Better Safe Than Sorry

When most of us think of safe sex, we think of AIDS. We know it kills; we know we need to worry about it. But the sexually transmitted diseases we don't know about are much more likely to infect us. A recent poll by the Kaiser Family Foundation asked men and women to name the two most common STDs. Only 13 percent of women named the human papilloma virus (HPV), and only 3 percent named trichomoniasis. Yet these two diseases were responsible for two thirds of the estimated 15.3 million new cases of STDs that occurred in the United States in 1996.

Trichomoniasis and HPV are just part of what the Centers for Disease Control and Prevention calls a "hidden epidemic." The number of people infected with genital herpes has risen by 30 percent since the late 1970s. And though syphilis and gonorrhea have declined sharply in recent decades, they remain more prevalent in the United States than anywhere else in the developed world. The medical cost of the STD epidemic tops $8 billion a year--and that doesn't include out-of-pocket expenses or lost wages. Unfortunately, the stigma surrounding STDs makes them hard to talk about with a partner or a doctor. And because many of the diseases--HPV, trichomoniasis, chlamydia, hepatitis B--can fester without causing outward symptoms, millions of carriers have no idea they're infected. The fact that STDs can do so much damage so silently makes it crucial to understand how they are spread and what you can do to protect yourself.

The first thing to remember is that STDs are a varied bunch. "We often treat STDs as if they are all the same," says Penny Hitchcock, chief of the STD branch of the National Institute for Allergies and Infectious Diseases at the National Institutes of Health. "They aren't, and the differences are complicated." Take trichomoniasis and HPV. Both are rampant, especially among women 15 to 24, but the similarities stop there. "Trich" is caused by a parasite that infects the genital area. Though it causes an uncomfortable vaginal discharge, it is considered relatively harmless--except in pregnant women. If they have trich, they are at risk for premature delivery and low-birth-weight babies. Antibiotics can cure the infection, but both partners need to be treated at the same time, and they should abstain from intercourse until the infection is completely gone.

HPV is much more insidious. There are 80 different versions of this virus. The sexually transmitted variants often cause itchy warts, which can be removed with medication or surgery. But they can also cause "subclinical" infections that, despite a lack of symptoms, are the single biggest risk factor for cervical cancer. The highest rates of infection in women are found among those 25 and younger. Researchers aren't sure if HPV is on the rise, but a 1997 study estimated that 1 percent of sexually active adults have visible genital warts, and 15 percent have a subclinical infection. Condoms don't offer complete protection against HPV, since the virus can be spread by contact with an infected part of the genitals not covered by a condom. But condoms do greatly reduce the risk. An abnormal Pap smear is usually the first sign of HPV if warts are not present, and tests can now pinpoint the virus's genetic material when symptoms are not present. Since HPV can lie dormant for years before triggering the cell changes that lead to cervical cancer, a woman with HPV should (like any woman) have yearly Pap smears to detect any abnormal cells.

HPV isn't the only virus that can hide out in cells for long periods. The herpes simplex virus (HSV) and the human immunodeficiency virus (HIV) are equally persistent. HIV, the virus that causes AIDS, was once associated primarily with homosexual and bisexual men. By 1996 HIV/AIDS was the fourth leading cause of death among women 25 to 44. From 1985 to 1997, the proportion of all AIDS cases reported among adult and adolescent women nearly tripled, reaching 22 percent. The majority of women now living with AIDS contracted it through heterosexual contact--often with IV-drug abusers who picked up HIV from shared needles. Recurrent yeast infections are the most common early indicator of HIV in women. Women who suspect they have HIV can get a blood test in a clinic, or purchase a home test kit from Home Access (www.homeaccess.com). Pregnant women with HIV can transmit the virus to infants during pregnancy, delivery or breast-feeding. They should talk to their doctors about drug therapy and the steps needed to reduce the risk of infecting others.

Like most STDs, sexually transmitted herpes infections can increase the risk of getting HIV. Herpes is usually caused by HSV-2, a cousin of the common cold-sore virus. Until recently, experts assumed that the virus spread only if there were visible sores on the genitals. But new studies show that herpes can be spread by an asymptomatic person. Flare-ups may be marked by headaches and fever as well as painful blisters. But the virus sheds for two to three days before sores appear. And because oral (HSV-1) herpes can thrive in other mucosal tissues, oral sex can cause genital infections.

For pregnant women, genital herpes is more than an annoyance. The infection can cause death for an infant if there are active lesions during childbirth (Caesarean delivery can reduce the risks). Though it's impossible to get rid of the herpes virus, three drugs--acyclovir, famciclovir and valacyclovir--can help shorten lesion time and reduce shedding of the virus. A vaccine for the disease is in clinical trials, and researchers are working on home test kits that would detect antibodies to the virus in the blood.

Home kits are also in the works for bacterial vaginosis and chlamydia, two bacterial STDs that were once considered innocuous but are now known to trigger serious health problems. BV, caused by several common strains of bacteria, raises the risk of low birth weight if it's present during pregnancy. Fortunately, it often causes itching and an odorous discharge that are hard to ignore. Chlamydia is more stealthy. Though some women experience vaginal bleeding or an unusual discharge within three weeks of infection, 75 percent experience no outward symptoms. Young women are particularly vulnerable. A recent study at Johns Hopkins in Baltimore tracked 3,200 sexually active teenage girls for three years and found that 29 percent of them tested positive for chlamydia at least once.

If they're recognized early, any of the bacterial STDs can be cured with a single dose of antibiotics. But left untreated, chlamydia and gonorrhea can lead to pelvic inflammatory disease (many experts believe bacterial vaginosis may, as well). PID occurs when one of these infections spreads from the cervix into the fallopian tubes. The scarring that follows can cause infertility and chronic pelvic pain, and it raises a woman's chances of having an ectopic (tubal) pregnancy. If PID is detected early, a two-week treatment with antibiotics can stop the infection and minimize scarring. In advanced cases, antibiotics will usually stop the infection and ease the pain of PID. But surgery may be needed to reopen the patient's severely scarred tubes.

A simple screening test is all it takes to avoid that kind of trouble. Bacterial vaginosis can be detected by examining the pH levels of vaginal secretions. And chlamydia can now be detected by a urine test, available through any gynecologist. Experts recommend that sexually active women in their early 20s or younger be screened for chlamydia every six months. Older women with multiple partners should be screened once a year.

Our weapons against STDs are improving all the time. Researchers are working on topical microbicides that, when applied like spermicides, would protect women from a range of STDs. A vaccine is now available for hepatitis B, and scientists are racing to develop vaccines against HPV, HIV and herpes. But these are still years from the market. Until then, safer sex and good screening are the best protection.