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@uw.edu uwptc.org 206-685-9850
Epidemiology Prevalence in STD Clinics 1 - Pharyngeal GC: 7.9% (range 1.2 19.3) - Rectal GC: 10.2% (range 5.4 21.1) - Rectal CT: 14.1% (range 11.4 19.8) - 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
Extragenital GC/CT in MSM in the STD Surveillance Network, 2010-2012 Patton, Clinical Infectious Diseases, 2014
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, 2001 2013 100 90 1.9 1.5 4.0 None Proportion 80 70 60 50 40 30 20 10 0 65.8 63.6 53.9 25.2 23.5 32.3% 25.2 34.9% 8.8 9.7 16.7 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
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, 2015 2. Kelly, AIDS Res Hum Retroviruses, 2015 3. Jin, JAIDS, 1999 4. Moran, STD, 1995 5. Kong, JAC, 2015 6. Khosropour et al, STD, 2014
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
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. ^http://www.kingcounty.gov/healthservices/health/communicable/hiv/providers/msmstd.aspx
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. ^http://www.kingcounty.gov/healthservices/health/communicable/hiv/providers/msmstd.aspx
Extragenital Infections are Under-screened Of 21,994 MSM seen at 42 STD clinics between 2010 2012. 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
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
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?