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VOL. 6 • NO. 9

SEXUALLY TRANSMITTED DISEASES

Early detection still key to beating the odds

Merilin Castillo, 18, has the next phase of her life pretty much set. She plans to enter Harvard College in the fall to study U.S. history and social science. At the moment other matters hold her interest — sex. But not the way it sounds. Actually, it’s sex education. Castillo realized that, while she had access to accurate sex information at Milton Academy, many of her peers in the Boston Public Schools (BPS), were not so privileged. “That’s a health equity issue,” she said. “Not only is it not

OK, it’s not fair.” What’s worse, the incidence of teenage pregnancies and STDs is much higher among teens of color, which make up the majority of high school students in the BPS. “They [the statistics] are about our community,” she explained. “We are the target people.” In its most current analysis the Centers for Disease Control and Prevention (CDC) finds that more than 19 million new cases of STDs are diagnosed every year in the United States. The CDC

estimates that these infections cost the U.S. health care system $17 billion every year. The impact of STDs is measured in more than just dollars. Untreated infections can result in sterilization in both females and males. Syphilis can lead to neurologic and cardiovascular problems. HIV, the virus that causes AIDS, and the human papillomavirus (HPV), which causes cervical cancer, can be deadly. Pregnant women often pass STDs on to their babies before, during or even after birth, depending on the particular infection. Though all 50 states mandate reporting of several STDs, providers can report only what they identify. Many infections are silent and go undetected and untreated. In addition, the CDC estimates that only 38 percent of sexually active females aged 25 and younger get screened yearly for chlamydia as suggested, further reducing the accuracy rate of reporting. Cases of chlamydia are steadily increasing nationwide. When in 2011 the rate of infection in Massachusetts escalated significantly, the Commonwealth, like several other states, invoked the Expedited Partner Therapy (EPT) rule. EPT allows certain health providers to offer prescriptions or medications for each sexual partner of infected patients. The rule allows partners to receive treatment without first seeing a provider. African Americans are hit hard by STDs. Though blacks constitute 14 percent of the U.S. population, they account for more than one third of all reported chlamydia cases, almost half of all cases of syphilis and almost three-fourths of the reported gonorrhea cases. Many reasons for this disparity are offered, including lack of insurance or access to health care. More probable is the lack of awareness and understanding of the prevalence of STDs and their long-term consequences. Dr. Alexy D. Arauz Boudreau is a pediatrician at MGH Chelsea, a community health center affiliated with Massachusetts General Hospital. She sees more than her fair share of patients with STDs in her practice. “It’s a very large issue,” she explained. “More attention should be focused on them.” Boudreau stated that she actually goes beyond the recommended STD screening guidelines of the CDC. Typically she tests teens every six months and screens regardless of gender. Fortunately, testing has become simplified and painless, Castillo, continued to page 4

NEVER TOO OLD TO LEARN — OR BE TESTED STDs are not just for kids anymore. At least that’s what people aged 45 and older are now learning. It could be because people are living longer or maybe it’s the baby boomers that just refuse to admit to advancing age. In all probability, the biggest culprit is ignorance. Regardless of the reason, older adults — even those well into their 70s and 80s — are engaging in sex. And, according to a survey by AARP, a non-profit organization for people 50 and older, it’s not just once in a blue moon, particularly for older singles. Chlamydia, once considered the bane of females 25 and younger, is increasing in people 45 to 64, according to a recent surveillance report by the Centers for Disease Control and Prevention (CDC). Between 2006 and 2010, the rate in that age group escalated more than 33 percent. And that “little blue pill” is causing its share of problems. Dr. Anupam B. Jena, an internist at Massachusetts General Hospital, examined the rates of STDs in men who use erectile dysfunction (ED) drugs and those who

don’t. Jena and his fellow researchers found that all STDs — particularly HIV and chlamydia — are higher in users versus nonusers of ED drugs. The study also found that the rate of STDs was higher in users both before and after the prescription. In an interview, Jena cautioned that “anyone who does not practice safe sex, no matter their age, can contract an STD.” And that’s part of the problem. Older adults associate condoms with protection against pregnancy and that STDs are the purview of the young and inexperienced. But a national divorce rate hovering around 40 percent propels newly designated — and ill prepared — singles into the dating scene. In its study on sex, Indiana University determined that the percentage of condom users drops with age and that only 10 percent of women between the age of 45 and 60 use them as protection. No state is more familiar with this problem than STDs, continued to page 4

Many people have chlamydia … and don’t even know it. Sexually active females aged 25 and younger should get tested every year.

STDs: Knowledge is the best defense Every year, an estimated 19 million people find they have sexually transmitted diseases (STDs). The bad news isn’t distributed equally. Nearly half are ages 15 to 24. Reported rates of chlamydia and syphilis were roughly nine times higher among African Americans than among whites, and gonorrhea more than 20 times higher, according to 2009 figures from the Centers for Disease Control and Prevention. That year, 44 percent of new HIV cases occurred among African Americans. Learning about STDs and safer sex practices can help you defend yourself and your family from these serious health problems. Start below, then find out more by talking to your doctor.

What are some common

STDs?

Chlamydia The most common sexually transmitted bacterial infection causes few or no symptoms, although it may prompt a burning sensation during urination or abnormal genital discharge. Because it’s so often “silent,” chlamydia can go untreated for a long time. That can be very harmful, especially in women, who may develop pelvic inflammatory disease (PID), tubal or ectopic pregnancy or infertility. Antibiotics can cure chlamydia.

Genital herpes Two herpes simplex viruses (HSV) cause genital herpes. Signs of herpes include one or more blisters on or around the genitals and rectum. The blisters break, forming painful, open sores. While these heal in two to four weeks, the virus remains in the body, sparking recurrent outbreaks that may start with tingling or burning in legs, buttocks or genital area. Even without symptoms, a person can spread herpes. No cure is available, but antiviral drugs can help shorten and prevent outbreaks.

Gonorrhea Burning during urination and abnormal genital discharge are signs of gonorrhea. Untreated, this STD may cause PID, tubal or ectopic pregnancy or infertility in women. Usually, antibiotics can cure gonorrhea.

HIV (human immunodeficiency virus) If you have an STD, you’re more likely to get — and spread — HIV, the virus that causes AIDS. HIV attacks the immune system, making people vulnerable to numerous lifethreatening diseases. HIV can spread through sexual activity, blood and even breast milk. While no cure is available, antiviral drugs and other medications can slow its progress and help prevent it from spreading.

HPV (human papillomavirus) Many strains of HPV exist. Some cause genital warts inside or outside the vagina or penis, which may spread to surrounding skin. Women with certain types of HPV are at higher risk for cervical cancer. More rarely, some strains of HPV are involved in cancers of the penis, anus or the back of the throat. A vaccine can reduce risk for getting certain strains of HPV. Although genital warts can be treated, the virus remains in the body and can recur.

Syphilis A painless sore on or around the vagina, penis or mouth that lasts three to six week is the first sign. A temporary rash may appear next. If not caught in early stages, syphilis can seriously harm

the heart, brain and nervous system. Antibiotics can cure syphilis. Other illnesses that can spread sexually include hepatitis B, pubic lice, vaginal yeast infections, trichomoniasis and scabies.

How can you tell if you have an STD? Unfortunately, many STDs initially cause fairly mild or no symptoms. Sometimes symptoms wax and wane. That’s common with herpes sores, for example. Call your doctor for advice if you think you might have been exposed to an STD or notice any of these warning signs: • A sore, blister, rash, warts, unusual discharge, swelling, redness, pain or other problems on or around the genitals or anus • A sore in the mouth or rectum • Burning sensation or pain when urinating • Pelvic pain • Vaginal bleeding between periods • Long-lasting, unexplained flu-like symptoms or swollen lymph nodes Untreated STDs can have devastating long-term health effects. When caught early, though, many STDs can be treated successfully.

How can you avoid getting an STD? Whenever body fluids like sperm, vaginal secretions or saliva are exchanged, lurking STD viruses or bacteria may find a new host. Some STDs are carried in blood. For example, HIV also spreads when an infected person shares needles for injecting drugs, piercings or tattoos. That’s one reason it’s essential to use only sterile needles for such purposes. Often, you can’t tell who has an STD. Abstaining from most kinds of sexual activity is the only sure way to avoid STDs. Even kissing can spread herpes and some other infections just as it transmits cold germs. And certainly, vaginal, anal and oral sex can do so, too.

If you’re sexually active, adopting these safer sex practices helps lower your risk of getting an STD: • Enjoy a mutually monogamous relationship in which neither you nor your partner has an STD. • Before starting a new sexual relationship, talk openly about past partners, STDs and drug and needle use. • Correctly use a latex or polyurethane condom every time you have intercourse (natural membrane condoms could let certain infections slip through). • If you have oral sex, use a dental dam or latex condom. • Pay attention to warning flags like sores, blisters, rashes, or abnormal discharge. Cold sores on the mouth or lips, for example, are a form of the herpes virus that can spread to a partner’s genitals during oral sex. • Don’t douche after intercourse. This can spread infection further into a woman’s reproductive tract. • Avoid intercourse when a woman has her period. • Choose sexual activities that allow you to avoid contact with body fluids or mucous membranes in the body, such as the mouth, vagina or anus. • Talk honestly to your doctor about drug and needle use, sexual partners and sexual activities. If you’re sexually active, ask how often to have exams for STDs. If you’re female, ask how often to have pelvic exams and Pap tests to check for cervical cancer.

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Questions & Answers 1. Why is chlamydia more frequent in females? Chlamydia is more frequently diagnosed in women in part due to greater reporting in females than males. Women are more frequently screened for chlamydia in the absence of symptoms during routine physicals. Men, on the other hand, are often treated for chlamydia based on clinical symptoms or contact with a woman with a chlamydia infection.

Generally, sexually transmitted diseases that are caused by bacteria or parasites are easy to treat. Often one dose or injection of antibiotics can do the trick. Viruses, on the other hand, are not curable, but can be treated. Below are some of the more common STDs and their potential treatment outcomes.

BACTERIA Chlamydia Curable with antibiotics Richelle C. Charles, M.D. Instructor Division of Infectious Diseases Massachusetts General Hospital

2. Why does the incidence of chlamydia decrease with age? Adolescents and young adults are at the highest risk of chlamydial infection. It is unclear why chlamydia infection decreases with age, but it is believed to be related to changes in behavior as well as the development of partial immunity through repeated exposure.

Gonorrhea Curable with antibiotics

Syphilis Curable with antibiotics, but will not repair damage already caused

VIRUSES Hepatitis B Not curable, but a vaccination is available

Genital Herpes 3. How do sexually transmitted diseases (STDs) affect pregnant women? STDs during pregnancy carry the added risk of potentially transmitting the infection to the fetus, and can lead to a number of adverse effects on the fetus including fetal death, premature delivery, low birth weight, congenital anomalies and a number of other complications. 4. Are STDs curable? STDs caused by several viruses (herpes, HIV, HPV and hepatitis) can be treated, but there is no cure. STDs caused by bacteria, such as chlamydia, gonorrhea and syphilis, can be cured with antibiotics. The antibiotic for chlamydia comes in pill form and can be given as a single dose or might involve taking the medicine for an entire week. The antibiotic for gonorrhea is usually given as a single shot. The antibiotic for syphilis is usually given as a single shot or as multiple shots over several weeks.

Not curable, but treatment can reduce symptoms

HIV Not curable, but can be treated with a combination of medicines to strengthen the immune system

HPV Not curable, but conditions it causes are treatable; vaccination can reduce its incidence

PARASITES Pubic lice Curable with over-the-counter lotions that contain the chemical permethrin

Trichomoniasis Curable with antibiotics

5. Is it possible to contract an STD from a source other than sexual contact or sharing infected drug paraphernalia? STDs are transmitted through blood, semen or other bodily secretions. However, STDs such as herpes, genital warts, and syphilis can also be transmitted through skin-to-skin contact. Contrary to common myths, it is not possible to acquire STDs on a toilet seat. Many disease-causing organisms can survive for only a short time on external surfaces. 6. What is the definition of high-risk sexual behavior? High risk sexual behavior includes the following: genital-to-genital intercourse without a male or female condom except in a long-term, singlepartner (monogamous) relationship; unprotected mouth-to-genital contact except in a long-term monogamous relationship; multiple sex partners; anal sex except in a monogamous relationship; exchange of sex for drugs or money; or sex with a partner who injects or has ever injected drugs, has multiple partners, or has anal sex. 7. Why is the incidence of STDs higher in African Americans and Hispanics? There are a number of factors that contribute to the higher incidence of STDs among African Americans and Hispanics. This includes financial barriers which limit access to quality health information and STD prevention services. Also, since STD prevalence is higher in African American and Hispanic communities, individuals in these communities have a higher risk of infection with each sexual encounter. 8. What is the link between STDs and HIV? STDs increase the risk for HIV infection and transmission.

An escalating problem Rate per 100,000

1500

1383 In 2010, the reported rate of new cases of chlamydia was nine times greater in blacks than in whites.

1200 900 600

467.9

300 0

156.1 Black

Hispanic

White

RACE Source: Centers for Disease Control and Prevention

The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.

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Castillo, continued from page 1

especially for chlamydia and gonorrhea. A few drops of urine are enough to make a diagnosis. More important, Boudreau counsels her patients about safe sex. The main message is on prevention — even before sex begins. What she tries to guard against is impulsiveness. “Think about it before you act,” she advises. “Prepare in advance. Have a conversation with your partner, so they’re more informed.” Castillo is doing more than her part in spreading the message. She and a group of her cohorts from Hyde Square Task Force and Southern Jamaica Plain Health Center decided to get the word out to teens in a way they could best understand. They made a video called “Sex in School: Does Ignorance Keep us Safe?” which premiered at the Connolly Library in Jamaica Plain.

Merilin Castillo (right) is pictured with Abigail Ortiz at the premier of the film “Sex in School: Does Ignorance Keep us Safe?” Students from the Hyde Square Task Force produced the film. (Lightchaser Photography)

In one scene, a young couple realizes they have the house to themselves and their thoughts turn to more amorous activities. A knock on the door disrupts their plans. The intruder is “Chlamydia” who warns the couple of the dangers of engaging in sex without the use of condoms. Castillo laughed as she explained that the group decided not to make chlamydia — one of the most common STDs among females under the age of 26 — less abstract. “We wanted her to be more ‘in your face,’ ” she explained. Like most teens, Castillo admitted she did not ask her parents about STDs. “I was too embarrassed,” she said. And that’s the problem. Young people often do not have enough information about STDs to

make informed decisions about sexual behavior. Since adolescents are the typical victim of many STDs, and may lack awareness of the extent of the problem, schools are potentially a good source of information. According to the Guttmacher Institute, a nonprofit organization that focuses on sexual and reproductive health, provision of sex education is inconsistent across the country. Only 21 states and the District of Columbia mandate sex education, while 12 additional states require HIV education only. Twenty-six states require that abstinence be stressed. Yet, high school students should be targeted early. The 2009 Youth Risk Behavioral Surveillance found that nationwide, almost half of high school students reported that they have already had sexual intercourse, and the percentage increases with the grade. By the time the students reached their senior year, more than 62 percent had been sexually active. The report indicated that almost 6 percent of students had sexual intercourse for the first time before the age of 13. Most disconcerting about sexual behavior in teens is that almost half admitted that they had not used a condom during their last sexual intercourse and 22 percent had drunk alcohol or used drugs before their last encounter — all examples of risky behavior that can lead to STDs. Despite their prevalence, many STDs are not only treatable, they are curable. Infections that are caused by bacteria — chlamydia, gonorrhea and syphilis, to name a few — are easily cured with antibiotics. A vaccination is available that protects against the majority of cases of cervical cancer and genital warts. Of course the fool-proof method is total abstinence. Fool-proof — yes — but not practical for many. Fortunately, it is not necessary to live a celibate life to remain STD-free. Latex condoms, if used consistently and correctly, can prevent most STDs. Some infections, such as HPV, however, can be transmitted through skinto-skin contact. In addition, regular screening for STDs is key. The CDC recommends that sexually active women 25 and under as well as older women with new or multiple partners be screened every year for chlamydia. Yearly tests for gonorrhea are advised for women with new or multiple partners. Pregnant women and men who have sex

Alexy D. Arauz Boudreau M.D., M.P.H. Associate Director Multicultural Affairs Office Massachusetts General Hospital

with men (MSM) should be screened for syphilis, HIV, chlamydia, hepatitis B and gonorrhea. MSM who have multiple or anonymous partners should be screened more frequently. CDC further recommends that all adults

and adolescents be tested for HIV. Those at high risk, such as injection drug users or persons who exchange sex for money or drugs, should be screened for HIV at least annually. Boudreau laments that most teens find out about STDs from friends and she advises parents that talking about sex is not a license to participate. It’s only to let them know and understand. And that’s what Castillo and her group of zealots wanted — knowledge. The group packed City Hall last year to pressure the BPS to offer comprehensive sex education that includes information on STDs and unwanted pregnancies. Apparently, that worked. According to Castillo, the BPS in response opened six health resource centers in high schools, which offer one-on-one counseling and distribution of condoms. The plan is to expand these centers to all BPS high schools within the next few years. “If sex education is not offered,” said Castillo, “kids will continue to rely on folk tales.”

Sexually transmitted diseases (STDs), for the most part, are preventable … if you take a few precautions.

Follow the STD testing recommendations of the Centers for Disease Control and Prevention.

When starting a new relationship, get tested. That means both of you. If both you and your partner are free of STDs and remain in a monogamous, or single partner, relationship you can avoid infections.

If you are not certain of your partner’s STD status always use a latex condom during every sexual encounter. If you have sex with more than one person, always use a latex condom during every sexual encounter.

Take the recommended medication if diagnosed with an STD. Advise your sexual partners of your status and make sure they get treated as well.

STDs, continued from page 1

Screening Guidelines Sexually transmitted diseases are often silent, and if left undetected, can result in infertility or can be passed on to fetuses. The Centers for Disease Control and Prevention recommend regular testing for STDs depending on an individual’s sexual behavior. Blood or urine samples are used for testing. CHLAMYDIA • Yearly screening for all sexually active females age 25 and younger. • Yearly screening for older women with risk factors, such as new or multiple sex partners GONORRHEA • Yearly screening for women with risk factors and women who live in communities with a high incidence of STDs • At-risk pregnant women at the first prenatal visit SYPHILIS, HIV, CHLAMYDIA AND HEPATITIS B • All pregnant women SYPHILIS, HIV, CHLAMYDIA AND GONORRHEA • At least once a year for all men who have sex with men (MSM) • More frequently (at 3-6 month intervals) for MSM who have multiple or anonymous partners or have sex in conjunction with illicit drug use HIV • All adults and adolescents at least once. • Those at high risk for HIV infection — injection drug users, persons who exchange sex for money, persons whose sex partners are HIV positive or MSM — should be tested at least yearly.

WALK RIGHT IN No appointment necessary these days and times MGH Cox 5 55 Fruit Street, Boston T, Th, F: 8:30 - 11:00 a.m. W: 1-3 p.m.

Chelsea Health Center 151 Everett Avenue, Chelsea T: 1:30- 3:30 p.m. Th: 3-6 p.m.

Other times require an appointment

Registration is required

before testing Call 617-726-2748 for more information

Call 800-232-4636 for a listing of other site

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that [your risk] by 10,” he explained. If Florida, where 19 percent of the residents are those 10 have slept with 10 others, the numelderly. Between 2001 and 2010, the number ber increases to 100. of cases of chlamydia in residents between The point Dixon is trying to make is the ages of 45 and 64 more than doubled. that a person may be sexually involved with Dr. Ronald Dixon, medical director only one person, but if that person is havat MGH Beacon Hill, sees first hand the ing sex with others, the risk of exposure to increase in STDs among older adults. “They STDs increases significantly. are more active (sexually) than they used to Explaining the positive results of an be,” he explained. STD test takes a couple of conversations, The uptick is in the most common Dixon admitted. The first reaction is shock. infections — chlamydia, gonorrhea and “You can almost see their mind whirring syphilis. About half of the patients intrying to come to grips with the situation,” he fected present with said. “How did I get symptoms. this?” or “Who gave Counseling it to me?” are quesabout STDs is tions they are asking imperative, acthemselves. cording to Dixon. He allows the “First I find out the patient to get over the relationship status,” shock before recomhe explained. If his mending treatment patients are single and advice on future — particularly those sexual behavior. who are considering It’s not uncomdating — he talks mon for STDs to about the use of come in pairs or even condoms. triplets. “If you have Ronaldald F. Dixon, M.D. “People who are Internist one STD, you’re Associate Medical Director entering into a new likely to have others,” relationship need to be Massachusetts General Hospital he explained. The tested,” he emphasized. Beacon Hill CDC agrees. There is And that includes both biological evidence partners. A clean slate is the first step in a that the presence of other STDs increases the monogamous, or single-partner, relationship. likelihood of both transmitting and acquiring He warns patients who initiate relation- HIV, the virus responsible for AIDS. ships without taking precautions. “If your That’s why when Dixon tests, he tests partner has slept with 10 people, multiply for everything — just to be sure.

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