High proportions of rectal and pharyngeal chlamydia and gonorrhoea cases among cisgender men are missed using current CDC screening recommendations

Abstract

ObjectivesPharyngeal and rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are often undiagnosed due to their asymptomatic nature. This study aims to determine (1) the prevalence of CT/NG infections by anatomical site among cisgender men; (2) the proportion of missed CT/NG rectal/pharyngeal infections if urogenital testing alone was performed or screening depended on self-reported behaviour alone; and (3) the predictive probability of self-reported behaviours for rectal CT/NG.MethodsThis cross-sectional study used electronic health records collected at a sexual health clinic in Los Angeles from 18 November 2018 until 28 February 2020. The included patients were ≥18 years of age cisgender men who received CT/NG testing at least once during the study period. We calculated the proportion of missed pharyngeal/rectal CT/NG infections if only urogenital testing had been done and if testing was based only on self-reported anal sex. Separately, we ran logistic regressions for predictive probability of self-reported anal sex on CT/NG rectal infections.ResultsOverall, there were 13 476 unique patients with 26 579 visits. The prevalence of any extragenital CT/NG infection was 37.28%. Over 80% rectal/pharyngeal CT cases and over 65% rectal/pharyngeal NG cases would be missed if urogenital testing alone was performed. Likewise, over 35% rectal CT/NG cases would be missed had testing relied on self-reported sexual behaviours alone.ConclusionsThe proportion of missed rectal and pharyngeal CT/NG infections is high. Our data from a sexual health clinic lend support to three-site opt-out testing for cisgender men attending a sexual health/Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ+) specialty clinic regardless of their sexual orientation or reported sexual behaviours.

Testing for extragenital Neisseria gonorrhoeae and Chlamydia trachomatis: At-home pharyngeal and rectal self-swabs are non-inferior to those completed in healthcare settings

“…Over 40% of chlamydia infections that were missed on one swab were identified at the other anatomical site, which ensured prompt identification and treatment of infection for these participants. This recommendation to complete comprehensive testing aligns with literature which has identified similarly high rates of rectal infections among MSM who deny receptive anal sex ranging between 20–35% [ 19 – 21 ]. Another lesson from this study is that clinicians should consider retesting patients if they obtain negative test results but have a high clinical suspicion of infection (e.g., if the patient is symptomatic or is a contact of someone diagnosed with chlamydia or gonorrhea).…”

High Prevalence of Rectal Chlamydia and Gonorrhea Among Men Who Have Sex With Men Who Do Not Engage in Receptive Anal Sex

“…In clinical practice, this translates to only screening MSM for rectal CT/GC if they report receptive anal sex (RAS). However, in a recent US study where clinic patients were screened for rectal CT/GC regardless of reported behaviors, 32% of all rectal CT cases and 40% of all rectal GC cases among MSM were among patients who did not report RAS 5 . Furthermore, a number of studies have found that behaviors other than RAS (e.g., rimming, use of sex toys, fingering) may lead to rectal CT/GC acquisition 6–8 .…”

“…However, in a recent US study where clinic patients were screened for rectal CT/GC regardless of reported behaviors, 32% of all rectal CT cases and 40% of all rectal GC cases among MSM were among patients who did not report RAS. 5 Furthermore, a number of studies have found that behaviors other than RAS (e.g., rimming, use of sex toys, fingering) may lead to rectal CT/GC acquisition. [6][7][8] However, most of these estimates were obtained from populations who also report RAS; thus, it is difficult to determine how common anal exposures are among men who do not engage in RAS and which specific behaviors other than RAS may lead to rectal CT/GC acquisition.…”

Added Value of Extragenital Sexually Transmitted Infection Testing in “IWantTheKit” Program Users

“…Pharyngeal gonorrhea may be more difficult to treat partly because of less good penetration of antibiotics into pharyngeal tissues compared with genital/rectal sites. 4,5 Rectal STI dramatically increases the risk for HIV acquisition for both men and women 6 and therefore warrants more attention and assessment. In studies among men who have sex with men (MSM), extragenital chlamydia and gonorrhea can persist for many months and are likely to serve as a reservoir of infection.…”

“…Extragenital STIs are often asymptomatic and may go undetected without screening. Pharyngeal gonorrhea may be more difficult to treat partly because of less good penetration of antibiotics into pharyngeal tissues compared with genital/rectal sites 4,5 . Rectal STI dramatically increases the risk for HIV acquisition for both men and women 6 and therefore warrants more attention and assessment.…”