Sexually Transmitted Infection Screening Among Gay, Bisexual, and Other Men Who Have Sex With Men Prescribed Pre-exposure Prophylaxis in Baltimore City, Maryland

Abstract

Background Human immunodeficiency virus pre-exposure prophylaxis (PrEP) clinical guidelines recommend men who have sex with men (MSM) PrEP users be screened biannually for syphilis and gonorrhea/chlamydia at all anatomic sites. We sought to determine the proportion screened and positive by STI and anatomic site at PrEP initiation and PrEP-care visits and patient-level characteristics associated with screening among MSM PrEP users in Baltimore City, Maryland. Methods Medical records among MSM initiating PrEP between 30 September 2015 and 31 March 2018 were abstracted. STI screening (syphilis and gonorrhea/chlamydia at all anatomic sites) and positivity at PrEP visits ≤12 months following initiation were calculated. Poisson regression with cluster robust SEs was used to assess associations with STI screening. Results Among 290 MSM initiating PrEP, 43.1% (n = 125) were screened per guidelines at PrEP initiation; 79.3% (230), 69.3% (201), 55.9% (162), and 69.3% (201) were screened for syphilis, urogenital, rectal, and oropharyngeal gonorrhea/chlamydia, respectively. Positivity among those screened was syphilis, 7.8% (n = 18/230); gonorrhea, 5.0% urogenital (10/201), 11.1% rectal (18/162), and 7.5% oropharyngeal (15/201); chlamydia, 5.0% urogenital (10/201), 11.7% rectal (19/162), and 1.5% oropharyngeal (3/201). Reported anal and oral sex (vs neither) was independently associated with STI screening (aPR, 2.11; 1.05–4.27) at PrEP initiation. At biannual PrEP-care visits, STI screening was lower and syphilis and rectal gonorrhea/chlamydia positivity was higher. Conclusions Observed STI screening levels and disease burden suggest the effectiveness of STI screening in PrEP care for STI prevention may be limited. Our results suggest providers may be offering screening based on sexual practices; clarification of STI screening guidelines for PrEP users is needed.

Gaps in Sexually Transmitted Infection Screening among Men who Have Sex with Men in PrEP Care in the United States

“…Several factors have been found to be associated with more recent or comprehensive STI screening: younger age, white race, college education, reporting exposure at anatomical sites that may trigger screening, and previous syphilis diagnoses [7,13,15,16]. We additionally found that residence in the Southeast was associated with inconsistent urogenital and rectal STI screening, after adjusting for potential confounders.…”

“…This study contributes to the growing literature on patterns of STI screening within PrEP care. With the exception of one national study [14], research has been limited to individual clinics or health systems, often with limited sample sizes [7,13,15,16]. These studies analyze a variety of data streams, including electronic health records, health insurance claims, or laboratory screening [15,16,27].…”

“…With the exception of one national study [14], research has been limited to individual clinics or health systems, often with limited sample sizes [7,13,15,16]. These studies analyze a variety of data streams, including electronic health records, health insurance claims, or laboratory screening [15,16,27]. Many different measures have been used as primary outcomes: screening at last PrEP care visit [13]; STI or rectal STI screening in the prior 12 months [7]; or proportion screened for STIs within 6 months of PrEP initiation [14].…”

“…Despite these different study designs and outcomes, research has consistently shown suboptimal STI screening among PrEP users, especially for extragenital (rectal or pharyngeal) screening [13–16]. Similar to a study conducted in Baltimore, we found that among all site-specific screening, rectal swabs were reported least often [16]. A study in New York City, in contrast, found that pharyngeal STI screening was the least reported (at the last PrEP care visit) [13].…”

“…Quantifying any gaps between PrEP STI screening recommendations and clinical practice is therefore critical to understanding the role of PrEP care in STI control. Several studies have evaluated this in different regions, finding lower rates of STI screening than recommended [7,13–16]. While these studies provide important evidence regarding gaps in PrEP care, there are still no national-level studies of MSM that have compared these gaps across geographic regions.…”