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HIV and STD - clinical picture, therapy and facts
Dr. Astrid Platzmann-Scholten

HIV is the name of the virus that causes AIDS.
HIV = Human Immundeficiency Virus
AIDS = Acquired Immune Deficiency Syndrom
A HIV-Infection is no AIDS disease. It just turns into AIDS when the infection becomes a disease.

Chronicle

• 1981 Outbreak of an unknown form of a fatal infection amongst gay men in California
• 1983 Gallo and Montagnier discover, independant from each other the HIV virus
• the first HIV test was licensed
• first antiretroviral drug available
• combination therapy for HIV

Origin + Spread

• Originally it was only a monkey species that carried the HIV virus
• By mutations new forms emerged, HIV-1/2, which could be transmitted to humans HIV-1: most widespread worldwide,
• HIV-2: mainly in Western Africa
• Reasons for the worldwide spread of HIV: monkeys were hunted and eaten, ritual acts, road construction, higher mobility, increasing tourism
• The oldest known case of HIV infection dates back to 1959 - all conspirancy theories are wrong

Numbers + Facts Stand Ende 2007

• Up to now 34 millon people got infected with HIV, 9 million of them got the disease and 28 million people died. Every 6 seconds someone is infected with HIV, every 10 seconds someone dies of AIDS
• FRG up to now 86.000 HIV - infections 27.000 people died of AIDS
• Actually 59.000 people infected / about 5000 cases.
• New infections in 2007: 3000 people
• Deaths in 2007: 650 people

NRW:
In NRW about 13.000 people infected/ about 1900 with full blown AIDS

Number of HIV - Infections worldwide
Total 33.2 mill. [30.6–36.1 mill.]
Adults 30.8 mill [28.2–33.6 mill.]
Women 15.4 mill [13.9–16.6 mill.]
Children younger than 15 2.5 Mio. [2.2–2.6 Mio.]

New infections with HIV in 2007 worldwide
Total 2.5 mill. [1.8–4.1 mill.]
Adults 2.1 mill. [1.4–3.6 mill.]
Children younger than 15 420 000 [350 000–540 000]

AIDS - deaths in 2007 worldwide
2.1 mill. [1.9–2.4 mill.]
Adults: 1.7 mill. [1.6–2.1 mill.]
Children younger than 15 330 000 [310 000–380 000]

„Main focus countries“ estimated number of HIV - infections

• Sub - Saharan region (25,4 mill.)
• South- / Southeast Asia ( Thailand, Indonesia, Malaysia, India etc.) 7,1 mill.
• South America (1,7 mill.)
• Eastern Europe (1,4 mill.)

Especially in Eastern Europe and Central Asia there is an enormous increase in HIV rates whereas 90 % of the infections are allotted to Ukraine and Russia

HIV - Affected People

• 69% MSM, „men who have sex with men“
• 18% Heterosexual contacts
• 13% Intravenous drug use (charing of needles)
• <1% Transmission from mother to child

HIV - Testing
HIV screening test positiv / negativ
Confirmatory test
If applicable repeat test
Tested negativ: No HIV - infection
Tested positiv : HIV-infection

Transmission
Unsafe sex
Unprotected anal intercourse 1:150
Unprotected vaginal intercourse 1:200
Possible transmission via oral intercourse Women are particularily endangered as the seminal fluid generally contains higher amount of viruses

Ways of Transmission

• Needle-sharing in drug users
• Blood transfusion (1 : 1.000.000)
• Transmission during birth < 1% in case of good pregnancy attendance
• Infringement by canulas or scalpels <0,3%
• Transmission much easier in the case of already existing STDs like syphilis, tripper, chlamydia, trichomonas
• Transmission
• Transmission depends on the infection status of the infected person.
• The highest risk of transmission is in the very first beginning of an infection and at the outbreak of AIDS

I M P O R T A N T
There is no danger of infection during normal daily life. You can use the same toilet, drink from the same glass. Neither cough and sneeze is a risk of infection, nor can HIV be transmitted by kissing.

Transmission
The transmission of HIV only occurs via body fluids:

• Blood
• Seminal fluid
• Vaginal fluid
• Breast milk

The virus concentration on urine, defaction, saliva, sweat, tears is not high enough for an infection (e.g. 8 l of salvia would be necessary for a transmission)
HIV enters the bloodstream
Body recognizes the virus and starts to develop antibodies to the virus.
HIV infects special, central cells of the immune system and destroys them (CD4 cells)
The more cells are infected the easier the number of viruses can grow.
In the case of a compleate failure of the immune system diseases can spread which the immune system would normally fight easily
The most frequent cause of death among persons with AIDS are unrulable complications in connection with opportunistc infections.

Course of Disease

Acute HIV - Infection
Symptoms of influenca: fever, sore throat, headache or aching limbs, lymph nodes are swollen
Just one half of all infected persons mark the acute infection, about 50% remain clinically unmarked

• Latency period - no symptoms - Duration: some months up to 10 years
• AIDS-associatad diseases
• Oral hair leukoplakia
• Candida infections
• Herpes simplex infections
• Tuberkulosis
• Syphilis,
• Aspergillosis
• AIDS- defining diseases
• HIV-caused brain deficiencies
• Ability of concentration decreases
• Deceleration, dementia
• Opportunistic infections / bacterial + viral
• Toxoplasmosis
• Mycosis
• Diarrhea
• Tuberkulosis
• Cancer, defining AIDS
• Kaposi-Sarkom
• Non-Hodgkin-Lymphoms

Therapy
Since 1996 a new combination therapy is possible. These drugs keep the amount of HIV in the body to a low level
Decisive for the success is the reliability of the patients - Possible resistance
CD4 count and viral load have to be kept under surveillance

Outlook
New therapies lower the risk of several opportunistc infections can be lowererd.
A cure is impossible
Vaccination is not to be expected
Only 30% of all people living with AIDS have got access to medical care.
70% don‘t get medical care as they can‘t afford the costs

Sexual transmitted diseases (STD)

Terminology:
STD = Sexual transmitted diseases, also named STI = Sexual transmitted infections
International term for sexual transmitted diseases

STD

• HIV
• Chlamydia
• Lues (syphilis)
• Gonorrhea (tripper)
• Hepatitis B
• Genital herpes
• Human papilloma viruses
• Trichomonas vaginalis

Chlamydia
Pathogens : chlamydia trachomatis (group D - K)
Frequency: one of the most common STD‘s worldwide
In Germany approximately 10 % of young women under 20 years are infected.
There is a higher infection risk with an increasing number of sexual partners

Chlamydia in Eastern Europe
Approximately 80% of all infections proceed clinically silent or show very unspecific symptoms therefore they often become chronic with respective long-term consequences
Incubation period: (definition: time between the penetration of pathogens until the occurrence of first symptoms) 5 - 40 days

Chlamydia - Clinical Picture

• Usually a cervical inflammation
• Yellowish-sticky discharge
• Mid-cycle bleedings
• Bleeding during sexual intercourse
• Burning urination

with an „ascending“ infection the uterus, the fallopian tubes and possibly also the whole pelvic minor are affected (PID= Pelvic Inflammatory Disease)

Long-term consequences can be:
an adhesion of the affected fallopian tubes and thus infertility,
perihepatic inflammations with peritoneal adhesions (Fitz-Hugh-Curtis-Syndrome)

Chlamydia - Infection Path + Therapy
Antibiotic therapy for 10 - 20 days

Important!!!! All sexual partners of the recent two months should also be treated

Chlamydia - Prognosis
If a chlamyida infection in acute stage is diagnosed, it can be well treated
Treatment of those forms which often remain undiagnosed and may become chronic is considerably harder
Long-term consequences: infertility, extra-uterine pregnancies

Syphilis
Worldwide occurring STD
Known since the 15th century, as the Frenchman disease
Also named: Hard chancre or LUES
In Germany MSM are especially affected (approximately 75%)

Syphilis - Transmission

• Pathogens: treponema pallidum (bacterium)
• Syphilis is transmitted through smallest skin lesions, often during sexual intercourse, but also through anal or oral intercourse
• Transmission also through blood or syringes
• In case of unprotected contact there is a 30% infection probability
• Transmission also through highly contagious secretion of small ulcers in the early stage

Incubation time of 2 - 6 weeks
A previous syphilis does not provide protection against a re-infection
Outside the body the pathogen is very sensitive and dies off, i.e. a close mucosa / mucous membrane contact is necessary
Once entered, the pathogen spreads through the entire blood and lymphatic system within a few hours

Syphilis - Clinical Picture
Syphilis proceeds via 4 clinical stages:

• Primary stage (about 8 weeks)
• Secondary stage (about 8 weeks - 2 years)
• Tertiary stage (3 - 5 years)
• Neurolues oder quaternary stage (about 25% of patients)

As there are manifold symptoms showing various expressions, the syphilis is also named the „chamaleon“ of medicine

Spontanuous healing in 30% of all cases

Syphilis - Clinical Diagnostics

• Syphilis can be reliantly diagnosed by means of blood examinations
• But: Special examinations have to be made as syphilis - like HIV - cannot be diagnosed from the „routine blood count“
• Problem is the manifold appearance forms of syphilis which often lead to a false diagnosis or „non-recognition“
• Since the introduction of the IfSG 2001 there has been an anonymous laboratory reporting obligation, exclusively for HIV and syphilis

Syphilis - Therapy

• Still penicillin G for periods which differ according to the respective clinical stage
• It works reliably
• Resistance is not known
• Cure rate of almost 100%
• Syphilis + HIV
• About 15% of HIV-positive patients have suffered a syphilis
• Syphilis is a „facilitator“ for an HIV-infection, like other STDs as well
• Both infections affect each other negatively
• Many cases of neurosyphilis formation

Syphilis + Pregnancy
According to the maternity regulations all women have to undergo a syphilis test in the early stage of pregnancy. Since the treponemals are only able to penetrate the placental border from the 17th week of pregnancy
Infected children die during pregnancy in 70 % of all cases, the survivors show extremely serious clinical pictures (lues connata)

Gonorrhea
Also known as tripper, it probably decreases significantly
Following IfSG no reporting obligation, therefore no figures for Germany available
Pathogens: neisseria gonorrhoeae
Since 2001 no reporting obligation in Germany anymore
Infection paths comparable with chlamydia infection, i.e. transmission occurs almost exclusively through vaginal, anal or oral sex

Gonorrhea - Symptoms
50% of infected women are free of symptoms, unlike most men
In acute courses the cervix is initially affected, but there is the risk of an „ascending“ infection with a sanious adhesion of the fallopian tubes, followed by scarring and sometimes also infertility as long-term consequence

Gonorrhea - Clinical Diagnostics + Therapy
Diagnosis can be difficult, as the pathogen quickly dies off in the outside world
Targeted antibiotic therapy in case of timely diagnosis, but meanwhile existence of multiple resistances
Prevention through condom use
Gonorrhea + Pregnancy
If gonorrhea is diagnosed during pregnancy, it is still well treatable
Nevertheless newborns have to undergo an „eye prophylaxis“ in most obstetric clinics to prevent a serious conjunctivitis

Hepatitis B
Worldwide epidemiology:

• 350 million chronic virus carriers
• 1 million deaths annually
• 40 - 100 times more infectious than HIV *
• Causes up to 80% of all liver cell cancers

Hepatitis B - Transmission

• Parenteral transmission (through blood, semen, vaginal liquids, breast milk, saliva)
• Infection also following:
• Sexual intercourse
• Birthgiving
• Blood contact / blood transfusions, trifle injuries
• Needle-stick injuries (4µl infected blood are sufficient for an infection!)
• Medical treatment with a contaminated device
• Bites (i.e. disabled, children etc.)
• Joint use of shavers and tooth brushes

Hepatitis B - Course of disease:
Incubation period: 30-180 days
Only 1/3 show symptoms (jaundice), the disease often proceeds unperceived
Duration of the incomplex, acute, clinical course: 6 weeks - 6 months
10% of infected adults, 90% of infected babies suffer a chronic course
Cirrhosis and liver cancer as long-term consequences of the chronic course are possible.
Annual costs approximately 700 million

Hepatitis B - Courses
a) „Healthy“ HBsAg-carrier -pot. infectious -
c) Acute cured hepatitis B (90-95%)
d) Chronic hepatitis B (5-10%)
Long-term effects : (with chron. aggressive course) liver cell cancer and cirrhosis

Hepatitis B - Prevention

• Vaccination Hep. A and B
• Use of condoms
• Vaccination of newborns within 72 h after birth in case of infectious mothers

Herpes Genitalis Infection

• About 25% of Germany‘s total population
• Transmission through sexual contacts, very rarely through smear infections.
• In case of primary infection unbearable pains and blistering, in case of repeated occurrence just moderated symptoms. Treatment with Acyclovir.
• Shortly before the confinement => indication for a caesarean section - sepsis risk for the newborn baby

HPV Human papilloma viruses

• More than 100 viral strains known
• HPV 6 and 11 pathogens of genital warts/condiloma (benign)
• HPV 16, 18 , 31 etc. are causally involved in the development of cervical cancer
• Vaccination available

Trichomonades

• Pathogens: trichomonas vaginalis; flagellates
• Men: in most cases free of symptoms
• Women: persistent discharge, it rarely cures spontanuously, remaining infection capacity
• Clinical diagnostics: microscopy
• Therapy: antibiotics
• Rather „harmless“ infection, but it gains importance as a „facilitator“ for the acquisition of an HIV infection!