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HIV and Sexually Transmitted

Infections Sexually transmitted (STIs) continue to be Untreated chlamydial can cause pelvic a significant issue in the United States. inflammatory in women, which can lead to In fact, most sexually active people will have an STI chronic pelvic pain and infertility. Chlamydial at some point during their lifetime (Satterwhite et infection has also been linked to problems during al., 2013). Including HIV infections, there are an pregnancy and, newborns may become infected estimated 19–20 million new STIs annually in the during birth, which can lead to eye or lung U.S. (CDC, 2013). The of STIs in the U.S. infections. CDC recommends that all pregnant population in 2008 was estimated at around 110 women be screened for (CDC, 2014c). million infections with lifetime direct medical costs estimated at $16 billion (CDC, 2013). Illinois In 2013, there were 63,797 cases of chlamydia Anyone who is sexually active risks exposure to an reported in Illinois or 497 cases per 100,000 th STI. Having unprotected (without use of a latex population. Illinois had the 12 highest rate of condom)vaginal or increases risk of STI chlamydia infection among the 50 states in 2013 . , without usage of a latex (CDC, 2014h). condom or dental dam, can also transmit infection. Additional risk factors including having sexual Sex contact with multiple partners and substance use, Females account for the majority of reported which can inhibit judgment and increase risky chlamydial infections. This is likely due to higher behaviors. screening rates among women. However, with increased availability of urine testing, men are STIs are often asymptomatic and treatment may be increasingly being tested for and diagnosed with delayed. Thus, screening for STIs is an important part chlamydial infection (CDC, 2014h). In 2013, reported of routine health care (CDC, 2014o). Unlike HIV, rates of chlamydial infections were over two-fold most STIs are curable with treatment. However, higher among Illinois women than men with 0.7 resistance has emerged as an issue for chlamydial infections diagnosed per 100 females. the treatment of some STIs. Figure 1. Rate of Reported Chlamydia Cases by Sex, Chlamydia, and Illinois, 2009–2013 In Illinois, chlamydia, gonorrhea, and syphilis are reportable conditions. Because individuals diagnosed with STIs may practice high-risk behaviors, IDPH Female Male Total conducts interventions targeting these high-risk 743 800 715 individuals (see section, “IDPH HIV Programs”). 703 682 700

Interventions include HIV testing and expedited 600 528 506 497 partner therapy, among others. 488 473 400 287 302 285 Chlamydia 263 254

Chlamydia, caused by the bacterium Chlamydia 200 trachomatis, is the most common sexually Cases per100,000 Population transmitted bacterial infection in the United States 0 2009 2010 2011 2012 2013 (CDC, 2014h). Most chlamydial infections are asymptomatic though some men (~10%) and women Source: Illinois Department of Public Health STD Program Data, (~10-30%) may develop symptoms (CDC, 2014c). 2015

2014 ILLINOIS HIV/AIDS PROFILE

Race/Ethnicity Figure 3. Rate of Reported Chlamydia Cases by Age Despite a decline in the rate of chlamydial infections at Diagnosis, Illinois, 2013 from 2009 to 2013, non-Hispanic (NH) blacks continued to have the highest among ≥50 12 all racial/ethnic groups in Illinois. In 2013, the rate 45-49 58 among NH blacks was seven-fold higher than among 40-44 122 NH whites and four-fold higher than among 35-39 226 30-34 477 Hispanics. In 2013, there were 1.5 chlamydial 25-29 1,061 infections for every 100 NH black Illinois residents. 20-24 2,826 15-19 2,216 10-14 77 Figure 2. Rate of Reported Chlamydia Cases by Cases per100,000 Population Race/Ethnicity, Illinois, 2009–2013 5-9 1 0-4 4

NH White NH Black 0 500 1,000 1,500 2,000 2,500 3,000 Hispanic Asian/Pacific Islander 2,000 American Indian/Alaskan Native Source: Illinois Department of Public Health STD Program Data, 2015 1,600 1,781 1,565 NH Black 1,200 Syphilis

800 Hispanic Syphilis is a sexually transmitted disease caused by the bacterium Treponema pallidum. Syphilis is 400 397 348 Cases per100,000 Population 302 239 transmitted person-to-person by direct contact with 89 0 80 a syphilitic sore, known as a chancre (primary 2009 2010 2011 2012 2013 syphilis). Chancres occur mainly in the genital and Source: Illinois Department of Public Health STD Program Data, rectal areas but can also occur on the lips and in the 2015 mouth. Transmission can occur during vaginal, anal, or oral sex and pregnant women with the disease Age at Diagnosis can transmit it to their unborn child (CDC, 2014q). Chlamydial infection rates peak in young adults aged Syphilis can be successfully treated with appropriate 20–24 years. In 2013, almost 3% of young adults in ; however, treatment does not reverse Illinois aged 20–24 years were diagnosed with organ damage that may have been caused by the chlamydia. bacterium (CDC, 2014q).

Sexually active youth are at higher risk of acquiring Untreated syphilis develops in stages and symptoms chlamydia for a combination of behavioral, vary with each stage. The first stage is development biological, and cultural reasons. In 2013, among of the chancre, normally at the location where the sexually active Illinois high school students, 42% entered the body. The chancre is painless reported not using a condom during last sexual and can be hidden within the or , intercourse (see section, “Youth”) (CDC, 2014a). making it difficult to detect. Secondary syphilis Youth may face barriers, such as transportation or occurs a few weeks after the chancre heals and can stigma, that can reduce access to STI prevention present as a non-itchy rash. Other symptoms of services (CDC, 2014c). Teenage girls and young secondary syphilis include sore throat, fever, and women are at increased risk due to cervical changes swollen lymph nodes. These that can increase susceptibility to STIs. may disappear within a few weeks or can reoccur. (CDC, 2014c). Without treatment, the disease moves from the second stage to the asymptomatic latent stage. The asymptomatic stage has two phases: early latent Did You Know? stage (within 1 year of infection) and late latent Youth (15–24 years) account for 50% of all new stage (after 1 year). Late latent syphilis is STIs in the U.S., although they represent just noninfectious. Symptoms may never return or may 25% of the sexually experienced population. progress to tertiary (late) syphilis, which occurs in

about 15–30% of untreated individuals. In the

2014 ILLINOIS HIV/AIDS EPIDEMIOLOGY PROFILE tertiary stage, the disease may damage the brain, Race/Ethnicity nerves, bones, and other organs and may result in NH blacks had the highest rates of early syphilis death. Tertiary syphilis usually occurs three or more infections from 2009–2013. In 2013, the rate among years after the original, untreated infection (CDC, NH blacks was 2.5 times higher than among 2014q). Hispanics and eight times higher than among NH whites. From 2009–2013, early syphilis infection Among pregnant women, untreated syphilis can rates increased among all racial/ethnic groups in result in complications during pregnancy including Illinois. fetal death. Children born with congenital syphilis can experience serious health effects. CDC Figure 5. Rate of Reported Early Syphilis Cases by recommends that all pregnant women be screened Race/Ethnicity, Illinois, 2009–2013 for syphilis. NH White NH Black Illinois 50 Hispanic Asian/Pacific Islander 45 43.7 In 2013, there were 2,661 cases of any stage of 40 NH Black syphilis and 1,607 cases of early syphilis reported in 35 32.7 Illinois. Twenty-three cases of congenital syphilis 30 were reported or 13.9 cases per 100,000 live births 25 (CDC, 2014h). 20 15 Hispanic 14.6

10 10.1 Cases per100,000 Population Sex 5 NH White 5.3 3.4 Asian/Pacific Islander In Illinois, rates of early syphilis infection are much 0 2009 2010 2011 2012 2013 higher in males than females. Rates among Illinois males have increased steadily since 2009. Nationally, Note: Early syphilis is defined as syphilis diagnosed at the syphilis rates have been increasing overall, after a primary, secondary or early latent stage. long period of decline. The rise in has been Source: Illinois Department of Public Health STD Program Data, 2015 attributed to increased cases among men who have sex with men (MSM). In 2013, MSM accounted for 75% of all primary and secondary syphilis cases in Age at Diagnosis the U.S. (CDC, 2014q). In 2013, early syphilis infection rates peaked in youth aged 20–24 years. Among adults >24 years, infection Figure 4. Rate of Reported Early Syphilis Cases by rates declined with increasing age. Sex, Illinois, 2009–2013 Figure 5. Rate of Reported Early Syphilis Cases by

Female Male Total Age at Diagnosis, Illinois, 2013

25 22.5 20.2 20.7 ≥50 4.0 19.3 20 45-49 16.6 16.2 40-44 20.0 15 12.5 35-39 20.9 11.4 11.7 11 30-34 27.4 8.8 10 25-29 31.7 20-24 38.0 5 3.0 2.9 3.0 2.9 15-19 8.2

Cases per100,000 Population 1.7 10-14 0.1

0 Cases per100,000 Population 5-9 0.0 2009 2010 2011 2012 2013 0-4 0.1

0 10 20 30 40 Note: Early syphilis is defined as syphilis diagnosed at the primary, secondary or early latent stage. Source: Illinois Department of Public Health STD Program Data, Note: Early syphilis is defined as syphilis diagnosed at the 2015 primary, secondary or early latent stage. Source: Illinois Department of Public Health STD Program Data, 2015

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Gonorrhea Race/Ethnicity Gonorrhea, the second most common bacterial STI, Gonorrheal infection rates were 20-fold higher is caused by infection with the Neisseria among NH blacks than NH whites in Illinois in 2013. gonorrhoeae bacterium. N. gonorrhoeae infects the Rates of gonorrheal infection have declined among mucous membranes of the reproductive tract. It can NH blacks since 2009 while remaining relatively level also infect the mucous membranes of the mouth, among other racial/ethnic groups. The racial/ethnic throat, eyes, and anus. Infections due to N. group with the second highest infection rate in 2013 gonorrhoeae, like those resulting from C. after NH blacks were American Indians/Alaskan trachomatis, can cause pelvic inflammatory disease. Natives. Higher gonorrheal infection rates in this Gonorrhea is transmitted through sexual contact and population have also been seen nationally (CDC, also perinatally during (CDC, 2014f). 2014h).

Nationally, gonorrhea infection rates decreased from Figure 7. Rate of Reported Gonorrhea Cases by the 1970s to the late 1990s. Since 2009, when rates Race/Ethnicity, Illinois, 2009–2013 reached a record low, rates have increased slightly. While a treatable infection, N. gonorrhoeae has NH White NH Black Hispanic Asian/Pacific Islander progressively developed resistance to the American Indian/Alaskan Native used for treatment. Current 800 793.4 treatment guidelines call for dual therapy using two NH Black antimicrobials with different mechanisms of action 600 582.3 (CDC, 2015a). 400

American Illinois Indian/Alaskan 200

In 2013, there were 16,646 gonorrhea cases Native Cases per100,000 Population th reported in Illinois and Illinois had the 13 highest 0 infection rate among the 50 states. 2009 2010 2011 2012 2013

Sex Source: Illinois Department of Public Health STD Program Data, Gonorrhea rates among women and men were 2015 similar in 2013; however, there was a trend of a decline in rates among women and an increase Age at Diagnosis among men from 2009–2013. This mirrors what was As with other STIs, rates of gonorrheal infection seen nationally (CDC, 2014h). The increase among peaked in youth 20–24 years. There were 0.7 men compared with a decrease among women may gonorrheal infections diagnosed per 100 Illinois be due to increased transmission among men or youth aged 20–24 years in 2013. After age 24 years, increased case ascertainment (e.g., through there was a decrease in infection rates with increased extra-genital screening) (CDC, 2014h). increasing age.

Figure 6. Rate of Reported Gonorrhea Cases by Figure 7. Rate of Reported Gonorrhea Cases by Age Sex, Illinois, 2009–2013 at Diagnosis, Illinois, 2013

Female Male Total ≥50 7.5 45-49 31.0 200 177.4 40-44 51.1 180 150.5 35-39 76.2 160 160.7 145.3 136.5 131.1 30-34 152.2 140 143.2 25-29 294.1 120 131.6 125.1 20-24 661.6 100 119.4 108.5 15-19 515.5 80 10-14 22.6 60 Cases per100,000 Population 5-9 0.5 40 Cases per100,000 Population 0-4 1.2 20 0 0 100 200 300 400 500 600 700 2009 2010 2011 2012 2013

Source: Illinois Department of Public Health STD Program Data, Source: Illinois Department of Public Health STD Program Data, 2015 2015

2014 ILLINOIS HIV/AIDS EPIDEMIOLOGY PROFILE

HIV and STI Co-Infection syphilis and HIV co-infection among MSM (Zetola Risk behaviors, such as having sex without a and Klausner, 2007). condom, and having multiple sexual partners, increase the risk of acquiring STIs, as well as HIV Table 2. Number of Individuals Diagnosed with (CDC, 2015c). Having an existing STI Early Syphilis by Sex and HIV Infection can increase risk of HIV infection and transmission Status, Illinois, 2014 due to biological factors such as mucosal Male Female Total

inflammation and ulcers which can increase HIV HIV 851 207 1,058 infectiousness, susceptibility or both (Galvin and Negative Cohen, 2004). In Illinois, rates of HIV and STI co- HIV 578 8 586 infection are monitored to better understand the Positive epidemiology of these and to inform Total 1,429 215 1,644 interventions. Note: Early syphilis is defined a primary, secondary and early Chlamydia and HIV latent stages. Infections have been de-duplicated to exclude In 2014, there was limited co-infection of HIV and individuals with multiple infections of early syphilis in the same chlamydia–among the almost 59,000 individuals year. Therefore, the total number of early syphilis infections in this table does not capture the total number of early syphilis diagnosed with chlamydia in Illinois, <1% of cases infections reported to IDPH in 2014 n=1,682 . were co-infected with HIV (n=609). Chlamydia is Source: Illinois Department of Public Health STD Program Data, primarily diagnosed among adolescent girls and 2015 young women and, because this population does not have a high prevalence of HIV, limited overlap of Gonorrhea and HIV these populations is expected. In 2014, co-infection of gonorrhea and HIV was low with 4% of individuals diagnosed with gonorrhea co- Table 1. Number of Individuals Diagnosed with infected with HIV. As seen with the other STIs, the Chlamydia by Sex and HIV Infection majority of those co-infected were male. Among Status, Illinois, 2014 males infected with gonorrhea, 7.5% were co- infected with HIV while among females, the co- Male Female Total infection rate was 0.3%. HIV 17,004 41,175 58,179

Negative Table 3. Number of Individuals Diagnosed with HIV 530 79 609 Gonorrhea by Sex and HIV Infection Positive Status, Illinois, 2014 Total 17,534 41,254 58,788 Male Female Total

Note: Infections have been de-duplicated to exclude individuals HIV 6,554 6,848 13,402 with multiple chlamydial infections in the same year. Therefore, Negative the total number of chlamydial infections in this table does not HIV 527 22 549 capture the total number of chlamydial infections reported to Positive IDPH in 2014 n=64,454 . Source: Illinois Department of Public Health STD Program Data, Total 7,081 6,870 13,951 2015 Note: Infections have been de-duplicated to exclude individuals Although the majority (70%) of chlamydia cases with multiple gonorrheal infections in the same year. Therefore, the total number of infections in this table does not capture the were female, the majority (87%) of co-infected cases total number of gonorrheal infections reported to IDPH in 2014 were male. Among males who tested positive for n=14,943. chlamydia, 3% were co-infected with HIV. Source: Illinois Department of Public Health STD Program Data, 2015 Syphilis and HIV In 2014, there was a high rate of co-infection of HIV and syphilis–of the 1,644 individuals diagnosed with early syphilis, 35.6% were co-infected with HIV. Almost all individuals with co-infection (96%) were male. Nationally, there has been an increase of

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REFERENCES and Incidence Estimates, 2008. Sex Transm Centers for Disease Control and Prevention (CDC). Dis, 40(3), 187-193. (2013, Feburary, 2013). Incidence, Zetola, N. M., and Klausner, J. D. (2007). Syphilis and Prevalence, and Cost of Sexually Transmitted HIV Infection: An Update. Clinical Infectious Infections in the United States. Retrieved Diseases, 44(9), 1222-1228. April 17, 2015, from http://www.cdc.gov/std/stats/sti-estimates- fact-sheet-feb-2013.pdf CDC. (2014a). 1991-2013 High School Youth Risk Behavior Survey Data. Retrieved December 16, 2013, from http://nccd.cdc.gov/youthonline/App/Defaul t.aspx CDC. (2014c). Chlamydia - CDC Fact Sheet (Detailed). Retrieved July 23, 2015, from http://www.cdc.gov/std/chlamydia/stdfact- chlamydia-detailed.htm CDC. (2014f). Gonorrhea - CDC Fact Sheet (Detailed Version). Retrieved July 23, 2015, from http://www.cdc.gov/std/gonorrhea/STDFact -gonorrhea-detailed.htm CDC. (2014h). Sexually Transmitted 2013. Atlanta: U.S. Department of Health and Human Services Retrieved from http://www.cdc.gov/std/stats13/surv2013- print.pdf. CDC. (2014o). STD and HIV Screening Recommendations. Retrieved July 24, 2015 CDC. (2014q). Syphilis - CDC Fact Sheet. Retrieved July 23, 2015, from http://www.cdc.gov/std/syphilis/stdfact- syphilis-detailed.htm CDC. (2015a). 2015 STD Treatment Guidelines: Gonococcal Infections. Retrieved July 30, 2015, from http://www.cdc.gov/std/tg2015/gonorrhea. htm CDC. (2015c). STDs and HIV - CDC Fact Sheet. Retrieved April 20, 2015, from http://www.cdc.gov/std/hiv/stdfact-std-hiv- detailed.htm Galvin, S. R., and Cohen, M. S. (2004). The Role of Sexually Transmitted Diseases in HIV Transmission. Nat Rev Micro, 2(1), 33-42. Illinois Department of Public Health STD Program Data. (2015). Satterwhite, C. L., Torrone, E., Meites, E., Dunne, E. F., Mahajan, R., Ocfemia, M. C., Weinstock, H. (2013). Sexually Transmitted Infections among U.S. Women and Men: Prevalence

2014 ILLINOIS HIV/AIDS EPIDEMIOLOGY PROFILE