Gonorrhea, chlamydia, and syphilis are all included on the Centers for Disease Control and Prevention’s (CDC’s) list of nationally reportable infectious diseases.⁶ Gonorrhea (commonly referred to as “the clap”) infects the penis, vagina, or anus and causes pain, burning,
and discharge. Although the 2003 infection rate may appear high—116.2 cases per 100,000— it actually represents a declining trend and is the lowest U.S. rate ever reported for this infection. There are no significant differences in rates between women and men.⁷

In contrast, chlamydia is a nonulcerative infection with few symptoms, especially in women. Rates of this infection rose 5.1% to 304.3 cases per 100,000 people between 2002 and 2003. Rates of chlamydia are three times higher in women than in men. Infection with gonorrhea or chlamydia can lead to pelvic inflammatory disease (PID), an infection of the womb, fallopian tubes, and reproductive organs leading to infertility, ectopic pregnancies, abscesses, and pelvic pain.⁷

Syphilis, which had been on the decline in the United States, has been increasing since 2001. Most of the increased incidence appears to be in men, and incidence rates are five times higher in African Americans than in Whites. Although the 2003 rate of 2.5 per 100,000 seems low compared to that of other bacterial STIs, close monitoring is warranted. Syphilis is readily treated in its early stages, but has the capability to spread throughout the body, affecting the heart, brain, and nerves and, as a result, may present clinically with more debilitating features.⁷ HIV can lead to reactivation of latent syphilis. In particular, HIV-positive individuals have earlier neurologic involvement and higher risk of developing neurosyphilis, an infection of the brain or spinal cord, than their HIV-negative counterparts.⁸

Viral STIs are frequently asymptomatic, and most are difficult to treat or incurable. The lack of effective treatments for viral STIs necessitates that individuals at risk be tested frequently to ensure that they are not unwittingly transmitting infections to others. The most common viral infections include HSV-2, HPV, CMV, HBV, and HCV. With the exception of HBV, none of these infections is included on the CDC’s list of nationally reportable infectious diseases; therefore infection rates are typically estimated from initial visits to doctors’ offices. HSV-2 produces ulcers in many of the mucosal regions and is readily transmitted through exchange of body fluids during, and in the days surrounding, an outbreak. Between outbreaks, the virus lies dormant in the nerves surrounding the genital area. During outbreaks, viral shedding is more active and risk of infection of both HSV-2 and HIV is greater. Sexual contacts should be avoided when HSV-2 is symptomatic, particularly for coinfected persons. Individuals with AIDS have more severe outbreaks, and ulceration can occur on other body surfaces (e.g., skin, eye, mouth, ear). The virus can also disseminate to the central nervous system (CNS), leading to encephalitis and resultant permanent neurologic damage or death. In the United States, HSV-2 is prevalent and in high-risk subpopulations seropositivity rates are as high as 50%.⁷

HPV, also known as genital warts, presents as wartlike growths or abnormal cell changes in the genital area and cervix. At any given time in the United States, 20 million people have HPV and approximately 6.2 million are newly diagnosed each year. Although HPV cannot be cured, the infection usually subsides on its own. HPV is more prevalent in women, and approximately 80% of the female population acquiring HPV will do so by the age of 50. Women are usually diagnosed by a Pap test, which screens for cervical cancer.⁷ The rate of coinfection of HPV with HIV is 60% to 77% in women. HIV-positive women have been shown to have a higher rate of persistent types of HPV often associated with cervical intraepithelial neoplasia (CIN) and cervical cancer.⁹

CMV is a member of the herpesvirus family and can remain dormant for long periods. CMV is transmitted via body fluids (including semen, urine, blood, saliva, tears, and breast milk) of infected individuals. The infection is not highly contagious and often can be prevented by simple hand washing. However, CMV antibody can be detected in 50% to 85% of U.S. adults by the time they are 40 years of age. Signs of infection include mononucleosis- like syndrome, prolonged fever, and mild hepatitis. Once infected, the virus can lie dormant for years unless the immune system is suppressed. CMV is of particular concern for HIV- infected individuals. As immune function decreases (i.e., CD4 count reduction), this infection can cause pneumonia, retinitis (eye infections, which can lead to blindness), mucosal ulcers, and gastrointestinal disease. Approximately 5% of HIV-positive individuals have active CMV infection.¹⁰

HBV and HCV, blood-borne infections that affect the liver, can be transmitted via body fluids (most commonly blood and semen). The coinfection rate of HBV is 70% to 90%, with higher rates representing those with a history of intravenous drug use. Although conflicting data exist on the effect of HBV on HIV infection, it does not appear that HBV significantly affects HIV progression. However, HBV carriage rates in HIV-positive individuals are 25% compared to 5% in HIV-negative individuals, indicating HIV affects HBV replication and clearance.¹¹

Approximately 4 million people in the United States have been infected with HCV. At highest risk of contracting HCV are individuals who inject drugs and share needles, those who body pierce or tattoo with unsterilized needles, and health care workers who come into direct contact with blood. Although blood-borne transmission through injection behaviors are the primary source of infection, the CDC now estimates that 15% to 20% of HCV infections are contracted through sexual transmission.⁷ Although most infected individuals are asymptomatic, HCV can develop as a chronic condition characterized by flulike symptoms, fatigue, jaundice, and liver pain 15 to 20 years postinfection. Because of the potentially long asymptomatic
period of HCV, estimating the incidence of new infections is difficult and under-reporting is a problem.¹² Approximately one fourth of HIV-positive individuals are coinfected with HCV. In coinfected individuals, HCV infection progresses at a faster rate than in those with HCV alone and response to HCV treatment is decreased. HCV, however, does not increase the rate of HIV multiplication, though damage caused to the liver can make it difficult for some HIV medications to be absorbed. Consequently, medications may be less effective and medication side effects may be more pronounced.¹³ Similarly, coinfection increases the risk of hepatotoxicity of HAART, making treatment of HIV problematic. Because of this stress on the liver, coinfected individuals must be mindful of risk factors that could result in an additional hepatitis infection. As a precaution, coinfected individuals are advised to be vaccinated against HBV.