Youth, AIDS and Sexually Transmitted Diseases

Anne Mitchell, Susan Moore, Doreen Rosenthal

• Publisher: Routledge
• Year: 2020
• Print ISBN:
  9780415106337
• eBook ISBN:
  9781317725534
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

What has been the impact of AIDS and sexually transmitted diseases on the lives of young people? Youth, AIDS and Sexually Transmitted Diseases provides a comprehensive overview of research and policy in this increasingly important area.
The book describes the world-wide incidence and prevalence of sexually transmitted diseases among adolescents and examines how their sexual behaviour has changed as a result of the threat of AIDS. It also looks at young people's knowledge and attitudes about their own sexual health, as well as the usefulness of models in predicting those at risk. The authors also discuss the effectiveness of institutional policies in educating young people and in preventing sexually transmitted diseases.
Youth, AIDS and Sexually Transmitted Diseases will be of considerable benefit to health care providers, sex educators and all those who work with and study adolescents.

1 The of the problem

‘Taking a chance on love’ ‘Taking a chance on love’

It is unlikely that the writer of this popular song of the 1940s had syphilis or gonorrhoea in mind when he wrote it. Taking a chance on love then had a more innocent, less disturbing meaning than it does today. For today’s young people, taking a chance on love has a potentially deadly or at least debilitating meaning. In this chapter we set the scene for the remainder of this book by describing some of the diseases that are sexually transmitted and the reasons why these diseases pose a special risk for adolescents.

A SHORT HISTORY

A short excursion into history reveals that concerns about sexual health and sexually transmissible diseases (STDs) are not new. Venereal diseases (VDs), to use an older term, have long been with us, waxing and waning as a public health issue over the centuries. For example, Waugh (1990) documents evidence of STDs from ancient Egyptian times to the modern day, with the establishment of the medical speciality of venereology. Some biblical descriptions of ‘plague’, where practices for preventing the contamination of others are specified, have been interpreted as references to venereal disease. The outbreak of syphilis in Europe in the fifteenth century began the thorough documentation of the history of this STD, and had a significant influence on public health measures as well as placing STDs within a moral context. Notification of syphilis became compulsory, and early in the sixteenth century it was decreed that syphilitics should lose their jobs. The moral condemnation surrounding syphilis continued into the nineteenth century, with syphilis being described in the 1867 edition of Chambers Encyclopaedia as ‘this repulsive form of disease … usually propagated by impure sexual intercourse’. To this day, it is not unusual to hear syphilis and other STDs being described as ‘shameful’ or ‘dirty’ even by young people (Smith et al. 1995).

The significance of syphilis and other STDs was often linked with its effects on soldiers and the war effort. In the same edition of Chambers Encyclopaedia, one Dr Aitken is quoted as observing that ‘The loss of strength from venereal diseases … is equal to the loss of more than eight days annually of every soldier in service.’ Another medical practitioner of the time, Dr Parkes, discusses the question of the prevention of syphilis. The means of prevention that he suggests are:

(1) Continence, which is promoted by (a) the cultivation of a religious feeling and of pure thought and conversation; (b) the removal from temptation and occasions to sin; (c) constant and agreeable employment, bodily and mentally; and (d) temperance. (2) Early marriage. At present only six per cent of our soldiers are allowed to marry. (3) Precautions after the risk of contagion. In some French towns, the use of lotions and washing is rigorously enforced, with the effect of lessening the disease considerably. (4) Cure of the disease in those affected by it. Health inspections, in reference to venereal disease, are made weekly in our army.

(1867 edition of Chambers Encyclopaedia)

The First World War gave a great impetus to STD prevention, with all nations involved in the fighting taking measures to protect their troops. Taking Victoria, Australia, as a case study, notification of venereal disease was made compulsory at the time of the First World War and there was considerable, although often uninformed, concern about the widespread prevalence of these diseases. Of all the men examined during call-up in 1916, twenty in every 1,000 were found to be infected with gonorrhoea or syphilis. Other contemporary data show much higher estimates. There was an interesting slant to notions of prevention. The cause of VD was unequivocally attributed to women — prostitutes or ‘scarlet women’ of both the amateur and professional variety. The emphasis on dealing with syphilis at its cause, namely women, featured in Dr Parkes’ writings in the mid-nineteenth century: ‘Inspections of all recognised prostitutes have long been supported by legal authority.’ Dr Parkes goes on to tell us that the Contagious Diseases Bill of 1864 allowed for diseased prostitutes found ‘in the neighbourhood of certain places’ to be taken into a hospital and detained there until cured. No such constraints appeared to apply to these women’s infected partners. By whatever means, and for whatever reasons, by the Second World War the numbers infected with gonorrhoea or syphilis had dropped, although women were still targeted as the major cause of the evil.

By the 1990s, gonorrhoea and syphilis were no longer the most common, or even the most devastating, STDs. More prevalent today are chlamydia, genital warts and herpes, and, of course, the human immunodeficiency virus (HIV) and its outcome, acquired immune deficiency syndrome (AIDS). Since its detection in the West early in the 1980s, HIV /AIDS has quite properly become and remained a priority public-health issue. Nevertheless, the incidence of other STDs and their possible consequences makes it imperative that we cast our prevention strategies wider than the present focus on HIV and AIDS. In addition, it now seems that infection with HIV makes infection with another STD more likely, and the converse is also true.

The potential of AIDS to cut a swath through productive sectors of the population, especially the young, has served the important purpose of focusing attention on the sexual health of individuals in our society and placing this STD on the public health agenda. But it has also directed attention away from other STDs and their consequences to the health and well-being of the community. In the remainder of this chapter, we document some distinguishing features of a range of common modern STDs, including HIV/AIDS, and consider the risks these STDs carry for young people.

DESCRIBING STDs: WHAT ARE THE SYMPTOMS?

Any attempt to be comprehensive in describing STDs and their symptoms would leave the non-medical reader bewildered and overwhelmed. Instead, we focus on those STDs that appear to have most relevance to young people in the Western world, with the aim of briefly describing the symptoms they produce, and their possible complications. The interested reader is referred to detailed accounts in Adimara et al. (1994), Holmes et al. (1990), and Wasserheit et al. (1991). For a user-friendly discussion of signs, symptoms and consequences, the primer by Plummer et al. (1995) is recommended.

The microbiological agents responsible for most STDs are bacteria and viruses. Bacterial STDs such as gonorrhoea, chlamydia and syphilis can be cured, unlike viral STDs, such as HIV, genital herpes, or human papillomavirus (HPV). Individuals who become infected with these viruses usually remain so. For viral and some bacterial STDs there may be no overt manifestations of the disease so that the individual may be unaware that he or she is infected. The only STD for which an effective vaccine is available at present is hepatitis B virus.

Gonorrhoea

Commonly known as the ‘clap’, gonorrhoea (Neisseria gonorrhoea) is usually associated with a vaginal discharge in women and urethral discharge in men, but there can be infection in the throat, the upper genital tract in women (uterus or fallopian tubes) or in the rectum, and pain on urinating is common. There has been a significant decrease in the number of cases of gonorrhoea in many Western countries, partly as a consequence of greater awareness of safe-sex issues. Mindel (1995) reports that in those countries where there has been a decrease in gonorrhoea, there has also been a significant increase in pelvic inflammatory disease and ectopic pregnancies. About 50 per cent of all women and between 1 and 3 per cent of men infected are asymptomatic and reinfections are common.

The organism cannot survive for a long period outside the human host and is most commonly spread through sexual intercourse. Jones and Wasserheit (1991) report that the chance of a woman who has intercourse with an infected man being infected is between 50 and 90 per cent, depending on the number of exposures. A single exposure from an infected woman results in a 20 per cent chance of a man becoming infected, with that chance increasing with subsequent exposure.

Treatment is safe and highly effective, the preferred option being single-dose regimes. Such quick, short-term treatment is more likely to be followed by patients than long-term alternatives.

Chlamydia trachomatis infections

Chlamydia infections are of particular concern because of their prevalence and the high likelihood that infection will be asymptomatic. Infections usually involve the same sites as those infected by gonorrhoea but are less acute and produce milder symptoms, or no discernible symptoms. Infections of the eye may result from contact with genital secretions. Estimates are that of those infected, 90 per cent of women and 50 to 90 per cent of men are asymptomatic. Because of this, early treatment (or indeed any treatment) is often not sought and, as a consequence, complications of chlamydia are common.

Transmission from one person to another is through sexual intercourse, and recurrent infections are common. About two-thirds of women and one-third of men with infected partners become infected themselves (Jones and Wasserheit 1991).

Diagnosis is best made through tissue culture although other less sensitive tests are available. Treatment is usually effective, although the need for multiple dose therapy means that compliance is often difficult to achieve and another major barrier to treatment is the difficulty of diagnosis.

Genital herpes

Genital herpes is a chronic disease, of which there are two types: herpes simplex virus type 1 (HSV1), which is commonly associated with the cold sore blister, and type 2 (HSV2), which occurs around the genital region and is usually associated with genital herpes. How-ever, both HSV1 and HSV2 can infect either site. It has been suggested that genital infection caused by HSV1 infections are increasing as a result of an increasing awareness of safer sex practices with respect to HIV infection, and thus an increase in oral—genital sex.

Symptoms are, initially, a period of discomfort characterised by hypersensitivity. Within one to three days, lesions develop to form painful superficial ulcers. Other symptoms may include fever, headache and a feeling of tiredness. The symptoms of primary infection persist for one to three weeks. The lymph nodes may be enlarged and tender for up to six weeks. Clinical manifestations of the infection will depend on the site of entry and any immunity acquired from a previous attack. Recurrent infections are less severe and shorter. Jones and Wasserheit (1991) report that individuals infected with HSV2 are almost twice as likely to have one or more recurrent infections within 12 months of first being infected than those infected with HSV1 (about 90 per cent of cases compared with 50 per cent). Corey (1990) reports a two-year follow-up study in which the median recurrence rate was five episodes per year. While there are periods of latency, relapses tend to occur when the individual is subjected to emotional or physical stress, fever, hormonal changes, or a number of other factors.

Diagnosis is relatively easy when the individual is symptomatic. In the absence of symptoms, viral cultures are necessary. There is no cure for genital herpes although antiviral therapy can shorten the duration of the primary infection and suppress recurrent infection. However, as Jones and Wasserheit note, when therapy ceases, recurrences of the infection occur at the same rate as previously.

A major problem with genital herpes is that the virus may be shed in the absence of obvious symptoms so that a person can be infected or infectious without realising it. In fact, Mindel (1995) argues that close questioning of most infected individuals reveals that they do have genital symptoms which neither they nor their doctors recognise as being due to genital herpes. Indeed, Mindel estimates that 60 per cent of infected people have unrecognised symptoms and only 20 per cent are asymptomatic. Fortunately, at least one study has shown that transmission rates are relatively low (Mertz et al. 1988).

Genital warts

Genital warts (resulting from infection with human papillomavirus) are contracted, as a rule, through direct sexual contact, and it is not uncommon for other STDs to be present concurrently (Oriel 1990). Infections with HPV are common (Mindel 1995) and the incidence of genital warts appears to have increased despite the use of safe-sex techniques. The reasons for this may be the lengthy incubation period for HPV infection, the asymptomatic nature of many infections, and that using condoms (the most preferred and most promoted safe-sex technique) does not cover all the areas that are likely to be exposed to the wart virus. Most people with genital warts have no symptoms and concern usually is with appearance of the warts. The virus manifests itself about two months after infection (or any time between one and six months). Initially there may be reddish swellings that grow into a cluster of small, painless, cauliflower-shaped lumps on the penis, perineum, labia, vulva, cervix, or in and around the anus. In men, warts may be infrequently located on the scrotum or urethra. Cervical lesions tend not to be warty. If occurring in the vagina or anus, warts may go undetected. Infection may also occur without the development of actual warts.

The likelihood of being infected after a single exposure is not known, but two studies reported by Oriel suggest moderately high levels of infectivity, with about two-thirds of the sex partners of infected individuals with genital warts developing the disease. There are various treatments for genital warts, such as electrocautery (heat) under local anaesthetic, the application of liquid nitrogen (cold), or antiviral therapy. Estimates are that only about 25 per cent of people with warts are cured and although it has been suggested that warts will disappear spontaneously, there is little evidence for this claim.

Hepatitis B (HBV)

Hepatitis B affects the functioning of the liver, and infection with HBV may, uncommonly, lead to death from acute or chronic liver failure or liver cancer. Sexual activity is a major factor in the transmission of HBV, especially for homosexual men, although other routes of infection are common. Lemon and Newbold (1990) suggest that many adults infected with HBV have silent infections which probably result in permanent immunity The onset of HBV is generally insidious, with an incubation period of about six weeks before onset of symptoms. The initial symptoms include fever, rash, and painful joints. There may be some jaundice causing yellowing of the skin and whites of the eyes. As HBV is a disease affecting the liver, there may be dark urine. Jones and Wasserheit report that only about one-third of infected adults are diagnosed clinically as having viral hepatitis, one-third have mild symptoms, and one-third are asymptomatic. Most patients recover completely, usually within six to eight weeks, although some individuals may develop chronic Hepatitis B, become a permanent carrier (more likely in the young), or develop cirrhosis.

Sexual transmission of HBV is strongly linked with number of partners and the practice of anal intercourse. Moderate rates of transmission are reported from an infected to an uninfected partner (about 18 to 27 per cent in heterosexual couples, with substantially higher rates for homosexual men).

Although there is no effective cure for HBV, there is a vaccine that provides immunity for most individuals for a period up to two years, although for some people protection for five years is possible.

Human immunodeficiency virus (HIV)

Although HIV is believed to have been spreading in Africa from the 1940s, it was not officially recognised until 1981, when the Center for Disease Control in the USA set up a task force to investigate reports of an unusual immune deficiency disease in a growing number of gay men. Its early title of gay-related immune deficiency (GRID) reflects this history and it was retitled AIDS (acquired immune deficiency syndrome) in 1982 when increasing numbers of non-gay infected people emerged, mainly intravenous drug users. The 1984 discovery, by both French and American scientists, of the human immunodeficiency virus that causes AIDS was the beginning of a real understanding of how the disease was transmitted and how it would need to be prevented.

This is not the place to present a full picture of the biology clinical manifestations, and treatment of HIV (see Holmes et al. 1990 for a full description). The virus attacks the cells of the immune system, eventually causing AIDS, and can be transmitted in one of three ways: through sexual contact with an infected person, by a pregnant woman to the foetus or after birth during breast feeding, and through exposure to contaminated blood (sharing needles and syringes that are contaminated, through needle-stick injuries, or through blood transfusions). Many individuals have no or very mild symptoms at the time of infection. However, in some, there is an influenza-like episode, and neurological signs may be present, including severe headaches, stiff neck, or more serious symptoms. The illness lasts about two to three weeks but there is usually full recovery. An infected person may remain asymptomatic for a variable period, with absence of symptoms now reported for periods of up to twelve years among some individuals. Plummer and his colleagues report that about one-third to half of those who have been infected with HIV for nine years will have developed AIDS (Plummer et al. 1995).

Early symptoms of AIDS are varied and include chronic fever, night sweats, diarrhoea, oral thrush, weight loss and herpes. The term ARC (AIDS-related complex) is sometimes used to characterise an early stage of AIDS with the presence of several symptoms. The development of AIDS is heralded by a range of conditions, including opportunistic infections, malignancies (such as Karposi’s sarcoma), wasting syndrome, and severe neurological symptoms.

The virus is detected through HIV antibody testing. There is a ‘window’ period of about three months when the test will produce a negative result despite presence of the virus. Because the virus cannot be destroyed, infection lasts for life and can be passed on to others. We now know that the periods of greatest infectivity are at the time of becoming first infected or seroconversion (when tests may prove to be falsely negative) and at the time of transition to AIDS. While, at present, the onset of AIDS is an inevitable consequence of HIV infection, there are a number of strategies to improve or maintain general health. These include attending to diet, physical fitness, reduction of stress, and treatment of infections. Several therapeutic strategies are currently being tested, although at present t...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Notes on the authors
• Acknowledgements
• Introduction
• 1 The scope of the problem: ‘Taking a chance on love’
• 2 Youths’ sexual behaviour
• 3 Understanding the risk: Young people’s knowledge of and attitudes towards STDs
• 4 Predicting sexual risk taking: Theoretical frameworks
• 5 Myths and stereotypes: Young people’s decisions to have and not to have safe sex
• 6 A matter of policy
• 7 Preventing STDs through education
• 8 Living with sexually transmissible disease
• 9 Conclusion
• References
• Index