What are the Common STDs?

There are many infections which may be passed by sexual contact and which have the potential to cause serious damage. This book will discuss the following familiar STDs: genital herpes, chlamydia, gonorrhoea, hepatitis, and syphilis. However, many of the important developments in the research literature of the last few years have centred on two particularly concerning STDs: human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and human papillomavirus (HPV). Because these two infections illustrate many of the serious concerns related to STD transmission in the adolescent population, this discussion will begin with an in-depth look at these two STDs.

Human Immunodeficiency Virus (HIV) & the Acquired Immunodeficiency Syndrome (AIDS)

While I was making a video on the issue of adolescent sexuality, (29) I met aa young woman who touched my heart deeply. She had heard about the video we were preparing and she approached me, asking if she could tell her story. This single mother of two children told me that she became infected with HIV a few years earlier after beginning a relationship with a seemingly gentle and caring boyfriend. He had been so different from previous guys and she illustrated her point by telling me how he had always been attentive to her needs and fun to be with. She told me that they were able to talk about all aspects of life and her children adored him. Unfortunately, even though he was fully aware that he was infected, he didn't tell her that he was HIV positive. It was when she was being tested in order to discover the cause of a variety of unexplained medical complaints that she learned that she was HIV positive. Needless to say, she was overwhelmed with shock and disbelief following this unexpected diagnosis. She requested that we interview her and include her story in the video. As she told her story to me again, this time with the camera running, I noticed silent tears running down the faces of the camera crew as she described her fears for herself and her children. Her previous boyfriend had been defiant in declaring his right to have sexual relationships with or without informing partners of the potential risk and she suspected that he was now passing on disease and death to other women.

What we know: AIDS has been identified as the second leading cause of serious sickness and disability in the world.

The annual AIDS conference held in various places throughout the world continues to bring focus to this tragic epidemic. HIV, human immunodeficiency virus, is the accepted name designated to the virus, or viruses, that are responsible for causing acquired Immunodeficiency syndrome, commonly known as AIDS. There have been a number of important developments regarding this viral infection; some that bring hope while others that raise important concerns.

A number of new antiviral therapies and protocols have been used with varying degrees of success in treating HIV infected individuals. Such treatments have allowed some patients to live longer and with improved quality of life. Unfortunately, this has not been the case for all patients and, despite considerable effort, a successful vaccine has not yet been discovered. (27) However, attention given to the success of some of the newer treatments of HIV/AIDS has resulted in the view, particularly in the western world, that HIV/AIDS is no longer a fatal affliction but that it has become a treatable, chronic problem. (30,31) The danger of this view is that people may consider the threat of transmission to be much less significant and, therefore, engage in high-risk sexual practices. (26) A worker at a local STD clinic told me that many youth consider HIV/AIDS to be an 'old man's disease' and do not think they are at significant risk. Along with the persistent problem of intravenous drug use, it is possible that the marked upturn in the incidence of new HIV infection in the last couple of years can be attributed, at least in part, to this apathetic attitude towards a still deadly infection.

There is a common misperception that a person is not at risk for catching HIV if their partner tests negative. Although this is frequently the case, it is important to realize that there is a 'window' between acquiring the virus and testing positive. Recent evidence confirms that HIV is highly transmissible in the very early stages of infection and the virus may be passed during this period of time even while an individual tests negative. (32)

What we know: HIV/AIDS is NOT an 'old man's disease'. There has been a marked upturn in the incidence of new HIV infection in the last number of years.

In some developing countries, the escalating HIV/AIDS epidemic is having serious personal repercussions, and social and economic infrastructures are being threatened. Widespread infection and death in the adult population has left a large number of children living on their own or being raised by grandparents or older siblings. Without appropriate love and care, these disadvantaged individuals, many of whom are now teenagers and young adults, experience a variety of personal difficulties and their communities have become vulnerable to many social problems.

A disturbing development in some nations as a result of the HIV/AIDS epidemic has been the emergence of dangerous myths related to AIDS infection. Fuelled by desperation and superstitious teachings, the myth that 'sex with a virgin' will cure AIDS, has become prevalent in some locations. This has resulted in unthinkable horror as the rates of raped children, including assaults on infants and toddlers, have tragically escalated. (33) Needless to say, such crimes result in horrific emotional trauma, the not infrequent transmission of HIV to victims, and a false sense of security for the infected perpetrator who continues to pass on the virus.

Another myth which is contributing to the spread of HIV in parts of the developing world is the belief of some adolescents that abstaining from sex leads to illness. (34) Driven by the fear that a lack of teen sexual activity may result in sexual dysfunction or infertility, teenagers are participating in behavior which is resulting in HIV infection. The need for education to combat these types of myths is evident.

From a global perspective, the HIV/AIDS epidemic is continuing to devastate populations in many countries. Particularly in developing nations, life expectancy in some areas is dropping as increasing percentages of the population become infected with this deadly virus. (24,30) The Department of Health in South Africa, for example, reported that in 1999, 32.5% of the population (including children) of the KwaZulu/Natal region was infected with the HIV virus. (35) By the end of 2001, an estimated 65 million people worldwide had been infected with HIV and in the most severely affected countries current statistics suggest that AIDS will kill more than half of the young adult population.(26) These examples are, unfortunately, only an illustration of the devastating reality of HIV/AIDS.

Human Papillomavirus (HPV)

A discouraged young man came to the medical clinic to have treatment for his genital warts, a symptom of human papillomavirus (HPV). While relating his medical history, he told me that he had had a brief sexual encounter some time ago with an old high school friend. The result was an infection with HPV, an illness he had never heard of previously. Since that time, he has had ongoing problems as his genital warts have repeatedly returned despite multiple treatments. Although he had come to the clinic because of physical problems related to his numerous genital warts and complaints of ongoing burning and irritation, he also related how he felt ashamed and how that brief encounter had "destroyed" his life. This patient stated that he had not had a sexual relationship in over two years because of concerns related to transmission. Although previously hoping to marry and have children, he now perceived these objectives as unattainable. He questioned why he was not told when he was in school health classes about the potentially life changing risks of such an infection.

In spite of the fact that doctors see the consequences of HPV on a regular basis, this virus is a challenge to deal with because of a number of crucial facts:

HPV spreads easily there is at least a 50% chance of transmission with a single sexual encounter with an infected individual; (36-38) HPV is often without symptoms in its early stages yet, with or without symptoms, it transmits readily; (39) HPV is currently incurable although symptoms such as genital warts may respond to treatment, the underlying infection is still present so difficulties and complications related to the virus may return.

Prevention of HPV is also a significant challenge because the virus may be present throughout the genital region and any skin-to-skin contact in that area may transmit the infection. Since condoms cover only a very limited area and do not prevent all direct physical contact in the genital region, transmission may occur despite condom use. (40,41) Although researchers are trying to find a simple way to detect infection in people who do not yet have signs or symptoms, there is currently no easily available test which identifies whether or not a person is carrying this STD.

What we know: There is at least a 50% chance of acquiring HPV during a single sexual encounter with an infected individual ...and, although symptoms such as genital warts may respond to treatment, HPV itself is currently incurable.

In the early 1990's, there was minimal public awareness of the significant problems caused by HPV. Even within the medical profession, this virus received limited attention and was viewed as a nuisance rather than as a serious, life-long and easily transmissible virus. Recently, however, research on this infectious agent has found that serious abnormalities of pap smears, indications of precancerous changes to the cervix or cancer of the cervix (both of which have escalated dramatically in young women), are, in most cases, the direct result of certain strains of HPV. (42-44)

According to the Centres for Disease Control, there are over a hundred different subtypes or strains of HPV, with over 30 of these being sexually transmitted and affecting the genital area some with the potential to cause cancer and others not. (45) Various studies reveal that genital HPV infection is widespread in sexually active youth (39,40,46) and a publication from Health Canada summarizes current research about HPV and women by stating: "the prevalence of all types of HPV (cancer and non cancer-causing) in different groups of Canadian women ranges from 20-33%. When only the cancer-causing types were examined, these studies found between 11 and 25% prevalence."(40) Over 5 million Americans contract a sexually transmitted HPV infection every year. (45)

For individual patients with significant abnormalities on their pap smear, the discovery that this problem is usually the result of an STD, that there is no way to eliminate the virus, and that they will likely pass it on to future partners, is devastating news. Because of increasing rates of HPV infection, cervical cancer is now the second most common cancer among women worldwide. (44) It is also well established that some other serious cancers, including cancer of the penis and anal area in men, can be a direct consequence of this viral infection. (40,45,47-54)

HPV, the most widespread sexually transmitted infection in most areas in the world, can also be transmitted by oral sex and has been detected in the mouth and throat area. (55-58) As a result, serious concern has been expressed about the relationship between HPV and certain cancers of the head and neck area, including some forms of respiratory and esophageal cancers. (40,50,51) This important finding challenges the teaching of some educators who suggest that oral sex may be a 'safe' alternative for adolescents.

While it has been known for some time that certain STDs may be transmitted during the birth process, "convincing evidence is now available for vertical transmission [mother to child] of high-risk HPVs." (44) The fact that HPV may transmit from mother to child during the pregnancy or birth process is a relatively new finding; (59-62) and very recent research indicates that there may be a direct connection between HPV and retino-blastoma, an eye tumor that is one of the most common childhood cancers. (52,53) Although the consequence of HPV infection in children is not yet clearly understood, this potentially cancer-causing virus has recently been discovered in more than 10 percent of apparently healthy children. (44) Many people now suspect that the infection is being acquired from the mothers during pregnancy or at birth.

What we know: Early sexual involvement is a major risk for developing some kinds of cancer.

Cancer has become one of the leading causes of death and serious suffering in many parts of the world. This diagnosis strikes fear into the hearts of many patients and family members even before the prognosis of a particular cancer is discussed. With the recent recognition that HPV is a cancer-causing virus and that other STDs, including hepatitis B and chlamydia may lead to cancer, (40,43-54,63) the evidence would suggest that early sexual involvement is a major risk factor for developing some kinds of cancer.

Not so long ago I spent time talking with a pregnant young woman because her pap smear, done at her first prenatal visit, revealed precancerous cervical changes as a result of HPV. Although her husband had been married previously, this young patient had no sexual partners prior to her husband and, early in their relationship, she had insisted that he be 'checked out' for STDs. He had been given a clean bill of health; but neither she nor her husband realized that there are STDs that cannot be easily detected in the early stages. Although he had never had genital warts, the most obvious symptom of HPV, it did appear that he was carrying the virus and had infected his new wife. Now, in addition to her feelings of betrayal and anger, this young woman had to deal with the physical problems related to infection, her future risk of cancer, and the concerns associated with mother to baby transmission.

Genital Herpes (Herpes Simplex Virus - HSV) I recently cared for a young woman who had recurrent genital herpes sores. They were intensely painful and occurred about four times per year, lasting about two weeks with each episode. Her only sexual partner had been her husband and, although he had no known history of genital herpes, she suspected that she contracted the infection from sores that he had in his mouth area. Because of an active outbreak of sores when she went into labour, she had a Caesarean section to deliver her first child.

Although the herpes virus that commonly causes mouth sores or 'cold sores' (HSV-1) is different from the virus most commonly causing genital herpes (HSV-2), recent research indicates that the virus causing mouth sores can also cause sores in the genital area and vice versa. (64,65) These viruses appear to be transmitted via skin-to-skin contact when a sore or infected area of an afflicted person comes into contact with the skin of the recipient. This often occurs during sexual activities, and may even occur during kissing. It is important to note that transmission can occur even when the infected individual does not see or feel the sores.

Newly infected individuals will often develop a first episode or outbreak of herpes. Initial attacks vary in intensity but frequently involve a cluster of painful sores or ulcers that may last for up to three weeks prior to healing. When the sores settle, the virus migrates up the nerve fibres where it remains dormant for varying lengths of time.

The infected individual may then develop recurrent attacks for the remainder of their life. In these recurrent episodes, the sores typically last for up to a week after which they usually clear up and the virus returns to a dormant stage. Available antiviral therapies appear to shorten the outbreaks and, when taken on a chronic basis, certain drugs may diminish the frequency of recurrences. However, despite the fact that symptoms can be controlled to some degree, there is currently no means to eliminate the virus from the infected person.

The herpes virus can also have a serious impact on offspring of infected mothers. A study reported in a medical journal, Archives of General Psychiatry, found that in some people there appears to be a correlation between herpes infection (HSV-2) in the mother and certain types of psychotic disorders (serious mental illnesses) in the offspring. (66) As well, herpes has a potential for death or serious neurological consequences if it is contacted by a newborn during vaginal delivery. (67,68) For this reason women with active herpes sores at the time of labour are often delivered by Caesarean section.

What we know: Some STDs such as herpes can pass to children during pregnancy or during delivery . this may cause birth defects, serious illness, or even death.

Along with human papillomavirus (HPV) and chlamydia, genital herpes is one of the most prevalent STDs in North America and one of the most common STDs worldwide.(64.69) The incidence of this infection varies from nation to nation; but, in the United States, a recent medical paper reported that more than 20% of the adult population is infected with herpes. (64) As many as one million people in the United States become infected each year and the incidence has increased most dramatically in teens and young adults. Many people with herpes have no symptoms and are unaware of their infection; however, with or without visible symptoms, the disease can be transmitted to sexual partners or from mother to newborn. This infection also significantly increases a person's risk of becoming infected with other STDs, such as HIV. (64,70) As with HPV, the virus can be present throughout the genital area; as a result, condoms may not prevent the spread of this infection.

Chlamydia

Throughout my career, I have seen numerous young women infected by chlamydia who, later in their lives, have been unable to conceive children because of damage done to their reproductive tracts by this microorganism. Over the last few years, chlamydia has been recognized as one of the most prevalent and damaging sexually transmitted infections. Methods have been recently developed that allow for the easier recognition and treatment of this bacterium.

There are now effective and easily available tests to diagnose this condition; however, since this STD is frequently without symptoms, infected individuals and their physicians may not realize that an STD is present and may not test for chlamydia. Although therapy with appropriate antibiotics usually eliminates the bacteria, there is frequently significant residual damage if the infection is not treated in the early stages.

What we know: Effective tests to diagnose gonorrhoea ant chlamydia are available; however, since these STDs are frequently without symptoms, the infected individual may not realize that an STD is present and may not be tested.

Chlamydia manifests itself differently in men and women. About half of the men infected have some complaints including painful urination, discharge, or an altered or itchy sensation at the end of the penis.

Women bear a disproportionate burden of complications and consequences as a result of chlamydia (and many other STDs). Although the vast majority of women carrying this infection have no symptoms during the early stages of the infective process, this STD can silently damage the female reproductive organs and often results in internal scarring, pelvic pain and infertility.

The newborn child is also a potential victim of chlamydia. The predominant sites of infection are the eyes and the lungs. If left untreated, chlamydia may cause corneal scarring and visual impairment; it also has the potential to cause pneumonia. Newborns often receive eyedrops at birth to address any potential risk of chlamydial infection.

Gonorrhoea

I first saw a patient with gonorrhoea when I was a medical student. This young gentleman pleaded with the attending physician, my clinical professor, for relief from his pain. The patient said that he felt like his genitals were on fire when he urinated. As a young man of 22, this scene imprinted itself on my mind as I saw first hand the human reality of STDs.

Gonorrhoea can have many sites of infection but most commonly it affects the cervix in women and the anterior portion of the urethra in men. The rectal area, the throat, and the eyes are also potential sites of infection in both sexes and, if untreated, the organism may spread to different areas in the body.

What we know: Although there is treatment to get rid of gonorrhoea and chlamydia, these drugs will NOT reverse the physical damage caused by the infections.

This infection is particularly insidious in females, as about eighty per cent of women have no symptoms in the early stages of the infection. Although there may be vaginal discharge, or some discomfort felt when urinating, the organism frequently spreads silently to infect the uterus and fallopian tubes, which may result in sterility.

Men may complain of burning discomfort when they urinate and may also notice a discharge of pus from the end of their penis. Although the majority of men who are infected experience symptoms, about twenty per cent have no complaints and carry the bacteria silently. Without medical attention, this organism can spread to infect the man's prostate or testicles and may be transmitted to sexual partners.

When this STD is recognized and treated with appropriate antibiotic agents, the infecting organism that causes gonorrhoea is usually eliminated effectively. However, physical damage caused by the organism is not reversed despite getting rid of the STD itself. Even though there is effective available treatment to wipe out bacterial infections like gonorrhea and chlamydia, the serious rates of these afflictions continue. (71)

Hepatitis

At a public lecture I gave a number of years ago, the event organizer, a soft spoken woman in her twenties, told me of a major challenge in her life: her husband of two years had been diagnosed with hepatitis C and was becoming increasingly ill. To his knowledge, he had no previous exposure to infected blood or blood products, had never used drugs, and had no body piercing; however, he had been promiscuous as a teen and had been involved in a 'partying' and alcohol oriented lifestyle as a young adult. He had recently become so ill from hepatitis C that he was unable to work or enjoy life. His wife, understandably, was very concerned about their future.

Hepatitis has received increasing attention in the last ten years as growing numbers of people have become infected with it. This illness may be caused by a number of different viruses or toxic agents and results in inflammation and potential damage to the liver. Although patients may recover from hepatitis, it is a concerning illness because of the critical role that the liver plays in filtering foreign and toxic substances from the body. There are a variety of forms of hepatitis infection; the most common ones are simply referred to as hepatitis A, hepatitis B and hepatitis C.

Hepatitis A: The consumption of contaminated food or water is the most common way by which people are infected with hepatitis A. This infection may also be inadvertently transmitted through close contact with an infected person. As a result, household or sexual contact may carry some degree of risk. Most people recover very well from this type of infection and, because transmission through human contact is relatively uncommon, it is not generally considered an STD. A vaccine is available and people traveling to areas where this infection is prevalent are often immunized.

What we know: Hepatitis B is readily transmitted through sexual intercourse and is widely recognized as a potentially serious STD.

Hepatitis B: Hepatitis B can be found in blood, semen, vaginal secretions, and even saliva. This infection can, therefore, be transmitted through contact with the body fluids of an infected person and can also be passed to a child born to an infected mother. It is readily transmitted through sexual intercourse and is widely recognized as a potentially serious STD. Most people infected with this virus will recover from their episode of hepatitis, but a small percentage will develop chronic liver problems and subsequently be at risk for cancer and death. There is now a widely available, effective vaccine that prevents infection with this virus. Particularly for those engaging in risky sexual behavior, the medical community strongly recommends this vaccination.

Hepatitis C: Although much less likely to contract through sexual activity, hepatitis C may be transmitted via shared needles, infected blood products, or infected instruments used for procedures such as body piercing, tattooing or acupuncture.

The mode of transmission of hepatitis C is thought to be through blood exposure to the virus and thus spread is not probable with intercourse unless there is blood present because of a break in the skin, an open sore or other infection, sexual practices resulting in bleeding, or sexual activity at the time of a woman's menstrual cycle.

What we know: Hepatitis C may be transmitted via shared needles, infected blood products, or infected instruments used for procedures such as body piercing, tattooing or acupuncture.

Although it is not generally classified as an STD because the risk of sexual transmission is thought to be low, (72,73) it has been noted that spouses of infected individuals are twice as likely to contract the infection as other family members. (74) Sexual promiscuity has also been associated with the transmission of hepatitis C. (75) Accordingly, it is recommended that the sexual partners of infected individuals be tested for evidence of the virus. It is also important to note that all modes of transmission are not fully understood and that this disease has been transmitted when no known risk factors have been identified. Although some patients have a mild, acute infection that clears without treatment, a significant number of people with hepatitis C develop serious and potentially fatal liver problems. Currently there is no vaccine against this virus.

Syphilis

Many people know that syphilis is a sexually transmitted infection because of its connection to numerous recognized individuals over the centuries. According to various historians, the list of well-known people thought to have suffered from the symptoms of syphilis include Al Capone, Henry VIII, Adolf Hitler, Scott Joplin, Friedrich Nietzsche, Oscar Wilde, and composers Ludwig van Beethoven and Franz Schubert.

Although many may think that this is a disease of the past, this sinister germ is in the process of making a resurgence, including a significant escalation in the newborn population.

Syphilis is caused by an organism called treponema pallidum, and is transmitted by direct contact with a syphilis-infected sore. If left untreated, the disease passes through a series of phases. About three weeks after the initial contact, the new recipient develops a painless lesion in the genital area, the hallmark of primary syphilis. This lesion spontaneously heals in a few weeks and is followed by the appearance of numerous skin lesions and a flu-like illness about six weeks later. This stage subsides in about three weeks and the disease enters a latent stage. At this point, there are generally no significant complaints or noticeable changes noted by the victim.

What we know: The World Health Organization has estimated that there are millions of new cases of syphilis. In North America, like many areas of the world, the overall rate of this infection is rising.

Following this latent phase, the disease appears to have a variable course if left untreated: the illness may remain in the latent phase with intermittent relapses similar to secondary syphilis; it has been reported that in some fortunate individuals the infection has spontaneously resolved; or the illness may proceed to tertiary syphilis, which affects various organs in the body including the brain, the heart, the bones and other sites. The infection appears to be most contagious during the primary, secondary, and early latent phases of the illness.

Antibiotic therapies remain extremely effective in treating and eliminating syphilis from the human system; however, the complications and damage caused by syphilis may persist after treatment. In 1995, the World Health Organization estimated that there were 12.2 million new cases of syphilis (76) and today in Canada, like many countries, the overall rate of this infection is rising. (77)

There are many other STDs including trichomoniasis, non-gonococcal urethritis (NGU), muco-purulent cervicitis (MPC), chancroid, and lymphogranuloma venereum. While it is not possible in this book to explore every single STD, the discussion in this chapter about the principles of transmission and general concerns related to STDs are applicable to other sexually acquired infections as well. For those readers who are interested in more information, there are many excellent resources that explain all known aspects of the various STDs in detail.