SEXUAL INFECTIONS

Click on the topic below which you want more information about:

AIDS
HIV
BACTERIAL VAGINOSIS
THRUSH
CHLAMYDIA
GENITAL HERPES
GENITAL WARTS
GONORRHOEA
NON-SPECIFIC URETHRITIS
PELVIC INFLAMMATORY DISEASE
SCABIES
SYPHILIS
TRICHOMONIASIS
VIRAL HEPATITIS

AIDS

AIDS stands for the Acquired Immune Deficiency Syndrome. It is caused by HIV (Human Immunodeficiency Virus), and a person who is HIV positive is said to have AIDS if they develop an "AIDS defining illness".

In the presence of HIV infection there will be a decline in the functioning of a person's cellular and humoral (antibody related) immune system over a period of time. From a practical level the degree of immune system compromise is measured as the "CD4 count"- a measure of the number of a particular type of white blood cell. Patients who are HIV positive also have their "Viral Load" measured and this quantifies the number of virus particles in a millilitre of plasma.

The Centres for Disease Control in the USA has devised a system of classification of the extent of HIV infection based on a person's CD4 count and the presence or absence of HIV related symptoms or the AIDS defining illnesses. In the past few years it has become arguable as to how useful this classification is. This is especially the case now that there are anti-HIV drugs available that boost the immune system (raise the CD4 count) and greatly affect a patient's symptoms and likelihood of developing an AIDS defining illness.

The AIDS related complex (ARC) describes a collection of symptoms such as fever, night sweats, weight loss, oral thrush, shingles and fungal skin infections that are often present in HIV positive patients prior to developing AIDS.

Approximately 75% of HIV positive patients develop AIDS within 9-10 years of becoming HIV positive. The aim in the future is that by more widespread HIV testing and surveillance patients will be able to start on anti-HIV drugs (antiretrovirals) prior to the development of AIDS. Certain HIV positive patients claim to be perfectly fit and healthy many years after the initial acquisition of the virus. This group of people form what is known as the "long-term non-progressors". It is not fully clear what makes some patients with HIV deteriorate more quickly than others.

Most of the AIDS defining illnesses have specific treatments that are applicable to them. Some of these treatments can be modified and used as "prophylaxis". This means prevention and can either be used in a primary or secondary setting. This would depend on whether or not a patient has already experienced a particular AIDS defining illness, or whether they are susceptible to one because of a declining CD4 count.

The commonest AIDS defining illnesses are as follows:

Pneumocystis Carinii Pneumonia (PCP)

This is a very severe and potentially fatal pneumonia, which is characterised by profound hypoxia or low oxygen levels. Although treatable with antibiotics, there are serious complications including pneumothoraces or collapsed lungs and respiratory failure requiring transfer to an Intensive Care Unit for artificial ventilation.

Tuberculosis

TB is caused by the organism Mycobacterium Tuberculosis and is very common in African patients. It can affect the lungs but also several other organs including the gut, brain, kidneys and bone marrow. There are several other mycobacteria in the same family as MTB including mycobacterium avium intracellulare (MAI) and mycobacterium kansasii, which can cause infection both in the lungs and sometimes the bone marrow.

One important aspect of TB infection is that treatment MUST include three if not four antibiotics which must be continued for prolonged periods of at least six to nine months if eradication of the infection is to be successful. Discontinuation of treatment early is a leading cause of antibiotic resistance and this can have disastrous consequences and can lead to untreatable cases of "multi-drug resistant TB".

Cerebral Toxoplasmosis

This infection is characterised by the development of mass lesions in the brain, which can give rise to a wide range of neurological symptoms including fits. It is usually diagnosed by performing a CT scan of the brain. Most patients with HIV who develop severe neurological symptoms such as sudden headaches, fits or visual loss will undergo this investigation.

Cytomegalovirus Retinitis

Cytomegalovirus (CMV) is from the Herpes family of viruses and can cause severe scarring of the retinae or backs of the eyes in HIV positive patients. This can lead to visual loss if untreated. It usually only affects patients with very low CD4 counts. The aim is to try and prevent people from developing this by starting them on antiretroviral drugs before the CD4 count becomes too low. In those who have already suffered an episode of CMV retinitis they must continue taking prophylactic Ganciclovir until their CD4 count rises appreciably. CMV can also affect any section of the gut causing severe ulceration.

Cryptosporidial Diarrhoea

This is a parasitic infection resulting in prolonged diarrhoea that is very difficult to control. Unfortunately, earlier attempts to eradicate the parasite with specific drugs proved futile. The mainstay of treatment for this condition includes the usage of loperamide and codeine to slow down bowel movements and antiretroviral therapy to raise the CD4 count. Patients are often advised to drink only filtered or boiled water if their CD4 counts are very low in order to try and avoid infection with this microorganism.

Cryptococcal Meningitis

This is a fungal meningitis and has the same symptoms as a bacterial meningitis namely severe headaches, fevers, and ultimately drowsiness, fits and coma. It requires a lumbar puncture to remove a sample of spinal fluid in order to be diagnosed and can usually be treated well with antifungal drugs. Although effective it must be remembered that these drugs like all others have side effects and can be unpleasant to take.

Kaposi's Sarcoma

This is a type of malignant tumour or cancer that affects predominantly homosexual men and Africans with HIV. It is thought to be related to a type of Herpes Virus known as human herpes virus 8 but the exact relationship is unclear. It causes lesions or spots and lumps on the skin and in the lungs, gut and lymph nodes. Skin lesions do not necessarily need treatment with radiotherapy unless they are particularly cosmetically disfiguring.

Other tumours such as Non-Hodgkin's Lymphoma and Primary Cerebral Lymphoma are common in HIV infection and classified as AIDS defining illnesses.

All of these conditions tend to improve and the risk of developing them decreases if effective antiretroviral therapy is taken. Please go to our link on the website to read more about this.

From the point of view of preventing the spread of HIV and AIDS there are several key factors. The practice of safer sex is probably the most important factor in the UK . This includes not only using condoms but also a reduction in the number of sexual partners and minimization of sexual practices that are considered particularly dangerous i.e. unprotected anal sex.

Injecting drug users are encouraged to not share equipment and needle exchange schemes are running in most major cities.

Screening of pregnant women and offering antiretroviral drugs at the time of delivery as well as consideration of planned Caesarean section for these women aims to reduce maternal transfer of the virus to offspring.

Vaginal microbicides or "chemical condoms" are currently being extensively researched and these two latter strategies are hoped to be particularly effective at reducing the spread of HIV in Africa . However, an effective microbicide has yet to be developed.

At present there is much research going on into vaccines against HIV. Currently there are in excess of 30 clinical trials of both preventative and therapeutic HIV vaccines which are underway around the world. At the moment, though, any prospect of an effective vaccine seems years away.

HIV

HIV stands for Human Immunodeficiency Virus.

AIDS stands for Acquired Immune Deficiency Syndrome.

HIV is the virus that causes AIDS. A person infected with HIV can look and feel perfectly well for a long time. Once infected with HIV a person is infected for life and can infect others, even if they look and feel well. HIV is a virus that damages the body's defence system rendering it unable to fight off certain infections that it would usually be able to deal with.

If someone has been infected with the HIV virus for a number of years the immune system gets so weak that they get certain serious illnesses. These are known as "AIDS defining illnesses" and when a person who is HIV positive contracts one of these, he or she is said to have AIDS.

How HIV is caught
There are three main ways that HIV is transmitted:

• Having vaginal or anal sex without a condom with someone who is HIV positive.
• A mother with HIV passing the virus onto her baby, either during pregnancy, at birth or by breast-feeding.
• Sharing drug-injecting equipment, such as needles or syringes, that are contaminated with HIV infected blood.

In this country, all equipment used in hospitals, clinics and dental or doctor's surgeries is sterilised and poses no risk for the transmission of HIV.

HIV Transmission and oral sex

Unprotected oral sex with an infected person carries some risk, but this risk is minimal. Infection from oral sex on its own seems to be very rare.

HIV cannot be caught by:

• Touching, kissing or hugging
• Eating food prepared by someone with HIV or sharing crockery or cutlery
• Insect or animal bites
• Sharing a toilet seat with someone with HIV
• Using swimming pools

The Prevalence of HIV

Over 60,000 people are living with HIV in the UK , of whom probably a third are unaware of their diagnosis. Over 7000 people were diagnosed with HIV in 2004 with the majority of new diagnoses occurring in heterosexual men and women who acquired their infection outside of the UK , predominently in Africa . Sex between men accounted for 30% of new infections of HIV overall but accounted for 75% of all new infections which occurred within the UK . There are some parts of the world - such as sub-Saharan Africa , Southern Asia and Eastern Europe - where HIV infection is very much more common. The risk of being infected with HIV is therefore based not just on what you do, but where you do it.

Treatment and HIV/AIDS

There is no cure for HIV or AIDS and no vaccine to prevent a person from becoming infected. There are cures and treatments for the significant number of other infections and diseases that people with HIV are prone to.

There are also combination treatments of anti-HIV drugs that people with HIV benefit from. These drugs are not able to get rid of the virus, but they stop it from reproducing and reduce the amount of virus in the body. This enables the immune system to recover and become better able to defend itself from infections. These combination therapies give patients with HIV major improvements in their health, delay the progression to AIDS and have dramatically reduced the death rates from HIV/AIDS. However this therapy has to be taken regularly, every day for life. The drugs sometimes have unpleasant side-effects and the long term effects of taking these therapies is not yet known. See AIDS page regarding treatment.

Safer Sex

Safer sex is any sex that doesn't allow a person's blood, semen or fluid from the vagina into the other partner's body. Some kinds of sex, such as kissing or masturbation, carry no risk of HIV. For an individual who is seriously and actively considering their sexual health it would make far more sense to consider and practice safer sex, rather than to rely on a prolonged and potentially toxic course of drugs to prevent HIV.

ANAL AND VAGINAL SEX WITHOUT A CONDOM CARRY THE HIGHEST RISK.

Oral sex (where one partner uses their tongue or mouth to stimulate their partner's genitals) carries only a very small risk of infection. You can reduce the risk by avoiding getting any semen in the mouth and being especially careful if you have a sore throat or any cuts, sores or ulcers in you mouth as these can all increase the risk of transmission.

Condoms
Condoms are an effective barrier against HIV. It is important to remember that HIV is not the only infection caught through unprotected sex and that condoms protect against other sexually transmitted infections and prevent unplanned pregnancies.

There are numerous types of condoms in different shapes, sizes, thicknesses, colours and flavours. Some condoms have added spermicide and others come already lubricated. If using extra lubrication during sex it is important to only use water-based lubricants with condoms. Oil based lubricants, such as massage oil, baby oil, or vaseline can very quickly destroy the latex that condoms are made from and cause them to break. Strong condoms and plenty of water-based lubricant are needed for anal sex. For condoms to be effective, it is important to use them properly, so always check the pack for instructions.
The riskiest time for catching any sexually transmitted infection (including HIV) is at the time of changing partners, at the beginning of a sexual relationship or with casual partners or one-night-stands. These are the times it is most important to use condoms.

Injecting Drug Use

Most HIV infection in this country is sexually transmitted. Sharing equipment for injecting drugs is also a potential risk. If you inject drugs, always use your own equipment. Needle exchange schemes provide free supplies of sterile equipment and condoms, and can also safely dispose of used equipment. Sharing needles etc., is also a risk for transmission of other blood borne viruses such as Hepatitis B and Hepatitis C.

For more information contact:

• National Drugs Helpline: 0800 77 66 00.
• Terence Higgins Trust: 020 7242 1010

The HIV Test

The standard HIV test is a blood test. It detects the antibodies to HIV. Antibodies are what our immune system produces to fight infection. The test does not look for the virus itself, but the antibodies against the virus, which is the body's response to the infection. It is not possible to have the antibodies without having the HIV virus.

It takes people a variable amount of time to develop these antibodies. In fact, it can take up to 3 months. This is called the 3 month 'window period' or 'incubation period'. It is therefore possible that an HIV test may not become positive until 3 months after someone has become infected. You will always be advised that if there is a specific incident that you are concerned about in terms of being at risk for HIV transmission, an HIV test needs to be performed 3 months after this incident.

The 'Early' HIV Proviral Test

Another way to test for HIV other then looking for antibodies is to look for the genetic material (the DNA) of the HIV virus itself in a blood sample. This allows for much earlier detection of the HIV virus than is possible using the standard test. One such test is known as the HIV Proviral DNA test. This may detect the presence of the HIV virus as early as 10-14 days following infection with a sensitivity of greater then 98%. Due to its complexity, it usually takes up to five days for the result to become available. If you undergo an early HIV test you are likely to be advised by your doctor that you should still have the standard test after 3 months for 100% accuracy.

What the test involves

When you attend for a test, you will see a doctor or a specialist nurse in private. He or she will take details of your medical and sexual history and discuss with you what the test involves and what the result means. The test will only be performed when you have given consent for it to be done.
A small sample of blood is taken and tested in our laboratory in the clinic. The results for the standard HIV test are available within 15 minutes and have a sensitivity of 99.9-100%. A negative result means that you do not have HIV. However, because of the 3 month window period, described above, you may be advised by staff in the clinic to have a repeat test at some point. The same procedure is followed for the early HIV Proviral test, with a result being available within 5 days.

Confidentiality
The clinic has strict rules of confidentiality. Your notes are stored securely and no information regarding your visit is disclosed to anyone without your consent.
For more information, or if you have any specific questions you would like to ask, please do not hesitate to phone us.

Alternatively you could contact the National AIDS Helpline on 0800 567 123.

BACTERIAL VAGINOSIS

Vaginal discharge in women can be a perfectly normal "physiological" occurrence or caused by infections. Not all infections are sexually transmitted. If you are unsure it is important to have a check-up.

Bacterial Vaginosis is a very common vaginal infection. It is caused by an overgrowth of bacteria that normally exist in the vagina. It cannot be passed to a man.

Signs and Symptoms

There may be none. However, there may be a change in your vaginal discharge - it may increase, become thin and watery, change colour and/or develop a strong fishy smell

How Bacterial Vaginosis develops

It occurs when the acidity of the vagina changes. This can be caused by

• Semen entering vagina during unprotected sex
• Douching and washing out the vagina
• Using too much soap/bubble bath/vaginal deodorants

Tests for Bacterial Vaginosis

This involves a genital examination by a doctor. Swabs are taken from the vagina and the acidity can be measured using pH paper. The test is not normally painful.

Diagnosis and Treatment

The diagnosis is made by looking at a specimen of discharge under the microscope in our laboratory. The result is usually available immediately.

Treatment is easy - antibiotic tablets or a cream to put inside the vagina will be prescribed from our pharmacy. The tablets are called "Metronidazole" (trade name Flagyl) and the cream is called "Clindamycin" (trade name Dalacin).

If it is possible that you are pregnant it is important to tell the doctor. Bacterial Vaginosis is a possible cause of miscarriage

It is important to finish the course of treatment

It is possible to have a sexually transmitted infection in addition to Bacterial Vaginosis - this why it is important to have an examination and full range of tests

The evidence linking bacterial vaginosis with early miscarriage is limited, nevertheless common sense dictates that treatment of "BV" under these circumstances is advisable. It is important to note that the standard course of treatment: Metronidazole antibiotics at a dose of 400mg twice daily has not been shown to be harmful to unborn babies. As always, anyone taking Metronidazole must not consume alcohol until 48 hours after the treatment is finished.

THRUSH

Vaginal discharge in women can be a normal "physiological" occurrence or caused by infections. Not all infections are sexually transmitted. If you are unsure it is important to have a check-up.

Candida Albicans (Thrush)

This is caused by a yeast that normally lives harmlessly on the skin, or in the mouth, gut and vagina without causing any problems. Normally it is kept in check by harmless bacteria, but occasionally conditions change and the yeast increases rapidly, causing symptoms known as Clinical Thrush or Candidiasis.

Signs and Symptoms

Thrush can occur in men and women. It is more likely to occur in uncircumcised men.

Women:

• Itching, soreness, redness around vagina, vulva, anus
• Thick white vaginal discharge
• Pain on sex or passing urine

Men:

• Irritation, burning, itching under foreskin or tip of penis
• Redness or red patches under foreskin or tip of penis
• Thick discharge under foreskin
• Difficulty in retracting the foreskin
• Discomfort on passing urine

How Thrush develops

It can develop due to:

• Pregnancy
• Antibiotic use
• Sex with someone who has a Thrush infection
• Excess use of vaginal soaps/bubble baths etc
• Diabetics and people who are immunosuppressed

Tests for Thrush

This involves a genital examination by the doctor. Swabs are taken from whichever place may be infected

Diagnosis and Treatment

Samples taken are looked at under the microscope - the result may be available immediately. A second sample may be tested in our laboratory for confirmation
Treatment is easy - women may be given pessaries (long tablets) to insert into the vagina, using an applicator and also a cream. The cream is applied externally to the genital area. The active drug in the pessaries and cream is " Clotrimazole" (trade name Canesten). Often the cream will also include some "Hydrocortisone" (a mild steroid). Occasionally pills called "Fluconazole" are given instead.

Follow-up

If symptoms do not resolve it is advisable to return for a check-up. Complications are rare.
Individual advice about having sex can be obtained on your visit.

CHLAMYDIA

This the most common treatable bacterial sexually transmitted infection. In 2005 there were nearly 100 000 new diagnoses in the UK . Chlamydia can cause serious problems later in life if it is not treated (see Complications). Chlamydia infects the cervix or entrance to the womb in women. The urethra, rectum and eyes can be infected in both sexes. Occasionally Chlamydia lives in other parts of the body, including the throat, lungs and liver.

Signs and Symptoms

Women:

The majority have no symptoms. Where symptoms occur these are likely to include:

• Slight increase in vaginal discharge
• Need to pass urine more often/pain on passing urine
• Lower abdominal pain
• Pain during sex
• Irregular menstrual bleeding
• Painful swelling/irritation in eyes (if infected)

Men:

Men are more likely to notice symptoms than women but may also have no symptoms. Where symptoms occur these are likely to include:

• Penile discharge
• Pain or burning when passing urine
• Painful swelling/irritation in eyes (if infected)
• Rectal Chlamydia rarely causes symptoms

How Chlamydia is passed on

Having sex with someone who is infected
Symptoms will usually appear between seven to fourteen days after the infection is acquired. If symptoms are absent it is sensible to wait for fourteen days after a particular exposure before having tests for Chlamydia

A mother to her baby at birth
Occasionally transfer of infection from genitals to eyes.

Tests for Chlamydia
This involves a genital examination by a doctor. Swabs are taken from which ever place may be infected. Women may be given an internal pelvic examination.

Diagnosis and Treatment
Samples are tested using a modern and highly sensitive nucleaic acid amplification test (NAAT) . The result is available 24 hours later.

The treatment is simple and effective once diagnosed - antibiotic tablets will be given. These are called either "Doxycycline" or "Azithromycin". It is important to finish any course of treatment. It is important to abstain form sex until you have finished treatment. Your recent sexual partners should also recieve treatment, regardless of whether they have symptoms.

Follow-up
A check to ensure the infection has gone is not usually required as long as both you and your sexual partner have taken your treatment and you are symptom free. However if you do wish to have a “test of cure” you need to allow at least 4 weeks to elapse after treatment - our tests are very sensitive and if you re-test too soon may pick up 'dead' chlamydia.

Complications

Women
If untreated, Chlamydia can lead to pelvic inflammatory disease. See our page on PID. This is an inflammation of the fallopian tubes (the tubes along which an egg passes to get to the uterus or womb). Pelvic inflammatory disease can lead to problems with fertility. Many cases of infertility can be traced back to infection with Chlamydia

If a woman has Chlamydia when she is pregnant she risks having a premature birth or an ectopic pregnancy which is a pregnancy that remains in the tube. The infection can be passed to the baby, giving it an eye or lung infection. Chlamydia can be safely treated during pregnancy Chlamydia can also lead to chronic or long term pelvic pain

Men
Complications are uncommon. However it may lead to painful inflammation of the testicles

Men and women
Reiter's Syndrome can occur – this causes inflammation of the eyes and joints and sometimes a rash on the soles of the feet and genitals. Treatment is with anti-inflammatory tablets such as Ibuprofen.

GENITAL HERPES

There are two types of virus both from the herpes virus family that cause genital herpes infection: Herpes Simplex 1 (HSV1) and Herpes Simplex 2 (HSV2).

Whilst HSV1 is usually associated with cold sores around the mouth and HSV 2 with genital ulcers, in practice each virus can cause both types of symptom. If a patient is already infected with HSV1 then it is likely that this will modify the severity of a subsequent infection with HSV2 thereby making the symptoms less severe.

There is often tremendous anxiety surrounding a diagnosis of Herpes. This is due not only to the painful nature of the lesions but also the fact that once acquired the virus remains in the body permanently. There is also a large amount of myth and stigma surrounding this infection.

An episode of ulceration can be thought of as primary (the first ever) or recurrent. Primary episodes are often the most painful and the severity of episodes often decreases greatly with recurrences.

In between episodes the virus lives in the body's nerve cells and periodically will cause either episodes of ulceration or asymptomatic viral shedding. This latter phenomenon is the release of the virus rendering it infective to a sexual partner without any symptoms at the time. It is impossible to predict when viral shedding or ulceration will occur and recognising clear precipitants is not often feasible. Some people associate periods of stress with development of Herpes ulcers however, this is largely anecdotal.

The symptoms of genital Herpes include painful blistering and ulceration or broken skin anywhere on the genitals: penis, scrotal skin, urethra, vulva, vagina and cervix. It is also possible to have ulcers on the skin of the thighs, pubic area and buttocks and also in the anus and rectum. Anal ulcers do not imply that a person has necessarily had anal sex. It is possible to pass Herpes infection on through oral sex if an infected partner has cold sores around the mouth. There are also general symptoms of fever, muscle aches and generalised pains in the groin and pelvis that can accompany attacks. The worst constitutional symptoms are often felt with a primary attack.

If the virus is to be isolated by taking a swab, it must be remembered that the test will only come out positive if there is fresh blister fluid (pus) on the swab and as such, a negative swab does not imply an absence of infection. This scenario often occurs when a swab is taken during the recovery phase of an attack and the skin has started to heal.

There is a also blood test available to show the presence of Herpes antibodies. In practice, this test is limited in that all it can do is tell you that if positive, you have been infected with the Herpes virus at some time in the past. It does not tell you when, by whom or whether you will experience any symptoms in future.

Treating Herpes attacks is relatively simple. The fundamental points are to keep the area clean and dry and avoid sex until the skin is fully healed. By doing this, the risk of transmission to a partner is minimized but not eradicated. If you think logically, the majority of sexual transmission will occur when someone is feeling well and has no ulcers.

Pain relief is vital and this can be achieved by using simple analgesics like Paracetamol and Ibuprofen, bathing in salt water and if necessary using local anaesthetic creams on the genitals. The body's immune system will gradually help the ulcers to heal given time and the main purpose of treatment is symptomatic relief.

In some cases drugs are prescribed for Herpes attacks. In general these are only effective if started in the first 24 hours and are reserved for very painful attacks. For example for those where there are severe constitutional symptoms and complications such as urinary retention. This is where severe pain caused by ulcers in the urethra prevents a patient from urinating and so causes a dangerous and painful build up of pressure in the bladder.

Occasionally an attack is so severe that a patient requires hospitalisation and needs drugs to be given by injection and a catheter inserted to help them pass urine. Fortunately, this is rare.

The drugs used to treat Herpes include Aciclovir and the related compounds: Famciclovir and Valaciclovir. In general these drugs are not effective if given as creams and most clinicians will only precribe them as tablets.

People who get regular recurrences of Herpes ulcers can take these medications as prophylaxis (prevention) against attacks. When taken daily, they can suppress the virus and can be very effective at minimizing or preventing further attacks and reducing the risk of passing on the infection. The drugs are taken in a different dosage to treatment and treatment is usually continued for 6 months to a year.

An important area to consider is the management of Herpes infection in pregnancy. Opinion is still divided as to what is best. However, most experts agree that a first episode in the third trimester of pregnancy is more serious than a recurrence. The main concern is the passage of HSV to the infant during delivery with subsequent development of a potentially serious eye infection in the child. As such, Obstetricians will consider giving Aciclovir to a woman with a primary Herpes attack in the third trimester of pregnancy and also performing a planned caesarean section.

On a practical level, it is worth remembering three important facts about genital Herpes. Firstly, infections are sometimes acquired a long time prior to the first recognised appearance of symptoms. As such, the development of Herpes ulcers may imply but not necessarily prove infection from a recent/current sexual partner. Secondly, treatment is simple and essentially aimed at keeping the patient free of pain whilst the immune system heals the skin. Finally, for particularly severe or frequently recurring attacks effective drug treatments are available.

GENITAL WARTS

These are small fleshy growths which may appear anywhere on a man or woman's genital areas. In 2004 more then 80 000 cases of genital warts were diagnosed in the UK making it the second most commonly diagnosed sexually transmitted infection in Britain , after Chlamydia. Genital Warts are caused by infection with the Human Papilloma Virus (HPV). It is estimated that there are more than 80 different types of Human Papilloma Virus - some cause genital warts, others cause warts on other parts of the body, for example, the hands

Signs and Symptoms

Following infection with wart virus it usually takes between 1 and 3 months for warts to appear, although some cases take longer, possibly up to one year. A proportion of people who come into contact with the virus do not develop warts. This is known as a "Sub-clinical infection".

Warts can appear around the vulva, in the vagina, the penis, the scrotum or the anus. They can be single or in groups. They may itch, but are usually painless. There may be no symptoms or, where there are, they may be difficult to see.

In women, warts can develop on the cervix and this may occasionally cause slight bleeding or an unusual discharge.

How Genital Warts are passed on

Warts are spread through skin-to-skin contact. Genital warts usually develop following sex or genital contact with someone who has them. They can be passed on during vaginal or anal sex. It is possible for warts to spread to the area around the anus without having had anal sex.

Tests for Genital Warts

This involves a genital examination by a doctor. The diagnosis is often made just by looking at the area, while sometimes a solution may be applied to see if any warts change colour. An internal examination of the vagina will be necessary
An internal examination of the anus may be necessary

Diagnosis and Treatment

A common treatment is freezing the warts. This is known as Cryotherapy.

Another common treatment is a brown liquid called Podophyllin which is painted onto the wart(s) and must be washed off 4 hours later or sooner if the area is irritated. A similar treatment exists for use at home. More than one kind of treatment is often necessary before the warts are gone. These treatments may be uncomfortable but they should not be painful. Advice on sex should be sought from the clinic doctor/health advisor/nurse. Never try to treat genital warts by yourself without seeking medical advice.

If you are pregnant or trying to conceive, it is important to inform the doctor, as Podophyllin treatment could be harmful to the developing baby and an alternative treatment can be used

Follow-up

All patients with genital warts should have tests for the other common sexually transmitted infections and possibly also an HIV test depending on the patient’s sexual history. Sexual partner(s) should have a check-up.

It is important to return regularly for treatment until the warts have gone so that progress can be checked and any necessary changes in treatment can be instituted.

Treatment can take a long time. Some people whose warts initially disappear will suffer a recurrence although it is impossible to predict if or when this will happen.

Warts and the Cervix

Some types of wart virus may be linked to changes in cervical cells that can lead to cancer – please see the page on cervical cytology. It is important for all sexually active women over 20 years of age to have regular cervical smear tests

There is no direct link between the types of wart virus causing visible genital warts and cancer of the cervix

If a problem is suspected a Colposcopy is done to look at cells on the cervix - this is a kind of small telescope used to give a magnified view of the cervix. Samples ("biopsies") may be taken at this time

If there are genital warts on the cervix, vaginal or intra-anally, specialist treatment may be required. Removal is often by freezing or by laser treatment under local anaesthetic.

GONORRHOEA

This is a bacterial infection. It is sexually transmitted and can infect the cervix, urethra, rectum, anus, throat and eyes

Signs and Symptoms

It is possible to be infected and have no symptoms. Men are far more likely to notice symptoms than women

Women
There may be a change in your vaginal discharge - it may increase, change in colour and/or develop a strong smell.

You may also experience:

• pain or burning when passing urine.
• irritation and/or discharge from the anus
• bleeding after having sex.
• pelvic Pain

Men

You may experience:

• Burning sensation when passing urine, (dysuria)
• Penile discharge
• Irritation and/or discharge from the anus
• Inflammation of the testes and prostate gland causing pain

How Gonorrhoea is passed on

It is passed on by penetrative sex and less often by rimming (using mouth/tongue to stimulate another person's anus).

Symptoms usually appear between two to five days after acquiring the infection. If you are worried about Gonorrhoea but do not have any symptoms it is sensible to wait for fourteen days after a particular exposure to be tested

Tests for Gonorrhoea

This involves a genital examination by a doctor. Swabs are taken from whichever place that may be infected. A sample of urine may be taken. Women may be given an internal pelvic examination

Diagnosis and Treatment

Samples taken during the examination are looked at under a microscope in our laboratory to check for infection - the result may be available immediately with confirmation in 24 hours. Treatment is easy but essential - antibiotics called cephalosporins are given as a single dose either by mouth or by injection. A second antibiotic, either Doxycycline or Azithromycin, is also taken in addition. It is important to finish any course of treatment

Follow-up

A check-up is sometimes recommended at leaat 10 days after treatment to ensure the infection has gone. You should not have penetrative sex until you have returned to the clinic and been given the all-clear. Your sexual partner(s) should also receive treatment

Complications

Women
If left untreated gonorrhoea can lead to pelvic inflammatory disease (see section on PID). This can cause fever, lower abdominal pain, backache and pain on having sex. (See section on chlamydia)

The infection can be passed onto a baby if you're pregnant. If a baby is born by vaginal delivery to a woman with untreated gonorrhoea there is a risk of a gonococcal conjunctivitis in the child - a severe eye infection requiring intense antibiotic treatment.

Men
Gonorrohoea can cause inflammation of the testicles and the prostate gland, which causes pain. Without treatment a narrowing of the urethra or abscesses can develop.

NON-SPECIFIC URETHRITIS

Non-specific or non-gonococcal urethritis (NSU or NGU) as it is sometimes known is the commonest acute bacterial sexually transmitted infection seen in UK Genito-Urinary Medicine clinics. It only occurs in men.

It is caused by several bacteria including Chlamydia, Ureaplasma and Mycoplasma. It can also be caused by viruses such as the adenovirus and Herpes virus, parasites ( Trichomonas) and even allergic reactions to soaps etc although this latter cause is rare. By definition it is not caused by Gonorrhoea and cannot occur in women, although when the bacteria causing NSU are transmitted to women they can cause a variety of symptoms including Pelvic Inflammatory Disease.

It is passed on through unprotected vaginal, oral or anal sex although it can also be transmitted when a condom splits or tears during use. If you are worried about acquiring NSU but have no symptoms it is best to wait for 7-10 days after a particular exposure before being tested.

The symptoms include a burning sensation when passing urine and urethral discharge. 50% of men are asymptomatic or have no symptoms.

At the clinic, NSU is diagnosed by taking a urethral swab and examining it under the microscope. This is usually a quick procedure. It is important for a man to NOT pass urine for three to four hours prior to having such a swab taken. This is because every time a man urinates, the urine washes any bacteria present out of the end of the penis. The bacteria need a certain amount of time to re-accumulate so that they can be detected by a swab.

If NSU is diagnosed then the treatment is a simple course of antibiotics, usually Doxycycline. There are other alternatives such as Azithromycin. It is easy to eradicate (cure) this infection however, it is vital for the sexual partner(s) of a man with NSU to be treated and for the man himself and his partner(s) to abstain from sex during the treatment period otherwise there is a high risk of the infection persisting.

A follow-up visit for a test is not usually recommended unless you have persistent symptoms at the end of treatment. In that case, a repeat swab is taken and if this shows persisting NSU then re-treatment with a different class of antobiotics is likely to be prescribed.. It is worth noting that the majority of men who complete their initial antibiotics AND abstain from sex are able to completely clear the infection.

If the infection persists or is left untreated then several complications may arise. These include epididymo-orchitis (infection of the testicles and spermatic cords), acute prostatitis (infection of the prostate), subfertility and occasionally Reiter's Syndrome (an immunological phenomenon with conjunctivitis and joint pains). The likelihood of all of these can be greatly reduced by prompt treatment of any infections.

After NSU has been successfully treated it is possible for it to recur. This is either by re-infection from a sexual partner or as a recurrence triggered by a number of factors including drinking excessive alcohol. Often, men seem to have "recurrent NSU" and in these cases it is likely that the inflammation seen under the microscope does not necessarily represent new infections. Treatment of the sexual partners of men with NSU needs to be considered on a case-by-case basis as drug treatment will sometimes but not always be necessary.

The most important aspects of prevention of NSU are limiting the number of sexual partners you have and using condoms for sex. It is worth bearing in mind that condoms limit but do nor eradicate risk since they can split or tear especially if not used properly. Infections can be easily passed on if genital secretions come into contact with a partner prior to penetration i.e. through mutual masturbation.

PELVIC INFLAMMATORY DISEASE

Pelvic Inflammatory Disease (PID) refers to a spectrum of diseases that arise from sexually transmitted and other infections ascending upwards from the cervix. This can include infections of the endometrium and parametrium (womb), Fallopian tubes (salpingitis), ovaries and even the pelvic lining itself (pelvic peritonitis).

The infections that cause it include Gonorrhoea, Chlamydia, Trichomoniasis and "anaerobic" bacteria as well as those causing Non Specific Urethritis (NSU) in men.

The symptoms a woman can have with PID vary greatly and can include pelvic pain, dyspareunia (pain during intercourse), vaginal discharge, abnormal vaginal bleeding, fevers and lethargy. There are many other conditions that cause a similar and overlapping spectrum of symptoms and the most important ones are appendicitis, ectopic pregnancy, endometriosis and complications of ovarian cysts.

Of the above, ectopic pregnancy is perhaps the most dangerous as it can be fatal if a foetus that is developing outside the womb ruptures and bleeds. For this reason, women with severe pelvic pain usually have a pregnancy test performed when seeing a doctor in order to exclude ectopic pregnancies.

It can be quite difficult to diagnose PID and the only definitive way of doing this is by performing a laparoscopy which is a keyhole surgery investigation to examine the pelvis. For obvious reasons this is not possible or practical for the large number of women who see doctors with pelvic pain. Ultrasound scans of the pelvis are informative but not always 100% accurate, as they can miss cases of PID where the level of inflammation is mild. In addition to this the severity of symptoms can be totally unrelated to the degree of inflammation present in the pelvis.

In practice, most doctors diagnose PID after taking a careful history from the patient and performing a physical examination. The most important aspect of the examination is the "bimanual" or "internal" examination. If it is very painful when the doctor touches the cervix (cervical excitation) this is often interpreted as a sign of infection above the cervix. This is used by many physicians as the deciding factor as to whether to treat a woman for infection or not.

The management of a woman with PID starts with the taking of a number of tests for sexually transmitted infections (STIs). If these are positive that lends support to a diagnosis of PID. However, it must be remembered that even if these tests are negative, this does not mean that PID is not present. This is because the swabs can only reach as far inside as the cervix and cannot detect infection higher up i.e. in the womb or Fallopian tubes.

The woman will need to start a course of antibiotic tablets that usually continue for two weeks. There are several approved combinations of antibiotics and the choice of a regimen depends on local guidelines, allergies and whether or not the woman is pregnant. In severe cases of PID the patient may be hospitalised and need to receive intravenous antibiotics (injections). Antibiotic regimens are typically "broad spectrum" that is to say they cover a wide range of potential infections including the anaerobic bacteria. These include the drugs Doxycycline, Ofloxacin and Metronidazole.

It is essential that the sexual partner(s) of a woman with PID are checked and treated for STIs. Both partners must abstain from sex whilst treatment continues and until a woman has either improved clinically or infection has been ruled out. If a sexual partner is untreated or the couple continue having sex then there is a high risk of the infection persisting.

If a woman with PID has an intra-uterine contraceptive device (coil) fitted then some doctors will remove this when the diagnosis of PID is made. It is believed that it would be hard to eradicate infection with the presence of a coil, however opinions and practices about this vary.

Once treatment has been started it is important for a woman to be seen again within three to four days and also at the end of the treatment period. At the first review visit, if the diagnosis is correct and the antibiotics are being taken then the woman can expect to feel a lot better. If she is not feeling better, then alternative diagnoses need to be considered and explored. At the final follow-up visit a doctor will check if the patient and her partner have successfully completed their antibiotics as well as reviewing the final results of the initial STI tests.

Some of the complications of PID are chronic pelvic pain, menstrual irregularities, a risk of ectopic pregnancy and even infertility. For this reason most doctors have a low threshold for treating suspected PID when a woman presents to them with pelvic pain. Compliance with treatment and follow-up is essential to evaluate whether or not the PID has been adequately treated and to arrange other tests should the initial diagnosis prove to be wrong. It is also worth bearing in mind that if an initial diagnosis of PID is subsequently proven wrong, a woman will sustain very little harm from a short course of antibiotics provided that allergies etc are taken into account.

A question that patients often have is "how will PID affect fertility?" It is thought that approximately 10% of women will have "tubal occlusion" (blocked tubes) after one episode of PID. The proportion rises with the number of episodes of PID and the longer an infection is left untreated, the more harm it could potentially be causing. However, it must be remembered that fertility is a complicated subject and there are numerous causes for it that are unrelated to STIs. Hence, although prompt treatment of STIs is always recommended this will not guarantee fertility in future years.

SCABIES

Scabies is caused by the mite Sarcoptes Scabiei. These mites travel very slowly on the skin and in keeping with pubic lice, they can have a long incubation period of up to six weeks. They are often transferred from person to person by close physical contact but can also cause outbreaks in non-sexual circumstances i.e. in schools and nursing homes.

The typical symptom of scabies infestation is an intense itch, which some people say is unbearable. This can be worse at night. The female of the species burrows into the skin and lays eggs as well as defecating. The burrows are usually visible to the naked eye and are silvery red in colour. The mite excrement causes a "hypersensitivity reaction" in the skin, which is responsible for the characteristic itch.

It is worth noting that the location of the burrows on the skin bears no location to where exactly the infestation was acquired.

The treatment of scabies is very similar to that for pubic lice. Malathion lotion is again applied. Once again, bed linen and towels must be washed at a high temperature and close physical contacts must also be treated. If the itch persists after treatment, which is a common occurrence, the best treatment is with an antihistamine tablet, rather than re-application of the Malathion which can result in further skin irritation.

SYPHILIS

Previously uncommon, the number of new diagnoses of Syphilis has increased by more than 1500% in the UK since 1998. There have been a number of epidemics of Syphilis reported in various areas of the UK ( Bristol , Manchester , Brighton , East London ) in recent years. The groups particularly at risk of Syphilis are gay men, those infected with HIV and men and women from Africa , Eastern Europe and the former Soviet Republics and sex workers. Due to international travel, the sexual partners of any of the above groups are also at increased risk of Syphilis. It is a bacterial infection. It is usually sexually transmitted, but may also be passed from an infected mother to her unborn child

Signs and Symptoms

The signs and symptoms are the same in both men and women and are detailed in the following Primary, Secondary and Latent Stage sections. They can be difficult to recognise and may take up to 90 days to show following a sexual contact.

Syphilis has a number of stages - the primary and secondary stages are the most infectious

Primary Stage

A painless sore known as a "chancre", occasionally more than one, can appear on the vulva or cervix in women, penis in men or around the anus and mouth in both men and women. This stage often goes unnoticed. The sore(s) is very infectious and can take up to 6 weeks to disappear

Secondary Stage

The Secondary Stage follows the appearance of the chancre if this goes untreated - usually 3 to 6 weeks later. There are many symptoms which include generalised rash; flat, wart -like growths in the genital regions; feeling unwell ('flu-like symptoms), swollen glands; white patches on the tongue or mouth; and patchy hair loss. This stage is also very infectious

Latent Stage

This refers to the presence of untreated Syphilis. Often there are no symptoms or signs and Syphilis is diagnosed by a blood test. If left untreated, tertiary or late Syphilis can develop although this is usually at least 10 years later. Tertiary Syphilis can affect the heart and nervous system. In the heart, the tissue found in the aortic valve and the wall of the large artery leaving the heart (the aorta) can be weakened by the effects of syphilitic infection. This is turn leads to a leaky valve "aortic regurgitation", which if untreated leads to heart failure. In the brain and nervous system tertiary syphilis causes a type of dementia "generalised paralysis of the insane" (GPI) and damage to nerves in the legs "tabes dorsalis".

How Syphilis is passed on

It is passed on by:

• Having sex with someone who has Syphilis
• By a mother to her unborn baby

Tests for Syphilis

Testing is done by:

• A blood sample being taken
• Swabs are taken from any sores
• A full examination including the genital area will be undertaken by the doctor

Diagnosis and Treatment

Blood samples are tested in our laboratory and results are available in forty-eight hours. In special circumstances some test results may be available in 24 hours. If the test result is positive further tests will be required.

If swabs were taken they will be examined under a microscope.

Treatment involves antibiotics - usually in the form of injections over 2 - 3 weeks, or tablets. The injections are either "Benzathine" or "Procaine Penicillin" and the tablets include "Doxycycline", "Azithromycin" and "Erythromycin". The exact choice of antibiotic depends on the stage of syphilis, the presence or absence of cardiac and neurological complications, the HIV status of the patient and any known allergies. As such, patients with Syphilis are recommended to have an HIV test.

Follow-up

Sexual intercourse should be avoided if early infectious syphilis is suspected. Sexual partner(s) should be screened and if necessary treated. Once syphilis has been successfully treated, it will not come back unless you become re-infected. However, some components of the blood tests usually remain positive in future tests unless the infection is caught very early

Pregnancy and Syphilis

In the UK all pregnant women are screened for syphilis when they visit an ante-natal clinic. If syphilis is diagnosed, treatment can be given safely during pregnancy with minimal risk to the unborn baby. If a woman has untreated syphilis she may pass the infection on to the baby before birth; this can lead to miscarriage, stillbirth or birth deformities in some cases

TRICHOMONIASIS

Trichomoniasis is caused by a tiny parasite which produces an infection in the vagina in women and in the urethra in men. In women this is known as Trichomanas Vaginalis and in men this is called Trichomonas Homonis.
It is usually sexually transmitted

Signs and Symptoms

Women

There may be none, however there may be:

• a change in the vaginal discharge - it may increase, become thinner or frothy, change colour and/or develop a musty/fishy smell
• Soreness, inflammation and itching in and around the vagina
• Pain when passing urine
• Pain when having sex

Men
There may be none, However there may be:

• Penile discharge
• Pain or burning when passing urine

How Trichomoniasis is passed on

Having penetrative sex with someone who has the infection
Sharing moist towels, Jacuzzis or hot baths where the parasite can live, but this is rare

Tests for Trichomoniasis

This involves an examination of the genitals by a doctor. Swabs are taken from the vagina or urethra. A sample of urine may be taken. These tests should not be painful

Diagnosis and Treatment

Specimens taken during the examination are looked at under a microscope in our laboratory to check for infection. The result is available immediately. Sometimes Trichomoniasis will be discovered during a routine cervical smear test.

Treatment is easy - antibiotic tablets called Metronidazole will be given. It is important to finish any course of treatment

Follow-up

A check-up should be performed after completing the treatment to ensure that the infection has gone.

You should not have penetrative sex until you have returned to the clinic and been given the all-clear.

Because it is possible to have Trichomoniasis and show no symptoms your partner may be carrying the infection without knowing it.

It is important if you have Trichomoniasis that your partner is treated as well

Complications

These are rare. If a woman is infected when she gives birth to a baby the child may become infected with conjunctivitis (eye infection)

VIRAL HEPATITIS

Hepatitis means inflammation of the liver. It has many causes including alcohol and drugs/toxins. However, the commonest cause worldwide is viral infection.
There are several viruses responsible for causing Hepatitis and the most common ones, covered here are named A,B,C, D and E. There are other viruses such as Epstein-Barr virus and Cytomegalovirus that are sometimes implicated in Hepatitis but these viruses only usually affect very young babies.

Hepatitis A

Hepatitis A (HAV) is passed on both through the faecal-oral (food) route and also sexually. It is more common in certain parts of the world for example the Mediterranean , Africa and Asia and factors favouring its transmission include poor food hygiene and eating certain undercooked foods like shellfish.

There have been documented outbreaks of Hepatitis A amongst gay men and the sexual risk factor here is believed to be digital-anal and/or oral-anal contact (rimming).

The incubation period for this virus is 4-6 weeks. This is the length of time from acquisition of the virus until a person would display symptoms.

HAV can cause an acute short-term illness, which can be identical to other causes of hepatitis. Typical symptoms would include severe malaise, jaundice, fevers, nausea and vomiting. It is possible for a person to have an asymptomatic infection i.e. to acquire viral hepatitis without experiencing any symptoms at all. However, this is probably more common with Hepatitis B and C than with HAV.

The mainstay of treatment for HAV is supportive. This means ensuring that a person is well hydrated and nourished and also has other symptoms such as fever and headache controlled. It is important, as with all other cases of hepatitis, to avoid alcohol and certain drugs that are "hepatotoxic" that is to say potentially damaging to the liver.

In the United Kingdom HAV is a notifiable disease. This means that the doctor diagnosing it is obliged to inform a local communicable diseases specialist who in turn will liaise with a patient and their family and colleagues to ensure that the spread of the infection is limited as far as possible. Usually all that is required for this is good hygiene practices at work and home. Sometimes though, close household and sexual contacts of the infected person are offered Immunoglobulin. This injection contains antibodies to HAV as well as other infections. It is thought to be effective at preventing HAV infection or reducing its severity if given within two weeks of exposure to an infectious person.

In some cases a person infected with any viral Hepatitis can develop "fulminant" Hepatitis. This complication leads to liver failure and is potentially fatal. The majority of people infected with HAV do however recover from the infection and clear the virus from the body. They are said to have lifelong natural immunity and cannot become infected with HAV again. There is no carrier state with HAV.
A vaccine is available against HAV and if a second dose is given between 6-12 months after the first dose, then the recipient will have immunity for approximately ten years. The other obvious method of prevention of this infection is scrupulous food and personal hygiene at all times whether at home or abroad.

Hepatitis B

Hepatitis B (HBV) is transmitted in three main ways: sexually, from mother to infant and by exposure to infected blood/ blood products through contaminated needles or medical/dental equipment. This is very similar to the way that HIV can be transmitted.

The population groups most at risk in the United Kingdom include homosexual and bisexual men, commercial sex workers, injecting drug users (IDUs) and their sexual partners and healthcare workers who are exposed to blood and other bodily fluids.

Worldwide HBV is endemic in large areas of Africa and South-East Asia and in these areas the commonest route of transmission is from mother to child. Any sexual contact of a person from one of these areas whether at home or abroad is also at risk of developing the infection.
The incubation period for Hepatitis B is up to 12 weeks.

The acute illness can be identical to HAV but a major difference between the two infections is that when infected with HBV there is a 5-10% risk of becoming a "carrier". Carriers are patients who continue to have ongoing viral replication in the body and never clear the virus. Although they may feel well for many years they are at risk of developing cirrhosis or chronic liver disease in the long run. This in turn puts them at risk from either liver failure or liver cancer (Hepatocellular Carcinoma) both of which can be fatal.
If a person in an "at risk" group attends a sexual health clinic it is possible to check blood tests to determine whether or not they have been exposed to HBV and if so, whether they are carriers. Carriers for HBV need to be referred on to liver specialists for assessment and consideration of treatment.
Treatments for HBV include drugs such as Interferon that work on the immune system. Recently, other drugs such as Lamivudine and Famciclovir have been investigated for this purpose. For HBV carriers co-infected with HIV they may be more infectious; however, the inflammatory activity in the liver may actually be reduced, as their immune system will be impaired.

People who have been infected with HBV but are not carriers are said to have lifelong natural immunity and need no follow-up with regard to this illness. People who have never been exposed to HBV and are in high-risk groups are offered a course of vaccines to prevent the infection.

A total of three doses of vaccine are given, the first being immediately, the second one month later and the third six months later. In order to maximise compliance, some clinics offer the third dose at two months with a booster at twelve months but this is not thought to be as effective as giving it at month 6. Eight weeks after the final dose a blood test must be taken to assess whether the person has developed sufficient antibodies to be judged "immune". If not, a booster dose can be given. Reasons for not developing sufficient immunity after vaccination include receiving the doses at the wrong times and immune-compromise such as HIV infection. Some people however, are naturally "poor responders" and they need a repeat course of vaccine often at double strength.

Five years after vaccination for HBV a person can either have a blood test to determine whether they still have sufficient immunity or alternatively proceed straight to receiving a booster dose of vaccine. Hepatitis A and B vaccines are different and offer no protection for the other virus. There is no available vaccine for any other cause of viral Hepatitis.

Hepatitis C

Hepatitis C (HCV) was previously known as non-A, non-B Hepatitis or Transfusion-associated Hepatitis. The virus itself was identified in 1989 and tests for it became available about two years later.

In common with HBV it is passed on through sharing needles with an infected person or through infected blood products. Patients with chronic renal (kidney) failure who undergo dialysis are also at risk of HCV.
Unlike HBV the transmission of HCV through sex or from mother to child is uncommon. Generally speaking it is only the long-term sexual partners of people infected with HCV who have unprotected sex who are at risk. It is thought that co-infection with HIV increases the risk of passing HCV on to a child.
HCV is endemic in North Africa , the Middle East and Eastern Europe and acquisition of the virus from sex with a person from one these areas is possible but not as likely as sexual acquisition of HBV.
The incubation period for HCV can be as long as six months.

By contrast with HBV a greater proportion of people infected with HCV go on to become carriers-the figure may be as great as 60%. These people have the same risk of developing chronic liver disease and its complications as HBV carriers.

At present there is no vaccine and no cure for HCV. If a person suspects that he or she is at risk of having acquired HCV then a blood test taken after the necessary incubation period can confirm or deny this diagnosis.

For people at high risk, for example injecting dug users, the most effective means of prevention is by refusing to share needles used for injecting.

For people who are HCV positive, referral to a liver specialist is essential. The specialist will be able to determine the extent and nature of liver damage and decide on the need for specific antiviral treatments. Often patients will need to undergo a liver biopsy before any treatment decisions can be made. This involves taking a sample of liver tissue and examining it under the microscope.
The specialist will also suggest testing for other causes of viral hepatitis and HIV and offer vaccination against HAV and HBV if appropriate.

The same general advice regarding avoidance of alcohol and certain drugs applies to people with HCV. Specific antiviral treatments for HCV include Interferon, given for longer periods than for HBV and Ribavirin. HIV co-infection may make liver disease progress more quickly in HCV infection.

Hepatitis D

The "delta" virus causes Hepatitis D. It can only be transmitted if HBV is present either as an acute HBV infection or more commonly in a state of chronic HBV carriage. It is transmitted commonly between injecting drug users and is rare in homosexual men. It can cause worsening of chronic liver disease if acquired as a "superinfection" in an HBV carrier.

Hepatitis E

Hepatitis E is transmitted by the faecal-oral route as in HAV but it is found predominantly in the tropics.
The incubation period is up to 6 weeks and in common with HAV there is no recognised carrier state after the initial infection has been cleared. It causes waterborne epidemics in South-East Asia and Africa and has a particularly high mortality or death rate when infection occurs in pregnancy. The mainstay of prevention and treatment again are scrupulous hygiene and supportive care respectively.

At the Regents Park Clinic we are able to offer blood tests for HAV, HBV and HCV. We can also immunize against Hepatitis A and B. We do not offer long-term follow-up for carriers of HBV or HCV and we would refer such patients to an NHS hospital in order to see a liver specialist.