Outline. HIV and Other Sexually Transmitted Infections. Gonorrhea Epidemiology. Epidemiology 11/2/2012

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1 HIV and Other Sexually Transmitted Infections Tanya Kowalczyk Mullins, MD, MS Division of Adolescent Medicine Cincinnati Children s Hospital Medical Center Outline Epidemiology of select STIs and HIV STIs and HIV Acquisition STIs and HIV Transmission Counseling HIV-Infected Patients STIs and the HIV Epidemic Epidemiology Gonorrhea Epidemiology : Health E-cards Gonorrhea Rates by Age and Sex, 2010 Gonorrhea: Rates by Race/Ethnicity/Sex,

2 Chlamydia Epidemiology Chlamydia Rates by Age and Sex, Chlamydia: Rates by Race/Ethnicity/Sex, 2010 Syphilis Epidemiology Primary and Secondary Syphilis Rates by Age and Sex, 2010 Primary and Secondary Syphilis Rates by Race/Ethnicity and Sex,

3 HIV Epidemiology STIs and HIV STIs play a role in the spread of HIV Two mechanisms: STIs increase susceptibility to HIV = HIV acquisition STIs increase infectiousness of HIV = HIV transmission 3

4 Effect of STIs on HIV Acquisition STIs and HIV Acquisition Disrupts physical barriers (i.e. ulcerations) Inflammation increases the number of HIV target cells in the genital tract and the density of receptors that HIV targets Changes vaginal environment: bacterial vaginosis (BV) or increased anaerobes/amines = more favorable environment for HIV Cohen 2004 Odds of HIV Acquisition Are Increased in the Setting of STIs STI CT Odds of HIV Acquisition (vs. not having the STI) This begs the question If you treat STIs, do you change the incidence of HIV? GC Trichomonas Syphilis Fleming 1999; Hilber 2010; Mavedzenge 2010 Treatment of STIs and HIV Incidence Study in Mwanza, Tanzania Intervention: Trained staff in STI care, treatment of STI syndromes, community health educators provided info on STIs and where to get treated After 24 months: 38% decrease in HIV incidence in these communities 1. Fleming 1999 Treatment of STIs and HIV Incidence A separate study in Rakai, Uganda Intervention: Delivery of in home, directly observed mass treatment of STIs regardless of symptoms every 10 months x 3 waves After 20 months: no decrease in HIV incidence in intervention communities 1. Wawer

5 Why the difference in results? Continuous access to STI treatment more effective than treatment every 10 mos Symptomatic STIs may be more indicative of recently acquired infection = recent risky sexual behaviors. Thus, treatment targets those with highest risk Rakai had more advanced HIV epidemic (prevalence =16%) vs. Mwanza (4%) STIs may play a more important role in earlier phases of epidemic when fewer people are infected The Special Case of Herpes Simplex Virus-2 (HSV-2) At least 25% of US adults are HSV fold increased risk of HIV acquisition in HSV-2 + across all risk groups and regions Evidence suggests that incident (recent) HSV infection is associated with higher risk of HIV acquisition vs. prevalent (older) HSV infection Perhaps due to the increased frequency of HSV reactivation in the first year Reynolds 2005 HSV-2 and HIV Acquisition STIs and HIV Transmission Even asymptomatic HSV-2 is associated with HIV acquisition More CD4 T cells (HIV targets) are present in areas of recurrent HSV-2 (even in healed ulcers for months following an outbreak) HSV-2 upregulates HIV replication leading to establishment of infection HSV ulcers disrupt the protective barrier of the mucosa Reynolds 2005 Sexual Behaviors Influence Risk of HIV Transmission Rate of HIV Transmission and Plasma Viral Load Varghese 2002 log 10 plasma HIV-1 RNA level Lingappa JR et al

6 Risk of Transmission Through Course of HIV Infection HIV Transmission and Seminal Viral Load Galvin 2004 Chakraborty 2001 Effect of STIs on HIV Transmission Increases genital HIV viral shedding HIV is detectable in genital ulcer exudates Genital ulcers may bleed during sex Cohen 2004 STIs in HIV+ Patients in the U.S. 7.1% of 1037 adult women in HIV care acquired GC and/or CT at least once 1 42% of 161 adolescent and adult women in care acquired an STI 2 13% of men were diagnosed with an STI after their HIV diagnosis 3 1. Page Bersoff-Matcha Whiteside HIV+ and Bacterial STIs CT, GC, trichomonas are associated with increased viral shedding in HIV+ women GC and CT are associated with increased genital viral shedding in semen Treating bacterial STIs leads to decreases in HIV viral shedding HOWEVER inflammation persists for weeks, increasing risk for transmission Mayer 2011 Median Concentration of HIV-1 RNA in Semen Among HIV-Infected Men With (n=86) and Without (n=49) Urethritis in Malawi X 10 4 copies/ml *** Similar findings in women after treatment of CT cervicitis (McClelland 2001) Cohen MS

7 HSV-2 and HIV Transmission HSV reactivation associated with increased HIV replication at the mucosa Reactivation also associated with increased serum HIV viral load HSV+ HIV+ patients have higher serum viral load (vs. HSV-) HSV activates latent HIV HSV upregulates cellular transcription proteins = increased HIV viral replication Reynolds 2005; Johnston 2012 Treatment of HSV-2 in HIV+ Daily suppressive therapy for HSV decreases plasma HIV viral load? Inhibitory effects on HIV replication or decreased inflammation = fewer HIV target cells Daily valacyclovir decreased the frequency and amount of HIV genital viral shedding But HSV suppression does not decrease risk of HIV transmission Johnston 2012 Counseling HIV+ Patients Sexual Risk Behaviors in HIV+ Several studies show decrease in sexual risk behaviors after learning HIV status and undergoing counseling However, rise in STIs (including CT and syphilis) in HIV+ men who have sex with men is concerning for ongoing risk behaviors 13.9% of HIV+ men and 11.9% of HIV+ women had a new STI diagnosis after their HIV diagnosis 1 1. Erbelding 2003 The Interface of STIs and HIV CDC recognizes the relationship between STIs and HIV Recommendations (2003) for making STI care and treatment a routine part of the medical care of HIV+ Recommendations for the Care of HIV + Developed by CDC, HRSA, NIH, HIVMA, with evidence-based approach Intended for those providing medical care to HIV+ persons Apply to medical care of all HIV+ adolescents and adults 7

8 Medical providers can impact the HIV epidemic by: Screening for risk behaviors Identifying & treating other STIs Communicating prevention messages Discussing sexual & drug-use behavior Positively reinforcing changes to safer behavior Referring patients for services (such as substance abuse treatment) Facilitating partner notification, counseling, and testing Partner Services Partner services: notification, prevention counseling, STI/HIV testing, linkage to care (e.g. medical, other social services) Integrate partner services for HIV, CT, syphilis, and gonorrhea as patients who have one STI are at risk for others STIs and the HIV Epidemic Circa 1940; National Library of Medicine Archive Is There Evidence that STIs are a Gateway to HIV? STIs are associated with increased susceptibility to HIV infection in those who are HIV- STIs are associated with increased HIV transmission from those who are HIV+ People still practice risky sexual behaviors If we target and treat STIs, HIV incidence can do down Thank you! 8

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