Sexually Transmitted Sexually transmitted Diseases diseases are bacterial or viral infections. They cause untold misery. Prevention is essential. The pharmaceutical industry has developed many medicines, and research continues in various directions. What are sexually transmitted diseases?
Sexually transmitted diseases (STDs), also commonly referred to as venereal diseases,
are passed from one person to another through sexual contact. STDs probably are as
old as human history, with the earliest records dating back nearly 5,000 years. STDs
remain a major global cause of acute illness, infertility, long term disability and mor-
tality. Today, syphilis, gonorrhoea, chlamydial infection and genital herpes are con-
sidered to constitute a secret world epidemic.
Syphilis (the word is derived from Latin meaning pestilence) is caused by the bacteri-
um Treponema pallidum which enters the human body through mucous membranes.
The primary stage is characterised by genital ulceration. Sores also can occur on the
lips and in the mouth. In pregnant women, syphilis causes congenital infection, spon-
taneous abortion and stillbirth. If left untreated, 30 per cent of all cases result in late-
stage complications which include neuro-syphilis, granulomatous lesions in the skin,
liver, bones and cardiovascular involvement. In 1530 Hieronymus Fracastor gave the
disease its name in a poem. It relates the tale of the shepherd Syphilis, who for an act
of impiety, was struck with the disease. The poem became so famous that the noun
syphilis became the universal term for the infection.
Gonorrhoea is caused by Neisseria gonorrhoeae, a bacterium that grows in the warm,
moist areas of the reproductive tract, including the cervix, uterus, and fallopian tubes
in women, and in the urethra in women and men. Two to five days after infection,
some men experience a painful sensation when urinating, or a white or yellow dis-
charge from the penis. In the second century BC, Galen, a Greek physician, coined the
noun gonorrhoea, which means “flow of seed.“ He mistakenly believed the urethral
discharge was an involuntary loss of semen. Sometimes men with gonorrhoea devel-
op swollen testicles. In most infected women, symptoms are mild or go unnoticed.
They include a burning sensation when urinating, increased vaginal discharge, or
Chlamydial infection is caused by the bacterium Chlamydia trachomatis. Often,
women are infected without knowing. They are frequently re-infected if their partners
are not treated. Untreated, Chlamydia can lead to an infection of the womb and fal-
lopian tubes called pelvic inflammatory disease, which may end in infertility.
Genital herpes is caused by herpes simplex virus (HSV). There are two types of the
virus, type 1 (HSV-1) and type 2 (HSV-2); both can cause the disease, although the
latter is more likely to produce frequent recurrences of genital lesions. The blisters
break, leaving tender ulcers that may take some weeks to heal. Because of the ulcer-
ation, HSV-2 infection may act as cofactor for transmission of other STDs, including
AIDS, a factor that has long been underestimated. Who do sexually transmitted diseases af fect?
Syphilis remains prevalent in developing countries and areas of the USA, Asia, and
Europe, especially Eastern Europe, with up to 250 cases per 100,000 population. Its
incidence has been increasing again since 2000, peaking at the age group 15-34
years. The increase is primarily noted in homosexual men. The cases reported in
women decreased, as did congenital syphilis cases.
During the 1980s, Western Europe saw a decline of the incidence of gonorrhoea to
below 20 per 100,000, but since 1990, an increase in cases has been reported. A
major rebound has been noted in Eastern Europe, with up to 125 cases per 100 000
population. The male to female ratio remained unchanged at 4:1. The 2003 rate for
gonorrhoea in the USA was 117 per 100,000 people.
Infection with Chlamydia trachomatis is the most commonly diagnosed bacterial sex-
ually transmitted infection in the developed world. Under-reporting is substantial
because most people are not aware of their infection. An estimated four million Euro-
peans are infected with chlamydia each year.
Genital HSV-2 infection is more common in women (approximately 25 per cent) than
in men (20 per cent); due to male-to-female transmissions being more likely than
female-to-male transmission. With a prevalence of one in four to five adults, the num-
ber of people with genital herpes in the EU is estimated to be around 60 million.
Recent epidemiological studies have shown that infection with HSV-2 is highly preva-
lent in sub-Saharan Africa, and that the finding of antibodies against HSV-2 is a mark-
Treating patients without treating their sexual partners results in a high rate of re-
infection, so that notification of partners and contact treatment are essential. For all
stages of syphilis, the treatment of choice is intramuscularly injected penicillin, either
as a single dose or long-term therapy. The need for alternative medicines is reserved
for documented penicillin-allergic patients. Alternative regimens include tetracycline
Treatment of gonorrhoea must be initiated as soon as possible after diagnosis. Ther-
apeutic options include a single dose of a macrolide antibiotic or a multiple dosing
regime with a tetracycline antibiotic, a gyrase inhibitor or a different macrolide antibi-
Chlamydia infection is treated with a single dose of a macrolide antibiotic. This sim-
plifies treatment compliance. The other option is a seven-day course of a tetracycline
HSV-2 infection can nowadays be targeted by anti-herpetic specific medicines, either
as a continuous prophylactic treatment during its asymptomatic shedding phase, or
as an episodic treatment during clinically-apparent genital ulcerations. There is no
cure for herpes, but antiviral medication shortens and prevents outbreaks.
What’s in the development pipeline?
In a phase 3 study, researchers are investigating the equivalence of the effectiveness
of a macrolide antibiotic administered orally as a single dose for treatment of untreat-
ed primary, secondary or early latent syphilis compared to the recommended treat-
A phase 1 trial evaluating the safety, tolerability and immune response of a newly
developed vaccine against HSV-2 is underway in patients suffering from genital
lesions. A special emphasis of vaccine development includes preventing primary infec-
tion, preventing the establishment of latency, and preventing transmission to
Stemming the spread of STDs is a major issue. In 2005, investigators showed that pro-
viding fast and direct access to antibiotics for partners of newly infected patients
reduces the spread of STDs, compared to standard practice. Some 1,800 patients and
their sexual partners were randomly assigned and offered either a standard referral or
expedited treatment. The latter resulted in significantly fewer re-infections with Neis-seria gonorrhoeae and Chlamydia trachomatis. The longer-term future
The sequencing of the genome of Treponema pallidum containing some 1.2 million
base pairs has been completed. The genome of Neisseria gonorrhoeae has been shown
to consist of 2.2 million base pairs, while the genome of Chlamydia trachomatis con-
tains around one million base pairs. The catalogue of genes will give a direction to
new options for the treatment of the infections.
Sexual transmission of bacteria and viruses involves a breach of the natural mucous
defence mechanism. Women currently have no way to protect themselves from STDs
that does not require male cooperation. While the male condom is effective in pre-
venting transmission of STDs, its use is hampered by deeply rooted cultural and social
barriers. Alternative prevention tools, such as locally applied microbiocides, would be
an interesting tool to prevent STD-causing organisms from entering their target cells
in the vagina or the cervix. Several candidate microbiocides are set to enter advanced
AIDS and Hepatitis B are not discussed in this chapter, because these diseases were
covered in separate chapters of the “Medicines for Mankind” publications. D I S C L A I M E R
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