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Sexually transmitted infections
Bacteria and viruses can cause sexually transmitted infections (STIs). Mites that burrow under the skin, called scabies, can also be passed on during sex, as can pubic lice (crabs). 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 and lice.
This section gives a brief explanation of the ways in which common STIs and infestations are passed on, their symptoms, and their treatment.
Chlamydia
Transmission
Chlamydia can be transmitted during anal, oral and vaginal sex if no condom is used, and can affect the anus, penis, cervix, throat and eyes.
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 per cent of women and 50 per cent 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. Chlamydia can also cause the testicles to swell. If a person has been infected anally, there may be soreness around the anus and a discharge.
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.
If chlamydia is left untreated it can lead to pelvic inflammatory disease (PID) in women, which can cause ectopic pregnancy, infertility, and even death in extreme cases. Men are less likely to develop serious complications, though untreated chlamydia may cause infertility. Both men and women may develop arthritis as a consequence of untreated chlamydia.
Diagnosis
Chlamydia is diagnosed by taking a swab from the penis or cervix. This can be a little uncomfortable, but is usually very quick. 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.
Treatment
Chlamydia is treated with antibiotics. Normally this consists of 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 is eradicated from your body. It’s also important to try and ensure that your partner receives treatment. Symptoms may persist for a few days after taking azithromycin, as the antibiotic takes time to work.
You may be asked to return a week later for a test to see if your treatment has been effective. You are likely to 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 a sexually transmitted infection caused by the human papilloma virus and are the commonest STI in the UK. They can be contracted during unprotected anal, vaginal or oral sex. They 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 symptoms, however, or else do not notice the presence of warts. 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 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, these are not the most common form of the wart virus.
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 at least once a year. The value of screening the anal canal for pre-cancerous cells is being studied.
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 the warts with a chemical that burns them, freezing, laser surgery or a new immune stimulating cream. Some of these procedures may be a little uncomfortable.
Gonorrhoea
Gonorrhoea is a bacterial STI 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, resulting in 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 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 mucousy or bloody discharge from the anus, pain in the anus, or pain when having anal sex. Gonorrhoea in the throat can cause a sore throat, but usually doesn’t.
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 in men.
Untreated gonorrhoea can also spread to the bloodstream, leading to fevers, and can affect the joints, causing arthritic-like pain and swelling.
Diagnosis
To test for gonorrhoea, a swab is taken from the tip of the penis or from the cervix. If you have told the doctor that you have had oral or anal sex, swabs will also be taken from the throat and/or anus. The swabs can be a little uncomfortable. A urine sample may also be taken. 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 usually 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 so treatment can be given if the bacteria have been detected.
Treatment
Gonorrhoea is treated with antibiotics. These are normally given by injection.
You will be asked to return seven days later for tests to see that you have been cured. You are likely to be advised not to have sex (even with a condom) until your treatment period is finished. This is to prevent reinfection.
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 (rimming) contact. 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.
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 or by eating fatty food. People normally get better after a couple of weeks.
Diagnosis
Sexual health clinics do not routinely test for hepatitis A, but blood tests can be used to detect the virus, as can examination of stool samples.
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 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
A vaccination is available for hepatitis A, 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 a number of months.
Hepatitis B
See the section on hepatitis B in the chapter Symptoms and illnesses .
Hepatitis C
See the section on hepatitis C in the chapter Symptoms and illnesses .
Herpes
An outbreak of herpes involves painful sores or ulcers that affect the mouth or genitals. Herpes is caused by a common virus called herpes simplex virus (HSV).
Once you are infected, the virus stays in skin and nerve cells for life. However, 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 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. 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.
HSV-2 is the usual cause of genital herpes – painful genital or anal ulcers, sometimes accompanied by fever, headache, muscle ache and malaise. 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. by 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.
There is evidence that recent infection with genital herpes ulcers substantially increases the chances of a person being infected with HIV.
In people with HIV, herpes recurrences tend to be more frequent, more severe and longer 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, colon and other organs, including the liver, eye and lung.
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 genetic material of the virus 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 recurrance
Herpes infections are treated with aciclovir. Other treatments for herpes include valaciclovir, and famciclovir.
Aciclovir is taken in tablet form (200-800 mg fives times a day for 5 - 10 days) to treat serious attacks of oral herpes and genital or anal ulcers. Although it is effective 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 - 10 mg/kg every 8 hours) for very severe attacks. Aciclovir has very few side-effects. Aciclovir cannot eliminate HSV virus in nerve cells, so herpes attacks may recur after an attack has been treated. Aciclovir cream is available from chemists to treat cold sores; however, many doctors question its efficacy.
Aciclovir may be taken on a regular basis to prevent recurrent attacks of herpes (400mg twice daily). Some people also find that salt baths relieve symptoms.
Non-specific urethritis (NSU)
Transmission
Non-specific urethritis (NSU) affects only men and is an inflammation of theurethra – the tube which urine and semen pass through in a man's penis. This inflammation can be caused by several 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, a white or cloudy discharge from the tip of the penis, which may be particularly noticeable first thing in the morning, and more frequent urination.
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 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 may be asked to return a week later for a test to see that you have been cured. You are likely to be advised not to have sex (even with a condom) until your treatment period has finished. Your partner should, whenever possible, also receive treatment. This is to prevent re-infection.
Pubic lice (crabs)
Transmission
Pubic lice 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.
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 Derbac are available from chemists, without prescription, for getting rid of crabs, and these are also available 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 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 picked up crabs on a hot cycle when you start treatment. You should also ensure that your partner, or people with whom you have shared a bed or had intimate bodily contact, have treatment at the same time as you to avoid reinfestation.
Scabies
Transmission
Scabies is a skin disease caused by a mite that burrows under the skin, causing intense itching that is usually most notable at night.
It is easy to pick up scabies – any skin contact is enough, 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.
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 if this is an area of infestation. After treatment, the itch can get worse temporarily. In this case, hydrocortisone cream can be applied, and the itch should not be scratched.
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 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 complex infection caused by bacteria. 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 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.
It's likely that untreated primary and secondary syphilis can make a person with HIV more infectious. Having syphilis may also make 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, swollen glands, fever, muscle pain, headache, ringing in the ears, and in rare cases, meningitis. Dark brown sores, about the size of a penny piece, may also appear on the hands and feet. The rash and sores are highly infectious. Secondary syphilis normally develops within six months of exposure.
Tertiary syphilis usually develops within ten years of infection and can cause damage to almost all the internal organs and the brain (neurosyphilis). 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 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 antibiotic 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 re-infected 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, 12 and 24 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 smelly 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 may be asked to return a week later for a test to see that you have been cured. You are likely to be advised not to have sex (even with a condom) until your treatment period has finished. This is to prevent re-infection.
Other infections
Other infections can also be spread during sex. Any sex which involves contact with faeces, even in microscopic amounts, such as rimming and anal sex and fisting, can lead to the transmission of gut infections such as giardia and cryptosporidiosis. These can cause bad diarrhoea and vomiting, which needs to be treated with antibiotics.
LGV
LGV is short for Lymphogranuloma venereum; it is a form of the common sexually transmitted infection Chlamydia.
LGV is very common in Africa, Asia, South America and parts of the Caribbean. However, 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, 150 cases have been identified in England (mostly in London), all involving gay men, most of whom were HIV-positive.
Transmission of LGV
Although the current outbreak of LGV in Europe has involved gay men (most of whom have been HIV-positive), 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 unprotected (sex without a condom) anal, oral and vaginal sex.
The cases seen in European gay men recently have all involved the anus and rectum, and it is thought that they are linked to fisting, as none of the men had LGV infection in their penis. 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 another 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 not sharing pots of lubricant can help prevent the transmission of LGV and other sexually transmitted infections.
Symptoms of LGV
LGV can cause very unpleasant symptoms. In the current outbreak, the commonest symptom has been 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 affect the bowels, and can cause a fistula.
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 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.