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Chapter 8: Sexually Transmitted Infections
• Sexual health includes the absence of sexually transmitted infections (STIs), which affects not only
physical sexual health, but also emotional, mental, and social aspects
• STI is more encompassing than sexually transmitted disease, including infections which are
• STIs disproportionately affect teens and young adults between ages 15-24. Sexuality education, and
combatting STI-related stigma (awareness that people are judged negatively for contracting an STI) and
STI-related shame (negative feelings people have about themselves as a result of an STI diagnosis) are
• Those who have higher STI-related stigma and shame are less likely to be screened and treated for
STIs, putting them in danger
• Bacterial infections can be cured with antibiotics, including chlamydia, gonorrhea, syphilis, and non-
sexually transmitted infections including cystitis (UTIs) and vaginosis
• Viral infections cannot be cured but can be treated to reduce symptoms, including herpes, HIV/AIDS,
HPV and hepatitis A/B/C. There can be many different strains of a virus.
• Infestations are transmitted through skin-to-skin contact or infected objects (linens, toilet seats, etc.),
curable with special creams but not with shaving
• Chlamydia trachomatis is a bacterium spread by sexual contact. Chlamydia is one of the most
prevalent bacterial STIs in Canada, with its rate rising steadily since 1997. Adolescent girls have a
particularly high rate of infection
• Men: Thin, usually clear discharge and mild pain on urination. This is similar to gonorrhea, but which
has more painful urination and more pus-like discharge.
• Women: 75% of cases are asymptomatic, and many go undiagnosed and untreated
• Diagnosis is made from a urine sample in men, and cervix or urine samples in women
• Chlamydia is curable with tetracyclines, but does not respond to penicillin
• Poorly treated cases can lead to urethral damage, epididymitis, Reiter’s syndrome , and proctitis in men
who have had anal intercourse. Women can experience serious complications, including pelvic
inflammatory disease (PID) and infertility due to scarring of the fallopian tubes.
• Vaccines have been developed and effective in mice, but not in humans yet
• Screening is most effective for prevention, as chlamydia is so often asymptomatic. Identifying and
treating asymptomatic carriers can effectively stop the spread of disease.
• Innovative programs have involved self-test screen kits with collection and confidential testing of
vaginal swabs, and of urine drop-off testing kits for gonorrhea and chlamydia
• HPV is human papillomavirus, with over 40 different types that can cause genital warts (low-risk) and
cervical cancer (high-risk). A person without symptoms can still transmit the virus. Page 200-222, 23 pages Page 2 of9
• Infection with HPV is widespread, but because it is not reportable there is no national data. However, it
is estimated that 20-33% have HPV with 11-25% having the high-risk variety.
• HPV is highly infectious, and although condoms reduce the risk of infection, they do not eliminate it –
HPV can also be transmitted through skin-to-skin contact with the penis, scrotum, vulva, or anus,
including in oral sex
• Genital warts are cauliflower-like warts appearing on the genitals, typically 3-8 months after infection.
• HPV causes almost all cases of cervical cancer, especially strains 16 and 18.
• Diagnosis can be made simply by visual inspection, but some warts are less obvious and may occur in
• Many infected individuals show no obvious symptoms, and for women the first indication may be
abnormal cells on a Pap test – men are not routinely tested
• Chemicals such as podophyllin or trichloroacetic acid can be directly applied to the warts, often
repeated several times, for the warts to fall off. This is also the case with cryotherapy (liquid nitrogen) and
• Cases of HPV can go away on their own, but those that persist for longer periods increase risk of
• HPV vaccines are available, with Gardasil protecting against 4 HPV types and administered over 6
months. This includes protection against HPV 16 + 18, which cause 70% of cervical cancers. The
vaccine is 95% effective, with immunity lasting at least 5 years.
• Immunization is typically administered between ages 9-13 before sexual intercourse; the vaccine does
not affect existing infections.
• The Canadian government provided funding to establish HPV immunization school-based programs for
free. However, this has raised controversy about potential side effects and that it may encourage young
girls to engage in sexual activity.
• Genital herpes is caused by the herpes simplex virus (HSV). HSV-1 tends to cause cold sores, and
HSV-2 genital herpes, but today there is crossing over between the two
• It is estimated that over 20% of adults are infected, increasing with age. Infection rates are higher
among individuals who have had more sexual partners
• Symptoms include small, painful bumps or blisters on the genital that appear 2-3 weeks after infection.
The blisters burst and can be painful, healing on their own but with the virus continuing in the body;
symptoms may recur unpredictably with 7-14 day periods of sores.
• Other symptoms include fever, painful urination, and headaches
• Most patients are asymptomatic, and may transmit the disease unknowingly although people are most
infectious when there is an active outbreak
• Drugs such as acyclovir, valacyclovir and famiciclovir help prevent outbreaks and reduce recurring
symptoms. They also reduce rates of transmission from the infected partner to an uninfected one.
• Vaccines for HSV are also being pursued Page 200-222, 23 pages Page 3 of9
• Recurrent herpes may lead to meningitis, narrowing of urethra, increased risk of HIV (open blisters
make it easier for HIV virus to be transmitted), and transfer of virus from mother to infant
• Transfer during parturition can lead to serious illness or death in the baby; highest risk in women who
have recently been infected and are experiencing their first outbreak; C-sections are usually performed in
Psychological Aspects: Coping with Herpes
• People who are asymptomatic are not aware they have the disease, and may be sexually active – while
perhaps unknowingly spreading the disease
• People with frequent, severe, painful recurrences (often unpredictable) may be turned off from sexual
activity, compacted by stigma of disease and belief they should abstain from sex to avoid infecting
• Treatment programs combine information on herpes, relaxation training, stress management, and use
of imagery technique where the patient imagines they are free from lesions and are highly resistant to the
HIV INFECTION & AIDS
• AIDS stands for acquired immune deficiency syndrome, and is caused by the virus HIV, human
immunodeficiency virus. HIV-1 tends to account for infections in North America, and HIV-2 in Africa.
• HIV destroys the body’s immune system, and opportunistic diseases may take over.
• Estimated 33 million people worldwide are infected with HIV, but most have no symptoms and are
• In 2008, HIV infection caused about 2 million deaths worldwide, especially in sub-Saharan Africa which
accounts for 71% of all new HIV infections
• An epidemic is a widespread occurrence of an infectious disease in a community at a particular time; a
pandemic is a widespread epidemic present over a whole country or the world.
• HIV is transmitted through the exchange of body fluids, specifically semen, blood, and cervical and
vaginal secretions. It can be spread through sexual intercourse (PIV or anal), contaminated blood
(unscreened blood transfusions), contaminated hypodermic needles (drug injections), and from a woman
to her baby
• Among Canadians, exposure is mainly among men who have sex with men (56%), followed by users of
injected drugs (18%), and heterosexuals (18%). 39% are age 30-40, indicating likely exposure in their
• More and more women are accounting for new cases, with most acquiring it through heterosexual
• The sexual behaviour most likely to spread HIV is anal intercourse, particularly for the receiving
partner. This is true for both men and women regardless of orientation.
• The greater number of sexual partners, the higher risk of HIV infection. There is cumulative risk with
increased chances with each additional unprotected sexual encounter.
• Male-to-female and female-to-male transmission rates are about equal. The higher the viral count in the
infected person, the greater the rate of transmission. Circumcision may reduce risk of HIV transmission
by up to 60%
• Condoms are 80-95% effective at protecting against HIV transmission with consistent use Page 200-222, 23 pages Page 4 of 9
• Activities like hugging, dry kissing, massage, and mutual masturbation without exchanging fluids are
• HIV is a retrovirus, reproducing only in living cells of the host species. They invade a host cell,
hijacking its machinery to copy the virus each time the host cell divides.
• HIV particularly invades white-blood cells (lymphocytes) called CD4+ T lymphocytes, which are critical
towards fighting off infections. Eventually the patient’s T cell count is so low they are susceptible to many
• Current research is aimed at fighting drugs that will prevent the virus from infecting new cells. This
includes interfering with HIV coreceptors CCR5 and CXCR4, which allow HIV to enter T cells, important
in the early and later stages of the disease respectively.
• Primary Infection: Begins with infection to development of antibodies over 2-8 weeks. There are no
immediate symptoms, or non-specific symptoms such as fever and sore throat. T4 count stays around
1000 cells/mL of blood, which is a normal level. People can be infectious in this stage.
• Asymptomatic Infection: Asymptomatic, although non-specific symptoms like swollen lymph glands
and night sweats may be present. Can be infectious.
• Progressive Infection: Conditions indicate immune system is suppressed, although symptoms are not
immediately life-threatening: fever, chronic diarrhea, weight loss, fatigue, shingles, abnormal cervical
cells, etc. T4 count has dropped halfway to 500. Treatment with drugs may begin.
• AIDS-Defining Opportunistic Infection: Diagnosis of AIDS applied when person is affected by life-
threatening opportunistic infections, which occur only with severely reduced immunity, such as
Pneumocystis carinii pneumonia (PCP) and Kaposi’s sarcoma, a rare form of skin cancer.
• The diagnosis is also used when other opportunistic infections of cancers of lymph tissue is present, or
when there is a positive test for HIV antibodies and a T cell count below 200
• Neurological problems occur when the virus infects brain cells, causing seizures and mental problems
• ELISA: Enzyme-linked immunosorbent assay is used to detect HIV antibodies.
• ELISA can be used to screen donated blood to prevent infections from transfusions. It is also used to
determine when patients are infected (HIV positive) but asymptomatic carriers.
• If diagnosed early, use of protection during sex and initiation of early treatment can be very important
• ELISA is very sensitive with low rate of false negatives, but can produce false positives. In such cases,
confirmation by the highly accurate Western/immunoblot method is necessary
• ELISA has a long waiting period before test results are known, over a week. A rapid test taking 1 minute
screening HIV-1 antibodies only can be used with ELISA as secondary confirmation.
• These tests detect HIV antibodies, and are not predictive of prognosis or progress to AIDS classification
• Tests taken in doctor’s offices or home tests may prevent the patient from getting enough pre-test
counselling and post-test counselling and support should they receive a positive result
• AZT azdothymidine has been used widely, stopping the virus from multiplying – but unable to repair
the already-damaged immune system. It also has various side effects, and may not be used by certain
• Other antiretroviral therapies include DDI (dideoxyinosine), DDC (dideoxycytidine), and D4T. Page 200-222, 23 pages Page 5 of 9
• Protease inhibitors attack the viral enzyme protease, which is necessary for HIV to make copies of
itself. Darunavir acts on viruses that are resistant to protease inhibitors.
• Today, patients take a drug cocktail of a protease inhibitor, AZT, and another anti-HIV drug. This is
HAART, highly active antiretroviral therapy. This significantly increases survival, making HIV a
manageable disease; HAART patients can expect to live 20-30 years.
• HAART itself can cause serious side-effects, such as diabetes-like problems, brittle bones, and heart
• HIV has mutated to drug-resistant forms, and persists in T cells and lymph nodes despite becoming
undetectable in blood of HAART users.
Women, Children, Ethnic Minorities, and AIDS
• Today the number of infected women is rapidly rising, accounting for 26% of HIV positive individual