Pharyngeal Chlamydia trachomatis in Men Who Have Sex With Men (MSM) in The Netherlands: A Large Retrospective Cohort Study.

Pharyngeal Chlamydia trachomatis (CT) was diagnosed in 1.2% and pharyngeal-only CT in 0.5% of routinely universally tested men who have sex with men (MSM). In these 3-anatomic-site tested MSM, pharyngeal-only CT comprised 4.8% of all CT. The low positivity of pharyngeal-only CT indicates low public health impact of pharyngeal CT.

Men and Women Have an Equal Oropharyngeal and Anorectal Chlamydia trachomatis Bacterial Load: A Comparison of 3 Anatomic Sites.

BACKGROUND: The Chlamydia trachomatis bacterial load could have impact on transmission and sequelae. This is the first study providing comparison of C. trachomatis load at 3 anatomic sites estimated by cycle quantification (Cq) values. METHODS: Data from 7900 C. trachomatis-positive samples were included (2012-2018). Cq value was used as an inversely proportional measure for C. trachomatis load. Multivariable linear regression analyses assessed differences in mean Cq values. RESULTS: Vaginal swabs had the lowest Cq values (31.0) followed by urine (32.5), anorectal swabs (34.0), and oropharyngeal swabs (36.8) (P < .001). Men and women had similar oropharyngeal (36.4 vs 37.3; P = .13) and anorectal (34.2 vs 33.9; P = .19) Cq values. Men (32.2) and women (30.7) aged <25 years had lower urogenital Cq values than men (32.8) and women (31.9) aged ≥25 years (P < .001). HIV-positive patients had higher urogenital Cq values than HIV-negative patients (33.8 vs 32.6; P < .03). CONCLUSIONS: Men and women have a similar C. trachomatis load at extragenital locations arguing for similar transmission potential and clinical relevance. Older patients and HIV-coinfected patients had lower C. trachomatis load, suggesting exposure to previous C. trachomatis infections potentially leading to partial immunity reducing load.

Culture-Independent Genotyping Revealed 3 Strain Clusters in a Potential Neisseria gonorrhoeae Outbreak in Young Heterosexuals (<25 Years), the Netherlands, October 2017 to March 2019.

BACKGROUND: Investigation was undertaken to determine the genetic relatedness of Neisseria gonorrhoeae (NG) isolates of young (<25 years) heterosexuals of a potential outbreak from October 2017 to March 2019 in South-Limburg, the Netherlands. METHODS: Data and residual sample material of routine diagnostics were retrieved for outbreak cases (78/81), young heterosexuals at baseline (January 2016 to September 2017, n = 30), and men who have sex with men (2018, n = 47). Total DNA was isolated, and NG was genotyped using culture-free NG multiantigen sequence typing. Sanger sequence data were used to construct a phylogenetic tree. Cases of outbreak clusters were geographically mapped, and descriptive analyses were performed on patient characteristics, comparing these clusters. RESULTS: Outbreak investigation showed 81 cases of young heterosexuals between October 2017 and March 2019 (4.5 per month) compared with 30 between January 2016 and September 2017 (1.4 per month), which was considered as baseline. Culture-independent genotyping of NG was performed to assess the genetic relatedness, as only 21 outbreak cases were culture confirmed. This revealed 3 independent outbreak clusters G2 (n = 18), G13113 (n = 11), and GNewST (n = 24). None of the clusters were geographically linked or introduced by bridging with men who have sex with men networks. Number of sex partners reported by men and Chlamydia trachomatis coinfection were associated with clusters G2 and GNewST, respectively. CONCLUSIONS: Culture-independent typing proved to be essential to identify the 3 outbreak clusters. However, targeted interventions were difficult because information on sex partners was limited. Therefore, prospective culture-independent typing could be used for early outbreak detection and aid in transmission prevention.

High rate of loss to follow-up and virological non-suppression in HIV-infected children on antiretroviral therapy highlights the need to improve quality of care in South Africa.

Provision of high-quality care and ensuring retention of children on antiretroviral therapy (ART) are essential to reduce human immunodeficiency virus (HIV)-associated morbidity and mortality. Virological non-suppression (≥1000 viral copies/ml) is an indication of suboptimal HIV care and support. This retrospective cohort study included ART-naïve children who initiated first-line ART between July 2015 and August 2017 in Johannesburg and rural Mopani district. Of 2739 children started on ART, 29.5% (807/2739) were lost to care at the point of analysis in August 2018. Among retained children, overall virological non-suppression was 30.2% (469/1554). Virological non-suppression was associated with higher loss to care 30.3% (229/755) compared with suppressed children (9.7%, 136/1399, P < 0.001). Receiving treatment in Mopani was associated with virological non-suppression in children under 5 years (adjusted odds ratio (aOR) 1.7 (95% confidence interval (CI) 1.1-2.4), 5-9 years (aOR 1.8 (1.1-3.0)) and 10-14 years (aOR 1.9 (1.2-2.8)). Virological non-suppression was associated with lower CD4 count in children 5-9 years (aOR 2.1 (1.1-4.1)) and 10-14 years (aOR 2.1 (1.2-3.8)). Additional factors included a shorter time on ART (<5 years aOR 1.8-3.7 (1.3-8.2)), and male gender (5-9 years, aOR1.5 (1.01-2.3)), and receiving cotrimoxazole prophylaxis (10-14 years aOR 2.0 (1.2-3.6)). In conclusion, virological non-suppression is a factor of subsequent programme loss in both regions, and factors affecting the quality of care need to be addressed to achieve the third UNAIDS 90 in paediatric HIV.

What Is the Optimal Testing Strategy for Oropharyngeal Neisseria gonorrhoeae in Men Who Have Sex With Men? Comparing Selective Testing Versus Routine Universal Testing From Dutch Sexually Transmitted Infection Clinic Data (2008-2017).

BACKGROUND: Most oropharyngeal Neisseria gonorrhoeae infections are asymptomatic, and many infections remain undetected, creating a reservoir for ongoing transmission and potential drug resistance. It is unclear what the optimal testing policy is in men who have sex with men (MSM), as routine universal testing data are lacking. METHODS: Surveillance data from all Dutch sexually transmitted infection (STI) clinics between 2008 and 2017 were used (N = 271 242 consultations). Oropharyngeal testing policy was defined as routine universal testing when ≥85% of consultations included oropharyngeal testing or as selective testing (<85% tested). Independent risk factors for oropharyngeal N. gonorrhoeae were assessed among MSM routinely universally screened using backward multivariable logistic regression analyses. RESULTS: Routine universal testing was performed in 90% (238 619/265 127) of consultations. Prevalence was higher using routine universal testing (5.5%; 95% CI, 5.4-5.6; 12 769/233 476) than with selective testing (4.7%; 95% CI, 4.4-5.0; 799/17 079; P < .001). Proportions of oropharyngeal-only infections were 55% and 47%, respectively. Independent risk factors were age <31 years (OR, 2.1; 95% CI, 1.9-2.3), age 31-43 years (OR, 1.7; 95% CI, 1.6-1.9, compared with >43 years), being notified for any STI (OR, 2.0; 95% CI, 1.9-2.1), concurrent urogenital N. gonorrhoeae (OR, 2.4; 95% CI, 2.1-2.7), and concurrent anorectal N. gonorrhoeae (OR, 11.4; 95% CI, 10.6-12.3). When using any of the risk factors age, notified, or oral sex as testing indicators, 98.4% (81 022/82 332) of MSM would be tested, finding 99.5% (4814/4838) of infections. CONCLUSIONS: Routine universal testing detected more oropharyngeal N. gonorrhoeae infections than selective testing, of which more than half would be oropharyngeal only. Using independent risk factors as testing indicator is not specific. Therefore, routine universal oropharyngeal testing in MSM is feasible and warranted, as currently advised in most guidelines.

Prevalence of drug use during sex among swingers and perceived benefits and risks - a cross-sectional internet survey in the Netherlands.

OBJECTIVES: Drug use during sex has been associated with sexually transmitted infections (STI). While a growing body of research has investigated drug use during sex among men who have sex with men, data in swingers is limited. Swingers are heterosexual couples who have sex with others and singles who have sex with these couples. Our study assessed the prevalence of drug use during sex and perceived benefits and risks among swingers. METHODS: In 2018, 1005 swingers completed an online questionnaire that was advertised at Dutch swinger-websites. We assessed the associations between drug use during sex <6 months (any drug use excluding alcohol and erection medicines) and sociodemographic characteristics, alcohol use and condomless sex using backward multivariable logistic regression analysis. We compared drug use, motives, beliefs and experienced effects between heterosexual male, bisexual male and female drug-using swingers using χ2-tests. RESULTS: Drug use during sex was reported by 44% (443/1005): 51% in women, 44% in bisexual men and 39% in heterosexual men (P<0.01). Condomless vaginal (46%) and anal sex (22%) was higher in drug-using swingers (vs 34% and 13% in non-drug-using swingers, P<0.001). Among drug-using swingers, XTC (92%), GHB (76%) and laughing gas (69%) were mostly used. Prolonging sex (68%) and increasing arousal (66%) were the most reported motives. Most reported positive effects were feeling happy (78%) and increasing energy (78%). Ninety-four per cent considered drug use to be pleasurable. The most reported negative effect was feeling tired (53%), 7% reported that they might become addicted or felt uncomfortable having sex without drugs. CONCLUSION: This study among a large group of swingers shows that drug use during sex is highly prevalent. STI clinics should discuss drug use during sex among swingers and provide information on safer sex and drug use, while acknowledging the perceived benefits, such as the increased quality of sex.

Sex Abroad Among Men Who Have Sex With Men and Its Association With Chemsex, Sexual Risk Behavior, and Sexually Transmitted Diseases: A Cross-Sectional Study in the Netherlands.

Almost half of men who have sex with men visiting Dutch sexually transmitted disease clinics reported sex abroad in the past 6 months, mainly in Western countries. One in 4 men who have sex with men who had sex abroad used drugs during sex ("chemsex") abroad. Having sex abroad was associated with having multiple sex partners and casual sex partner(s).

The Availability and Feasibility of Chemsex Services Within Sexually Transmitted Disease Clinics in the Netherlands: A Cross-Sectional Survey Among Sexually Transmitted Disease Nurses.

OBJECTIVES: Chemsex-using illicit drugs during sex-is prevalent among men who have sex with men (MSM) and associated with sexual and mental health harms. Sexually transmitted disease (STD) clinics are a frequently visited and trusted health care facility for MSM. This study assessed the frequency and extent to which chemsex is addressed by Dutch STD nurses. METHODS: Of the 24 Dutch public STD clinics, an online questionnaire was distributed in 20 STD clinics (83%) in 2019; the questionnaire was sent to 191 STD nurses, of whom 108 (57%) completed the questionnaire. The main outcome was addressing chemsex during regular MSM consultations, measured on a 5-point Likert scale (never-always). Items measuring knowledge, attitude, self-efficacy, and the social norm were also measured on a 5-point Likert scale (totally disagree-totally agree). RESULTS: Of the 108 participating STD nurses, 77 (71%) addressed chemsex regularly or always during MSM consultations. In general, STD nurses indicated to have sufficient knowledge about chemsex (mean [SD], 3.6 [0.5]) and a positive attitude toward addressing chemsex (mean [SD], 4.3 [0.5]). A need for training on chemsex was reported by 82 (76%) STD nurses, especially in signaling problematic chemsex (56/82; 68%). Three STD clinics (15%) had a protocol on addressing chemsex, and 3 STD clinics (15%) had referral pathways to addiction care. CONCLUSION: Sexually transmitted disease nurses from Dutch STD clinics regularly addressed chemsex during MSM consultations. Our results show relevance of educating STD nurses on signaling problematic chemsex and arranging referral pathways to addiction care to optimize chemsex related health care.

Men and Women Repeatedly Infected With Chlamydia trachomatis Have a Lower Urogenital Bacterial Load.

We assessed whether patients repeatedly infected with Chlamydia trachomatis (CT) have a lower urogenital or anorectal CT load. A CT-positive retest was independently associated with higher vaginal and higher urine Cq values (P<0.01). Partial immunity could play a role in repeat urogenital infections, potentially not in anorectal infections.

The characteristics of patients frequently tested and repeatedly infected with Chlamydia trachomatis in Southwest Limburg, the Netherlands.

BACKGROUND: Repeat Chlamydia trachomatis (CT) infections are common. To better understand the characteristics of patients frequently infected with CT at our sexually transmitted infection (STI) care services, we assessed the differences between patients repeatedly infected with CT and those who repeatedly tested negative. METHODS: In this cross-sectional analysis of cohort data, we assessed individuals tested for CT at different STI care providers between 2011 and mid-2018 in Southwest Limburg, the Netherlands (n = 17,616). Patients with ≥2 repeat CT infections in the study period were categorized as "patients with repeat CT infections." Multivariable logistic regression analyses were performed for the binary outcome measure: patients with repeat CT infections versus patients who repeatedly tested negative (reference group). Additional analyses were performed for only the STI clinic population. RESULTS: Patients aged < 25 years (OR: 1.83; 95%CI:1.38-2.43), co-infected with HIV (OR: 2.07; 95%CI: 1.02-4.22) or co-infected with Neisseria gonorrhoeae (NG) (OR: 5.04; 95%CI: 3.33-7.63) had more repeat CT infections. In additional analyses among exclusively STI clinic visitors, patients with urogenital symptoms (OR: 2.17; 95%CI: 1.41-3.35), and patients notified for STIs (OR: 4.55; 95%CI: 3.17-6.54) had more frequent repeat CT infections. CONCLUSIONS: Patients aged < 25 years and patients coinfected with HIV or NG had more frequent repeat CT infections, accounting for ~ 20% of the diagnosed CT infections. These patients are likely at the highest risk for transmitting and acquiring CT. Therefore, testing and retesting this group remains important to enhance CT control.

Spontaneous clearance of urogenital, anorectal and oropharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae in women, MSM and heterosexual men visiting the STI clinic: a prospective cohort study.

OBJECTIVE: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections can clear without treatment. Despite high prevalence of anorectal infections in men who have sex with men (MSM) and women, studies on anorectal clearance are scarce. Moreover it is unknown whether bacterial load affects urogenital/anorectal CT clearance. In this prospective cohort study, CT and NG clearance is assessed at three anatomical sites of men and women. METHODS: CT-positive and NG-positive MSM, heterosexual men and women ≥18 years of age visiting our STI clinic between 2011 and 2013 underwent a repeat test when returning for treatment (n=482). The primary outcome was clearance, defined as a positive nucleic acid amplification test (NAAT) at screening-consultation, followed by a negative NAAT at treatment-consultation. Sociodemographics, sexual risk behaviour and CT bacterial load (inhouse quantitative PCR) were tested as determinants for clearance using multivariable logistic regression for CT and Fisher's exact test for NG. RESULTS: CT clearance was 9.1% (10/110) for urine, 6.8% (20/292) for vaginal swabs, 12.7% (8/63) for anorectal swabs (ie, 4.0% [1/25] in MSM and 18.4% [7/38] in women) and 57.1% (4/7) for oropharyngeal swabs. For NG this was 33.3% (2/6), 28.6% (2/7), 20.0% (2/10) and 27.3% (6/22), respectively. The number of days between tests (median 10, IQR 7-14) was not associated with clearance. Lower bacterial load at screening was the only predictor for CT clearance (urine mean 1.2 vs 2.6 log CT/mL, p=0.001; vaginal swabs mean 2.1 vs 5.2 log CT/mL p<0.0001; anorectal swabs mean 2.0 vs 3.7 log CT/mL, p=0.002). None of the tested determinants were associated with NG clearance. CONCLUSIONS: This study reports the largest number of anorectal infections tested for CT and NG clearance to date. Clearance in all sample types was substantial: between 7% and 57% for CT, and between 20% and 33% for NG (notwithstanding low absolute numbers). CT clearance was associated with a lower load at screening. However, not all individuals with low bacterial CT load cleared the infection, hampering STI guideline change.

Genital and anal Chlamydia trachomatis bacterial load in concurrently infected women: a cross-sectional study.

OBJECTIVES: Most international STI guidelines recommend Chlamydia trachomatis anorectal testing in women after self-reported sexual exposure or symptoms in women. However, it has been shown that the prevalence of anorectal C. trachomatis is as high (7%-17 %) in women who do not report anorectal intercourse (AI) as in women who do. This study assessed the correlation between the genital and anorectal C. trachomatis load in concurrently infected women for increased microbiological insight. METHODS: A convenience sample of 105 women with a concurrent (genital and anorectal) C. trachomatis infection was included from the STI clinic in South Limburg, the Netherlands. Women provided self-collected vaginal and anorectal swabs. The C. trachomatis load was quantified with qPCR and the human cell load was assessed to ensure sample adequacy. Genital and anorectal C. trachomatis loads were divided into tertiles for comparison. The χ2 test and linear regression were used to compare genital and anorectal C. trachomatis loads and identify determinants associated with load. RESULTS: The overall median C. trachomatis load was higher in genital (median 5.3 log10C. trachomatis/ml) than anorectal samples (median 3.4, p ≤ 0.001), but both loads were within the same range. The genital and anal load categories were not related within one woman (p = 0.99), both in women with and without AI. The anorectal C. trachomatis load was in the same or higher load category than the genital load in 56% of women without AI, and 79% of women with AI. CONCLUSIONS: Although no cut-off for clinical relevance is known, an anorectal C. trachomatis load in the same or higher load category than the genital C. trachomatis load is likely to be clinically relevant. Other measurements should also be taken into account, such as leucocytes or bacterial viability to distinguish infection from contamination or exposure.

Standardisation is necessary in urogenital and extragenital Chlamydia trachomatis bacterial load determination by quantitative PCR: a review of literature and retrospective study.

OBJECTIVES: Pathogen load has been linked to disease severity in patients infected with HIV, resulting in international standards to adequately and reproducibly quantify load. Chlamydia trachomatis (CT) load has been inconsistently linked to disease severity since extensive differences exist in quantification methods (14 methods in 28 articles). Differences include normalisation for human cell load due to CT's intracellular nature, despite the inability to distinguish inflammatory cells from epithelial cells with molecular techniques. We compared the human cell load in CT-positive men and women at the genital and anal site to a CT-negative control group to estimate the impact of inflammatory cells in these samples. METHODS: 188 women (tested at genital and anal site) and 519 men (207 tested at the anal site and 312 tested at the urogenital site) were included from our STI-clinic in the Netherlands. Specimens were self-collected vaginal swabs, anal swabs and urine samples. Quantitative-PCR targeting the HLA-gene quantified human cell load. Mann-Whitney-U-test was used for statistical analyses. RESULTS: The genital cell load had a similar range and median (6.5 log10) between CT-negative and CT-positive women . The urogenital cell load was significantly higher than the anal cell load (median 3.6 log10). The anal cell load was significantly higher in men with- than without anal CT infection (median 4.5 versus 3.9 respectively). The anal cell load is significantly higher in CT-positive men than in women. Both Neisseria gonorrhoeae-co-infections and reported anal intercourse significantly increased the human cell load in anal samples. CONCLUSION: Standardisation in CT load studies is necessary as current studies show 14 different quantification methods in 28 studies . In this study we demonstrate the inappropriateness of normalising the CT load for the human cell load using molecular techniques, as the presence of inflammatory cells cannot be excluded.

High Rate of Repeat Sexually Transmitted Diseases Among Men Who Have Sex With Men in South Africa: A Prospective Cohort Study.

We observed a high rate of incident sexually transmitted diseases within 55 days (median) of follow-up (78% retention) among symptomatic men who have sex with men (n = 78) in South Africa (188 per 100 person-years; 95% confidence interval, 1.2-2.7); 16 newly acquired and 10 with persistent positivity. This highlights the need to strengthen prevention efforts, whereas introduction of diagnostics is urgently warranted.

High Proportion of Anorectal Chlamydia trachomatis and Neisseria gonorrhoeae After Routine Universal Urogenital and Anorectal Screening in Women Visiting the Sexually Transmitted Infection Clinic.

BACKGROUND.: Testing on indication of self-reported anal sex or symptoms is used to manage anorectal Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea) infections in women. Little is known about the impact of another testing strategy, routine universal anorectal screening with respect to chlamydia and gonorrhea prevalence and risk factors. METHODS.: All women (n = 1012) aged ≥16 years attending our sexually transmitted infection clinic in 2015 were offered routine universal screening. In total, 19.5% (n = 185) of women had an indication (reported anal sex or symptoms), 72.5% (n = 689) did not have an indication, and 8.0% (n = 76) had missing information on indication. Logistic regression analyses were used to identify determinants associated with anorectal chlamydia and gonorrhea. RESULTS.: Of all women who visited our clinic, 94% (n = 950) participated in the study. Overall anorectal chlamydia/gonorrhea positivity was 13.4% (n = 127)/1.3% (n = 12). Self-reported anal sex and anal symptoms were independently associated with anorectal gonorrhea (odds ratios [ORs], 3.3 [95% confidence interval {CI}, 1.01-10.7] and 14.5 [95% CI, 2.8-75.0], respectively), but not with anorectal chlamydia. Of all anorectal chlamydia/gonorrhea cases, 72% (n = 92)/33% (n = 4) were diagnosed in women without an indication, of which 19% (n = 19)/0% (n = 0) were anorectal only. For women with missing indication, this was 7% (n = 9)/8% (n = 1) and 44% (n = 4)/100% (n = 1). CONCLUSIONS.: Anorectal screening in women without an indication is feasible and highly acceptable. Selective testing on indication could be an appropriate control strategy for anorectal gonorrhea, as few infections would be missed. In contrast, selective testing is a suboptimal control strategy for anorectal chlamydia, as we found a high prevalence in women both with and without indication for anorectal testing, along with a substantial amount of anorectal-only infections.

Incidence of repeat testing and diagnoses of Chlamydia trachomatis and Neisseria gonorrhoea in swingers, homosexual and heterosexual men and women at two large Dutch STI clinics, 2006-2013.

OBJECTIVE: Swingers, that is, heterosexuals who as a couple have sex with others, including group sex and bisexual behaviour, are an older-aged risk group for STIs. Here, we report on their repeat testing (reattendance) and STI yield compared with other heterosexuals and men who have sex with men (MSM, homosexual men) at two Dutch STI clinics. METHODS: Swingers are routinely (since 2006, South Limburg, registration-completeness: 99%) or partially (since 2010, Amsterdam, registration-completeness: 20%) included in the clinic patient registries. Data (retrospective cohort) are analysed to assess incidence (per 100 person-years (PY)) of reattendance and STI (Chlamydia trachomatis (CT) and/or Neisseria gonorrhoeae (NG)) and associated factors calculating HRs. RESULTS: In South Limburg 7714 and in Amsterdam 2070 swinger consultations were identified. Since 2010, swingers' incidence of reattendance was 48-57/100 PY. Incidence was lower in MSM (30-39/100 PY, HR 0.56; 95% CI 0.51 to 0.61, South Limburg; HR 0.88; 95% CI 0.80 to 0.96, Amsterdam), heterosexual men (8-14/100 PY, HR 0.16; 95% CI 0.15 to 0.17, South Limburg; HR 0.33; 95% CI 0.30 to 0.36, Amsterdam) and women (13-20/100 PY, HR 0.56; 95% CI 0.51 to 0.61, South Limburg; HR 0.46; 95% CI 0.42 to 0.51, Amsterdam). Swingers' STI incidence at reattendance was 11-12/100 PY. Incidence was similar in heterosexual men (14-15/100 PY; HR 1.19; 95% CI 0.90 to 1.57, South Limburg; HR 1.20; 95% CI 0.91 to 1.59, Amsterdam) and women (12-14/100 PY; HR 1.14; 95% CI 0.88 to 1.49, South Limburg; HR 0.98; 95% CI 0.74 to 1.29, Amsterdam) and higher in MSM (18-22/100 PY; HR 1.59; 95% CI 1.19 to 2.12, South Limburg; HR 1.80; 95% CI 1.36 to 2.37, Amsterdam). Risk factors for STI incidence were partner-notified (contact-tracing), symptoms and previous STI. Swingers' positivity at any clinic attendance was 3-4% for NG (ie, higher than other heterosexuals) and 6-8% for CT (ie, lower than heterosexuals overall but higher than older heterosexuals). CONCLUSIONS: Systematic identification reveals that swingers are part of the normal STI clinic populations. They frequently repeat test yet are likely under-recognised in clinics which not routinely ask about swinging. Given swingers' notable STI rates, usage of services is warranted, although use may be restricted, that is, to those with an STI risk factor (as did Dutch clinics). As swingers have dense sexual networks, enhancing contact-tracing may have high impact.

What explains anorectal chlamydia infection in women? Implications of a mathematical model for test and treatment strategies.

OBJECTIVES: Female anorectal Chlamydia trachomatis (chlamydia) infections are common irrespective of recent anal sex. We explored the role of anorectal infections in chlamydia transmission and estimated the impact of interventions aimed at improved detection and treatment of anorectal infections. METHODS: We developed a pair compartmental model of heterosexuals aged 15-29 years attending STI clinics, in which women can be susceptible to or infected with chlamydia urogenitally and/or anorectally and men urogenitally. Transmission probabilities per vaginal and anal sex act, together with an autoinoculation probability, were estimated by fitting to anatomic site-specific prevalence data (14% urogenital; 11% anorectal prevalence). We investigated the 10-year reduction in female chlamydia prevalence of interventions (universal anorectal testing of female STI clinic attendees or doxycycline use for urogenital chlamydia) relative to continued current care (anorectal testing on indication and doxycycline for anorectal and azithromycin for urogenital chlamydia). RESULTS: The transmission probability per anal sex act was 5.8% (IQR 3.0-8.3%), per vaginal sex act 2.0% (IQR 1.7-2.2%) and the daily autoinoculation probability was 0.7% (IQR 0.5-1.0%). More anorectal chlamydia infections were caused by autoinoculation than by recent anal sex. Universal anorectal testing reduced population prevalence modestly with 8.7% (IQR 7.6-9.7%), yet the reduction was double that of doxycycline use for urogenital infections (4.3% (IQR 3.5-5.3%)) relative to continued current care. CONCLUSIONS: Autoinoculation between anatomic sites in women might play a role in sustaining high chlamydia prevalence. A shift to more anorectal testing of female STI clinic attendees may be considered for its (albeit modest) impact on reducing prevalence.

A comprehensive overview of urogenital, anorectal and oropharyngeal Neisseria gonorrhoeae testing and diagnoses among different STI care providers: a cross-sectional study.

BACKGROUND: Gonorrhoea, caused by Neisseria gonorrhoeae (NG), can cause reproductive morbidity, is increasingly becoming resistant to antibiotics and is frequently asymptomatic, which shows the essential role of NG test practice. In this study we wanted to compare NG diagnostic testing procedures between different STI care providers serving a defined geographic Dutch region (280,000 inhabitants). METHODS: Data on laboratory testing and diagnosis of urogenital and extragenital (i.e. anorectal and oropharyngeal) NG were retrieved from general practitioners (GPs), an STI clinic, and gynaecologists (2006-2010). Per provider, we assessed their contribution regarding the total number of tests performed and type of populations tested, the proportion of NG positives re-tested (3-12 months after treatment) and test-of-cure (TOC, within 3 months post treatment). RESULTS: Overall, 17,702 NG tests (48.7% STI clinic, 38.2% GPs, 13.1% gynaecologists) were performed during 15,458 patient visits. From this total number of tests, 2257 (12.7%) were extragenital, of which 99.4% were performed by the STI clinic. Men were mostly tested at the STI clinic (71%) and women by their GP (43%). NG positivity per visit was 1.6%; GP 1.9% (n = 111), STI clinic 1.7% (n = 131) and gynaecology 0.2% (n = 5). NG positivity was associated with Chlamydia trachomatis positivity (OR: 2.06, 95% confidence interval: 1.46-2.92). Per anatomical location, the proportion of NG positives re-tested were: urogenital 20.3% (n = 36), anorectal 43.6% (n = 17) and oropharyngeal 57.1% (n = 20). NG positivity among re-tests was 16.9%. Proportions of NG positives with TOC by anatomical location were: urogenital 10.2% (n = 18), anorectal 17.9% (n = 7) and oropharyngeal 17.1% (n = 6). CONCLUSIONS: To achieve best practice in relation to NG testing, we recommend that: 1) GPs test at extragenital sites, especially men who have sex with men (MSM), 2) all care providers consider re-testing 3 to 12 months after NG diagnosis and 3) TOC is performed following oropharyngeal NG diagnosis in settings which provide services to higher-risk men and women (such as STI clinics).

Antibiotic use before chlamydia and gonorrhea genital and extragenital screening in the sexually transmitted infection clinical setting.

Background antibiotic use (i.e., administration of antibiotics not directly related to Chlamydia trachomatis or Neisseria gonorrhoeae infections) has been associated with a lower prevalence of genital C. trachomatis infection in a clinical setting. Associations with specific antibiotic types or with N. gonorrhoeae are lacking. Here, we assessed the prevalence of antibiotic use, the different classes and agents used, and their association with a subsequent sexually transmitted infection (STI) clinic C. trachomatis and N. gonorrhoeae test result. At our STI clinic, we systematically registered whether antibiotics were used in the past month (in 29% of the cases, the specific antibiotic agent was named). Patients were screened for urogenital C. trachomatis and N. gonorrhoeae; a third of them were also screened for anorectal and oropharyngeal C. trachomatis and N. gonorrhoeae. The proportion of antibiotics used and their association with C. trachomatis and N. gonorrhoeae prevalence were assessed for heterosexual men, men who have sex with men (MSM), and women. During 14,775 clinic consultations, antibiotic use was reported by 12.2% (95% confidence interval [CI], 11.7% to 12.7%), i.e., 14.8% of women, 8.6% of heterosexual men, and 11.6% of MSM. The most reported antibiotics were penicillins, tetracyclines, and macrolides, respectively. The prevalence was 11.0% (95% CI, 10.3% to 11.3%) for C. trachomatis and 1.9% (95% CI, 1.7% to 2.1%) for N. gonorrhoeae. Only tetracycline use was associated with a lower C. trachomatis prevalence (3%). Overall antibiotic use was associated with lower anorectal C. trachomatis prevalence in MSM only (odds ratio, 0.4; 95% CI, 0.2 to 0.8). STI clinic visitors commonly report recent antibiotic use. Even in a country with low antibiotic consumption, tetracycline use impacted C. trachomatis prevalence, while there was a notable absence of association with azithromycin.