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Vol. LVII, No. 8
April 22, 2005

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Sexually Transmitted Diseases Commonly Overlooked in Clinical Medicine, Holmes Reports

On the front page...

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 Amphitheater.


  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.
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. trachomatis, or chlamydia, which remains very common in the U.S.

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 of Medicine.

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 HPV infection.

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 reported.

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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