SEXUALLY TRANSMITTED INFECTIONS

What is a Sexually Transmitted Infection:
Sexually transmitted infections (STI's), also known as sexually transmitted diseases or venereal diseases refers to more than 50 syndromes, which may be transmitted through the exchange of body fluids such as semen, vaginal fluid, and blood. However, you can get some STI's, such as Herpes and HPV, by kissing and caressing or direct contact with infected areas.

Sexually transmitted infections (STI) is serious, sometimes painful, and can cause long term damage. Some STI's infect your sexual and reproductive organs. Others (HIV, Hepatitis B, Syphilis) cause general body infections. You may have more than one STI at a time. One may mask another that poses a more serious health problem. Nearly 65% of all STI's occur in people younger than 25 years of age.

Some of the common STI's are Chlamydia, Gonorrhea, Syphilis, Trichomoniasis, HIV/AIDS, Hepatitis B, Genital Warts, Herpes, Pubic Lice and Scabies.

How are STI's Spread:
STI's are spread during close, sexual activity. It is spread during vaginal, anal, and oral sex. Some STI's (HIV and Hepatitis B) are also spread by contact with infected body fluids.
Most STI germs need to live in warm, moist areas--that's why they infect the mouth, rectum, and sex organs (vagina, vulva, penis, and testes).

How easy is it to cure STI's:
STI's include bacterial and viral organisms and parasites. Bacterial STI's, such as gonorrhea, chlamydia, and syphilis, are relatively easy to cure with antibiotics if diagnosed early. Parasites can be removed with special shampoos. Viral STI's, such as genital herpes, genital warts, and HIV/AIDS cannot be cured, however symptoms can be relieved.

What to do if you think you have an STI:
If you think you have an STI, or don’t feel normal, get checked out. Don't just hope the STI will go away. Most county health departments have special STI clinics. Private doctors also treat STI's. If you don't know where to get help, call BEBASHI for information. No matter where you get treated, your case will be kept private.

You may feel embarrassed about having an STI. It may be hard for you to go to a doctor or clinic for help. But you must get treatment for the STI, even if it is a hard thing for you to do. This is the only way you will get well. Most STI's can be treated with antibiotics. To kill STI germs, do exactly what your doctor tells you. Be sure to use all of your medicine. You also must tell your sexual partner(s). If they aren't treated, they can spread the STI. They might even give it to you again.

What to watch for:
Here are some signs that may mean you have an STI. If you have any of these symptoms go to an STI clinic or a private doctor.

Women:

• An unusual discharge or smell from your vagina
• Pain in your pelvic area, the area between your belly button and sex organs.
• Burning or itching around your vagina.
• Pain deep inside your vagina when you have sex.

Men:

• A drip or discharge from the area around your penis.

Both Men and Women:

• Sores, bumps, or blisters near your sex organs, rectum, or mouth.
• Burning or pain when you urinate or have a bowel movement.
• Need to urinate often.
• Itching around your sex organs.
• A swelling or redness around the inside area of your throat.
• Flu-like feelings with fever, chills, and aches.
• Swelling in your groin--the area around your sex organs.

What is the link between HIV and other STI's:
Individuals who are infected with STI's are at least two to five times more likely than uninfected individuals to acquire HIV if exposed to the virus through sexual contact. In addition, if an HIV-infected individual is also infected with another STI, that person is substantially more likely than other HIV-infected persons to transmit HIV through sexual contact (Wasserheit, 1992).

There is substantial biological evidence demonstrating that the presence of other STI's increases the likelihood of both transmitting and acquiring HIV.

• Increased susceptibility. STI's probably increase susceptibilty to HIV infection by two mechanisms. Genital ulcers (e.g.,syphilis, herpes, or chancroid) result in breaks in the genital tract lining or skin. These breaks create a "portal of entry" for HIV. Non-ulcerative STI's (e.g., chlamydia, gonorrhea, and trichomoniasis) increase the concentration of cells in genital secretions that can serve as targets for HIV (e.g., CD4+ cells).
  
  
• Increased infectiousness. Studies have shown that when HIV-infected individuals are also infected with other STI's, they are more likely to have HIV in their genital secretions. For example, men who are infected with both gonorrhea and HIV are more than twice as likely to shed HIV in their genital secretions than are those who are infected only with HIV. Moreover, the median concentration of HIV in semen is as much as 10 times higher in men who are infected with both gonorrhea and HIV than in men infected only with HIV.
  

You can protect yourself from STI's:
Abstinence is the best way to protect yourself from STI's.
Having sex with only one uninfected partner, who only has sex with you, is also safe.

Here are other things you can do to protect yourself:

• Talk to your partner about past sex partners and about past (or present) drug use. Don't have sex with someone who you think may have an STI.
  
  
• Before you have sex, look closely at your partner for any signs of STI's--a rash, a sore, redness, or discharge. If you see anything that concerns you, don't have sex.
  
  
• Use a latex condom (rubber) for vaginal, anal, and oral sex. Condoms will help protect you from STI's. Both men and women should carry condoms. In addition to condoms, use birth control foam, cream, or jelly. These kill many STI germs.
  
  
• Get checked for STI's every time you have a health exam. If you have more than one sex partner, get an STI check any time you think you might be at risk, even if you don't have any symptoms.
  
  
• Know the signs and symptoms of STI's.
  
  
• If you notice a symptom that worries you, get checked out!
  
  
• If you have an STI, your partner(s) should get treated when you do to avoid reinfection.

Profiles of some of the most common STI's

Chlamydia
Chlamydia is the number one bacterial sexually transmitted infection (STI) in the United States today. Four million new cases of chlamydia occur each year. It's particularly common among teens and young adults. Pelvic inflammatory disease (PID), which can be caused by Chlamydia if left untreated, is a leading cause of infertility when left untreated.
Symptoms: Chlamydia is known as the "silent epidemic" because three quarters of the women and half of the men with the disease have no symptoms. Possible symptoms include discharge from the penis or vagina and a burning sensation when urinating. Additional symptoms for women include lower abdominal pain or pain during intercourse and bleeding between menstrual periods. Men may experience burning and itching around the opening of the penis and/or pain and swelling in the testicles.

Testing: There are two kinds of tests for chlamydia. One involves collecting a small amount of fluid from an infected site (cervix of penis) with a cotton swab. These tests are universally available. The other involves taking a urine sample. BEBASHI offers-urine based Chlamydia screening free of charge on a walk in basis.

Treatment: There has been major progress in the treatment of chlamydia with antibiotics over the past few years. A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments (For the U.S. only). Common side effects of these treatments include diarrhea (7%), nausea (5%), abdominal pain (5%), and vomiting (2%).

Prevention: You can get and spread chlamydia through unprotected vaginal and anal sex. Preventing chlamydia means approaching sexual relationships responsibly: limit the number of your sex partners, use condoms, and if you think you are infected, avoid any sexual contact and visit a local STI clinic, hospital, or your doctor. Be sure your partner is treated to avoid becoming re-infected.

Genital Warts
Genital Warts are caused by the Human Papilloma Virus (HPV), one of the most common sexually transmitted infections (STI's). HPV is the name of a group of viruses that includes more than 60 different types. An estimated 40 million Americans are infected with HPV, with 1 million new cases each year.

Symptoms: Most HPV infections are subclinical--that means that there are no visible signs. Subclinical HPV infections can cause abnormal cell growth (dysplasia) on the female cervix. Visible signs of the disease include condylomata, which range from soft, pink, cauliflower-like warts to hard, smooth, yellow-gray warts. In women, they may develop inside the vagina, where they are hard to detect. They may also appear on the lips of the vagina or around the anus. In men, they usually appear on the penis, but are sometimes found on the scrotum (the sac that holds the testicles) or around the anus. If there are visible signs, you will notice them within 3 weeks to 6 months after having sex with someone who is infected. This time period makes it difficult to track the infection as it is passed from partner to partner.

Testing: Your healthcare provider can check closely to detect warts or other abnormal tissue. For women, the Pap smear is designed to detect precancerous changes in the cervix and may show changes caused by HPV infection. Generally, asymptomatic men with HPV are hard to diagnose and usually aren't treated.
Treatment: There are several ways to remove visible genital warts, but the underlying HPV infection can't be cured. The virus that causes genital warts stays in your body and can cause warts to appear in the future. A doctor can get rid of smaller warts by freezing them (cryotherapy) or by burning them off with an acidic chemical such as podophyllin. In severe cases, wart treatment may require laser surgery. All three procedures can typically be done in a doctor's office with local anesthetic.

Prevention: Genital warts are transmitted when the HPV virus is passed from one person to another during sex. It requires skin to skin contact with the infected area (wart). People who have many sexual partners put themselves at higher risk for genital warts. Latex condoms, used properly, provide some protection if they cover the area of infection.

Women: be sure to have regular pap smears!

Gonorrhea
Gonorrhea is a common sexually transmitted infection (STI) which, if not treated early, can cause serious problems, especially for women. About 1 million American men and women contract gonorrhea each year.

Symptoms: It's possible to have gonorrhea without symptoms. If symptoms do appear, they may include discharge from the penis or vagina, the need to urinate often, burning or pain when urinating, and in women, bleeding between monthly periods. About half of the women with gonorrhea have no symptoms.

Testing: The only way to find out whether you have gonorrhea is to get tested. The test is simple: the doctor takes a sample of fluid from the penis or vagina and sends it to a lab.

Treatment: Gonorrhea is treated with antibiotics. Common treatments use drugs such as ciprofloxacin, ofloxacin, cefixime, ceftriaxone, and most recently- azithromycin. Azithromycin is a single-dose oral medication. The most common side effects with 2-gram azithromycin include nausea (18%), diarrhea/loose stools (14%), vomiting (7%), abdominal pain (7%), vaginitis (2%), dyspepsia (1%), and dizziness (1%). Ineffective or incomplete treatment can result in serious problems later, such as chronic lower abdominal pain, sterility, tubal pregnancy, and painful joints. In order to avoid re-infection and potential transmission of infection to others, you should stop having sex until both you and your partner are cured.

Prevention: You can get and spread gonorrhea through oral, anal, and vaginal sex. Preventing gonorrhea means approaching sexual relationships responsibly: limit the number of your sex partners, use condoms, and if you think you are infected, avoid any sexual contact and visit a local STI clinic, hospital, or your doctor. Make sure both partners are treated.

Hepatitis B
Hepatitis B is an infection of the liver caused by a virus. In other words, bodily fluids infected with Hepatitis B transmit the virus much more easily than HIV is transmitted. It's 100 times more infectious than HIV. About 300,000 Americans get hepatitis B each year. Most people recover, but a few become chronic carriers with increased risk of serious problems later, such as permanent liver disease and cancer of the liver.

Symptoms: Symptoms usually appear within 2 to 6 weeks after contact. They can include poor appetite, nausea, vomiting, headaches, general malaise, jaundice (yellowing of eyes and skin), dark, tea colored urine, and light-colored stools. Even without symptoms, you can pass the virus to others. Chronic carriers carry the hepatitis B virus for the rest of their lives and unknowingly pass it to their sex partners.

Testing: Routine testing is not usually indicated unless the patient is symptomatic from jaundice or has had a recent sexual exposure to someone with hepatitis. Sometimes, serological testing is done as part of a hepatitis B vaccination program. However, if you've already had hepatitis B, you don't need to be vaccinated. Remember that 90% to 95% of people who have hepatitis B will fully recover.

Treatment: For acute hepatitis B, treatment includes rest and diet. There are some new treatments for chronic hepatitis, including interferon. If your sex partner or a member of your household is found to have hepatitis B, you should consult your doctor or healthcare provider and get immunized. Immunization may include hepatitis B immune globulin and hepatitis B vaccination series.

Prevention: Like acquired immunodeficiency syndrome (AIDS), the hepatitis B virus is spread through contact with infected blood or body fluids. You can get hepatitis B from vaginal, oral, or anal intercourse. It also can be passed from an infected mother to her baby at childbirth. To minimize your risk of contracting hepatitis B, do not share needles or syringes, or instruments used in ear-piercing, tattooing, or hair removal. Do not share toothbrushes or razors. If you have sex, reduce your risk by using condoms. If you are infected, avoid sex and other close contact, such as kissing, until your doctor says it's okay. Hepatitis B is the only sexually transmitted infection (STI) that can be effectively prevented by a vaccine. The Centers for Disease Control (CDC) now recommends vaccination for all newborns in order to prevent infection of hepatitis B later on. The vaccine is highly effective and should be strongly considered. Check with your doctor to find out if you should be vaccinated against it.

Herpes
Genital herpes is a chronic, lifelong viral infection. An estimated 40 million people have it. Each year, about 500,000 new people get symptomatic herpes. There are even more people who have no symptoms.

Symptoms: Symptoms vary. Most people have no noticeable symptoms. If you do not get symptoms, you'll probably notice them 2 to 20 days after having sex with someone who is infected. Early symptoms may include a burning sensation in the genitals, lower back pain, pain when urinating, and flu-like symptoms. A few days later, small red bumps may appear in the genital area. Later these bumps can develop into painful blisters, which then crust over, form a scab, and heal.

Testing: Sometimes the diagnosis can be made by physical examination alone. For testing, the doctor will collect a small amount of fluid from the sores and send it to a lab to see if the herpes virus is present. It may take up to 2 weeks to get the results. If no sores are present, testing may be difficult. At present, a blood test for herpes is available only in a few research centers.

Treatment: Although herpes is a chronic, lifelong viral infection, you can treat the symptoms. Treatment of genital herpes outbreaks, especially when started early, shortens the duration of the outbreak and reduces the symptoms. The drugs used are acyclovir, famcyclovir and valacyclovir.

Prevention: You can get and spread herpes through oral, anal, and vaginal sex. Preventing the spread of herpes means approaching sexual relationships responsibly: limit the number of your sex partners, use condoms, and if you think you are infected, avoid sexual contact and visit a local sexually transmitted infection (STI) clinic, hospital, or your doctor. Remember that many genital herpes infections are spread by people with no noticeable symptoms. You also can get the herpes virus from kissing, touching, and caressing infected areas. In cases where people have more than six outbreaks a year, preventative (prophylactic) suppressive therapy is available.

HIV/AIDS
AIDS stands for Acquired Immunodeficiency Syndrome. AIDS is currently the leading cause of death in African American men between the ages of 25 and 44 in the United States. Think women aren't at risk? Think again. AIDS is the third leading cause of death in African American women in this age group. AIDS is caused by HIV, the Human Immunodeficiency Virus, which attacks the bodies immune system. Without immunologic protection, people with AIDS suffer from fatal infections and cancers.

Symptoms: You can be infected with HIV, the virus that causes AIDS, and have no symptoms at all. On average, it takes about 7 to 9 years for symptoms to develop. Most symptoms of AIDS are not caused directly by the HIV virus, but by an infection or other condition acquired due to the weakened immune system. Symptoms can include severe weight loss, fevers, headaches, drenching night sweats, fatigue, severe diarrhea, shortness of breath, and difficulty swallowing. The symptoms tend to last for weeks or months at a time and do not go away without treatment. Since these symptoms are commonly seen in other diseases, you can't assume any symptom is HIV/AIDS related until you get laboratory tests. See a doctor if you think you may be at risk or if you have symptoms.

Testing: The only way to tell if you have been infected with HIV is by taking an HIV blood test. BEBASHI offers free anonymous and confidential HIV testing. HIV testing includes pretest counseling and an explanation of the benefits of testing. You may want to seek anonymous testing. When you undergo anonymous testing, you're identified only by a number, and you're the only one who finds out the test results.

Treatment: There is no cure for HIV infection or AIDS. Anti-HIV treatment is usually indicated once the T-cell count goes below 500 (indicating a very weakened immune system)

If you have been exposed to HIV, you need to tell your sex partners and anyone with whom you have shared needles and syringes that they too may have been exposed to the virus. They should all be tested for HIV infection. BEBASHI can help you contact former partners if you don't want to do this yourself.

Therapy for the viral infection, with antiretroviral drugs, uses two classes of drugs: the nucleoside analogs (AZT, ddi, ddc, D4T) and the protease inhibitors. Treatment is complex and is shown to prolong life.
A major focus of HIV treatment is preventing other infections (opportunistic infection prophylaxis). For example, pneumocystis (PCP), tuberculosis, and systemic fungal infections can be effectively prevented, and all of these are big problems in HIV patients.

Treatment of pregnant women with AZT has been shown to substantially reduce transmission of HIV to the unborn baby.
Prevention: HIV is spread primarily in two main ways: through unprotected sexual intercourse with an infected person, or through sharing drug needles or syringes with an infected person.

Women infected with HIV also can pass the virus to their babies during pregnancy, birth, or through breast feeding.
HIV is not passed by everyday social contact. Touching, hugging, and shaking hands with an infected person is safe. Some people think they may get HIV by donating blood. This is not so. A new needle is used for every donor, and you do not come into contact with anyone else's blood. Donated blood is now always screened for HIV, therefore, the risk of getting it from a blood transfusion in the United States is very, very low. Kissing an infected person on the cheek or with dry lips is not a known risk.

Short of avoiding sex entirely, you can protect yourself by having safer sex. Stay with one partner with whom you have discussed AIDS and who is prepared to have safer sex. Latex condoms have been shown to prevent HIV infection and other sexually transmitted diseases. Personal items such as razors and toothbrushes also may be blood-contaminated.

Do not share them with an infected person.

Pubic Lice and Scabies
Pubic lice (often called "crabs") and Scabies (itch mites) are tiny insects that live on the skin. They are sometimes spread sexually, but you can also pick them up by using the same bed linen, clothes, or towels as an infected person. Scabies, an itchy rash, is the result of a female mite burrowing into a person's skin to lay her eggs. Pubic lice infect hairy parts of the body, especially around the groin and under the arms. Their eggs can be seen on the hair close to the skin, where they hatch in 5 to 10 days.

Symptoms: Although some people infected with pubic lice have no symptoms, you may experience considerable itching around the genitals. You may see light-brown insects the size of a pinhead moving on the skin or oval eggs attached to your body hair. The main symptom of scabies is itching, especially at night. A rash may appear in the folds of skin between or on the wrists, elbows, abdomen, or genitals.

Testing: If you think you may have pubic lice or scabies, see your healthcare provider. They can determine whether or not you need to seek treatment.

Treatment: The most effective treatments include shampoos and creams that contain lindane or a related compound. You can treat pubic lice at home with these special creams, lotions, and shampoos available in drugstores without a prescription. Follow directions carefully. The infestation may be stubborn, and you may need to repeat the treatment. Do not try to treat scabies on your own. Avoid contact with others if you have scabies or pubic lice. Wash clothes and bed linen in hot water, or dry-clean or press them with a very hot iron. If you have scabies or pubic lice, be sure to tell your sex partners. Anyone with whom you've had close contact or who has shared your bed linen, clothes, or towels should be treated, even if they don't have an itch or rash.

Prevention: Scabies and pubic lice are transmitted through contact with an infested materials such as sheets and towels. The best way to protect yourself is to know your partner's sexual history and to and to wash or dry-clean materials that you think may carry scabies or pubic lice.

Syphilis
Syphilis is a serious disease that can be debilitating and even result in death if left untreated. You can have syphilis without knowing it and pass it on to others. There are an estimated 120,000 new cases of syphilis in the United States each year.

Symptoms: Syphilis has three stages. During the first stage, a painless sore may appear at the spot where the bacteria first entered the body (usually from 10 to 90 days after sexual contact with an infected person). This sore may appear around or on the vagina, on the penis, or inside the mouth or anus. Sores inside the vagina or anus are often unnoticed and may disappear on their own if not treated, but the bacterial infection remains. The second stage occurs from 3 weeks to 3 months after the primary stage and includes flu-like symptoms and possible hair loss. Some people experience a rash on the palm of their hands and soles of the feet, as well as over the entire body. Although extremely rare, tertiary syphilis can appear 3 to 10 years or more after the first and second stages. Symptoms of this stage may include skin lesions, mental deterioration, loss of balance and vision, loss of sensation, shooting pains in the legs, and heart disease.

Testing: BEBASHI offers free, confidential syphilis blood testing. However, if you become infected 2 to 3 weeks prior to testing, the blood test might not be sensitive enough to pick it up.

Treatment: Fortunately syphilis can be treated with proper antibiotics. The most common treatments are penicillin injections.

Prevention: You can get and spread syphilis through oral, anal, and vaginal sex. Preventing syphilis means approaching sexual relationships responsibly: limit the number of your sex partners, use condoms, and if you think you are infected, avoid any sexual contact and visit BEBASHI, a hospital, or your doctor. Be sure that your partners are tested, as well.

Trichomoniasis
Trichomoniasis ("trich") is a common sexually transmitted infection (STI), attacking 2 to 3 million Americans every year. It is caused by infection with a flagellated protozoan, Trichomonas vaginalis.

Symptoms: Many people with trichomoniasis experience no symptoms. Women may experience itching, burning, vaginal or vulval redness, unusual vaginal discharge, frequent and/or painful urination, discomfort during intercourse, and abdominal pain. Symptoms tend to worsen after menstruation. Men are usually asymptomatic, but symptoms can include unusual penile discharge, painful urination, and tingling inside the penis.

Testing: The healthcare provider will collect a sample of secretions from the penis or vagina and send it to the lab to see if trichomonas is present. It may take up to 2 weeks to get the result. Some providers can do a quick office examination of vaginal secretions.

Treatment: Trichomoniasis can be treated with antibiotics, usually a single dose of metronidazole (Flagyl).

Prevention: As with other diseases, trichomoniasis is spread through sexual contact. Using condoms (or another barrier method) provides some protection, as does knowing your partner's sexual history. Trichomania can also survive on infected objects such as sheets and towels, and could possibly be transmitted by sharing those objects. It is especially important for the male partner to be treated--even though he is almost always asymptomatic.

Hepatitis C
HCV (Hepatitis C Virus) is the most prevalent blood-borne disease in the United States, where the number of infections likely exceeds 4 million. Approximately 85 percent of HCV-positive individuals develop chronic HCV infection, 70 percent develop chronic liver disease, and 10 to 20 percent develop cirrhosis. From 8,000 to 10,000 persons die from HCV every year in the United States alone (CDC, 1999).

There is no vaccination or cure for HCV. Treatment is expensive, and only successful in a minority of patients. Like HIV, HCV now strikes disproportionately among the poor and uninsured. A majority of new infections occur through injection drug use. Sexual transmission of HCV also occurs and is associated with a high number of sexual partners and sexual activities without a condom.

Neither HCV nor HIV/HCV interaction is well understood. Many people are unaware they are HCV-positive because they can remain asymptomatic for 20 years or more. When chronic hepatitis C is diagnosed, it is often at an advanced stage and, consequently, data on the early stages of infection are limited. Even less information on disease progression in co-infected patients is available, yet clinicians increasingly are required to treat both infections.

Forty percent of chronic liver disease- the 10th leading cause of death in the United States- is HCV-related, and HCV is the leading indicator for liver transplants in the country.

The Virus
The hepatitis C virus is small, even for a virus: at 50 nanometers in diameter, 200,000 hepatitus C viruses end to end would measure a single centimeter in length. Like HIV, HCV has RNA rather than DNA at its core. RNA molecules tend to make frequent mistakes when replicating and have poor "proofreading" capabilities; since errors are not corrected the virus mutates rapidly (Koop, 1998). A high mutation rate is an effective strategy for evading the human immune system and therapy, and makes development of a vaccine extremely difficult.

Natural History

Acute Infection
Only 30 to 40 percent of individuals newly infected with HCV exhibit symptoms of acute infection; these symptoms occur anywhere from 3 to 20 weeks after exposure (Hoofnagle, 1997; CDC, 1998). They often are mild and intermittent and include fatigue, nauseau, muscle and joint pain, poor appetite and right upper quadrant tenderness or discomfort (NIDDK, 1999). Twenty to 30 percent of those infected may have jaundice, a condition typically associated with liver disease (CDC, 1998). Illness associated with acute hepatitis C, when it appears at all, lasts from 2 to 12 weeks. Fulminate hepatitis (severe and rapid progression of liver disease) resulting from HCV is rare (Hoofnagle, 1997).

Other markers for hepatitis C appear earlier than the onset of symptoms. HCV RNA can be detected in the blood as early as 1 to 3 weeks after exposure. Levels of the liver enzyme alanine aminotransferase (ALT) may begin to rise after several weeks- although even among the chronically infected, ALT levels are not always elevated. Antibodies to the virus appear somewhat later than HCV RNA in the blood: in 80 percent of patients within 15 weeks of exposure; 90 percent within 5 months; and 97 percent by 6 months (CDC, 1998).

Chronic Infection
Virtually all infected persons develop liver cell damage within an average of 50 days of infection and chronic infection develops in up to 85 percent of those who contract the virus; for reasons not well understood, the remaining individuals eradicate the virus without treatment (NIH Consensus, 1997; CDC, 1998). Infection may not be apparent for decades, but the virus is not dormant. Cirrhosis of the liver develops in 10 to 20 percent of HCV-infected individuals, usually slowly--over a period of 20 to 30 years. Liver cancer may develop in up to 5 percent of individuals infected with HCV (CDC, 1998). In 1 to 2 percent of HCV-infected individuals, extrahepatic (non liver-related) complications may appear. These include cryglobulinemia, membranoproliferative glomerulonephritis and porphyria cutanea tarda (CDC, 1999).

HCV produces approximately 10 trillion hepatitis virions daily (Sulkowski). The HIV replication rate is slower- approximately 10 billion virions daily.

Epidemiology
HCV prevalence in the United States is increasing- incidence is greater than mortality- however, incidence has declined dramatically from an estimated average of 242,000 from 1985 through 1990 (CDC, 1999). Today, incidence is estimated at between 35,000 and 40,000. This decline is largely due to the virtual elimination of transmission through tainted blood products. Transmission among injection drug users has also decreased, but much less significantly. Most new infections occur in individuals ages 20 to 39 years. Incidence is similar among White and Black Americans, and is slightly higher among Hispanics.

Mortality
Between 8,000 and 10,000 Americans die annually from hepatitis C. Without substantial improvement in treatment options, that number will increase over the next decade: large numbers were infected with HCV 20 to 25 years ago and are approaching the stage of infection at which severe complications typically become apparent.

Transmission
Hepatitis C virus is a blood-borne disease, and transmission can occur in a number of ways.

Injection Drug Use
Injection drug use (IDU) has been the leading risk factor for HCV in the United States since the onset of the epidemic. Hepatitis C is easily blood borne--much more so than HIV--and is a prime candidate for transmission through shared contaminated syringes.

The prevalence of hepatitis C among IDU's is extremely high--more than 90 percent in some samples. This means that the likelihood of coming into contact with contaminated blood is quite significant, and that there is a real risk of infection in those who ever injected drugs--even once.

Other Drug Use
Although documentation is limited, HCV infection may be associated with a history of intranasal cocaine use (CDC, 1998). The speculation is that delicate nasal membranes are broken during intranasal drug use and shared straws are contaminated with infected blood. If transmission does occur through this method, it appears to do so rarely.

Transfusions and Transplants
Tainted blood products were once a significant source of HCV infection, but transmission of the virus in this manner is now very rare. It is estimated that the likelihood of aquiring HCV from transfusions is only .001 percent per unit tranfused (CDC, 1998).

Sexual Transmission
Sexual transmission of HCV occurs, but the level of risk through sexual exposure remains unclear. In some studies, HCV infection has been associated with individuals reporting a greater number of sexual partners, a history of STD's, and no condom use; the risk of sexual transmission rises substantially in the presence of two or more of these risk factors.

Vertical Transmission
The rate of HCV transmission from an HCV-infected mother to her newborn is about 5 to 6 percent. However, if the mother is co-infected with HIV, the vertical transmission rate jumps to between 14 and 17 percent (CDC, 1998).

Nosocomial Transmission
Nosocomial transmission (infection of patients through contaminated medical equipment) is uncommon in the United States, but has been reported in chronic hemodialysis settings.

Occupational Exposure
It is possible for health care workers to acquire HCV through needle sticks, but the prevalence in health care workers is about the same as that in the general population. The range of "needle stick conversion rates" is 0 to 7 percent, depending on the risk factors of the individual in whom the needle was originally used (Sherman, 1999).

Household Contact
Infection from household contact is probably extremely uncommon. It has not been documented in the United States, although studies in Japan and Italy have shown that it does occur (Herrine, 1999).

Tattooing and Body-piercing
There is no documentation of transmission during tattooing or body-piercing in the United States, although it has apparently occurred elsewhere in the world (Herrine, 1999).

It currently is estimated that up to 60 percent of new infections occur through injection drug use; up to 20 percent through sexual contact; and up to 10 percent through occupational, household, perinatal, and hemodialysis exposure combined.

HCV Testing
HCV can be diagnosed by detecting HCV antibodies in the blood. Two tests are FDA-approved for detection of HCV antibodies: the enzyme immuno assay, commonly referred to as EIA or ELISA; and the recombinant immuno blot assay (RIBA). Both detect HCV antibodies in 97 percent of infected patients.

The advantages of the EIA are ease of use and low cost. Disadvantages are: false positives occur more often than with the RIBA, the interval between infection and detection may be as long as 3 to 6 months, and people who are immuno-suppressed or immuno- compromised may not have detectable antibodies to HCV. The RIBA is more complex and considerably more expensive to administer but has higher specificity. Because false positive, false negative, and indeterminate results occur, a second "confirmatory" assay is required to confirm a positive result, or a negative result in an individual thought to be positive. In some cases, a third may be required. Neither the EIA not the RIBA indicates whether HCV infection is acute (new), chronic (long term) or resolved (past infection)

Tests to directly detect hepatitis C RNA in the blood (viral load) are commonly available in clinical practice but are not yet standardized. The reverse transcript polymerase chain reaction (PCR) and branched DNA assay (bDNA) both detect the nucleic acid of the virus in the blood, and are indicators of the active infection. The PCR test has high sensitivity and may be able to detect a very low level of virus in the blood as early as 1-2 weeks after infection. However, it is technically difficult to administer and false results are a common problem.

Until very recently, HCV diagnostic testing was available only in a physician's office or clinic. In June, the FDA approved an "at-home" test kit for hepatitis C. Individuals provide a small blood sample, which is sent to a laboratory for testing.

Results are available in about 10 days.

Assessment of Liver Damage
HCV tests cannot assess liver damage. A liver enzyme, alanine aminotransferase (ALT), must be measured to determine if the liver is inflamed. Elevated ALT indicates active liver disease.

A single ALT reading will be insufficient, since ALT levels have a tendency to fluctuate over time. Sixty to 70 percent of chronically infected patients show either persistently or intermittently elevated ALT levels. In the remaining 30 to 40 percent, ALT levels are normal (CDC, 1998). In a study of 1,042 HCV-positive individuals, researchers conducted four or more ALT evaluations over a period of 25 months. Forty-two percent showed persistently normal values, 15 percent persistently elevated values, and 43 percent had intermittently elevated values (Inglesby et al., 1999)
Liver damage also may be assessed through a liver biopsy. It is used in conjunction with repeated measurement of ALT levels to determine the severity and activity of the disease, and the amount of fibrosis in the liver. It is recommended before treatment to both assess the status of the disease and to exclude other types of liver disease or complications.
HCV appears to be more efficiently transmitted from males to females than from females to males.

Treatment

Interferon and Ribavirin
The FDA recently approved the combination of alfa interferon with ribavirin for the treatment of HCV. Originally used only in cases where patients had relapsed of not responded at all to interferon monotherapy, it is now used as an initial treatment as well. In one recent study, a sustained response was achieved in 43 percent of patients who received the interferon/ribavirin combination for 48 weeks (Poynard, 1998). In another study, 38 percent of patients who received the combination demonstrated a sustained response after 48 weeks of therapy, compared to 13 percent of those who had received interferon alone (NIH Consensus, 1997). A number of other studies show similar results. Ribavirin alone has not proven effective in treating the hepatitis C virus.

Side Effects
Interferon and ribavirin are not without side effects. The major side effect associated with ribavirin is hemolytic anemia. The majority of patients treated with interferon suffer flu-like symptoms, which can include fever, chills, malaise, headache, myalgia, and tachycardia, but these tend to diminish with continued treatment. Later side effects include fatique, alopecia, bone marrow suppression, apathy, cognitive changes, irritability, and depression. Ten to 40 percent of patients under treatment require a reduction in interferon dosage due to side effects, and 5 to 10 percent msut discontinue treatment. Severe side effects include autoimmune disease, depression with suicidal risk, seizure disorder, acute cardiac and renal failure, retinopathy, interstatial pulmonary fibrosis, hearing impairment, and sepsis effects. They occur in less than 2 percent of patients. Infequently, a paradoxical worsening of liver disease with therapy occurs (NIH Consensus, 1997). Therefore, ALT levels must be monitored frequently.

Initiating Treatment
It is not always clear who to treat for HCV and when to initiate treatment. The course of the disease is variable and usually slow. CDC guidelines and the NIH Consensus Conference indicate that those patients most likely to progress to cirrhosis should be treated- those with persistently elevated ALT levels, detectable HCV RNA in the blood, and liver biopsy indicating portal or bridging fibrosis, or moderate degrees of inflammation and necrosis (CDC, 1998; NIH, 1997). New research confirms that treatment with interferon before serious symptoms develop reduces the incidence of liver cancer (Yoshida et al., 1999).

70 to 80 percent of individuals living with HCV in the United States are infected with HCV genotype1, which is less responsive to interferon than other strains.