Hello, I am Dr. Gail Bolan, Director of the Division of Sexually Transmitted Disease (STD) Prevention at the Centers for Disease Control and Prevention (CDC). I am speaking to you as part of the CDC Expert Commentary Series on Medscape.
Each year in the United States, there are more than 1 million new gonorrhea and chlamydia infections. Although most gonorrhea and chlamydia infection are found in female adolescents and young women, increases in these infections in men who have sex with men (MSM) have been documented. Rising rates of gonorrhea and chlamydia in MSM are concerning because urethral, rectal, or pharyngeal infections may increase the risk for HIV infection (if HIV-uninfected), and may increase HIV transmission to others (if already HIV-infected).
Many factors contribute to the high number of infections, but one factor in particular is relevant to clinicians. Most rectal and pharyngeal infections are asymptomatic and providers generally limit screening to urine-based tests, which fail to detect nongenital infections. Studies have found that more than 60% of gonorrhea infections and more than 50% of chlamydia infections are extra- genital, serving as reservoirs of infection and increasing the likelihood of further transmission.
Here is how to appropriately screen and treat sexually active MSM for rectal and pharyngeal gonorrhea and rectal chlamydia infections:
Take a sexual history. Taking a sexual history is an important part of any clinic visit and provides a more complete picture of your patient's health and disease risk. A sexual history allows you to identify appropriate anatomical sites for examination and specimen collection. It also provides you with an opportunity to discuss sexual health and risk behaviors with your patients.
When conducting a sexual history with a patient, it is important to:
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Ask about the number of male and female partners they have had.
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Ask specific questions about the sites of sexual contact, such as receptive anal sex or insertive oral sex, and if a condom was used. For example, you might ask "Did you have anal intercourse?" If yes, "Was it receptive or insertive and was a condom used?"
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Ask straight-forward and open-ended questions about sexual behavior using formal language rather than slang. To normalize the conversation, emphasize to your patient that you ask these questions to all of your patients to provide the best care possible.
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Avoid assumptions and judgment, ensure confidentiality, and always ask permission to note sexual orientation and gender identity in the medical chart. For example, marriage does not guarantee monogamy, or that the individual is exclusively heterosexual. A man who identifies himself as "straight" may be having sex with other men.
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Describe what screening tests will be done and why, and how the patient will be notified of screening test results.
Additional questions should be considered for assessing a patient's HIV and hepatitis risks. At the end of this page are links to some excellent resources.
Screen according to CDC recommended intervals. Annual screening for HIV (in uninfected patients) and for bacterial STDs, such as syphilis, gonorrhea, and chlamydia, is recommended for all sexually active MSM. More frequent screening is indicated for MSM who are at higher risk, such as those who have multiple or anonymous partners, those who have sex in conjunction with illicit drug use (such as methamphetamine), and those who have drug-using partners; these higher-risk MSM should be screened every 3-6 months.
Screen at exposed sites. For MSM who have had receptive anal intercourse in the past year, CDC recommends rectal screening for gonorrhea and chlamydia. For MSM who have had receptive oral intercourse, CDC recommends screening for oropharyngeal gonorrhea but not chlamydia because of the low prevalence of oropharyngeal chlamydia infection. For MSM who have only had insertive intercourse, CDC recommends a urine specimen to test for urethral gonorrhea and chlamydia.
CDC recommends the nucleic acid amplification test (NAAT), for gonorrhea and chlamydia screening at nongenital sites. Although NAATs are more sensitive and superior to culture at these sites, these tests are not US Food and Drug Administration cleared for these indications. However, they can be used by laboratories that have met all regulatory requirements for an off-label procedure. The National Network of Prevention Training Centers' Website has a list of laboratories that are Clinical Laboratory Improvement Amendments (CLIA)-verified to test rectal and pharyngeal specimens for gonorrhea and chlamydia using NAATs.
The treatment regimens for MSMs with gonorrhea and chlamydia are available in the CDC 2010 STD Treatment Guidelines. The 2010 recommended regimen for gonorrhea involves administering 2 drugs: ceftriaxone (250 mg intramuscularly in a single dose) plus azithromycin 1 gm orally in a single dose or doxycycline 100 mg orally twice a day for 7 days.
Visit CDC STD for more information on the 2010 STD Treatment Guidelines (including a gonorrhea clinical management guidelines Webinar).
We hope this resource is useful to you. Thank you very much.
Web Resources
CDC Sexually Transmitted Diseases
The Guide to Taking a Sexual History
Screen, Test, Diagnose, and Prevent: A Clinician's Resource for STDs in Gay and Other MSM
Gail Bolan, MD, is the director of the Division of Sexually Transmitted Disease Prevention (DSTDP) within the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC).
Dr. Bolan began her public health career in 1982 as a CDC EIS officer. She gained international experience with a 3-month meningitis surveillance project in Burkina Faso, Africa. In 1987, she was named the Director of the STD Prevention and Control Program at the San Francisco Department of Public Health jointly with an academic appointment in the Department of Medicine at University of California San Francisco Medical School.
In 1997, she became Chief of the STD Control Branch at the California Department of Public Health as well as the Director of the California STD/HIV Prevention Training Center. In these positions, she has consistently demonstrated a strong and enthusiastic commitment to the field of STD prevention. Throughout her career, Dr. Bolan has held numerous scientific leadership positions on many national committees related to STD prevention and control and has been a senior technical consultant with CDC on a wide variety of strategic scientific initiatives. She has published more than 125 articles of which many appear in high-profile journals such as Nature, Proceedings of the National Academy of Sciences, The Lancet, The New England Journal of Medicine, and Journal of the American Medical Association . Dr. Bolan earned her medical degree from the Dartmouth Medical School in Hanover, New Hampshire. She completed her training in internal medicine at the University of Virginia, Charlottesville, and subspecialty training in infectious diseases at the Tufts New England Medical Center in Boston and the Stanford Medical Center.