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Caitlin Whyte: According to the CDC, one in five Americans has an STD. But there is still so much stigma and shame attached to these illnesses. To tell us more about STDs, STIs, and how to protect yourself is Dr. Edwin Hayes, an infectious diseases physician with Prisma Health.

This is Flourish, a podcast brought to you by Prisma Health. Well, doctor, I'm so thrilled to be having this important conversation with you. To kick us off, tell us what is the difference between an STD and an STI?

Dr. Edwin Hayes: You know, we get that question a lot. I think that, you know, there's a little bit of nuance in the language for why people prefer one term or the other. But really, if you look at a lot of the guidance that's put out and where we kind of go with this information, it's a lot of the same thing. So an STI is a sexually transmitted infection. An STD is a sexually transmitted disease. Some people are a little hesitant about the connotations of a word like disease. I feel infection maybe is a little less stigmatized. If you look on websites for like the CDC or the Mayo Clinic, you'll often see the terms interchangeably used, but both of these terms essentially mean an infection, an organism that passes from one person to another through sexual contact. And that can be oral sex, anal sex, genital-involved sex with penis in the vagina.

Caitlin Whyte: So what are some of the most common STDs that you see then?

Dr. Edwin Hayes: So I would say the most common STDs that we see in the clinic are the same ones that we're seeing across the country. HPV is extremely prevalent. Statistically speaking, probably over 80% of people in the United States are going to have at least one strain of HPV infection in their lifetime. And then HPV, of course, being the virus that's associated with cervical cancer and genital warts, as well as rectal and oral cancers. So it's an extremely prevalent disease.

Gonorrhea and chlamydia, also very, very common, and we see that quite regularly in our clinic; treatable, but you need to test for it to be able to treat it. Syphilis has been on the rise significantly. Unfortunately, in South Carolina especially, we've seen an increase in congenital syphilis with pregnant women passing syphilis to their babies, which is completely unnecessary. That is something that should be completely avoidable in this day and age, but syphilis has been an ongoing and rising issue in the area.

Herpes would also be a very common STD that we see spread person to person. Herpes type 1 that people can get, that's just a cold sore that passes between family members with kissing or sharing drinks or herpes type 2, which is generally more of what's found on the genitals, but there is some interchangeability between those two viruses and where those source can appear between the mouth and the genitals. But that can also be found quite prevalently in the general population.

And then another one that we see in our clinic quite commonly, although it tends to be less common than those other STDs in the overall population is HIV, which is a very treatable disease, but it needs to be found to be treated like many of these STDs and can be very subtle for a long portion of the patient's life, where they could be contagious, not even know that they have the virus. So we end up treating a lot of HIV in our office to give people kind of longer and healthier lives.

Those would probably be some of the really big STDs that we regularly see and treat. Trichomoniasis, bacterial vaginosis are some of the others that are pretty common that we see folks dealing with in the community as well.

Caitlin Whyte: So, how would I know if I have an STD, are there symptoms or signs I can keep in mind?

Dr. Edwin Hayes: Great question. And a lot of people can get hung up on what it means to have an STD or not, and kind of the clues. These STDs that I've mentioned so far are extremely varied in how they present themselves. And some of them are going to have more kind of obvious signs than others. Some of the classic findings for an STD that we think about are things like discharge from the urethra, so from where someone urinates. If they're having pain with urination, they're having pain in that location, if they're having discharge or drainage from that area, that could be a sign of an STD.

Some STDs like syphilis or HIV when they're first contracted may present as a more diffuse finding of a rash on the body that transiently stays and leaves, sores on the genitals or on the mouth or the rectum, wherever someone has been having sex, engaging in sex, potentially could be a sign of an STD as well.

It's important to bear in mind that the symptoms of STDs like discharge, discomfort and sores may show up more clearly in the area where the person has been having sex. So if someone is only engaging in oral sex, they can still contract gonorrhea, but the symptoms of the gonorrhea may not show up in their genitals or their rectum. Those symptoms may be confined to their throat until the disease progresses over time if not treated appropriately. So depending on where you're having sex on your body helps to kind of clue in as to whether or not you're dealing with an STD. And definitely, ongoing pain, discomfort and lesions could be signs of that.

Some of the more subtle, long-term infectious diseases like HIV and HPV may show no symptoms for years before they start to get people in a lot of trouble. HPV, some of the strains of HPV, can sit inside of a person's body for years before they start to have signs of cancer growth. And those cancer growth signs particularly in a woman can be hard to see because they're happening on the cervix inside of the vagina, which means it's so important for sexually active individuals with a vagina to have their cervix checked, particularly their cervix. If hey have a cervix, have their cervix checked, because it could be a very long time that they're going with an infection of HPV, as well as having issues with growth and even cancer before they would have any symptoms or signs that something is wrong. And that's why it's so important for folks who have a cervix to get it checked with a Pap smear usually at least once every two years.

HIV also can be a very subtle disease process for many years before it progresses into AIDS. That virus can sit in the body, working away at the immune system for years with no signs that someone has an active infection, although that person, you know, has the potential to be contagious, spread disease and overtime can become very, very ill. And for that reason, especially with the prevalence of these issues in the United States, it's recommended that all individuals, all individuals who are coming into a doctor's office gets at least one screening test of HIV, regardless of kind of the shared history of their sexual experiences or exposures, because it can be such a subtle and insidious disease process.

So it really varies depending on the STDs. But I'd say those are some of the clues for what we do see with STDs. And just to remember that there are many STDs where there may be no symptoms and it's important to regularly touch base with your doctor to make sure you're getting screened for some of those more subtle infectious diseases.

Caitlin Whyte: Well, that leads me into my next question, talking about screenings, because like you've mentioned knowing your status is so, so important. So what does a screening involve?

Dr. Edwin Hayes: Yes. So screenings for STDs are essentially a test that we can do in the office. And this office can be at Prisma Health in the Infectious Diseases Office. This can be in your primary care's office. This can be done at the health department. I believe right now you can contact DHEC and get set up to have a large STD screening for no more than $10, potentially less, depending on your income.

These screening tests are testing individuals who usually are not showing symptoms, but potentially could have a risk of having contracted an STD at some point. So these are tests for anyone who potentially meets criteria to get tested and see if they have an STD. Those screening tests are often blood tests. So for things like HIV and syphilis, these are blood tests that are drawn and sent to a lab and usually have results back within a day to two days. There are rapid tests or swabs that can be done for HIV that can return in 20 minutes. Those can be swabs of the mouth sometimes, or they can be quick blood prick tests. They can be followed up by a more involved blood test, depending on the results.

Other STDs, such as gonorrhea and chlamydia, which are extremely prevalent in the community right now are tests that are taken from the site of where someone is having sex. So if someone is having oral sex, then it would be a swab of the back of their throat that could test for gonorrhea and chlamydia. If they're having anal receptive sex, then it would be a swab of their rectum and their anus, which would be sent for gonorrhea and chlamydia testing. And if they're having sex involving their genitals in the front, it's usually a test of their urine, again, testing for gonorrhea and chlamydia.

These tests do not necessarily work for all of those spots. You could test the urine in one individual and have it look perfectly clean and normal, and they could still have chlamydia or gonorrhea in their throat that's missed if you do not get a swab of the throat specifically. So it really does matter where the test is done to help get a better sensitivity for some of these STDs, particularly gonorrhea and chlamydia is where we see this.

Those swabs of the throat and the rectum, depending on the comfort level of the individual, can be done by the patient themselves with a little bit of tutelage and guidance, or they can be done by the practitioner. So the practitioner can help guide them through the process, but it depends on the comfort of the individual. There are different ways to kind of access that test depending on what's comfortable for folks. And it's usually a quick swab at the back of the throat or the rectum. One useful reason to have a provider actually do a swab of the rectum is to also look at the anus because if someone is having anal receptive sex, as I said, HPV could potentially cause cancer around the anus and the rectum. Having someone who can actually look in that region to make sure there are no growths can pick up things much quicker than someone just waiting for a sensation of something happening there. It can be very subtle.

Similarly, doing Pap smears as I said before, and having someone actually visualize the cervix and swab it and test it for signs of early cancer can catch problems with HPV much sooner than just waiting for symptoms to appear. So depending on the STD and depending on the kinds of sex people are having is going to depend on which screening tests are right for them. And their primary care physician, their infectious diseases physician, their OB-GYN can help walk through that process to make sure they're getting the right testing that they're needing. But a lot of it is meant to be very focused on what's accessible and comfortable for the patient. A lot of it tends to be blood tests, urine tests, and potentially swabs from either in the vagina, the rectum or the throat.

Caitlin Whyte: I know we've talked about a lot of different scenarios and the fact that some STDs can be just hard to see the symptoms of. So what populations are at a higher risk when it comes to STDs?

Dr. Edwin Hayes: That's an excellent question. The populations that are at a higher risk typically that we see are going to be varied for many reasons. And it's going to depend a little bit on which STDs we see. We do see that receptive sex, so having an open reproductive system like you see on folks who have a vagina can lead to a little bit more of a retention of fluids and the potential to develop an STD than penetrative sex on the side of the individual who's penetrating them. So receptive sex into the vagina, receptive sex into the anus, into the rectum could have a higher risk of contracting an STI or STD than the individual who's doing the penetrating in that region. So that's important to know, and there tends to be a little bit more aggressive measures to do regular screening tests for folks who have a vagina and folks who are having anal receptive sex, often men who have sex with men.

So proportionally, when we look at where we're seeing STD rates be higher than the general population, it's going to be men who have sex with men. We see much higher rates of syphilis, HIV, these other STDs. Transgender individuals, particularly transgender women, we tend to see dramatically higher rates of these STDs, which is part of why it's so important to get them in touch with care early and get them tested and get them treated as quickly as possible because of the proportionately higher risk. We see proportionately high risk in people of color where there's more syphilis and HIV compared to the general population. There's disparities of care there, and sometimes lack of access to care that perpetuates some of these issues a little bit more.

And you also see some high risk populations who are kind of navigating our system and those who are incarcerated. So you do see some higher issues with HIV, syphilis amongst those who have been in prison and folks who engage in transactional sex work. So individuals who are having sex for pay potentially for a roof over their head tend to have higher rates of HIV, syphilis and these STDs. And for that reason, it's so important to try and touch base with people who are at these higher risks and make sure that they're getting the screening tests that they need to kind of halt the cycle of these STDs in the community.

Caitlin Whyte: Focusing on specific populations, STDs are on the rise now among seniors. Can you tell us why that is?

Dr. Edwin Hayes: Yeah. So that's a very interesting thing that we've seen and I'll tell you, you know, these nursing homes are not sterile places. Elderly individuals are sexually active and we're seeing them engaging in more of that part of their lives than ever before. And part of that's because they have better functionality to have sex than ever before. And that's coupled a little bit with the fact that they may have less education about sexual health than younger folks do today as they're passing through school and talking to their parents. So they may have less of an understanding of the risks associated with different STDs or whether or not it's really something that's going to be as much of an issue for them at that point in their lives. These might be folks who don't see as much of a justification for something like condoms, because they're not worried about getting pregnant. They don't seem to have the ability to do that anymore. But at the same time, they could still be passing STDs from one to the other and kind of perpetuating these issues.

And I think some of it too is that we're seeing older populations for some of these more chronic diseases. So HPV and HIV, as I said, are diseases that can be dormant inside of people for many years. So they may not show up until they reach an older age. And even if they do have these diseases and they've kind of manifested and they've been found, they may be well treated with medications that allow them to live to a senior living age. So you'll see a shift in some of these STDs into the elderly. I think it's multifactorial, but I think that's some of the contributing factors for that. And that's something that's just a very important reason why it's important to educate seniors as well and to screen them as well and make sure everyone is screened for STDs. Talk to them about their sexual encounters and risks.

Caitlin Whyte: That is so interesting. There's so many intersections that play into that rise among seniors. Now on that note, is there anything more dangerous about getting an STD when you're older, as opposed to when you're younger?

Dr. Edwin Hayes: So there may be less of a capacity to handle the illness associated with an STD. Some STDs may be a little bit more of an issue when you're younger. Chlamydia, for instance, could, if not caught at a reasonable time, make it impossible for someone to get pregnant. So fertility issues from STDs are a real concern. For someone who's a senior citizen, that may be less of a concern. But they may not have the same capacity to deal with some of the systemic effects of these diseases. They may have gonorrhea that spreads from their genitals into their knee or into their eye, that they are not able to come back from as easily as someone who's younger. Really any extra trip to the hospital for an elderly individual is just a recipe for disaster. And doing anything to keep them out of that scenario is a good thing.

Protecting them from getting STDs in the first place is probably the best thing that you can do for these folks. And some of that's going to be testing the community to kind of stop the spread of these STDs. And some of it's going to be walking through the ways that you can personally protect yourself from getting these infections.

Caitlin Whyte: Great. Well, doctor, we've covered so much information here today. As we wrap up one more question, how can you prevent STDs and STIs?

Dr. Edwin Hayes: Yeah. So this is so fundamentally important. Just like anything in medicine, we talk about an ounce of prevention is worth a pound of cure. STDs are that in spades. Prevent the STD, way simpler than trying to like turn around and treat what's already out in the community, especially because these things can cycle back. And someone who has an STD may get cured, but they may get infected all over again if you're not treating the other folks that they're interacting with in their community.

Now, probably, the classic thing that we all hear in terms of STDs, STS and preventing them is condoms, barrier methods. If people wear condoms during sex, it decreases the chance of them transmitting STDs. This is known, it's not a guarantee. There's still possible with skin to skin contact for instance, if a condom is not completely covering the areas that are connecting, that someone could transmit something like herpes or HPV. It's still possible. If people are not wearing condoms during oral sex, but they are wearing them during genital-involved sex, they could still be transmitting STDs to each other through that oral sex, even though they're using those condoms for genital-involved sex, rectal-involved sex. So condoms decrease the risk, but using them consistently is going to do the best work of making sure there is as little risk as possible. There's no guarantees, but there are better practices that can be done. So consistency with condoms is certainly valuable.

Barrier methods include dental dams as well. So other than typical condoms that are often placed upon the penis, you can actually tear a condom into a square, or you can buy squares that are made from similar materials to condoms to be placed over the vulva or the vagina for oral sex interactions and rubbing for any involvement of the vagina. These barrier methods all do the same thing. They prevent very directly the transmission of those fluids and everything that's in those fluids from one person to another.

That's probably the most fundamental thing that people think about when they think about preventing STDs. But I'll tell you that it is a much, much broader field. There's so much more that people can do to help prevent STDs. Fundamental things include communication, so talking to your partners, asking them about their sexual histories, their sexual risk, and talking to them about getting tested, especially if you're transitioning from one partner to another, to kind of get a new baseline of whether or not you're dealing with any STIs currently that could be passed from one person to another. As I said, there are many places to get tested and cost should not be a prohibitive issue to do that. The health department can be done potentially for free, depending on your income. So testing and communication is so important on top of condoms and dental dams.

And depending on the particular STD that you're protecting against, there's medications that can be useful to keep people safe. So HIV, for instance, can be protected against by taking pills called PrEP. If people take PrEP, which is usually a once a day pill, two medications inside of one pill, taking that every day in conjunction with condoms greatly, precipitously reduces the chances of transmitting HIV from one person to another. So taking medications and decrease HIV, one pill a day. People who have HIV, if they've been proven to have HIV, if they take medicine to treat the HIV and decrease the viral load in their body, suppress the HIV with this medicine so that it can no longer be found on machines, which is very common, which is the case for most of the patients in my clinic, they no longer have the ability to transmit HIV sexually to their partners. So if you can find someone who has HIV, put them on therapy, once they get treated, you're not only protecting them from AIDS and allowing them to live a long, healthy, functional life, but you're also protecting their future sexual partners from obtaining HIV from them. The medications we have these days are that good.

I think HPV is another important one to mention in terms of protection that can be done from STDs through medications. HPV, again, at least 85% of people are going to get some strain of HPV infection in their lifetime. HPV being the virus that precipitates cancer in the cervix, the rectum and throat. That can be for anyone, really. Anyone. Although what we traditionally think of is doing Pap smears for people who have a cervix to see if they have cancer there from HPV, but all individuals can be infected by HPV infection in their lifetime. It's it's something that can affect all of us.

And it's been a big enough field that they were able to precipitate a vaccination for this. Now, routine vaccination is typically going to be around like 12, maybe 11 years old, so it's going to be for kids. There is a catch-up vaccination potentially that could be done between like your teens and your early 20s but really you could get an HPV vaccination up to age 45. It really depends on risk benefits. But for someone who potentially is kind of coming into their own sexually or having more partners later in life, there still may be a place for them to get an HPV vaccine, which would have the potential to protect them from cancer potentially. Protect them from not just discomfort when they urinate or sore in their mouth, but literally protect them from something that could kill them. So I think vaccination against HPV has come a very long way and it's something that many more people need to consider than they are currently considering.

So those I would say are some of the more direct ways that people can protect themselves from STIs STDs, prevent them from spreading. There are other factors that supplements as well. So people who have poor oral hygiene may have more breakdown on the mucosal barriers that allow them to contract an STD. STDs, we get STDs, so if someone's got an STD, it makes it a little bit easier for other STDs to kind of spread. One more reason it's important to get tested for STDs and to treat them when you find them, because getting those under control protect from other STDs.

And of course, things get a lot more complicated. We talk about communication and working with partners and being able to use condoms, dental dams, all of these things. All of these things can get a lot more complicated when mind-altering substances are involved. Alcohol, methamphetamines can lower inhibitions, affect decision-making and even lower pain thresholds, all of which could mean an increased risk of transmitting STDs from one person to another.

So being very judicious about incorporating anything that's a mind-altering substance is extremely important. And thinking about the safety of the position that you're in and what you think is reasonable risk to engage in ahead of time as best you can and whether or not that's going to be affected by things like mind-altering substances, I think is very, very important.

So as you said, there's many intersections to this. Like it really comes from a lot of different angles. Not all STDs are the same and there's very different ways to protect against them. There's very different ways that they manifest. But I think it's so important that everyone takes into account that STDs will not always have symptoms. It's extremely important to touch base with your personal caregivers, providers, healthcare providers in the system, to make sure that you're getting appropriate testing for those subtle STDs before they have the time to really do some damage or pass on to someone else that you don't want to spread these diseases to. And that there are many, many ways on top of testing that people can protect other individuals and protect themselves from the spread of STDs, including barrier methods, like condoms and dental dams, getting tested ahead of time and getting their partners tested, taking PrEP medications to help protect from HIV, getting an HPV vaccine to help protect from HPV infection and cancer, and all these other factors that just lower those risks.

Caitlin Whyte: Well, thank you so much, doctor, again for sharing this critical information with us. For more, you can head on over to prismahealth.org/flourish. This has been Flourish, a podcast brought to you by Prisma Health. I'm Caitlin Whyte. Stay well.