Stanley M. Bierman M.D., F.A.C.P.

With the disintegration of Communism, the fall of dictators, and the hoped-for successful fight against terrorism, the early twenty-first century will hopefully see the rise of a new world order and a change in the priorities of American society. Notwithstanding this optimistic view of life, this era will regrettably be tainted by the emergence of a global plague of sexually transmitted diseases that promise to profoundly alter civilization and devastate parts of the planet. This apocalyptic pronouncement is born out by statistics from the World Health Organization assert that there have been 25 million deaths from AIDS since the disease was first described by Michael Gottlieb MD in 1981. In the United States, the Center for Disease Control estimates that of the million plus or so individuals who are infected with the human immunodeficiency virus, 920,566 people have developed AIDS as of 2003 and 524,060 individuals have died of the tragic affliction. There have been a total of 79,984 deaths in California alone, with males constituting 81% cases, females 18% and children 1% of cases. This nation's medical bill for treating patients with this affliction has been estimated well in excess of $15 billion with the economic burden to third world countries only about $3.5 billion. Given the cost of $10,000 to $15,000 yearly outlay for drug treatment for those affluent Americans able to pay and costs to the governmental agencies responsible for the poor, it is difficult and nearly impossible to determine the financial cost to the world to treat and control AIDS.

There are currently 40,000,000 plus individuals in the world infected with HIV including some 1,000,000 children most whom will die within the first year of their birth. Some 16,000 new infections with HIV are acquired each day worldwide and nearly 8,000 die every day of this dread disease. AIDS is cutting a broad swath through Africa where the World Health Organization (WHO) estimates that AIDS has already killed millions of men, women and children and infected million more individuals imperiling an already weak economic system and arresting Third World development. Because it takes ten years for the more fatal aspects of AIDS to appear following HIV infection, a fourth of black Africa's work force will be wiped out within 20 years. AIDS is also emerging in as a malignant psychosocial problem in Asia and Europe.

While Europe ultimately recovered from the lice-borne pandemic of bubonic plague in the Middle Ages, one wonders whether the planet can survive AIDS, a pernicious disease spread by sex, one of humankind's most compelling instincts and insistent drives.

There are dismaying statistics revealing a striking increase in incidence of STDs in America over the past decade or so. Chlamydia, the cause of non-gonococcal urethritis and pelvic inflammatory disease is currently the number one STD with 4,000,000 individuals infected. Genital Herpes Simplex Virus (HSV) is believed to have infected 45,000,000 Americans and 16.4% of the population have HSV-2 antibodies to the virus. In the past decade, there has been a ten-fold increase incidence of Human Papilloma Virus (HPV), the causative agent of genital warts, with prevalence of 12,000,000. As mentioned, Human Immunodeficiency Virus (HIV) has emerged as a major public health concern with in excess of 500,000 deaths due to AIDS and prevalence of between 800,000 and 1.4 million HIV seropositive individuals. There are 1,000,000 cases of pelvic inflammatory disease (PID) yearly with 25% suffering serious long-term sequelae.

While most people are acquainted with the well-publicized risks of AIDS, the average individual seems uninformed, if not completely unaware, of the potential mortal dangers posed by other STDs. While patients no longer die of syphilis, both HSV and HPV are believed responsible for the induction of cervical carcinoma that can be fatal to the afflicted woman. Many young people are ignorant as to the potential of heterosexual transmission of AIDS. Hepatitis B and pelvic inflammatory diseases (PID) are other potentially lethal STDs. Likewise; many people are sorely uninformed regarding the influence of STDs on reproduction. Tubal scarring resulting from PID and gonorrhea may result in infertility. It is notable that sexually active adolescents are ten times as likely to develop PID as women 20 years or older. Against this statistical backdrop, it is distressing to note that 2,500,000 adolescents acquired STDs, and 1/500 college students are HIV positive.

Evidence does favor the fact that there seems to be a rise in sexual conservatism and general decline in incidence of STDs at least in the educated middle class. Fear of HIV has decreased rates of gonorrhea and syphilis in gay males. However, there is an increase in STDs in lower socioeconomic groups which may be the consequence of an earlier age of sexual initiation and greater adolescent sexual activity. There is an increase in casual sex without commitment particularly among economically disadvantaged youths, along with a striking sex-for-drug culture with crack cocaine that acts as a stoker of this pernicious trade. It is clear that an increasing number of young men and women turn to prostitution to support their drug habit, and in so doing they become a reservoir of subclinical STD infections.

While sex education is now taught in grade school, evidence seems to indicate that young people have inconsistent patterns of safe sex practices, and knowledge regarding STDs is not necessarily translated into safe sex. In one study, fully 44% of sexually experienced participants reported that they had not changed their behavior in any way to reduce their risk of acquiring AIDS. It is also clear that oral contraception is still favored over barrier methods.

For the past seven years I have taught a ten week lecture series to undergraduate students at UCLA introducing the subject with the following statement: "There is no grey-matter in an erect penis." There have usually been a few snickers of recognition to the declaration recognizing the obvious difficulty of defusing a strong sexual attraction between two mutually-attracted partners ending in unprotected intercourse. However, in this day of fatal STDs such as AIDS, and with the simple intercession of condoms by either of the parties, we should all pause to reflect on this glib admonition.

I have attempted in this brief essay to cover a broad field of sexually transmitted diseases. More importantly, I hope to have stimulated your interest in STDs and prompted your own thoughtful reflections on this troubling and complex problem.
BIERMAN CENTURY CITY DERMATOLOGY
MEGATRENDS IN SEXUALLY TRANSMITTED DISEASES 2005
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