Extragenital Gonorrhea and Chlamydia among MSM

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1 Extragenital Gonorrhea and Chlamydia among MSM Laura Quilter, MD Infectious Disease and STD PTC Fellow University of Washington Division of Allergy and Infectious Diseases 3/28/2016 uwptc.org

2 Epidemiology Prevalence in STD Clinics 1 - Pharyngeal GC: 7.9% (range ) - Rectal GC: 10.2% (range ) - Rectal CT: 14.1% (range ) - Pharyngeal CT: 2.9% Asymptomatic - Pharyngeal GC: 92% 2 - Rectal GC: 84-86% 2 Majority of GC/CT in MSM isolated to extragenital sites 1. Patton, CID, 2014 (SsUN data) 2. Morris, CID, 2006

3 Extragenital GC/CT in MSM in the STD Surveillance Network, Patton, Clinical Infectious Diseases, 2014

4 Proportion of Gonococcal, Chlamydial, and Non-gonococcal, non-chlamydial Symptomatic Urethritis by Urethral Exposure, and the Proportion Attributed to Oral Sex among MSM attending PHSKC STD Clinic, None Proportion % % Gonorrhea Chlamydia NGNCU 41.9% UIAI -- Unprotected Insertive Anal Sex PIAI -- Protected Insertive Anal Sex & Oral Sex IOS -- Oral Sex Only Barbee et al, STI 2015

5 Importance of Extragenital GC/CT GC/CT Transmission HIV Transmission - Potentiate acquisition, even after controlling for sexual behaviors 1-3 Treatment differences - Pharyngeal GC 4 Ceftriaxone > Cefixime - Rectal CT 5,6 Doxycycline >>> Azithromycin 1. Vaughan, BMC Med Res Methodol, Kelly, AIDS Res Hum Retroviruses, Jin, JAIDS, Moran, STD, Kong, JAC, Khosropour et al, STD, 2014

6 CDC Recommended STD Screening for MSM The triple dip: Syphilis & HIV serology Pharyngeal GC Urine GC/CT Rectal GC/CT Annually for all sexually active MSM Every 3-6 months for high-risk MSM

7 Public Health Seattle & King County MSM Screening Guidelines ^ Who to screen? Sexually active MSM and transgender persons who have sex with men * At least once per year How often? What to screen for and how? Every 3 months if any of the following risks in 12 months: Condomless anal intercourse with a serodiscordant partner >10 sexual partners Diagnosis of bacterial STI Methamphetamine or popper use Pharyngeal gonorrhea (NAAT or culture) Rectal gonorrhea & chlamydia (NAAT or culture) Syphilis (EIA or RPR if previous history of syphilis) HIV (4 th Gen or RNA) If previously HIV negative Hepatitis A (HAV IgG EIA) If not vaccinated Hepatitis B (HBV core Ab, sag EIA) If not vaccinated HIV-infected MSM and transgender persons who have sex with men should obtain a syphilis serology with each blood draw (up to four times per year). MSM or transgender patients on PrEP should perform STD screening (as above) whenever testing for HIV. Other comments * Screening is not needed in persons in long-term (>1 year), mutually monogamous, HIV concordant relationships. Providers should ask patients about their sexual behavior regularly, particularly if not screening for HIV/STD. ^

8 Public Health Seattle & King County MSM Screening Guidelines ^ Who to screen? Sexually active MSM and transgender persons who have sex with men * At least once per year How often? What to screen for and how? Every 3 months if any of the following risks in 12 months: Condomless anal intercourse with a serodiscordant partner >10 sexual partners Diagnosis of bacterial STI Methamphetamine or popper use Pharyngeal gonorrhea (NAAT or culture) Rectal gonorrhea & chlamydia (NAAT or culture) Syphilis (EIA or RPR if previous history of syphilis) HIV (4 th Gen or RNA) If previously HIV negative Hepatitis A (HAV IgG EIA) If not vaccinated Hepatitis B (HBV core Ab, sag EIA) If not vaccinated HIV-infected MSM and transgender persons who have sex with men should obtain a syphilis serology with each blood draw (up to four times per year). MSM or transgender patients on PrEP should perform STD screening (as above) whenever testing for HIV. Other comments * Screening is not needed in persons in long-term (>1 year), mutually monogamous, HIV concordant relationships. Providers should ask patients about their sexual behavior regularly, particularly if not screening for HIV/STD. ^

9 Extragenital Infections are Under-screened Of 21,994 MSM seen at 42 STD clinics between Infection Mean % Tested Low High Pharyngeal GC 66% 0% 81% Rectal GC 50% 0% 65% Rectal CT 46% 0% 65% Pharyngeal CT 32% 0% 80% Urogenital GC 84% 56% 96% Urogenital CT 82% 24% 96% Patton, Clinical Infectious Diseases, 2014

10 Barriers to Screening Patient-related Barriers 1 - Want frequent, convenient, affordable testing Provider-related Barriers 1 - Knowledge, time & comfort with sexual history/exam Systems barriers - Testing costs - Lab issues: requires internal validation Barbee, STD, 2015

11 Discussion Points Are there other barriers that your clinic has had to extragenital GC/CT screening among MSM? How frequently do you recommend STD testing for MSM in your clinic? - Does that differ for MSM on PrEP? Have you had trouble with billing for q 3-6 month tests? Do you treat rectal CT with doxycycline or azithromycin?