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There are more than 30 sexually transmitted infections
known to medicine so far, and many people in the United States
have at least one, reported Dr. King Holmes during Clinical Center "Great
Teachers" Grand Rounds on Mar. 9. A number of STIs, chiefly those
associated with gay male sex, are reemerging in the United States
after a period of quiescence, he told a packed house at Lipsett
In the first of eight cases he presented for attendees' consideration,
Holmes, who is professor of medicine and director of the Center
for AIDS and STD at the University of Washington, described a patient
with proctitis caused by lymphogranuloma venereum (LGV), which
has re-emerged in the San Francisco Bay area, Amsterdam and other
parts of the developed world. The disease is caused by C.
or chlamydia, which remains very common in the U.S.
||Dr. King Holmes, professor of medicine and director of the
Center for AIDS and STD at the University of Washington, gives
Great Teacher rounds Mar. 9 at the Clinical Center.
Holmes' cases illustrated either medicine's advancing diagnostic
acuity or therapeutic innovation. They also yielded behavioral
insights. For example, "up to 90 percent of people with an STD
who are asked to bring their sex partners to the STD clinic for
testing and treatment don't do it." Holmes, Dr. Matt Golden, and
their colleagues at the Seattle- King County health department
have taken to providing kits containing drugs for chlamydia and
gonorrhea to patients with STDs to deliver to their partners. So
effective has this approach been that two pharmaceutical chains
in the Northwest have cooperated by distributing the kits, together
with information about the treatment for the partners. Holmes also
said that partner notification efforts, which receive federal money
devoted to STD control, are widely regarded as inefficient and
in need of upgrading — as recommended in a past report from the Institute
His fourth case might give pause to parents sending their kids
off to college in the fall. A study that followed the 4-year progression
from freshman year to senior year at the University of Washington
showed that 75 percent of the undergraduate women acquired genital
human papillomavirus (HPV) infection by the time they earned their
diplomas. "It's a very common infection," Holmes noted.
|Holmes, a recent lecturer in the Clinical
Center’s “Great Teachers”
Series, offered a sobering take-home message: Most people have
had at least one sexually transmitted infection.
There are more than 40 types of HPV that cause genital infection,
he explained, and some patients are infected with multiple varieties.
The infection is just as common in men as in women, and was 10
times more prevalent than any other STD in a new study of a random
sample of some 3,200 young U.S. women whose urine was analyzed
for HPV, chlamydia, gonorrhea and trichomonas infection. Had the
researchers used the more sensitive method of cervical swab instead
of urinalysis, even more infections would undoubtedly have turned
up, Holmes suggested.
Some variants of HPV have been shown to increase cancer risk.
A randomized controlled trial of condom use or no condom use by
couples in which the female had cervical dysplasia showed that
condom use led to significantly faster regression of the dysplasia
and disappearance of the HPV infection. A current prospective study
of University of Washington female students being conducted by
Rachel Winer and Dr. Laura Koutsky is also encouraging in suggesting
that consistent, correct condom use offers protection against acquiring
Also on the prevention front, "Merck and Glaxo are testing HPV
vaccines, and early results indicate a significant reduction not
only in acquisition of HPV, but also in risk of cervical dysplasia," Holmes
Herpes simplex virus (HSV) was the culprit in several case studies
Holmes presented. The risk of acquiring HSV-2 dramatically increases
with the number of sex partners one has, he showed. As with HPV,
condom use is effective in reducing risk, although many HSV-infected
people opt for suppressive antiviral therapy, in addition to condoms.
Such suppressive therapy also significantly reduces the risk of
transmission to an uninfected partner.
Holmes alerted the audience that "syphilis is back — you've got
to start thinking about it." It is a resurgent infection, mostly
in men, he noted, where rates in some places are back up to what
they were in the pre-AIDS era.
Holmes' take-home message was sobering: Most people have had at
least one sexually transmitted infection; in aggregate, these infections
can affect any organ; physicians ought to consider them in many
differential diagnoses; there have been important advances in etiological
studies, diagnostics, therapy and prevention; and lastly, "Don't
forget about them!"
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