The document discusses sexually transmitted diseases (STDs) in the United States. It provides estimated annual incidence rates for common STDs, with human papillomavirus the most prevalent at over 5 million cases annually. STDs can cause various health complications if left untreated, including fetal wastage, infertility, and increased risk of HIV transmission. Rates of chlamydia, the most commonly reported STD, vary significantly between states and are highest among women ages 15-19 and men ages 20-24.

1. Sexually Transmitted
Diseases
What’s New?
Linda Creegan, FNP
California STD/HIV Prevention
Training Center

2. Common STDs
Estimated Annual Incidences
 Humanpapilloma Virus: 5.5 million
 Trichomoniasis: 5 million
 Chlamydia: 3 million
 Genital herpes: 1 million
 Gonorrhea: 650,000
 Hepatitis B: 120,000
 Syphilis: 70,000

3. Overview of Complications of
Sexually Transmitted Diseases
Fetal Wastage*
Low Birthweight*
Congenital Infection*
Upper Tract
Infection
Systemic Infection
STDs
Infertility
Ectopic Pregnancy*
Chronic Pelvic Pain
HIV Infection*
Cervical Cancer*
* Potentially Fatal

4. Increased Transmission of
HIV in the Presence of Other
STDs
 Transmission increased 3-5 times
 Increased susceptibility
Mucosal breakdown due to genital ulcer may
facilitate HIV entry
Recruitment of WBCs to site of active infection
(inflammation) acts as an area of increased HIV
receptors
 Increased infectiousness
Increase in HIV viral load in semen, genital
secretions and genital ulcers

5. Chlamydia — Reported
rates: United States, 1984–
2000
Rate(per 100,000population)
0
60
120
180
240
300
1984 86 88 90 92 94 96 98 2000

6. Chlamydia — Rates by
state: United States and outlying
areas, 2000
Note: The total rate of chlamydia for the United States and outlying areas
(including Guam, Puerto Rico and Virgin Islands) was 254.8 per 100,000
population.
Rate per 100,000
population
<=150
150.1-300
>300
VT 88.6
NH 94.1
MA 177.6
RI 265.6
CT 231.7
NJ 132.8
DE 379.0
MD 281.0
Guam 321.1
Puerto Rico 69.3 Virgin Is.116.1
(n=9)
(n=35)
(n=9)
350.7
414.7
263.5
243.8
287.8 295.8
221.0
377.0
299.2
152.4
272.0 236.6
208.6
228.2
203.6
408.2
117.6
266.0
169.7
458.6
245.9
166.4
227.5
222.1
299.1
173.1
287.4
143.5
277.1
277.9
214.3
220.7
256.1
250.2
274.8
343.3
102.8
223.4
227.0
118.7
311.7
168.3

7. Chlamydia
Age- and gender-specific rates U.S.
2000
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Men Rate(per 100,000population) Women
Age
2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
9.3
348.5
544.9
270.3
124.8
60.4
30.0
14.3
4.4
2.4
102.8
141.8
2,406
2,250.6
761.0
273.7
107.0
45.6
16.9
5.0
3.2
404.1
Age Gender Total
10-14 73.9
15-19 1,348.5
20-24 1,381.7
25-29 516.9
30-34 200.0
35-39 83.8
40-44 37.9
45-54 15.6
55-64 4.7
65+ 2.9
Total 256.9
.0

8. Chlamydia Positivity among 15-24 y.o.
women tested in family planning clinics by
state, 2000
Positivity (%)
<4
4.0-4.9
>=5
VT 2.8
NH 4.5
MA 5.4
RI 11.9
CT 5.1
NJ 6.1
DE 5.2
MD 6.2
DC 6.5
Puerto Rico 5.6 Virgin Is. 14.5
(n=8)
(n=12)
(n=33)
7.9
2.9
5.0
6.4
7.3 4.8
5.0
7.1
5.1
4.1
7.4 5.2
4.3
4.2
3.6
9.7
4.0
4.5
5.5
15.8
4.3
5.1
4.0
6.4
6.8
3.5
7.5
3.0
6.3
6.0
3.9
6.3
8.6
3.2
4.9
9.3
4.6
6.9
6.3
2.3
7.2
4.7
Note: States reported chlamydia positivity data on at least 500 women aged 15-24
years screened during 2000 except for Minnesota and Rhode Island.
SOURCE: Regional Infertility Prevention Programs; Office of Population Affairs;
Local and State STD Control Programs; Centers for Disease Control and Prevention

9. Prevalence of Chlamydia Infections in 15–19 Year Old Adolescent Girls
by Health Care Setting, California, 2000
5.2
8.8
15.5
5.2
9.3 9.4
22.3
0
5
10
15
20
25
M
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e
d
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a
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T
D
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l
i
n
i
c
s
Chlamydia Prevalence
(% Positive)
Source: California Department of Health Services, STD Control Branch; Los Angeles Infertility Prevention Project; and San Francisco
infertility Prevention Project

10. Gonorrhea
Reported rates: U.S. 1970–2000 and the
Healthy People year 2010 objective
Rate(per 100,000population)
Gonorrhea
2010Objective
0
100
200
300
400
500
1970 73 76 79 82 85 88 91 94 97 2000
Note: The Healthy People 2010 (HP2010) objective for gonorrhea is 19.0
cases per 100,000 population.

11. Gonorrhea
Rates by state: U.S. and outlying areas,
2000
Note: The total rate of gonorrhea for the United States and outlying areas
(including Guam, Puerto Rico and Virgin Islands) was 129.9 per 100,000
population. The Healthy People year 2010 objective is 19.0 per 100,000
population.
Rate per 100,000
population
<20
20-100
>100
VT 10.9
NH 9.2
MA 49.3
RI 66.7
CT 88.7
NJ 88.8
DE 230.2
MD 190.2
Guam 37.9
Puerto Rico 13.5 Virgin Is.21.3
(n=9)
(n=21)
(n=23)
276.0
58.3
86.4
142.7
65.2 76.7
150.8
260.2
40.7
7.8
170.4 109.8
48.5
105.3
88.4
302.9
7.2
184.3
66.2
332.9
162.4
6.8
92.1
85.8
66.2
110.5
233.0
11.5
171.5
125.9
31.3
113.4
215.7
37.8
216.6
164.2
10.8
148.0
42.0
35.7
133.6
11.1

12. Gonorrhea
Age- and gender-specific rates: U.S.
2000
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Men Rate(per 100,000population) Women
Age
750 600 450 300 150 0 0 150 300 450 600 750
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
8.3
327.9
589.7
362.2
210.6
140.4
92.6
49.5
18.6
5.0
134.7
53.3
715.6
656.7
252.1
112.5
60.3
29.3
9.1
1.8
0.9
128.4
Age Gender Total
10-14 30.3
15-19 516.3
20-24 622.5
25-29 306.9
30-34 161.1
35-39 100.1
40-44 60.7
45-54 28.9
55-64 9.8
65+ 2.6
Total 131.4

13. Gonorrhea
Positivity among 15-24 y.o. women
tested in family planning clinics by state,
2000
Positivity (%)
See *
<1
1.0-1.9
>=2
VT 0.1
NH 0.1
MA
RI
CT 0.7
NJ 1.7
DE
MD
DC
Puerto Rico Virgin Is. 2.1
(n=18)
(n=19)
(n=11)
(n=5)
2.0
0.6
1.6
1.2 0.4
0.9
1.7
0.0
1.8 0.9
0.7
0.7
0.4
2.7
1.3
4.5
0.8
0.9
0.6
1.1
0.6
1.1
0.8
2.0
0.9
1.5
1.1
0.6
1.7
0.3
*States reported gonorrhea positivity data on less than 500 women aged 15-24 years
during 2000 except for Alaska submitting data for June-December only and Ohio
submitting data for August-December only.
SOURCE: Regional Infertility Prevention Programs; Office of Population Affairs; Local
and State STD Control Programs; Centers for Disease Control and Prevention

14. Gonorrhea
Rates by gender: U.S. 1981–2000 and the
Healthy People year 2010 objective
Rate(per 100,000population)
Male
Female
2010Objective
0
120
240
360
480
600
1981 83 85 87 89 91 93 95 97 99

15. Gonorrhea and Chlamydia in
Hawaii, 2001
Gonorrhea
 Incidence 49.9 per 100,000
 25% increase from 2000 to 2001
Chlamydia
 Incidence 333 per 100,000
 Rate doubled between 1997 and 2001
Hawaii DOH CD Report,
March/April 2002

16. Chlamydia Prevalence Rate by Year
Hawaii and U.S., 1986-2001
0
100
200
300
400
1986 1988 1990 1992 1994 1996 1998 2000
Year
Rate
per
100,000
Pop'n
National
Objective
US Rate
Hawaii
Rate

17. Chlamydia Morbidity by Gender and Year
Hawaii, 1986 – 2002*
0
500
1000
1500
2000
2500
3000
3500
1986 1989 1992 1995 1998 2001
Year
No.
of
Cases
Female
Male
*Jan-June, 2002
Note: The Chlamydia Screening Program/Infertility Project (active screening of females
participating in family planning services) may contribute to the disproportionate number of
females detected with chlamydia infection.

18. Gonorrhea Morbidity by Gender and Year
Hawaii, 1980 –2002*
0
500
1000
1500
2000
2500
3000
3500
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
Year
No.
of
Cases
Female
Male
Jan-June, 2002

19. Gonorrhea Morbidity: 15-19 yo By Gender
Hawaii, 1994 –2001
0
20
40
60
80
100
120
140
160
No.
of
Cases
1994
1995
1996
1997
1998
1999
2000
2001
Year
Females
Males

20. Reported Cases of Chlamydia (CT) and
Gonorrhea (GC) in Hawaii, 1996-2000
0
20
40
60
80
100
120
Male-CT Male-GC Female-
CT
Female-
GC
Percent
Unk
Other
White
Black
Asian/Pacific
Islander
Native Am
N=2286 N=1184 N=10675* N=1279
•The disproportionate number of female cases may be attributed to the active
screening of women participating in family planning services.

21. Chlamydia and GC Cases(%) Among
Asian/Pacific Islanders in Hawaii,
1996-2000
0
20
40
60
80
100
120
Male-CT Male-GC Female-
CT
Female-
GC
Percent
Korean
Japanese
Hawaiian
Filipino
Chinese
Pacific
Islander
Indo-Chinese

22. Chlamydia
incidence by
county, Hawaii,
2001
0
50
100
150
200
250
300
350
400
State Honolulu Hawaii Maui Kauai
0
10
20
30
40
50
60
70
State Honolulu Hawaii Maui Kauai
Gonorrhea
incidence by
county, Hawaii,
2001
Hawaii DOH CD Report,
March/April 2002

23. CipR GC in Hawaii
Rate now 20% resistant!
Risk Factors (Chart review, N=117)
 Heterosexual orientation
 Travel to Asia
 Commercial sex
Recommendations
 AVOID fluoroquinolones to treat GC
CD Report May/June 2002

24. Gonococcal Isolate Surveillance Project
(GISP) Participating Clinics and Regional Laboratories
Twenty-five sentinel sites across the nation monitor
culture isolates of GC for antibiotic resistance

25. (GISP) — Percent of Neisseria gonorrhoeae
isolates with decreased susceptibility or resistance to
ciprofloxacin, 1990–2000
Percent
Decreasedsusc.
Resistance
0.0
0.4
0.8
1.2
1.6
2.0
1990 91 92 93 94 95 96 97 98 99 2000
Note: Resistant isolates have ciprofloxacin MICs >1 mg/mL. Isolates with decreased
susceptibility have ciprofloxacin MICs of 0.125 - 0.5 mg/mL. There were sixty-one
(61) resistant isolates: one in 1991, one in 1993, two in 1994, eight in 1995, two in
1996, five in 1997, four in 1998, nineteen in 1999, and nineteen in 2000.
Susceptibility to ciprofloxacin was first measured in GISP in 1990.

26. GISP: Percent of N. gonorrhoeae
isolates obtained from MSM 1998, 1999
and 2000
Percent
1998
1999
2000
0
15
30
45
60
75
ALB ANC ATL CHI DEN HON LBC
Clinics
MIA ORA PHX POR SDG SEA SFO
Note: In 2000, these 14 clinics reported 91.7% (633/690) of GISP gonorrhea cases in men who
have sex with men (MSM). In 1998 ALB reported 0.0% MSM. Clinics include:
ALB=Albuquerque, NM; ANC=Anchorage, AK; ATL=Atlanta, GA; CHI=Chicago, IL;
DEN=Denver, CO; HON=Honolulu, HI; LBC=Long Beach, CA; MIA=Miami, FL;
ORA=Orange County, CA; PHX=Phoenix, AZ; POR=Portland, OR; SDG=San Diego, CA;
SEA=Seattle, WA; and SFO=San Francisco, CA.

27. CipI/CipR Gonococcal Isolates Hawaii,
1993-2002*
0
2
4
6
8
10
12
14
16
18
20
CipI/CipR
Isolates
(%)
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Year
CipI: Ciprofloxacin
intermediate Isolates
CipR: Ciprofloxacin
resistant Isolates
Jan-June, 2002

28. Syphilis
Reported cases by stage of illness: U.S.
1941–2000
Thousands of cases
P&S
EarlyLatent
Total Syphilis
0
120
240
360
480
600
1941 46 51 56 61 66 71 76 81 86 91 96

29. Primary and Secondary
Syphilis Reported rates: U.S. 1970–
2000 and the Healthy People year 2010
objective
Rate(per 100,000population)
P&SSyphilis
2010Objective
0
5
10
15
20
25
1970 73 76 79 82 85 88 91 94 97 2000
Note: The Healthy People 2010 (HP2010) objective for primary and
secondary syphilis is 0.2 case per 100,000 population.

30. Primary and Secondary
Syphilis Rates by state: U.S. &
outlying areas 2000
Note: The total rate of primary and secondary syphilis for the United States
and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 2.2
per 100,000 population. The Healthy People year 2010 objective is 0.2 per
100,000 population.
Rate per 100,000
population
<=.2
.21-4
>4
VT 0.0
NH 0.2
MA 1.1
RI 0.4
CT 0.5
NJ 0.9
DE 1.2
MD 5.8
Guam 0.6
Puerto Rico 4.5 Virgin Is.2.7
(n=14)
(n=29)
(n=10)
2.8
0.0
4.0
4.1
1.0 0.3
2.7
5.2
0.2
0.1
3.4 5.9
0.4
0.2
2.1
4.8
0.1
3.3
0.3
4.9
0.5
0.0
0.1
0.3
0.9
0.7
6.3
0.0
0.6
3.5
0.4
0.6
5.9
0.0
9.7
2.0
0.1
1.8
1.1
0.2
0.9
0.2

31. Primary and Secondary
Syphilis Rates by race and ethnicity:
U.S. 1981–2000 and the Healthy People year
2010 objective
Rate(per 100,000population)
White
Black
Hispanic
Asian/PacIsl
Nat Am/AK Nat
2010 Objective
0
30
60
90
120
150
1981 83 85 87 89 91 93 95 97 99

32. P&S Syphilis
Counties with rates above the Healthy
People year 2010 objective, U.S. 2000
Rate per 100,000
Population
<=0.2
>0.2
(n=2,544)
(n=595)

33. Primary and Secondary
Syphilis Age- and gender-specific
rates: U.S. 2000
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Men Rate(per 100,000population) Women
Age
7.5 6.0 4.5 3.0 1.5 0.0 0.0 1.5 3.0 4.5 6.0 7.5
Total
65+
55-64
45-54
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0.0
1.6
4.6
5.8
5.7
5.4
4.6
3.0
1.4
0.5
2.6
0.2
3.1
5.2
4.1
4.1
3.5
2.5
1.0
0.2
0.0
1.8
Age Gender Total
10-14 0.1
15-19 2.3
20-24 4.9
25-29 4.9
30-34 4.9
35-39 4.5
40-44 3.5
45-54 2.0
55-64 0.8
65+ 0.2
Total 2.2

34. P&S Syphilis in Hawaii, 2001
 Incidence: 1.0 per 100,000
 Increase from 2 cases in 2000 to 12
cases in 2001
 10 from Honolulu county, 2 from Hawaii
county
 7 of 12, 60% are MSM
 Of MSM, 40% are HIV-infected
Hawaii DOH CD Report,
March/April 2002

35. Genital Herpes
Initial visits to physicians’ offices: U.S. 1966–
2000
Visits (inthousands)
0
50
100
150
200
250
1966 69 72 75 78 81 84 87 90 93 96 99
SOURCE: National Disease and Therapeutic Index (IMS America, Ltd.)

36. Herpes simplex virus type 2 - Percent
seroprevalence according to age in
NHANES* II (1976-1980) and NHANES III
(1988-1994)
Note: Bars indicate 95% confidence intervals.
*National Health and Nutrition Examination Survey
Percent
NHANESII
NHANESIII
0
8
16
24
32
40
AgeGroup
12-19 20-29 30-39 40-49 50-59 60-69 70+

37. Genital Warts
Initial visits to physicians’ offices: U.S. 1966–
2000
SOURCE: National Disease and Therapeutic Index (IMS America, Ltd.)
Visits (inthousands)
0
80
160
240
320
400
1966 69 72 75 78 81 84 87 90 93 96 99

38. STD Services in Hawaii
 Oahu: Diamond Head Health Center
808-733-9281
 Hawaii: Chester Wakida
808-933-0912
 Maui: Kris Mills
808-984-8313
 Kauai: Jo Manea
808-241-3563

39. What’s New with Chlamydia
Infection?
 New diagnostic tests
 Single dose treatment options
 Screening recommendation
 Partner management options

40. Chlamydia Infection
 Most common reportable disease in the U.S.
 Estimated > 3 million cases annually
 Incidence is highest among sexually active
adolescents and young adults
 Most infections are asymptomatic
 Leading cause of preventable infertility in
women
 Direct and indirect costs estimated
at $1.7 billion annually

41. Chlamydia Infection in Men
 Urethritis
 Epididymitis
 Proctitis
 Conjunctivitis
 Reiter’s Syndrome
>50% ASYMPTOMATIC

42. Chlamydia Infections in
Women and Neonates
 Cervicitis
 Urethritis
 Conjunctivitis
 Proctitis
 Peri-hepatitis (Fitz-
Hugh-Curtis
syndrome)
 70-80%
ASYMPTOMATIC
 Conjunctivitis
 Pneumonia

43. Genital Chlamydia in Women:
Complications
Untreated
genital CT
infection
Ectopic
pregnancy
Infertility
Chronic
pelvic pain
Acute PID
Silent PID
9%
14-20%
18%
20-50%

44. Chlamydia Infections
Estimated Complications, U.S.
 PID: 400,000 cases/year
 Ectopic pregnancy: 14,000 cases/year
 Infertility: 8,000 cases/year
 Neonatal pneumonia: 37,000 cases/year

45. Risk Factors for Genital CT
 Age < 25 years
 Female gender
 Black race (proxy)
 New or multiple sex partners
 Inconsistent use of barrier methods

46. Public Health Approaches to
Chlamydia Control
 Health promotion & education
 Condom availability & use
 Early detection through screening
high risk populations
Increase in case finding
Decrease in community prevalence and
complications (PID)
 Health policy

47. Chlamydia Screening &
Treatment
 Decreases community prevalence
 Prevents pelvic inflammatory disease
 Cost effective
 Opportunity to increase awareness
and provide risk reduction counseling

48. Chlamydia prevalence among women tested
in FP clinics by age: Region X, 1988-1998
Percent
<18Years
18-19Years
20-24Years
25-29Years
30+Years
0
3
6
9
12
15
1988 89 90 91 92 93 94 95 96 97 98

49. CT Screening Prevents PID
Clinical trial, Seattle HMO, 1990-1992
 Randomized controlled trial
 1009 high risk women 18-34 assigned to intervention
(invitation to get tested) and 1598 to usual care
 Among intervention group, 64% were tested and 7%
were positive and treated
 Outcome of PID within 1-year follow-up:
• 9 cases among screening group compared to
33 cases among usual care group
• RR = 0.44 (0.20-0.90), less than half as many
cases of PID among screening group
Scholes et al., NEJM, 1996; 334:1362-6

50. CT Screening Cost-Effective
 CDC estimated that “for every dollar spent on
chlamydia screening, we could save $12”
 Outcomes of cost effectiveness analyses most
sensitive to prevalence, costs of diagnostic
tests, and costs of complications
 In general, screening can be cost effective if
the prevalence is greater than 3%

51. Chlamydia Reinfection Rates
0
5
10
15
20
25
30
0 1 2 3 4 5 6 7 8 9 10
Months after Infection
Percent
Reinfected
Whittington et al. 2001; Fortenberry et al. 1999; Blythe et al. 1992

52. What about chlamydia screening
among men?
 Obvious source of transmission
 Urine-based testing advantage
 Unpublished cost effectiveness analysis
demonstrate community and future
partner benefits
 Limited data on prevalence & outcomes
 No guidelines available

53. Chlamydia Screening
Recommendations
 CDC, NCQA HEDIS, USPSTF, ACOG and others
are similar
 All sexually active women under 26 yoa
 Initial screen
 Repeat annually
 Consider repeat with new or multiple sex partners
 Repeat 2-3 months after an infection
 All pregnant women under 26 yoa
 Men, and women 26 and older, consider with
 New or multiple sex partners,
 Inconsistent condom use

54. Chlamydia Testing
Current Diagnostic Methods
 Culture
 Antigen Detection
 EIA
 DFA
 Nucleic Acid Detection
 Probe Hybridization
 Nucleic Acid Amplification
 Hybrid Capture

55. Chlamydia Testing
Nucleic Acid Amplification
Tests
Nucleic Acid Amplification Tests
(NAATS)
 Polymerase Chain Reaction
 Ligase Chain Reaction
 Transcription Mediated Amplification
 Strand Displacement Amplification
Hybrid Capture

56. Genital Chlamydia
Diagnostic Tests
 EIA
 DNA probe
 DFA
 Culture
 DNA
amplification tests
(LCR, PCR, TMA,
SDA) *
Sensitivity
50-70%
65-75%
70-75%
75-85%
90-95%
Specificity
95-99%
95-99%
95-99%
100%
98-99%
* Able to use URINE specimens!

57. Urine-Based CT Tests
 NAAT technology
 High sensitivity
 Non-invasive collection
 High patient
acceptability
 Only test appropriate for
screening asymptomatic
males
 Screening in non-
clinical settings
 Community settings
 Home testing

58. Chlamydia Screening
Cost Effectiveness of NAAT
 Study comparing EIA, DNA probe, cell
culture, PCR and LCR of both cervical
and urine specimens
 Findings: most cost-effective strategy is
to perform LCR on cervical specimen if
pelvic exam is done, and LCR on urine
if no pelvic exam performed
Howell, STD 1998;25(2):108-117

59. Chlamydia : Treatment
Non-pregnant Adults
 Recommended regimens
Azithromycin 1 g orally in a single dose
Doxycycline 100 mg orally BID for 7 days
 Alternative regimens
Erythromycin base or EES QID for 7 days
Ofloxacin 300 mg BID for 7 days
Levofloxacin 500 mg QD for 7 days

60. Chlamydia: Treatment
Pregnant Women
 Recommended regimens
Erythromycin base 500 mg orally QID x 7
days
Amoxicillin 500 mg orally TID x 7 days
 Alternative regimens
Erythro. Base 250 mg orally QID x 14 days
EES 800 mg orally QID x 7 days, or 400
mg QID x 14 days
Azithromycin 1 g orally, single dose

61. Chlamydia Follow-up
Is Test-of-Cure Necessary?
 Antibiotic resistance has been reported
but is extremely rare
 Single-dose, observed therapy
increases compliance
 Routine test-of-cure is not
recommended, except in pregnant
women
 Repeat testing at 3-4 months is
recommended b/o re-infection risk

62. Chlamydia Partner
Management
 Transmissibility:
 male to female: 45-55% (culture) to 70% (PCR)
 female to male: 28-42% (culture) to 68% (PCR)
 Partners with contact during the 60 days
preceding the diagnosis should be
evaluated, tested and treated
 If no sex partners in previous 60 days,
treat the most recent partner

63. Patient-Delivered Therapy:
Rationale
 Repeat CT infections place women at greater
risk for PID and infertility than first infection
 Most important risk factor for re-infection is an
untreated partner
 Multi-center CDC trial demonstrated 20%
decrease in re-infection with PDT
 Single-dose azithromycin has very few
adverse reactions

64. A Multi-Center Randomized Controlled Trial:
Patient-Delivered Partner Therapy
Randomized Controlled Trial of partner referral versus
patient-delivered therapy (PDT)
Multiple Centers in the US:
 Birmingham, Seattle, New Orleans, San Francisco,
Indianapolis and Long Beach
Goals:
 To determine whether the risk for early recurrent CT
infection can be reduced by providing women with
medication to deliver to their male sex partners
 To determine the acceptability of PDT and any
problems associated with PDT
Schillinger et al 2001

65. Reinfection Rates by Study Arm
15%
12%
0
2
4
6
8
10
12
14
16
Percent
Reinfection
Partner Referral PDT
P=.102
Schillinger et al 2001
PDT TRIAL

66. Patient- Delivered Therapy
for Chlamydia in California
 Senate Bill 648
Provides new option for ensuring effective
partner treatment of both male and female
patients
Exam of partner is not required
Specifically mentions NPs, certified
midwives, and PAs
Does not specifically state which
medication, how the medication is
provided or paid for

67. What’s New with Gonorrhea?
 New diagnostic tests
 Treatment options
 Antibiotic resistance
 Screening recommendations

68. Gonorrhea (GC)
 Caused by Neisseria gonorrhoeae
 ~360,000 reported cases in US in 2000
(2nd most common reportable disease)
 Estimated annual incidence: 650,000
 Overall rates falling, but incidence in
certain groups remains high

69. Gonorrhea Infection
 Men are usually symptomatic (urethra),
women are commonly asymptomatic
 Most common in young adults and
adolescents
 CT co-infection of GC cases remains at
about 40%
 Fluoroquinolone resistance is an emerging
problem (established in Hawaii and
California)

70. Gonorrhea
Clinical Presentation
 Incubation period 2-8 days
 Men: urethral infection
 Usually presents with abrupt onset of severe
dysuria and copious purulent discharge; few may
be asymptomatic carriers
 Women: cervical infection
 ~50% women asymptomatic, others have dysuria,
vaginal discharge or bleeding
 Other presentations: purulent conjunctivitis,
proctitis, pharyngitis

71. Gonorrhea
Complications
 Pelvic inflammatory disease (PID)
 Fitz-Hugh-Curtis Syndrome
(perihepatitis)
 Epididymitis or urethral strictures (men)
 Disseminated infection (DGI):
occurs in < 5% of patients
>90% have arthritis +/- dermatitis
rarely, can see meningitis, endocarditis

72. Gonorrhea
Diagnosis
 Gram stain of urethral or cervical discharge
 95% sensitive in symptomatic males
 50-70% sensitive in asymptomatic males
 50-70% sensitive in women
 Culture: 80 - 95% sensitive
 DNA probe: 89-97% sensitive
 Nucleic acid amplification tests (NAATs)
 LCR, PCR and TMA; 95-98% sensitive, can be
performed on urine

73. Gonorrhea
Anal and Pharyngeal
Infections
 Gonococcal infections commonly
asymptomatic at these sites
 Most pharyngeal infection resolves
spontaneously by 3 months
 Only culture is approved for use in
testing these sites
 Most important to consider testing for
high-risk individuals (MSM, CSWs)

74. Gonorrhea Treatment
Uncomplicated Genital and Rectal Infections,
Non-Pregnant Adults
 Recommended regimens:
 Cefixime 400 mg PO x 1
 Ceftriaxone 125 mg IM x 1
 Ofloxacin 400 mg PO x 1
 Ciprofloxacin 500 mg PO x 1
 Levofloxacin 250 mg OD x 1
 Any of above PLUS Doxycycline or Azithromycin
 Alternative regimens:
 Spectinomycin 2g IM x 1
 Single dose cephalosporin (2nd or 3rd generation)
 Other fluoroqinolone (Gatifloxicin 400 mg PO x 1)

75. GC Partner Management
 Transmissibility:
Male to female: 50 - 90%
Female to male: 20 - 80%
 Partners with contact during the 60 days
preceding the diagnosis should be
evaluated, tested and treated
 If no sex partners in previous 60 days,
treat the most recent partner

76. Increasing Quinolone Resistence
in the U.S.
 CipR GC up to 60% in Japan,
Philippines, parts of SE Asia and the
Pacific Islands
 Antimicrobial resistance to
fluoroquinolones increasing in the U.S.,
but still < 1%
About 20% of isolates in Hawaii (2001-
2002)
5% of isolates in California ( July-
December,2001)

77. Use of Fluoroquinolones to
Treat GC
Infection:Recommendations
 Obtain travel history; if infection may
have been acquired in HI, CA, Asia or
the Pacific Islands, patient should be
treated with a cephalosporin
 Treatment failures should be cultured
and tested for resistance (and re-
treated)

78. Gonorrhea Infection
Screening Considerations
 Accuracy of screening is dependent on:
Prevalence of disease in the population
Sensitivity and specificity of test used
 Screening a low-prevalence population
can result in more false-positives than
true-positives
 Screening is probably not warranted
when GC prevalence is under 1%

79. GC LCR Screening
 Urine LCR screening of adolescents at
juvenile halls in Los Angeles from 2/97 -
12/97
 2500 girls screened: 4% positive, 83%
without symptoms
 2032 boys screened: 0.6% positive,
92% without symptoms

80. Gonorrhea
Screening Recommendations
 Consider in
Populations with prevalence of 1-2% or
more
MSM
High-risk women
 Young age
 New or multiple partners
 Pregnant women

81. What’s New with Syphilis?
 Low national incidence and Syphilis
Elimination Effort
 Urban outbreaks among men who have
sex with men (MSM)
 New alternative treatments

82. Syphilis
 Incidence has been steadily declining in the
U.S. since 1990
 Now at lowest rates since the 1940s
 28 U.S. counties account for 50% of the
reported cases
 In 1999, the CDC initiated a nation-wide
Syphilis Elimination Effort, targeting these
areas
 Recently, local outbreaks centered in urban
areas among MSM

83. Syphilis Elimination
Public Health Importance
Persistence of syphilis is a sentinel public
health event
 identification & repair of breakdown in
basic public health capacity
 rebuilding of trust in public health
system
Reduction of glaring racial disparity
Prevention of HIV transmission
Improved infant health
Annual cost-savings of almost $1 billion

84. National Plan for Syphilis Elimination
Five Key Strategies
Cross-Cutting Strategies
Enhanced surveillance
Strengthened community involvement
and partnerships
Intervention Strategies
Rapid outbreak response
Expanded clinical and laboratory
services
Enhanced health promotion

85. Regional Syphilis Hotspots
 Higher endemic levels in rural South
and Phoenix, AZ
 Outbreaks among MSM in many urban
areas
SF, LA, Denver, NY, Chicago, District of
Columbia, Miami

86. Understanding STD Trends in
MSM
 Why? (increases in unprotected anal sex)
 Assumptions about reduced HIV infectivity in HAART era
 Less exposure to persons with advanced AIDS
 STDs considered minor and readily treatable nuisances
 Who?
 Subsets of MSM (minority MSM, older men, both HIV-&+ )
 Mixing by HIV serostatus
 What contexts?
 Drug use (Methamphetamines, Viagra)
 Anonymous venues for meeting partners (internet,
bathhouses, circuit parties) “Sleepless in Seattle” Study, 1999

87. Syphilis Management in HIV
Co-Infected Patients
 Syphilis is a risk-marker for HIV infection
 3-5 X increased risk
 Concerns re: disease variation have not been
born out in studies
 No marked alteration in clinical manifestations
 Standard serologic tests can be used for diagnosis
and follow-up (though titers may de cline more slowly)
 Standard treatment regimens are also
recommended in HIV co-infected patients
 Closer and longer follow-up, and lower
threshold for LP referral are prudent

88. Syphilis
Diagnostic Testing
 Treponema pallidum Particle
Agglutination (TP-PA) test (SERODIA)
Replaces MHA-TP
Along with FTA-Abs, is a treponemal
(confirmatory) test
Comparable in sensitivity and specificity to
MHA-TP

89. Syphilis
New Therapies
 Penicillin G remains the first line treatment
 Limited data support the use of Azithromycin
as an alternative regimen
 Azithromycin 2 gm orally in a single dose as
treatment for early syphilis
 Azithromycin 1 gm orally in a single dose as
prophylactic treatment for contacts to infectious
syphilis
 Has not been studied in HIV + patients; larger
trials ongoing
 Cefrtiaxone almost certainly effective, but
best dose/duration has not been established

90. What’ s New with
Genital Herpes?
 Information about natural history
Atypical symptoms
Asymptomatic infection and shedding
 New diagnostic tests
 Shorter treatment regimens

91. Herpes: Overview
 Etiologic agent: Herpes simplex virus
 Types: HSV 1 & HSV 2
HSV 1: orolabial herpes
HSV 2: genital herpes
 Both symptomatic & asymptomatic
infections are common
 Can cause serious complications
 Asymptomatic shedding is well
documented

92. Genital Herpes Infection
Epidemiology
 Estimated annual incidence: 600,000 to
1 million cases
 NHANES data provided new view of
HSV-2 prevalence in the U.S.
Twenty-two percent of adults estimated to
be infected with HSV-2
Prevalence increased 30% between 1979
and 1990.
 Most infections are unrecognized b/o mild
symptoms or absence of symptoms

93. HSV-2 Seropositivity
Epidemiology in the U.S.
 Prevalence: over 40 million adults (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

94. Human Herpesvirus Family
 HSV-1 and HSV-2
 VZV: Chicken pox, shingles
 EBV: Infectious mononucleosis
 CMV: Congenital infections,
immunosuppressed patients
 HHV 6: Roseola infantum
 HHV 7: Pityriasis rosea
 HHV 8: Kaposi’s sarcoma
STD Atlas, 1997

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

96. Genital Herpes
Natural History
 Initial Infection
 Virus enters through microscopic breaks in integument, replicates in
kerotinocytes
 Transported along peripheral axons to establish latent infection in
paraspinous ganglia
 Established (Chronic) infection
 Infection persists despite host immune response
 Virus may remain latent indefinitely or can reactivate
 Viral Reactivation
 Precipitating factors: trauma, fever, UVL, stress
 Virus replicates andmigrates along axon to skin or mucosa, and
recurrent lesions can occur
 Reactivation (shedding) can also be asymptomatic

97. Genital Herpes
Categories of Infection
 First clinical episodes
 Primary: first infection ever with either HSV type
 Non-primary: newly acquired infection with HSV-1
or HSV-2 in a person seropositive to the other
virus
 Recurrent episodes
 Antibody is present to the same viral serotype
when symptoms appear
 Patient may not be aware of previous episodes
 Asymptomatic/subclinical infection
 Serum antibody is present; no history of clinical
outbreaks

98. Genital Herpes
First Clinical Episodes
 Primary
 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
 Non-primary
 Newly acquired infection with HSV-1 or HSV-2 in a
person who is seropositive to the other HSV type
 Symptoms tend to be milder
 Antibody to new HSV type then develops

99. Genital Herpes
Reactivation of Virus
 Symptomatic recurrences
 Symptoms are generally mild and short in duration
 25% of patients with first clinical episode have
had prior asymptomatic infection, or may be
unaware that previous mild symptoms were
caused by herpes
 Subclinical/Asymptomatic Infection
 Diagnosed by positive type-specific serology test
 Patient has never noticed symptoms
 Most probably have mild, unrecognized disease
 Probably all shed virus from the genital area
intermittently; accounts for much of transmission

100. Genital Herpes
Educating to Recognize
Symptoms
 62 HSV-2 seropositive women denying
history of genital symptoms were
intensively educated
77% then presented with culture-+ lesions
 53 seropositive asymptomatic men and
women with education
87% with subsequent symptoms
Landenberg, 1989 & Wald, 2000

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

102. Genital Herpes
Asymptomatic Shedding
 Multiple studies have documented
asymptomatic shedding with culture and
DNA amplification techniques
 Occurs in up to 90% of patients with HSV-2
 Most common in first two years after infection (5-
10% of days), less common thereafter (2% of
days)
 Shedding may occur from cervix, vulva, urethra,
rectum, penis
 Asymptomatic shedding reduced by acyclovir
suppression

103. Genital Herpes
Spectrum of Presentations
Unrecognized
Symptoms
60%
Recognized
Symptoms
20%
Asymptomatic
20%

104. Neonatal Herpes Infection
 Neonatal infection occurs in 1/3000 -
 1/ 7,500 births in US
 Clinical disease manifests at 3-30 days
of age
 Skin, eye or mucous membrane: low
mortality, but recurrences possible
CNS: 30% mortality, 50% serious sequelae
Disseminated: 80% mortality, 10% serious
sequelae
 Overall mortality ~ 20%

105. Herpes
Transmission in Pregnancy
 Most transmission occurs at time of
delivery, rarely in utero
 Risk factors: primary infection, new
infection, scalp electrodes
 Over half of infants with neonatal
infection are born to mothers with no
history of genital herpes

106. Herpes: Transmission Rates
by Stage of Maternal Infection
 Primary (acquired during 3rd trimester):
up to 50%
 Recurrent (at time of delivery): up to 4%
 Asymptomatic shedding (at delivery): <
0.004%
 Most transmission due to asymptomatic
shedding

107. Herpes Diagnostic Tests
 Culture
 Antigen detection methods
Direct Fluorescent Antibody (DFA)
Indirect Fluorescent Antibody (IFA)
Enzyme Immunoassay (EIA)
 Serology
 Hybrid capture DNA test (under development)
 PCR (not FDA approved for clinical use)
 Tzank smear (not recommended)

108. Herpes Diagnosis
Culture
 Highly specific; sensitivity depends on stage of
lesions and proper collection technique
 50% overall
 Collect specimen by rubbing swab at base of moist
lesion; place into transport medium
 Highest in primary and fresh lesions, lower in
recurrent or older lesions
 Viral typing can be done on positive
specimens
 Lab turn-around time: 5-7 days

109. Herpes Diagnosis
Serologic Tests
 Older serologic tests (CF, EIA) did not
distinguish HSV-1 from HSV-2 antibody
 Newer serologic tests accurately distinguish
type-specific glycoproteins gG1 and gG2
 Sensitivities vary
 80-98%
 False-negatives more common early after
infection (up to three months)
 Specificities  96%
 Cost may be a limiting factor

110. Herpes Diagnosis
Type-Specific Serology Tests
 Meridian Premier HSV-1 or HSV-2 gG
ELISA
 Focus Technologies, Inc.
HSV-1 or HSV-2 gG ELISA
HSV-1 and HSV-2 Differentiation
Immunoblot
 Diagnology POCkit HSV-2
 Western Blot (limited availability)

111. HSV Serology Testing
Potential Uses, Diagnostic
Testing
 Confirm diagnosis
 Recurrent undiagnosed GUD
 Atypical presentations (e.g. urinary
symptoms)
Note: positive test does not necessarily correlate
with symptoms
 Can help differentiate between
Primary & non-primary infections
Newly-acquired and older infections

112. HSV Serology Testing
Potential Uses, Screening
 Not currently recommended for routine
screening
 May be useful in certain at-risk
populations and individuals
Patients with other STDs
HIV infected persons
Contacts to HSV
Certain prenatal patients

113. HSV Serology Testing
Potential Uses, Prenatal
 May be useful when
Patient has unconfirmed history of genital
herpes
Partner is known to have genital or oral
herpes
 Usefulness is less clear for general
screening
 No current recommendations for
screening from CDC, ACOG

114. HSV Serology Testing
Benefits and Limitations of
Screening
 May be useful to patients for informing
partners
 May be helpful for pregnant couples or for
planning pregnancy
 Cost-benefit analyses have not been
performed comparing costs of test vs. savings
resulting from preventing further cases
 Does not tell
 How long infected
 If person has had or will have symptoms
 How likely a person is to shed asymptomatically

115. Genital Herpes
Principles of Treatment
 Treatment in first clinical episodes is
recommended
 Episodic antiviral therapy during
recurrent episodes may shorten the
duration of lesions (patient should self-
start treatment)
 Suppressive antiviral therapy can
ameliorate recurrent episodes

116. Antiviral Medications for
Uncomplicated HSV
 Acyclovir (Zovirax™, generics)
 Valacyclovir (Valtrex™)
 Famciclovir (Famvir™)
 Penciclovir (Denivir™, for treatment of
herpes labialis only)

117. Genital Herpes
What’s New in Treatment?
 Valacyclovir 500 mg orally twice a day
for three days was as effective as five
days
 Similar studies have not been done with
acyclovir or famciclovir

118. Treatment of Genital Herpes
When to Use Suppression
 Suppression decreases frequency and
severity of recurrences by 75%
 Consider suppressive therapy for:
Six or more outbreaks a year
Severe or complicated disease
Patients with poor psychological
adjustment to diagnosis
 Discontinue after 1 year to reassess
need

119. Genital Herpes
Treatment in Pregnancy
 Safety of acyclovir & valacyclovir in
pregnant women has not been
established
 First clinical episode may be treated
with oral acyclovir
 In life-threatening maternal HSV
infections, IV acyclovir is indicated

120. Genital Herpes
Psychological Impact
 A diagnosis of herpes can cause
significant psychological distress
Depression
Anger
Fear of rejection/discord in relationship
Fear of passing infection to sex partners or
infants
Frustration regarding lack of a cure
Uncertainty about asymptomatic shedding

121. Genital Herpes
Counseling and Prevention
 Topics to discuss:
Natural history of the disease, including
potential for:
 Recurrences
 Sexual transmission
Sex partners may benefit from evaluation &
counseling
Risk of neonatal infection with both male
and female patients
Benefits of treatment

122. Genital Herpes
Counseling about Transmission
 Encourage patients to inform their sex
partners of the herpes diagnosis
 Advise patients to abstain from sexual
activity when lesions are present
 Discuss possibility of asymptomatic
shedding
 Encourage condom use with new or
uninfected partners

123. Perinatal Herpes Infection
Prevention
 Emphasize preventing acquisition of genital
HSV during late pregnancy
 Counsel susceptible pregnant women whose
partners have oral or genital HSV to avoid
unprotected genital & oral sexual contact in late
pregnancy
 Examine women in labor for genital herpes
 Abdominal delivery is recommended with
prodrome or active lesions at onset of labor
 Suppressive therapy near term to reduce
number of C-sections in women with
recurrent herpes is under investigation

124. Genital Herpes
Condom Effectiveness
Latex condoms, when used consistently
and correctly, are highly effective for:
HIV
And can reduce the risk of:
GC, CT, and Trichomonas
Genital herpes, syphilis, chancroid, and
HPV, only when the infected areas are
covered by the condom
CDC, 2002

125. Genital Herpes
Vaccine Development
 SmithKline Beecham Biologicals
Two multicenter, double-blind, randomized
placebo-controlled trials
Participants had no history of genital herpes and a
regular sex partner with HSV-2
73% reduction in symptomatic cases in women
who were also HSV-1 negative
Protects against symptoms of genital herpes,
although not against acquisition of HSV-2 virus
No protective effect found in men

126. What’s New with HPV?
 New Pap methodologies
 New HPV tests
 Anal cancer screening

127. > 80 HPV Types
Dermal HPVs
nonsexual contact
(>50 types)
“Common”
Warts
(e.g., hands/feet)
Genital HPVs
sexual contact
(>30 types)
“High-risk”
types
“Low-risk”
types
• low grade cervical
abnormalities
• cancer precursors
• genital cancers
• low grade cervical
abnormalities
• genital warts
• respiratory papillomatosis
6,11,42,43,44
16,18,
31,33,35,39,
45,51,52,56,58

128. What happens once people get
infected with HPV?
 For most people, nothing will happen
 The body’s immune system usually eliminates
HPV infection
 After HPV is found on the cervix, it becomes
undetectable within 2 years in at least 90% of
women
 Some people who get “low-risk” types will
develop:
 Visible genital warts
 Low-grade Pap smear abnormalities that can
go away on their own

129. What happens once people get
infected with HPV?
 Some women who get “high-risk” types
will develop:
 Low or high grade Pap smear abnormalities
 Cervical cancer (rarely)
 Persistent infection with high-risk HPV
types is associated with the development
of pre-cancerous and cancerous cervical
changes
 The course of penile infection in men has
not been well studied

130. Thin-Layer Pap Preparations
 Change in Pap specimen collection and lab
specimen preparation
 Can be read conventionally by cytologist or,
with some systems, by an automated method
(AutoCyte SCREEN)
 Two tests available
 TriPath PREP system (TriPath,Inc.Burlington, NC)
 Thin Prep Pap Test (Cytyc Corp., Boxborough,MA)

131. Thin-Layer Paps vs
Conventional Paps
 Generally compare favorably
Simple collection procedure for the
clinician
Increased sensitivity
Fewer unsatisfactory/inadequate
results
Greater standardization
More expensive

132. ThinPrep Pap Specimen Collection
Tighten Vial
Obtain
Broom
Spatula
Brush
Rinse
Immediately &
Vigorously
OR
&

133. Conventional Pap ThinPrep Pap Test
Overcoming the Limitations of the
Conventional Pap Smear
 Majority of cells not
captured
 Non-representative
transfer of cells
 Clumping and
overlapping of cells
 Obscuring material
 Virtually all of sample is
collected
 Representative transfer
of cells
 Even distribution of
cells

134. HPV DNA Tests
 Hybrid Capture Test (Digene) detects high-
risk HPV by typing nucleic acids
 Results are reported as positive or
negative for high-risk viral types
(16,18,31,33,35 etc)
 Can be performed on same specimen
collected for thin-layer Pap

135. Hybrid Capture II HPV DNA Test
Hybrid Capture HPV DNA Test uses
RNA probe cocktails to the most
common cancer-associated HPV types:
16, 18,
31, 33, 35, 39, 45,
51, 52, 56, 58, 59, & 68

136. HPV DNA Tests: Possible
Uses
 NOT recommended for screening
 NOT recommended for diagnostic
purposes with external genital warts
 May be useful in management of
ASCUS paps

137. Utility of HPV Testing
 Utility of HPV testing for triage of
ASCUS Paps confirmed in ALTS Trial
ALTS Group. JNCI 2000; 92: 397-402
Solomon et al. JNCI 2001; 93:293-299
 HPV testing NOT helpful for LSIL
because of the high percentage of HPV
positive

138. ASCUS Paps: Proposed Algorithm
Routine Pap smear,
including specimen
collection for HPV
ASCUS
Conduct HPV test on
stored specimen
SIL
Normal
Routine Pap
schedule
Usual follow-up
and treatment
Repeat Pap 6 - 12 mo Colposcopy
HPV (+)
HPV (-)

139. HPV, Anal Ca and MSM
 High prevalence of anal HPV infection
 Incidence of anal carcinoma
35/100,000 MSM
 Anal cancer 30-80 x higher in AIDS
patients
 Small studies and models demonstrate
that routine anal Pap screening may
be cost-effective
Goldie et al. JAMA 1999; 281: 1822-1829

140. HPV Disease Management of
HIV Infected MSM
 No current recommendations:
Uncertain natural history of anal LSIL
Sampling and laboratory
uncertainties
Effectiveness and complications of
ablative therapy not well researched
Effect of HAART unclear
Prevention of Genital HPV Infection and Sequelae:
Report of an External Consultants’ Meeting.
DHHS, Atlanta: CDC, December 1999

141. What’s New with Vaginitis?
 Bacterial Vaginosis
New diagnostic tests
Treatment regimens
Screening in pregnancy
Management of recurrent disease
 Trichomoniasis
New diagnostic test
Management of resistant infection

142. Abnormal Flora in
Bacterial Vaginosis (BV)
 Anaerobes:
 Mobiluncus
 Bacteroides spp.
 Prevotella spp.
 Aerobic GNRs: Gardnerella vaginalis
 Mollicutes: Mycoplasma hominis
 Haemophilus
 peptostreptococci

143. Microbial Shifts in BV
G vaginalis
Anaerobes
Mycoplasmas
Lactobacillus
10
11
10
4
Bacteria
100-1000 x increase in pathogenic bacteria

144. Bacterial Vaginosis (BV)
 Foul, “fishy” odor
 Increased or changes in vaginal
discharge
 Vulvar itching and/or irritation
 Symptoms worse after intercourse
and during menses
 50% may be asymptomatic
NOT an STD, but may be sexually
associated

145. BV: Complications in Pregnancy
 Preterm delivery and low birth
weight
 Premature rupture of membranes
 Chorioamnionitis
 Post-partum endometritis
 1st trimester miscarriage in IVF
patients

146. BV: Diagnostic Criteria
Amsel Criteria (3 of the following 4):
 Homogeneous white noninflammatory
discharge that adheres to the vaginal
walls
 Vaginal pH > 4.5
 Positive “whiff” test
 > 20% Clue cells on saline wet mount
>90% sensitive

147. BV: Screening in Pregnancy
 USPSTF Recommendations
 Asymptomatic pregnant women with a history
of preterm delivery
 Screen at the beginning of the 2nd trimester
 May need repeat screen in 3rd trimester
 2002 CDC Guidelines
 No firm recommendation
 “Some specialists recommend” screening
and treatment of women with a history of a
premature birth.
 Screen at the first prenatal visit.

148. BV: Treatment
Non-Pregnant Women
Recommended regimens:
Metronidazole 500 mg PO BID x 7 d
Clindamycin cream* 2% 5 g per vagina QHS x 7 d
Metronidazole gel 0.75% 5 g per vagina BID x 5 d
Alternative regimens:
Metronidazole 2 g PO x 1
Clindamycin 300 mg PO BID x 7 d
*oil-based cream, may weaken condoms
and diaphragm

149. BV: Treatment in Pregnancy
Recommended regimen:
 Metronidazole 250 mg PO TID x 7 days
Alternative regimens:
 Metronidazole 2 g PO x 1
 Clindamycin 300 mg PO BID x 7 days

150. BV: Recurrent Infection
 Recurrent BV is common
 25% within 4-6 weeks after treatment
 Up to 85% will have recurrence within one year.
 Happens equally often after vaginal or oral therapy, and
after metronidazole or clindamycin
 No improvement in recurrence rates after treatment of
male partners
 Possible management strategies
 Oral or vaginal metronidazole intermittently (MetroGel 1
or 2x/wk)
 Vaginal acidifiers (? effectiveness)
 Condoms to reduce semen exposure

151. BV: Patient Counseling
 Estimated 50 - 70% recurrence rate,
15% in 1 mo, 30% in 3 mo, 80% in 7 mo
 Avoid douching or intravaginal soaps
 Treating male partners does not
decrease risk of recurrence
 Over-the-counter lactobacillus and
vaginal acidifying preparations of
unproven effectiveness

152. McCall's Magazine, July 1928

153. Trichomoniasis
 Etiologic agent: Trichomonas vaginalis,
flagellated anaerobic protozoa
 May infect ectocervix, vagina, urethra or
bladder
 In women, causes malodorous yellow-
grey discharge with irritation and vulvar
itching
 In men, causes urethritis
 Often asymptomatic ( 50%)

154. Trichomoniasis: Diagnosis
 Thin frothy grey/yellow vaginal discharge
 May see punctate cervical hemorrhages
(strawberry cervix) 5 -10%
 Motile trichomonads on saline wet mount
(sensitivity may be as low as 60%)
 pH > 4.5
 Whiff test may be positive
 Culture available (InPouch TV Test)

155. Culture System for T.
vaginalis
 In-Pouch TV System( Biomed
Diagnostics-1-800-964-6466)
 Dual lumen culture pouch
 Inoculate with patient specimen (vaginal
fluid or spun urine sediment)
 Incubate as directed and read in pouch
or as wet mount at 3 and 5 days

156. Trichomoniasis
Treatment During Pregnancy
Recommended regimen:
 Metronidazole 2 g orally in a
single dose

157. Drug Resistance in
Trichomoniasis
 High-level resistance to metronidazole
is well-documented, but uncommon
 Most resistance is lower-level and can
be overcome with higher doses of
metronidazole

158. Evaluation of Possible Resistant
Trichomoniasis
 Re-confirm infection by wet mount
 Consider re-infection from untreated
partner or new partner
 Retreat with:
 Metronidazole 500 mg PO BID x 7 days
 In repeated failure occurs, treat with:
 Metronidazole 2 g PO QD x 3-5 days
 Obtain isolate and send to CDC for
resistance testing and treatment consult

159. Treatment Alternatives
Resistant Trichomoniasis
 Higher dose, longer course metronidazole
 Tinidazole or other oral “azole” drugs
 Paramomycin vaginal suppositories
250 mg intravaginally x 7-14 days together with
PO metronidazole

160. Trichomoniasis
Role in Urethritis
 Well-documented as an uncommon cause of
NGU
 Most men with T. vaginalis infection are
asymptomatic
 Recent study showed T. vaginalis as
causative organism in 50% of NGU in men >
age 40
 Diagnosis: perform wet mount of urethral
discharge or spun urine sediment