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  ID Week
Oct 8-12 2014
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Only One Third of MSM in Routine HIV Care Tested for Gonorrhea or Chlamydia
  IDWeek 2014, October 8-12, 2014, Philadelphia
Mark Mascolini
One third of men who have sex with men (MSM) in care for HIV at the University of Alabama at Birmingham (UAB) got tested for gonorrhea or chlamydia in a 12-month study [1]. Most positive results in this 1500-person analysis came from rectal tests of MSM.
MSM run a high risk of sexually transmitted infections (STIs), which increase genital shedding of HIV and so boost HIV transmission risk. The Centers for Disease Control and Prevention (CDC) recommends yearly urogenital and extragenital gonorrhea and chlamydia screening for sexually active MSM, researchers who conducted this study observed. Underscreening at extragenital sites--rectum and oropharynx--contributes to further spread of these STIs. To get a better understanding of gonorrhea and chlamydia screening rates in MSM, and correlates of screening, they conducted this cross-sectional study at the UAB HIV clinic.
The study involved HIV-positive people 19 or older in care at the UAB clinic for more than 1 year and with at least two visits at least 90 days apart within the previous year. The study period ran from January through December 2012. The primary endpoint was gonorrhea/chlamydia testing as a composite outcome. The investigators used multivariable log-binomial regression models to identify associations of patient characteristics with gonorrhea/chlamydia testing
The 1523 adults averaged 46 years in age. Most, 59%, were MSM, 18% heterosexual men, and 23% women. Most participants, 53%, were African American, though only 39% of MSM were African American. Overall gonorrhea/chlamydia testing prevalence was 41% within the previous year, including rates of 67% for women, 32% for heterosexual men, and 34% for MSM. Of the 307 MSM screened for gonorrhea/chlamydia, 93% received urogenital testing, 25% rectal testing, and 8% pharyngeal testing.
Among the 632 people tested for gonorrhea/chlamydia, 15 (including 14 MSM) were positive for gonorrhea and 16 (including 13 MSM) were positive for chlamydia. Among MSM, positive rectal tests did not correspond to positive urogenital tests: Of 9 MSM with positive rectal tests for gonorrhea, 6 had urogenital testing and only 1 was positive. Of 12 MSM with positive rectal tests for chlamydia, 9 had urogenital testing and only 2 were positive.
More than half of MSM, 58%, had a prior STI. Among men completing a survey on current sexual risk behavior, 500 of 890 (56%) reported at least one sexual risk behavior, 492 of 765 (64%) reported more than 1 sex partner, 209 of 374 (56%) reported sex without condoms, and 169 of 765 (22%) reported sex after using drugs or alcohol.
Among MSM, multivariate analysis identified three independent predictors of increased gonorrhea/chlamydia testing and three independent predictors of decreased testing, at the following adjusted prevalence ratios (aPR) (and 95% confidence intervals):
Raised chances of gonorrhea/chlamydia testing:
African American: aPR 1.26 (1.06 to 1.51), P < 0.01
No insurance vs private insurance: aPR 1.25 (1.02 to 1.54), P < 0.04
One or more sexual risk behaviors: aPR 1.24 (1.03 to 1.50), P < 0.04
Lowered chances of gonorrhea/chlamydia testing:
Every 5 years of age: aPR 0.93 (0.89 to 0.98), P < 0.005
Viral load below 200 copies: aPR 0.74 (0.61 to 0.89), P < 0.005
Prior STI: aPR 0.79 (0.67 to 0.95), P < 0.01
The researchers concluded that "MSM are underscreened for gonorrhea/chlamydia, especially at extragenital sites." They stressed that most positive tests came from rectal testing of MSM, and urogenital tests were usually negative in men with positive rectal results.
The association between a prior STI and lower chances of gonorrhea/chlamydia screening suggested to the investigators that "HIV providers are likely suboptimal at assessing risk." They also surmised that HIV providers have biases about which patients run a higher STI risk because testing rates were higher for MSM who were African American, younger, or without insurance after statistical adjustment for sexual risk behavior and prior STI.
1. Tong CM, Heudebert JP, Tamhane A, et al. Gonorrhea and chlamydia testing in routine clinical care of HIV-infected men who have sex with men. IDWeek 2014. October 8-12, 2014, Philadelphia. Abstract 1584.