Epidemiology of Sexually-

Transmitted Infections
Louella Patricia D. Carpio

April 8, 2019
Objectives
• To provide an overview of STDs and related conditions
• To briefly discuss the unique features in the epidemic dynamics of
sexually-transmitted diseases
• To discuss the natural history, risk factors, and identification of
syphilis and HIV
• To describe the distribution of syphilis and HIV in the local and global
setting
• To enumerate examples of STD surveillance globally and locally
 Sexually-Transmitted Infections
STDs are transmitted through sexual intercourse, which is defined as
sexual contact including vaginal intercourse, oral intercourse (ie.
fellatio or cunnilingus), or rectal intercourse

These can be transmitted between either heterosexual or homosexual

partners

Different types of sexual activities may result in increased risks

Nelson KE, Williams CM. (2014)

Why Study STDs?
In the US, 19 million new cases of STD occur annually and costs 10-17
billion USD per year, primarily affecting adolescents and young adults

Understanding the epidemiology of STDs is a crucial step in developing

rational diagnostic, treatment and control strategies

STDs have been conclusively linked to increased risk of HIV

transmission and acquisition

Nelson KE, Williams CM. (2014)

Sexually Transmitted Infections

There are about 30 STIs or disease syndromes that

result from STIs

WHO. 2012. Sexually Transmitted Infections Epidemiology

Sexually Transmitted Diseases
Bacterial Infection
Gonorrhea (Neisseria gonorrhea)
Syphilis (Treponema pallidum)
Chlamydia (Chlamydia trachomatis)
Chancroid (Hemophilus ducreyi)
Granuloma inguinale (Campylobacter granulomatis)
Lymphogranuloma venereum (Chlamydia trachomatis LGV serovars)
Bacterial vaginosis (ecological disturbance of the vaginal flora)

Viral
Genital herpes (HSV 1 and HSV 2)
Human herpesvirus 8 (Kaposi sarcoma)
Human papillomavirus infection
Condyloma acuminate (genital warts)
Cervical/anal dysplasia and epithelial cancers
Hepatitis B infection
Human Immunodeficiency virus
Human T-cell lymphotropic virus type 1 (HTLV-1)
Cytomegalovirus

Parasitic
Trichomonas
Scabies
Pediculosis
Dynamics of STD
• Although technically transmitted by direct contact, the
dynamics of STDs are often highly dependent on the special
nature of sexual contact
• The population and contact structure plays a particular
important role for STIs
• Existence of two distinct populations: male and females
• Pattern of partnerships in a population forms it sexual network
Dynamics of STD
Network models have proved especially useful for modeling such
networks

Nelson KE, Williams CM. (2014)

 Rate of spread of STIs
Ro = β x c x D

β – mean probability of transmission per exposure

C- mean rate of sexual partner change within the population
D- mean duration of infectiousness of the newly infected persons

If Ro <1, the infection eventually disappears from the population

May RM, Anderson RM., Transmission dynamics of HIV infection, Nature. 1987
Dynamics of STD
Elements of the course in the infection
Incubation Period
• Discrepancy in the latent and
incubation period is
pronounced in HIV/AIDS
• Incubation period can last years
longer than the latent period
Infectious Period
• Years of infectiousness of HIV is
years, and this plays an
important role in determining
the reproductive number for
that disease
• Even a difficult to transmit
infection can cause a large
number of secondary cases if
individuals remain infectious for
a long period of time
Determinants of STIs epidemic
Microenvironment
Biological
• Gender
• Age
• Co-existence of other STIs
• Pregnancy
• Immune status
Behavioral
• Age at coital debut
• Multiple sexual partners
• Sexual practices
• Anal sex
• Male circumcision
• Drug or alcohol use
Macroenvironment
Cultural, Social and Economic
• Poverty
• Gender inequality
• Health seeking behaviors
• Silence on sex issues
• Stigma and discrimination
Epidemiologic
• STIs prevalence
Demographic
• Population age structure
• Sex ratio
Political and structural
Studies on STIs as risk factor for HIV
transmission
Estimated new cases of curable STIs (WHO,
2005)
STI Global Burden (2005)
Estimated Incidence of curable STIs by region,
in million (WHO, 2005)
Syphilis
Syphilis

• Bacterial STD caused by Treponema

pallidum
• Transmission by sexual or vertical means
• Remains chronic without treatment and
progresses in stages characterized by
episodes of active disease
• Incubation Period: 3 weeks
Pathogenesis and Microbiology
• Etiologic agent: Treponema pallidum, subspecies pallidum
• Corkscrew-shaped, motile microaerophilic bacterium
• Cannot be viewed by normal microscopy
• Penetration:
• Entry via skin and mucous membranes through macroscopic and microscopic
abrasions during sexual contact
• Tranplacentally from mother to fetus during pregnancy
• Dissemination
• Before clinical signs and symptoms, T. pallidum accesses the circulatory
system, including the lymphatic system
• Invasion of the CNS can occur
Syphilis: Clinical Course
• Traditionally divided into 3 clinical stages:
• Primary
• Secondary
• Late
Primary Stage
• One or more chancres (usually firm, round, small, & painless but can be
atypical, subtle lesions) thought to appear at site of exposure (mainly genital
area) ~3 weeks after infection (range 10–90 days)
• Chancres can heal on their own in a few days to weeks, even without
treatment
• Patient is highly infectious, and in utero transmission is likely in pregnant
women.
• Serologic tests may be (-)
Secondary Stage
• Mucocutaneous lesions (most commonly rashes) can occur as chancre(s)
fade ~6 weeks after infection (range 3 wks–6 mos)
• Rashes may first appear on the palms of hands or the soles of feet, but
typically appear on trunk & other areas of the body
• Lesions such as condyloma lata, a moist ,wart-like lesion found in the
genital area& mucous patches on the tongue occur in ~25% of patients
Secondary Stage
• Other common findings: lymphadenopathy & constitutional
symptoms
• Less common: patchy alopecia (~10% of patients) & neurologic
symptoms (1–2% of patients).
• Symptoms clear within 2–6 wks but may take up to 3 months, even
without treatment.
• Patient is highly infectious, especially if direct contact with a moist
lesion
• In utero transmission is likely in pregnant women
• Serologic tests are usually highest in titer during secondary stage
Latent and Tertiary Stages
Early Latent
• Patient has reactive
nontreponemal and treponemal
tests within 1 year of onset of
infection, but no symptoms
• Patient is potentially infectious,
as signs of primary & secondary
syphilis can reoccur and go
unnoticed
Late Latent or Latent of
Unknown Duration
• Patient has reactive
nontreponemal and treponemal
tests ≥1 year after onset of
infection or onset of infection
cannot be determined, but no
symptoms
• Patient is not infectious in late
latent stage but may be in latent
of unknown duration if onset of
infection within past year
Tertiary Stage
• Without treatment, ~30% of patients progress to the tertiary stage within
1 to 20 years of infection
• Rare because of widespread availability of antibiotics
• Manifestations in skin and bones (gummas) & cardiovascular system
• Gummatous lesions: onset 10-15 years after infection
• Cardiovascular syphilis: 20-30 years after infection
• Patient is not infectious
Congenital Syphilis
• Transmission from a pregnant woman with syphilis to her fetus
• May lead to stillbirth, neonatal death, and infant disorders
such as deafness, neurologic impairment and bone deformities
• Untreated syphilis results in:
• Stillbirth rate: 25%
• Neonatal deaths: 14%
• Overall perinatal mortality: 40%
Syphilis Epidemiology
• Transmission is relatively inefficient
• Transmission efficiency between an infected and an uninfected partner is only
20%
• After the initial exposure, a latency period of 3 weeks passes prior to
development of the initial symptoms
• During the latency period, a newly infected individual is not
infectious to his or her partners
• This period changes rapidly after development of the initial genital
ulcerative lesion (chancre)
Syphilis Epidemiology

Average duration of infection for individuals with

Syphilis depending on stage in which they are treated
Stage Duration of Infection
Primary 1 month
Secondary 3 months
Latent 3 years
Tertiary 15 years

World Health Organization. Prevalence and incidence of selected Sexually Transmitted Infections, Chlamydia, Neisseria Gonorrhoeae,Syphilis
and Trichomonas vaginalis: Methods and Results used by WHO to generate 2005 estimates. WHO, Geneva 2010
Syphilis Epidemiology

Risk factors
• Syphilis occurs in a setting where there is a high turnover of sex
partners
• Commercial sex workers and other transient individuals with multiple sex
partners are at increased risk
• In developed countries, it has been associated with a variety of social and
behavioral factors, including bathhouses frequented by homosexual men,
prostitution-related drug abuse, and poor access to healthcare
• In the developing countries, more important issues are prostitution,
transience, and poor access to healthcare
Syphilis Epidemiology
• In 2000 and 2001 in the US, the national rate of primary and
secondary (P & S) syphilis cases was 2.1 per 100,000 population
• However, the P&S syphilis rate has increased almost every year since
2000-2001
• Attributed to increased cases among men, specifically among gay,
bisexual and other MSM
• Left untreated, syphilis infection can span decades
• P&S syphilis are indicators of incident infection

CDC. 2017. Syphilis surveillance

 Syphilis Statistics – United States

• 2017: total of 30,644 cases

of P&S syphilis
• 9.5 cases per 100,000
population
Aggressive Safe sex
• 10.5% increase compared Drop until 1975 Gay Ethnic control
HIV scare fatigue
with 2016 revolutionminorities
programs
• 72.7% increase compared
with 2013
 P&S Syphilis by Sex and Sexual Behavior

Men 16.9 per 100,000 males

Women 2.3 per 100,000 females

MSM accounted for most P&S

syphilis cases (57.9%)
Homosexual 51.9%
Bisexual 5.8%
 P&S Syphilis by Sex and Sexual Behavior

Men Rates of syphilis has

increased since 2000

Women P&S rates fluctuated

between 0.8 and 1.7
cases per 100,000
during 2000-2013, but
has increased
substantially since 2013
P&S Syphilis by Sex and Sexual Behavior

8.6%

17.8%
24.9%
 P&S Syphilis by Sex and Age Group

Highest among men aged 25-29

years and women 20-24 years
P&S Syphilis by Sex and Age Group
In 2017, persons aged 15-44 years accounted for 80.2% of reported P%S cases

Increases in all age groups for both sexes from 2016-2017

 P&S Syphilis by Race

2017
Blacks 24.2 per 100,000
Whites 5.4 per 100, 000
NHOPI 13.9 per 100,000
AI/AN 11.1 per 100,00
Asians 4.4 per 100,000
P&S Syphilis and HIV co-infection

45.5%

8.8% 4.5%
 Congenital Syphilis

23.3 cases per 100,000 live births

(2017)

• 43.8% increase relative to 2016

• 153.3% relative increase to 2013
• Parallels the increase in P&S
syphilis among all women &
reproductive aged women during
2013-2017 (155.6% and 142.8%
increases)
Syphilis: Global data
Estimated new cases of syphilis amongst adults
Regional Estimates of Maternal Syphilis
Seroprevalence
HIV/AIDS
HIV
• Human immunodeficiency virus
• Can lead to acquired immunodeficiency syndrome or AIDS if not
treated
• Attacks the body’s immune system, specifically the CD4 cells (T cells),
which help the immune system fight off infections
• Untreated, HIV reduces the number of CD4 cells (T cells) in the body,
making the person more likely to get other infections or infection-
related cancers
HIV
• No effective cure currently exists, but with proper medical care, HIV
can be controlled
• The medicine used to treat HIV is called antiretroviral therapy or ART
• If people with HIV take ART as prescribed, their viral load (amount of
HIV in their blood) can become undetectable
Where did HIV come from?
• Chimpanzee version of the immunodeficiency virus (called simian
immunodeficiency virus, or SIV) most likely was transmitted to
humans and mutated into HIV when humans hunted these
chimpanzees for meat and came into contact with their infected
blood
• Over decades, the virus slowly spread across Africa and later into
other parts of the world
 Global emergence of HIV over time
Airline travel Haiti Sexual Revolution HIV Discovery
Dominican Republic
• Zoonotic infection in humans Serologic evidence
occurring in Congo of HIV infection
• Manifested by increases in from 1959 1984
cryptococcal meningitis and 1980-
disseminated TB
1960s - 1981
1970s AIDS first identified in
1950s the US
HIV-1 Probable origin: Chimpanzees in West
1890s and Central Africa
Transmitted to humans during hunting
from bush meat
HIV-2 Discovered in African green monkeys
Early Epidemiologic
Studies
• Rise in Pneumocystiis carinii
pneumonia (PCP) cases

• Illness cluster of PCP and Kaposi

sarcoma was noted among MSM
in LA, NY and a few other cities

• Similar patterns also noted among

injection drug users, persons with
hemophilia, and some transfusion
recipients
The HIV virus
• Retrovirus
• Double-stranded RNA that undergoes reverse transcription to form a
dsDNA in the host cell
• Attaches to CD4 cell of T lymphocytes
• Has a high replication rate: 10 billion viral particles produced each
day
• Has a huge error rate in viral replication
• High level of immune system activation, but only a fraction of viruses actually
being able to productively infect other cells
• HIV is not long-lived (half-life: 6 hours)
• Its genome is integrated in both activated cells and long-lived memory T cells
(becomes viral reservoir)
 HIV Infection • Viral RNA can be detected in 7-10 days

• 7-21 days later, HIV antibodies appear in the blood

Immune
response • Immune response occurs (CD8) against the virus
HIV Natural History

• Level of viremia declines

Viral set point • Viral “set point” at 3-4 months

• Predictive of the rate at which the disease will progress

• Massive numbers of viral particles are produced

Gradual decline
• Immune system responds to their presence
in CD4+ cells
• Accelerates infection of additional cells

Rapid loss of T-
• 18-24 months, prior to development of clinical AIDS,
cell homeostasis CD3+ cells decreases more rapidly → loss of T-cell
homeostasis
• Development of “acute HIV infection syndrome” 2-4
AIDS weeks after maximal blood HIV levels
• Median time to AIDS: 9.5 – 10 years
• Median survival: 10.5 – 11.8 years
HIV Natural History
 Meta-analysis of Time
N = 13,030
HIV-seroconversion to AIDS and
death prior to ART

• Median time to AIDS: 9.5 – 10

HIV Natural History

years
• Median survival: 10.5 – 11.8
years

• Patients who were older, had

more rapid progression

Lancet. 2000. CASCADE

HIV Natural History
Stages of HIV
• Stage 1: Acute HIV Infection
• Stage 2: Clinical latency (HIV inactivity or dormancy)
• Stage 3: Acquired Immunodeficiency syndrome (AIDS)
Stage 1: Acute HIV Infection
• Within 2-4 weeks, people may experience a flu-like illness which may
last for a few weeks
• Flu-like symptoms include fever, chills, rash, night sweats, muscle aches, sore
throat, fatigue, swollen lymph nodes, or mouth ulcers
• HIV infection may not show up on an HIV test, but people who have it are
highly infectious and can spread the infection to others
• When people have acute HIV infection, they have a large amount of
virus in their blood and are very contagious
Stage 2: Clinical latency (HIV inactivity or
dormancy)
• Asymptomatic HIV infection or chronic HIV infection
• During this phase, HIV is still active but reproduces at very low levels
• May persist in this stage for decades if patients are taking ART
correctly
• If without ART, progression can be faster
• People can still transmit HIV to others during this phase, although
people who are on ART and stay virally suppressed are much less
likely to transmit HIV
Stage 3: Acquired immunodeficiency syndrome
(AIDS)
• Most severe phase of HIV infection
• Increasing number of severe illnesses, called opportunistic infections
• Without treatment, people with AIDS typically survive about 3 years
• Common symptoms of AIDS include chills, fever, sweats, swollen
lymph glands, weakness, and weight loss
• People are diagnosed with AIDS when their CD4 cell count drops
below 200 cells/mm or if they develop certain opportunistic
infections
• People with AIDS can have a high viral load and be very infectious
Opportunistic Infections
Modes of Transmission and Risk Factors
• Sexual intercourse
• Injection drug use or other parenteral exposures
• Transfusion of blood or blood products
• Organ transplantation
• Occupational exposure to HIV-contaminated blood or body
fluids
Modes of Transmission and risk factors

Sexual Intercourse
• Estimated to account for 75-80% of global HIV infections
• Unprotected anal intercourse is the most effective means of
sexual transmission
• Risk varies according to various factors but is on order of 0.5-
1.0% per contact
• Male to female vaginal intercourse: 0.3%
• Traumatic sex (fisting, rough sex) is associated with increased risk
• Sociocultural situations: rape, sex while under the influence of drugs
• Presence of genital ulcer disease/ STDs in partner
• High viral load in infected partner
• Cervical ectopy, use of contraceptives
• Circumcision appears to be protective
Modes of Transmission and risk factors

Injection Drug Use

• Estimated to account for 15-25% of global HIV infections
• Eastern Europe, the Russian federation, Southern China,
East Asia and Middle East, IDU account for majority of HIV
infection
• Risk behavior associated: sharing of contaminated injection
equipment
Modes of Transmission and risk factors

Perinatal Transmission
• Approximately 90% of HIV/AIDS cases in children are
perinatally acquired
• In the absence of preventive intervention, 20-25% of HIV-
infected women (US, Europe) and 25-40% of such women in
Sub-Saharan Africa transmit the infection to their infants
• Occurrence:
• In-utero: 20%
• During delivery: 60-65%
• Breastfeeding: 12-15%
Modes of Transmission and risk factors

Blood Transfusion, Blood Products, and Organ

Transplantation
• More than 90% of seronegative recipients are infected by
transfusion of a single contaminated unit of blood
Modes of Transmission and risk factors

Transmission in Healthcare Setting

• 0.4% HIV seroconversion rate with workers who had
percutaneous injuries with contaminated surgical
instruments
• 0.1% from exposure of mucosal and nonintact skin to HIV-
contaminated body fluids
HIV: Global Burden
36.9 Million Globally, people living with HIV in 2017

0.8% Adults aged 15-49 living with HIV in 2017

21.7 Million Receiving antiretroviral treatment by end 2017

59% People living with HIV receiving ART

940,000 Number of deaths due to HIV

WHO. 2017
 HIV: Global burden

WHO. 2017
HIV: Global Burden

Populations at risk
The risk of acquiring HIV is:
• 27 times higher among men who have sex with men
• 23 times higher among people who inject durgs
• 13 times higher for female sex workers
• 13 times higher for transgender women

UNAIDS. 2017
 HIV: Local burden

WHO. 2017
 HIV: Local burden

UNAIDS. 2018
 HIV: Local burden

UNAIDS. 2018
HIV/AIDS & ART Registry of the Philippines
(HARP)
• Passive surveillance system
• Official record of the total number of laboratory-confirmed HIV
positive individuals and deaths in the Philippines
• Confirmed by San Lazaro Hospital STD/AIDS Cooperative Central
Laboratory of DOH
HIV: Local Burden

52,280 confirmed cases since 1984

93% male, 7% female
Median age: 28 years old
51% from 25-34 age group

DOH EB. 2018

HIV: Local Burden

DOH EB. 2018

HIV: Local Burden

DOH EB. 2018

HIV: Local Burden

DOH EB. 2018

HIV: Local Burden

Special Populations: Children and Adolescents

DOH EB. 2018

HIV: Local Burden

Special Populations: OFWs

From 1984-2018,
11% of the cases
were OFWs

DOH EB. 2018

HIV: Local Burden

Special Populations: People engaging in

transactional sex
A total of 4,853 cases
reportedly engaged in
transactional sex
• 96% were males
• 53% paid for sex

DOH EB. 2018

References
• Nelson KE, Williams CM. (2014). Infectious Disease Epidemiology
• https://www.cdc.gov/std/syphilis/Syphilis-Pocket-Guide-FINAL-508.pdf
• https://www.ilo.org/wcmsp5/groups/public/---asia/---ro-bangkok/---ilo-
manila/documents/publication/wcms_184607.pdf
• https://www.cdc.gov/std/stats17/infographic.htm
• https://www.cdc.gov/std/stats17/syphilis.htm
• https://www.cdc.gov/hiv/basics/whatishiv.html
• https://www.cdc.gov/std/stats17/syphilis.htm
• http://data.unaids.org/publications/fact-sheets01/philippines_en.pdf
• https://www.gfmer.ch/SRH-Course-2012/sti/pdf/STI-Epidemiology-Toskin-2012.pdf
• http://www.unaids.org/en/regionscountries/countries/philippines
• https://www2a.cdc.gov/stdtraining/self-study/syphilis/self_study_syphilis_epidemiology.html
• https://www.doh.gov.ph/sites/default/files/statistics/EB_HIV_February_AIDSreg2018.pdf
Thank you!