Roundups Sexual Health

STI News: Chlamydia and Gonorrhea Rates Rise, STIs in NYC Concentrated in Low Income Zip Codes, and HPV Reactivates

Martha Kempner

The CDC surveillance numbers for 2011 show that gonorrhea and chlamydia are up especially among young people and that three-quarters of all syphilis cases are among men who have sex with men; an analysis of STIs in New York City finds they are inextricably linked to poverty, and research suggests dormant HPV may reactivate as women near menopause.  

CDC Releases STI Statistics for 2011, Rates Go Up Especially Among Young People and MSM

Last week the Centers for Disease Control and Prevention (CDC) released tracking data on three Sexually Transmitted Infections (STIs): Chlamydia, Gonorrhea, and Syphilis. The news is not great; rates of these infections are going up especially among some groups.  

The report found that in 2011:

  • 1.4 million chlamydia infections were reported to the CDC. The rate of cases per 100,000 people increased 8 percent, to 457.6 in 2011 from 423.6 in 2010.
  • 321,849 gonorrhea infections were reported to the CDC. The rate increased 4 percent to 104.2 cases per 100,000 in 2011 from 100.2 in 2010.  
  • 13,970 cases of primary and secondary syphilis were reported to the CDC. The rate of 4.5 cases per 100,000 was unchanged from 2010.  

According to the report, the majority of cases of both gonorrhea and chlamydia were found in young people ages 15 to 24. Specifically, 27 percent of gonorrhea cases were among adolescents ages 15 to 19 and 35 percent of gonorrhea cases were among young adults ages 20 to 24. The break downs for chlamydia cases were similar with adolescents 15 to 19 accounting for 32 percent of the cases and young adults ages 20 to 24 accounting for 38 percent of cases. This is particularly disturbing because if untreated both chlamydia and gonorrhea can lead to Pelvic Inflammatory Disease which is a major cause of infertility among young women. 

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The 2011 trends for syphilis found that 72 percent of cases of primary and secondary syphilis occurred among men who have sex with men. The CDC explains that primary and secondary syphilis “are the most infectious stages of the disease, and if not adequately treated, can lead to visual impairment, stroke, and in rare cases, even death.” Syphilis also increases an individual’s risk for HIV infection—in part because it increases an HIV-positive individual’s viral load which makes him/her more contagious. The CDC concludes:

“Given the high prevalence of HIV in the MSM community, increasing syphilis infections among men who have sex with men are particularly troubling.”

This report is a good opportunity to look at trends in reported cases of STIs but it likely does not capture the extent of this epidemic of this country. In truth, these STIs often have no symptoms and many individuals who are infected go undiagnosed. Moreover, the CDC does not collect data on other common STIs including HPV, Herpes, and trichomoniasis, all of which are quite widespread. In total, the CDC estimates that over 19 million new cases of STIs occur in this country each year and that STIs cost the health care system approximately 17 billion dollars each year.

To combat this epidemic the CDC recommends that all sexually active young women under 25 and all older women considered at-risk (such as those in new relationships or communities with high STI rates) get screened for Chlamydia each year; at-risk sexually active women should be screened for gonorrhea annually; and all sexually active men who have sex with men should be screened each year for chlamydia, gonorrhea, syphilis, and HIV.

It is also important to remember that condoms are highly effective in preventing STDs.  

STIs in New York City Concentrated in a Few Zip Codes

Also released last week was a report by New York City’s Department of Health and Mental Hygiene that used 2010 STI data and census data to determine where the city’s STI cases were most concentrated. The department analyzed disease data on HIV/AIDS, hepatitis B, hepatits C, chlamydia, gonorrhea, syphilis, and tuberculosis (which is a communicable disease though not sexually transmitted). High-morbidity zip codes were defined as those with disease rates in the top 20 percent of all NYC zip codes. Zip codes were then given a score (0-7) indicating the number of diseases for which they had rates in the top 20 percent.  

The study found that: 68 percent of zip codes in the Bronx were in the top 20 percent for multiple STDs, compared to 45 percent of zip codes in Manhattan, 25 percent in Queens, and 22 percent in Brooklyn. No zip codes in Staten Island were in the top fifth for multiple STDs.

Not surprisingly, poverty and STI Rates are inextricable linked. The study found that 19 zip codes with high rates of poverty in the South Bronx, north-central Brooklyn, and northern Manhattan had HIV/AIDS, chlamydia, and gonorrhea rates in the top 20 percent. Perhaps most telling are the results for the Tremont section of the Bronx. This neighborhood ranked in the top quintile for all of the seven diseases surveyed and 43 percent of its residents live below the federal poverty line.

HPV Makes a Comeback in Menopausal Women

A new study in the Journal of Infectious Diseases suggests that HPV may make a comeback in women as they near menopause. The study looked at over 850 women ages 35 through 60 who had cervical cancer screening between 2008 and 2011. Though the study did find that women who had had a new sexual partner within the six months prior to screening were more likely to have HPV, these women accounted for only 3 percent of those in the sample. Other women tested positive for HPV without having had new partners. Researchers believe the cause of this to be a reawakening of a dormant infection.

The researchers suggest that a woman’s immune system may be capable of controlling or suppressing HPV when she is young but as the immune system weakens with age, the virus can come back. They liken this to what has been show to happen with the varicella zoster virus which causes chicken pox: “The virus can lie dormant in the bodies of people who were infected as children, then come raging back as shingles later in life.” Though linked primarily to cervical cancer, HPV is also linked to cancers of the head and neck, vulva, vagina, penis, and anus all of which could pose great risk for the older population.

This new research also found that the 77 percent of the women who tested positive for HPV reported having had five or more lifetime partners. The researchers suggest that the women entering menopause now—who came of age during or after the sexual revolution of the 60’s and 70’s—will be at far greater risk of reactivated HPV infections than the generations before them who were much less likely to be exposed to the virus in the first place.

The authors conclude that these finding may mean we have to change our screening measures to include more regular pap smears for women over 40 years of age. 

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.