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— "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."

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