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Q&A with Dr. Laura Kogelman.

It's a different dating world than it was 30 years ago. It's important to get up to speed on how to protect yourself from contracting an STD. In this Q&A, Dr. Laura Kogelman, a leading expert in HIV treatment and Associate Professor at Tufts University School of Medicine, talks about how to ensure a clean bill of health for yourself and your new partner, including therapies that can treat STDs, what type of lubricants to use with your condoms and more. If you have some tips of your own, feel free to share them in oudiscussion pages.  

 

If an older female snuggles (no intercourse and no oral sex) with an older nude man who cannot get hard enough for a condom, how does she protect herself from STD's?

This is a tricky one.  She cannot get HIV from this type of activity. Risk of gonorrhea or chlamydia would be extremely low.  If the man had syphilis lesions, herpes lesions (or a history of herpes), or genital warts, then it is possible that he could transmit these to areas of the woman that his genitals touch.  Having him wear undergarments could decrease the risk of transmission.  But the safest way to avoid these STDs would be to have an open and honest discussion with the man to find out if he has ever had any type of STDs and how and when they were treated.  This does not eliminate all risk but it can decrease it.  

 

Are there any physical signs I need to look for before having sex? 

Look to see if there are any sores or lesions on your partner’s genitals. Even if the lesions do not seem to bother your partner, they may represent a sexually transmitted disease (STD) and should be treated to avoid possibly transmitting an infection to you.

 

I just had sex and didn't use a condom, what should I do? 

You can go to your local emergency room for evaluation and treatment.  They can give you therapy to prevent certain STDs like chlamydia or gonorrhea and can give you HIV post-exposure prophylaxis, or PEP.  PEP meds are medications used to treat HIV. You take them as soon as possible after a possible exposure to HIV and take them for 28 days.  Taking these meds promptly after a risky sexual encounter is very effective in reducing the risk of getting HIV.  It is critical that you follow up closely with an ID physician or your PCP to get follow up HIV testing while you are on PEP and for about 2 months after completing PEP.

 

My partner tells me not to worry about using condoms because I can't get pregnant, is it safe? 

No. Condoms are very effective for preventing HIV as well as many other STDs. But, unless you know you are  in a monogamous relationship and your partner has been recently screened for HIV or STDs, condoms are still recommended.

 

I have an STD. Do I have to tell my partner if I have sex with a condom? 

Yes. Though condoms are very effective at preventing transmission of HIV and other STDs, they cannot prevent all transmission.  STDs may be passed on through oral sex, vaginal sex and anal sex, as well as just from genital contact.  Particularly infections such as herpes and syphilis may affect parts of the genitals not completely covered by condoms.  You should get treated promptly for any STDs and avoid sexual contact for at least a week after treatment.  You should disclose the information to your partner so they can get tested and treated as well. 

 

I've tested negative for HIV and STDs for the last 3 years. I always ask my partners to use condoms. Do I need to keep getting tested? 

Unless you are in a strictly monogamous relationship, it is always a good idea to get tested before engaging in sexual activity with a new partner.  This is also a good way to open up the dialogue with your partner to make sure he gets tested as well, eg “I got tested and have a clean bill of health, why don’t you show me yours.”
 

I need to use a vaginal lubricant for sex. Can I use with a condom? 

Yes.  But make sure you only use water-based (eg K-Y or Astroglide) or silicone-based (eg Pjur Woman Bodyglide and Uberlube) lubricants.  NEVER use an oil-based lubricant with latex condoms (baby oil, coconut oil, Vaseline etc).  These can weaken the latex and increase the risk of condom breakage.

 

When I was younger, I used spermicide with a condom. Now that I'm post-menopause, do I still need spermicide? 

Spermicides are generally not recommended.  They do not significantly increase the effectiveness of condoms and the can lead to urinary tract infections in women as well as genital irritation.

 

What are some of the symptoms of STDs in a man?

STD symptoms can appear in a variety of ways.  Some symptoms are unique to men, such as a discharge from the penis, and other symptoms are the same for men as they are for women.

The most common STDs are Gonorrhea, Chlamydia, Syphilis, Genital Herpes, and of course HIV.  HPV (Human papilloma virus) is also sexually transmitted and can cause symptoms in some individuals. 

Many of these STDs can be asymptomatic, that is, the person does not know he is infected because there are no symptoms. For people who have sexual activity with multiple partners, or whose partner may have other partners, particularly for MSM (men who have sex with men), screening for some STDs may be appropriate, even if there are no symptoms.

HIV: many people who are infected with HIV don’t have any symptoms at all. Sometimes, however, in early infection, people may have a flu-like or mono-like illness.  Symptoms can include fevers, fatigue, swollen lymph nodes (glands), sores in the mouth, rash, etc.  If these symptoms occur within several weeks after a potential exposure to HIV, e.g. high-risk sexual encounter, needle-sharing, etc, testing for HIV should be strongly considered.  

People who have been infected with HIV for a very long time can have weight loss, fatigue, diarrhea, thrush, etc.  This is an indication for HIV testing as well.  However, recommendations are that everyone from the ages of 13-65 should have at least one test for HIV, regardless of risk factors or symptoms. This is because most people will have no symptoms at all and testing and treating while someone is asymptomatic improves long-term health and decreases transmission to others.

Chlamydia: this bacterial infection is the most common sexually transmitted disease in the US. It may be asymptomatic in a large number of people. 

For men who do have symptoms, the most typical one is a discharge from the penis that can be watery or more mucous like. There can be a lot of discharge or very little, and may only be seen as a stain on one’s undergarments. Often there will be pain with urination. In some cases it can cause epididymitis, which presents with testicular pain and swelling of the epididymis (a duct that attaches to the testes).  Chlamydia can also infect the prostate, causing prostatitis which results in pelvic pain, and pain and difficulty with urination. 

For men who engage in anal receptive intercourse (i.e. are “the bottom” partner) it can also cause proctitis, which is an infection of the rectum. This can present with pain with having a bowel movement, anal discharge and bleeding. 

Gonorrhea: this bacterial infection may also be asymptomatic in a large number of people, especially when it is present in the pharynx (throat) or anus.  For those who do have symptoms, the most typical one is discharge from the penis and pain with urination.  The discharge may be similar to that seen with chlamydia, but in some cases much be thicker and a in a larger amount than that seen with chlamydial infections. Similarly to chlamydia it can cause epididymitis and proctitis as discussed above. Gonorrhea infection of the throat can also lead to pharyngitis, or “sore throat.”

 

 

Syphilis: is a bacterial infection that is easily transmitted through all forms of sexual activity.  Symptoms vary by which stage of the disease a person has. With primary syphilis a person can develop a sore that starts as a small red bump, then turns into a painless ulcer.  These ulcers can appear on the penis or anus, but can also be inside the mouth or throat, or inside the anus. Because the ulcer doesn’t hurt, I can easily be missed. The ulcer will go away on it’s own, even without treatment, but the bacteria does not go away. The infection can then progress to the second stage, called secondary syphilis.  Symptoms can include rash that affects the whole body, including the palms and soles; large white patches particularly in the mouth or on the genitals; fever; headache; body aches; swollen lymph nodes.  It is during the first and second stages that syphilis is most easily transmitted to others.  The third stage can last for many years and is called latent syphilis. There are no symptoms associated with this stage, but the bacteria still remains in the body. Third stage syphilis can lead to neurologic and psychological complications, among others, which is why it is important to get tested and treated early in the course of the infection.

Genital Herpes: is a sexually transmitted infection caused by the herpes simplex virus (either HSV 1 or HSV 2). Symptoms are quite variable. Some individuals will have no symptoms at all.  For many, however, after they are first exposed, they may have multiple lesions in the genital or anal/buttock area.  Lesions typically start out as blisters that then become painful ulcers.  Sometimes tingling, pain or itching may precede the appearance of the lesions.  During the first episode some people will also have flu-like symptoms, swollen lymph nodes, and headache. The virus can also cause proctitis (infection of the rectum or anus), which can lead to rectal pain and pain with bowel movements.  Lesions will eventually go away on their own, but the virus does not go away completely. It remains in the nerves at the base of the spine, where it remains inactive, or latent. Some individuals may never have another outbreak, whereas others may have multiple recurrences. The risk of transmission to partners is highest when there are active lesions, however there may be some shedding of the virus even when there are no symptoms.

HPV (Human Papilloma Virus): There are more than 100 different types of HPV, which can cause a range of different symptoms and diseases. Certain types can cause a variety of warts, only some of which are related to sexual activity.  Warts can appear on the ano-genital region and in most cases are benign.  Some other types can HPV can also lead to penile, head and neck and anal cancer in some individuals.

 

How do you test and treat STDs?

HIV: most HIV testing is done with a blood test. Most of the HIV tests available can pick up HIV infection within about 3 weeks after infection. There are oral tests available as well, and these may be used in some clinics.  These tests aren’t quite as sensitive as the blood tests, so you can sometimes get a “false negative” result, i.e. the person is infected but the comes up as negative.  If there is a high concern for HIV, especially a recent infection, following up an oral test with a blood test is recommended.

Treatment is with a combination of medications (anti-retrovirals).  Many of these medications are now combined into one tablet to simplify treatment.  All patients with HIV should start treatment as soon as possible and will remain on treatment for life.

Chlamydia: testing for men is done on a urine sample or on a swab of the anus, if the man engages in anal receptive intercourse (e.g. is the “bottom” partner).  This testing can be done for screening, i.e. even if the person is not having symptoms, and for testing symptomatic men. Treatment is with antibiotics that are taken by mouth, either one dose of Azithromycin or 7 days of doxycycline. 

Gonorrhea: testing in men can be done on a urine sample or on an anal or throat swab. Treatment is with an injection of an antibiotic (Ceftriaxone) AND one dose of azithromycin taken by mouth. 

Syphilis: testing is with a blood test.  For primary or secondary syphilis, treatment is usually with a shot of Penicillin.  Doxycycline taken by mouth for 2 weeks is an alternative. For latent syphilis is with 3 shots of penicillin, each a week apart, or 4 weeks of doxycycline taken by mouth.  For Late stage or tertiary syphilis, a spinal tap (or lumbar puncture) may be required to make the diagnosis. Treatment is usually with intravenous penicillin for 10-14 days.

Genital Herpes: sometimes the diagnosis can be made clinically, if there are very typical symptoms.  Lesions can also be swabbed and sent for special staining, culture or PCR to confirm the diagnosis. Blood tests can also be done to see which type of herpes they might have been exposed to if they have no lesions that can be swabbed.  There are several antiviral treatments available to decrease the duration of outbreaks. These medications can also be taken long term to prevent frequent recurrences and to decrease risk of transmission to partners.

HPV: Diagnosis of ano-genital warts can usually be made clinically, based on their appearance. If the diagnosis is not certain, then a biopsy can be done (usually performed by a dermatologist).  If there is concern for HPV infection inside the anal canal, a pap smear can be done (similar to the idea of a pap smear done on women) to look for abnormal cells and for HPV types that can be associated with cancer. 

Treatment of warts can be with topical therapies applied to the area, as directed by a doctor. The HPV vaccine is also highly effective in preventing diseases related to HPV infection and is available to high-risk men up to age 26 and to men in general up to age 21.

 

Which doctors do STD testing and treatment?

Any primary care provider can do STD testing and treatment. Infectious disease specialists and providers at specialized STD clinics can also provide testing for and treatment of STDs.

 

 

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