There is a consensus among infectologists that sexually transmitted diseases are on the rise in the young population of Brazil.
“This latest generation, which started having sex after 2010, has a different way of looking at STDs”, says Alexandre Naime Barbosa, professor of Infectious Diseases at Unesp. The notion that AIDS has become a chronic and treatable disease has reduced adherence to condoms, according to him.
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 HIV/AIDS Epidemiological Bulletin released by the Ministry of Health. Among 15- to 19-year-old males, the increase reached 590%, according to the same document.
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 younger than one year 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 subject to compulsory notification. That is, health units are not required to register each diagnosed case. However, according to specialists who work in reference centers, most are on the rise among young people.
To make matters worse, sexually transmitted bacteria such as Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium are becoming resistant to the most common antibiotics, requiring the development of increasingly complex treatment regimens.
The increase in sexually transmitted infections is not exclusive to Brazil, observes infectologist Lucy Cavalcanti Vasconcelos, a member of the board of the Sociedade Paulista de Infectologia. She claims that one cannot blame only the lack of awareness of young people for the phenomenon, but also a generalized 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 means of protection. Vaccines, preventive medications and post-exposure treatments are part, along with condoms, of a more complete anti-STD arsenal.
General methods of prevention
The condom is 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. Infectologist Sidnei Pimentel, from the State of São Paulo STD/AIDS Reference and Training Center, recognizes that the female condom is strange because it is 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.
Whichever condom you choose, the ideal is to use it together with lubricating gel, to reduce friction and the risk of breakage. Both types of condoms are available for free at any SUS health service.
Pimentel remembers 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 oral hygiene conditions are crucial to measure this risk, according to the specialist. “The risk is greater when the person has gingivitis and bleeding sites, which are entry points for infections”, says Pimentel. When the man receives oral sex, the use of a condom is recommended. When the woman receives it, an alternative is to use plastic wrap to cover the genital region.
The condom may not be fully effective against HPV, as areas not covered by the condom – such as the labia of the vagina, the base of the penis or the scrotum – also have the 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 hebiatricians.
HIV can be transmitted through vaginal, anal and oral sex. Infection can still occur by sharing syringes and other sharp objects, such as pliers, or by blood transfusion. A mother can also transmit it to her child during pregnancy, childbirth or breastfeeding.
Since December 2017, SUS has offered HIV Pre-Exposure Prophylaxis (PrEP) free of charge to groups with 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 the SUS in Brazil.
PrEP consists of taking one pill a day of the brand name drug Truvada, which combines two drugs that inhibit HIV replication: tenofovir and emtricitabine. In healthy people who have unprotected sex, the drug stops HIV from spreading throughout the body. “It’s like putting a stone in the HIV gear”, says infectologist Alexandre Naime Barbosa.
Even those who do not fit into the groups covered by the SUS can use the method with a 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 possible exposure to the HIV virus. The regimen, available free of charge through the 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 through vaginal, anal and oral sex, HPV can lead to the formation of warts on the genitals and anus. But the most serious consequences are cancer of the cervix, anus, penis, mouth and throat.
A study carried out by the Hospital Moinhos de Vento, 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 the use of condoms, 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). The vaccine is available free of charge for girls ages 9 to 14 and boys ages 11 to 14, as well as people ages 9 to 26 who are living with HIV. For those who are not part of the target groups, the vaccine is available in private clinics for about R$ 300 a 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 output of a whitish liquid through the urethra or vagina. The affected areas may 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 a treatment with antibiotics that works for the conditions. two diseases. “The risk of waiting for the results is for the patient to continue transmitting to other people and the situation may also become complicated”, says Barbosa.
Recently, the treatment regimen 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 is known to be infected with gonorrhea or chlamydia, preventive use of antibiotics such as Post-Exposure Prophylaxis is also recommended.
Mycoplasma genitalium is a bacteria transmitted through sexual intercourse that causes symptoms similar to gonorrhea and chlamydia. The most common is urethral and vaginal discharge, but the picture 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 treatment is done using antibiotics that can treat different bacteria that lead to these same symptoms.
A recent concern regarding Mycoplasma genitalium is the bacteria’s resistance. So the British Association for Sexual Health and HIV (BASHH) released new treatment guidelines in July to try to prevent it from becoming the latest ‘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 panorama worrying”, says Campos. He adds that, with current globalization, it is easy for resistant bacteria to reach Brazil.
Studies carried out by Campos and his colleagues found an incidence of 28.1% of the bacterium in a sample of women treated at public health services in Bahia. “We consider these data to be an important alert for health managers, given that there are few epidemiological studies carried out in different regions of the country”, says the researcher.
Syphilis can be transmitted through sexual intercourse without a condom and also from mother to baby during pregnancy or childbirth. The best form of prevention is the use of condoms. In the case of pregnant women, it is important to take the test at different times of pregnancy and, if detected, treat the disease as soon as possible to avoid transmission to the child. Treatment consists of administering the antibiotic benzathine penicillin.
The disease can manifest itself in three stages if left untreated. The first signs are small sores on the penis or vagina. They are painless and, for women, it can be difficult to identify them if they appear on the cervix. After a period, these sores disappear spontaneously. This is primary syphilis.
After a while without symptoms, spots appear on the skin that can affect 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 through sexual intercourse, but also through direct contact with the lesions of an infected person. Prevention is through the use of condoms and avoiding contact with the wounds.
These lesions are a group of bubbles that, when ruptured, cause pain. They can appear anywhere on the body, but the most common are the mouth, genitals and anus. Herpes has no cure and symptoms come and go several times throughout a lifetime. But there are treatments capable of alleviating the symptoms.
Hepatitis B and C
Hepatitis B can be transmitted through sex and also through contact with infected blood through sharing syringes, pliers and other sharp materials. In addition to using condoms, prevention is done through the hepatitis B vaccine. The ideal is to receive the vaccine soon after birth. Another three doses are needed at 2, 4 and 6 months of age. Those who have not been vaccinated at this stage can be vaccinated at any age. In this case, the vaccination scheme 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 rarer 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 condom: 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 sexual intercourse, it is possible to prevent HIV infection by taking antiretroviral drugs for 28 days. The start of the scheme should be up to 72 hours after exposure.
HPV vaccine: Available at SUS for girls and boys aged 9 to 14 years and boys aged 11 to 14 years, the quadrivalent vaccine protects against the main subtypes of HPV that cause cervical cancer.
Hepatitis B vaccine: Indicated for newborn babies in a four-dose schedule or for people of any age in a three-dose schedule.
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 potent prevention tools, as they interrupt the chain of transmission.