February 19, 2001
Dr. Zenilman discussed the epidemiology of sexually transmitted disease(s), particularly among African Americans, and especially in relation to HIV. He began by acknowledging that sexually transmitted disease rates in African American women and men are higher than in their non-African American counterparts. He cited a Baltimore sexually transmitted disease and behavior survey of 1,100 random households, 68% of which were African American. In this study, behavior surveys were conducted and urine tests for GC (gonorrhea) and chlamydia done. Results showed that 15.6% of the women and 6.8% of the men tested positive for GC or chlamydia, whereas in other households 1.3% of women and 3% of men tested positive. The study underscored the asymptomatic nature of sexually transmitted disease(s) in both genders.
He discussed possible reasons for the discrepancy; notably differences in access to care, poverty, the legacy of discrimination, and social/sexual networks. He went further to discount some perceived causes for the different rates of sexually transmitted diseases among races (i.e., biological susceptibility and differences in sexual behavior). Women, on the other hand, have been shown to be more susceptible to sexually transmitted diseases per unit exposure for anatomic reasons.
Dr. Zenilman proceeded to review sexually transmitted diseases and their interactions with HIV. Genital ulcers (caused by syphilis, chancroid, HSV) increase the risk of contracting HIV via sexual intercourse. Men with urethritis in both natural and challenge studies have been shown to have higher levels of HIV in semen than do men without urethritis, with no increase in peripheral HIV viral load. Genital inflammation is known to attract lymphocytes, which are a target cell of HIV, and women with cervicitis demonstrate increased cytokine secretion as well as enhanced HIV replication. Sexually transmitted diseases have fueled the HIV epidemic in sub-Saharan Africa and, indeed, aggressive sexually transmitted disease treatment has been recognized as an important way of slowing the spread of HIV in this part of the world.
Dr. Zenilman mentioned circumcision as a factor decreasing genital ulcer disease, acknowledging the difficulty inherent in using this broadly as a tool for the control of sexually transmitted diseases.
Dr. Zenilman concluded by summarizing major strides made against sexually transmitted diseases and the challenges remaining. Notable strides included the acquired expertise in behavioral interventions, the availability of urine tests, which could conveniently be used in the field, and the national Centers for Disease Control-coordinated program to eliminate syphilis. He stressed the need to maintain vigilance as syphilis rates decline. Major challenges are the need for interventions specifically geared to the men who have sex with men population, the growing focus on abstinence-only interventions, and the lack of adequate drug treatment programs.
Dr. Maxwell discussed sexually transmitted diseases and HIV particularly as they relate to women. She began by reminding the audience that 75% of women with HIV are infected through heterosexual intercourse. Of these, most (77% of women with AIDS in the U.S.) are African American or Hispanic, although these make up only 19% of the female population.
She emphasized that while women in their 20s were more likely to present to the health care system with gynecologic complaints and conditions such as cervical dysplasia, menstrual abnormalities, pelvic inflammatory disease, and other infections. Women over the age of 45 years, on the other hand, often present with medical issues such as hypertension, diabetes, and osteoarthritis. HIV is often overlooked in this latter population.
Additional risks for HIV transmission in addition to sexually transmitted diseases include estrogen deficiency (e.g., depo provera use peri or post menopause) and nonoxynol-9 use due to its irritant effect. Dr. Maxwell touched briefly on the effect of the vaginal environment (pH, endogenous bacterial balance) on transmission. She stressed the presence of virus in semen even when peripheral levels are undetectable, and pointed out differences in penetration of semen by antiviral agents (e.g., indinavir penetrates to a higher degree than saquinavir in combination with ritonavir).
In a discussion of the interaction of sexually transmitted diseases and HIV, Dr. Maxwell illustrated unusual manifestations of syphilis in patients with HIV, such as multiple chancres, rapid progression, and slow healing. She discussed cervical dysplasia in HIV, citing a study that showed that the clinical course of cervical dysplasia in women with HIV was modified by HAART. She stressed the importance of evaluating lesbian women for cervical dysplasia. In a related study looking at high-grade cervical dysplasia, 30% of the women enrolled were lesbian. Of them, only 14% of them had low-grade cervical lesions.
Dr. Maxwell concluded her overview by stressing "there is no safe sex," just degrees of risk.