Sexually Transmitted Diseases Los Angeles County Department of

Sexually Transmitted Diseases Los Angeles County Department of Health Services Sexually Transmitted Disease Program 1

Reportable STDs in LAC • Chlamydia • Gonorrhea • Syphilis • Chancroid • PID • NGU 2

Other STDs -- Viral • HSV • HPV • HIV 3

Reported Sexually Transmitted Diseases United States, 2002 Source: CDC Sexually Transmitted Disease Report, Year 2002 4

Chlamydia trachomatis • Most common bacterial STD in US • Chlamydial infections can cause PID, ectopic pregnancy, infertility and pregnancy complications • Up to 70% of sexually active women have asymptomatic chlamydial infections • ~15 -30% women re-infected by 6 -12 months • Asymptomatic rectal infections in MSM 5

Chlamydia — Rates: United States, 1984– 2002 Potential reasons for continuing increase: 1. More complete national reporting 2. Improvement in information systems for reporting Rate (per 100, 000 population) 3. Use of more sensitive diagnostic tests 300 4. Expansion of screening services 297 240 180 120 51 60 0 1984 86 88 90 92 94 96 98 2000 02 6

Chlamydia Rates by Gender: United States, 1984– 2002 Potential reasons for gender differential: 1. Greater number of women screened 2. Sex partners of women not diagnosed or reported 455 130 Urine screening* *55% increase (males): 84 -130 cases per 100, 000; 20% increase (females): 381 to 455 cases per 100, 000 from 1998 to 2002 7

Chlamydia — Age- and sex-specific rates: United States, 2002 8

Chlamydia — Rates by State: United States and outlying areas, 2002 Note: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 293. 6 per 100, 000 population. 9

Reported Sexually Transmitted Diseases, Los Angeles County, 2003 10

Los Angeles County Chlamydia Rates 1991 -2003 Per 100, 000 population Urine screening 11

Los Angeles County Chlamydia Rates by Gender 1991 -2003 Introduction of nucleic amplification tests Per 100, 000 population 12

Los Angeles County Chlamydia Rates by Age and Gender, 2003 Per 100, 000 population 13

Los Angeles County Chlamydia Rates by Race/Ethnicity, 2003 Rate per 100, 000 pop. 14

Chlamydia take home points • Epidemic particularly among young women in • • • Los Angeles County Often asymptomatic Serious sequelae, particularly with repeat infections & co-factor for HIV infection Need novel strategies for control • • • Expanded screening Patient Delivered Partner Therapy Field Delivered Partner Therapy • Need testing technology to screen MSM for rectal infections 15

Gonorrhea • Second most common bacterial STD in US • Usually symptomatic in males, often asymptomatic in women • Can cause PID, infertility, ectopic pregnancy, and complications in pregnancy in women • High prevalences reported from non-genital sites among MSM (oropharynx & rectum) • Fluoroquinolone resistance 16

Gonorrhea — Rates by state: United States and outlying areas, 2002 Note: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 123. 4 per 100, 000 population. The Healthy People 2010 objective is 19. 0 cases per 100, 000 population. 17

Gonorrhea — Rates: United States, 1970 – 2002 and the Healthy People 2010 objective Reasons for decline in gonorrhea rates: 1. Increased screening 2. Increase use of sensitive diagnostic tests 3. Improved reporting and casefinding Note: The Healthy People 2010 objective for gonorrhea is 19. 0 cases per 100, 000 population. 18

Gonorrhea — Age- and sex-specific rates: United States, 2002 19

Gonorrhea Rates by Gender, California, 1993– 2002 Note: Gender "Not Specified" accounted for less than 0. 6% of all cases. Source: California Department of Health Services, STD Control Branch, 02/2003 Provisional Data 20

Gonorrhea Rates* Los Angeles County, 1990 -2003 Introduction of nucleic amplification tests Healthy People 2010 Objective *Per 100, 000 population Year 21

Gonorrhea Rates* by Age and Gender Los Angeles County, 2003 *Per 100, 000 LA County population Age Group 22

Gonorrhea Rates by Race/Ethnicity Los Angeles County, 2003 Rate per 100, 000 pop. 23

Fluoroquinolone Resistant GC (QRNG) • Widespread in parts of Asia, the Pacific, Hawaii. Many cases reported in CA. • Culture with antibiotic sensitivities recommended. • Avoid treatment with fluoroquinolones 24

Gonococcal Isolate Surveillance Project (GISP) — Location of participating clinics and regional laboratories: United States, 2002 25

Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990– 2002 Note: Resistant isolates have ciprofloxacin MICs > 1 g/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0. 125 - 0. 5 g/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990. 26

Prevalence of quinolone-resistant Neisseria gonorrhoeae (QRNG)* among tested gonococcal isolates, and gonorrhea rate, California, 1993 -2002 *QRNG is defined as N. gonorrhoeae, resistant to ciprofloxacin [minimal inhibitory concentration (MIC) >1. 0 g/m. L by agar dilution or disk diffusion zone size <27 mm] or ofloxacin (disk diffusion zone size 24 mm) by the National Committee on Clinical Laboratory Standards. 27

March 2003 – September 2004 South HC (47. 6%) GLC (54. 2%) Cultures Processed N=843 Isolates Recovered N=417 (49. 5%) 28

Ciprofloxacin Resistant Isolates Los Angeles Sentinel Site South HC (9. 1%) GLC (25. 8%) Positive Cultures March 2003 – July 2004 N=352 Resistant Isolates (14. 8%) 29

Gonorrhea Treatment in California Uncomplicated Genital/Rectal Infections • Avoid fluoroquinolones (ciprofloxacin, and levofloxacin) to treat gonorrhea in California • Recommended regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum: ¨Ceftriaxone 125 mg intramuscularly in a single dose OR ¨Cefixime 400 mg orally in a single dose • Co-treatment of chlamydia is recommended unless chlamydia infection has been ruled out 30

Gonorrhea take home points • Overall increase in rates in California • Fluoroquinolone resistance increasing • Limited first line therapies: • Ceftriaxone (IM) • Cefpodoxime • Cefixime (still limited availability) 31

Syphilis (Treponema pallidum) 32

Primary and secondary syphilis — Rates by sex: United States, 1981– 2002 and the Healthy People 2010 objective 33

Primary & Secondary Syphilis Cases by Gender, California, 1996– 2002 ALL MALE Rate per 100, 000 known MSM FEMALE 02/2003 Provisional Data - CA DHS STD Control Branch 34

Primary & Secondary Syphilis, Rates by Gender and Age Group, California, 2002 Male Source: Rate per 100, 000 Female California Department of Health Services, STD Control Branch 35 Provisional Data 03/18/2002

Number of MSM P&S Syphilis Cases by Region and Year 36 3/03 Provisional Data - CA DHS STD Control Branch

Early Syphilis, Los Angeles County, 2001 -2003 37

Los Angeles County Early Syphilis By SPA Of Residence (n=371) (n=198) Cases (n=389) Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 38

Early Syphilis Cases By Age & Sexual Orientation, Los Angeles County, 2003 Age Group Source: Early Syphilis Surveillance Summary, Aug. 2004 Sexual Orientation 39

Cases Primary & Secondary Syphilis by Race/Ethnicity among MSM and Non. MSM Ethnicity/Race Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 40

MSM 1 Early Syphilis Cases by Race/Ethnicity, 2003 MSM includes MSM, MSM/W, and male to female TG or men or women who have sex with M to F transgenders 41

HIV Serostatus of LA County MSM Early Syphilis Cases 2003, n=466 42

Early Syphilis Cases By HIV Serostatus & Sexual Orientation, 2001 – 2003 (n=724) Sexual Orientation Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003 43

The Impact of STDs on Sexual Transmission of HIV Types of evidence • Studies on the biological plausibility and potential pathogenic mechanisms • Cohort studies of HIV seroconversion associated with specific STDs • Community level interventions assessing the impact of STD treatment on HIV incidence 44

STDs and HIV Transmission Pathogenic/Biologic Mechanisms • Transmission: • Inflammatory conditions increase viral load in secretions • Virus can be cultured from genital ulcers • Susceptibility: • Breaks in epithelial barrier allow viral access • Inflammation increases number and/or receptivity of target cells • Enhancement of viral survival 45

Urethritis and HIV Transmission • HIV+ men with urethritis had HIV RNA levels in seminal plasma 8 x > controls • Levels highest with GC • Levels returned to baseline within two weeks of treatment of urethritis • No change in serum viral loads Cohen et al. Lancet 1997, 349: 1868 -73 46

Impact of STDs on Sexual Transmission of HIV Problems in Study Design/Interpretation • Must control for sexual behavior • Studies should be prospective to document the temporal sequence of events • HIV increases the expression of certain STDs • Coinfections make interpretation difficult • Must stratify by gender and sexual preference 47

Effect of STD on HIV Susceptibility Estimates (ORs) from Cohort Studies STD M to F F to M Syphilis 2. 1 2. 5 Gonorrhea 2. 6 3. 9 Chlamydia 2. 8 ns HSV insuff data 2. 7 GUD 2. 8 4. 4 Rottingen et al STD 2001 49

Behavioral Risk Factors for MSM Syphilis Cases 50

Sexual Encounter Venues Among MSM Early Syphilis Cases, Los Angeles, 2001 -2003 (YTD) Internet (n=830) Bars/Clubs (n=852) CSVs (n=869) Source: Epidemiology Unit, STD Program, 2003. 51

HIV Sero-status Among MSM Early Syphilis Cases Attending CSVs, Los Angeles County 2001 -2003 (YTD) Source: Epidemiology Unit, STD Program; n=815 52

MSM Early Syphilis Cases & Specific CSV’s Mentioned for Sexual Encounters, 20002003 (YTD) N (%) • 9 Bathhouses • Club 1350 • • Flex Hollywood Spa KLYT Melrose Spa Midtowne Spa North Hollywood Spa Roman Holiday Spa/II 1 4 2 32 59 1 22 35 1 5 15 28 0. 5 10 17 0. 5 2 -35 -17 • 3 Sex clubs • MB Club • Slammer 53

Multivariate Analysis for Predictors of CSV Attendance, 2001 – 2003 (YTD), N=997 • Variables in model: • • Age • • HIV Status Race/Ethnicity Behavioral Risk Factors (anal insertive, anal receptive, oral, history of anonymous partners, condom use, past incarceration, IDU, non-IDU) 54

Multivariate Analysis for Predictors of CSV Attendance, 2001 – 2003 (YTD), N=997 • Significant predictors of CSV attendance: HIV status and multiple anonymous partners. • MSM with syphilis: • Twice as likely to be HIV positive (OR=1. 77, 95% CI 1. 13 – 2. 77). • Six times as likely to have multiple anonymous partners (OR=6. 53, 95% CI 3. 04 – 14. 05). 55

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Regulation of CSVs • Environmental regulations for pools etc • No formal regulation regarding safer sex practices, drug use • Ongoing collaboration with owners/operators, CBO (APLA) and LAC PH programs to develop guidelines 71

Proposed Guidelines • 1. Condoms, lube available on site • 2. Safer sex and risk reduction guidelines • 3. • 4. • 5. posted Display of educational materials Provision of space for onsite health education services. Provision of training and periodic updates for staff 72

Proposed Guidelines, cont • 6. Consumption of ETOH and drugs per • • applicable laws 7. Solicitation of patron agreement to adhere to house rules upon entry 8. Adherences to local ordinances regarding public assembly and fire codes 9. Provision of wash up facilities with soap and water 10. House rules enforced through periodic monitoring by trained staff. 73

Other Control Measures Social Marketing –Media Campaign 74

Stop the Sores Syphilis Campaign for MSM Background • Funded by LA County Board of Supervisors and overseen by the STD Program, Department of Health Services • Coordinated by Aids Health. Care Foundation in collaboration with 5 other community agencies serving MSM in LA County 75

Stop the Sores Syphilis Campaign for MSM Objective • Increase awareness of syphilis among the MSM population and promote testing Activities • Print, outdoor and Internet ads geared towards MSM • Palm cards, stress grips and posters for venues and outreach activities • Campaign Web Site Stop the Sores 76

Healthy Penis Media Campaign San Francisco Print Ad 77

Healthy Penis Media Campaign San Francisco Print Ad 78

Herpes Simplex Virus (HSV): Overview • Types: HSV 1 & HSV 2 • • • HSV 1: orolabial herpes • HSV 2: genital herpes Both symptomatic & asymptomatic infections are common Can cause serious complications 80

Genital Herpes in the U. S. u Estimated annual incidence: 600, 000 to 1 million cases u NHANES studies (1976 and 1988) showed 32% increase in prevalence by serology testing u Approximately two-thirds are unaware of infection u Most genital and perianal cases are caused by HSV-2, but 10 -50% of first episodes are due to HSV-1 81

Genital Herpes NHANES* II (1976– 1980) and NHANES III (1988– 1994) Note: Bars indicate 95% confidence intervals. *National Health and Nutrition Examination Survey 82

HSV-2 Seropositivity Epidemiology in the U. S. • Prevalence: over 40 million adults in U. S. • • (22%) Among blacks, 35% of men and 55% of women are seropositive Among whites, 15% of men and 20% of women are seropositive Seropositivity increases with age Rates are higher in HIV infected persons and adults of lower socioeconomic status 83

Genital Herpes Transmission u. Major routes: sexual & vertical u. Most sexual transmission probably occurs when index case is asymptomatic u. Efficiency is greater from men to women than women to men u. Mertz, et al: 144 serodiscordant couples u. Almost 17% man-to-woman transmission u. Almost 4% woman-to-man transmission Mertz et al, Annals of Internal Medicine, Feb. , 1992 87

Genital Herpes Local Symptoms of Primary Herpes u. Pain 95% u. Vaginal discharge 85% u. Inguinal adenopathy 80% u. Cervicitis 70% u. Itching & dysuria 68% u. Urethral discharge 30% 88

Genital Herpes Spectrum of Presentations 89

Genital Herpes Established (Chronic) Infection • Establishes latent infection in paraspinous ganglia • Infection persists despite host immune response • Virus may remain latent indefinitely or reactivation can occur 93

Genital Herpes Primary Infection • First infection ever with either HSV-1 or • • • HSV-2 No serum antibody is present when symptoms appear, then rises in convalescence Symptoms are usually more severe than in non-primary or recurrent disease Average incubation period: 2 -12 days 97

Genital Herpes Subclinical/Asymptomatic Infection • Serum antibody is present • Patient has never noticed symptoms • Most probably have mild, unrecognized • • disease Probably all shed virus from the genital area intermittently Thought to account for much of transmission 100

Genital Herpes Patient’s Perception of Etiology Women Men • Yeast infection • Folliculitis • Vaginitis • Jock itch • UTI • “Normal” itch • Menstrual complaint • Zipper burns • Hemorrhoids • Allergies (condoms, • Allergy to condom sperm, spermicide, pantyhose • Rash from sex, shaving, bike seat • Irritation from tight jeans, sex, bike seat • Insect bite Koutsky, NEJM, 1992 102

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