Last partial update: July 2016 - Please read disclaimer before proceeding
Avoiding Sexually Transmitted Diseases
Most sexually transmitted diseases (STD) can be prevented by common sense and a responsible attitude to sex. This unfortunately is not always the done thing and unsafe sexual practices are responsible for about one per cent of all burden of disease. The list of serious sexually transmitted diseases is large and includes HIV/AIDS, hepatitis B, genital herpes, chlamydia, syphilis, genital warts and gonorrhoea. Cervical cancer from Human Papilloma Virus could also be added to this list and the trauma associated with an unwanted pregnancy should not be forgotten.
STDs are most common in young people. (The average age of infection with chlamydia in Australia is 15 to 24 years in women and 20 to 35 years in men.) Young people are more vulnerable because they are less likely to be in a long-term relationship, are more likely to have multiple partners, and are more likely to take risks such as participating in intercourse without condoms.
Preventative measures were partly covered in the section on the preventing teenage pregnancy and this section is worth reading again. Prevention should include the following.
- Anticipation / effective contraception People who are sexually active or soon likely to be need to see a doctor to obtain adequate contraception and advice about protection from STDs. Unfortunately, about 50 per cent of first time intercourse occurs without contraception. This is a topic that parents need to discuss with their daughters early on in their teenage years as feeling uneasy about approaching their family doctor is a major reason teenage girls (and boys) fail to address this issue. While condoms are certainly better than nothing, they are not the most effective form of contraception and using a more effective form of contraception, usually the oral contraceptive pill, as well is by far the best option.
- Use condoms. Unless both partners have decided to have one sexual partner for a prolonged period (not just a few months), condoms need to be used with intercourse. This applies to both heterosexual and male homosexual relationships. To be useful, they need to be carried when use is likely. People should not rely on their present partner’s version of his or her previous sex life (or lack thereof) in deciding on the need to use condoms, especially if it is early on in the relationship. Research has shown that such stories are often not factually based. If couples have made the decision to become monogamous, then both partners probably need to be checked by a doctor first for sexually transmissible diseases. If either partner thinks this is too much hassle, then the long-term nature of the commitment should perhaps be questioned. Would a person really want to transmit a disease to a potential lifetime partner that he or she loves? Some sexually transmitted diseases, such as chlamydia, have very few symptoms and either partner may be unaware they have this disease. Diseases such as genital herpes and genital warts can be present on areas that condoms do not cover and thus transmitted even when condoms are being used.
- Oral sex is not safe sex: Oral sex can also be involved in the transmission of STDs and it is important to realise that oral sex is not safe sex. The most common infection involved in oral transmission the herpes simplex virus that causes cold sores (HSV1). Having oral sex with someone with this virus, especially if there is an active cold sore present, can cause a genital infection identical to the one caused by the genital herpes virus (HSV2).
- Discuss sexually transmitted diseases with your partner. As stated, people are not always completely honest when it comes to discussing sexually transmitted diseases. However, any information that a partner does reveal about past or present STDs can only help and it does provide an opportunity for extra trust to develop in the relationship. This does not mean not using condoms if a partner says all is OK as some STDs have few symptoms and many people are not aware they have these STDs. Examples of such conditions include chlamydia, genital warts and even more serious diseases such as HIV/AIDS.
- Avoid excessive alcohol consumption: Try to avoid excessive alcohol consumption, especially ‘loading doses’, as it reduces inhibitions and make people far more likely to engage in unintended sexual activity that may later be regreted. It also increases the risk of date rape.
- Learn refusal skills and skills to avoid date rape. (Information regarding this topic can be gained from one of the excellent texts and references mentioned below.)
- Discuss problems with your GP: People who are worried that they have a sexually transmitted disease should not be apprehensive about seeing their doctor. Doctors realise that such consultations are often difficult for patients and will be sympathetic and helpful.
Diseases that are predominantly transmitted by sexual intercourse
Chlamydia – A sexually transmitted disease epidemic in Australia
Chlamydia is a sexually transmitted infection that is increasing greatly in incidence in both young men and young women; the incidence in Australia has increased significantly over the past 12 years. (74,300 cases were reported in Australia in 2010.) It is difficult to diagnose because in both men and women there are often very few symptoms, if any. At least 50 per cent of infections are symptom free. Women with the infection sometimes experience a vaginal discharge, pain with sexual intercourse or abdominal pain, but most symptoms are mild and transient and thus not acted upon. The highest rates of infection occur in 15 to 25 year old females, the group most at risk of contracting the disease, and 25 to 35 year old males. However, the disease is present in all adult age groups.
Long-standing chlamydia infection in women is important because it can cause infections around the ovaries and fallopian tubes. The resultant scarring may lead to fertility problems, with about five per cent of women with the disease becoming infertile. It can also result in ectopic pregnancies. (Ectopic pregnancies are pregnancies that occur in the fallopian tubes and they can cause serious problems due to bleeding.)
The main risk factor for chlamydia is having multiple sexual partners.
To assist in preventing transmission of this disease, it is important that condoms are used with all sexual intercourse. When entering a long-term relationship, it is important that both partners are tested for chlamydia and other sexually transmitted diseases before condom use is ceased. (In the past, it has mostly been women that have been tested for the disease.)
Chlamydia screening programs have been introduced in several countries and have helped to significantly reduce the incidence of the disease. Those at high risk (i.e. people who do not use condoms all the time, especially if they have multiple sexual partners) should discuss being screened for the disease on a yearly basis with their GP. Pap smear visits are a good time to also do clamydia screening tests, although Pap smears are usually done every two years. At present few at risk females are screened in Australia. Some GPs are wary about talking to young people about their sexual activity, fearing that it might stop them from coming back. Thus, do not be afraid to bring up the topic even if a doctor doesn’t.
Chlamydia infection is diagnosed by testing a urine sample and is easily treated (with antibiotics); but re-infection will obviously occur unless condom use is maintained and all present sexual partners are treated. Past partners should also be notified and future long-term partners will need to be screened for the disease.
Genital herpes
There are two herpes simplex viruses that cause genital herpes; type 2 (HSV-2) and type 1 (HSV-1). HSV-1 is the usual cause of cold sores around the mouth but it can also cause genital herpes if oral lesions are present when oral sex is practiced. The HSV-2 virus is the more common cause of genital herpes, although in the under 20 age group HSV-1 has become the more common virus involved, presumably because of a higher incidence of oral sex.
Genital herpes is most commonly acquired in late adolescence and early adulthood and the risk increases with the number of sexual partners. In all, about 90 per cent of adult couples will have at least one partner who previously contracted oral HSV-1 from exposure to an oral cold sore, most commonly in childhood. Thus, most couples will be exposed in some way to this virus. People who have previously been had oral HSV-1 cold sores are immune from getting HSV-1 genital infections and tend to get less severe initial HSV-2 infections which are often asymptomatic. Thus, many HSV-2 infections go unnoticed.
Constant condom use is not 100 per cent effective in preventing transmission of genital herpes but is helpful in preventing transmission from an infected male to a female partner. Condom use is less effective in preventing female to male transmission, mainly because the usual site of infection in females is the vulva. However, while condom use can slow down the process, the reality is that in a long-term relationship an infected partner will almost always infect an uninfected partner eventually. (The rate is about 10 per cent per year.)
A person with their first infection usually has an irritated looking red rash that may be blistery and ulcerated. It is often painful and can last up to three weeks. However, milder presentations are becoming increasingly common with some mild enough for the condition not to be noticed. The severity of the infection is more to do with the immune response of the infected person and not the virus itself. Thus, there is no guarantee that a person infected from a partner with mild symptoms will also develop an infection with mild symptoms. Very severe reactions including spread to other parts of the body including the brain can occur in people who have a compromised immune system e.g. people with HIV.
Both herpes simplex viruses unfortunately continue to live in the skin nerve endings near the site of the initial infection and recurrences of the infection occur at regular intervals. These recurrences are milder than the initial infection, often lasting less than a week and tend to become less frequent with time.
Most people who test positive to HSV-2 have no idea that they have the disease. It is likely that most transmissions occur from people with a mild, asymptomatic infection (i.e. little or no evidence of infection) and people who have had obvious evidence of the disease are still likely to be infective at times when they have no symptoms; that is, in between recurrences. (It is still wise however not to have intercourse while active infection is present.)
Testing for the disease is best done by taking a PCR swab from an active lesion. Blood testing is not as helpful as it does not tell where the infection lies. (It will be positive in people with an oral cold sore as well.)
Blood testing can however be useful in testing a woman who wishes to become pregnant and has a male partner with the disease. Women who become infected while they are pregnant have an increased risk of transmitting the illness to the foetus, especially if the infection occurs in the third trimester. If the woman is not infected, treatment of the male partner throughout the pregnancy with suppressive anti-viral drug therapy and abstinence from vaginal sex later in the pregnancy is recommended. Transmission to the baby during delivery from a mother with an active infection may also occur and caesarean section is recommended when active infection exists at the time of delivery.
Treatment is with the antiviral drugs acyclovir and valaciclovir. These medications reduce the severity of initial infections but treatment of the initial infection does not influence the incidence of recurrent infections. However, long-term suppressive drug therapy does reduce recurrence rates by about 70 per cent and will obviously also help reduce the likelihood of transmission; but not eliminate it!! (This is particularly useful early in relationships and in pregnancy as described above.) The use of antiviral drugs during recurrences reduces the length of infections by up to 24 hours.
Unfortunately there is no vaccine against this disease.
HIV/AIDS
HIV is a viral infection that is mainly transmitted through sexual intercourse, with anal intercourse being the easiest method of spread. In Australia it mainly occurs in homosexual men (89 per cent), with the average age at diagnosis now being about 34 years in this group. Heterosexual transmission is responsible for about 10 per cent of new cases.
In Africa and other developing countries, vaginal intercourse is the more common method of spread. Transmission associated with intravenous drug use accounts for only about two per cent of cases in Australia but is a more common method of spread in Europe, Asia and the USA. Worldwide there were five million new cases in 2003.
Transmission by accidental needle stick injury only occurs in about 0.3 per cent of exposures to needles used by infected individuals and transmission by blood transfusion is exceedingly rare.
Perinatal transmission from an infected mother to her baby occurs in about 20 to 45 per cent of cases unless preventative measures are taken. Such preventative measures can reduce this rate to about 5 per cent and include antiviral drug treatment during the pregnancy, the labour and after delivery, birth by caesarean section, and avoidance of breast feeding.
Generally the rate of HIV infection is starting to increase again and between 2000 and 20005 there was a 41 per cent increase in new case diagnosed. (In
Victoria, the number of new HIV cases increased from 140 in 1999 to 286 in 2005.) This increase has coincided with a significant rise in the incidence of unprotected anal intercourse amongst homosexual men. The reason for this is not clear, although it may be that men are less afraid of HIV/AIDS now that there is better treatment available.
Preventing HIV/AIDS infection involves the following.
- Unless both partners are in a monogamous, long-term relationship and do not have any sexually transmissible diseases, safe sex (condom use) needs to be practiced with every sexual encounter, whether vaginal or anal. The unfortunate truth is that many people, whether homosexual or heterosexual, do not think rationally in the ‘heat of the moment’. This is especially unfortunate for gay men who are at greatest risk of HIV/AIDS infection. Unprotected sex by homosexual men is more common:
- after illicit drugs or excess alcohol has been consumed.
- when the person suffers from depression. Depression is relatively common in the homosexual community and better recognition and treatment of this condition may help reduce the rate of HIV infection.
- Practicing safe sex is discussed above.
- People who use intravenous drugs need to ensure that they do not share needles, swabs or any other materials, such as water, spoons etc, that may be contaminated with blood.
- Needle-stick injuries. See boxed section.
- Needle exchange programs need to be expanded throughout Australia so that all those at risk have access to safe injecting materials. All people infected with HIV (and especially hepatitis B or C) need to be especially careful when disposing of blood contaminated materials.
- Infection can also occur with cosmetic procedures that involve piecing the skin, such as tattooing or body piercing (e.g. ear piercing or having studs inserted). It is best to make sure that such procedures are done professionally using instruments that have been properly sterilised (using an autoclave). With tattooing, the repeated skin penetration means there is a significant risk to the operator as well as his/her clients.
- Preventing the infection of babies requires that infected mothers be identified early in their pregnancy. All prospective mothers need to be questioned about whether they are likely to be infected with HIV and should be tested if there is any risk. If positive, they then need to be given careful counselling regarding the best options for reducing the risk of transmitting their infection.
Post HIV exposure prophylaxis
People who have had unprotected sexual intercourse with a person who has HIV or has a high risk of having HIV can reduce their risk of contracting the disease by taking a course of antiretroviral medications. Two or more drugs are usually taken for a period of 28 days and should be commenced as soon as possible after contact (within 72 hours).
Similar post-exposure prophylaxis can be used for needle stick injuries where the chance of HIV exposure is significant. This treatment can give no guarantee of infection avoidance and should never be seen as a back up for using unsafe sexual / drug use practices.
Preventing needle stick injuries Needle stick injuries can be minimised by adequate training of health professionals in the safe use and disposal of needles. Important points include the following.
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Hepatitis B
Hepatitis B is a viral infection that affects the liver, with some chronic infections causing serious liver damage and liver cancer. About 25 to 40 per cent of people with chronic infections die from the disease. Whether infected individuals eradicate the illness or develop a long term chronic infection depends on the age at which they are infected. People who develop the disease in early childhood have 90 per cent chance of being chronically infected. Only about five per cent of those infected in adult develop chronic disease.
Most cases in countries with a high incidence of the disease, such as China, South East Asia and the Pacific nations, occur due to infection from mother to baby at birth. In adults, transmission is mostly through sexual contact or injecting drug use. There are thought to be about 200,000 carriers of the disease in Australia. Transmission by needle stick injury occurs in about three to 30 per cent of exposures from needles used by infected individuals, depending on the infectiousness of the affected person.
Preventing Hepatitis B infection involves the following.
- Hepatitis B infection can be prevented by immunisation and this immunisation is part of the immunisation schedule in Australia. Some older children and adults will not have been immunised and people who are unsure about their immunity status for hepatitis B should discuss the matter with their GP.
- Methods for preventing infection through sexual contact or injecting drug use are similar to those described for HIV/AIDS.
- Infection of newborns can be prevented by the administration of hepatitis B immunoglobin and hepatitis B vaccine to the newborn baby. This needs to be done soon after birth and it is therefore imperative that all mothers who are carriers of the disease are detected early in their pregnancy. (This involves testing those at risk of having hepatitis B and those who have not been immunised against hepatitis B.)
About 90 per cent of cervical cancer is caused by the human papilloma virus that is contacted as a sexually transmitted disease. This topic is covered in detail in the section on cervical cancer.
See section on cervical cancer prevention
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