                           AIDS NEWS SERVICE
                      Michael Howe, MSLS, Editor
                        AIDS Information Center
                   VA Medical Center, San Francisco
                        (415) 221-4810 ext 3305
                           November 11, 1994

                 Safer Sex: Information for Counselors
                               (Part XI)

                             STDs and HIV
                             by John Tighe

      Health education related to sexually transmitted diseases
(STDs) other than HIV has been largely overlooked throughout the
HIV epidemic.  This is true even though STDs are serious in and of
themselves and their occurrence can be looked to as a measure of
a person's HIV infection risk.  Because behaviors that lead to
other STDs are generally the same ones that lead to HIV infection,
the presence of an STD can be a warning sign of potential HIV
infection.  In addition, ulcerations, lesions and other harmful
effects of STDs can increase vulnerability to HIV infection.  For
someone infected with HIV, bouts of STDs can be far more serious
and they can directly harm the immune system.

Research Update
      Each year in the United States an estimated 12 million people
are infected with STDs; two-thirds of these people are under age
25 (1).
      More than 50 organisms and syndromes are recognized as being
sexually transmitted.  STDs are caused by a variety of agents,
including bacterial and viral ones.  Bacterial STDs include
gonorrhea and syphilis.  Medications can be used as preventive
therapy as well as to treat and cure bacterial STDs.
      Viral STDs include HIV, genital herpes, hepatitis B, and human
papillomavirus (HPV).  Viral STDs can be transmitted through sexual
and non-sexual routes.  While treatable, viral STDs are not
curable, and therefore they can recur or they can progress.  Fungal
and parasitic agents, including trichomoniasis, can also be
transmitted sexually.
      STD symptoms typically include one or more of the following: 
burning or pain during urination and defecation; itching or burning
around the genitals; mucous discharge or bleeding from the
genitals; ulceration or blistering; rashes on the body; and flu-
like symptoms.  STD infections lead to a variety of illnesses,
including pelvic inflammatory disease (PID) and non-gonococcal
urethritis.
      After being infected with most STDs, people may remain
asymptomatic, or free of symptoms, for extended periods ranging
from days to several months.  During this period, however, people
can transmit the infection to others.
      Symptoms related to bacterial or viral STDs often dissipate
and recur.  Because of long periods in which a infection may not
produce symptoms, public health and medical experts recommend that
people at risk for STDs seek an STD risk assessment, a physical
examination based on symptoms, and laboratory tests to detect
infections that may be asymptomatic.

Relationship Between HIV and Other STDs
      HIV and other STDs are related in several ways.  They are
transmitted through similar routes and they respond to similar
prevention messages (2,3).
      Researchers have identified a complex relationship between HIV
and other STDs that results in a synergistic interaction -- that
is, the presence of HIV with another STD produces a result
affecting the course of HIV disease that would not be produced if
the STD was absent (4).  Of the major STDs, syphilis, chlamydia,
gonorrhea, genital herpes, trichomoniasis, genital warts, and
hepatitis B have been investigated for their impact on HIV.
      Researchers have demonstrated that the presence of STDs, both
ulcerative and non-ulcerative, increases the risk of HIV
transmission about 3- to 5-fold (4).  STDs appear to promote HIV
transmission by causing inflammation and lesions of the genital
tract, thus creating an accessible place of entry for HIV. 
Ulcerations, which are caused by syphilis and genital herpes, have
been related to increased susceptibility for HIV transmission. 
Increased risk of HIV transmission can also be attributed to non-
ulcerative STDs such as chlamydia, gonorrhea and trichomoniasis,
which weaken the body's defenses against disease.  However,
research related to the relationship between non-ulcerative STDs
and HIV is more limited (4).
      Researchers suggest that the debilitating effects of STDs may
accelerate progression of HIV for someone who is infected with HIV. 
In addition, for someone with HIV, it appears that the suppressive
effects of HIV on the immune system worsen the symptoms of other
STDs and decrease the healing effects of STD therapies (4).
      It is also possible that the course of an STD may be altered
by HIV.  For example, genital herpes ulcers normally heal within
two to three weeks but persist much longer in people with HIV. 
Similarly, syphilis treatments sometimes fail or the disease
develops more severely in people with HIV (5).

Facts About STDs
      Syphilis.  Syphilis is a bacterial STD that produces ulcers
in the genitals, throat and rectum.  Effective treatment with
penicillin is widely available; without treatment, heart disease,
brain damage, blindness and death can result.  Although the rate
of syphilis infection has declined steadily in the last 50 years,
sporadic outbreaks occurred during the 1980s in some urban areas. 
The occurrence was most common among African-American men and women
in urban communities with high HIV incidence (2).  In 1990, 134,000
syphilis cases were reported nationally.
      Gonorrhea.  Affecting as many as one million people each year
in this country, gonorrhea is a bacterial infection that causes
inflammation of the urethra and rectum in men.  In women, it causes
inflammation of the cervix, and infections of the uterus, fallopian
tubes and pelvic organs -- leading to PID.  Symptoms include pain
during urination or defecation and discharge from the vagina or
penis.
      While penicillin historically has been the most widely used
treatment to cure gonorrhea, strains resistant to penicillin have
developed in recent years (5).  Therefore, suspected gonorrhea
cases are now treated with other medicines, even though these are
often many times more expensive than penicillin (1).
      Chlamydia.  Chlamydia, like gonorrhea, causes inflammation of
the urethra, cervix and prostate, and can cause PID and genital
ulcers.  Manifestations of chlamydia have both bacterial and viral
characteristics.  In women, chlamydia can lead to premature birth,
ectopic pregnancy and sterility.  During ectopic, or tubal,
pregnancy, the fetus develops outside the uterus in the fallopian
tubes.
      Nationally, as many as four million people across all
socioeconomic and ethnic groups may be infected with chlamydia. 
A person with this STD can remain asymptomatic for long periods. 
Accurate and affordable diagnostic tests have only recently become
widely available.  When diagnosed, infections can be cured by
taking tetracycline or other antibiotics (6).  Several studies from
Africa clearly indicate that women with cervical chlamydia
infection are at increased risk of being infected with HIV through
unsafe sexual intercourse (5).
      Trichomoniasis.  Trichomoniasis, a parasitic condition
estimated to affect three million people in the United States, has
not been thoroughly studied for its relationship to HIV.  Those
with the disease may be asymptomatic for extended periods.  In
women, trichomoniasis may cause severe vaginitis, and in men,
painful swelling of the penis as well as epididymitis.  Treatment
regimens usually involve the drugs flagyl or metronidazole.
      Genital herpes (herpes simplex virus types 1 and 2).  Genital
herpes, a viral infection, is an ulcerative disease that causes
painful blisters on the genitals, mouth, anus, and other mucous
membranes, and sometimes on the skin of other areas of the body. 
Men and women infected with genital herpes are often asymptomatic
for long periods.  Women can have a longer asymptomatic period and
a more severe initial manifestation of disease than men, and women
can transmit the virus during pregnancy and childbirth.  Recurrent
episodes are common, but are usually less severe over time. 
Acyclovir is the standard treatment for genital herpes.
      Various studies estimate that 25% to 50% of all people in this
country are infected with a herpes virus (1).  Studies have found
infection rates two to three times higher among African Americans
and highest among African-American women.  Infection rates are
disproportionately higher among poorer people living in inner city
areas (5).
      Human papillomavirus (HPV).  There are more than 60 types of
HPV, and millions of sexually active people are known to be
infected with the virus.  Some types of HPV cause genital
infection, and a small number produce benign genital warts, which
are non-ulcerative and frequently recur.  Certain types of HPV are
linked to pre-cancerous lesions or cancer of the cervix, vulva,
penis, anus and throat.  HPV cannot be eradicated; treatment
usually involves removal of warts by cold-based therapies such as
liquid nitrogen, or though laser therapy.
      While there are no well-designed, prospective studies of HPV's
effects on HIV, it seems clear that the immunosuppression caused
by HIV affects the course of HPV.  A recent study confirmed that
gay men with HIV are at increased risk for HPV infection (7).  In
the presence of HIV, a broader variety of HPV infections tends to
occur, infections often worsen and larger lesions appear.  In
people with HIV, HPV infections typically do not respond as well
to therapy.
      Hepatitis B virus.  People infected with hepatitis B may
develop cirrhosis, carcinomas and chronic active hepatitis.  While
a vaccine was introduced 10 years ago, and it is considered
effective, incidence has remained unchanged since then (8).  No
special treatments are recommended for active infection.
      In addition to sexual routes of transmission, hepatitis B may
be transmitted to a fetus during pregnancy or to a child at birth,
as well as through injection drug use.  It is estimated that up to
half of all hepatitis B infections ar sexually transmitted (9). 
The proportion of hepatitis B cases attributed to sexual contact
between men has declined in recent years, while the proportion
attributed to heterosexual contact and infection drug use has
increased.  Multiple sex partners and high-risk sex practices,
especially receptive anal intercourse, place both gay men and
heterosexuals at increased risk for hepatitis B transmission (9).

Implications for Counseling

      Throughout the HIV epidemic, and in fact for decades,
prevention of STDs has generally been overlooked, as more attention
has been given to medical diagnosis and treatment of STDs than to
changing behaviors.
      There are compelling reasons for HIV test counselors to
discuss STDs with clients.  Because both HIV and other STDs are
sexually transmitted, prevention messages for both are similar. 
By hearing clients' STD histories, HIV test counselors can learn
about attitudes related to HIV, such as the client's views of
sexuality, sexual behavior, risk reduction and being infected with
STDs.  Some clients may have given little thought to HIV, but have
extensive experience with STDs.  Or, they may have extensive HIV
knowledge, but little knowledge of other STDs.
      This section presents STD-related issues that are relevant to
the HIV test counseling session, including behavioral risks and the
health implications of STDs.  In addition, the section responds to
concerns of clients with or without STDs, as well as to young
people, who are disproportionately affected by STDs.
      The following are key points for HIV test counselors to
discuss with clients.

o  By engaging in safer sex, clients can protect themselves from
infection or reinfection with both HIV and other STDs.  When a
client does not see his or her HIV-related risk as significant
enough to warrant behavior change, present information about the
risk of other diseases that may result from these behaviors.  For
someone who shows little concern about HIV because its debilitating
effects may not be felt for years, state that many STDs can have
immediate and damaging effects.

o  The occurrence or recurrence of an STD along with a repeated
negative HIV test result does not mean a person is not susceptible
to HIV infection.  In fact, multiple STD episodes are a clear
warning that a person is engaging in high-risk behaviors for HIV
infection.

o  STDs can make a person more susceptible to HIV infection.  And,
STDs put strain on the body's immune system, making it more
susceptible to other infections and less able to defend against
them.

o  People who have contacted STDs through injection drug use may
not see their risk for HIV infection through sexual behavior.  For
instance, someone infected with hepatitis B virus (HBV) through
infection drug use may perceive his or her drug use as risky, but
feel he or she can engage in unprotected sex without being
infected.

Sexual Behaviors and STDs
      After learning the behaviors clients practice or desire to
practice, describe to them the specific diseases that may be
transmitted through these behaviors.  For instance, clients who
engage in oral sex without a condom are not only putting themselves
at risk for HIV infection, but also for gonorrhea, syphilis,
chlamydia, herpes and hepatitis B infections.  Remember that there
are behaviors, such as rimming, also know as oral-anal sex, that
some client may not consider a high risk or HIV infection, but
which definitely put a person at high risk for other STDs,
including parasites and hepatitis B virus.

Responding to STD Infection
      STD testing is important for anyone who has symptoms of an STD
or anyone who has had unsafe sex with someone with an STD. 
Symptoms may not develop for extended periods after infection, but
STDs can progress in the absence of symptoms.  Symptoms generally
occur sooner after infection for men than for women.  Laboratory
testing can detect most STDs in the absence of symptoms.
      Many times, even with symptoms, people disregard STDs.  Not
wishing to acknowledge an infection, they avoid examining the
genital area.  They may even notice a skin lesion, but believe it
is not a problem that needs immediate attention.  For this reason,
urge clients who think they are infected with, or have symptoms of,
and STD to visit an STD clinic or their primary care provider. 
Talk to these clients about the complications of untreated STDs as
well as the risk of future infections.  State that STDs respond
best to treatment before symptoms develop, and they generally
worsen and become more infectious when untreated.
      Clarify myths about STDs. For instance, clients may believe
incorrectly that good personal hygiene, or a "clean" appearance,
is a sign that someone is free of STDs.
      In counseling clients with no STD history, support them for
any steps they have taken to avoid STDs.  If these clients appear
to have little STD knowledge, make sure they understand that HIV
is not the only disease that can be transmitted sexually, and that
other STDs are serious unto themselves and can make a person more
susceptible to HIV infection.

Clients with an STD History
      Clients with an STD history have, in most cases, engaged in
behaviors that have placed them at risk for HIV infection, and they
may be several times more likely than other clients to become
infected with HIV.  Counselors may feel their efforts to repeat
information to clients with extensive STD histories are futile. 
However, counselors have a unique, and perhaps "last chance"
opportunity to offer assistance before these clients become
infected with HIV.
      Recognize that a person with a history of STDs may never have
received thorough or effective counseling.  Ask clients about their
previous counseling and how effective they believe it has been in
helping them understand and change risk behaviors.  Through the HIV
test counseling session, the client may, for the first time, see
his or her STDs as a warning sign, and may perceive the need to
change behaviors and even ask for help in doing so.
      Many people with a history of STDs may not have strong
feelings about the dangers of HIV.  They may know from their
personal experience that STDs can cause pain, but they may not
realize these STDs can be life-threatening.
      Explain that, even without HIV infection, repeated episodes
of STDs can have debilitating and far-reaching effects.  STDs can
destroy organs, break down tissue, make it difficult for a women
to become pregnant, and increase risk for other diseases.  For
instance, venereal warts for women and genital warts for men can
increase risks for certain cancers.
      Stress the importance of following the full course of
treatment for STDs even if symptoms of disease have cleared. 
Failure to follow the full treatment course can allow disease to
recur and lead to bouts with drug-resistant STDs.
      After taking an STD history, ask the client to describe his
or her risk behaviors and the context in which they occurred.  Ask
how the client feels about the safety of those behaviors, and how
he or she felt when STDs were detected or diagnosed.  Hearing this,
the counselor may be able to identify  a client's motivation to
avoid STDs in the future and assist in developing skills to avoid
risky behaviors.
      Be prepared for a variety of factors that may lead clients to
state they do not wish or feel able to change behaviors.  These
include rationalizations about unsafe sex, denial bout the safety
of specific behaviors, and compulsive sexual behavior, in which a
person may feel compelled to have sex and unable to control sexual
desires.
      Some clients may believe that if they engage in significant
amounts of sex with many partners, they deserve or expect STD
infections.  Clients with an STD history may be especially
vulnerable to fatalistic feeling about HIV infection, and they may
express that being infected with HIV is inevitable and beyond their
control.
      Unsafe sex may be such a significant part of a person's life
that he or she may not be able to imagine life without unsafe sex. 
Empathize with the client's position, and help him or her see that
no matter how distant safer sex may seem, it is possible.  Empower
the client to see that he or she can have control over behaviors
and becoming infected.  Ask the client if there was ever a time he
or she did not need to engage in unsafe sex, and, if so, explore
the feelings of that time, including feelings of self-esteem.
      Clients who have had thorough counseling previously, yet are
unable to change sexual practices, may respond to direct statements
about their risks.  For instance, it may be appropriate to state:
"You've had several counseling sessions.  Your behaviors continue
to put you at risk for a life-threatening disease.  Are there
things we can talk about doing that might help you change your
behavior?  Do you want to change?"
      Some people with STDs may avoid taking responsibility for
actions that leads to STD infection.  They may view partners as
responsible for  the STD.  This may lead clients to avoid reducing
their risk in the future.  Such clients may also decline to notify
partners of their STD.  Inform people with STDs that they are
legally liable if they transmit that disease to another person. 
And, people who fail to use protective devices, such as condoms,
have a legal obligation to inform prospective partners of their
STDs.  [Editor's Note:  The last two statements apply to California
residents; they may or may not be applicable to other states.]

STDs and Clients with HIV
      Make clients aware that people with HIV are more susceptible
to infection with other STDs.  In addition, STDs are faster-acting
and their effects on the immune system more threatening for people
with HIV.  Provide this information in both pre- and post-test
counseling.
      For clients who test HIV positive, recommend medical
intervention and STD screening.  Stress the importance of avoiding
unsafe sex not only to avoid reinfection with HIV or infecting
others, but also to avoid other STDs.

Young People
      People under age 25 account for two-thirds of all STD cases,
yet prevention messages often overlook young people, and young
people generally have little knowledge of STDs.  Often, STD
counseling for young people has been limited because counselors
have been reluctant to talk about sex with them and do not
recognize the ability of young people to respond to counseling
messages.
      Be sensitive to differences between younger and older people. 
Be careful to avoid messages that may be conveyed as "sex
negative."  These can be particularly alienating for young people
who may feel their sexuality and independence are being questioned
by test counselors who are generally older.
      Young people may believe STDs are to be expected from healthy
sexual expression.  They are often less willing to acknowledge
risks for infection or the seriousness of disease.  Because young
people may have heard fewer prevention messages, they may need to
have them repeated more often.  Or, they may need to use new
information to refocus attitudes and behaviors.
      Be aware of the unique dynamics of sexual and emotional
relationships of young people.  Because of their relative
inexperience in relationships, young people may not be certain what
they desire from relationships.  In addition, relationships may be
shorter-lasting for young people than for older people, yet
feelings in the relationship may be experienced as being especially
intense.  Because sexual and emotional intimacy develop quickly,
people may soon find themselves feeling comfortable engaging in
unsafe sex.
      Often for young people, engaging in sex is not considered a
result of a decision or choice, but rather as something that is
necessary.  In some cases, experiences or relationships of young
people may consist of rape, incest or other forced sexual or
violent behavior.
      Talk with young people about the meaning of making choices
consciously.  Help them understand their rights and responsibil-
ities in making their own choices, as well as the benefits that
come from giving thought to the decision-making process and slowing
down to do so.  Ask clients what they perceive their choices to be
and which choices they wish to make.  Ask young people if they are
aware of what they want from sex partners or relationships.  If
they are, they may be better able to define their choices.

Referrals
      To determine appropriate referrals, first ask the client what
he or she needs regarding STDs.  Understand that clients may be
resistant to visiting public STD clinics.  In addition, clients may
fear that at clinics they will be thoroughly quizzed on their
sexual histories and that their sexual partners will be notified. 
Listen to a client's concerns and address them.
      Provide telephone numbers and addresses of local STD clinics,
and, if possible, the names of clinic staff.  Also, let clients
know they can visit personal physicians for STD care.  Contact and
become familiar with referrals.
      For clients who feel unable to change sexual behavior to
reduce their STD risks and who report a pattern of compulsive and
self-destructive sexual "acting out," ask if they are interested
in gaining help to avoid these behaviors.  If so, provide referrals
to 12-step recovery programs such as Sex and Love Addicts Anonymous
or Sex Addicts Anonymous.  These programs are found in phone
directories in most larger cities.
      In addition, offer referrals to therapists trained in dealing
with behaviors related to sexual compulsion.  Be aware that clients
often are most receptive to behavior change intervention and more
likely to follow up on referrals at the time they are experiencing
symptoms of disease.

References

 1. CDC. Division of STD/HIV Prevention Annual Report 1991.
Atlanta, GA: Division of STD/HIV Prevention, 1991.

 2. Holmes KK. Mardh PA. Sparling PF et al., eds. Sexually
Transmitted Diseases. 2nd ed. New York: McGraw Hill, 1990.

 3. Sexually Transmitted Diseases in California, 1991. Sacramento:
State of California Department of Health Services, 1992.

 4. Wasserheit JN. Epidemiological synergy: interrelationships
between human immunodeficiency virus (HIV) infection and other
sexually transmitted diseases (STDs). Sexually Transmitted
Diseases. 1992;19(2):61-77.

 5. Aral SO. Holmes KK. Sexually transmitted diseases in the AIDS
era. Scientific American. 1991;264(2):62-9.

 6. Sexually transmitted diseases treatment guidelines, 1989. MMWR:
Recommendations and Reports. 1989;38(S-8):[pages inclusive].

 7. Critchlow CW. Holmes KK. Wood R. et al. Association of human
immunodeficiency virus and anal human papillomavirus infection
among homosexual men. Archives of Internal Medicine.
1992;152(8):1673-76.

 8.  Alter MJ. Hadler SC. Margolis HS. et al. The changing
epidemiology of hepatitis B in the United States. Journal of the
American Medical Association. 1990;263(9):1218-22.

 9.  Piot P. Goilav C. Kegels E. Hepatitis B: transmission by
sexual contact and needle sharing. Vaccines. 1990;8(supplement):
S37-S39.

10. McGregor JA. French JI. Spencer NE. Prevention of sexually
transmitted diseases in women. Obstetrics and Gynecology Clinics
of North America. 1989;16(3):679-701.

11. Wolfe H. Vranizan KM. Gorter RG. et al. Crack use and human
immunodeficiency virus infection among San Francisco intravenous
drug users. Sexually Transmitted Diseases. 1992;19(2):111-14.

12. Marx R. Aral SO. Rolfs RT. et al. Crack, sex, and STD. Sexually
Transmitted Diseases. 1991;18(2):92-101.

13. U.S. Preventive Services Task Force. Counseling to prevent HIV
infection and other sexually transmitted diseases. American Family
Physician. 1990;41(4):1179.

                             Test Yourself

1. True or False: The presence of STDs has been found to greatly
increase the risk of HIV transmission.

2. True or False: Gonorrhea can lead to pelvic inflammatory disease
(PID) in women.

3. Chlamydia can lead to which of the following outcomes a) genital
ulcers, b) premature birth and sterility, c) a and b, d) none of
the above.

4. True or False: Viral STDs can be treated but not cured.

5. True or False: It has been conclusively found that STDs have no
effect on the rate at which HIV infection progresses.

6. True or False: Open lesions caused by STDs can make a person
more susceptible to HIV infection.

7. Which of the following is the most commonly reported STD in
California? a) chlamydia, b) syphilis, c) chancroid, d) hepatitis
B virus.

8. For a person with HIV, STDs can a) progress far more rapidly
than for a person free of infection, b) be more severe than for a
person free of HIV infection, c) both a and b are correct, d) none
of the above.

                         Discussion Questions

o  Clients with STDs may believe STDs, including HIV, are to be
expected.  How can counselors help clients see that this
expectation is dangerous?

o  Clients may feel shame about STDs, and this shame can lead them
to believe they cannot make necessary behavior changes to avoid
STDs. How can counselors recognize this shame, work with clients
to mange it, and see that behavior change is possible?

o  Many clients with STDs have received extensive STD counseling,
yet they have been unable to avoid STDs. What can HIV test
counselors offer that these clients have not received in other
counseling?

o  Given that there are dozens of STDs, how can counselors describe
the basics of STDs in a easy-to-understand way and in a brief
period of time?  How can counselors combine a discussion of HIV
with a discussion of other STDs?

o  Because HIV test counselors may not have training in STD work,
how can they learn about STDs or remain current in their knowledge?

o  Can combined messages related to prevention of both HIV and
other STDs strengthen counseling interventions?  How can messages
be combined?

                      Answers to "Test Yourself"

1. True.

2. True.

3. C. In women, chlamydia can lead to genital ulcers, premature
births and sterility.

4. True.

5. False. It is believed that STDs can speed the progression of
HIV.

6. True.

7. A. Chlamydia is the most frequently reported STD in California.

8. C. For a person with HIV, STDs can progress far more rapidly and
be far more severe than for a person who is not infected.


                             Editor's Note

      The information included in this document was obtained from
the 1993 February issue (Vol. 3, No. 1) issue of "HIV Counselor
PERSPECTIVES."  PERSPECTIVES is an educational publication of the
California Department of Health Services, Office of AIDS, written
and produced by the AIDS Health Project of the University of
California San Francisco (John Tighe, writer and editor).  Reprint
permission is granted, provided acknowledgment is given to the
Department of Health Services.
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