AIDS NEWS SERVICE Michael Howe, MSLS, Editor AIDS Information Center VA Medical Center, San Francisco (415) 221-4810 ext 3305 November 11, 1994 Safer Sex: Information for Counselors (Part XI) STDs and HIV by John Tighe Health education related to sexually transmitted diseases (STDs) other than HIV has been largely overlooked throughout the HIV epidemic. This is true even though STDs are serious in and of themselves and their occurrence can be looked to as a measure of a person's HIV infection risk. Because behaviors that lead to other STDs are generally the same ones that lead to HIV infection, the presence of an STD can be a warning sign of potential HIV infection. In addition, ulcerations, lesions and other harmful effects of STDs can increase vulnerability to HIV infection. For someone infected with HIV, bouts of STDs can be far more serious and they can directly harm the immune system. Research Update Each year in the United States an estimated 12 million people are infected with STDs; two-thirds of these people are under age 25 (1). More than 50 organisms and syndromes are recognized as being sexually transmitted. STDs are caused by a variety of agents, including bacterial and viral ones. Bacterial STDs include gonorrhea and syphilis. Medications can be used as preventive therapy as well as to treat and cure bacterial STDs. Viral STDs include HIV, genital herpes, hepatitis B, and human papillomavirus (HPV). Viral STDs can be transmitted through sexual and non-sexual routes. While treatable, viral STDs are not curable, and therefore they can recur or they can progress. Fungal and parasitic agents, including trichomoniasis, can also be transmitted sexually. STD symptoms typically include one or more of the following: burning or pain during urination and defecation; itching or burning around the genitals; mucous discharge or bleeding from the genitals; ulceration or blistering; rashes on the body; and flu- like symptoms. STD infections lead to a variety of illnesses, including pelvic inflammatory disease (PID) and non-gonococcal urethritis. After being infected with most STDs, people may remain asymptomatic, or free of symptoms, for extended periods ranging from days to several months. During this period, however, people can transmit the infection to others. Symptoms related to bacterial or viral STDs often dissipate and recur. Because of long periods in which a infection may not produce symptoms, public health and medical experts recommend that people at risk for STDs seek an STD risk assessment, a physical examination based on symptoms, and laboratory tests to detect infections that may be asymptomatic. Relationship Between HIV and Other STDs HIV and other STDs are related in several ways. They are transmitted through similar routes and they respond to similar prevention messages (2,3). Researchers have identified a complex relationship between HIV and other STDs that results in a synergistic interaction -- that is, the presence of HIV with another STD produces a result affecting the course of HIV disease that would not be produced if the STD was absent (4). Of the major STDs, syphilis, chlamydia, gonorrhea, genital herpes, trichomoniasis, genital warts, and hepatitis B have been investigated for their impact on HIV. Researchers have demonstrated that the presence of STDs, both ulcerative and non-ulcerative, increases the risk of HIV transmission about 3- to 5-fold (4). STDs appear to promote HIV transmission by causing inflammation and lesions of the genital tract, thus creating an accessible place of entry for HIV. Ulcerations, which are caused by syphilis and genital herpes, have been related to increased susceptibility for HIV transmission. Increased risk of HIV transmission can also be attributed to non- ulcerative STDs such as chlamydia, gonorrhea and trichomoniasis, which weaken the body's defenses against disease. However, research related to the relationship between non-ulcerative STDs and HIV is more limited (4). Researchers suggest that the debilitating effects of STDs may accelerate progression of HIV for someone who is infected with HIV. In addition, for someone with HIV, it appears that the suppressive effects of HIV on the immune system worsen the symptoms of other STDs and decrease the healing effects of STD therapies (4). It is also possible that the course of an STD may be altered by HIV. For example, genital herpes ulcers normally heal within two to three weeks but persist much longer in people with HIV. Similarly, syphilis treatments sometimes fail or the disease develops more severely in people with HIV (5). Facts About STDs Syphilis. Syphilis is a bacterial STD that produces ulcers in the genitals, throat and rectum. Effective treatment with penicillin is widely available; without treatment, heart disease, brain damage, blindness and death can result. Although the rate of syphilis infection has declined steadily in the last 50 years, sporadic outbreaks occurred during the 1980s in some urban areas. The occurrence was most common among African-American men and women in urban communities with high HIV incidence (2). In 1990, 134,000 syphilis cases were reported nationally. Gonorrhea. Affecting as many as one million people each year in this country, gonorrhea is a bacterial infection that causes inflammation of the urethra and rectum in men. In women, it causes inflammation of the cervix, and infections of the uterus, fallopian tubes and pelvic organs -- leading to PID. Symptoms include pain during urination or defecation and discharge from the vagina or penis. While penicillin historically has been the most widely used treatment to cure gonorrhea, strains resistant to penicillin have developed in recent years (5). Therefore, suspected gonorrhea cases are now treated with other medicines, even though these are often many times more expensive than penicillin (1). Chlamydia. Chlamydia, like gonorrhea, causes inflammation of the urethra, cervix and prostate, and can cause PID and genital ulcers. Manifestations of chlamydia have both bacterial and viral characteristics. In women, chlamydia can lead to premature birth, ectopic pregnancy and sterility. During ectopic, or tubal, pregnancy, the fetus develops outside the uterus in the fallopian tubes. Nationally, as many as four million people across all socioeconomic and ethnic groups may be infected with chlamydia. A person with this STD can remain asymptomatic for long periods. Accurate and affordable diagnostic tests have only recently become widely available. When diagnosed, infections can be cured by taking tetracycline or other antibiotics (6). Several studies from Africa clearly indicate that women with cervical chlamydia infection are at increased risk of being infected with HIV through unsafe sexual intercourse (5). Trichomoniasis. Trichomoniasis, a parasitic condition estimated to affect three million people in the United States, has not been thoroughly studied for its relationship to HIV. Those with the disease may be asymptomatic for extended periods. In women, trichomoniasis may cause severe vaginitis, and in men, painful swelling of the penis as well as epididymitis. Treatment regimens usually involve the drugs flagyl or metronidazole. Genital herpes (herpes simplex virus types 1 and 2). Genital herpes, a viral infection, is an ulcerative disease that causes painful blisters on the genitals, mouth, anus, and other mucous membranes, and sometimes on the skin of other areas of the body. Men and women infected with genital herpes are often asymptomatic for long periods. Women can have a longer asymptomatic period and a more severe initial manifestation of disease than men, and women can transmit the virus during pregnancy and childbirth. Recurrent episodes are common, but are usually less severe over time. Acyclovir is the standard treatment for genital herpes. Various studies estimate that 25% to 50% of all people in this country are infected with a herpes virus (1). Studies have found infection rates two to three times higher among African Americans and highest among African-American women. Infection rates are disproportionately higher among poorer people living in inner city areas (5). Human papillomavirus (HPV). There are more than 60 types of HPV, and millions of sexually active people are known to be infected with the virus. Some types of HPV cause genital infection, and a small number produce benign genital warts, which are non-ulcerative and frequently recur. Certain types of HPV are linked to pre-cancerous lesions or cancer of the cervix, vulva, penis, anus and throat. HPV cannot be eradicated; treatment usually involves removal of warts by cold-based therapies such as liquid nitrogen, or though laser therapy. While there are no well-designed, prospective studies of HPV's effects on HIV, it seems clear that the immunosuppression caused by HIV affects the course of HPV. A recent study confirmed that gay men with HIV are at increased risk for HPV infection (7). In the presence of HIV, a broader variety of HPV infections tends to occur, infections often worsen and larger lesions appear. In people with HIV, HPV infections typically do not respond as well to therapy. Hepatitis B virus. People infected with hepatitis B may develop cirrhosis, carcinomas and chronic active hepatitis. While a vaccine was introduced 10 years ago, and it is considered effective, incidence has remained unchanged since then (8). No special treatments are recommended for active infection. In addition to sexual routes of transmission, hepatitis B may be transmitted to a fetus during pregnancy or to a child at birth, as well as through injection drug use. It is estimated that up to half of all hepatitis B infections ar sexually transmitted (9). The proportion of hepatitis B cases attributed to sexual contact between men has declined in recent years, while the proportion attributed to heterosexual contact and infection drug use has increased. Multiple sex partners and high-risk sex practices, especially receptive anal intercourse, place both gay men and heterosexuals at increased risk for hepatitis B transmission (9). Implications for Counseling Throughout the HIV epidemic, and in fact for decades, prevention of STDs has generally been overlooked, as more attention has been given to medical diagnosis and treatment of STDs than to changing behaviors. There are compelling reasons for HIV test counselors to discuss STDs with clients. Because both HIV and other STDs are sexually transmitted, prevention messages for both are similar. By hearing clients' STD histories, HIV test counselors can learn about attitudes related to HIV, such as the client's views of sexuality, sexual behavior, risk reduction and being infected with STDs. Some clients may have given little thought to HIV, but have extensive experience with STDs. Or, they may have extensive HIV knowledge, but little knowledge of other STDs. This section presents STD-related issues that are relevant to the HIV test counseling session, including behavioral risks and the health implications of STDs. In addition, the section responds to concerns of clients with or without STDs, as well as to young people, who are disproportionately affected by STDs. The following are key points for HIV test counselors to discuss with clients. o By engaging in safer sex, clients can protect themselves from infection or reinfection with both HIV and other STDs. When a client does not see his or her HIV-related risk as significant enough to warrant behavior change, present information about the risk of other diseases that may result from these behaviors. For someone who shows little concern about HIV because its debilitating effects may not be felt for years, state that many STDs can have immediate and damaging effects. o The occurrence or recurrence of an STD along with a repeated negative HIV test result does not mean a person is not susceptible to HIV infection. In fact, multiple STD episodes are a clear warning that a person is engaging in high-risk behaviors for HIV infection. o STDs can make a person more susceptible to HIV infection. And, STDs put strain on the body's immune system, making it more susceptible to other infections and less able to defend against them. o People who have contacted STDs through injection drug use may not see their risk for HIV infection through sexual behavior. For instance, someone infected with hepatitis B virus (HBV) through infection drug use may perceive his or her drug use as risky, but feel he or she can engage in unprotected sex without being infected. Sexual Behaviors and STDs After learning the behaviors clients practice or desire to practice, describe to them the specific diseases that may be transmitted through these behaviors. For instance, clients who engage in oral sex without a condom are not only putting themselves at risk for HIV infection, but also for gonorrhea, syphilis, chlamydia, herpes and hepatitis B infections. Remember that there are behaviors, such as rimming, also know as oral-anal sex, that some client may not consider a high risk or HIV infection, but which definitely put a person at high risk for other STDs, including parasites and hepatitis B virus. Responding to STD Infection STD testing is important for anyone who has symptoms of an STD or anyone who has had unsafe sex with someone with an STD. Symptoms may not develop for extended periods after infection, but STDs can progress in the absence of symptoms. Symptoms generally occur sooner after infection for men than for women. Laboratory testing can detect most STDs in the absence of symptoms. Many times, even with symptoms, people disregard STDs. Not wishing to acknowledge an infection, they avoid examining the genital area. They may even notice a skin lesion, but believe it is not a problem that needs immediate attention. For this reason, urge clients who think they are infected with, or have symptoms of, and STD to visit an STD clinic or their primary care provider. Talk to these clients about the complications of untreated STDs as well as the risk of future infections. State that STDs respond best to treatment before symptoms develop, and they generally worsen and become more infectious when untreated. Clarify myths about STDs. For instance, clients may believe incorrectly that good personal hygiene, or a "clean" appearance, is a sign that someone is free of STDs. In counseling clients with no STD history, support them for any steps they have taken to avoid STDs. If these clients appear to have little STD knowledge, make sure they understand that HIV is not the only disease that can be transmitted sexually, and that other STDs are serious unto themselves and can make a person more susceptible to HIV infection. Clients with an STD History Clients with an STD history have, in most cases, engaged in behaviors that have placed them at risk for HIV infection, and they may be several times more likely than other clients to become infected with HIV. Counselors may feel their efforts to repeat information to clients with extensive STD histories are futile. However, counselors have a unique, and perhaps "last chance" opportunity to offer assistance before these clients become infected with HIV. Recognize that a person with a history of STDs may never have received thorough or effective counseling. Ask clients about their previous counseling and how effective they believe it has been in helping them understand and change risk behaviors. Through the HIV test counseling session, the client may, for the first time, see his or her STDs as a warning sign, and may perceive the need to change behaviors and even ask for help in doing so. Many people with a history of STDs may not have strong feelings about the dangers of HIV. They may know from their personal experience that STDs can cause pain, but they may not realize these STDs can be life-threatening. Explain that, even without HIV infection, repeated episodes of STDs can have debilitating and far-reaching effects. STDs can destroy organs, break down tissue, make it difficult for a women to become pregnant, and increase risk for other diseases. For instance, venereal warts for women and genital warts for men can increase risks for certain cancers. Stress the importance of following the full course of treatment for STDs even if symptoms of disease have cleared. Failure to follow the full treatment course can allow disease to recur and lead to bouts with drug-resistant STDs. After taking an STD history, ask the client to describe his or her risk behaviors and the context in which they occurred. Ask how the client feels about the safety of those behaviors, and how he or she felt when STDs were detected or diagnosed. Hearing this, the counselor may be able to identify a client's motivation to avoid STDs in the future and assist in developing skills to avoid risky behaviors. Be prepared for a variety of factors that may lead clients to state they do not wish or feel able to change behaviors. These include rationalizations about unsafe sex, denial bout the safety of specific behaviors, and compulsive sexual behavior, in which a person may feel compelled to have sex and unable to control sexual desires. Some clients may believe that if they engage in significant amounts of sex with many partners, they deserve or expect STD infections. Clients with an STD history may be especially vulnerable to fatalistic feeling about HIV infection, and they may express that being infected with HIV is inevitable and beyond their control. Unsafe sex may be such a significant part of a person's life that he or she may not be able to imagine life without unsafe sex. Empathize with the client's position, and help him or her see that no matter how distant safer sex may seem, it is possible. Empower the client to see that he or she can have control over behaviors and becoming infected. Ask the client if there was ever a time he or she did not need to engage in unsafe sex, and, if so, explore the feelings of that time, including feelings of self-esteem. Clients who have had thorough counseling previously, yet are unable to change sexual practices, may respond to direct statements about their risks. For instance, it may be appropriate to state: "You've had several counseling sessions. Your behaviors continue to put you at risk for a life-threatening disease. Are there things we can talk about doing that might help you change your behavior? Do you want to change?" Some people with STDs may avoid taking responsibility for actions that leads to STD infection. They may view partners as responsible for the STD. This may lead clients to avoid reducing their risk in the future. Such clients may also decline to notify partners of their STD. Inform people with STDs that they are legally liable if they transmit that disease to another person. And, people who fail to use protective devices, such as condoms, have a legal obligation to inform prospective partners of their STDs. [Editor's Note: The last two statements apply to California residents; they may or may not be applicable to other states.] STDs and Clients with HIV Make clients aware that people with HIV are more susceptible to infection with other STDs. In addition, STDs are faster-acting and their effects on the immune system more threatening for people with HIV. Provide this information in both pre- and post-test counseling. For clients who test HIV positive, recommend medical intervention and STD screening. Stress the importance of avoiding unsafe sex not only to avoid reinfection with HIV or infecting others, but also to avoid other STDs. Young People People under age 25 account for two-thirds of all STD cases, yet prevention messages often overlook young people, and young people generally have little knowledge of STDs. Often, STD counseling for young people has been limited because counselors have been reluctant to talk about sex with them and do not recognize the ability of young people to respond to counseling messages. Be sensitive to differences between younger and older people. Be careful to avoid messages that may be conveyed as "sex negative." These can be particularly alienating for young people who may feel their sexuality and independence are being questioned by test counselors who are generally older. Young people may believe STDs are to be expected from healthy sexual expression. They are often less willing to acknowledge risks for infection or the seriousness of disease. Because young people may have heard fewer prevention messages, they may need to have them repeated more often. Or, they may need to use new information to refocus attitudes and behaviors. Be aware of the unique dynamics of sexual and emotional relationships of young people. Because of their relative inexperience in relationships, young people may not be certain what they desire from relationships. In addition, relationships may be shorter-lasting for young people than for older people, yet feelings in the relationship may be experienced as being especially intense. Because sexual and emotional intimacy develop quickly, people may soon find themselves feeling comfortable engaging in unsafe sex. Often for young people, engaging in sex is not considered a result of a decision or choice, but rather as something that is necessary. In some cases, experiences or relationships of young people may consist of rape, incest or other forced sexual or violent behavior. Talk with young people about the meaning of making choices consciously. Help them understand their rights and responsibil- ities in making their own choices, as well as the benefits that come from giving thought to the decision-making process and slowing down to do so. Ask clients what they perceive their choices to be and which choices they wish to make. Ask young people if they are aware of what they want from sex partners or relationships. If they are, they may be better able to define their choices. Referrals To determine appropriate referrals, first ask the client what he or she needs regarding STDs. Understand that clients may be resistant to visiting public STD clinics. In addition, clients may fear that at clinics they will be thoroughly quizzed on their sexual histories and that their sexual partners will be notified. Listen to a client's concerns and address them. Provide telephone numbers and addresses of local STD clinics, and, if possible, the names of clinic staff. Also, let clients know they can visit personal physicians for STD care. Contact and become familiar with referrals. For clients who feel unable to change sexual behavior to reduce their STD risks and who report a pattern of compulsive and self-destructive sexual "acting out," ask if they are interested in gaining help to avoid these behaviors. If so, provide referrals to 12-step recovery programs such as Sex and Love Addicts Anonymous or Sex Addicts Anonymous. These programs are found in phone directories in most larger cities. In addition, offer referrals to therapists trained in dealing with behaviors related to sexual compulsion. Be aware that clients often are most receptive to behavior change intervention and more likely to follow up on referrals at the time they are experiencing symptoms of disease. References 1. CDC. Division of STD/HIV Prevention Annual Report 1991. Atlanta, GA: Division of STD/HIV Prevention, 1991. 2. Holmes KK. Mardh PA. Sparling PF et al., eds. Sexually Transmitted Diseases. 2nd ed. New York: McGraw Hill, 1990. 3. Sexually Transmitted Diseases in California, 1991. Sacramento: State of California Department of Health Services, 1992. 4. Wasserheit JN. Epidemiological synergy: interrelationships between human immunodeficiency virus (HIV) infection and other sexually transmitted diseases (STDs). Sexually Transmitted Diseases. 1992;19(2):61-77. 5. Aral SO. Holmes KK. Sexually transmitted diseases in the AIDS era. Scientific American. 1991;264(2):62-9. 6. Sexually transmitted diseases treatment guidelines, 1989. MMWR: Recommendations and Reports. 1989;38(S-8):[pages inclusive]. 7. Critchlow CW. Holmes KK. Wood R. et al. Association of human immunodeficiency virus and anal human papillomavirus infection among homosexual men. Archives of Internal Medicine. 1992;152(8):1673-76. 8. Alter MJ. Hadler SC. Margolis HS. et al. The changing epidemiology of hepatitis B in the United States. Journal of the American Medical Association. 1990;263(9):1218-22. 9. Piot P. Goilav C. Kegels E. Hepatitis B: transmission by sexual contact and needle sharing. Vaccines. 1990;8(supplement): S37-S39. 10. McGregor JA. French JI. Spencer NE. Prevention of sexually transmitted diseases in women. Obstetrics and Gynecology Clinics of North America. 1989;16(3):679-701. 11. Wolfe H. Vranizan KM. Gorter RG. et al. Crack use and human immunodeficiency virus infection among San Francisco intravenous drug users. Sexually Transmitted Diseases. 1992;19(2):111-14. 12. Marx R. Aral SO. Rolfs RT. et al. Crack, sex, and STD. Sexually Transmitted Diseases. 1991;18(2):92-101. 13. U.S. Preventive Services Task Force. Counseling to prevent HIV infection and other sexually transmitted diseases. American Family Physician. 1990;41(4):1179. Test Yourself 1. True or False: The presence of STDs has been found to greatly increase the risk of HIV transmission. 2. True or False: Gonorrhea can lead to pelvic inflammatory disease (PID) in women. 3. Chlamydia can lead to which of the following outcomes a) genital ulcers, b) premature birth and sterility, c) a and b, d) none of the above. 4. True or False: Viral STDs can be treated but not cured. 5. True or False: It has been conclusively found that STDs have no effect on the rate at which HIV infection progresses. 6. True or False: Open lesions caused by STDs can make a person more susceptible to HIV infection. 7. Which of the following is the most commonly reported STD in California? a) chlamydia, b) syphilis, c) chancroid, d) hepatitis B virus. 8. For a person with HIV, STDs can a) progress far more rapidly than for a person free of infection, b) be more severe than for a person free of HIV infection, c) both a and b are correct, d) none of the above. Discussion Questions o Clients with STDs may believe STDs, including HIV, are to be expected. How can counselors help clients see that this expectation is dangerous? o Clients may feel shame about STDs, and this shame can lead them to believe they cannot make necessary behavior changes to avoid STDs. How can counselors recognize this shame, work with clients to mange it, and see that behavior change is possible? o Many clients with STDs have received extensive STD counseling, yet they have been unable to avoid STDs. What can HIV test counselors offer that these clients have not received in other counseling? o Given that there are dozens of STDs, how can counselors describe the basics of STDs in a easy-to-understand way and in a brief period of time? How can counselors combine a discussion of HIV with a discussion of other STDs? o Because HIV test counselors may not have training in STD work, how can they learn about STDs or remain current in their knowledge? o Can combined messages related to prevention of both HIV and other STDs strengthen counseling interventions? How can messages be combined? Answers to "Test Yourself" 1. True. 2. True. 3. C. In women, chlamydia can lead to genital ulcers, premature births and sterility. 4. True. 5. False. It is believed that STDs can speed the progression of HIV. 6. True. 7. A. Chlamydia is the most frequently reported STD in California. 8. C. For a person with HIV, STDs can progress far more rapidly and be far more severe than for a person who is not infected. Editor's Note The information included in this document was obtained from the 1993 February issue (Vol. 3, No. 1) issue of "HIV Counselor PERSPECTIVES." PERSPECTIVES is an educational publication of the California Department of Health Services, Office of AIDS, written and produced by the AIDS Health Project of the University of California San Francisco (John Tighe, writer and editor). Reprint permission is granted, provided acknowledgment is given to the Department of Health Services.