, 2011b; Török & Farrar, 2011). e body is also vulnerable to
cancers, such as lymphomas (cancers of the lymph system), cervical cancer, and Kaposi’s
sarcoma, a common cancer in male AIDS patients that aects the skin and can also
involve internal organs (Shiels et al., 2011).
Before the advent of much-improved antiretroviral treatments, once people living
with AIDS developed life-threatening illnesses, such as pneumonia, tuberculosis, or
cancer, the disease tended to run a fairly rapid course. Death usually occurred within
2 years for both men and women (Suligoi, 1997). Furthermore, most people who have
developed AIDS since the beginning of the epidemic in the United States have already
died. However, a signicant decline in the rate of AIDS deaths began in 1996 (the rst
year that the death rate declined since the onset of the epidemic) and has continued to
It has been suggested that all adolescents
and adults should be required to undergo
screening for the presence of HIV. Do you
agree with this recommendation? How might
the results of such testing be effectively
used to reduce the transmission of HIV?
What problems might occur as a result of
compulsory screening? Do you believe that
mandatory testing would be an unjustiable
violation of privacy rights?
Critical Thinking Question
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Sexually Transmitted Infections471 471
the present. is reversal in death trends was largely due to improve-
ment in combination drug therapies, which we discuss in the next
section. Even with this trend toward a lowering of the number of
annual deaths from AIDS in the United States, an estimated 16,000
Americans died from AIDS in 2011 (Tasker, 2011).
A reduction in AIDS deaths is also occurring in other developed
nations that have the resources to implement the more eective drug
therapies. Unfortunately, this reversal in AIDS deaths is minimal or
nonexistent in developing nations, especially those located in Africa,
where HIV/AIDS continues to result in an unacceptable incidence
of both infections and deaths. e high cost and diculty of admin-
istering new and better therapies are barriers to the eective use of
these treatments in poor, developing nations. Less than half of HIV-
infected persons in the developing world receive antiretroviral drug
therapy (Kelland, 2011). Drug therapy for infected people in the
developing world is also negatively impacted by the recent downturn
in the global economy, which resulted in a 10% drop in HIV/AIDS
funding in 2010 compared to 2009 (Voelker, 2011).
Reduced accessibility to antiretroviral drugs is commensu-
rate with a reduction in donor funds (Berkley, 2010). Signicantly
reduced donations to various African nations have resulted in fund-
ing cuts for HIV/AIDS treatment in many countries including
South Africa, Kenya, Uganda, Zimbabwe, Congo, and Mozambique.
e worldwide economic crisis has also resulted in decreased acces-
sibility to antiretroviral medications in the United States. In 2010
long waiting lists for these drugs were the norm as many infected
people lost health insurance along with their jobs. In addition, many
states were forced to cut back on AIDS treatment programs due to
the high cost of antiretroviral drugs.
Treatment
No cure currently exists for HIV/AIDS. However, thousands of scientists are involved
in an unprecedented worldwide effort to ultimately cure and/or prevent this horrific
disease. This war is being waged on several fronts, including attempts to develop effec-
tive antiretroviral drugs that will kill or at least neutralize HIV and efforts to create a
vaccine effective against HIV.
As we described earlier, HIV is classied as a retrovirus because, after invading a
living cell, it works backward, using an enzyme called reverse transcriptase. is enzyme
transcribes the viral RNA into DNA, which then acts to direct further synthesis of the
lethal HIV RNA. HIV also encodes another enzyme, called a protease (protein digest-
ing), that is equally critical to its reproduction. Once HIV invades a host CD4 cell, it
eventually takes over the host cell’s genetic material and manufacturing capacity, pro-
ducing additional viruses to infect other cells. During this process, HIV kills the host
cell and injects copies of its own lethal RNA into the blood to invade other healthy cells.
To date, treatment strategies have focused on drug interventions designed to block
the proliferation and seeding of HIV throughout the immune system and other bodily
tissues and organs. Up to the mid-1990s the main class of drugs used to combat HIV
comprised products that inhibited the action of the reverse transcriptase enzyme. ese
reverse transcriptase (RT) inhibitors were designed to prevent the virus from copy-
ing its own genetic material and making more viruses. A major breakthrough in drug
Kaposi’s sarcoma, shown here with its distinctive skin
lesions, is the most common cancer aficting men
with AIDS.
Roger Ressmeyer/CORBIS
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472 CHAPTER 15
therapy took place in 1996 with the emergence of a new class of drugs that inhibit
HIVs protease enzyme, which the virus uses to assemble new copies of itself. When a
protease inhibitor (PI) drug was combined with two RT inhibitor drugs in early clinical
trials, the combination was shown to dramatically reduce viral load in blood to minimal
or undetectable levels in most patients (Louis et al., 1997; Wong et al., 1997).
Highly Active Antiretroviral Therapy
The use of a combination of three or more drugs to combat HIV has come to be known
as highly active antiretroviral therapy (HAART). Most clinicians commence treat-
ment of HIV/AIDS with a combination of various RT and PI drugs. The availability of
new antiretroviral drugs, including drugs in new classes, requires clinicians to constantly
update and modify the HAART regimens used to combat HIV. Until recently it was
common practice to begin HAART for any HIV-infected person whose CD4 count
dropped below 200 or for anyone who manifested symptomatic disease (i.e., infections
or cancers associated with HIV/AIDS). However, new data on treatment choices for
infected people warranted an update of the International AIDS Society–USA guide-
lines for HAART. It is now suggested that treatment should be initiated before CD4
count declines to less than 350 (Hammer et al., 2008). The decision regarding when to
begin therapy must be tailored to the individual patient based on the
potential benefits and risks of early or delayed therapy.
HAART has proven to be an eective treatment regimen for
many HIV/AIDS patients. Various studies have demonstrated
that, when properly administered, HAART can inhibit HIV repli-
cation and frequently can reduce viral load to an undetectable level,
improve immune function, and delay progression of the disease.
e excellent clinical results produced by HAART in the early
years after it was implemented led to a surge of optimism that this
advance in antiretroviral therapy might not only delay HIV/AIDS
progression but also ultimately eradicate the virus. Unfortunately, as
we will see, these early projections were overly optimistic.
A signicant drawback of HAART that inuences adherence is
drug toxicity. Low compliance is often associated with adverse drug
side eects, including anemia; insomnia; mouth ulcers; diarrhea;
inammation of the pancreas; respiratory diculties; metabolic dis-
turbances; increased cholesterol and triglyceride levels (major risk
factors for cardiovascular diseases); gastrointestinal discomfort; liver
damage; excess fat accumulation in areas such as the abdomen, upper
back, and breasts; fat atrophy in the face, legs, and arms; and skin
rashes (Lo et al., 2008; Mosack et al., 2009). ese side eects can be
so severe that aected people are unable to tolerate HAART. Fortu-
nately, some of the HAART drug combinations introduced in recent
years have fewer side eects than previously used combinations, mak-
ing adherence less of an issue. Researchers have recently detected an
especially troubling condition attributed to HAART called immu-
nosenescence, a form of premature aging of the immune system that
may occur among some people on this drug regimen. While the ver-
dict is still out on this possible side eect, there are indications that
prolonged use of antiretroviral medications may lead to loss of men-
tal acuity and other age-related issues (Tasker, 2011).
Lack of adherence to HAART because of dosing complexities
and/or drug toxicity side eects can lead to less than optimal therapy,
In 1991 Earvin (Magic) Johnson, Los Angeles Lakers
basketball All-Star, announced that he had been infected
with HIV through heterosexual contact. By April 1997,
HAA
RT had reduced HIV to undetectable levels in his body.
© Stephen Dunn/Allsport/Getty Images
highly active antiretroviral therapy
(HAART)
A strategy for treating HIV-infected
people with a combination of antiret-
roviral drugs.
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Sexually Transmitted Infections473 473
outright treatment failure, and the development of drug-resistant strains of HIV (S.
Boyer et al., 2011; Li et al., 2011). Recent improvements in medication dosing schedules
(e.g., once or twice a day versus three times a day) and reductions in pill quantity (e.g.,
combining two or three drugs in one pill) have resulted in better adherence to HAART.
Despite the recent improvement in HAART regimens, evidence indicates that only
about 28% of HIV-infected Americans are recipients of HAART treatment that pro-
duces optimal reduction in their viral load (Brown, 2011). is low percentage is pri-
marily attributable to a large number of infected people who are unaware of their status
or who cannot get or do not want treatment. Fortunately, about 77% of people receiving
HAART have a fully suppressed viral load (Brown, 2011).
Another problem with HAART that surfaced in recent years further dampened the
optimism and excitement associated with the early years of this treatment protocol. It is
now clear that HAART does not eradicate HIV from latent or silent reservoirs in the
brain, lymph nodes, intestines, bone marrow, and other tissues, cells, and organs where
the virus may reside undetected and intact, even though blood plasma viral loads drop
to minimal or undetectable levels (Carter et al., 2010; Fang, 2010; Sigal et al., 2011).
Once treatment with the HAART regimen stops or is seriously compromised because a
patient is too sick with toxic side eects or too confused by the complexity of dosing regi-
mens, the virus sequestered in these lethal reservoirs typically comes roaring back, or it
mutates, resulting in new strains of HIV that are less susceptible to the HAART drugs.
On a more positive note, HAART has been shown to reduce the likelihood of HIV
transmission (Cohen et al., 2011; Hammer, 2011; Torian et al., 2011). A recent study
indicates that treating HIV-infected people with HAART medications at an early stage
of the disease process, when their immune systems are still relatively healthy, can reduce
the likelihood of transmitting HIV to an uninfected partner by 96% (National Institute
of Allergy and Infectious Diseases, 2011). However, an infected person can transmit
the virus at any time after becoming infected, even while undergoing HAART (Shapiro
& Ray, 2007). Many infected people transmit HIV to sexual partners before they are
aware of their HIV-positive status and prior to beginning treatment.
Has the availability of HAART inuenced HIV-negative people to change their
sexual behaviors? Do people undergoing this treatment regimen change their sexual
behaviors after beginning treatment? Evidence collected in the early years of HAART
indicated that at least some HIV-negative gay and bisexual men increased their involve-
ment in risky sex, perhaps because of the availability of this treatment regimen (Dilley
et al., 1997; Kelly et al., 1998). More recent studies have conrmed a continuation of
this trend toward increased sexual risk taking among gay and bisexual men as a result,
at least in part, of improved treatment for HIV/AIDS (Brewer et al., 2006; Oster et al.,
2011; Peterson & Bakeman, 2006).
Many persons who are aware that they are infected with HIV do refrain from engag-
ing in risky sexual behavior (Shapiro & Ray, 2007). Two studies—one a 16-state sample
of HIV-infected MSM and the other a representative sample of the adult U.S. population
in care for HIV/AIDS—found that 31% of the MSM and 32% of the adult respondents
in the broader study were engaging in deliberate abstinence by refraining from vaginal,
anal, or oral intercourse over the previous 6 months to a year (Bogart et al., 2006).
Drug Therapy to Prevent Mother-to-Child Transmission of HIV
In 1994, research demonstrated that zidovudine, an RT inhibitor drug administered
to both HIV-infected mothers and their newborns, reduced perinatal mother-to-
child transmission (MTCT) by two thirds (Connor et al., 1994). In August 1994 the
U.S. Public Health Service recommended zidovudine to reduce perinatal MTCT of
HIV. Since 1994 the number of infants infected through MTCT has been almost
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474 CHAPTER 15
eliminated in the United States and Europe via widespread
implementation of medical interventions (Lallemant et al.,
2011). Sadly, this is not the case in Africa, where MTCT of
HIV is still rampant and a majority of HIV-infected children
do not receive antiretroviral therapy and half die before they
reach age 2 (Lallemant et al., 2011).
e limited health systems of most African nations have
stimulated a search for a less costly, more practical, and more
eective short-course antiretroviral regimen. Studies in South
Africa and Uganda found that infants who were provided with
either (1) a single dose of the RT inhibitor drug nevirapine
within 24 hours of birth or (2) a short-course regimen with
this drug experienced excellent protection from HIV infection
(Altman, 2002; Moodley et al., 2003). Because single-dose
or short-course nevirapine therapy is dramatically less costly
than the longer and more complex zidovudine regimen, many
countries with limited resources are now utilizing this drug to reduce MTCT of HIV
(Spensley et al., 2009).
Preventing perinatal MTCT does not eliminate the possibility of later transmission
of the virus from a mother to a child through breast-feeding (Osborn, 2008). In sub-
Saharan African countries, breast-feeding is usually essential for infant survival, because
alternatives to breast milk are generally nonexistent or unaordable. It is estimated that
about 16% of untreated infants, whose mothers are HIV infected, will acquire MTCT
of HIV if breast-feeding continues into the second year of life (Kumwenda et al., 2008).
A recent investigation in Botswana revealed that HAART regimens were eective in
suppressing viral loads during pregnancy and later during breast-feeding. e HAART
regimen, commenced no later than the 34th week of gestation and continued through
up to 6 months of breast-feeding, achieved a 1.1% rate of MTCT at 6 months, the low-
est recorded in a breast-feeding population (Shapiro et al., 2010).
Health ocials also hope that presenting alternatives to breast-feeding, such as breast-
milk substitutes or early weaning, will help reduce the transmission of HIV through
breast milk. Unfortunately, breast-milk transmission continues “in vast areas in which
alternatives to breast-feeding are unavailable, unsafe, or both (Osborn, 2008, p. 582).
The Search for a Vaccine
We close this section on treatment with an update on efforts to develop an effective
vaccine for HIV. Development of a safe, effective, and affordable vaccine is a global
public health priority and remains the best long-term hope for bringing the worldwide
HIV/AIDS pandemic under control (Johnston & Fauci, 2011).
ere are two broad categories of vaccines: (1) those that prevent initial infection by
HIV (prophylactic vaccines) and (2) those that delay or prevent progression of disease
in people already infected (therapeutic vaccines). Despite extensive eorts, researchers
have failed to develop vaccines from either category that are broadly eective against
HIV. e most promising vaccine trials conducted to date have all failed (Osborn,
2008). In July 2008, plans to conduct a large U.S.-based human trial of a government-
developed HIV vaccine were canceled when federal health researchers realized that they
had insucient knowledge about how HIV vaccines interact with the immune sys-
tem (Altman, 2008a). Discovery of an eective HIV vaccine remains elusive, and some
HIV/AIDS specialists wonder whether an eective vaccine will ever be developed (De
Cock et al., 2011; Johnston & Fauci, 2008).
A number of problems confront vaccine researchers, including the absence of an ideal
animal model for research and the combined facts that HIV is extremely complicated, is
African children are often aficted with HIV/AIDS as a result of
mother-to-child transmission.
Jens Grossmann/laif/Redux
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Sexually Transmitted Infections475 475
present in multiple strains, and can change rapidly through genetic mutation (Johnston
& Fauci, 2008; Osborn, 2008).
Some recent developments in HIV vaccine research do provide a basis for cautious
optimism. A large study in ailand provided evidence that a small percentage of vac-
cinated people exhibited immunity to HIV infection (Collins & Fauci, 2010). Several
vaccine candidates are entering the development pipeline. Two recent studies with
macaque and rhesus monkeys challenged with simian immunodeciency virus (SIV)
suggest that these animals may provide a viable study group for future vaccine research
(R. Johnson, 2011; Liu et al., 2009).
Researchers are currently investigating the possibility that a mild-mannered virus
carried by most people, cytomegalovirus (CMV), can be used to carry a few HIV genes
to prime immune defenses against HIV (Hansen et al., 2011; Rojas-Burke, 2011). e
advantage of using CMV as a carrier is that this virus persists indenitely in humans
without causing harm and thus may provide lifelong HIV immunity. How well modi-
ed CMV may eectively defend against HIV remains to be seen.
In spite of many setbacks in the search for a vaccine, many researchers are optimistic
that the tools of modern science will enable us to develop HIV vaccines that induce
eective immune responses that . . . can prevent HIV infection (Johnston & Fauci,
2011, p. 875).
For the sake of the worlds population, especially in developing countries, we can
only hope that eective, low-cost vaccines are available soon. Unfortunately, the time
line for nding an eective HIV vaccine appears to stretch years into the future.
Prevention
The only certain way to avoid contracting HIV sexually is either to avoid all varieties
of interpersonal sexual contact that place one at risk for infection or to be involved in
a monogamous, mutually faithful relationship with one noninfected partner. If nei-
ther of these conditions is applicable, a wise person will act in a way that significantly
reduces his or her risk of becoming infected with HIV.
Safer-sex practices that reduce the risk of contracting HIV/AIDS and other STIs
are described in some detail in the last section of this chapter. Most of these preventive
methods are directly applicable to HIV/AIDS. However, it is important to note that
any strategies that reduce your risk of developing the other STIs previously discussed
will also reduce your risk of HIV infection because of the known association between
HIV/AIDS and other STIs.
Beyond the obvious safer-sex strategies of consistently and correctly using latex con-
doms and avoiding sex with multiple partners or with individuals at high risk for HIV,
the following list provides suggestions particularly relevant to avoiding HIV infection.
Note that several of these suggestions are less signicant for two healthy people in a
monogamous relationship who apply common sense in evaluating what is most likely
to be risky for them.
1. If you use injected drugs, do not share needles or syringes.
2. Injection drug users may wish to check with local health departments to see if a
syringe-exchange program (SEP) exists. These programs, which provide clean
syringes or needles in exchange for used syringes or needles, have been shown
to reduce the spread of HIV and other blood-borne infections among high-risk
injection drug users (H. Cooper et al., 2011; Drach et al., 2011). In 2009, 189
SEPs were known to be operating in 36 states (Centers for Disease Control,
2010g). The U.S. federal government did not support SEPs until the onset of
Obamas presidency (De Cock et al., 2011).
3. Avoid oral, vaginal, or anal contact with semen.
SEXUALHEALTH
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476 CHAPTER 15
4. Avoid anal intercourse, because this is one of the riskiest of all sexual behaviors
associated with HIV transmission (Ibanez et al., 2010; Jenness et al., 2011).
5. Do not engage in insertion of fingers or fists (“fisting”) into the anus as an active
or receptive partner. Fingernails can easily cause tears in the rectal tissues, thereby
creating a route for HIV to penetrate the blood.
6. Avoid oral contact with the anus (a practice commonly referred to as rimming).
7. Avoid oral contact with vaginal fluids.
8. Do not allow a partner’s urine to enter your mouth, anus, vagina, eyes, or open
cuts or sores.
9. Avoid sexual intercourse during menstruation. HIV-infected women are at increased
risk for transmitting their infection through intercourse while menstruating.
10. Do not share razor blades, toothbrushes, or other implements that could become
contaminated with blood.
11. In view of the remote possibility that HIV may be transmitted by means of
prolonged open-mouth wet kissing, it might be wise to avoid this activity. There
is no risk of HIV transmission through closed-mouth kissing.
12. Avoid sexual contact with sex workers (male or female). Research indicates that
sex workers have unusually high rates of HIV infection (Lamptey et al., 2006).
All these methods for preventing HIV infection focus on preventing exposure to
the virus. Several years ago the U.S. Department of Health and Human Services issued
guidelines for using antiretroviral drugs to prevent HIV infection after unanticipated
sexual or injection-drug-use exposure. ese guidelines indicate that a 28-day course
of HAART commenced as soon as possible after exposure can signicantly reduce the
risk of infection (Centers for Disease Control, 2005). A number of health departments,
clinics, and individual physicians in the United States are now providing postexposure
prophylaxis (PEP) via HAART after unanticipated exposure to HIV. PEP has also
been utilized as an HIV infection prevention strategy with South African children who
have been raped (Collings et al., 2008). Some health professionals believe that preexpo-
sure prophylaxis (PrEP) via a daily pill may also be a viable option for preventing HIV
infection. is possibility is discussed in the following paragraphs.
Is it possible that uninfected people could take a pill once daily to prevent HIV
infection? Recent research suggests that PrEP with a once-daily ingestion of Truvada
(a combination of two antiretroviral drugs) may accomplish this goal. In a study that
included 2,494 gay men drawn from six countries, researchers found that men taking
Truvada were 44% less likely to become infected with HIV than men taking a placebo.
In addition, in men who took the pill every day, as indicated by blood tests, Truvada
was more than 90% eective in preventing HIV infection (D. Smith et al., 2011). Some
health professionals suggest that PrEP may prove especially advantageous for unin-
fected people whose primary partner is infected, for people who feel unable to insist on
condom use, and for commercial sex workers who often experience unprotected expo-
sure to HIV. Concern has also been expressed that people utilizing PrEP may become
less concerned about HIV infections and thus less vigilant about protecting themselves
via safer sexual behaviors (Hayden, 2011).
A recent study in Africa found that PrEP via Truvada did not help prevent HIV
infection in women (Stephenson, 2011). However, other recent research that studied
about 5,000 heterosexual couples in Kenya and Uganda demonstrated that a daily
dose of antiretrovirals did signicantly reduce transmission of HIV for both men and
women (Maugh, 2011). We await further research to clarify the eectiveness of PrEP.
At present, the best hope for curtailing the spread of HIV/AIDS is through edu-
cation and behavior change. Because neither an eective vaccine nor a drug-based
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Sexually Transmitted Infections477 477
cure seems likely to be available soon, the best strategy for signicantly curtailing this
pandemic is preventing exposure through education about eective prevention and
risk-reduction strategies. A wide range of published studies of a variety of preven-
tion strategies, directed at a broad range of target populations, has provided promising
ndings, indicating that intensive educational and behavioral interventions are often
eective in reducing risky behaviors that increase vulnerability to HIV infection. e
Obama administration recently increased HIV/AIDS prevention by establishing a
national HIV/AIDS strategy that targets prevention eorts to those individuals most
likely to be infected (Melby, 2012).
Many HIV/AIDS experts have stated that more emphasis needs to be placed on
behavioral interventions that have been shown to help prevent the spread of HIV/
AIDS (Altman, 2008b). ese prevention strategies include increasing awareness of
risk behaviors for HIV infection and promoting safer sex through condom use, hav-
ing fewer sexual partners, delaying sexual debut, decreasing use of injection drugs, pro-
viding access to needle-exchange programs, and promoting male circumcision. Clearly,
behavior-based HIV prevention interventions help slow the spread of HIV infections
(Altman, 2008b; Jae, 2008; B. Johnson et al., 2011). In the absence of a cure or an
eective vaccine, these eorts provide the best weapons in the worldwide war being
waged against this devastating illness. An enduring frustration for the authors of this
text and a multitude of researchers and health practitioners worldwide is the likelihood
that “we will not know how the story of AIDS will nally end because the epidemic will
outlast us (De Cock et al., 2011, p. 1047).
Preventing Sexually Transmitted Infections
Many approaches to curtailing the spread of STIs have been advocated. These range
from attempting to discourage sexual activity among young people to providing easy
public access to information about the symptoms of STIs, along with free medical treat-
ment. Unfortunately, the efforts of public health agencies have not been very successful
in curbing the rapid spread of STIs. For this reason, it is doubly important to stress a
variety of specific preventive measures that can be taken by an individual or a couple.
Clearly, abstinence from partner sex is one virtually surere way to avoid an STI.
Being infection-free and monogamous yourself and having a partner who is also infec-
tion-free and monogamous is another way to prevent contracting an STI. However,
it is often dicult for people to assess the infection-risk status of prospective or cur-
rent partners and, for that matter, to assess how committed their partners are to being
monogamous.
Having a frank and open discussion before initial sexual interaction may seem dif-
cult and embarrassing. However, in this era of epidemic health-damaging and life-
threatening STIs, such discussions are essential to making sound judgments that may
have profound ramications for your physical and psychological well-being. Conse-
quently, we address this issue early in our outline of prevention guidelines.
Prevention Guidelines
We discuss several methods of prevention—steps that can be taken before, during, or
shortly after sexual contact to reduce the likelihood of contracting an STI. Many of these
methods are effective against the transmission of a variety of infections. Several are appli-
cable to oral–genital and anal–genital contacts in addition to genital–genital interaction.
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478 CHAPTER 15
None of the methods is 100% effective, but each method acts to significantly reduce the
chances of infection. Furthermore—and this cannot be overemphasized—the use of pre-
ventive measures may help to curtail the booming spread of STIs. Because many infected
people have sexual contact with one or more partners before realizing that they have
an infection and seeking treatment, improved prevention rather than better treatment
seems to hold the key to reducing these unpleasant effects of sexual expression.
Assess Your Risk Status and Your Partner’s Risk Status
As a result of informed concern about acquiring an STI, you may understandably
focus on assessing the risk status of a prospective sexual partner. However, in doing so,
you may overlook the equally important need to evaluate your own risk status. If you
previously engaged in sexual activity with others, is there any possibility that you may
have contracted an STI from them? Have you been tested for STIs in general, not just
for one specific infectious agent? Remember, many of the STIs discussed in this chap-
ter produce little or no noticeable symptoms in an infected person. If you care enough
to be sexually intimate with a new partner, is it not reasonable that you should also be
open and willing to share information about your own sexual health?
Some experts maintain that one of the most important STI prevention messages
to convey to people is to spend time, ideally several months or more, getting to know
prospective sexual partners before engaging in genital sex. Unfortunately, research indi-
cates that eective communication about risk factors and safer sexual behavior seems to
be more the exception than the rule in dating couples” (Buysse & Ickes, 1999, p. 121).
Research has revealed that individuals who are beginning or are involved in romantic or
intimate relationships are often reticent to discuss past sexual experiences (Anderson et
al., 2011). We strongly encourage you to take time to develop a warm, caring relation-
ship in which mutual empathy and trust are key ingredients. Use this time to convey to
the other person any relevant information from your sexual history regarding your risk
status—and to inquire about your partner’s present or past behavior in the areas of sex
and injection drug use. As discussed in Chapter 7, self-disclosure can be an eective
strategy for getting a partner to open up. us you might begin your dialogue about
these matters by discussing why you think that such an information exchange is vitally
important in the AIDS era, and then share information about your own sexual history.
Studies indicate that reciprocal sexual self-disclosure contributes to greater relational
and sexual satisfaction (Anderson et al., 2011, p. 383).
Getting to know someone well enough to trust his or her answers to these important
questions means taking the time to assess a persons honesty and integrity in a variety
of situations. If you observe your prospective partner lying to friends, family members,
or you about other matters, you may rightfully question the truthfulness of her or his
responses to your risk-assessment queries.
Research suggests that we cannot always assume that potential sexual partners will
accurately disclose their risk for STIs. Various studies have shown that people often
engage in sexual deceptions with their partner(s) that may include failing to reveal the
number (or identity or both) of previous sexual partners, other current sexual involve-
ments, or their own STI status, or making false claims about testing negative for HIV/
AIDS and other STIs. Several investigations reveal that it is not uncommon either to
fail to disclose ones STI status or to lie about it in order to have sex (Anderson et al.,
2011; Marelich et al., 2008; Newton & McCabe, 2005; Sullivan, 2005).
Obtain Prior Medical Examinations
Even when people are entirely candid about their own sexual histories, there is no
way to ensure that their previous sexual partners were honest with them—or, for that
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Sexually Transmitted Infections479 479
matter, that they even asked previous partners about STI risk status. In view of these
concerns, we strongly encourage couples who want to begin a sexual relationship to
abstain from any activity that puts them at risk for STIs until both partners have had
medical examinations and laboratory testing designed to rule out all STIs, including
HIV. Taking this step not only reduces ones chance of contracting an infection but
also contributes immeasurably to a sense of mutual trust and comfort with developing
intimacy. If cost is an issue, contact your campus health service or a public health clinic
in your area; both of these venues can provide examinations and laboratory testing free
of charge or on a sliding fee scale commensurate with your financial status.
Use Condoms
It has been known for decades that condoms, when consistently and correctly used,
help to prevent the transmission of many STIs (Reece et al., 2010b). The condom,
one of the great underrated aids to sexual interaction, is the only current contraceptive
method (other than abstinence) that protects against pregnancy and most STIs (Reece
et al., 2010b). Male latex condoms, when used correctly and consistently, are effective
in preventing the sexual transmission of HIV, and they reduce the risk of transmission
of other STIs, such as chlamydia, gonorrhea, NGU, bacterial vaginosis, and tricho-
moniasis, that are also transmitted by fluids from mucosal surfaces. Condoms are less
effective in preventing infections that are transmitted by skin-to-skin contact, such as
syphilis, HSV, and HPV, and they have no value in combating pubic lice and scabies.
Condoms made from sheeps membrane (also known as natural skin or natural mem-
brane”) contain small pores that may permit passage of some STIs, including HIV,
HSV, and hepatitis viruses.
e NSSHB reported that adults who used condoms during intercourse were
just as likely to rate the sexual experience as positive in terms of pleasure as those who
engaged in condomless intercourse (Reece et al., 2010b).
Unfortunately, the proven value of condoms in reducing the spread of HIV/AIDS
in Africa was undermined by a change in U.S. policy during George W. Bushs admin-
istration. is change is discussed in the Sex and Politics box, U.S. Policy During the
Bush Administration Reduced Condom Promotion in Africa.
In March 2009, Pope Benedict XVI stated publicly during a visit to Africa that
condoms have added to the problem of HIV/AIDS and that this pandemic should be
tackled via abstinence rather than condom use. Lancet, a leading medical journal, called
on the Pope to retract these inaccurate remarks that undermine HIV/AIDS prevention
eorts in Africa (Staines, 2009). Fortunately, in November 2010 the Pope appeared
to reverse his position on condoms by stating that condoms are the lesser of two evils
when used to curb the spread of AIDS, even if their use prevents pregnancy” (Simpson
& Wineld, 2010, p. 1). is revision in the ponti s position on condoms appears to
reect the Catholic Churchs belief that staunch opposition to condoms as a birth con-
trol device cannot be justied when it puts lives at risk.
Laboratory studies indicate that the female condom (see Chapter 10) is an eective
barrier to viruses, including HIV. If used correctly and consistently, the female condom
can substantially reduce the risk of transmission of some STIs, and when the use of
male condoms is not an option, we strongly encourage our readers to consider using a
female condom. e female condom can be especially valuable to sexually active women
who are at substantial risk for acquiring STIs from male partners who are unwilling to
use male condoms consistently or at all.
Evidence indicates that vaginal spermicides containing nonoxynol-9 (N-9) are not
eective in preventing transmission of chlamydia, gonorrhea, or HIV (Workowski et
al., 2010). In fact, frequent use of N-9 has been associated with genital lesions in the
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480 CHAPTER 15
vagina, which can increase vulnerability to HIV infection transmitted during vaginal
intercourse (Van Damme, 2000). Furthermore, animal research has shown that N-9
can damage the cells lining the rectum, thus providing a portal of entry for HIV and
other STI pathogens (Workowski et al., 2010). e CDC recommends against use of
condoms lubricated with N-9 spermicide.
Available barrier methods for preventing STI transmission are often disadvanta-
geous to women because they are either male controlled (the male condom) or require
male cooperation (the female condom). Consequently, researchers are actively pursuing
methods for STI prevention that can be controlled solely by women. ese eorts are
described in the following paragraphs.
Microbicides
Research efforts are currently under way to develop safe and effective topical gel or
cream products or suppositories, called microbicides, that can be inserted into the
vagina or rectum to prevent or minimize the risk of being infected with HIV and other
STIs. These products would be applied before sexual intercourse, but they would not
be a substitute for condoms. Rather, they would provide extra protection at low cost.
In the developing world, where financial resources are limited and women are often
unable to depend on male cooperation, microbicides would offer an especially benefi-
cial option for STI prevention (Mahan et al., 2011).
Technically, the term microbicide means a product that kills microbes. However,
there are several ways that microbicide products could function to prevent STIs. Some
microbicides would kill or destroy infection-causing organisms present in semen or vag-
inal secretions. Other microbicides under development would work not by destroying
an infection-causing pathogen but by blocking its entry or fusion with target cells or by
stopping its replication once inside target cells.
U.S. Policy During the Bush Administration Reduced Condom
Promotion in Africa
SEX &
POLITICS
Policy changes implemented by the U.S. government dur-
ing the Bush administration made condom promotion in
Africa controversial, resulting in a serious setback in efforts
to bring the AIDS pandemic under control. Conservative
U.S. government ofcials made clear the Bush adminis-
tration’s preference for abstinence-only approaches and
registered strong misgivings about the moral and ethical
advisability of providing condoms as part of AIDS preven-
tion programs. In addition, U.S. ofcials removed scienti-
cally accurate information about condom use effectiveness
from the websites of several federal agencies and ques-
tioned whether condoms provide protection against STIs,
including HIV (Kirby, 2008a; Masters et al., 2008).
To date, there is absolutely no evidence that abstinence-
only programs have reduced HIV transmission anywhere in
the world (Kirby, 2008a; Masters et al., 2008). Nevertheless,
this unproven approach was exported to many sub-Saharan
nations, especially Uganda, as part of
President Bushs
Emergency Plan for AIDS Relief (PEPFAR) (Human Rights
Watch, 2006; Jaffe, 2008).
A report by the U.S. Government Accountability Ofce
revealed that the requirement to allocate a sizable portion
of PEPFAR’s funds to promote abstinence and delity sig-
nicantly eroded other preventive efforts, including MTCT,
prevention services for couples in which one person is HIV
infected and the other is not infected, and promotion of
comprehensive programs focused on high-risk groups such
as sexually active youth (Brown, 2006; Steinbrook, 2008).
In 2011 the Obama administration issued new science-
based guidance on U.S.-funded HIV/AIDS prevention pro-
grams overseas. These new directives essentially negated
old prevention guidelines issued by the Bush administration
that emphasized a narrow and largely ineffective focus on
abstinence and being faithful. The new guidance “details a
comprehensive approach to prevention including emphasis
on combination prevention approaches” (Allana, 2011, p. 1).
microbicide
A topical gel or cream product that
women can use vaginally to prevent
or minimize the risk of being infected
with HIV or other STIs.
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Sexually Transmitted Infections481 481
Several microbicide candidates are currently being studied in clinical trials with
large study populations in developing countries that are at risk for infection by HIV and
other STIs (Stadler & Saethre, 2011). e National Institutes of Health (2009) issued
a report on a large-scale clinical trial of a microbicide known as PRO 2000 that was
conducted with several thousand women in Africa and the United States. Although the
ndings of this study indicate that PRO 2000 may eectively protect women against
HIV infection, more data are necessary to conclusively determine the eectiveness of
this microbicide candidate.
e eectiveness of microbicide products is related to adherence to or consistency
of use. is connection was revealed in the PRO 2000 study in which only about 60%
of the enrolled subjects reported using the microbicide gel during every sexual act (Hei-
sea et al., 2011).
Unfortunately, a recent research trial in Africa found that a vaginal gel microbicide
containing the antiretroviral drug tenofovir was no more eective than a placebo gel in
preventing HIV infection (Friedrich, 2012).
Some of the products under investigation have both spermicidal and antimicrobial
capabilities. Health ocials hope to eventually have eective products from both cat-
egories, because some users will want protection against both unwanted pregnancies
and STIs, whereas others will seek only protection against infection. We hope that one
or more of these much-needed products will be available soon.
Avoid Sexual Activity With Multiple Partners
You may wish to reevaluate the importance of sex with multiple partners in light of
the clear and extensive evidence that having many sexual partners is one of the stron-
gest predictors of becoming infected with HIV, HSV, chlamydia, HPV, and numer-
ous other sexually transmitted infections. You might also elect not to have sex with
individuals who you know or suspect have had multiple partners. People with multiple
partners probably know each partner less well and thus may be less successful in avoid-
ing people who engage in high-risk behaviors.
Correctly used condoms help prevent the transmission of many STIs, including HIV.
© Michael Newman/PhotoEdit
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482 CHAPTER 15
Inspect Your Partner’s Genitals
Examining your partner’s genitals before coital, oral, or anal contact might reveal the
symptoms of an STI. Herpes blisters, vaginal and urethral discharges, and chancres
and rashes associated with syphilis, genital warts, and gonorrhea may be seen. In
most cases symptoms are more evident on a man. (If he is uncircumcised, be sure to
retract the foreskin.) The presence of a discharge, an unpleasant odor, sores, blisters, a
rash, warts, or anything else out of the ordinary should be viewed with some concern.
Milking” the penis is a particularly effective way to detect a suspicious discharge.
This technique, sometimes called the short-arm inspection, involves grasping the
penis firmly and pulling the loose skin up and down the shaft several times, apply-
ing pressure on the base-to-head stroke. Then part the urinary opening to see if any
cloudy discharge is present.
People frequently nd it dicult to openly conduct such an inspection before sexual
involvement. Sometimes the simple request Let me undress you” can provide some
opportunity to examine your partner’s genitals. Sensate focus pleasuring, discussed in
Chapter 14, could provide the opportunity for more-detailed visual exploration. Some
people suggest a shower before sex, with an eye toward examining a partner. is may be
helpful for noting visible sores, blisters, and so forth, but soap and water can also remove
the visual and olfactory cues associated with a discharge.
If you note signs of infection, you may justiably and wisely elect not to have sex-
ual relations. Your intended partner may or may not be aware of his or her symptoms.
erefore it is important that you explain your concerns. Some people may decide to
continue their sexual interaction after discovering possible symptoms of an STI; they
would be wise, though, to restrict their activities to kissing, hugging, touching, and man-
ual genital stimulation.
Obtain Routine Medical Evaluations
Many authorities recommend that sexually active people with more than one partner
routinely visit their health-care practitioner or local public health clinic for periodic
checkups, even when no symptoms of infection are evident. In view of the number of
people, both women and men, who are symptomless carriers of STIs, this seems like
good advice. How often to have such examinations is a matter of opinion. Our advice
to people who are sexually active with several partners is that they should have check-
ups every 3 months and certainly no less often than twice a year.
Inform Your Partner(s) if You Have an STI
The high frequency of infections without symptoms makes it imperative for infected
individuals to inform their sexual partner(s) once they are diagnosed with an STI.
Partner notification, which is beneficial in reducing the spread of all STIs, is an espe-
cially imperative prevention tactic for curtailing the spread of HIV infections (Bird &
Voisin, 2011; Obermeyer et al., 2011). Partner notification can be conducted by the
infected person, by health-care providers, or by specially trained city, state, and federal
employees called disease intervention specialists (DISs) (Kissinger et al., 2003). The
Let’s Talk About It box, Telling a Partner, which appeared earlier in this chapter,
offers suggestions that may be helpful to a person who elects to notify a partner about
an STI infection. A potential benefit of partner notification conducted by a health-
care provider or DIS is that informed people typically receive counseling about how to
reduce the risk of exposure to STIs and are often provided with options for health-care
services, including testing and treatment (Hoxworth et al., 2003).
A number of studies have found that partner notication often facilitates several
desirable behavior changes, including increased condom use, reduction in number of
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Sexually Transmitted Infections483 483
sexual partners, and reduction in the incidence of STIs following notication (Niccolai
et al., 2006; Semaan et al., 2004). Even though partner notication can be a powerful
STI prevention strategy, we cannot assume that a sexual partner will be forthcoming
about a diagnosed STI.
A survey of a national sample of 1,421 people receiving medical care for HIV infec-
tion found that 42% of gay or bisexual men, 19% of heterosexual men, and 17% of
women participants reported engaging in sexual interaction without disclosing their
HIV-positive status to their sex partners. is nondisclosure occurred primarily within
nonexclusive partnerships (Ciccarone et al., 2003). In general, research indicates that
even when people diagnosed with an STI inform a primary partner, other sexual con-
tacts are likely to be left uninformed (Niccolai et al., 2006).
About half of the STIs diagnosed annually in the United
States occur among 15- to 24-year-olds.
A number of factors probably contribute to the high inci-
dence of STIs, including more people having unprotected
(condomless) sex with multiple partners, the increased use
of birth control pills, limited access to eective systems for
prevention and treatment of STIs, inaccurate diagnosis
and treatment, and the fact that many of these infections
do not produce obvious symptoms, which results in people
unknowingly infecting others.
Bacterial Infections
Chlamydia infections are among the most prevalent and
the most damaging of all STIs. Chlamydia is transmitted
primarily through sexual contact. It can also be spread by
ngers from one body site to another—for example, from
the genitals to the eyes.
ere are two general types of genital chlamydia infections
in females: infections of the lower reproductive tract, com-
monly manifested as urethritis or cervicitis; and invasive
infections of the upper reproductive tract, expressed as PID
(pelvic inammatory disease).
Most women with lower reproductive tract chlamydia infec-
tions have few or no symptoms. Symptoms of PID caused
by chlamydia infection include disrupted menstrual periods,
pelvic pain, elevated temperature, nausea, vomiting, and
headache.
Chlamydia salpingitis (infection of the fallopian tubes) is a
major cause of infertility and ectopic pregnancy.
Chlamydia infection also causes trachoma, the worlds lead-
ing cause of preventable blindness.
Recommended drugs for treating chlamydia infections
include doxycycline and azithromycin.
Summary
Gonorrhea is a common communicable bacterial infection
that is transmitted through sexual contact. e infecting
organism is a gonococcus bacterium.
Early symptoms of gonorrhea infection are more likely to be
manifested by men, who will probably experience a dis-
charge from the penis and a burning sensation during urina-
tion. e early sign in women, often not detectable, is a mild
vaginal discharge that may be irritating to vulval tissues.
Complications of gonorrhea infection in men include
prostate, bladder, and kidney involvement and, infrequently,
gonococcal epididymitis, which can lead to sterility. In
women gonorrhea can lead to PID, sterility, and abdominal
adhesions.
Recommended treatment for gonorrhea is the dual therapy
of a single dose of a cephalosporin medication (e.g., ceftriax-
one) plus a single dose of azithromycin (or doxycycline for
7 days).
Nongonococcal urethritis (NGU) is a common infection
of the urethral passage, typically seen in men. It is primarily
caused by infectious organisms transmitted during coitus.
Symptoms of NGU most apparent in men include penile
discharge and a slight burning sensation during urina-
tion. Women may have a minor vaginal discharge and are
thought to harbor the infecting organisms.
Doxycycline or azithromycin therapy usually clears
up NGU.
Syphilis is less common but potentially more damaging than
gonorrhea. It is almost always transmitted through sexual
contact.
If untreated, syphilis can progress through four phases:
primary, characterized by the appearance of chancre sores;
secondary, distinguished by the occurrence of a general-
ized skin rash; latent, a several-year period of no overt
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484 CHAPTER 15
symptoms; and tertiary, during which the infection can pro-
duce cardiovascular disease, blindness, paralysis, skin ulcers,
liver damage, and severe mental pathological conditions.
Syphilis can be treated with benzathine penicillin G at any
stage of its development. People allergic to penicillin can be
treated with doxycycline, tetracycline, or ceftriaxone.
Viral Infections
Some of the most common herpes viruses are type 1, which
generally produces sores on or in the mouth, and type 2,
which generally infects the genital area. Type 1 can be found
in the genital area, and type 2 can be found in the mouth
area. Type 2 is transmitted primarily through sexual contact;
type 1 can be passed by sexual contact or kissing.
It has been estimated that more than 100 million Americans
are aicted with oral herpes and that 50 million people in
the United States have genital herpes.
e presence of painful sores is the primary symptom of
herpes. A person is highly contagious during a herpes erup-
tion, but evidence indicates that herpes can also be transmit-
ted during asymptomatic periods.
Genital herpes can predispose a woman to cervical cancer. It
can also infect her newborn child, resulting in severe damage
to or death of the child.
Herpes has no known cure. Treatment is aimed at reducing
pain and speeding the healing process. Acyclovir, valacyclo-
vir, or famciclovir administered orally is eective in promot-
ing healing during rst episodes and, if taken continuously,
in suppressing recurrent outbreaks.
Genital and anal warts are an extremely common viral STI.
Genital warts are primarily transmitted through vaginal,
anal, or oral–genital sexual interaction.
Research has revealed a strong association between genital
warts and cancers of the cervix, vagina, vulva, urethra, penis,
and anus.
Genital warts are treated by freezing, applications of topical
agents, cauterization, surgical removal, or vaporization by a
carbon dioxide laser.
Vaccines eective against several types of HPV were
recently developed and approved by the FDA.
Hepatitis A, hepatitis B, and hepatitis C are three major
types of viral infections of the liver. All three types can be
sexually transmitted.
Hepatitis B can be transmitted through blood or blood
products, semen, vaginal secretions, and saliva. Manual, oral,
and/or penile stimulation of the anus are practices strongly
associated with the spread of this viral agent.
Oral–anal contact seems to be the primary mode of sexual
transmission of hepatitis A.
Hepatitis C is transmitted most commonly by means
of injection drug use or less frequently through
contaminated blood products and sexual contact; perina-
tal mother-to-fetus or mother-to-infant transmission is
also possible.
e symptoms of viral hepatitis vary from mild to inca-
pacitating illness. No specic therapy is available to treat
hepatitis A. Chronic hepatitis B infections can be treated
with a variety of antiviral drugs. Most people infected
with A and B types recover in a few weeks with adequate
bed rest.
e most health-threatening of the hepatitis viruses, hepa-
titis C, is an emerging communicable disease of epidemic
proportions.
Hepatitis C accounts for the majority of deaths from
complications of viral hepatitis. Combination therapy with
antiviral drugs is relatively eective in controlling the severe
complications associated with hepatitis C.
Common Vaginal Infections
Bacterial vaginosis—typically caused by an overgrowth of
anaerobic bacteria, Mycoplasma bacteria, or a bacterium
known as Gardnerella vaginalis—is the most common cause
of vaginitis (vaginal infection) in U.S. women. Male partners
of infected women also harbor the infectious microorgan-
isms, usually without clinical symptoms. Coitus often
provides a mode of transmission for this infection.
e most prominent symptom of bacterial vaginosis in
women is a shy- or musty-smelling, thin discharge that is
like our paste in consistency. Women can also experience
irritation of the genital tissues.
e treatment for bacterial vaginosis is metronidazole (Fla-
gyl) taken by mouth or intravaginal applications of topical
metronidazole gel or clindamycin cream.
Candidiasis is a yeast infection that aects many women.
e Candida albicans organism is commonly present in the
vagina but causes problems only when overgrowth occurs.
Pregnancy, diabetes, and the use of birth control pills or oral
antibiotics are often associated with yeast infections. e
organism can be transmitted through sexual or nonsexual
means.
Symptoms of yeast infections include a white clumpy
discharge and intense itching of the vaginal and vulval
tissues.
Traditional treatment for candidiasis infection consists of
vaginal suppositories or topical creams, such as clotrimazole,
or orally administered uconazole or itraconazole.
Trichomoniasis is a common STI caused by a protozoan
parasite called Trichomonas vaginalis. e primary mode of
transmission of this infection is through sexual contact.
Women infected with trichomoniasis and their male sexual
partners can be successfully treated with one dose of metro-
nidazole (Flagyl) or tinidazole.
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Sexually Transmitted Infections485 485
Ectoparasitic Infections
Ectoparasites are parasitic organisms that live on the outer
skin of humans and other animals. Pubic lice and scabies are
two relatively common STIs caused by ectoparasites.
Pubic lice (“crabs”) are tiny biting insects that feed on blood
from small vessels in the pubic region. ey can be transmit-
ted through sexual contact or by using bedding or clothing
contaminated by an infested individual.
e primary symptom of a pubic lice infestation is severe
itching that is not relieved by scratching. Sometimes pubic
lice can be seen.
Pubic lice are treated by application of prescription or over-
the-counter lotions or creams to aected body areas.
Scabies is caused by a tiny parasitic mite that forages for
nourishment in its host’s skin. Scabies is a highly contagious
condition that can be transmitted by close sexual or non-
sexual physical contact between people.
e primary symptoms of scabies are small bumps and a red
rash that itches intensely, especially at night. e bumps and
rash indicate areas of infestation.
A single application of a topical scabicide, applied from the
neck to the toes, is usually an eective treatment.
Acquired Immunodeciency Syndrome
(AIDS)
AIDS is caused by infection with a virus (HIV) that
destroys the immune system, leaving the body vulnerable to
a variety of opportunistic infections and cancers.
It now appears likely that HIV originated early in the 20th
century by means of cross-species transmission from a subspe-
cies of African chimpanzees to humans. e virus then spread
worldwide much later, when Africa became less isolated.
More than 1 million people in the United States and 34 mil-
lion people worldwide are infected with HIV.
e number of new AIDS cases reported annually in the
United States grew rapidly through the early 1980s and
moderated in the late 1980s. is more moderate rate has
continued to the present time.
Even though the overall incidence of new HIV infections
in the United States has remained relatively stable in recent
years, the number of new cases among teenagers, women,
racial and ethnic minorities, and MSM continues to rise.
Even though the prevalence of HIV infection in the United
States and the rest of the Western world remains highest
among MSM, the proportion of reported AIDS cases among
MSM declined sharply and then leveled o in the period
from the mid-1980s to the late 1990s. In recent years the inci-
dence of HIV infections among MSM has been increasing.
In the United States, AIDS cases attributable to hetero-
sexual transmission have declined slightly in recent years.
Heterosexual contact has always been the primary form of
HIV transmission worldwide.
HIV has been found in semen, blood, vaginal secretions,
saliva, tears, urine, breast milk, and any other bodily uids
that can contain blood.
Blood, semen, and vaginal uids are the major vehicles for
transmitting HIV, which appears to be passed primarily
through sexual contact and through needle sharing among
injection drug users.
HIV can also be passed perinatally from an infected
woman to her fetus or infant before or during birth, or by
breast-feeding.
Viral load refers to how much virus is present in an infected
persons blood. In general, the greater the viral load, the
higher the chance of transmitting the infection.
HIV can be transmitted to the receptive partner during oral
sex, when HIV comes into contact with mucous membrane
tissues in the mouth. Evidence indicates that the risk of
transmission of HIV via oral sex is minimal.
e present possibility of being infected with HIV by
means of transfusion of contaminated blood is remote.
Furthermore, there is no danger of being infected as a result
of donating blood.
A small percentage of people appear to be resistant to HIV
infection.
e risk of transmitting HIV through saliva, tears, and
urine appears to be low. ere is no evidence that HIV can
be transmitted by casual contact.
High-risk behaviors that increase ones chances of becoming
infected with HIV include engaging in unprotected (con-
domless) sex, having multiple sexual partners, having sexual
contact with people known to be at high risk, and sharing
injection equipment for drug use.
HIV is not as easily transmitted from women to men as it is
from men to women.
HIV often causes a brief, ulike illness within a few weeks
of initial infection. e initial illness tends to fade fairly rap-
idly. However, as the virus continues to deplete the immune
system, other symptoms occur.
Most people develop antibodies to HIV within months of
being infected, but some silent infections can go undetected
for 3 years or more.
HIV infection can be detected by blood tests for blood
serum antibodies to HIV.
e incubation time for AIDSdened as the time
between infection with HIV and the onset of one or more
severe, debilitating diseases—is estimated to range between
8 and 10 years.
e symptoms of HIV/AIDS disease are many and varied,
depending on the degree to which the immune system is
compromised and the particular type of cancer or opportu-
nistic infection that aicts an infected person.
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486 CHAPTER 15
A signicant decline in the rate of AIDS deaths began in
1996. is reversal in death trends was due to improvement
in combination drug therapies.
ere is still no cure for HIV/AIDS. However, when
properly used, a combination of three or more antiretro-
viral drugs—a treatment approach known as highly active
antiretroviral therapy (HAART)—can dramatically reduce
viral load, improve immune function, and delay progression
of the disease.
HAART involves a complex protocol of drug dosing that
can be dicult to adhere to. Furthermore, drug toxicity can
result in adverse side eects that induce low compliance
with the HAART protocol.
HAART does not eradicate HIV from latent or silent res-
ervoirs in various bodily tissues or organs.
e availability of HAART has apparently inuenced some
people to increase their involvement in risky sex.
e administration of nevirapine and/or zidovudine to
newborns signicantly reduces the incidence of mother-to-
child transmission of HIV.
Although progress has been made in developing HIV vac-
cines, many health ocials believe that we may be years
away from having an eective vaccine available.
e best hope for curtailing the HIV/AIDS epidemic is
through education and behavioral change.
A person can signicantly reduce her or his risk of becoming
infected with HIV by following safer-sex strategies, which
include using condoms and avoiding sex with multiple
partners or with individuals who are at high risk for HIV
infection.
Preventing Sexually Transmitted
Infections
Taking the time to carefully assess your risk status and your
partner’s risk status for transmitting STIs is perhaps the
most important preventive strategy.
Because it is often dicult to accurately assess risk sta-
tus from conversations alone, couples are encouraged to
undergo medical examinations and laboratory testing to rule
out STIs before engaging in any sexual activity that puts
them at risk for STIs.
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Also access links to chapter-related websites, including
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Information Center, An Introduction to Sexually Transmitted
Diseases, SaferSex.org, AIDSinfo, National Herpes Resource
Center, and Centers for Disease Control and Prevention.
Media Resources
Condoms, when used correctly, oer good but not foolproof
protection against the transmission of many STIs.
Topical gel or cream products, called microbicides, may help
prevent or minimize the risk of HIV infections.
Avoid sex with multiple partners or with individuals who
likely have had multiple partners.
Inspecting a partner’s genitals before sexual contact may be
a way to detect symptoms of an STI.
Sexually active people with multiple partners should
routinely visit their health-care practitioner or local public
health clinic for periodic checkups, even when no symptoms
of infection are present.
It is imperative for infected individuals to tell their sexual
partner(s) once they are diagnosed as having an STI.
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