genital warts (HPV, 2011) (HUMAN PAPILLOMA VIRUS AND HIV/AIDS, 2011)
Mar 14, 2011
if a person have genital warts does it mean that he/she is going to have a positive syphilis test like VDRL or RPR?
Response from Dr. Frascino
No. Genital warts are caused by a virus, the human papilloma virus (HPV). Syphilis is caused by a bacteria, Treponema pallidum. You can read much more about HPV and syphilis in the archives of this forum. I'll repost below a sample of what you can find in the archives of this forum.
hpv infection (HPV, HUMAN PAPILLOMA VIRUS AND HIV/AIDS, 2010) Dec 10, 2010
hello Dr. Frascino,
I know that HIV is more your area of expertise but I was wondering if you knew anything about hpv. I was diagnosed with hpv about 10 years ago and was reading recently that some percentage of people actually clear the infection, as well as the actual warts, from their body. Recently I had a partner of mine absolutely freak out because I conveyed to him that I didnt think it was that big of a deal, especially considering everything that's out there today. Regardless, I was wondering if it is true that some or most people actually clear the infection form their body. Perhaps if it is true this may give some consolation to my partner in the hopes of not contracting my hpv. Thank you...wishing all the best.
Response from Dr. Frascino
There are many different types of HPV (30-40 varieties). Over half of all sexually active folks become infected with some type of HPV. In 90% of these cases the body's immune system completely clears the infection. (See below.)
Hope that helps.
Human Papilloma Virus (HPV) and HIV/AIDS April 2010
What Is HPV?
Human Papillomavirus (HPV) is the name of a large group of viruses. Certain types of HPV cause warts on the hands or feet. About 30-40 types can cause infections in the genital area (the vulva, vagina, penis, buttocks, scrotum, and anus).
Genital HPV types are often referred to as "low risk" and "high risk." Low-risk types can cause genital warts. High-risk types can cause cervical cancer or cancer of the vulva, vagina, anus, and penis.
The types of HPV that can cause genital warts are not the same as the types that cause cancer. However, if you have warts, you may have also been exposed to the types of HPV that could cause cancer.
Genital HPV is spread easily through skin-to-skin contact during vaginal or anal sex with someone who has the infection. Condoms do not totally prevent transmission. Even though many people who have HPV don't know it, they can still pass it on to someone else.
Genital HPV is the most common sexually transmitted disease (STD) in the US. Over 50 percent of all sexually-active men and women become infected with HPV at some time in their lives.
Most people with HPV do not know they have it because they do not develop symptoms. In 90 percent of cases, the body's immune system clears HPV infection naturally (without treatment) within two years.
People living with HIV (HIV+ people) are more likely to be infected with HPV than HIV-negative people. HIV+ people with HPV are also more likely to develop genital warts, as well as cervical or anal cancer.
If you have sex, it is important to be checked for signs of HPV such as genital warts or cervical and anal cancer. This is because the body does not always clear HPV on its own and you may need treatment to prevent health problems.
Certain types of HPV can cause warts on the vulva; in or around the vagina or anus; or on the penis, scrotum, groin, or thigh. Warts can appear anywhere from a few weeks to a few months after you are exposed to HPV. They can even appear years after exposure.
Flesh-colored, pinkish, or white warts that appear as small bumps or groups of bumps. They can be raised or flat, different sizes, and are sometimes shaped like cauliflower. Diagnosis
Health care providers can usually identify genital warts by looking at them Sometimes a biopsy is done (a sample of the suspected wart is cut off and examined under a microscope) Some health care providers may use a vinegar solution to help identify flat warts, however, this test may sometimes wrongly identify normal skin as a wart Treatment
There is no cure for HPV, but genital warts can be treated by removing the wart.
The following treatments must be done in a health care provider's office: TCA (trichloracetic acid): A chemical is applied to the surface of the wart Cryotherapy: Freezing off the wart with liquid nitrogen Electrocautery: Burning off the wart with an electrical current Laser therapy: Using an intense light to destroy the wart Excision: Cutting the wart out Some treatments can be done at home with prescription creams Do not use over-the-counter wart removal products to treat genital warts Some wart treatments should not be used by pregnant women Warts can reappear after successful treatment If left untreated, genital warts may go away, remain unchanged, or increase in size or number. Some people decide not to have treatment right away to see if the warts will go away on their own. When considering treatment options, you and your health care provider may take into account the size, location and number of warts, changes in the warts, your preference, and the side effects of treatment.
Many HIV+ women, especially those with low CD4 cell counts, may not be able to get rid of genital warts using standard treatments. Several different treatments may be needed.
Dysplasia and Cervical Cancer
Certain types of HPV can cause abnormal cells to form. This is called dysplasia. The main place dysplasia occurs is on the cervix. Other less common areas are the vagina, vulva, and anus. Dysplasia is not cancer, but if left untreated, it can develop into cancer.
Cervical cancer can be life threatening. It is one of the few AIDS-defining conditions specific to women. Fortunately, it can be prevented through early diagnosis and treatment.
Cervical cancer screening is done by using a Pap test (sometimes called a Pap smear). This test checks for changes in the cervix. Cervical cancer usually takes years to develop, but it does not have symptoms until it is quite advanced. This is why getting screened on a regular basis is important; screening can catch potential problems before they get worse.
It is especially important for HIV+ women to have regular Pap tests. This is because HIV+ women are more likely to have abnormal Pap tests than HIV-negative women.
Many women do not experience symptoms In very advanced stages, a woman may experience pain, vaginal discharge, and bleeding between periods Diagnosis
HIV+ women should have a complete gynecological examination, including a Pap test and a pelvic exam, when they are first diagnosed or when they first seek prenatal care HIV+ women should have another Pap test six months later If both tests are normal, yearly screening is recommended An abnormal Pap test can indicate inflammation, infection, dysplasia, or cancer If you have an abnormal Pap, you may need a colposcopy (an exam of your cervix using a magnifier to look at the tissue more closely) and a biopsy (cells or tissues are removed so they can be checked under a microscope for signs of cancer) An HPV test can be used along with the Pap test to detect cancerous and pre-cancerous conditions. However, there are no firm recommendations for using the HPV test in HIV+ people. Speak with your health care provider to see if the HPV test is appropriate for you. Treatment for Dysplasia
If it is determined that you have dysplasia, discuss your treatment options with your health care provider. While there is no cure for HPV, dysplasia can be treated. Most treatments focus on destroying the abnormal tissue so that it doesn't progress to cancer.
Electrocautery Burning off the cells with an electrical current Laser therapy: Using an intense light to destroy the cells Cold-knife cone biopsy: Cutting the cells out LEEP: Loop electrosurgical excision procedure Cryotherapy: Freezing the cells with liquid nitrogen In cases of mild dysplasia, your health care provider may just monitor the cervix by colposcopy, repeat Pap, or HPV test Dysplasia is more common in HIV+ women than HIV-negative women, especially women with advanced HIV disease and low CD4 cell counts. Dysplasia is often more serious and difficult to treat in HIV+ women than HIV-negative women.
Treatment of Cervical Cancer
Cervical cancer is most treatable when it is diagnosed and treated early, so regular Pap tests are vital. Treatment depends on the type of cervical cancer and how far it has spread. Often, more than one kind of treatment is used.
Surgery: Cancer tissue is cut out in an operation Chemotherapy: Drugs (pills and/or intravenous medications) are used to shrink or kill the cancer Radiation: High-energy rays (similar to X-rays) are used to kill the cancer cells
Dysplasia and Anal Cancer
Nearly all HIV+ men with a history of receptive anal intercourse have anal HPV infection. Certain strains of HPV may cause dysplasia and cancer in the anus. Although the risk of developing dysplasia is higher among men who have sex with men, women are also at risk, especially those with HIV or who have had anal intercourse.
May be no symptoms Anal bleeding, irritation, itching, or a burning sensation In very advanced stages, there may be abscesses, lumps, ulcers, and anal discharge Diagnosis
Careful physical examination by a health care provider may be the best way to detect anal cancers An abnormal anal Pap test may indicate dysplasia or cancer If you have symptoms, you may need an anoscopy (an exam of the anus using a magnifier to look at the tissue more closely) and a biopsy (cells or tissues are removed so they can be checked under a microscope for signs of cancer) It is important to ask your health care provider to check for anal cancer on a regular basis Treatment
Same as treatment for dysplasia and cervical cancer (see section above)
HPV is More Common and Can Be More Serious for HIV+ People
HIV+ people are more likely to be infected with HPV than HIV-negative people. One study found HPV in more than 3 out of 4 HIV+ women. Because of immune suppression, HIV+ women are more likely to have:
HPV infection that does not clear up on its own Infection with the HPV strains that are more likely to cause cancer Higher risk of developing cervical cancer HPV in both the cervix and anus Several strains of HPV at once HPV infections that were previously under control that come back again HPV that responds poorly to standard therapies -- multiple treatments using different methods may be needed
Prevention of HPV
There are two Food and Drug Administration (FDA)-approved HPV vaccines: Merck's Gardasil and GlaxoSmithKline's Cervarix. Gardasil is approved for females and males ages 9 to 26. Cervarix is approved for females ages 10-25. Pregnant women should not use the vaccines. Both vaccines protect against types of HPV that cause the majority of cervical cancer cases and genital warts.
It is important for young people to get vaccinated before their first sexual contact (before they have been exposed to HPV). People who are already infected with HPV are not protected by the vaccines. Also, the vaccines do not protect against less common HPV types. Therefore, health care providers still recommend regular Pap tests to look for dysplasia before it becomes cancer.
There are payment assistance programs for people who cannot afford the HPV vaccines, see the resource section of this sheet for contact info.
The safety and effectiveness of the vaccines in HIV+ people has not been determined. Speak to your health care provider about the HPV vaccine to see if it is appropriate for you.
Regular pelvic and anal exams and Pap tests are very important. While they cannot prevent HPV-related problems, they can help catch warts and dysplasia before they progress and cause greater problems.
It has been found that many HIV+ women skip PAP tests. It is crucial that HIV+ women get routine Pap testing and follow up as needed to identify problems before cancer develops. Prevention is always better than treatment.
Even though condoms do not fully protect HPV, when used correctly, they can help reduce the risk of HPV transmission.
Smoking has been shown to increase the chance of developing numerous types of cancer including cervical and anal. If you smoke, it is a good idea to try and quit.
Taking Care of Yourself
HPV can be very serious for HIV+ people. Since there are frequently no symptoms, regular monitoring by your health care provider is the best way to be sure that any problems are found and treated before they progress.
A recent study also found that HIV+ women who were adherent (stuck closely) to their HIV drugs and had an undetectable viral load, had lower levels of HPV and were less likely to have pre-cancerous cervical cell changes. Although more research is needed, these findings suggest that sticking to an effective HIV drug regimen may help reduce HPV-related problems.
Syphilis and HIV (SYPHILIS 2011) Mar 12, 2011
I recently submitted a question regarding syphilis and HIV and you were very brief in your response, indicating that you were confused about my question. Without regard to your opinion about my safe sex practices, the question I was asking was how is it possible for me to test reactive to syphilis, negative for HIV and Hepatitis and my partner to test HIV positive. He has been my only partner in the last 2 years, so the syphilis infection was from him. What I would like to understand is how it is possible for me to be reactive for syphilis and have a negative HIV test. It is suggested that I am beyond the "window period" for seroconversion. There is no doubt that he will also test reactive for syphilis, but those lab results have yet to come in. All I am wondering is how is it possible that I can be reactive to syphilis and negative for HIV when it is clear the infection is from one person?
Response from Dr. Frascino
Thanks for clarifying your question. If you've been completely faithful to your partner for the last two years and recently tested positive for syphilis, you either have had syphilis for quite some time or you contracted it from your partner. (Have you tested negative for syphilis in the past?)
Getting to the crux of your question, let's assume your partner has had some unsafe extracurricular activities and managed to contract both syphilis and HIV. You are wondering how it's possible he transmitted syphilis to you but not HIV. The answer is that syphilis (and many other STDs) is far easier to transmit than HIV. Not every HIV exposure leads to transmission of the virus, even when HIV coexists with another STD! Yes, the HIV-transmission risk increases with a co-infection STD, but that increase does not lead to a 100% transmission rate. So it's entirely possible your partner is co-infected with both HIV and syphilis but only transmitted syphilis to you. It's also important to note that you will need follow-up HIV tests out to six months from your last exposure (unprotected sex) to be certain you have not contracted the virus. You can read much more about this topic, syphilis and HIV diagnostic tests in the archives of this forum, as I've responded to many similar questions in the past. Have a look, OK?
I'll repost some information below about syphilis.
Syphilis and HIV Infection Mar 10, 2011
I recently tested reactive for syphilis and have received the appropriate treatment. My HIV antibodies and Hepatitis both were negative. Due to being severely ill for several months, there had been no sexual contact with my partner for about 4 months. He just received a positive result for HIV today and I am completely freaked out. How is it possible for me to be reactive for syphilis and have a negative test result for HIV? My doctor tells me I don't need to be worried because my test is negative, but how can I not worry....can you please help me understand what is going on??????
Response from Dr. Frascino
I'm not sure I understand what you are asking.
As for what's going on, it seems obvious that neither you nor your partner are practicing safer sex, as you have both contracted separate STDs over recent months!
Syphilis worries... Aug 17, 2010
Dear Dr Bob
How long should it take for symptoms of syphilis to go after a course of penilcilin has been administered to an HIV positive patient with syphilis as well? I'm a sex addict and have been infected with syphilis 3 times this year (I have started a 12 step program for the addiction). I abused crystal meth for the 1st 4 months of this year. Would each re-infection be worse than the one before? If the person who infected me had neurosyphilis would I have that too straight away. What is the shortest amount of time syphilis can progress to neurosyphilis in a HIV patient? Can drug damage to the nervous system cause the same neurological symptoms as neurosyphilis? When the skin peels of one's palms is that a sign of progression of the disease or that its dying? Thank you for this amazing resource you have provided. I wish I'd seen it before I got infected with HIV.
Many thanks Andrew Cape Town South Africa
Response from Dr. Frascino
The clinical course of syphilis can vary considerably from person to person. Add HIV into the equation and things become even more confusing, as HIV severity varies considerably as well and this can effect the course of a concurrent syphilis infection. Three bouts of syphilis within one year is indeed alarming. It's also particularly worrisome because it means you are having unsafe sex. This not only puts you at risk for STDs, but it puts your partners at risk for HIV in addition. I urge you to continue with your 12 step program for addiction and to immediately stop putting others and yourself at risk for STDs including HIV. Latex condoms for all penetrative sex is imperative.
I'll repost below some information from the archives that addresses your concerns.
Syphilis and MSM (Men Who Have Sex With Men) April 8, 2008
What is syphilis?
Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. It has often been called "the great imitator" because so many of the signs and symptoms are indistinguishable from those of other diseases.
How common is syphilis?
In the United States, health officials reported over 36,000 cases of syphilis in 2006, including 9,756 cases of primary and secondary (P&S) syphilis. In 2006, half of all P&S syphilis cases were reported from 20 counties and 2 cities; and most P&S syphilis cases occurred in persons 20 to 39 years of age. The incidence of P&S syphilis was highest in women 20 to 24 years of age and in men 35 to 39 years of age. Reported cases of congenital syphilis in newborns increased from 2005 to 2006, with 339 new cases reported in 2005 compared to 349 cases in 2006.
Between 2005 and 2006, the number of reported P&S syphilis cases increased 11.8 percent. P&S rates have increased in males each year between 2000 and 2006 and among females between 2004 and 2006. In 2006, 64% of the reported P&S syphilis cases were among men who have sex with men (MSM).
How do people get syphilis?
Syphilis is passed from person to person through direct contact with a syphilis sore. Sores occur mainly on the external genitals, vagina, anus, or in the rectum. Sores also can occur on the lips and in the mouth. Transmission of the organism occurs during vaginal, anal, or oral sex. Pregnant women with the disease can pass it to the babies they are carrying. Syphilis cannot be spread through contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils.
What are the signs and symptoms in adults?
Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late complications if they are not treated. Although transmission occurs from persons with sores who are in the primary or secondary stage, many of these sores are unrecognized. Thus, transmission may occur from persons who are unaware of their infection.
The primary stage of syphilis is usually marked by the appearance of a single sore (called a chancre), but there may be multiple sores. The time between infection with syphilis and the start of the first symptom can range from 10 to 90 days (average 21 days). The chancre is usually firm, round, small, and painless. It appears at the spot where syphilis entered the body. The chancre lasts 3 to 6 weeks, and it heals without treatment. However, if adequate treatment is not administered, the infection progresses to the secondary stage.
Skin rash and mucous membrane lesions characterize the secondary stage. This stage typically starts with the development of a rash on one or more areas of the body. The rash usually does not cause itching. Rashes associated with secondary syphilis can appear as the chancre is healing or several weeks after the chancre has healed. The characteristic rash of secondary syphilis may appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet. However, rashes with a different appearance may occur on other parts of the body, sometimes resembling rashes caused by other diseases. Sometimes rashes associated with secondary syphilis are so faint that they are not noticed. In addition to rashes, symptoms of secondary syphilis may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The signs and symptoms of secondary syphilis will resolve with or without treatment, but without treatment, the infection will progress to the latent and possibly late stages of disease.
Latent and Late Stages
The latent (hidden) stage of syphilis begins when primary and secondary symptoms disappear. Without treatment, the infected person will continue to have syphilis even though there are no signs or symptoms; infection remains in the body. This latent stage can last for years. The late stages of syphilis can develop in about 15% of people who have not been treated for syphilis, and can appear 10-20 years after infection was first acquired. In the late stages of syphilis, the disease may damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. This damage may be serious enough to cause death.
Why should MSM be concerned about syphilis?
Over the past several years, increases in syphilis among MSM have been reported in various cities and areas, including Chicago, Seattle, San Francisco, Southern California, Miami, and New York City. In the recent outbreaks, high rates of HIV co-infection were documented, ranging from 20 percent to 70 percent. While the health problems caused by syphilis in adults are serious in their own right, it is now known that the genital sores caused by syphilis in adults also make it easier to transmit and acquire HIV infection sexually.
How is syphilis diagnosed?
Some health care providers can diagnose syphilis by examining material from a chancre (infectious sore) using a special microscope called a dark-field microscope. If syphilis bacteria are present in the sore, they will show up when observed through the microscope.
A blood test is another way to determine whether someone has syphilis. Shortly after infection occurs, the body produces syphilis antibodies that can be detected by an accurate, safe, and inexpensive blood test. A low level of antibodies will likely stay in the blood for months or years even after the disease has been successfully treated.
What is the link between syphilis and HIV?
Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV infection sexually. There is an estimated 2- to 5-fold increased risk of acquiring HIV if exposed to that infection when syphilis is present.
Ulcerative STDs that cause sores, ulcers, or breaks in the skin or mucous membranes, such as syphilis, disrupt barriers that provide protection against infections. The genital ulcers caused by syphilis can bleed easily, and when they come into contact with oral and rectal mucosa during sex, increase the infectiousness of and susceptibility to HIV. Having other STDs is also an important predictor for becoming HIV infected because STDs are a marker for behaviors associated with HIV transmission.
What is the treatment for syphilis?
Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an antibiotic, will cure a person who has had syphilis for less than a year. Additional doses are needed to treat someone who has had syphilis for longer than a year. For people who are allergic to penicillin, other antibiotics are available to treat syphilis. There are no home remedies or over-the-counter drugs that will cure syphilis. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.
Because effective treatment is available, it is important that persons be screened for syphilis on an on-going basis if their sexual behaviors put them at risk for STDs.
Persons who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed. Persons with syphilis must notify their sex partners so that they also can be tested and receive treatment if necessary.
Will syphilis recur?
Having syphilis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection. Only laboratory tests can confirm whether someone has syphilis. Because syphilis sores can be hidden in the vagina, rectum, or mouth, it may not be obvious that a sex partner has syphilis. Talking with a health care provider will help to determine the need to be re-tested for syphilis after being treated.
How can syphilis be prevented?
The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.
Avoiding alcohol and drug use may also help prevent transmission of syphilis because these activities may lead to risky sexual behavior. It is important that sex partners talk to each other about their HIV status and history of other STDs so that preventive action can be taken.
Genital ulcer diseases, like syphilis, can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of syphilis, as well as genital herpes and chancroid, only when the infected area or site of potential exposure is protected.
Condoms lubricated with spermicides (especially Nonoxynol-9 or N-9) are no more effective than other lubricated condoms in protecting against the transmission of STDs. Use of condoms lubricated with N-9 is not recommended for STD/HIV prevention. Transmission of an STD, including syphilis cannot be prevented by washing the genitals, urinating, and or douching after sex. Any unusual discharge, sore, or rash, particularly in the groin area, should be a signal to refrain from having sex and to see a doctor immediately.
The CDC's 2006 Sexually Transmitted Diseases Treatment Guidelines recommend that MSM who are at risk for STDs be tested for syphilis annually.
Where can I get more information?
Sexually Transmitted Diseases - Home Page Syphilis - Topic Page Syphilis - Fact Sheet STDs and Pregnancy - Fact Sheet Order Publications Online
STD information and referrals to STD Clinics CDC-INFO 1-800-CDC-INFO (800-232-4636) TTY: 1-888-232-6348 In English, en Español
CDC National Prevention Information Network (NPIN) P.O. Box 6003 Rockville, MD 20849-6003 1-800-458-5231 1-888-282-7681 Fax 1-800-243-7012 TTY E-mail: firstname.lastname@example.org
American Social Health Association (ASHA) P. O. Box 13827 Research Triangle Park, NC 27709-3827 1-800-783-9877
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR 2006;55(no. RR-11). Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2006. Atlanta, GA: U.S. Department of Health and Human Service, November 2007. Centers for Disease Control and Prevention. Primary and Secondary Syphilis Among Men Who Have Sex With Men -- New York City, 2001. MMWR 2002;51(38);853. Centers for Disease Control and Prevention. Primary and Secondary Syphilis -- United States, 2003-2004. MMWR 2006;55(269-272). Centers for Disease Control and Prevention. Unrecognized HIV Infection, Risk Behaviors, and Perceptions of Risk Among Young Black Men Who Have Sex with Men -- Six U.S. Cities, 1994-1998. MMWR 2002;51(33);733. Centers for Disease Control and Prevention. HIV Incidence Among Young Men Who Have Sex With Men -- Seven U.S. Cities, 1994-2000. MMWR 2001;50(21);440. Centers for Disease Control and Prevention. HIV and AIDS -- United States, 1982-2000. MMWR 2001;50(21);430. Centers for Disease Control and Prevention. Outbreak of Syphilis Among Men Who Have Sex With Men -- Southern California, 2000. MMWR 2001;50(07);117. Centers for Disease Control and Prevention. Notice to Readers: CDC Statement on Study Results of Product Containing Nonoxynol-9. MMWR 2000;49(31);717. Centers for Disease Control and Prevention. STD Increases Among Gay and Bisexual Men. Reported at 2000 National STD Prevention Conference in Milwaukee, Wisconsin. December 2000. Centers for Disease Control and Prevention. Resurgent Bacterial Sexually Transmitted Disease Among Men Who Have Sex With Men -- King County, Washington. MMWR 1999;48(35);773. Centers for Disease Control and Prevention. HIV Prevention Through Early Detection and Treatment of Other Sexually Transmitted Diseases -- United States Recommendations of the Advisory Committee for HIV and STD Prevention. MMWR 1998;47(RR12);1. K. Holmes, P. Mardh, P. Sparling et al (eds). Sexually Transmitted Diseases, 3rd Edition. New York: McGraw-Hill, 1999, chapters 33-36.
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