Latest STD data in United States continues to portend problems with prevention, HIV
Other research notes high STDs among HIV-infected women
The national picture on sexually-transmitted diseases (STDs) shows a positive trend of a decline in new infections of gonorrhea, while the rates of syphilis infections is increasing among men who have sex with men (MSM), and chlamydia remains a major health threat, especially to young women.
Although gonorrhea rates have dropped overall, some surveillance data suggest increasing rates among MSM.
For four years running, from 2000 to 2004, the rate of primary and secondary syphilis in the U.S. has increased, with an 8 percent jump between 2003 and 2004, according to the most recent statistics from the CDC of Atlanta, GA. (See chart on STDs, p. 136).
The syphilis rate among women remained stable, while the rate among men rose 11.9 percent between 2003 and 2004, totaling an 81 percent increase between 2000 and 2004.1
Syphilis increases reflect the rising number of cases among men who have sex with men (MSM), including all racial and ethnic groups, says John Douglas, MD, director of the CDC’s division of STD prevention.
"Men who have sex with men accounted for 64 percent of all cases in 2004," Douglas says.
The syphilis rates for women decreased 55 percent from 1999 to 2004, although the rates reached a plateau in 2003 and remained steady in 2004, Douglas says.
"We have good and sound information showing that since the late 1990s, we have seen increases in high-risk behaviors among sexually-active MSM," says Ronald Valdiserri, MD, MPH, acting director for the CDC’s National Center for HIV, STD, and TB Prevention. Valdiserri and Douglas announced the new STD data at a teleconference on Nov. 8.
"Since the outbreaks of syphilis were observed among MSM, there has been ongoing concern about whether or not that would translate into increased HIV incidence," Valdiserri says.
According to the CDC’s latest available data, there are increases in HIV diagnoses in states that provide for HIV diagnoses and, while this isn’t direct evidence of an increase in HIV incidence, it is suggestive of a negative trend, Valdiserri says.
"We know that syphilis diagnoses are increasing among that group, and we remain concerned that that might reflect an increase in HIV incidence," Valdiserri says.
"We do have good evidence that men are engaging in higher risk behaviors, and we do know that in several communities—first on the West coast and more recently on the East coast—epidemics of methamphetamine use among MSM are intersecting and exacerbating transmission of syphilis," Valdiserri says.
Two behavioral factors complicate any direct comparisons to rises in HIV rates and rises in syphilis rates among MSM, Valdiserri notes.
To the extent that HIV positive MSM select partners with the same HIV status and engage in unsafe sex, and some studies have suggested this behavioral trend, this could contribute to the spread of syphilis, but not increase transmission of HIV, he says.
"The other dimension of that is we’ve learned through some of our epidemiological investigations that some of these men are engaging in oral sex, recognizing that it is a much less risky mode of sex in terms of transmitting HIV and not realizing that it’s a highly effective way that syphilis can be transmitted," Valdiserri says.
Sexual risk behaviors also appear to be a problem with other at-risk groups.
A new study found high rates of STDs among urban, minority women infected with HIV.
Specifically, the research conducted in Newark, NJ, which has among the highest HIV prevalence rate in the nation, found that 34 percent of the HIV-positive women studied had at least one STD, with the most common being Herpes (22 percent), human papilloma virus (14 percent), and syphilis (6 percent).2
"These are not women who found out yesterday they had HIV," says Sally L. Hodder, MD, director of HIV programs in the department of medicine at the New Jersey Medical School, University of Medicine and Dentistry of New Jersey in Newark.
The women included in the study were mostly African American with a mean age of 42.7 years, and they had a mean duration of 8.3 years of knowing their HIV status.1
"About 41 percent of the women reported current sexual activity," Hodder notes.
The study demonstrates a high prevalence of STDs in this population, and it raises the question of what should be done, Hodder says.
"We need to ask ourselves, Do we really have very effective prevention strategies and education, particularly in this population?’" Hodder says.
"I think behavioral interventions have not always been the panacea that we would like them to be," Hodder says. "I think we really need to be very creative talking to folks and perhaps looking at strategies that are effective."
Also, this urban, poor, and minority population of HIV-infected women had enormous challenges, Hodder says.
"We really need to look at risk behaviors in that group and find something that works for this group, but which may not work for all groups," Hodder says.
The Newark study highlights some of the same concerns found in the CDC’s recent STD report.
"I think what this says is STDs really signify risky behaviors, and I think we need to have an aggressive prevention agenda to prevent STDs and also the transmission of HIV," Hodder says.
Even the good news in the CDC’s STD report was provided with caution.
Although reported cases of gonorrhea at 113.5 per 100,000 population fell to the lowest levels since 1941, when reporting began, this STD largely is under diagnosed and under reported, according to the CDC report.1
Also, there is some evidence that gonorrhea rates are increasing among MSM.
"We do think the gonorrhea rates are likely to be going up among men who have sex with men, although there’s so much more gonorrhea nationally than there is syphilis now that we haven’t been able to tease that blip out in the national number of cases reported," Douglas says.
A gonorrhea susceptibility project involving 28 STD clinics across the country has pulled data about sexual behavior of participants, and this indicates an increase in gonorrhea among MSM, Douglas adds.
"The proportion of men involved in that study who acknowledge same sex activity has grown dramatically," Douglas says. "We’re talking upwards of 23, 24 percent at this point, whereas in the late 90s we were back in the single digit figures."
The same data indicate a growing number of fluoroquinolone-resistant gonorrhea cases—now at 6.8 percent—and this is a growing problem, Douglas says.
The CDC reports a 23.8 percent drug resistance rate among MSM, which is of particular concern, Douglas says.
Chlamydia continues to be the most widespread and largely under diagnosed of STDs, despite improved screening and testing, CDC officials say.
While the number of reported cases rose between 2003 and 2004, this likely was due to an expansion of screening efforts, Douglas says.
Young women are the hardest hit by the disease, with the greatest number of cases reported in the 15-24 age group of women.3
Of the total 929,462 cases, 539,785 or 58 percent are women in the 15-24 age group.3
Chlamydia cases and rates have risen steadily for young women in the past five years, and this includes African American, Hispanic, and white women.3
Although the increased cases may be attributed to better testing, they do show that there have been no positive trends of decreases in the chlamydia infection rate, Douglas says.
"We think the response to that needs to be multiple: it will include a larger proportion of the women in those age groups being tested and a better job of preventing them from getting re-infected, which is largely a better job of treating their sexual partners," Douglas says. "And once we have done a good job of covering the female population, we believe there will be incremental value in screening, testing, and treating young men as well."
References
- Trends in Reportable Sexually Transmitted Diseases in the United States, 2004; National Surveillance Data for Chlamydia, Gonorrhea, and Syphilis. Centers for Disease Control and Prevention. Nov. 2004.
- Reilly E, et al. Sexually Transmitted Disease in an Urban Population of HIV Infected Women. Presented at the 43rd Annual Meeting of IDSA, Oct. 6-9, 2004, in San Francisco, CA. Abstract: 855.
- Sexually Transmitted Disease Surveillance 2004. Centers for Disease Control and Prevention. Sept. 2004;1-184.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content