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People with alcohol use disorders are more likely than the general population to contract HIV (human immunodeficiency virus).¹ Similarly, people with HIV are more likely to abuse alcohol at some time during their lives (1). Alcohol use is associated with high-risk sexual behaviors and injection drug use, two major modes of HIV transmission. Concerns about HIV have increased as recent trends suggest a resurgence of the epidemic among men who have sex with men² (2), as well as dramatic increases in the proportion of cases transmitted heterosexually (3,4). In persons already infected, the combination of heavy drinking and HIV has been associated with increased medical and psychiatric complications, delays in seeking treatment (5), difficulties with HIV medication compliance (6,7), and poorer HIV treatment outcomes (8). Decreasing alcohol use in people who have HIV or who are at risk for becoming infected reduces the spread of HIV and the diseases associated with it.

This Alcohol Alert briefly examines the changing patterns of HIV transmission in the United States; the role of alcohol in the transmission of HIV within, and potentially beyond, high-risk populations; the potential influence of alcohol abuse on the progression and treatment of HIV-related illness; and the benefits of making alcoholism treatment an integral part of HIV prevention programs.

Trends in HIV Transmission in the United States

HIV is most commonly transmitted by sexual contact and the sharing of contaminated needles by injection drug users (9). By the end of 2000, an estimated 900,000 Americans were living with HIV. Approximately 40,000 new cases of active AIDS disease are diagnosed annually (3). Historically, HIV has been most prevalent among men who have sex with men (10) whereas most new HIV infections are reported among men who have sex with men and among injection drug users (3). Recently, however, the proportion of HIV cases acquired through heterosexual contact has increased and almost equals the proportion of cases attributable to injection drug use (3,4). The proportion of all AIDS cases reported among women has tripled since the mid-1980s, primarily as a result of heterosexual exposure and secondarily through injection drug use (4). Minority groups are the most heavily affected by HIV associated with drug injection, and Blacks and Hispanics now account for an estimated 70 percent of all new AIDS cases (3,4).

Alcohol and HIV Transmission

People who abuse alcohol are more likely to engage in behaviors that place them at risk for contracting HIV. For example, rates of injection drug use are high among alcoholics in treatment (11,12), and increasing levels of alcohol ingestion are associated with greater injection drug-related risk behaviors, including needle sharing (13).

A history of heavy alcohol use has been correlated with a lifetime tendency toward high-risk sexual behaviors, including multiple sex partners, unprotected intercourse, sex with high-risk partners (e.g., injection drug users, prostitutes), and the exchange of sex for money or drugs (11,14-16). There may be many reasons for this association. For example, alcohol can act directly on the brain to reduce inhibitions and diminish risk perception (17-19). However, expectations about alcohol’s effects may exert a more powerful influence on alcohol-involved sexual behavior. Studies consistently demonstrate that people who strongly believe that alcohol enhances sexual arousal and performance are more likely to practice risky sex after drinking (19-22).

Some people report deliberately using alcohol during sexual encounters to provide an excuse for socially unacceptable behavior or to reduce their conscious awareness of risk (20). According to McKirnan and colleagues (23), this practice may be especially common among men who have sex with men. This finding is consistent with the observation that men who drink prior to or during homosexual contact are more likely than heterosexuals to engage in high-risk sexual practices (14,24-26).

Finally, the association between drinking levels and high-risk sexual behavior does not imply that alcohol necessarily plays a direct role in such behavior (18) or that it causes high-risk behavior on every occasion (19-22). For example, bars and drinking parties serve as convenient social settings for meeting potential sexual partners (25,27). In addition, alcohol abuse occurs frequently among people whose lifestyle or personality predisposes them to high-risk behaviors in general (14,28,29).

Alcohol and Medical Aspects of AIDS

Alcohol increases susceptibility to some infections that can occur as complications of AIDS. Infections associated with both alcohol and AIDS include tuberculosis; pneumonia caused by the bacterium Streptococcus pneumoniae; and the viral disease hepatitis C, a leading cause of death among people with HIV (9,30). Alcohol may also increase the severity of AIDS-related brain damage, which is characterized in its severest form by profound dementia and a high death rate (9,31).

The progression of HIV and the development of AIDS-associated infections may be controlled by highly active antiretroviral therapy (HAART), a combination of powerful antiviral medications. Despite markedly increased survival rates (9), HAART is associated with several disadvantages, including the emergence of medication-resistant HIV strains and the occurrence of adverse interactions with other medications, some of which are prescribed for AIDS-related infections (32). In addition, many patients fail to comply with the complex medication regimen (2,33). Studies have associated heavy alcohol use with decreased medication compliance (7,8) as well as with poorer response to HIV therapy in general (8). The outcome of HIV therapy improved significantly among alcoholics who stopped drinking (8).

Alcoholism Treatment as HIV Prevention

Studies show that decreasing alcohol use among HIV patients not only reduces the medical and psychiatric consequences associated with alcohol consumption but also decreases other drug use and HIV transmission (8). Thus, alcohol and other drug abuse treatment can be considered primary HIV prevention as well (12). For example, Avins and colleagues (34) found a 58 percent reduction in injection drug use, with similar decreases in high-risk sexual behaviors, among heterosexual patients one year after treatment. Participants who remained abstinent showed substantially greater improvement in both outcomes compared with those who continued to drink (34).

Boscarino and colleagues (15) suggest that for heterosexual alcoholics, the focus of screening and prevention for HIV risk factors should be on people with more severe alcohol dependence. For male alcoholics who have sex with men, the focus should be on those who socialize primarily in bars (15).

Alcoholism prevention among youth is of particular importance. AIDS is a leading cause of death among people ages 15 to 24 (16), and new injection drug users who contract HIV or viral hepatitis often become infected within 2 years after beginning to inject drugs (35). Researchers have found that:

• the prevalence of current, binge, and heavy drinking peaks between the ages of 18 and 24 (36), which is a high-risk period for initiating injection drug use (37);
• drug injection is usually associated with prior use of alcohol in conjunction with non-injection drugs (38), especially among adolescents with alcohol use disorders (37); and
• high rates of risky sexual practices have been reported among adolescents (39) and may be correlated with alcohol consumption (16).

Therefore, it has been suggested that HIV prevention programs for youth should target alcohol consumption in addition to injection drug use and sexual risk reduction (35).

Treatment Access and Integration

Analyses of HIV surveillance data collected by the national Centers for Disease Control and Prevention (3,40), urban and rural health departments (40), and health maintenance organizations (40) revealed that Blacks, Hispanics, women, the chronically mentally ill, and the poor are less likely to obtain appropriate HIV therapy compared with the general population (3). HIV-infected people in rural areas report reduced access to medical and mental health care services relative to their urban counterparts (41).

Timeliness is an essential aspect of effective HIV treatment and prevention. Early detection of HIV infection facilitates the prompt initiation of behavioral changes aimed at reducing transmission and also may enhance treatment effectiveness (42). Unfortunately, many facilities for the treatment of alcohol or other drug use disorders do not routinely or consistently screen their patients for HIV (42). In addition, many people who test positive for HIV fail to seek medical care until the disease has reached an advanced stage (5). Alcohol abuse has been associated with longer delays in seeking treatment (5).

Some evidence suggests that such problems may be ameliorated in part by designing programs that link primary medical care with treatment for abuse of alcohol and other drugs, HIV risk-reduction education, and psychiatric care when appropriate (43,44). In drug treatment programs, for example, both patients and clinicians may focus on what is perceived as the main problem (typically heroin or cocaine use), and neglect or minimize the use of other drugs, including alcohol (45). Yet in one study, a large proportion of patients in a residential drug treatment program reported daily consumption of large quantities of alcohol (45).

In a randomized controlled trial, Samet and colleagues demonstrated the feasibility of incorporating a multidisciplinary medical clinic within a detoxification unit designed to treat alcohol, heroin, and cocaine dependence (46). Because the integration of different services at a single site can be expensive, the researchers recommended that efforts be made to facilitate information transfer or patient transportation among programs based at multiple locations (46).

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Overview

Genital herpes is a sexually transmitted infection (STI). According to the Centers for Disease Control and Prevention (CDC), 1 out of 5 American teenagers and adults is infected with genital herpes. Women are more commonly infected than men. In the United States, 1 out of 4 women has herpes.

Although at least 45 million people in the United States have genital herpes infection, there has been a substantial decrease in cases from 21 percent to 17 percent, according to a 1999 to 2004 CDC survey. Much of the decrease was in the 14 to 19 year age group, and continued through the young adult group.

Cause

Genital herpes is caused by herpes simplex virus (HSV). There are two types of HSV.

• HSV type 1 most commonly infects the mouth and lips, causing sores known as fever blisters or cold sores.
• HSV type 2 is the usual cause of genital herpes, but it also can infect the mouth.

Transmission

If you have genital herpes infection, you can easily pass or transmit the virus to an uninfected partner during sex.

Most people get genital herpes by having sex with someone who is shedding the herpes virus either during an outbreak or an asymptomatic (without symptoms) period. People who do not know they have herpes play an important role in transmission because they are unaware they can infect a sexual partner.

You can transmit herpes through close contact other than sexual intercourse, through oral sex or close skin-to-skin contact, for example.

The virus is spread rarely, if at all, by objects such as a toilet seat or hot tub.

Reduce your risk of spreading herpes

People with herpes should follow a few simple steps to avoid spreading the infection to other places on their body or other people.

• Avoid touching the infected area during an outbreak, and wash your hands after contact with that area.
• Do not have sexual contact (vaginal, oral, or anal) from the time of your first genital symptoms until your symptoms are completely gone.

Symptoms

Symptoms of herpes are called outbreaks. The first outbreak appears within 2 weeks after you become infected and can last for several weeks. These symptoms might include tingling or sores (lesions) near the area where the virus has entered your body, such as on your genital or rectal area, on your buttocks or thighs. Occasionally, these sores may appear on other parts of your body where the virus has entered through broken skin. Sores also can appear inside the vagina and on the cervix (opening to the womb) in women, or in the urinary passage of women and men. Small red bumps appear first, develop into small blisters, and then become itchy, painful sores that might develop a crust and will heal without leaving a scar.

Sometimes, there is a crack or raw area or some redness without pain, itching, or tingling. Other symptoms that may accompany the first (and less often future) outbreak of genital herpes are fever, headache, muscle aches, painful or difficult urination, vaginal discharge, and swollen glands in the groin area.

Often, though, people don’t recognize their first or subsequent outbreaks. People who have mild or no symptoms at all may not think they are infected with herpes. They can still transmit the virus to others, however.

Recurrence of herpes outbreaks

In most people, the virus can become active and cause outbreaks several times a year. This is called a recurrence, and infected people can have symptoms. HSV remains in certain nerve cells of your body for life. When the virus is triggered to be active, it travels along the nerves to your skin. There, it makes more virus and sometimes new sores near the site of the first outbreak. Recurrences are generally much milder than the first outbreak of genital herpes. HSV-2 genital infection is more likely to result in recurrences than HSV-1 genital infection. Recurrences become less common over time.

Symptoms from recurrences might include itching, tingling, vaginal discharge, and a burning feeling or pain in the genital or anal area. Sores may be present during a recurrence, but sometimes they are small and easily overlooked.

Sometimes, the virus can become active but not cause any visible sores or any symptoms. During these times, small amounts of the virus may be shed at or near places of the first infection, in fluids from the mouth, penis, or vagina, or from barely noticeable sores. This is called asymptomatic shedding. Even though you are not aware of the shedding, you can infect a sexual partner during this time. Asymptomatic shedding is an important factor in the spread of herpes.

Diagnosis

Your health care provider can diagnose typical genital herpes by looking at the sores. Some cases, however, are more difficult to diagnose.

The virus sometimes, but not always, can be detected by a laboratory test called a culture. A culture is done when your health care provider uses a swab to get and study material from a suspected herpes sore. You may still have genital herpes, however, even if your culture is negative (which means it does not show HSV).

A blood test called type-specific test can tell whether you are infected with HSV-1 or HSV-2. The type-specific test results plus the location of the sores will help your health care provider to find out whether you have genital infection.

Coping with herpes

A diagnosis of genital herpes can have substantial emotional effects on you and your sexual partner, whether or not you have symptoms. Proper counseling and treatment can help you and your partner learn to cope with the disease, recurrent episodes, personal relationships, and fertility issues.

Treatment

Although there is no cure for genital herpes, your health care provider might prescribe an antiviral medicine to treat your symptoms and to help prevent future outbreaks. This can decrease the risk of passing herpes to sexual partners. Medicines to treat genital herpes are

• Acyclovir (Zovirax)
• Famciclovir (Famvir)
• Valacyclovir (Valtrex)

For updated information on treatment for genital herpes, read the CDC STD Treatment Guidelines.

Prevention

Because herpes can be transmitted from someone who has no symptoms, using the precautions listed below is not enough to prevent transmission. Recently, the Food and Drug Administration approved Valtrex for use in preventing transmission of genital herpes. It has to be taken continuously by the infected person, and while it significantly decreases the risk of the transmission of herpes, transmission can still occur.

Do not have oral-genital contact if you or your sexual partner has any symptoms or findings of oral herpes.

Using barriers such as latex condoms during sexual activity may decrease transmission when you use them consistently and correctly, but transmission can still occur since condoms may not cover all infected areas.

You can get tested to find out if you are infected with the herpes virus

Complications

Genital herpes infections usually do not cause serious health problems in healthy adults. In some people whose immune systems do not work properly, however, genital herpes outbreaks can be unusually severe and long lasting.

Occasionally, people with normal immune systems can get herpes infection of the eye, called ocular herpes. Ocular herpes is usually caused by HSV-1 but sometimes by HSV-2. It can occasionally result in serious eye disease, including blindness.

A woman with herpes who is pregnant can pass the infection to her baby. A baby born with herpes might die or have serious brain, skin, or eye problems. Pregnant women who have herpes, or whose sex partner has herpes should discuss the situation with her health care provider. Together they can make a plan to reduce her or her baby’s risk of getting infected. Babies who are born with herpes do better if the disease is recognized and treated early.

Genital herpes, like other genital diseases that cause sores, is important in the spread of HIV infection. A person infected with herpes may have a greater risk of getting HIV. This may be due to the open sores caused by the herpes infection or by other factors in the immune system. In addition, HIV-positive people may be more contagious for herpes.

Source: National Institute of Allergy and Infectious Diseases (NIAID)

If you have any specific question, you can ask the doctors at - www.MyMedExpert.com

MyMedExpert - Medical Consultation Online

Genital herpes infections usually do not cause serious health problems in healthy adults. In some people whose immune systems do not work properly, however, genital herpes outbreaks can be unusually severe and long lasting.

Occasionally, people with normal immune systems can get herpes infection of the eye, called ocular herpes. Ocular herpes is usually caused by HSV-1 but sometimes by HSV-2. It can occasionally result in serious eye disease, including blindness.

A woman with herpes who is pregnant can pass the infection to her baby. A baby born with herpes might die or have serious brain, skin, or eye problems. Pregnant women who have herpes, or whose sex partner has herpes should discuss the situation with her health care provider. Together they can make a plan to reduce her or her baby’s risk of getting infected. Babies who are born with herpes do better if the disease is recognized and treated early.

Genital herpes, like other genital diseases that cause sores, is important in the spread of HIV infection. A person infected with herpes may have a greater risk of getting HIV. This may be due to the open sores caused by the herpes infection or by other factors in the immune system. In addition, HIV-positive people may be more contagious for herpes.

Source: National Institute of Allergy and Infectious Diseases (NIAID)

If you have any specific question, you can ask the doctors at - www.MyMedExpert.com

MyMedExpert - Medical Consultation Online