EPID 623-88 Introduction to Analysis and Interpretation of HIV/STD Data Introduction: STDs and...

EPID 623-88 Introduction to Analysis and

Interpretation of HIV/STD Data

Introduction:

STDs and HIV—a brief background

Manya Magnus, Ph.D.

Summer 2001

Objectives

• To briefly describe magnitude of STD and HIV problem in the United States

• To discuss relationship between classical STDs and HIV

Magnitude of the problem

• Annual global incidence of curable STDs is 333 million cases

• The top four most common are gonorrhea (62 million), chlamydia (89 million), syphilis (12 million) and trichomonas (170 million)

• An estimated 250 million new infections occur each year

• 15 million new cases diagnosed annually in the United states

• 3 million of these cases in US are teenagers• Annual cost of major STDs in US: almost $17 million

TWENTY-FIVE SEXUALLY TRANSMITTED PATHOGENS AND ASSOCIATED DISEASES OR SYNDROMES -

BACTERIA Pathogen

Associated Disease or Syndrome

BACTERIA

Neisseria

gonorrhoeae

Urethritis, epididymitis, proctitis, cervicitis, endometritis, salpingitis, perihepatitis, bartholinitis, pharyngitis, conjunctivitis, prepubertal vaginitis, prostatitis ( ?), accessory gland infection, disseminated gonococcal infection ( DGI ), chorio-amnionitis, premature delivery, amniotic infection syndrome

Chlamydia

trachomatis

All of the above except DGI, plus otitis media, rhinitis, and pneumonia in infants and Reiter?s syndrome

Mycoplasma

hominis

Postpartum fever, salpingitis ( ?)

Ureaplasma

urealyticum

Nongonococcal urethritis

Treponema

pallidum

Syphilis

TWENTY-FIVE SEXUALLY TRANSMITTED PATHOGENS AND ASSOCIATED DISEASES OR

SYNDROMES- BACTERIA Pathogen


BACTERIA

Gardnerella vaginalis

Bacterial ( ? nonspecific ? ) vaginosis ( in conjunction with Mycoplasma hominis and vaginal anaerobes, such as Mobiluncus spp )

Haemophilus ducreyi

Chancroid

Calymmatobacterium

granulomatis

Donovanosis ( granuloma inguinale)

Shigella spp

Shigellosis in homosexual men

Campylobacter spp

Enteritis, proctocolitis


SYNDROMES - VIRUSES Pathogen


VIRUSES

Human immunodeficiency virus, types 1 and 2

AIDS

Herpes simplex

virus

Initial and recurrent genital herpes, aseptic meningitis, neonatal herpes

Human papilloma

virus

Condyloma acuminata, laryngeal papilloma, cervical intraepithelial neoplasia and carcinoma, vaginal carcinoma, anal carcinoma, vulvar carinoma, penile carcinoma

Hepatitis B virus Acute hepatitis B virus infection, chronic active hepatitis , persistent ( unresolved)


SYNDROMES - VIRUSES Pathogen


Hepatitis A

Acute hepatitis A

Cytomegalovirus Heterophil-negative infectious mononucleosis; congenital CMV infection with gross birth defects and infant mortality, cognitive impairment (e.g., mental retardation, sensorineural deafness); protean manifestations in the immunosuppressed host

Molluscum contagiosum virus

Genital molluscum contagiosum

Human T-cell

lymphotrophic virus, types I and II

Human T-cell leukemia or lymphoma

Human herpes

virus type 8

Kaposis sarcoma, body cavity lymphoma


SYNDROMES - OTHER

Pathogen


PROTOZOA

Trichomonas

vaginalis

Trichomonal vaginitis

Entamoeba

histolytica

Amebiasis in men who have sex with men

Giardia lamblia

Giardiasis in men who have sex with men

FUNGI

Candida albicans

Vulvovaginitis, balanitis

ECTOPARASITES

Phthirus pubis

Pubic lice infection

Sarcoptes scabiei

Scabies

Gonorrhea — Reported rates: United States, 1970–1999 and the Healthy People year 2000

objectiveRate (per 100,000 population)

Gonorrhea2000 Objective

0

100

200

300

400

500

1970 73 76 79 82 85 88 91 94 97

Gonorrhea — Rates by region: United States, 1981–1999 and the Healthy People year 2000

objectiveRate (per 100,000 population)

WestMidwestNortheastSouth2000 Objective

0

120

240

360

480

600

1981 83 85 87 89 91 93 95 97 99

Gonorrhea — Rates by state: United States and outlying areas, 1999

Note: The total rate of gonorrhea for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 131.4 per 100,000 population. The Healthy People year 2000 objective is 100 per 100,000 population.

Rate per 100,000population

<=100100.1-200>200

VT 8.8 NH 9.7 MA 39.9 RI 60.8 CT 101.4 NJ 96.8 DE 223.5 MD 203.1

Guam 36.9

Puerto Rico 8.3 Virgin Is. 46.5

(n=29)(n=15)(n=9)

250.2

49.2

92.0127.1

57.2 63.6

153.8

278.0

38.8

7.2

193.1 103.3

47.7

101.4 85.1

301.9

6.7

162.0

59.9

378.3

150.5

6.0

88.5 74.6

56.1

109.1

257.4

13.0

161.8

120.1

27.5

110.8

392.0

26.0

209.3

166.6

12.1

138.4

37.5

32.2

127.5

8.9

Gonorrhea — Rates by race and ethnicity: United States, 1981–1999 and the Healthy

People year 2000 objectiveRate (per 100,000 population)

WhiteBlackHispanicOther2000 Objective

0

500

1,000

1,500

2,000

2,500

1981 83 85 87 89 91 93 95 97 99

Note: "Other" includes Asian/Pacific Islander and American Indian/Alaska Native populations. Black, White, and Other are non-Hispanic.

Syphilis — Reported cases by stage of illness: United States, 1941–1999

Thousands of cases

P&SEarly LatentTotal Syphilis

0

120

240

360

480

600

1941 46 51 56 61 66 71 76 81 86 91 96

Primary and secondary syphilis — Reported rates: United States, 1970–1999 and the

Healthy People year 2000 objectiveRate (per 100,000 population)

P&S Syphilis2000 Objective

0

5

10

15

20

25

1970 73 76 79 82 85 88 91 94 97

Primary and secondary syphilis — Rates by state: United States and outlying areas, 1999

Note: The total rate of primary and secondary syphilis for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 2.5 per 100,000 population. The Healthy People year 2000 objective is 4.0 per 100,000 population.


<=44.1-8>8


Guam 1.3


(n=42)(n=10)(n=1)

4.6

0.2

4.5 3.4

0.9 0.2

2.6

5.6

0.3

0.1

3.5 7.6

0.3

0.5 2.6

7.0

0.0

2.5

0.2

7.0

1.8

0.1

0.4 0.3

0.7

0.8

6.1

0.0

0.8

5.6

0.2

0.7

7.0

0.0

11.8

2.4

0.1

2.3

1.4

0.3

0.8

0.0

Primary and secondary syphilis — Rates by region: United States, 1981–1999 and the

Healthy People year 2000 objectiveRate (per 100,000 population)

WestMidwestNortheastSouth2000 Objective

0

10

20

30

40

50

1981 83 85 87 89 91 93 95 97 99

Chlamydia — Reported rates: United States, 1984–1999

Rate (per 100,000 population)

0

60

120

180

240

300

1984 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

Chlamydia — Rates by state: United States and outlying areas, 1999

Note: *The New York City rate was 360.7 per 100,000 population. No cases were reported outside of New York City. The total rate of chlamydia for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 250.9 per 100,000 population.


<=150150.1-300>300


Guam 311.0


(n=10)(n=34)(n=9)

284.4

307.2

259.4231.1

260.7 273.2

212.8

397.4

265.3

144.7

272.9 198.9

192.5

231.8187.4

380.8

98.1

235.4

157.7

419.5

245.6

179.9

217.5176.7

288.8

*

289.0

148.4

262.3

244.9

186.7

225.1

482.3

209.2

261.8

318.6

105.7

202.2

210.3

100.5

276.9

163.6

Chlamydia — Rates by region: United States, 1984–1999


WestMidwestNortheastSouth

0

60

120

180

240

300

1984 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

Chlamydia — Rates by gender: United States, 1984–1999


MenWomen

0

90

180

270

360

450

1984 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

Chlamydia — Positivity among 15-24 year old women tested in family planning clinics by state,

1999

Note: States reported chlamydia positivity data on at least 500 women aged 15-24 years screened during 1999 except for Rhode Island; for Puerto Rico, ‑ chlamydia positivity data were reported for August-December only. SOURCE: Regional Infertility Prevention Programs; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

Positivity (%)

<44.0-4.9>=5

VT 2.8 NH 6.6 MA 3.8 RI 10.5 CT 3.5 NJ 6.3 DE 6.3 MD 5.9 DC 5.6


(n=12)(n=8)(n=33)

10.0

4.0

5.5 7.1

7.2 5.3

5.5

7.7

6.1

4.3

7.2 5.0

4.6

4.2 3.7

10.9

3.0

4.6

4.2

14.6

4.1

4.5

3.3 6.1

5.5

3.2

8.5

3.3

5.9

5.2

3.7

6.5

9.3

2.6

5.5

9.0

3.6

6.4

6.1

2.6

7.2

5.0

Chlamydia — Age- and gender-specific rates: United States,

1999Men Rate (per 100,000 population) Women

Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4

Men Rate (per 100,000 population) Women

Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4


Age2,500 2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000 2,500

Total 65+

55-6445-5440-4435-3930-3425-2920-2415-1910-14 8.9

343.7

503.8

245.1

108.2

55.7

29.2

12.6

4.6

2.2

97.0

147.0

2,483.8

2,187.1

725.9

246.5

99.0

40.4

14.4

4.0

3.0

403.4

Chlamydia — Rates by region: United States, 1984–1999


WestMidwestNortheastSouth

0

60

120

180

240

300

1984 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

HIV/AIDS

• Relationship between classical STDs and HIV• Increases in HIV transmission in presence of

STDs.– Increased genital track shedding of virus

(transmission)– Increased attraction of CD4+ lymphocytes to

mucosa (transmission)– Micro-abrasions of genital tissueincreased

portals of entry/exit (transmission/acquisition)– Increased attraction of CD4+ lymphocytes to

mucosa (acquisition)

Estimated Number of Persons Living with AIDS,1993 -1998, by Sex, United States

Year

Th

ou

san

ds

1993 1994 1995 1996 1997 1998

250

200

150

100

50

0

Men

Women

American Indian/Alaska Native

Black, not Hispanic

Hispanic

Asian/Pacific Islander

White, not Hispanic

1993 1994 1995 1996 1997 1998Year

0

20

40

60

80

100

120

140

Estimated Number of Persons Living with AIDS,1993 - 1998, by Race/Ethnicity, United States

Th

ou

san

ds

20

40

60

120

100

80

0

U.S. dependencies and possessions

North Central

NortheastSouth

1995 1996 1997 199819941993Year

Estimated Number of Persons Living with AIDS,1993 -1998, by Region, United States

West

Th

ou

san

ds

0

Year of Report

Proportion of AIDS Cases, by Race/Ethnicity and Year of Report,1985-1999, United States

Perc

en

t of

Case

s

1985 1987 1989 1991 1993 1995 1997 1999

10

20

30

40

50

60

70

American Indian/Alaska Native

Black, not Hispanic

Hispanic

Asian/Pacific Islander

White, not Hispanic

0

10

20

30

40

50

60

70

80

1985 1987 1989 1991 1993 1995 June 1999

Year of Diagnosis

Adult/Adolescent AIDS Cases by Exposure Categoryand Year of Diagnosis, 1985 - June 1999

United States

Other includes cases with other or unreported risk exposure. Data adjusted for reporting delays and risk redistribution.

1997

MSM & IDU

Men who have sex with men (MSM)

Injection drug use (IDU)

Other

Heterosexual contact

Perc

en

t of

Case

s

AIDS Cases and DeathsReported through 1999, United States

DeathsCases

Adult/Adolescent724,656 425,357

Children 8,718 5,084

Total 733,374 430,441

<55 - 14.915+

AIDS Rates per100,000 PopulationReported in1999

Rate per 100,000

8.4VI 32.6PR 32.1

DE

MARICTNJ

MDDC

NH

VT3.4

3.8

25.124.7

17.9

23.510.8

29.5161.5

36.2

15.2

42.3

16.4

24.7

21.5

19.515.9

18.4

2.4

16.4 3.8

4.9

2.9

3.0

4.0

4.4

4.0

2.2

1.1

3.1

1.5

2.0

6.3

6.8

13.47.3

5.3

7.9 6.4

7.6

9.7

12.8

6.6

6.1

7.0

13.8

10.9

10.4

13.7

6.4

EPID 623-88 Introduction to Analysis and Interpretation of HIV/STD Data Introduction: STDs and...

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