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Part 2: HIV and sexual health
   Last updated: 01.03.06
 
Sexual health is important to everybody, but is especially important if you have HIV because sexually transmitted infections (often shortened to STIs) can not only cause illness, but increase the chances of you passing on HIV during unprotected sex, even if you have an undetectable viral load.

Although sexually transmitted infections can seem minor, 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 and in extreme cases, be fatal.

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

In some cases people have been reinfected (sometimes also called superinfected) with different or drug-resistant strains of HIV.

Having good sexual health also includes feeling comfortable with your sexuality, and the kinds of sex you are having and who with.


Anal and vaginal sex
Unprotected (i.e. without a condom) anal and vaginal sex have the greatest risk 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 STI, or if you ejaculate inside your partner. Similarly, if an HIV-negative person has an untreated STI their chances of contracting HIV from you during unprotected sex are increased.

If you are receptive, or passive during sex, the risk of passing on HIV is reduced, but is still present, especially if you have a high viral load or an untreated STI.

Unprotected vaginal sex also carries the 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 transmission of HIV is 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, with others putting the figure much lower, even at zero.

The risk from oral sex is much lower than the risk from unprotected anal or vaginal sex. Having a very high viral load, an untreated STI, ejaculating in the mouth of the person sucking and bleeding gums or sores or wounds in the mouth of the person sucking seem to increase the very small risk.


Condoms
Condoms, when used properly, provide excellent protection against getting most STIs and passing on HIV to other people, or being reinfected with another strain of HIV.

In the UK and some other countries it was usual to recommend extra-strong condoms for anal sex, however recent research has found that standard strength condoms are just as safe.

Condoms are usually made of latex. Some people are allergic to latex condoms. If this is the case, then polyurethane condoms are a safe alternative.

A water based lubricant should be used with condoms, as oil based ones weaken condoms and can cause tiny tears.

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.

Condoms should be disposed of as rubbish in a bin and not flushed down the toilet or discarded in the street or in parks or fields.


Use of anti-HIV drugs to prevent infection with HIV
If a person is exposed to HIV during sex, many 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. However, not all clinics offer it for sexual exposure, pointing to worries about side-effects and resistance. Nevertheless, it is becoming more widely available. PEP is not a kind of ‘morning after pill’ for HIV and it's not 100% effective.

PEP may also be considered in cases of rape and sexual assault where there is 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, but many believe that this is too late.

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 involve risks. Some HIV drugs, particularly abacavir (Ziagen) and nevirapine (Viramune) can cause an allergic reaction or severe side-effects which 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 taking a few doses of your anti-HIV medicines could lead to resistance developing.

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 this is closed then go to the accident and emergency department of your local hospital who 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. However, you can choose which sexual health clinic you go to.
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, what is wrong and examine you for symptoms. It is important to be honest if you have has unprotected sex so you can have 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 Africans, and their services should be non-judgmental.

Check-ups normally involve having swabs taken from the tip of the penis or inside the 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 for some 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 you have an STI you may be offered the opportunity to see a health adviser. Health advisers can give you information about STIs 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 16 – 24 year olds.


Sexually transmitted infections
Bacteria, viruses and parasites can cause sexually transmitted infections.

Bacterial infections can be cured with antibiotics, and antiviral drugs can be used to treat some of the viral infections. Lotions can clear infestations with scabies and lice.

This section includes a brief explanation of how common STIs 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 with chlamydia, and 50% of men with chlamydia have no symptoms.

Where symptoms do occur, in men it usually consists 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 also be vaginal bleeding during sex and bleeding between periods. There may also be pain 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 frequentlywomen 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 vuvlo-vaginal area or by a simple urine test. The swabs can be a little uncomfortable but are very quick to take. Some clinics also 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 and it is important to contact your clinic for the result of your test so treatment can be given if the infection has been detected so make sure you contact your clinic for your results.

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 reinfection.


Genital warts
Transmission

Genital warts are a sexually transmitted infection caused by the human papilloma virus (HPV) and are the commonest STI in the UK. They can be contracted during unprotected anal, vaginal or oral sex. It can also be transmitted by close physical contact with the genital warts themselves, as these may shed the wart virus.

Symptoms

Genital warts look just like warts which 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 genital warts 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 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 early, before 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 which 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 wart involves either the warts being painted with a chemical that burns them, freezing, laser surgery or a new self-applied cream. These procedures may feel a little uncomfortable.


Gonorrhoea
Transmission

Gonorrhoea is a bacterial STI and 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 mucoid 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 resulting in pain, infertility, and ectopic pregnancy, and testicular problems and narrowing of the urethra in men.

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

Diagnosis

To test for gonorrhoea, a swab is taken from the tip of the penis, anus, urethra, throat or from the 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, and 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 see 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 which 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 amongst 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 whilst you are recovering from hepatitis A. Hepatitis A can last longer and be more severe in people with HIV and weakened immune systems. If you have hepatitis A it might be necessary to stop taking anti-HIV drugs for a time as most medicines are broken down by the liver and when the liver is inflamed by hepatitis A side-effects can become worse.

Vaccination

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

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, and 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 on infection.

At this point, most people will develop protective immunity. However in about 5% of adults, hepatitis B continues to reproduce in the body long after infection. These are chronic carriers of hepatitis B, meaning that they are infectious for life, although they may not experience any symptoms themselves. About a quarter of chronic hepatitis B carriers eventually develop chronic liver inflammation and are at increased risk of liver disease (cirrhosis) or cancer of the liver. HIV-positive people who develop hepatitis B are at higher risk of becoming chronic carriers of hepatitis B (around one-third).

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 with fully functioning immune systems. However, there is a danger that the liver could become damaged due to the immune system reacting after improvement 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 uninfected people because less hepatitis B is cleared from the body by the immune system, 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 this protective immunity, 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 switching off 3TC when beginning a new anti-HIV combination. If you are co-infected, you should talk to your doctor about how this might affect your anti-HIV treatment options.

Vaccination

Unless you are naturally immune, you are recommended to receive hepatitis B vaccination. This consists of 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 this 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, recently there has been an increase in the number of HIV-positive gay men testing positive for hepatitis C whose only risk factor was unprotected sex. Sexual practices which involve contact with blood, such as fisting, and having syphilis at the time of hepatitis C infection also appear to be factors involved in the infection's transmission.

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, though this can only be accurately shown by a liver biopsy, in which a small sample of liver tissue is removed.

HIV infection can make the diagnosis of hepatitis C more difficult as infection may not show up on antibody tests in HIV-infected people.

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 reduce as treatment goes on. They 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 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 which both 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 with fever, headache, muscle ache and malaise can be caused by 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, typically taking one or two weeks to heal in people with normal immune systems.

Transmission

The virus can be passed from person-to-person by contact between these lesions and mucous membranes e.g. kissing, and 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.

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

In people with HIV, herpes recurrences 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 eye.
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 recurrances

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, pain killers and rest help relieve symptoms.

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


LGV
LGV is short for lymphogranuloma venereum; it is a form of the common sexually transmitted infection chlamydia.

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 2005, over 150 cases of LGV had been identified in England (mostly in London), nearly all 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 that took place in the Netherlands. 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, wearing latex gloves and do not share pots of lubricant. This will reduce 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 commonest symptom is the sign of the secondary phase of the infection, proctitis – pain and inflammation in the anus and rectum. 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), and constipation.

If left untreated, LGV can cause general swelling of the lymph glands, extreme swelling of the genitals, 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 becoming more skilled 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.

It is important that you do not have sex if you have LGV, or any other sexually transmitted infection, until follow-up tests confirm that you have been cured.


Non-specific urethritis (NSU)
Transmission

Non-specific urethritis (NSU) is an inflammation of the tube which urine and semen pass through in a man's penis, the urethra. This inflammation can be caused by several sexually transmitted infections transmitted during unprotected anal, oral, or vaginal sex. However, very rarely it can have a non-sexual cause, such as friction during sex.

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 with NSU have 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 which may be particularly noticeable first thing in the morning.

Diagnosis

NSU is diagnosed by taking a swab from the penis. This can be uncomfortable but is very quick to take. A urine sample may also be looked at for evidence of infection.
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. Normally this consists of 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. This is 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.

Shaving pubic hair will not get rid of crabs. It is important to wash all clothes, towels and bedding you have used since you were infected with crabs on a hot cycle when you start treatment. You should also ensure that your partner, or people with whom have had intimate bodily contact, or shared a bed, use treatment at the same time as you to avoid reinfestation.


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

Transmission

It is easy to pick up scabies, any skin contact is sufficient, and sharing towels or bedding is enough for transmission to occur.

Symptoms

Scabies are invisible to the naked eye, but leave red 'track marks' in the skin. Usually scabies affect the hands between the fingers, the genitals, breasts, buttocks, abdomen and feet. Norweigan scabies can occur in HIV-positive who have weak immune systems. White flakes appear on the skin in mounds and cause intense itching.

Treatment

The same lotions used to treat crab infestations are also effective against scabies, 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, other than the face and scalp, and reapplied to the hands after hand-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 anybody who you think might have been infested at the same time as you, and with whom you are in intimate contact, treats themselves at the same time as you to avoid reinfestation.

Neither scabies 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 have 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.

Untreated primary and secondary syphilis can make a person with HIV more infectious. Having syphilis may also makes it much more likely that an HIV-negative person will be infected with HIV if exposed to the virus.

Symptoms

Syphilis can cause a range of symptoms or none at all. In the early stage of 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 and usually heals quite quickly. It 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 almost all the heart, the brain (neurosyphilis), the bones and the skin (gumma). If left untreated syphilis can cause death.

Diagnosis

A general sexual health check-up will include a blood test for syphilis, and any lesions 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 doxycyline tablets. To ensure that the syphilis is completely cured it is vital to have all your prescribed injections or take all your medication. 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 and12 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 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 which involves contact with faeces, even in microscopic amounts, such as rimming and, anal sex and fisting can lead to infection with gut infections such as giardia and cryptosporidiosis. These can cause bad diarrhoea and vomiting which 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 been cured of HIV, but that the combination of drugs you are taking has reduced HIV's ability to reproduce so it can no longer be detected in the blood.

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

Although many people with undetectable viral loads in their blood also have an undetectable viral load in their sexual fluid and seem less likely to transmit HIV, this is not always the case. Some people with 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 STI, particularly gonorrhoea, increases the chances that HIV viral load 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 also found that men with high blood viral loads have very high viral loads in their semen and are very infectious.

If a person is resistant to anti-HIV drugs, it is thought they can infect other people with drug resistant HIV, and about 10% of new HIV-infections in the UK are with drug resistant virus. This means that the person newly infected with HIV has limited treatment options before they have taken a single anti-HIV drug.


Reinfection
In addition to STIs, unprotected sex can have 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 which 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 amongst 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 rare, there seem to be some factors that might increase the risk of it happening. The main one appears to be taking a break from treatment. The reasons for this are not fully understood.


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 healthcare team.

The use of anti-HIV drugs during pregnancy and delivery, caesarean delivery, and not breast feeding can mean that an HIV-positive mother can have an HIV-negative baby.

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