San Diego According to Dr. Robert Gunn of the county health department, the term "venereal" was phased out in favor of "sexually transmitted disease" (STD) in the 1970s because "the term 'venereal' comes from Venus, the goddess of love, and British officials called it venereal disease. In the British Venereal Disease Act, they only listed gonorrhea and syphilis, and there's a lot of things that are sexually transmitted, not just the old-fashioned venereal diseases. There are about 30 to 40 pathogens transmitted by sexual activity. I think we use the term STD instead of VD to keep a broader scope and say what it really is."
Gunn has been the director of the Sexually Transmitted Disease and Hepatitis Prevention Division for the county department of Health and Human Services since 1991. "The overall rates of sexually transmitted diseases, excluding AIDS, is down. Now the rates for 50 years ago, I don't know. But I know there was a lot of syphilis in the old days, until penicillin came along in the 1940s. Syphilis has come down pretty dramatically from the '40s and '50s."
What Gunn does have are the statistics from the beginning of his tenure at County Health, which indicate that between 1990 and 2001, syphilis rates have dropped from 323 cases to 26 cases (the lowest rates were in 1997 and 1998, when there were only 23 reported cases). The largest number of cases were in the 25-to-29- and 30-to-34-year-old age groups and primarily among men. "We had an upswing in the late '70s and early '80s among men who had sex with men, increasing the curve. It came down again, then there was another blip in the late '80s and early '90s from heterosexual transmission among African-Americans related to prostitution and crack cocaine.
"There's always been a lot of syphilis in the South too. It's come down pretty dramatically all over the country since the Centers for Disease Control put a syphilis elimination initiative in effect in 1997. We're almost at the elimination level right now. The rate is less than 1 per 100,000. However, Seattle in '99 was down to no cases, and they had a resurgence among men who have sex with men. San Francisco was down in the teens in numbers of cases, and now they're up to 150, 200 cases. And I had one a couple of weeks ago. We've had an upsurge in the number of cases among men having sex with men. We're afraid this little upsurge in San Diego might mirror what we're seeing in L.A. and San Francisco. The men who are getting syphilis are having multiple anonymous partners, bathhouse connections, soliciting partners over the Internet, and that sort of thing. It's a small portion of men that are doing this, but they are."
It takes approximately three weeks to see any noticeable signs of infection from syphilis. "It starts off with a syphilitic chancre or sore. It's a painless shallow ulcer that comes after the exposure, either on the penis, scrotum, vagina, or labia. It can also be internally in the anal canal and not noticed, since it's not painful. It could be in the throat, on the lips, anywhere where the spirochete enters the body. That sore will stay for about three weeks and then go away. Six weeks after that, you can have secondary symptoms, like a rash, fever, or chills. That means that the bacteria has gone all through your body. That usually lasts three or four weeks or longer, then it will go away too. Then you have this long latent period, where nothing can happen, or you can get long-term complications like neurosyphilis, cardiovascular syphilis -- things we don't hardly see anymore."
Gonorrhea ("the clap") and chlamydia are much more common than syphilis and a much bigger cause of concern for Gunn. In 1990 there were 4107 cases of gonorrhea in San Diego; by 1997, numbers were much lower at 1505. The last available statistical year, 2002, shows the rate escalating at 1875. The largest age groups were from 15 to 19, 20 to 24, and 25 to 29 years old. In the two younger groups, more cases were reported among females. "It was down to the 1500 range, then by 1999, it reversed and started back up again. There's been about a 20 percent increase in gonorrhea in the last couple of years -- again, among men who have sex with men." The symptoms include painful urination and genital discharge. "Lots of times women don't notice that they have anything. Chlamydia and gonorrhea have the same kind of symptoms. Gonorrhea symptoms are just more acute. Chlamydia is much more common."
It's more than common. Unlike the other charts showing syphilis and gonorrhea rates from 1990 to 2001, the chlamydia chart is moving in the opposite direction: up. In 1990 there were 4347 reported cases in the county. By 2001, that figure more than doubled with 9168 cases. The largest groups are the 15-to-19- and 20-to-24-year-old age brackets, with three times as many cases reported for females than for males. "It's a widespread bacterial infection that's prevalent among the population of teens and young adults. We have between 7000 and 9000 cases reported every year, and that's been on a steady upswing -- not so much because of increased infections -- that's hard to prove. It's more likely because of increased testing and using better, more sensitive tests."
Other diseases spread primarily by sexual contact include hepatitis B, herpes, and the human papilloma virus or HPV (also known as genital warts). Gunn does not have statistics on these diseases, claiming they are "hard to get a handle on" because they are not "reportable." Unlike syphilis, gonnorhea, chlamydia, and hepatitis, doctors and lab technicians are not required by law to report incidence of herpes lesions or genital warts to public health officials. Since they are not reportable, it's almost impossible to get accurate statistics. Gunn did say, however, that a few years ago, a random nationwide sample of adults found that about 16 percent had been infected with herpes.
"I'll focus on the bacterial," Gunn says, "which we can diagnose and treat and make the person noninfectious. With HPV and herpes, we can't do that." (HPV and herpes are permanent viruses that never go away. The carrier is always at risk of infecting others.)
While both sexes suffer, the results are often more tragic for women, since they are humanity's agents of reproduction. "Both gonorrhea and chlamydia affect the fallopian tubes and the internal pelvic organs," Gunn explained. "They can get pelvic inflammatory disease; they can get tubal scarring, which leads to infertility; they can get partial tubal scarring, which leads to ectopic pregnancy. It can lead to chronic pelvic pain syndrome, which might require a hysterectomy. Those two bacteria can also be transmitted to an infant, causing conjunctivitis and chlamydian pneumonia. Women suffer all the adverse consequences of STDs to a much greater degree than men."
Genital warts, or HPV, is painful, troublesome, and permanent, since it is a virus instead of a bacterium. "Women can get warts that they don't see, and those are the ones that are related to cervical cancer. It's a very mysterious disease. We don't know a lot about it. We thought it was lifelong, but it comes and goes. It can last a couple of years and go away, but you can get reinfected. It's worrisome because of its relationship to cervical cancer, otherwise it's a nuisance type of infection. We can just treat the symptoms. We scrape [the warts] off, burn them off, cut them off."
Herpes, the STD nuisance of the '80s, is definitely a lifelong infection and, like HPV, is a virus, not a bacterium. It is manifested by genital ulcers. "The problem there is that the recurrence of the ulcers can be painful and disrupt your life. Women can transmit it to infants and cause neonatal herpes, which is a very severe disease. That's not very common, but it does occur. A lot of people have herpes and don't know it. There's a study from a national sample that shows there's about a 16 percent prevalence in people under the age of 45. In fact, the last couple of years it's been about 20 percent. There is a treatment that can lower the number of recurrences. It's called acyclover, or it's known by the trade name Valtrex."
Hepatitis B is also classified as an STD, although it can be transmitted through IV drug use as well. "It's a blood-borne pathogen, but most of the transmission comes from having sex with a carrier."
The viruses HPV and herpes do not respond to antibiotics, and, increasingly, the bacterial STDs are proving resistant. "Antibiotics only work on bacteria, like chlamydia. Chlamydia is a one-dose therapy -- azithromyacin or Zithromax. Penicillin is still effective for syphilis. Gonorrhea became resistant to penicillin back in the '70s, so that treatment was abandoned. For gonorrhea, there was a class of drugs called floroquinolones that we've used and another class called cephalosporins, which are also very effective. The floroquinolone resistance popped up in the Far East about ten years ago, made its way to Hawaii, then made its way to California at the end of last year...to such an extent that floroquinolones are no longer recommended for gonorrhea treatment in California. We've lost that one. The cephalosporins are being more widely used, but the floroquinolones were less expensive."
Besides men who have sex with men, the most problematic group for STDs remains teenagers. "We have a chlamydia-awareness program. We want institutions to insert into their educational materials something about chlamydia, because it's mostly asymptomatic, so screening is very important. Teens tend to feel that it won't happen to them. But I've had 70-year-old men and women come in with STDs. It's not real common, but it happens. Some are pretty happy about it, actually!"
One of the traditional screenings for STDs, the marriage license blood test, was dropped in the 1990s. "It was put in place back in the '30s or '40s so you could identify infected men and keep them from infecting their wives. They found lots of infected people that way. But now, about 1 in 1000 was positive, so it just wasn't worth it. It's like screening workers in restaurants for TB. In those days, you used to find a lot of TB in restaurant workers. When the population had a high enough prevalence, the screening was worthwhile. But the premarital blood test was no longer effective in finding people with syphilis."
There are still caseworkers for STDs, but it is limited to syphilis. "Physicians are still supposed to report gonorrhea," Gunn admits, "but they don't do a very good job of it. They rely on the laboratories, which works out okay. We only have four field workers who deal with the syphilis issues as they come up. They investigate and so forth. If your doctor diagnoses a primary syphilis lesion, and you can name your sex partners, we have time to get to them and give them penicillin before they develop an ulcer. It's called partner services or partner notification. For gonorrhea there's 2000 cases, and with chlamydia it's 9000 cases. If a doctor asks us, we'll do partner services for very select situations, but in general they don't. We rely on the physician telling the patient that their partners need to get treated. It's kind of a passive way of doing it, but that's the best we can do."