There is a consensus among infectologists that sexually transmitted diseases are on the rise in the young population of Brazil.
"This last generation, which started its sexual life after 2010, has a different way of looking at STDs", says Alexandre Naime Barbosa, professor of Infectology at Unesp. The notion that AIDS has become a chronic and treatable disease has caused adherence to condoms to decrease significantly, he said.
In the case of HIV, the number of new annual cases rose by almost 140% between 2007 and 2017 in the general population: from 6,862 to 16,371, according to the most recent Epidemiological Bulletin of HIV / AIDS released by the Ministry of Health. 15 to 19 year old males, the increase reached 590%, according to the same document.
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In the same period, the number of new cases of syphilis increased by 133% among pregnant women, according to data from the Ministry of Health. The increase in congenital syphilis in babies under one year old was 60%.
There are no national data on cases of syphilis in other groups or on other sexually transmitted infections – such as HPV, gonorrhea and chlamydia – because they are not compulsory to report. That is, health facilities are not required to register each diagnosed case. However, according to specialists who work in reference centers, the majority is on the rise among young people.
To make matters worse, sexually transmitted bacteria like Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium are becoming resistant to the most common antibiotics, which requires the development of increasingly complex treatment schemes.
The increase in sexually transmitted infections is not exclusive to Brazil, notes infectologist Lucy Cavalcanti Vasconcelos, a member of the board of the Sociedade Paulista de Infectologia. She affirms that it is not only to blame the lack of awareness of young people for the phenomenon, but also a general failure of prevention plans, which for a long time focused exclusively on condom use.
The good news is that new prevention strategies are being developed and, for some of these diseases, condoms are no longer the only way to protect themselves. Vaccines, preventive drugs and post-exposure treatments are part, along with the condom, of a more complete anti-STD arsenal.
General prevention methods
Condoms are still, according to the World Health Organization, one of the most effective methods to prevent sexually transmitted infections when used correctly and consistently. Although the male condom is by far the most popular, the female condom is just as effective. Infectious disease specialist Sidnei Pimentel, from the STD / AIDS Reference and Training Center in the State of São Paulo, recognizes that female condoms are strange because they are twice the size of the male version. But it is the ideal solution for cases where the partner has difficulty maintaining an erection with a condom.
Whatever the choice of condom, the ideal is to use it together with lubricating gel, to reduce friction and the risk of breakage. Both types of condoms are available free of charge at any SUS health service.
Pimentel recalls that it is important to protect yourself even during oral sex, in which there is a risk of transmission of HPV, hepatitis B and C, chlamydia, gonorrhea and HIV. The conditions of oral hygiene are crucial to measure this risk, according to the expert. "The risk is greater when the person has gingivitis and bleeding sites, which are the gateway to infections," says Pimentel. When the man receives oral sex, the use of condoms is recommended. When the woman receives, an alternative is to use plastic wrap to cover the genital area.
Condoms may not be fully effective against HPV, as areas not covered by condoms – such as the lips of the vagina, the base of the penis or the scrotum – also have potential for transmission when there is friction.
Early diagnosis and treatment are also important prevention strategies. "When you treat a patient, you are breaking the epidemiological chain and may be preventing another 10 infections," says Vasconcelos. According to her, there needs to be a greater effort to actively track sexually transmitted infections, which should involve other specialists such as gynecologists, urologists, geriatricians and hebiatrists.
HIV can be transmitted through vaginal, anal and oral sex. Infection can also occur by sharing syringes and other sharp objects, such as pliers, or by blood transfusion. The mother can also transmit to the child during pregnancy, childbirth or breastfeeding.
Since December 2017, SUS has offered HIV Pre-Exposure Prophylaxis (PrEP) free of charge to groups in which there is a higher prevalence of HIV in the country, such as men who have sex with men, transgender people, men and women sex workers and couples where one person has HIV and the other does not. In all, 36 health services currently offer PrEP through SUS in Brazil.
PrEP consists of taking one tablet a day of the brand-name medicine Truvada, which combines two drugs that inhibit HIV replication: tenofovir and emtricitabine. In healthy people who have unprotected sex, the drug prevents HIV from spreading through the body. "It is like putting a stone in the gear of HIV", says infectologist Alexandre Naime Barbosa.
Even those who do not fit into the groups contemplated by SUS can use the method through medical prescription since May 2017, when Anvisa approved the indication of Truvada for this purpose. In these cases, the purchase of medication at the pharmacy costs about R $ 300 per month.
Another important form of prevention is Post-Exposure Prophylaxis (PEP). The method consists of using antiretroviral drugs for 28 days after a possible exposure to the HIV virus. The scheme, available free of charge by SUS, must start no later than 72 hours after exposure. The use of PEP is indicated for people who have had unprotected sex, suffered sexual violence or had accidents with needles or other sharp objects.
HPV (Human Papillomavirus)
Although there are no national statistics on HPV, it is estimated that this is the most common sexually transmitted infection in the population. Transmitted by vaginal, anal and oral sex, HPV can lead to the formation of warts on the genitalia and anus. But the most serious consequences are cancer of the cervix, anus, penis, mouth and throat.
A study by the Moinhos de Vento Hospital, in Porto Alegre, in partnership with the Ministry of Health, revealed a prevalence of HPV of 53.6% in young people aged 16 to 25 years in Brazil.
In addition to condom use, SUS offers a quadrivalent vaccine that protects against HPV types 6 and 11 (which cause genital warts), and 16 and 18 (which cause cervical cancer) as prevention. The vaccine is available free of charge to girls aged 9 to 14 and boys aged 11 to 14, in addition to people aged 9 to 26 who live with HIV. For those who are not part of the target groups, the vaccine is available in private clinics for around R $ 300 per dose.
Gonorrhea and chlamydia
Gonorrhea and chlamydia are very similar diseases caused by the bacteria Neisseria gonorrhoeae and Chlamydia trachomatis. After HPV, these are the most common sexually transmitted infections in Brazil. According to a study published in 2005 by the Ministry of Health, gonorrhea was detected in 18.5% of a sample of men who sought care at STD clinics in six Brazilian capitals and chlamydia in 13.1%.
They can be transmitted through vaginal, anal and oral sex, so the best form of prevention is the use of condoms. The main symptom is urethral or vaginal discharge, characterized by the discharge of a whitish liquid through the urethra or vagina. The affected areas can also burn when urinating.
As it is very difficult to distinguish one disease from another by clinical criteria, it is recommended to make a syndromic diagnosis – that is, to identify the group of diseases that cause the same symptoms – and to apply antibiotic treatment that works for women. two diseases. "The risk of waiting for the results is that the patient continues to transmit to other people and the condition can also complicate," says Barbosa.
Recently, the treatment plan for gonorrhea and chlamydia had to be updated by the Ministry of Health due to bacterial resistance.
In cases of sexual violence or unprotected sex with a partner who was known to be infected with gonorrhea or chlamydia, the preventive use of antibiotics such as Post-Exposure Prophylaxis is also recommended.
Mycoplasma genitalium is a bacterium transmitted by sexual intercourse that causes symptoms similar to gonorrhea and chlamydia. The most common is urethral and vaginal discharge, but the condition can also include burning when urinating, bleeding, infertility and pregnancy complications. The main form of prevention is the use of condoms.
The epidemiological situation of the disease in the country is still unknown, according to professor at the Federal University of Bahia Guilherme Barreto Campos, mainly because the test to detect the infection is not widely available for routine use in health services. This test is complex and requires a sophisticated technological structure. That is why in Brazil the treatment is done with the use of antibiotics that can treat different bacteria that lead to these same symptoms.
A recent concern regarding Mycoplasma genitalium is the resistance of the bacteria. That is why the British Association for Sexual Health and HIV (BASHH) in July launched new treatment guidelines to try to prevent it from becoming the newest "superbug".
"In Brazil, data on prevalence and resistance are scarce, but there is a worldwide increase in the prevalence of strains resistant to various drugs, which makes the situation somewhat worrying," says Campos. He adds that, with the current globalization, it is easy for resistant bacteria to reach Brazil.
Studies by Campos and his colleagues found an incidence of 28.1% of the bacterium in a sample of women seen at public health services in Bahia. "We consider these data an important alert for health managers, given that there is little epidemiological research carried out in different regions of the country," says the researcher.
Syphilis can be transmitted through sexual intercourse without a condom and also from the mother to the baby during pregnancy or delivery. The best form of prevention is the use of condoms. In the case of pregnant women, it is important to get tested at different times of the pregnancy and, if detected, to treat the disease as soon as possible to avoid transmission to the child. Treatment consists of administration of the benzathine penicillin antibiotic.
The disease can manifest itself in three stages, if it is not treated. The first signs are small sores on the penis or vagina. They are painless and, in the case of women, they can be difficult to identify if they appear in the cervix. After a period, these wounds disappear spontaneously. This is primary syphilis.
After a time without symptoms, spots appear on the skin that can reach the entire body, especially the soles of the feet and the palms of the hands. This is secondary syphilis.
In tertiary syphilis, it can affect the central nervous system, the cardiovascular system and various organs of the body. Syphilis can even kill.
Herpes is a disease caused by a group of viruses that can be transmitted during sexual intercourse, but also by direct contact with the lesions of an infected person. Prevention occurs through the use of condoms and avoiding contact with wounds.
These lesions are a group of blisters that, when ruptured, cause pain. They can appear anywhere on the body, but the most common are the mouth, genitalia and anus. Herpes has no cure and the symptoms appear and disappear several times throughout life. But there are treatments that can alleviate the symptoms.
Hepatitis B and C
Hepatitis B can be transmitted through sex and also through contact with infected blood through the sharing of syringes, pliers and other sharp materials. In addition to the use of condoms, prevention is done through the hepatitis B vaccine. The ideal is to receive the vaccine right after birth. Another three doses are necessary at 2, 4 and 6 months of life. Those who did not get vaccinated at this stage can get vaccinated at any age. In this case, the vaccination schedule consists of three doses with an interval of one month between the first and second and five months between the second and third.
As for hepatitis C, transmission by sex is also possible, but more rare in the case of heterosexual sex. Transmission by blood transfusion and sharing of non-disposable manicure kits is also possible. There is no vaccine for hepatitis C.
Male and female condoms: The condom, both male and female, is one of the most effective ways to protect against sexually transmitted infections.
Pre-Exposure Prophylaxis: Daily use of the drug Truvada reduces the risk of HIV infection, but does not protect against other sexually transmitted infections.
Post-Exposure Prophylaxis: After unprotected sex, it is possible to prevent HIV infection by using antiretroviral drugs for 28 days. The start of the regimen should be within 72 hours of exposure.
HPV vaccine: Available in SUS for girls and boys from 9 to 14 years old and boys from 11 to 14 years old, the quadrivalent vaccine protects against the main HPV subtypes that cause cervical cancer.
Hepatitis B vaccine: Indicated for newborn babies in a four-dose regimen or for people of any age in a three-dose regimen.
Circumcision: According to data from the World Health Organization, male circumcision reduces the risk of HIV infection in heterosexual relationships by 60% and offers some protection against herpes and HPV.
Diagnosis and treatment: Early detection and treatment are also powerful prevention tools, as they interrupt the transmission chain.