Remaining free of sexually transmitted infections should be important to everyone, but it is especially important if you have HIV. This is because sexually transmitted infections can not only cause illness, but also increase the risk that you will pass on HIV during unprotected sex, even if blood tests show that you have an undetectable viral load. This is because sexually transmitted infections can raise the amount of virus in your sexual fluids to a very high level, making you much more infectious. There’s more about this in on page xx.

Although sexually transmitted infections can seem a minor issue, they can and do cause unpleasant symptoms. If left untreated, some can cause severe health problems. In the very long term, some can cause irreversible damage or even, in extreme cases, be fatal.

Some sexually transmitted viral infections, such as herpes simplex virus -2 (HSV-2, normally just called herpes), and HIV, of course, cannot be cured, though symptoms can be controlled. Hepatitis B is very easily passed on during sex, and hepatitis A and C can also be transmitted during sex. Hepatitis A, B and C can make you ill in the short term, and hepatitis B and C can both cause long-term liver disease, which can even be fatal. Being coinfected with HIV and Hepatitis B and/or C can make HIV harder to treat.

In some cases, people have been reinfected (this is sometimes called superinfected) with different or drug-resistant strains of HIV. There’s more on this on page xx.

Anal and vaginal sex

Unprotected (i.e. without a condom) anal and vaginal sex have the greatest risks of HIV transmission. Oral sex is considered in detail in a section below.

The chances of you passing on HIV during unprotected anal or vaginal sex are greatest if you are the active, or insertive, partner during sex. The risk is particularly high if you have a high viral load, an untreated sexually transmitted infection, or if you ejaculate inside your partner. Similarly, if an HIV-negative person has an untreated sexually transmitted infection, their chances of contracting HIV from you during unprotected sex are increased.

If you are the receptive, or passive, partner during sex, the risk that you will pass on HIV is reduced, but it’s still there – especially if you have a high viral load or an untreated sexually transmitted infection.

Don’t forget that unprotected vaginal sex carries another risk – of pregnancy. Emergency contraception is available from clinics and from pharmacies without prescription.

Oral sex

The risk of transmitting HIV by oral sex is much less certain.

The Health Protection Agency, which monitors HIV in the UK, estimates that about 1-3% of all sexual transmissions of HIV are due to oral sex.

However, the evidence is conflicting, with some doctors and studies suggesting that as many as 8% of HIV infections are due to oral sex, while others put the figure much lower – some putting it as low as 0%.

It is widely accepted that the risk of acquiringHIV from oral sex is very much smaller than the risk from unprotected anal or vaginal sex. Having a very high viral load or an untreated sexually transmitted infection, ejaculating in the mouth of the person sucking and bleeding gums or sores or wounds in the mouth of the person sucking are thought to increase the very small risk.

As for oral sex on women, the risk of transmission through this route is thought to be extremelysmall. However, the levels of HIV in vaginal fluid vary. They are likely to be highest around the time of your period, when HIV-bearing cells shed from the cervix are most likely to be found in vaginal fluid, along with blood. Oral sex will therefore be more risky around the time of menstruation if there are open wounds in the mouth.

Condoms

Condoms, when used properly, provide excellent protection against HIV and most other sexually transmitted infections.

In the UK and some other countries, HIV prevention professionals used to recommend extra-strong condoms for anal sex, but recent research has found that standard strength condoms are just as safe.

Condoms are usually made of latex. Some people are allergic to latex, and polyurethane condoms are a safe alternative.

A water-based lubricant should be used with condoms, as oil-based ones can weaken and make holes in condoms very quickly.

If you are having sex for a long time, then it is safest to change condoms every 30 minutes.

HIV and sexual health clinics provide free condoms, and, in some cities, free condoms can also be obtained from gay venues. Family planning clinics also provide free condoms.

Used condoms should be wrapped in paper and put in a bin – not flushed down the toilet or discarded in the street or in parks or fields.

Using anti-HIV drugs to prevent infection with HIV (PEP)

If a person is exposed to HIV during sex, many GUM clinics are willing to provide them with a short course of anti-HIV drugs to prevent infection. This is called post-exposure prophylaxis, or PEP for short, and it is becoming more widely available. PEP is not a kind of ‘morning after pill’ for HIV – and it is not thought to be 100% effective.

PEP may also be considered in cases of rape and sexual assault where there is thought to have been a risk of HIV transmission.

It is important to get and take PEP as soon as possible after possible exposure to HIV – ideally within four hours, and certainly within 72 hours.

If you are taking anti-HIV drugs and have unprotected sex with a person who is HIV-negative or whose HIV status you do not know, or if there is a condom accident during sex, you may be tempted to offer them some of your anti-HIV drugs in an attempt to reduce the risk of them becoming infected with HIV. This could be risky.

Some HIV drugs, particularly abacavir (Ziagen) and nevirapine (Viramune), can cause an allergic reaction or severe side-effects that can be fatal. There is also a chance that the person you are giving your HIV drugs to could already be infected with HIV and not know it. In this case, taking a few doses of your anti-HIV medicines could give the HIV in their body a chance to develop resistance to those drugs. This would limit their future treatment options.

The thought that you may have exposed somebody to the risk of HIV infection is very worrying. If you do think that PEP might be appropriate, go to your local sexual health clinic as soon as possible. If it is closed, then go to the accident and emergency department of your local hospital. Staff there should contact the on-call HIV doctor.

Sexual health check-ups

If you are sexually active, it is wise to have regular sexual health check-ups. These are free and confidential. Many HIV clinics have sexual health clinics (sometimes called GUM clinics) attached, and some HIV clinics now include sexual health screens as part of their routine HIV care. You can choose which sexual health clinic you go to, and it need not be the one nearest your home.

Most people with HIV in the UK were diagnosed through sexual health clinics, so you may already know what services they provide.

Visits to sexual health clinics normally involve seeing a doctor or nurse who will ask you about the kind of sex you are having and whether you have any symptoms, and examine you. It is important to be honest if you have had unprotected sex, so you can be given the appropriate tests. Sexual health clinics should be very used to seeing all the communities affected by HIV in the UK, including gay men and African people, and their services should be non-judgmental.

The examination will normally involve having swabs taken from the tip of your penis or from inside your vagina and from the mouth and throat and anus if you have had oral or anal sex. You will also be asked to provide a urine sample. These are then examined under a microscope or cultured to see if any bacteria grow.

Blood samples are also taken, to check them for infections. Some results can be given to you at your visit, but it may be necessary to telephone or come back a week or so later for some other results.

All treatment at NHS sexual health clinics is free of charge and confidential.

If it turns out that you have a sexually transmitted infection, you may be offered the opportunity to see a health adviser. Health advisers can give you information about sexually transmitted infections and how to avoid them and can help you contact your sexual partners, if this is possible or practical and you agree, so they can be tested and treated. Health advisers can also offer referrals to other specialist services.

Some GPs and their practice nurses now offer sexual health screens and the high street chemist, Boots, offers free chlamydia testing and treatment for people aged 16 – 24.

Sexually transmitted infections

Sexually transmitted infections can be caused by bacteria, viruses or parasites.

Bacterial infections can be cured with antibiotics, and antiviral drugs can be used to treat some of the viral infections. Lotions can clear infestations of scabies or pubic lice (sometimes called crabs).

This section includes a brief explanation of how the common sexually transmitted infections and infestations are passed on, their symptoms, and their treatment.

Chlamydia

Transmission

Bacteria called Chlamydia trachomatis cause chlamydia. It can be transmitted during anal, oral and vaginal sex if no condom is used, and can affect the anus, penis, cervix, throat and eyes. It can be transmitted to a baby during delivery, resulting in eye and chest infections. Also see the entry on LGV (which is caused by a variety of chlamydia), below.

Symptoms

Symptoms of chlamydia normally occur one to three weeks after infection. However, many people who have chlamydia are unaware that they have the infection. It is thought that as many as 75% of women and 50% of men with chlamydia have no symptoms.

Where symptoms do occur, in men they usually consist of a milky discharge from the penis, particularly in the morning, and a burning sensation when urinating. The testicles can swell and be very painful.

Women with chlamydia may notice a milky discharge from the vagina and/or lower abdominal or back pain, or pain when having sex. There may be vaginal bleeding during sex and bleeding between periods, or pain when urinating.

If a person has been infected anally, there may be soreness around the anus and a discharge.

If chlamydia is left untreated, it can lead to pelvic inflammatory disease (PID) in women, which can cause ectopic pregnancy and infertility. Men can become infertile. Men and, less frequently, women may develop Reiter’s syndrome (sore eyes and joints, skin rashes) as a result of chlamydia, and this can lead to disabling arthritis.

Diagnosis

Chlamydia is diagnosed by taking a swab from the penis or cervix or vagina. The swabs can be a little uncomfortable but are usually very quick to take. Some clinics will examine a urine sample for evidence of infection with chlamydia.

It can, however, take up to a week for tests to show if chlamydia is present. It is important to contact your clinic for the result of your test, so that you can be given treatment if the infection has been detected.

Treatment

Chlamydia is treated with antibiotics. Normally this consists of a seven-day course of doxycycline, or a single dose of azithromycin. It’s important to take all your tablets to ensure that the infection is eradicated from your body. It's also important to try and ensure that your partner receives treatment before you have sex again. Symptoms may persist for a few days after taking azithromycin, as the antibiotic takes time to work.

You will be advised not to have sex (even with a condom) until your treatment period is finished. This is to prevent re-infection.

Genital warts

Transmission

Genital warts are caused by the human papilloma virus (HPV). HPV is the most common sexually transmitted infection in the UK. The virus can be transmitted during unprotected anal, vaginal or oral sex, or simply by close physical contact with the warts themselves.  Condoms reduce the risk of transmission if they cover the infected area, but this is not always the case.

Symptoms

Genital warts look just like the warts that may appear on other parts of the body – usually small lumps on the skin with a slightly rough texture. Some people who contract the wart virus do not have visible warts or do not notice them. In women, warts may appear on the inside or outside of the vagina, or on the neck of the cervix, or around the anus. In men, warts may appear on the tip or shaft of the penis, the scrotum, or around the anus.

Some forms of the HPV virus are associated with an increased risk of cervical or anal cancer, and this risk might be increased even further in people with HIV. However, having visible warts does not mean you have the particular wart virus that is linked with cancer.

Diagnosis

Genital warts are diagnosed by visual and manual examination of the genital and anal area.

A Pap smear is a procedure designed to detect pre-cancerous cellular changes (called dysplasia) in a woman’s cervix – before the cancer develops. Most women know the Pap smear as a 'cervical smear'. Pap smears involve taking a small scraping of cells from the cervix. When these cells are examined under a microscope, it is possible to see if there are any changes in the cells that suggest a risk that cancer could develop in the future.

HIV-positive women are recommended to have Pap smears when they are first diagnosed with HIV, six months later, and then once a year. The value of screening the anal canal for pre-cancerous cells is being studied.

A type of testing called liquid cytology can also detect the wart virus linked to cancer and is gradually replacing Pap smears.

Treatment

Infection with the genital wart virus is cured by your own immune system and this can take a long time. Treatment to remove the visible warts involves either painting them with a chemical that burns them off, or freezing them off, or laser surgery or a new self-applied cream. These procedures may feel a little uncomfortable.

A vaccine against the types of human papilloma virus thought to cause anal and cervical cancer and genital wartshas recently been developed. Though trials have suggested it may be effective for some groups, it has not been tested on HIV-positive people. To date, no decisions have been taken about the best way to use this vaccine

Gonorrhoea

Transmission

Gonorrhoea is a bacterial sexually transmitted infection that can be passed on during anal, vaginal, oral, and mouth-to-anus (rimming) sex. Gonorrhoea can affect the anus, penis, cervix and throat. Untreated gonorrhoea can make a person with HIV more infectious. Having gonorrhoea can also make it more likely that an HIV-negative person will be infected if they are exposed to the virus. Gonorrhoea can also be passed on from mother to baby during childbirth, and can cause infection in the baby's eyes, with a high risk of blindness if left untreated.

Symptoms

Symptoms of gonorrhoea usually appear between two and ten days after infection.

However, some people may not realise they have the infection, as symptoms may not always be present, or may be very mild. In men, symptoms usually consist of a yellowish or greenish discharge from the penis and burning when passing urine. The testicles may also hurt and swell.

Symptoms in women can include a burning sensation when passing urine and a discoloured or bloody discharge from the vagina. If the infection is rectal, both men and women may notice a mucus-like, or bloody, discharge from the anus, pain in the anus, or pain when having anal sex. Gonorrhoea in the throat usually has no symptoms.

If left untreated, gonorrhoea can cause more serious health problems, including pelvic infections in women that can result in pain, infertility, and ectopic pregnancy, and testicular problems and narrowing of the urethra in men.

Untreated gonorrhoea can spread to the bloodstream, leading to fevers, and can also affect the joints, causing arthritis and swelling.

Diagnosis

To test for gonorrhoea, a swab is taken from the tip of the penis, the anus, urethra, throat or cervix. The swabs can be a little uncomfortable. A urine sample may be taken instead. It is usually possible to tell immediately from examination of the swabs if gonorrhoea is present in the penis or, in many cases, the cervix, but gonorrhoea in the throat can only be diagnosed later. However, whatever the site of infection, it can take up to three days for testing to provide conclusive results. It is important, therefore, to contact your clinic for the result of your test.

Treatment

Gonorrhoea is treated with antibiotics. Treatment is normally given by injection.

You will be asked to return seven days later for tests to check that you have been cured. It is very important not to have anal, oral or vaginal sex during this period, as you may be re-infected with gonorrhoea, or pass the infection to your partner.

Hepatitis A

Transmission

Hepatitis A is a virus that affects the liver and is transmitted through contact with infected faeces (excrement, shit), normally in contaminated food. However it can be passed on during sex, particularly oral-anal contact, or rimming. There have been outbreaks of hepatitis A among gay men in several cities in recent years. Once you have had hepatitis A, you cannot get it again, but some people do have relapses.

Symptoms

Hepatitis A can cause a short-term mild illness, and symptoms can include a yellowing of the skin and eyes (jaundice), extreme tiredness, weight loss, vomiting, diarrhoea, dark urine and pale stools. Symptoms can be made worse by drinking alcohol, tea or coffee and eating fatty food. People normally get better in a couple of weeks.

Diagnosis

A blood test can show present or prior hepatitis A infection. Sexual health clinics do not routinely test for hepatitis A.

Treatment

Treatment for hepatitis A consists of rest, drinking fluids, and avoiding alcohol and recreational drugs. It's also important not to take paracetamol while you are recovering from hepatitis A. Hepatitis A can last longer and be more severe in people living with HIV or weakened immune systems. If you do pick up hepatitis A, it might be necessary for you to stop taking anti-HIV drugs for a time. This is because the liver does most of the work of breaking down drugs in the body, and when it is inflamed, it doesn’t work so well, and this can make any side-effects your treatment causes worse.

Vaccination

Unlike most infections considered in this section, a vaccination against hepatitis A is available and everyone living with HIV is recommended to have it if they do not have natural immunity to the infection. The vaccination consists of two injections, given six months apart.

For more information, see the booklet HIV and hepatitis in this series.

Hepatitis B

Transmission

Hepatitis B is passed on by contact with the blood, semen, saliva, or vaginal fluids of an infected person. It is easily passed on during unprotected sex and from a mother to her baby during delivery. It is many times more infectious than HIV.

Symptoms

When someone first becomes infected with hepatitis B, they may develop jaundice (yellowing of the eyes and skin), lose their appetite, have pain in the abdomen, malaise, nausea, vomiting, muscle and joint aches or fever. These symptoms can be very serious or, in very rare cases, even fatal. However, most people do not notice any symptoms.

At this point, early in the infection, most people will develop protective immunity. However, in about 5% of adults, hepatitis B continues to reproduce in the body long after infection. These people become chronic carriers of hepatitis B, meaning that they will be infectious for the rest of their lives, although they may not experience any symptoms themselves. About a quarter of chronic hepatitis B carriers eventually develop chronic liver inflammation and, therefore, increased risk of liver disease (cirrhosis) or cancer of the liver. HIV-positive people who develop hepatitis B are much more likely to become chronic carriers of hepatitis B (around 33% do so).

The liver damage experienced by some people with hepatitis B is caused not by the virus itself, but by the immune system's destruction of hepatitis B-infected cells in the liver. Because the immune responses of people with HIV are often impaired, HIV-positive people with chronic hepatitis B infection may actually be less likely to experience liver damage than people who have fully functioning immune systems. However, there is a danger that the liver could become damaged later, if their immune systems improve in response to anti-HIV treatment.

Conversely, levels of hepatitis B in the body fluids of HIV-positive people may be higher than those seen in HIV-negative people. This is because their immune systems are not so efficient at clearing the hepatitis B from the body – so HIV-positive carriers of hepatitis B may be more infectious than their HIV-negative counterparts.

Diagnosis

Blood tests can detect the presence of hepatitis B antibodies, which show that you have been exposed to, and have cleared, the virus. If you have been exposed and have not developed any protective antibodies, then fragments of the virus itself, called hepatitis B surface antigen (HBsAg), will persist in your blood. This means that you are a chronic carrier and are capable of infecting other people. A sub-group of carriers also test e-antigen positive and this means that their hepatitis infection is highly infectious to others.

Treatment

During the initial period of infection with hepatitis B, it's important to take lots of rest, drink plenty of fluids, not to take paracetamol, and to avoid alcohol and recreational drugs.

If you are HIV-positive and have chronic hepatitis B infection, then you must receive care from a doctor skilled in the treatment of both HIV and hepatitis.

Hepatitis B can be treated with interferon alfa (Roferon-A/Viraferon) in injections of 3 - 5 million units three times per week. The anti-HIV drugs 3TC (lamivudine, Epivir), FTC (emtricitabine, Emtriva), and tenofovir (Viread) are also active against hepatitis B, and both 3TC and FTC have been shown to reduce levels of detectable hepatitis B in people infected with both HIV and hepatitis B. Clinical trials are underway to assess the use of combinations of these drugs and if you think you might benefit from joining one, you should enquire at your treatment centre.

Adefovir (Hespera) is also used to treat hepatitis B. There have been case reports, however, of flare-ups of hepatitis B in people who have stopped using 3TC and begun a new anti-HIV combination. If you are co-infected with hepatitis B, you should talk to your doctor about how it might affect your anti-HIV treatment options.

Vaccination

People with HIV, unless naturally immune, are recommended to receive hepatitis B vaccination. This consists of a course of three injections, given over several months. People with HIV can lose their immunity to hepatitis B as their immune system weakens, and should have it checked regularly.

For more information, see the booklet HIV and hepatitis in this series.

Hepatitis C

Transmission

Hepatitis C is normally transmitted by blood-to-blood contact. However, there has recently been an increase in the number of HIV-positive gay men who have tested positive for hepatitis C when their only risk factor was unprotected sex. Other factors that seem to be associated with sexual transmission of hepatitis C are: group sex, snorting drugs, anal administration of drugs and the presence in either person of syphilis infection.

Symptoms

The effects of infection with hepatitis C vary. Less than 5% of people who contract the virus develop acute hepatitis symptoms such as jaundice and nausea at the time of infection, and a significant minority may experience no symptoms at any stage. For those who do, common symptoms include extreme tiredness and depression.

Diagnosis

A blood test for antibodies to hepatitis C can tell you whether you have been exposed to the virus, but as these tests can give false negative results, a PCR (viral load) test may be used to confirm infection. Liver function tests may give an indication of whether hepatitis C has damaged your liver, but to be sure of this, doctors will normally give one of two tests. The first of these is a liver biopsy, in which a small sample of liver tissue is removed for examination. The second, now available at many centres, involves a simple blood test.

In people with HIV, the diagnosis of hepatitis C can be more difficult, as the infection may not show up on their antibody tests.

Treatment

Current practice is to start treatment for hepatitis C only if liver function is consistently abnormal. The goals of treatment are to cure hepatitis, to normalise liver enzymes (a marker of liver function), to lower hepatitis C viral load, to improve liver inflammation and to prevent progression to cirrhosis or liver cancer.

Treatment for hepatitis C is not life-long and usually lasts 24 or 48 weeks. Antiviral drugs are approved for hepatitis C. The British HIV Association recommends that hepatitis C be treated with a combination of pegylated interferon and ribavirin. Side-effects may be very severe, though they tend to lessen as treatment goes on, and include high fevers, joint pain, hair loss, depression and low white cell count. Ribavirin should not be taken at the same time as AZT (zidovudine, Retrovir), and can't be used during pregnancy.

The best approach to treating people co-infected with HIV and hepatitis C is unclear. Most specialists advise treating the infection that is more immediately life-threatening, and in the majority of cases that will be HIV. However, treatment with some anti-HIV drugs, e.g. protease inhibitors, may be problematic for people with liver damage and requires very careful monitoring. There is some evidence that the restoration of the immune system seen with successful anti-HIV therapy may temporarily increase the risk of liver damage in people with hepatitis B and hepatitis C.

For more information see the booklet HIV and hepatitis in this series.

Herpes

An outbreak of herpes involves painful sores or ulcers that can affect the mouth, genitals or anus. Herpes is caused by a common virus called herpes simplex virus (HSV).

Once you are infected, the virus stays in nerve cells for life. You may not know that you are infected with HSV. Most of the time it is dormant and causes no symptoms. From time to time flare-ups can occur, especially if you have a weakened immune system. Even among people without HIV, stress, a common cold or exposure to strong ultra-violet light can cause an outbreak of active herpes.

There are two main types of HSV, both of which can cause oral and genital infection. HSV-1 usually causes oral herpes or cold sores – tingling or painful spots on the edge of the lip where it meets the skin of the face. These can occasionally develop on the nostrils, on the gums or on the roof of the mouth. It can also cause genital infection.

Painful genital or anal ulcers, sometimes accompanied by fever, headache, muscle ache and malaise can be caused by both HSV-1 and HSV-2. Herpes lesions often start as numbness, tingling or itching. This feeling indicates that the virus is travelling up a nerve to the skin. There it causes small bumps that rapidly develop into small, inflamed, fluid-filled blisters. These burst and crust over, and typically take one or two weeks to heal in people whose immune systems are functioning normally.

Transmission

The virus can be passed from person to person by contact between the ulcers and mucous membranes, for example by kissing and/or sexual contact.

Herpes may also be transmitted when sores are not present, if HSV is replicating and infectious HSV particles are being shed from the skin or, more likely, from mucous membranes. HIV-positive people may experience such shedding more frequently.  Condoms do not always protect against HSV as the lesions/shedding skin may not be covered by the condom.

Having genital herpes increases the risk of transmission/acquisition of HIV.

In people with HIV, herpes outbreaks can be frequent, severe and long lasting. Sometimes the lesions can become infected with other bacteria or fungi. As well as causing large oral and genital lesions, herpes can occasionally affect the throat and the eyes.

Diagnosis

HSV is diagnosed by growing (culturing) the virus from a swab taken from a lesion, or by using a fluorescent screening test to detect the virus. A test that looks directly for the virus's genetic material is used for research purposes, but is not generally available. Herpes in the oesophagus (gullet) or colon may be examined using fibre-optic instruments.

Treatment and preventing recurrences

Herpes infections are treated with aciclovir. Other treatments for herpes include valaciclovir, known by the brand name Valtrex, and famciclovir.

Aciclovir is taken in tablet form (200 to 800 mg five times a day for 5 to 10 days) to treat serious attacks of oral herpes and genital or anal ulcers. Although effective at a different dosage at preventing outbreaks of herpes, once an attack of genital herpes is established, aciclovir often provides minimal benefit. It is also given as an intravenous drip (5 to 10 mg/kg every 8 hours) for very severe attacks. Aciclovir has very few side-effects. Aciclovir cannot eliminate HSV, so herpes attacks may recur. Aciclovir cream is available from chemists to treat cold sores; however, many doctors question how effective it really is. Some people find that salt baths, ice packs (wrapped in a towel), lidocaine gel, painkillers and rest help relieve symptoms.

Aciclovir may be taken on a regular basis to prevent recurrent attacks of herpes (400mg twice daily).

LGV

LGV (lymphogranuloma venereum) is a form of chlamydia, a common sexually transmitted infection.

LGV occurs in Africa, Asia, South America and parts of the Caribbean. With the introduction of antibiotics in the 1940s, LGV became very rare in the UK and Europe.

However, outbreaks of LGV have recently been reported in gay men in the Netherlands, France, Germany, the US and Sweden. In the UK, measures have been introduced to detect and monitor any outbreak. By the summer of 2006, around 300 cases of LGV had been identified in England (mostly in London and Brighton), nearly all of them involving gay men, most of whom were HIV-positive.

Transmission of LGV

The current outbreak of LGV in Europe has mostly involved gay men (most of whom have also been HIV-positive). However, LGV can affect both men and women, regardless of their HIV status.

LGV can affect the penis, vagina and anus, and can be passed on during anal, oral and vaginal sex.

The cases seen in European gay men recently have mostly involved the anus and rectum, and it is thought that they are linked to fisting. However, some of the men with anal and rectal infection with LGV said that they had never been fisted, but had had unprotected anal sex.

The cases of LGV seen so far have been in clusters. It is known that many of the cases were linked with fisting sex parties. Many of the men who attended these parties were HIV-positive.

Most of the men diagnosed with LGV in the European outbreak also had other sexually transmitted infection such as gonorrhoea, syphilis, herpes, hepatitis B virus and hepatitis C virus.

Condoms are very effective at preventing the transmission of sexually transmitted infections, including chlamydia, of which LGV is a form. 

If you are fisting, wear latex gloves and do not share pots of lubricant. This shouldreduce the risk of LGV and other sexually transmitted infections being passed on.

Symptoms of LGV

LGV can cause very unpleasant symptoms. In the current outbreak, the most common symptom is indicative of the secondary phase of the infection – pain and inflammation in the anus and rectum (proctitis). In some cases, this has been accompanied by swollen glands in the groin, and often by a discharge of mucus from the rectum (which can be bloody), as well as constipation.

If left untreated, LGV can cause general swelling of the lymph glands, extreme swelling of the genitals and ulcers on the genitals. It can also affect the bowels.

Because it is so rarely seen, some of the recent cases of LGV in Europe were initially misdiagnosed as another sexually transmitted infection, such as syphilis or herpes, or as an inflammatory bowel disease, such as Crohn’s disease. However, sexual health and HIV clinics across the UK have been alerted to the outbreak of LGV and its symptoms and are getting better at recognising it.

Diagnosis of LGV

If you go for a general sexual health check-up, you will be screened for a number of sexually transmitted infections. If you are found to have chlamydia in the anus, the clinic should send the sample for special tests to see if is LGV.

If you are concerned that you might have LGV, make sure that you tell the doctors or nurses at the clinic you are attending.

Treatment of LGV

LGV can be cured using a 21-day course of the oral antibiotic doxycycline. This antibiotic is also used to treat other sexually transmitted infections (and some other infections), but in shorter courses.

Non-specific urethritis (NSU)

Transmission

Non-specific urethritis (NSU) is an inflammation of the urethra (the tube that runs down a man’s penis, through which urine and semen pass). This inflammation can be caused by any one of several sexually transmitted infections. However, very rarely it can have a different cause, such as friction during sex or irritation caused by soap.

Symptoms

Symptoms of NSU normally develop within a week or so of infection, although some irritants, such as soap, can cause symptoms to occur almost immediately. However it is estimated that as many as 50% of men who have NSU show no symptoms at all.

When symptoms do occur, they normally consist of pain or a burning sensation when passing urine, more frequent urination and a white or cloudy discharge from the tip of the penis that may be particularly noticeable first thing in the morning.

Diagnosis

NSU is diagnosed by taking a swab from the penis. This can be very briefly uncomfortable.

In many cases it will be possible to tell instantly if NSU is present, but it can take up to a week for tests to show if chlamydia, the symptoms of which can resemble NSU, is present.

Treatment

NSU is treated with antibiotics, usually either a seven-day course of doxycycline or a single dose of azithromycin. It is important to take all your tablets to ensure that the infection has been eradicated from your body. Symptoms may persist for a few days after taking azithromycin, as the antibiotic takes time to work.

You will be advised not to have sex (even with a condom) until your treatment period has finished. Your partner, wherever possible, should also receive treatment – to cure them and to prevent reinfection.

Pubic lice

Pubic lice, also called ‘crabs’, are small insects that resemble crabs because of their claws, which allow them to hold onto pubic hair (body hair near the genitals and anus). Although crabs are particularly fond of pubic hair, they can live in hair in other parts of the body, particularly the armpits, and even in the eyebrows and eyelashes, although this is uncommon.

Transmission

Crabs are normally picked up and passed on during sex, though any form of intimate bodily contact can be enough to pass them on. They can also be picked up from sharing towels, bedding or clothing, but this is less common.

Symptoms and diagnosis

Some people notice the infestation within hours, but others do not become aware that they have crabs for several weeks. Crabs are very small and can be very difficult to see, but symptoms usually include an intense itching in the groin, and some people notice the lice eggs firmly attached to pubic hair. Small spots of blood may appear on underwear or sheets.

Treatments

Lotions such as malathion (Derbac M) are available from chemists, without prescription, for getting rid of crabs, or free of charge from sexual health and GUM clinics. It is important to follow the instructions properly, as improper use could mean that you fail to clear the infestation, and using too much could provoke an allergic reaction. Do not use Derbac M or similar lotions after a hot bath.

Once you start treatment, it is important to wash all the clothes, towels and bedding you have used since you were infected with crabs – on a hot cycle. You should also ensure that your partner, or anyone else with whom have had intimate bodily contact or shared a bed, uses treatment at the same time as you, to avoid reinfestation.

Scabies

Scabies is a skin infection caused by a mite that burrows under the skin, causing intense itching, usually most noticeable at night.

Transmission

It is easy to pick up the scabies mite, through prolonged skin contact with an infected person, or by sharing towels or bedding.

Symptoms

The mites themselves are invisible to the naked eye, but their burrowing leaves red 'track marks' in the skin. These are most often seen in the webs of the fingers, on the backs of the hands, around the tummy, on wrists, elbows, armpits, the genitals, breasts, buttocks, and feet.

People whose immune systems aren’t fully functioning (and having HIV is only one possible cause of this) may develop a widespread rash with thick scaling and intense itching. This is called Norwegian scabies.

Treatment

The same lotions used to treat crab infestations are also effective against scabies mites, although it may be necessary to leave the lotion on the body for longer (usually 24 hours). It should be applied to the whole body, except the face and scalp, and needs to be reapplied to the hands after washing. After treatment, the itch can get worse temporarily. In this case, hydrocortisone cream can be applied, and the itch should not be scratched. Do not use scabies treatment after a hot bath.

Clothing, towels and bedding should be washed on a hot cycle to avoid infecting others or yourself. As with crabs, it is important that anyone who has been in intimate contact with you treats him/herself at the same time as you, to avoid reinfestation.

Neither scabies mites nor crabs can pass on HIV. People with long-standing crab and scabies infestations can feel generally unwell (which is the origin of the term ‘lousy’) and, if left untreated, scabies can cause severe skin irritation.

Syphilis

Syphilis is a bacterial infection. The number of cases in the UK and many other countries has increased dramatically in recent years. There are three stages to the disease: primary syphilis, secondary syphilis and tertiary syphilis. During the primary and secondary stages, the disease is highly contagious.

Transmission

Syphilis can be contracted from contact with syphilitic sores during unprotected anal, oral or vaginal sex. It can also be transmitted by close physical contact with secondary syphilitic rashes and lesions, which can be anywhere on the body, and from contact with blood. Syphilis can also be transmitted from mother to baby, usually during delivery.

Untreated primary and secondary syphilis can make a person with HIV more infectious. And an HIV-negative person who has syphilis is much more likely to be infected with HIV if they are exposed to it.

Symptoms

Syphilis can cause a range of symptoms or none at all. In the early stage of the disease, symptoms may be easily missed. Syphilis can progress more quickly and severely in people with HIV, and may present slightly different symptoms.

Shortly after becoming infected with syphilis (primary syphilis) a small sore, spot or ulcer (called a chancre) may appear at the site of infection, usually on the penis, in or around the anus or vagina or in the mouth. The chancre does not hurt, usually heals quite quickly, and can be accompanied by swollen glands.

Secondary syphilis can cause a rash on the body, palms and soles, swollen glands, fever, muscle pain, headache, ringing in the ears, and, in rare cases, meningitis. The rash and sores are highly infectious. Secondary syphilis normally develops within six months of exposure.

Tertiary syphilis can develop about ten years or more after infection and can cause damage to the heart, the brain, the bones and the skin. If left untreated, syphilis can cause death.

Diagnosis

A general sexual health check-up will include a blood test for syphilis, and any sores will be swabbed. Many HIV clinics now test for syphilis as part of their routine HIV care. It can take up to three months for the body to develop antibodies to the bacteria that cause syphilis, so a test taken shortly after exposure may not detect infection. There is some evidence to suggest that tests for syphilis are not as reliable in HIV-positive people. If brain involvement is suspected, a lumbar puncture (often called a ‘spinal tap’) may be carried out to assess the extent of disease.

Treatment

Syphilis is usually treated with a course of penicillin injections. People who are allergic to penicillin are given a course of doxycycline tablets. To ensure that the syphilis is completely cured, it is vital to have all your prescribed injections or take all your tablets and attend for follow up blood tests. To avoid infecting other people with syphilis, or being reinfected with the bacteria, it is important to avoid sex altogether until treatment has been completed and you have been given the all clear.

Follow-up blood tests will be carried out at intervals of 1, 2, 3, 6 and 12 months to ensure the infection has gone.

Trichomonas

Trichomonas vaginalis is a common sexually transmitted infection caused by a tiny parasite.

Transmission

Trichomonas is spread by unprotected sex between men and women.

Symptoms

In women, symptoms can include a heavy vaginal discharge, vaginal itching, lower back pain, pain during sex and a frequent need to urinate. Often men have no symptoms, but when they do, a discharge from the penis, a burning pain when urinating and an increased need to urinate are most common.

Diagnosis

Swabs taken from the vagina or penis are examined for the presence of trichomonas under a microscope, and it is often possible to tell immediately if infection is present. Swabs can also be cultured, with results available in a week.

Treatment

Trichomonas is treated with antibiotics. It is important to take all your tablets to ensure that the infection has been eradicated from your body. You will be asked to return a week later for a test to see that you have been cured. You will be advised not to have sex (even with a condom) until your treatment period has finished and your partner(s) has received treatment. This is to prevent reinfection.

Other infections

Other infections can also be transmitted during sex. Any sex that involves contact with faeces, even in microscopic amounts, such as rimming, anal sex or fisting, can lead to infection with gut infections such as giardia and cryptosporidiosis. These can cause bad diarrhoea and vomiting that needs to be treated with antibiotics.

Undetectable viral load and infectiousness

An undetectable HIV viral load is the goal of anti-HIV treatment. This does not mean that you have been cured of HIV, but that the combination of drugs you are taking has so reduced HIV's ability to reproduce that it can no longer be detected in your blood.

An undetectable viral load in your blood does not necessarily mean that you are not infectious.

Although many people who have an undetectable viral load in their blood also have an undetectable viral load in their sexual fluids and seem less likely to transmit HIV, this is not always the case. Some people who have an undetectable viral load in their blood have sufficient viral load in their sexual fluids to infect somebody else.

Studies have mainly been conducted in men, and these have found that having an untreated sexually transmitted infection, particularly gonorrhoea, increases the chances that HIV will be detectable in semen.

HIV can also be present in cells and it is possible that these could transmit HIV infection even when a person has an undetectable viral load.

In addition, studies have found that men who have high blood viral loads also have very high viral loads in their semen, and are very infectious.

If a person has HIV that has become resistant to anti-HIV drugs, they can infect other people with drug-resistant HIV. About 10% of new HIV-infections in the UK are with drug-resistant virus. A person infected with drug-resistant virus has limited treatment options – before they have taken a single anti-HIV drug.

Reinfection

In addition to sexually transmitted infections, unprotected sex can carry other health risks for HIV-positive people. There have been cases reported where a person with HIV has been reinfected (or superinfected) with another subtype or strain of HIV that is resistant to anti-HIV drugs.

In some cases this has resulted in the person's HIV viral load increasing and CD4 cell count falling. In addition, their treatment options have been limited because the type of HIV they were reinfected with was resistant to some or all of the anti-HIV drugs they were taking, as well as others they had never taken.

It is not known how easy it is for somebody to become reinfected with HIV. So far only a few cases have been reported worldwide, almost all among gay men who had unprotected anal sex. However, there has also been a case reported of reinfection involving a heterosexual couple.

Although reinfection appears to be very rare, there seem to be some factors that might increase the risk of it happening. Nearly all the reported cases of reinfection occurred in people who had HIV for three years or less, and either had not started HIV treatment or were on a break from treatment. However, there has been a single case report of reinfection in a man who had long-term HIV infection. It remains to be seen whether further cases will be reported.

Pregnancy

If you are HIV-positive and thinking of becoming pregnant, or are pregnant and diagnosed with HIV, it is very important to discuss your options with members of your health care team.

The chance of an HIV-positive woman giving birth to an HIV-negative baby are greatly increased by:

• Taking HIV drugs during the pregnancy
• Choosing not to breastfeed
• If you have an undetectable viral load you should be able to have a vaginal delivery. If viral load is detectable at the time of labour then you’ll need to have a caesarean delivery.

The booklet HIV and women in this series explores these issues in more detail.