imageOne of the worst legacies of the late ‘60s/early ‘70s sexual revolution in this country is today’s epidemic of sexually transmitted diseases. And women are bearing the brunt of it.

Over the course of a lifetime, women have an 80 percent chance of contracting the human papillomavirus (HPV, which manifests few, if any, symptoms). If left untreated, certain strains of HPV, which can be treated but not cured, may cause cervical cancer. Women infected with HPV often have higher rates of abnormal Pap smears and, consequently, spend more time in the gynecologist’s office.

Chlamydia and gonorrhea are also on the rise, but thanks to a new family of urine-based tests from Calypte Biomedical Corp., that are performed on the BD ProbeTec ET system, they will be easier to detect. The Sentinel Testing Service, developed by BD and Calypte, offers urine-based tests for chlamydia, gonorrhea and HIV-1 antibody testing. The HIV test is offered alone or in combination with the chlamydia and gonorrhea tests. The service was created to simplify and take the fear out of STD testing. Urine testing eliminates the fear associated with needle-based HIV testing and the invasive urogenital swab collection method for STDs.

This month’s Women’s Health Disease Management story looks at some of the causes and consequences of unchecked STD infection and how the availability of non-invasive urine testing may help stem the tide of infertility and other needless suffering.

— Coleen Curran

The women least likely to contract the sexually transmitted human papillomavirus (HPV) are nuns. In fact, that’s how doctors connected HPV to cervical cancer. Nuns were nearly the only group of women who didn’t get the cancer.

On the other hand, most women have an estimated 80 percent lifetime chance of contracting HPV, certain strains of which may cause cervical cancer if left untreated. Today, STDs have reached epidemic proportions, infecting one in four Americans. The nation’s No. 1 and No. 2 STDs, chlamydia and gonorrhea, if left untreated, can cause infertility, ectopic pregnancies and chronic pelvic pain in women. In addition, an STD infection more than doubles a person’s risk of contracting HIV. Fortunately, most STDs are highly responsive to antibiotics, and cervical cancer, which grows slowly, responds well to surgery, if caught in the early stages. Thus, an early diagnosis is key to reducing the spread of HIV, protecting women’s fertility and preventing cervical cancer.

Much to the medical community’s chagrin, cervical cancer remains the world’s second leading cancer killer of women. It’s even on the rise in the United States (3 percent a year). The disease burden of the AIDS epidemic is shifting from men to women. Females now account for 43 percent of all people living with HIV/AIDS, compared to 1992, when they accounted for just 25 percent of the AIDS population. STDs also rob almost one-third of American women of their fertility and infect an estimated 12 million new victims a year, 3 million of which are teenagers, according to the Centers for Disease Control and Prevention.

Like most diseases, early detection and treatment often can prevent the serious consequences of STDs. On the down side, traditional detection methods such as Pap smears and urethral swabs can be uncomfortable and embarrassing. Further complicating matters, most STDs show no symptoms in the early stages, and then there’s our age-old stigma surrounding STDs because they are associated with sex.

To prevent cervical cancer, “The question is getting women in for pap tests,” said Cornelia Trimble, M.D., assistant professor of gynecology and obstetrics at Johns Hopkins School of Medicine in Baltimore. “The truth is that pap smears are uncomfortable.” In addition, Americans like a quick fix.

Fortunately, the quick fix for part of the STD problem is here. Urine-based testing – easy to collect and pain-free to patients – is now available for HIV and two of the nation’s most common STDs, chlamydia and gonorrhea. The Sentinel Test Service, which provides the bundled urine-test, went on the market last year. Because of its convenience to the patient, “We believe we can get more people tested,” said Vicki Mitteco, product manager for Calypte Biomedical Corp. in Alameda, Calif.

There is no urine test yet for HPV, the leading cause of cervical cancer. However, chlamydia, which also has been linked to cervical cancer in a recent study, can be tested through urine. Previous data on chlamydia’s link to cervical cancer was inconclusive, but recent Scandinavian research suggests that women infected with certain types of chlamydia may be at increased risk for the cancer. If supported by future data, the urine-based chlamydia tests could serve as a screening to prevent cervical cancer as well.

Another reason why women may avoid STD testing is they think they don’t have a problem. Up to 75 percent of women and 50 percent of men have no symptoms of STDs. With no physical problems, most will avoid invasive STD testing. For women, it involves a cervical swab taken at the time of a Pap smear. For men, STD testing is even more uncomfortable. A swab, inserted into the penile opening, is rotated for 15 seconds.

“Screening patients without symptoms can reveal an enormous number of cases previously undetected,” said Jennifer Walsh, worldwide product manager for molecular infectious diseases at Becton Dickinson in Sparks, Md. “It’s far easier, it doesn’t cause pain, and medical staff isn’t required to obtain the sample. It’s more convenient and cost-effective than taking a cervical exam and/or blood sample.” However, urine STD testing shouldn’t replace the annual Pap smear for women, since a urine sample doesn’t assess cervical disease, Trimble adds.

The urine tests are catching on well in the public health arena, where the main goal is to prevent further spread of STDs. Screening and treatment of asymptomatic people with the disease can further enhance educational and treatment efforts at the community level. Several hundred labs throughout the world are using the BD ProbeTec test, which can be performed on urine specimens, Walsh said.

Community-based urine testing identified a high rate of previously unrecognized cases of HIV infection in a Johns Hopkins study done in Baltimore, a city known for its high rates of STDs as well as its Superbowl-

winning Ravens. Between February 1999 and August 2000, a dozen Baltimore community sites participated in a urine-HIV testing study that used the Calypte HIV-1 Urine EIA (confirmation by Western blot). The community coalition, which included Churches United Against AIDS, Deaf AIDS Project and other grass-roots groups, held discreet one- and two-day screening events in churches, shelters and food kitchens. In all, 963 people (aged 13 and older) were tested and asked about risk factors. Johns Hopkins researchers learned that Baltimore communities widely accepted the HIV urine test, which detected new HIV cases in 10 percent of the study’s 963 participants. Of the new cases, 68 percent, previously not in care, are now in medical care.

The cost of untreated STDs far outweighs the cost of prevention. We spend $17 billion a year on treating the havoc of STDs and AIDS, according to the Journal of the American Medical Association. The two leading causes of preventable infertility, chlamydia and gonorrhea, cause about 27 percent of American women’s infertility. Treating the consequences of chlamydia, for example, is estimated to cost 12 times more than the cost of screening and antibiotic treatment. A random trial of chlamydia screening showed a 60 percent reduction of pelvic inflammatory disease (which causes infertility) in the screened group during the 12 months following testing. In addition, STDs are one of the most important preventable causes of adverse outcomes of pregnancy, including low birth weight/ prematurity, congenital infection, stillbirth and postpartum infection, which notoriously hoist labor and delivery costs.

Yet despite STDs cost-effective screening, its commonality among Americans, and its successful treatments, the stigma has been hard for the country to shake off — even for its own good. “If doctors aren’t going to ask, patients should ask to be tested for STDs,” said Becton Dickinson’s Walsh. “She’s protecting her own health and her future reproductive health. But the stigma remains, even for coming clean and saying ‘I’m sexually active.’ ”