Speakers: Thomas Cherneskie, M.D., M.P.H.
James Brown, New York City Department of Health STD Control Program

It can be hard to get people to talk frankly about sex, let alone to talk about sexually transmitted diseases (STDs) -- not exactly dinnertime conversation. But for Dr. Thomas Cherneskie and James Brown, talking about STDs is the first step in preventing the more than 50 diseases and conditions associated with the more than 26 infectious organisms spread through sexual contact, some of which (including HIV, syphilis, and hepatitis) can be fatal. At the October 2000 community forum, the two men discussed the links between HIV and other STDs and offered tips for preventing, recognizing, and treating STDs.

HIV and other STDs have a strong interplay. Among men reporting sex with other men who were diagnosed with gonorrhea or syphilis at one of the NYC Department of Health STD Clinics in 1999, thirty-two percent were also HIV-positive. Herpes, a viral infection that causes lesions (including open sores or small breaks in the skin) often around the genitals is also of concern in HIV transmission. Having an STD makes it easier both for HIV-negative men and women to get infected with HIV and for HIV-positive persons to infect their partners. Why? Well, there are a couple of reasons. First, open sores in the genital area resulting from STDs decrease the skin's ability to act as a barrier to infection and allows HIV easy access to the body. Second, inflammation at the site of an STD (including gonorrhea and chlamydia) results in a flood of inflammatory blood cells traveling to that area. This leads to a high concentration of CD4 cells at the site of infection, serving as easy targets for HIV. Finally, in the case of herpes, proteins that the herpes virus uses to copy itself can "rev up" HIV reproduction thus increasing the HIV viral load at the site of a herpes ulcer. A person's susceptibility to HIV infection seems to be increased 2-5 fold by an ulcer-causing STD or inflammatory STDs like gonorrhea and chlamydia.

Dr. Cherneskie described some of the health problems caused by STDs, which can be even more serious in people who are HIV-infected. Left untreated, syphilis can cause severe brain or heart disease. Syphilis hits harder in people with HIV, more often leading to neurosyphilis (syphilis in the nervous system) in HIV-positive people than in HIV-negative people. Although most Human papillomavirus (HPV) infections are either silent or cause benign genital warts, infections with certain strains of HPV increase a person's risk of developing cancer of the cervix or anus. People with HIV are more likely to develop cancer than their HIV-negative counterparts if they are infected with HPV. Women who have STDs such as gonorrhea or chlamydia may develop Pelvic Inflammatory Disease (PID) if the infection spreads into the upper reproductive tract. PID can lead to infertility, ectopic pregnancy (a pregnancy in which the fetus develops in the Fallopian tubes instead of in the uterus), or chronic pelvic pain. The rates of PID are higher in HIV-positive women than in HIV-negative women, and HIV-positive women are more likely to develop abscesses and require surgery to control the infection. A number of STDs can be easily treated, but effective treatment only occurs if STDs are caught early are treated before serious damage occurs.

The NYC Department of Health STD control program aims to decrease the rates of STDs in the community. Dr. Cherneskie described the techniques used by the Department of Health (DOH) to pursue that goal: primary prevention, early detection, recognition/evaluation of symptoms, and post exposure prophylaxis (PEP) against STDs.

In primary prevention, DOH officials emphasize consistent condom/dental dam use in sexual intercourse (including oro-anal and oro-genital contact). Dr. Cherneskie noted that vaccinations against hepatitis A and B (viral infections that damage the liver) are also useful in disease prevention, especially in persons with HIV.

It is important to note that although effective treatment exists for many of the bacterial STDs (e.g. gonorrhea, chlamydia, and syphilis), we are left without a cure for many others including herpes, genital wart virus, hepatitis and HIV; therefore primary prevention is the only effective means of remaining healthy.

Because STDs don't always have symptoms, STD screening tests should be performed regularly. These screening tests are crucial to early detection of STDs, the second component of the Department of Health's program. Screening tests should be performed at the time of HIV diagnosis and periodically thereafter depending on risk. Screening tests are often performed for women during regular gynecological examinations. Women should have cervical Pap smears (collection of cervical cells to check for early cancer) at least once a year, irrespective of HIV-status; both HIV-infected men and women may want to consider having anal pap smears as well to detect early cancer changes in this area.

When there are symptoms of STDs, recognizing them may lead to earlier access to treatment and prevention of long-term damage. Let's review some of the biggies.

  • First is syphilis, caused by Treponema pallidum, a kind of bacteria. Syphilis occurs in four stages. In the first stage, an open sore called a chancre forms. It doesn't hurt, and it goes away after a couple of weeks even without treatment. A chancre can occur anywhere on the body. It appears at the first place that contact with syphilis occurred. Even after the chancre heals, syphilis stays in the body. About four months after becoming infected with syphilis, a skin rash all over the body may develop, often including the palms of hands and soles of the feet and usually accompanied by flu-like symptoms and swollen glands. Other signs of secondary syphilis include spots on the tongue and moist warty bumps on the genitals. Syphilis can then enter a silent period for decades when the only way to detect it is by blood test. In its final stage, syphilis can eat away at skin, bones and other organs throughout the body. Most people found to be infected with syphilis do not report any symptoms at all and therefore asymptomatic screening by blood testing is the only way to detect the infection before severe brain, bone, or heart damage can occur.

  • Chlamydia is caused by a bacterium called Chlamydia trachomatis. In most cases there are often no visible signs of chlamydia infection. In men, there may be clear discharge from the urethra (penis) or burning with urination; in women, symptoms include abnormal vaginal discharge or bleeding, pain with sex, burning with urination, or lower belly pain. An infection can last for months, or longer, if not treated, but can still cause damage even when silent.

  • Men who have gonorrhea may have a pus-like yellow discharge from the urethra, or pain when they urinate. The majority of women don't have symptoms of gonorrhea. If they do have symptoms, they are similar to those of chlamydia.

  • Infection with a Human Papilloma Virus (HPV) can cause genital warts. These warts are either bumpy like cauliflower or small flat growths. They don't hurt, and they can be big or small. Some strains of HPV can cause cervical cancer.

The final element of optimal STD care and prevention is post-exposure prophylaxis (PEP). Through PEP, health department workers and private clinicians hope to interrupt incubating disease before it has serious ill effects by treating early stages of STDs.

James Brown, the second speaker, described his work with the Department of Health STD control program. He began by listing the STDs that are reportable to the Department of Health: syphilis, gonorrhea, chlamydia, non-gonorrhea urethritis, and other rarer STDs (Chancroid, Lymphogranuloma Venereum, and Donovanosis). It is the responsibility of testing laboratories and clinical providers diagnosing these STDs to report all new infections to the DOH. The DOH, in turn, tries to interrupt the chain of further infection in several ways. First, the DOH educates infected individuals about STD transmission to prevent them from being re-infected. Next, the DOH uses partner notification to prevent spread of the STD. In partner notification, the DOH offers assistance to patients with an STD in informing their partners that they have been exposed to an STD and encourages them to seek treatment (Post-exposure Prophylaxis) so that they can avoid passing the disease to others. Mr. Brown stressed that participating in partner notification is totally voluntary, and that notification is anonymous. The exposed individual will only learn that they have been exposed to an STD, not when the exposure happened or who exposed them.

Mr. Brown and his colleagues do extensive work in STD case management, helping infected individuals to treatment and prevention services. DOH officials also perform field follow up, heading out into the community to locate infected individuals and their exposed partners to refer them for their STD care. Their efforts have contributed to the relatively low rate of syphilis in NYC. Nevertheless, given recent outbreaks of syphilis in multiple U.S. cities within the past year (LA and Seattle), the city encourages both patients and health care providers to remain vigilant in attempting to diagnose, treat, and prevent as many infections as possible. Mr. Brown noted that 91% of New York City's new syphilis cases are in men, most of whom have other issues, such as substandard housing and poor access to healthcare, that must be addressed in order for STD treatment to be successful. He also noted that chlamydia is most prevalent among adolescents, and that teen-specific education efforts are necessary.

Through their work, Dr. Cherneskie and Mr. Brown are helping to end the silence around STDs and optimize patient care in the diagnosis, treatment and prevention of these serious infections. Advances in medicine have facilitated the treatment and prevention of many STDs -- now it will take education to ensure that these resources are used.