The Dirty Dozen
Swing into action-and don't forget your partner(s).

HIV is one of more than a dozen sexually-transmitted diseases (STDs) including gonorrhea, syphilis, genital warts (human papillomavirus, or HPV), hepatitis, chlamydia, trichomoniasis, herpes, and scabies. An STD is a term used to describe any disease primarily contracted through sex and can be caused by bacteria, viruses, insects or parasites. STDs don't always cause symptoms in everyone, and they can go undetected and unreported in many people.

Whereas syphilis is curable, STDs like herpes and genital warts (also HPV) are not. Once you're infected, you've got these critters for life. In the case of herpes, for example, there are various drugs that can control an active outbreak, but the infection remains dormant or latent in your body and can be triggered by stress or other illnesses. Whenever it flares up, you can transmit herpes infection to a sexual partner. But most cases of transmission actually occur when people show no symptoms. It's also common for STDs to recur and become chronic infections that resist standard therapies. This is especially true for HIV-positive people and those with impaired immune systems.

In women, some STDs are also linked to an increase in vaginal pH (which makes the vagina less acidic) that can be affected by oral contraceptives, pregnancy, bacterial overgrowth, cervical or vaginal lesions, and frequent douching. Vaginal yeast infections can be also be a warning sign of STD infection. Ask your doctor about these risks. Pregnant women are vulnerable to STDs that can harm the fetus and be passed on during pregnancy and birth. They also often can't use standard drugs used to treat STDs. For this reason, experts recommend STD screening as part of routine prgnancy care.

Maintaining good overall health and sexual health is the key to preventing STDs. Not all diseases can be cured, so prevention is your best weapon. The key words are Early Detection, Rapid Treatment, Follow-Up and the biggie: Safer Sex. Latex condoms with lube, the female condom Reality and dental dams, all work to protect against STDs and HIV (see "Safer Sex," page 15). Some spermicides work against some STDs, but they can also cause vaginal irritation, haven't been tested in anal sex and aren't generally recommended.

Tip: If you think you've got an STD, don't guess, don't wait for the little bumps or funny smell to just go away, and don't pretend it's not there. Denial is common, but dangerous, especially if you have HIV. That counts for your sexual partners, too. Chances are, if you've got a love bug, they might too. You'll both need to get checked out and treated. When it comes to STDs, a little action-a medical checkup, a chat with your lover-can go a long way. That includes washing before and after sex for men, particularly after anal sex and before vaginal or oral sex. In general, it's best to avoid unprotected sex if you have an STD and during the period of treatment.

The following basic guide to STD care is culled from various sources, with updates on HIV co-infection. Listed below are the 12 main STDs (excluding HIV) and their causes, primary symptoms, standard treatments and HIV-related concerns. Additional therapies are listed in the table of HIV-related illnesses. Don't forget that good nutrition, a daily multivitamin and acidophilus supplements may help fight STDs, especially vitamins A, C, B complex and zinc; many alternative therapies also exist. There are many new STD treatments in the works, so check with your health provider and HIV groups for updates. For more information on STD treatment and screening, call the CDC STD hotline at 1-800-227-8922. Updated guidelines can be found on the Internet at: http://www.cdc.gov/nchstp/dstd/dstdp.html or call 1-888-232-3228 (prompts, 2-5-1) to order copies.

Gonorrhea is a venereal disease that is caused by the Neisseria gonorrhoeae organism. It is spread by sexual contact and blood. Infected mothers can also transmit the infection to their newborns through the birth canal. Gonorrhea infects the genitourinary tract, particularly the urethra and cervix in women and the urethra in men. The infection can also affect the rectum, pharynx, and eyes. It can be spread to the eyes of the infected person by contaminated hands. If untreated, gonorrhea can spread through the blood to other parts of the body and cause pain and tenderness in the pelvis, lower abdomen, liver, and other affected sites.

Due to a high incidence of co-infection of gonorrhea and chlamydia, experts recommend regular screening for both infections.

Primary symptoms: Some men have no symptoms; most women have no or mild symptoms. In men: After an initial three-to-six day incubation period, gonorrhea may cause redness, swelling, burning and itching of the penis and urethra at the site of infection, and a thick, white smell discharge. In women: Vaginal swelling, itching, burning, pain or tenderness in the lower abdomen, and a greenish-yellow discharge from the cervix. Vulval symptoms are more serious before puberty and after menopause. If untreated, gonorrhea may cause pelvic inflammatory disease (PID) and sterility. Women should be checked on every gynecological visit.

Gonorrhea can be spread through oral sex from a man's penis to a sexual partner's throat (pharyngeal gonorrhea). There may be no symptoms in the affected partner, or a sore throat and swollen lymph glands.

Treatment: Penicillin; spectinomycin for those allergic to penicillin; pregnant women should avoid quinolones or tetracyclines and use cephalosporin or spectinomycin. All states now require newborns to be treated with silver nitrate or other antibiotic drops to prevent gonococcal conjunctivitis (gonorrhea of the eyes).

HIV-Related Concerns: Gonorrhea may facilitate HIV transmission. Follow-up screening is important.

Chlamydia is the most common STD in the United States and infects an estimated 4 million Americans a year. It is caused by the bacterium Chlamydia trachomatis. Regular screening is recommended for chlamydia, and a new sensitive polymerase chain reaction (PCR) test is available. If untreated, the disease can lead to serious genitourinary and reproductive complications. Signs of infection vary depending on the specific type of chlamydial infection and the route of transmission to tissue.

Symptoms: About 10 percent of men have no symptoms; Four-fifths of women have no symptoms. Signs of infection may appear late in the course of disease. Initial symptoms are similar to gonorrhea, but milder and typically appear one-to-three weeks after exposure. In men: Redness, tenderness, itching and burning of the urethra and head of the penis or site of infection, with a discarge (odorous, mucous or clear), and swelling of the scrotum. If the infection spreads to the prostate, it may cause lower back pain, frequent or painful urination, and painful ejaculation. In women: Increased vaginal discharge seven to 14 days after exposure. Other signs include painful urination, unusual bleeding after sex, low abdominal pain, inflammation of the cervix, tenderness of the uterus and lymph nodes, PID, chills and fever. Women should be checked for chlamydia on every gynecological visit. About eight to 10 percent of pregnant women may be infected with chyamydia.

Treatment: doxycycline or azithromycin; alternatively tetracycline. Pregnant women should avoid tetracycline or doxycycline and use erythromycin.

HIV-Related Concerns: Chlamydia may facilitate HIV transmission. Follow-up screening is important.

Trichomoniasis is a genitourinary tract infection caused by the one-celled parasite Trichomonas vaginalis that affects about 10 percent of sexually active men and 15 percent of women. It is sexually transmitted through intercourse. Moist objects can also spread the infection, including damp towels, douche equipment, and toilet seats. Infants may acquire the infection from their mothers at birth. A positive diagnosis may be a marker for other STDs, particularly gonorrhea and chlamydia.

Primary symptoms: Most men and 70 percent of women have no symptoms. In men: Mild to severe inflammation of the urethra, causing frequent and painful urination. In women: Thin, foamy discharge, yellowish-green or gray with a foul odor; severe vaginal itching, redness, swelling, tenderness, painful intercourse, painful or frequent urination, sometimes bleeding after sex, excessive or painful menstrual bleeding. Symptoms may be worse after menstruation or during pregnancy. Untreated trichomoniasis may be linked to an abnormal Pap smear.

Treatment: metronidazole; alternative home treatment is garlic suppository at bedtime for two to three weeks. Unprotected sex should be avoided until treatment is completed. Sexual partners should be treated.

Herpes Simplex Genitalis (also Herpes Simplex II) is a recurrent viral infection caused by Herpesvirus hominis (HVH) which enters the body through the skin and mucous membranes of the mouth and genitals. The virus travels along the nerve endings to the base of the spine, where it locates itself permanently in nerve cells. Herpes Simplex II affects the genital area and is usually passed through sexual contact, from direct skin-to-skin contact during anal, vaginal, or oral sex with someone in the active stage of infection. But most transmission occurs when people are asymptomatic. The virus can be passed from mother to child during birth, causing potentially fatal complications.

Herpes Simplex II is different from Herpes Simplex I, which primarily affects the skin and the mucous membranes of the mouth and face, and causes fever blisters and cold sores. But oral sex can cause a cross-infection of both herpes I and II. A herpes infection of the eye causes swelling of the eyelid (conjunctivitis).

Recurrence of herpes is very common, occuring in 75 percent of cases, usually within three to 12 months after the first outbreak. Recurrences are usually milder and shorter, lasting three days to two weeks, but may be more severe and harder to treat in immunocompromised patients. These new outbreaks are linked to may factors, including illness, lowered immunity, co-infection with other STDS, stress, fever, vitamin B deficiency, heat and cold, menstruation, pregnancy, illnesss, skin trauma, and diet.

Symptoms: First signs are a tingling, aching or itching sensation on the skin in the genital region followed by a burning sensation. Red bumps appear, which turn into fluid-filled blisters that heal within one to three weeks. Other symptoms include fever, headache, tenderness and swelling in the lymph nodes of the groin, and painful urination. The first outbreak is usually the worst and the most painful, taking longest to heal. Other signs in men: pain in the testicles, sores on the legs, buttock, genitals, and inside the urethra with watery discharge. Other signs in women: sores on the cervix which cause no symptoms. Women with herpes have an increased risk of miscarriage and premature delivery.

Treatment: There is no cure for herpes, but treatment can lessen the severity of outbreaks. Acyclovir or famciclovir is used for initial outbreaks; foscarnet is alternative for acyclovir-resistant strains. Topical penciclovir leals lesions, eases pain and stops the spread of infection. Xylocaine cream or ethyl chrloride may help for very painful sores. A natural alternative to control herpes flare-ups is Lysine, an amino acid. Other self-help treatments include Vitamin C, Vitamin E or aloe vera applied to the sore, Echinacea, daily zinc, and acupuncture.

HIV-Related Concerns: Herpes-HIV co-infection may cause more severe, frequent and atypical recurrences of herpes and make herpes hard to treat. Herpes also appears to increase HIV infection. There is also correlation between a fall in CD4 T-cell counts and herpes infection and herpes recurrence. Experts say the initial dose of acyclovir should be increased in immunocompromised patients. Chronic oral or IV acyclovir may be used for frequent or severe infections, followed by suppressive therapy, and in immunocompromised patients (but not pregnant women).

Chancroid is caused by the streptobacillus Haemophilus ducreyi and is transmitted through sexual contact. Poor hygiene, especially in uncircumcised men, can predispose them to chancroid. The infection occurs worldwide, more frequently in tropical countries, and is more common in men than women.

Symptoms: Painful genital ulcers (ulcerative lesions) and inflammation of the lymph nodes or glands in the groin (inguinal adenitis). After a three- to five-day incubation period, a small papule (bump) develops at the site of infection, usually the groin or inner thigh, but also on the penis, vagina, vulva, cervix, tongue, breast, lip, or navel. These quickly become painful, soft and smelly, and turn into pus-filled ulcers that are gray and shallow, with irregular edges up to an inch in diameter. Lymph node swelling occurs two to three weeks later. Headaches and malaise may occur.

Treatment: Azithroymycin (safety for pregnant women is not established); ceftriaxone, erythromycin, ciprofloxacin. Since co-infection with other STDs is common, blood tests for syphilis and a one-week follow-up exam is esecially recommended.

HIV-Related Concerns: A high rate of HIV co-infection has been reported in people with chancroid, especially in developing nations. Experts recommend testing for HIV on diagnosis of chancroid.

Human Papillomavirus (HPV) and Genital Warts (also Venereal Warts, Condylomata Acuminata) There are over 60 types of HPV; 20 types infect the genital tract. HPV-16 and HPV-18 are linked to invasive cancers of the cervix, anus, penis and vagina; HPV-31, 33 and 35 also cause anogenital cancers. HPV-6 and HPV-11 cause genital warts, which are usually visible benign warts on the genitals. The warts are spread by sexual contact and are contagious during the incubation period, as well as after they appear. Warmth, moisture, poor hygiene, and pregnancy can cause them to grow rapidly. Co-infection with other STDs is common. Experts recommend women with genital warts get a Pap smear and a follow-up visit with a gynecologist to monitor HPV infection of the cervix. Men and women who are high risk for HPV should also consider anal Pap smears.

Symptoms: Human papillomaviruses may not cause visible symptoms. Genital warts may hard to detect; subclinical warts appear as flat white areas after application of acetic acid. Warts occur one to six months (two months average) after exposure and begin as hard, tiny red or pink bumps that grow into white or gray clusters that resemble cauliflower. The warts are painless but may be itchy. In men, they appear on the head and sometimes the shaft of the penis and the scrotum. In women, they appear on the vulva, the vagina and cervix. Genital warts tend to grow larger during pregnancy. In either sex, the warts can appear on the region between the genitals and around the anus.

Treatment: There is no treatment to eradicate HPV. Removal is the primary goal of treating genital warts, but recurrence rates are higher than 25 percent. About 20-30 percent of warts clear up spontaneously. The removal of warts may or may not decrease infectivity. Warts can be treated with drugs like imiquimod, trichloracetic acid, podophyllin solution, 5-fluorouracil cream, and alpha-interferon; and by freezing and laser surgery. Pregnant women can't use some drugs like podophyllin that are absorbed by the skin and may cause birth defects or fetal death. Protect the skin around warts with petroleum jelly (Vaseline). Alternative treatment is podofilox.

HIV-Related Concerns: Co-infection with various types of HPV is common and poses an increased risk of cancers linked to HPV types 16 and 18. In men: New studies show HIV-positive gay men may develop persistent HPV infections and are a high risk for HPV-related anal cancers. In women: Approximately 25 to 40 percent of Pap smears are abnormal in HIV-positive women. They are also seven times more likely to have persistent HPV infections than HIV-negative women and have a greater risk of having HPV types 16 and 18 that are linked to cervical cancer. Recurrence of HPV has also been linked to a drop in CD4 T-cell counts below 200. For that reason, experts recommend aggressive screening for HPV, including Pap smears every six months. Experts also suggest gay men and women consider anal Pap smears. In women with HIV, external warts on the vulva, perineum, and anal areas may become florid and respond inadequately to treatment. Recent reports show 5-fluorouracil cream works well in HIV-positive women.

Syphilis is a chronic, genital ulcer disease caused by the bacterium Treponema pallidum. The disease is primarily transmitted through sex, but can be spread through skin contact (by penetrating broken skin) with someone in the infectious stages of the disease. The spirochete enters the mucous membrances of the anus, genitals, and mouth and spreads to the blood and lymph nodes. When untreated, syphilis has four stages: primary, secondary, latent, and late. Early treatment can successfully treat the infection, but if untreated, syphilis can lead to severe complications and death.

Symptoms: Primary stage: After an average three-week incubation that can last from nine to 90 days, a painless chancre that looks like a pimple, blister or ulcer appears. It is very infectious and usually appears on the genitals, but may show up on the anus, fingers, lips, tongue, nipples, tonsils or eyelids. In women, the chancres may be on the inside of the vagina or cervix, and are often easy to miss. In men the sores are on the penis and scrotum or hidden in the folds under the foreskin. Swollen lymph glands in the groin may be another sign of infection. The chancres go away after three to six weeks, but the infection continues to spread. Secondary stage: Symptoms develop a few days up to eight weeks after the chancre first appears, and may last for weeks to months, sometimes years. These include swollen lymph glands, an all-over body rash or rash on the palms of the hands and soles of the feet, and flu-like symptoms. The chancres are highly infectious. Latent stage: This stage lasts 10-20 years and is still contagious for the first few years. There are no outward symptoms, but the disease invades inner organs. Late stage: Not contagious, but causes severe illness, attacking major organs and the central nervous system.

Treatment: Benzathine penicillin for primary, secondary, and latent infections; the alternatives are Doxyclycline for penicillin-allergic patients who are not pregnant, or tetracyclines. Aqueous penicillin is used for late-stage neurosyphilis.

HIV-Related Concerns: Syphilis stimulates HIV activity (if you already have it.) Syphilis may be harder to treat in an HIV-positive individual and treatment failures are more common.

Molluscum contagiosum is a benign viral infection caused by skin-to-skin contact that causes small lesions on any part of the skin except the palms or soles of the feet.

Symptoms: Small pearly white or flesh-colored papules with "punched out" centers that usually appear on the face or genitals. They can be itchy and spread rapidly.

Treatment: Treatments are done for cosmetic reasons and include topical drugs like cantharidin, podophyllin, 5-fluorouracil, tretinoin, cidofovir; laser surgery, cryotherapy, acid peel, curetage, liquid nitrogen.

HIV-Related Concerns: Molluscum can be harder to treat in someone with HIV. Reports show highly active antiretroviral therapy (HAART) has reduced rates of molluscum.

Bacterial Vaginosis (BV; formerly Gardnerella or Hemophilus) only affects women and is a vaginal condition linked to the organism Gardnerella, but is most likely due to overgrowth of mixed bacteria that causes an imbalance of the natural vaginal flora. The infection can be sexually transmitted, and may be spread through moist objects, such as washcloths, towels, swimsuits, etc. If left untreated, BV can lead to gynecological and obstetrical complications, abnormal vaginal bleeding, and abnormal Pap smears, urinary tract infections.

Primary symptoms: May be asymptomatic. Most common: a vaginal discharge with a fishy smell.

Treatment: Female sexual partners should be treated, since concurrent infection is possible. Male partners are not usually treated. Metronidazole is the standard drug used; alternatives are vaginal sulfa cream (less effective). For pregnant women or alcohol-intolerant people, use ampicillin, amoxicillin, or augmentin. Alternative home treatment is a garlic suppository once at bedtime for two-three weeks. Lactobacillus acidophilis is used to balance vaginal flora.

HIV-Related Concerns: Recent studies show that BV increases a woman's risk of acquiring HIV in direct proportion to the severity of the bacterial infection. Some experts believe in treating immune-suppressed women even in the absence of clinical symptoms.

Crabs (Pubic Lice or Pediculosis pubis) are parasitic lice shaped like tiny "crabs" that live in pubic hair and sometimes chest hair, armpit hair, eyelashes, and eyebrows. They lay their eggs (nits) in human hair and clothing fibers. When they bite, they inject a toxin into the skin, causing a mild irritation that can lead to a more serious inflammation. Pubic lice are spread through sexual contact with someone who has lice or by lice-infected clothing, bedding, or towels. The lice can be spread to unifected parts of the body by scratching. A magnifying glass can help detect lice. The eggs are usually attached to genital hair, and may be coarse and grainy to the touch.

Symptoms: Intense itching in genital area, skin irritation from scratching; also rash or papules.

Treatment: Permethrin cream rinse; lindane shampoo (not recommended for pregnant or lactating women) or pyrethins with piperonyl butoxide (nonprescription). Itching may continue for a while after treatment. Sexual partners and close household contacts should also be screened and treated if infected. All clothing and bedding should be washed with hot water and bleach, or dry cleaned. Alternative: wait a week before using these items again.

Scabies is a skin infection of tiny parasitic mites called sarcoptes scabiei var. hominis that burrow under the skin, leaving eggs and feces and causing intense irritation and itching. Scabies is highly contagious and is spread by sexual and skin contact and direct contact with infested bedding, towels and clothing (see Crabs).

Treatment: Same as Crabs; additional treatments are sulfur ointment and Ivermectin. Sexual partners and close household contacts should be screened and treated if infected. Clothing and bedding should be washed with hot water and dried at hot temperatures or dry cleaned.

HIV-Related Concerns: Scabies can be worse if you have HIV, ranging from itchy skin to widesoread crusted blisters .

Viral Hepatitis is a common systemic disease that damages the liver. There are six major types of hepatitis (A through G; type F has been ruled out); several are known to be sexually transmitted; others are suspected to be. Co-infection with different types of hepatitis and with HIV occurs and poses a special problem for HIV-positive people. There is also a risk that a pregnant women can pass on hepatitis to her fetus. Hepatitis is a high risk for injection drug users who share dirty needles.

Vaccination: There are preventive vaccines for hepatitis A and B. Anyone with a household or sexual contact with someone with hepatitis A or hepatitis B should be vaccinated. The hepatitis B vaccine is recommended for all children, and for those at high risk for the disease, including anyone with a history of STDs, sexually-active adults with multiple partners, gay and bisexual men and injection drug users. Some doctors suggest those with chronic hepatitis C be vaccinated for hepatitis A.

Hepatitis A (HAV) is rising among gay and bisexual men and in people with HIV-related immunosuppression. It is highly contagious and spread by oral-anal and digital-rectal sex and may be transmitted from a mother to her fetus. It can also be spread though contaminated water, milk, or food, including seafood. Acute hepatitis A is very dangerous in someone with chronic hepatitis B or C. Hepatitis B (HBV) is increasing among gay and bisexual men, HIV-positive individuals, and intravenous drug users, and is spread through sexual contact or contact with genital fluids and feces, and from a mother to her fetus. Hepatitis C (HCV) is spread primarily through blood transfusions from asymptomatic donors or dirty needles. Co-infection with HIV is estimated to affect 40 precent of people with HIV and 90 percent of injection drugs users. The virus may be passed from mother to fetus. Hepatitis D (HDV) is only found in people with acute or chronic hepatitis B co-infection. Hepatitis E (HEV) is transmitted much like hepatitis A and is hard to detect. Hepatitis G (HGV) is considered an STD that commonly occurs with hepatitis B and C co-infection and can be transmitted from mother to fetus.

Symptoms: Early stage: fatigue, anorexia, malaise, depression, headache, weakness, nausea with vomiting, sensitivity to light, jaundice, abdominal pain, changes in taste and smell, fever, and dark-colored urine. Clinical stage: elevated liver enzymes, itchy skin, jaundice, fever, abdominal pain, indigestion, nausea, and enlarged liver.

Treatment: Various antiviral drugs used alone or in combination can control active infection but do not completely eradicate viral hepatitis (see table, "HIV-related illnesses").

HIV-Related Concerns: Co-infection with different types of hepatitis occurs, and is a serious problem for HIV-positive people. HIV drugs may harm the liver and cause drug-related hepatitis. Chronic hepatitis remains a problem for those with HIV. To date, HIV-related combination therapies have had little effect on preventing viral hepatitis. HIV infection can also impair the body's response to hepatitis B vaccine, so HIV-positive individuals who are vaccinated should be tested for hepatitis B after the third vaccine dose.

-ACD