Sexually transmitted infections


The most important facts about venereal diseases


HIV Virus



General

Sexually transmissible infections or venereal diseases belong to the group "infec-tious diseases", which is why they are globally referred to as STIs. These are caused by more than 30 causative agents, including bacteria, viruses, parasites and fungi. Twelve further causative agents, which are sexually transmitted, have been discovered since 1975 alone, and it is highly likely that more will follow. The common factor with STIs is that they are transmitted in the main during sexual intercourse. There are, however, differences in the degree of infectiousness of the causative agents, the course of the disease and possible therapeutic or preventive measures.

The classical venereal diseases (syphilis, gonorrhoea etc.) have lost their horror image, since they have become curable with antibiotics. For a long time now there has also been a protective vaccination available against hepatitis B, a further serious, sexually transmissible infection. Likewise, there is now a protective vaccination available against special types of papilloma viruses (HPV), to prevent cervical cancer and genital warts. The most feared STI to-day is AIDS, since neither a curative drug nor a protective vaccination is available.

World-wide, an estimated 330 million people per year are affected by a venereal disease. The most widespread are trichomonas with 120 million, followed by chlamydia at 50 million and gonorrhoea at 25 million affected persons. The number of people affected is much higher, if it includes the very frequent infections with papilloma viruses or the herpes viruses. The number of HIV infected persons worldwide is estimated by UNAIDS at the end of 2008 to be 33.4 million.

Infection with an STI occurs primarily during sexual intercourse through the direct contact of infected body fluids (such as seminal and vaginal fluid) with the mucous membranes. Most venereal diseases, especially her-pes infections, but also syphilis, can also be transmitted via oral sex, kissing or petting (via direct contact with infectious sites apart from the genitals). An infection can also be transmitted from the mother to the unborn or new-born child. Some venereal diseases (hepatitis B/C, AIDS and syphilis) can also be transmitted via the blood (e.g. by the exchange of syringes between drug addicts or, more rarely in the western world, from infected blood preserves and blood products). An indirect infection via shared use of sex toys, is possible, but very rarely through towels and toilet articles. Infection via drops (e.g. coughing, sneezing) is not possible. In the course of everyday social contacts (household, workplace etc.) infection with an STI can be excluded, provided normal rules of hygiene are observed.

The majority of STIs (most important ex-ceptions: hepatitis B/C and AIDS) manifest them-selves initially at the place of entry, i.e. penis, vagina and labia (lips of the vulva), and, depending on contact, also the anus, lips and mouth. Some STIs are simply unpleasant, while others are dangerous: if they remain untreated, they can spread throughout the whole body and may, in some instances, cause irreparable damage such as infertility, brain damage or even death. Also significant is the fact that for most STIs, they simultaneously lead to an easier HIV infection, which is still incurable even now, and makes lifelong therapy necessary.



The most important venereal diseases


Syphilis (lues, hard chancre)
Syphilis is caused by spiral-shaped bacteria (Treponema pallidum). The course of the di-sease can be split into three stages: in stage 1, about three weeks (but sometimes not for up to 3 months) after the infection there appears a hard, painless nodule at the site of the infection (generally the genitals). The most closely situated lymph nodes (usually in the groin) start to swell. Generally the ulcer heals after 6 weeks, even without treatment. If not treated, however, the disease proceeds to stage II, when the bacteria spread throughout the whole body, and cause skin eruptions, fever and swelling of the lymph nodes. These manifestations disappear for a time, but then recur repeatedly for months. If this stage is also not treated, then after several years it progresses to stage III, and the inter-nal organs become affected, especially the cardiovascular system, the skin and the central nervous system, with disturbances of gait when the spinal medulla is affected, and in dementia when the brain is affected.

Identification of the infection is performed by examination under the microscope at Stage I or via the syphilis test in the blood, which only provides reliable results about 3 weeks after infection. Treatment with antibiotics (injection of depot penicillin) at stages I and II leads to a complete cure. The damage in the later stage (III) cannot always be reversed, even when the bacteria are eliminated with antibiotics. In pregnancy, syphilis can cause severe damage to the un-born child or lead to stillbirth.

Gonorrhoea (clap)
Gonorrhoea is also caused by bacteria (Neisseria gonorrhoeae). Two to seven days following the infection, there is a creamy discharge from the penis and vagina, together with pain on urinating. In women, especially, these symptoms may not occur. If the disease is not treated, this can lead in the man to an infection of the prostate, the vas deferens and the epididymis. In the woman the womb, the fallopian tubes and the ovaries can be affected to such an extent that it can lead to infertility. If left untreated, the bacteria can spread throughout the whole body, in particular to the joints, the skin and the abdominal cavity. Identification of a gonorrhoeal infection takes place via examination under the microscope and culturing of the discharge. Gonorrhoea can be cured with antibiotics.

A great problem in this respect is the increasing resistance to various antibiotic groups, hence the choice of antibiotic is important and depends on where the infection took place.

Ulcus molle (soft ulcer)
Ulcus molle is caused by bacteria (Haemophilus ducreyi), and is a rare disease in central Europe, though it occurs frequently in tropical developing countries. Two to six days following the infection, soft, painful and somewhat diffuse ulceration occurs at the site of the infection. The lymph nodes in the area of the groin may become very swollen and also painful. Diagnosis is by microscopic examinations of the ulcers to detect the bacteria. The disease can be cured with antibiotics.

Veneral lymph node inflammation (Lympho-granuloma venereum)
Lymphogranuloma venereum is caused by particular strains of Chlamydia trachomatis, and is very rare in central Europe. At least 14 days following infection, small discrete nodules appear in the genital or anal area, which are scarcely painful nodules so are often not noticed, healing spontaneously within 10-14 days. It is not until the swelling of the lymph nodes in the groin area (up to fist size) that the patient is prompted to consult a doctor. Problems arise, above all, when lymph nodes rupture externally (fistulae) or internal scarring occurs. Diagnosis takes place via direct demonstration of the causative agent at the site of infection or by means of blood tests. The disease can be cured, in the initial stage, by means of antibiotics. After many years when this disease was no longer seen in Europe, there have in recent years been outbreaks, especially in homosexuals, mostly HIV-infected men, with painful rectal infections.

Infection with Chlamydia
IInfections with Chlamydia are very widespread in Europe and are caused by bacteria (Chlamydia trachomatis). They lead to very uncomfortable urethral infections, causing severe itching and a burning sensation when urinating. In the male the prostate and the epididymis may be affected and, in women, the vagina, the womb, the fallopian tubes and the abdominal cavity, which can lead to infertility and ectopic pregnancies. The course of the infection, which is often symptomless, can easily be cured with antibiotics. Transmission to the new-born child is frequent, and leads to con-junctivitis and pneumonia.

AIDS
AIDS (Acquired Immune Deficiency Syndrome) is the final stage of an infection with HIV (Human Immunodeficiency Virus). Up to now, two virus types (HIV 1+2), with nu-merous subgroups, have been identified. The period between infection and the eruption of the disease comprises on average about ten years. During this time infected per-sons can, without themselves being aware of the infection, transmit the virus to other persons. Simultaneously existing classical ve-nereal diseases (especially syphilis, genital herpes and ulcus molle) increase susceptibility to an infec-tion with the AIDS virus. Identification of an HIV infection takes place by means of a blood examination (HIV test). Under optimal treatment with AntiRetroviral Therapy (ART), Aids rarely breaks out and the risk of transmission becomes small. HIV infection has been converted from a fatal to a lifelong chronic disease, on condition, however, that it is found easily by an HIV test. At present there is no prospect of a protective vaccine.

Hepatitis (infectious jaundice)
There are various hepatitis viruses, of which the hepatitis B virus (HBV) and, to a lesser extent, the hepatitis C virus (HCV) are sexually transmissible. The course of the disease varies considerably. The infection may proceed without complications, or it can lead to a severe acute inflammation of the liver (hepatitis), which in some cases can prove fatal. In the majority of cases the infection develops into chronic inflammation of the liver, which can lead to cirrhosis and liver cancer.

The problem with hepatitis B/C is that some people remain lifelong carriers without them-selves becoming ill, and can infect others. In addition to sexual intercourse, the hepatitis B/C viruses can be transmitted via blood trans-fusions, syringe sharing in drug addicts, and sometimes even by direct and indirect contact with body fluids.

In third-world countries hepatitis B is widespread among the general population, while in Europe, it is mainly injecting drug addicts and homosexual men that are affected. For years now, there has been a reliable protective vaccination against hepatitis B.

Herpes genitalis
Genital herpes is a widespread virus infec-tion with the Herpes Simplex virus (HSV). This virus occurs in two different forms (type 1 and 2). While type 2 occurs almost exclusively on the genitals, the type 1 virus can cause both fever blisters on the lips and, increasingly, genital lesions. Three to seven days after infection small, intensely itchy or painful blisters appear in the genital region, which contain an infectious fluid. In addition lymph node swelling and general febrile conditions may occur. The virus can be detected directly in the blister liquid. Despite treatment with a drug that kills the virus (e.g. Aciclovir) the virus can survive in the nerve cells and, weeks or even years later, lead to a new attack of blisters or ulcers that is, however, generally milder in its course. In infected pregnant women the her-pes virus can be transmitted during the birth to the new-born child, and can cause serious disorders (e.g. encephalitis) with lasting damage, or result in death.

Genital Warts (Condylomata acuminata)
After a varying incubation period (weeks to months), genital warts grow as flat or often cauliflower-like lesions in the genital area. They are caused by viruses (human papilloma viruses = HPV, type 6 and 11), and can be removed either physically (laser, liquid nitrogen, electrocoagulation or with the scalpel) or by locally applied means (solutions / creams). Papilloma viruses can be transferred during birth to the new-born child. Other HPV types (mainly type 16 and 18) are responsible for cancer of the cervix in women. For a few years now, a safe protective vaccination (against types 6, 11, 16 and 18) has been available for girls. This should, however, be given before starting sexual activity.

Trichomonas
Trichomonas is a widespread monocellular parasite that infests the urethra and vagina. The infection is expressed by a watery discharge and irritation. Diagnosis is by detection of the causative agents under the microscope. This harmless infectious disease, although common all over the world, is cured by special antibiotics (e.g. Metronidazole).

Fungal infections
The yeast fungus (Candida albicans) is very widespread and can also be sexually transmitted. In principle, however, fungal infections play a subordinate role in STIs. This, in itself harmless, infection (inflammation of the vagina or, in men, the glans) can, however, lead to unpleasant discomfort such as severe itching and a burning sensation. A woman also experiences a whitish discharge. Fungal infec-tions can be successfully treated by means of special medication (antimycotics) and appropriate hygienic measures.

Crab lice
Crab lice (Phthirius pubis) are small (1-1.5 mm) parasitic insects that infest the pubic hair (or more rarely, armpit hair or eyebrows). They can be seen with the naked eye, as can their eggs (nits) which attach themselves to the hairs. Intense itching is the most important symptom. This harmless venereal disease is treated by local means.

Scabies
Scabies are caused by mites (Sarcoptes scabiei) which can be transferred during sexual intercourse - but also by close physical contact within the family. They dig burrows into the skin (between the fingers, wrists, armpits, private parts, navel and breasts). This also causes intensely itchy (especially at night) rashes. A so-called mite burrow can often be seen with the naked eye. Treatment with local means (cream) requires simultaneous and thorough treatment of the entire family and any other exposed persons, as well as a change of clothing.



The most important sexually transmitted infections at a glance


Infection Causative agent Time between infection and affection Treatment Remarks
Syphilis Bacteria (Treponema pallidum) 3 weeks (to 3 months antibiotics complete cure with timely treatment
Gonorrhoea Bacteria (Neisseria gonorrhoeae) several days antibiotics complete cure with timely treatment
Ulcus molle Bacteria (Haemophilus ducreyi) several days antibiotics complete cure with timely treatment
Lymphogranuloma inguinale Bacteria (special strains of Chlamydia trachomatis) several days antibiotics complete cure with timely treatment
Chlamydien-Infektionen Bacteria (Chlamydia trachomatis) several days antibiotics complete cure with timely treatment
HIV-Infection / AIDS Viruses (HIV-1/-2)
HIV-Test positive usually within 2 to 6 weeks, max. 3 months		 about 12 years anti-retroviral preparations not curable, virus remains in the body; life-prolonging and palliative treatment possible
Hepatitis B / C Viruses (HBV/HCV) several weeks, sometimes longer symptom-atic, anti-viral prep-arations generally spontaneous healing; antiviral treatment possible, vaccination for HBV available
Herpes genitalis Viruses (Herpes simplex virus type 2, also increasingly type 1) several days symptom-atic, anti-viral prep-arations virus cannot be eliminated from the body
Genital Warts Viruses (papillomaviren) weeks to months topical (solutions/cream) or physical (laser, etc.) cure possible; increased risk of cervical cancer, vaccination available for girls
Trichomoniasis parasite (Trichomonas vaginalis) several days antibiotics complete cure possible
Fungal Infection Yeast fungi (mainly Candida albicans) several days antimycotic agents complete cure possible
Crabs insect (Phthirus pubis) several days antiparasitic agents (local) complete cure possible
Scabies mites (Sarcoptes scabiei) often several weeks antiparasitic agents (local) complete cure possible


What to do if you are affected by a venereal disease?


If you suspect that you have become infected with a venereal disease, you should immediately consult a doctor in whom you can confide. In addition to your family doctor this could be a dermatologist, a gynaecologist, urologist or a specialist in internal medicine. The attempt to "cure" a venereal disease yourself is problematical - perhaps even dangerous - since this could later complicate the diagnosis of the doctor, and the infection might remain undetected.

Most venereal diseases can be cured with appropriate medical treatment. Exceptions are the viral STIs such as, for example, herpes infections, hepatitis B/C and AIDS. Even in HIV infections, however, modern drugs improve the life expectancy and, above all, the quality of life of the patient. However, only those patients who become aware of their HIV infection at early date can profit from this. It is therefore worthwhile, if you have another venereal disease, always to have an HIV test performed. Talk to your doctor about it.

If you are suffering from a venereal disease you should - in order to protect your partner - refrain from sexual contacts until the disease is cured and can no longer infect your partner. Your doctor will tell you when there is longer any danger of infection. You should inform your earlier and/or present partner(s) about your venereal disease. At least one of these is suffering from the same disease (otherwise you couldn't have caught it), and you might already have passed on the infection to others. These partners should also consult a doctor and, where necessary, receive treatment.

In Switzerland there is an Epidemics Law (currently under review), and this also applies to sexually transmissible infections. Patients suffering from a "classical" venereal disease (e.g. syphilis or gonorrhoea) must consult a doctor for treatment. In addition the doctor must see to it that patients inform their sexual partner, and that they also receive treatment. If the patient or a contact person does not consult a doctor for examination or submit to treatment (or breaks off the treatment prematurely), the doctor is obliged to report the patient, by name, to health authorities.

Many people have inhibitions when it comes to talking about venereal diseases. It is important, however, to have confidence in your doctor and to be perfectly frank with him; he will then treat you competently, confidentially and without prejudice.


What protection is available against venereal diseases?


Since infection with venereal diseases occurs almost exclusively via sexual intercourse, protective measures must begin here. Some venereal diseases are visible externally, though generally one does not recognize that the partner is suffering from such a disease.

Faithfulness
In a faithful sexual relationship between two healthy partners an infection with a venereal disease is virtually excluded.

Careful choice of partners
A new sexual relationship brings with it, in principle, the danger of infection with a venereal disease. Only when the partner is not infected can an infection be excluded. For this reason it is particularly important to choose the partner very carefully. Possible risks should be clarified by means of frank discussions with the partner. How was the former life of the future partner. How can we protect ourselves? Hiding the truth only favours the pathogenic agents.

HIV-Test
Since AIDS is incurable it is advisable today to have an HIV test performed, so as to exclude an undetected infection in the past.

No unprotected sexual contacts
Since not all venereal diseases are curable and may in certain circumstances, prove fatal (AIDS, hepatitis B/C), or could result in infertility, it is advisable to refrain from unprotected casual contacts. A single sexual contact may suffice for infection with a venereal disease. Changing partners frequently also increases the risk of encountering an infected partner.

Condoms
In contacts outside a firm relationship the risk of infection with a venereal disease can be reduced, though not excluded, by the use of condoms. In view of the fatal disease AIDS there is an important residual risk of the order of several per cent. Young people in particular have, naturally, little or no experience with condoms, so that the danger of errors in use is high.

Vaccination against hepatitis B, cervical cancer and genital warts
Should you belong to a risk group for hepatitis B (e.g. medical staff, intravenous drug addicts or someone staying a long period in a developing country, homosexual), vaccination against hepatitis B is advisable. Nowadays this vaccination is recommended in principle for everyone. Also advisable is vaccination against HPV types 6, 11,1 6 and 18 to prevent genital warts and cervical cancer. This is now intended for girls before starting sexual activity.

Vaccination against Hepatitis B
Should you belong to a risk group for hepatitis B (e.g. medical staff, dialysis patients, intravenous drug addicts or someone staying a long period in a developing country), vaccination against hepatitis B is advisable.





©AIDS Information Switzerland – 2001, last updated 2010

Frontispiece: Auguste Renoir - La danse à Bougival (detail)
©Picture Fund Courtesy, Museum of Fine Arts, Boston