Pill Pushing©

The treatment and prevention of viral STDs - (10/1/2017)

By Dr. Ron Gasbarro

Society at the time
The year was 1963. The Beatles' songs "I Want to Hold Your Hand" and "I Saw Her Standing There" are released in the US, marking the beginning of Beatlemania on an international level. The first push-button telephone is made available to AT&T customers. Harvey Ball invents the ubiquitous smiley face symbol. The Dick Van Dyke Show won an Emmy for best comedy show. 

The Vietnam War, a protracted military conflict (1954-1975) between South Vietnam, supported by United States forces, and Communist North Vietnam, was in full swing. The war resulted in a North Vietnamese victory and unification of Vietnam under Communist rule. 58,226 American soldiers also died in the war or are missing in action. 

Brad Pitt, American actor and film producer, and Whitney Houston, African-American singer and drug addict were born. American poet and 4-time Pulitzer winner Robert Frost (“Stopping by woods on a snowy evening”) died. John F. Kennedy, 35th US president, was assassinated in Dallas, Texas. Lee Harvey Oswald, the assassin of John F. Kennedy, is shot dead by Jack Ruby in Dallas, an event seen on live national television.

And in 1963, the breakthrough understanding of hepatitis came when Dr. Baruch Blumberg discovered an antigen that detected the presence of hepatitis B (HBV) in blood samples, ultimately leading to the development of the hepatitis B vaccine.

The diseases in question
While many sexually transmitted diseases (STDs) are caused by bacteria, such as gonorrhea, chlamydia, and syphilis, the following STDs are caused by viruses.

Hepatitis B virus (HBV)
Herpes simplex virus (HSV)
Human immunodeficiency virus (HIV)
Human papillomavirus virus (HPV)
Molluscum contagiosum virus (MCV)

HBV
Etiology
Hepatitis B is a liver infection caused by the Hepatitis B virus (HBV). Hepatitis B is transmitted when blood, semen, or another body fluid from a person infected with the Hepatitis B virus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or other drug-injection equipment; or from mother to baby at birth. For some people, hepatitis B is an acute, or short-term, illness but for others, it can become a long-term, chronic infection. The risk for chronic infection is related to age at infection: approximately 90% of infected infants become chronically infected, compared with 2%–6% of adults [CDC, 2015a]. Chronic Hepatitis B can lead to serious health issues, like cirrhosis or liver cancer.

Note: Hepatitis A and Hepatitis E are transmitted via the fecal-oral route; Hepatitis C is rarely sexually transmittable, and the route of transmission of Hepatitis D (only if infected with B) is uncertain but may include sexual transmission.

Treatment
The goal of treatment is to reduce the risk of liver disease and prevent the patient from passing the infection to others [Mayo Clinic, 2017]. Treatments include:
Antiviral medications. Several antiviral medications — including lamivudine (Epivir®), adefovir (Hepsera®), telbivudine (Tyzeka®) and entecavir (Baraclude ®) — can help fight the virus and slow its ability to damage the liver. 
Interferon alfa-2b (Intron A®). This synthetic version of a substance produced by the body to fight infection is used mainly for young people with hepatitis B who do not want to undergo long-term treatment or who might want to get pregnant within a few years. 
Liver transplant. If the liver has been severely damaged, a liver transplant may be an option. During a liver transplant, the surgeon removes the damaged liver and replaces it with a healthy liver. Most transplanted livers come from deceased donors, though a small number come from living donors who donate a portion of their liver.

Prevention
Hepatitis B vaccine has been successfully integrated into the childhood vaccination schedule, contributing to a 96% decline in the incidence of acute hepatitis B in children and adolescents [CDC, 2017]. Currently, approximately 95% of new HBV infections occur among adults, and unvaccinated adults with behavioral risk factors or who are household contacts or sex partners of HBV-infected persons remain at risk.

HSV
Etiology
Genital herpes is a chronic, life-long viral infection. Two types of herpes simplex viruses (HSV) can cause genital herpes: HSV-1 and HSV-2. Most cases of recurrent genital herpes are caused by HSV-2, and approximately 50 million persons in the US – more than 1 out of every 6 people aged 14 to 49 years - are infected with this type of genital herpes [CDC, 2015b]. However, an increasing proportion of anogenital herpetic infections have been attributed to HSV-1 infection, which is especially prominent among young women and men who have sex with men (MSM).
Most persons infected with HSV-2 have not had the condition diagnosed. Many such persons have mild or unrecognized infections but shed virus intermittently in the anogenital area. As a result, most genital herpes infections are transmitted by persons unaware that they have the infection or who are asymptomatic when transmission occurs.

Treatment
There are two types of pharmacotherapy for persons infected with HSV whose symptoms are recurrent, if not frequent: suppressive therapy and episodic therapy [CDC, 2015b]. The antiviral drugs typically used are acyclovir, famciclovir, and valacyclovir.  

Suppressive therapy – Suppressive therapy reduces the frequency of genital herpes recurrences by 70%–80% of patients who have frequent recurrences; many persons receiving such therapy report having experienced no symptomatic outbreaks. Treatment also is effective in patients with less frequent recurrences. In suppressive therapy, medication is continuous so as to thwart quality-of-life eroding eruptions. 

Episodic therapy – Effective episodic treatment of recurrent herpes requires initiation of therapy within 1 day of lesion onset or during the prodrome (subcutaneous tingling) that precedes some outbreaks. The patient should be provided with a supply of drug or a prescription for the medication with instructions to initiate treatment immediately when symptoms begin. Depending on the antiviral used, the patient will take the medication anywhere from 2 to 5 days.

Prevention 
No vaccine exists for genital herpes. 

HIV
Etiology
HIV is spread primarily by unprotected sex (including anal and oral sex), contaminated blood transfusions, hypodermic needles, and from mother to child during pregnancy, delivery, or breastfeeding. Some bodily fluids, such as saliva and tears, do not transmit HIV. Methods of prevention include safe sex, needle exchange programs, treating those who are infected, and male circumcision. Disease in a baby can often be prevented by giving both the mother and child antiretroviral medication. 

Treatment
There is currently no cure or effective HIV vaccine. Treatment consists of highly active antiretroviral therapy (HAART) which slows progression of the disease. Current HAART options are combinations (or "cocktails") consisting of at least 3 medications belonging to at least two types, or "classes," of antiretroviral agents [WHO, 2010; WHO, 2013]. Initially, treatment is typically a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside analog reverse transcriptase inhibitors (NRTIs). Typical NRTIs include zidovudine (AZT) or tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC). Combinations of agents which include protease inhibitors (PI) are used if the above regimen loses effectiveness.

Prevention

There is presently no vaccine to prevent an HIV infection. In 1987, the first HIV vaccine clinical trial opened at the National Institutes of Health (NIH) Clinical Center in Bethesda, Maryland. Thirty years later research continues to realize the promise of safe and effective HIV vaccines. HIV research includes studies of both preventive and therapeutic vaccines:
Preventive HIV vaccines are intended to prevent HIV infection in people who are not infected with HIV. A safe and effective preventive HIV vaccine is the key to ending the HIV/AIDS pandemic.
Therapeutic HIV vaccines are designed to treat people who are infected with HIV. A safe and effective therapeutic HIV vaccine could prevent HIV from advancing to AIDS, replace daily use of HIV medicines, and help rid the body of HIV.

Pre-exposure prophylaxis for prevention of HIV
An estimated 50,000 individuals become infected with HIV in the United States annually [CDC, 2014]. A new prevention strategy, Pre-exposure Prophylaxis (PrEP), is intended for high-risk populations to reduce their risk of becoming infected with HIV. PrEP includes daily antiretroviral medication and routine follow-up. When used consistently, PrEP is shown to reduce the risk of HIV infection. If delivered effectively and used in combination with other proven prevention methods, PrEP may play a significant role in helping to address the HIV epidemic in the United States.

HPV
Etiology
Human papillomavirus infection is a common infection by human papillomavirus (HPV) that can lead to cancer. Most HPV infections cause no symptoms and resolve spontaneously [WHO, 2017]. In some people, an HPV infection persists and results in warts or precancerous lesions. The precancerous lesions increase the risk of cancer of the cervix, vulva, vagina, penis, anus, mouth, or throat. Nearly all cervical cancer is due to HPV with two types, HPV16 and HPV18, accounting for 70% of cases. Between 60% and 90% of the other cancers are also linked to HPV. HPV6 and HPV11 are common causes of genital warts and laryngeal papillomatosis, a rare medical disorder of viral etiology where papillomas or wart-like tumors proliferate in the surface lining of the respiratory tract and cause significant airway obstruction and voice disorders. Without treatment, the condition is potentially fatal

Treatment 
No specific treatment for HPV infection currently exists [CDC, 2017]. However, the viral infection typically clears to undetectable levels by itself. According to the CDC, the body's immune system clears HPV naturally within two years for 90% of cases. However, researchers conflict on whether the virus is completely eliminated or reduced to undetectable levels, and it is difficult to know when it is contagious.

Prevention
HPV vaccines are used to prevent HPV infection and therefore cervical cancer. They are recommended for females, 9 to 25 years old, who have not been exposed to HPV. Since the vaccine only covers some high-risk types of HPV, cervical cancer screening is recommended even after vaccination has been shown to also be effective in preventing genital warts in males. In 2009, the FDA licensed one of the vaccines, Gardasil®, for males ages 9–26, to prevent genital warts and anal cancer. If the person is already infected with HPV, the vaccine is not effective. 

MCV
Etiology 
Molluscum contagiosum, also called water warts, is an infection caused by a poxvirus (molluscum contagiosum virus) [CDC, 2015c]. The result of the infection is usually a benign, mild skin disease characterized by lesions (growths) that may appear anywhere on the body. Within 6-12 months, Molluscum contagiosum typically resolves without scarring but may take as long as 4 years.

The lesions, known as Mollusca, are small, raised, and usually white, pink, or flesh-colored with a dimple or pit in the center [CDC, 2015c]. They often have a pearly appearance. They are usually smooth and firm. In most people, the lesions range from about the size of a pinhead to as large as a pencil eraser (2 to 5 millimeters in diameter). They may become itchy, sore, red, and/or swollen. Mollusca may occur anywhere on the body including the face, neck, arms, legs, abdomen, and genital area, alone or in groups. 

Treatment 
Physical removal – Procedures include cryotherapy (freezing the lesion with liquid nitrogen), curettage (the piercing of the core and scraping of caseous or cheesy material), and laser therapy [CDC, 2015c]. 

Oral therapy – Gradual removal of lesions may be achieved by oral therapy. This technique is often desirable for pediatric patients because it is generally less painful and may be performed by parents at home in a less threatening environment. Oral cimetidine (Tagamet®) has been used as an alternative treatment for small children who are either afraid of the pain associated with cryotherapy, curettage, and laser therapy or because the possibility of scarring is to be avoided. While cimetidine is safe, painless, and well tolerated, facial Mollusca do not respond as well as lesions elsewhere on the body.

Topical therapy – Podophyllotoxin cream (0.5%) is reliable as a home therapy for men but is not recommended for pregnant women because of presumed toxicity to the fetus [CDC, 2015c]. Each lesion must be treated individually as the therapeutic effect is localized. Other options for topical therapy include iodine and salicylic acid, potassium hydroxide, tretinoin, cantharidin (a blistering agent usually applied in an office setting), and imiquimod (T cell modifier). These treatments must be prescribed by a healthcare professional.

Prevention 
No vaccine exists for this virus. The best way to avoid getting molluscum is by following good hygiene habits [CDC, 2015c]. Remember that the virus lives only in the skin and once the lesions are gone, the virus is gone and you cannot spread the virus to others. Keep the area with molluscum lesions clean and covered with clothing or a bandage so that others do not touch the lesions and become infected. Keep the affected skin clean and dry.

Ron Gasbarro, PharmD, is a registered pharmacist, medical writer, and principal at Rx-Press.com. Read more at www.rx-press.com

References

Centers for Disease Control and Prevention (CDC). Genital HSV infections; 2015 (b). www.cdc.gov.  

Centers for Disease Control and Prevention (CDC). Hepatitis B – Vaccination of adults; 2017 www.cdc.gov. 

Centers for Disease Control and Prevention (CDC). Molluscum contagiosum; 2015(c). www.cdc.gov.

Centers for Disease Control and Prevention (CDC). Preexposure prophylaxis for the prevention of HIV infection in the United States; 2014. www.cdc.gov. 

Centers for Disease Control and Prevention (CDC). Viral hepatitis. Hepatitis B; 2015 (a). www.cdc.gov. 

Centers for Disease Control and Prevention. Genital HPV infection - Fact sheet; 2017. www.cdc.gov. 

Mayo Clinic. Hepatitis B; 2017. www.mayoclinic.org    

World Health Organization. Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach. 2010; 19–20. 

World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection 2013;28–30. World Health Organization. Human papillomavirus (HPV) and cervical cancer; 2017. www.who.int.   


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