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THE NEGLECTED HEALTH AND ECONOMIC IMPACT OF STDs
Pages 28-68

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From page 28...
... Of the top ten diseases, five are STDs (i.e., chlamydial infection, gonorrhea, AIDS, primary and secondary syphilis, and hepatitis B virus infection)
From page 29...
... Kristina Ramstedt, Swedish Institute for Infectious Disease Control, Epidemiological Department, personal communication, November 1996; 7) United States: Division of STD Prevention, Sexually transmitted disease surveillance, 1995.
From page 30...
... Of these "modern" STDs, some, including HIV infection, human papillomavirus infection, and hepatitis B virus infection, are viral infections that are incurable and are now recognized as major preventable causes of death and disability. The bacterial STDs, such as gonorrhea and syphilis, can be easily diagnosed and successfully treated; others, such as chlamydial infection, are curable but will require a much stronger, coordinated national effort to be brought under control.
From page 31...
... 53,000aNot available AIDS79,897c185,000d HIV infectionNot available630,000-897,000e Chancroid3,500Not available Trichomoniasis3,000,000Not available Pelvic inflammatory disease>1,ooo,ooofNot available NOTE: The Division of STD Prevention, CDC, is currently developing a process for systematically generating and updating incidence and prevalence estimates for specific STDs. aNumber reflects reported cases to the CDC plus estimated unreported cases.
From page 32...
... In one study of female college students presenting for care at a university health center, genital human papillomavirus infections were five times more common than all other STDs combined (Laura Koutsky and King Holmes, University of Washington, unpublished data, 1995~. 2 The term "sexual intercourse" is used throughout this report to refer to all forms of intercourse, including vaginal, anal, and oral intercourse.
From page 33...
... Approximately 200,000-500,000 new cases of genital herpes occur each year in the United States, and 31 million individuals already are infected (CDC, DSTD/HIVP, 1995~. In 1990, the prevalence of antibodies to herpes simplex virus type 2 among persons 15-74 years of age was estimated at 21.7 percent (Johnson et al., 1993~.
From page 34...
... Uncomplicated chlamydial infections can be easily treated with antibiotics (CDC, 1993~; however, primarily as a result of unrecognized and untreated cervical infections, more than one million women each year develop pelvic inflammatory disease (Rolfs et al., 1992~. Impact of STDs on Women's Health Complications of STDs are greater and more frequent among women than men for a number of reasons (Wasserheit and Holmes, 1992~.
From page 35...
... For example, the risk to a woman of acquiring gonorrhea from a single act of intercourse may be as high as 60 to 90 percent, while transmission from a woman to man is about 20 to 30 percent (Holmes et al., 1970; Hooper et al., 1978; Platt et al., 1983; Judson, 1990; Donegan et al., 1994~. Among couples where only one partner was initially infected, the annual risk of transmission of herpes simplex virus was 19 percent from man to woman, but only 5 percent from woman to man (Mertz et al., 1992~.
From page 36...
... Even then, symptoms of pelvic inflammatory disease due to chlamydial infection may be absent or nonspecific, resulting in as many as 85 percent of women delaying seeking medical care, thus increasing their risk for long-term complications (Hillis et al., 1993~. Fortunately, the advent of newer tests for detecting gonococci and chlamydia in urine may permit testing women for these organisms without pelvic examination in the future, as described in Chapter 4.
From page 37...
... Cervical cancer rates and cohort mortality from cervical cancer (Krone et al.,1995; Kathleen Toomey, Georgia Department of Human Resources, unpublished data, 1996) are increasing among young women, undoubtedly a reflection of increased exposure to STDs such as human papillomavirus.
From page 38...
... Although women who only have sex with women seem to be at less risk for some bacterial STDs compared to women who have sex with men (Robertson and Schachter, 1981) , bacterial vaginosis and genital human papillomavirus infections are not uncommon in such women (Berger et al., 1995; Marrazzo et al., 1996~.
From page 39...
... The most wellknown of the recently described STDs is HIV infection. Since HIV-1 was found to be the cause of virtually all cases of AIDS in the United States in the mid1980s, a closely related retrovirus, HIV-2, and a more distantly related pair of retroviruses, human T-lymphotrophic virus types I and II (HTLV-I, -II)
From page 40...
... Using a database of country-specific prevalence rates and estimated regional prevalence rates for each curable STD, WHO estimated that there were 333 million new cases of the four curable STDs worldwide in 1995 among adults 1549 years of age. Prevalence rates for other STDs for which estimates are not available, such as human papillomavirus and herpes simplex virus type 2 infections, are much higher, and the number of adults infected is likely to exceed one billion.
From page 41...
... NOTE: STDs included syphilis, chlamydial infection, gonorrhea, and pelvic inflammatory disease; DALY = disability-adjusted life year. SOURCE: World Bank.
From page 42...
... Much of the cervical cancer burden related to human papillomavirus infection may be averted by preventing high-risk sexual behaviors (Brinton, 1992) , especially avoiding unprotected sex with multiple male partners, some of whom may have chronic genital infection with oncogenic human papillomavirus types.
From page 43...
... In one study, nearly half of female college students tested had evidence of genital human papillomavirus infection (Bauer et al., 1991~. Other STD-Related Cancers Although carcinomas of the vulva, vagina, anus, and penis each occur considerably less frequently than cervical carcinoma, aggregate numbers of vulvar, vaginal, anal, and penile carcinomas equal nearly half the total numbers of cases of cervical cancer in the United States.
From page 44...
... At least onequarter of women with acute pelvic inflammatory disease will experience serious long-term sequelae, the most common and important of which are ectopic pregnancy (the development of a fetus outside the uterus) and tubal-factor infertility.
From page 45...
... Infertility Infertility can occur when the fallopian tubes become blocked or damaged by STDs. Of all infertile American women, at least 15 percent are infertile because of tubal damage caused by pelvic inflammatory disease.
From page 47...
... , or after birth as a result of breast-feeding or close direct contact. Common sexually transmitted infections that have been shown to cause adverse health effects among pregnant women and their infants include chlamydial infection, gonorrhea, syphilis, cytomegalovirus infection, genital herpes, and HIV infection.
From page 48...
... As mentioned previously, ectopic pregnancy caused by previous pelvic inflammatory disease is one of the leading causes of maternal death during pregnancy. Health Consequences for Men In the United States, HIV infection is currently much more common among men than among women.
From page 49...
... The largest number of deaths related to STDs other than AIDS are caused by cervical and other human papillomavirus-related cancers; liver disease (e.g., chronic liver disease and liver cancer) caused by hepatitis B virus; pelvic inflammatory disease and ectopic pregnancy; and various pregnancy, fetal, and neonatal complications.
From page 50...
... As summarized in Table 2-4, three prospective cohort studies in Africa have demonstrated increased risk of HIV infection following genital ulcer disease among heterosexual men (Cameron et al., 1989) and among female sex workers3 3 The term "sex worker" is commonly used by public health workers to refer to persons who exchange sex for drugs, money, or other goods.
From page 51...
... However, an earlier retrospective cohort study in gay men found that herpes simplex virus type 2 infection was a risk factor for HIV infection (Holmberg et al., 1988~. In addition, a study of heterosexual men attending an STD clinic in New York showed that men presenting with chancroid were more likely to become infected with HIV than were men presenting with other STDs (Telzak et al., 1993~.
From page 52...
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From page 53...
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From page 54...
... Although the third explanation may account for at least some of the association of STDs with subsequent HIV infection, there are strong data to support the concept that STDs increase HIV infectivity and HIV susceptibility. An effect on HIV infectivity is strongly supported by the presence of HIV in genital ulcers (Plummer et al., 1991; Kreiss et al., 1994~; by the increased rate of detection of HIV DNA (cell-associated HIV)
From page 55...
... Improved syndromic management was developed through extensive training and supervision of primary health center workers, provision of antimicrobials, and educational activities to improve health-care seeking behavior for symptoms of STDs. Sentinel cohorts of one thousand persons per community were followed for two years to measure the incidence of new HIV infections.
From page 56...
... also supports the concept that reducing STDs could have a significant impact on sexually transmitted HIV infections. As mentioned previously, they estimated that successfully treating or preventing one hundred cases of syphilis among high-risk groups for STDs would prevent 1,200 HIV infections that would be linked to those one hundred syphilis infections during a 10-year period.
From page 59...
... Bacterialb Chlamydial infection Gonorrhea Pelvic inflammatory disease Syphilis Chancroid Viral Herpes simplex virus infectionb Human papillomavirus infections Hepatitis B virus infectiond Cervical cancera Subtotal STDs (excluding HIV/AIDS) Sexually transmitted HIV/AIDSf Total (including HIV/AIDS)
From page 60...
... A study of payment sources for pelvic inflammatory disease from 1983 through 1987 found that private insurance and public payment sources covered 41 and 30 percent, respectively, of the direct costs associated with this STD (Washington and Katz, 1991~. During the study period, the proportion of payments from private insurance decreased from 54 to 41 percent.
From page 61...
... et al. Genital human papillomavirus infection in female university students as determined by a PCR-based method.
From page 62...
... Atypical pelvic inflammatory disease: can we identify clinical predictors? Am J Obstet Gynecol 1993;169:341-6.
From page 63...
... Harrington PE, Bush TJ, Schoenfisch SA, Oxtoby MJ, et al. Heterosexually transmitted human immunodeficiency virus infection among pregnant women in a rural Florida community.
From page 64...
... Prior herpes simplex virus type 2 infection as a risk factor for HIV infection.
From page 65...
... Sweet RL. Risk factors associated with pelvic inflammatory disease of differing microbial etiologies.
From page 66...
... Proportional payment for pelvic inflammatory disease: who should pay for chlamydial screening? Sex Transm Dis 1989;16:36-40.
From page 67...
... Cost of and payment source for pelvic inflammatory disease. Trends and projections, 1983 through 2000 [see comments]
From page 68...
... Wolner-Hanssen P Silent pelvic inflammatory disease: is it overstated?


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