CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024.

No vaccines and few chemoprophylaxis options exist for the prevention of bacterial sexually transmitted infections (STIs) (specifically syphilis, chlamydia, and gonorrhea). These infections have increased in the United States and disproportionately affect gay, bisexual, and other men who have sex with men (MSM) and transgender women (TGW). In three large randomized controlled trials, 200 mg of doxycycline taken within 72 hours after sex has been shown to reduce syphilis and chlamydia infections by >70% and gonococcal infections by approximately 50%. This report outlines CDC's recommendation for the use of doxycycline postexposure prophylaxis (doxy PEP), a novel, ongoing, patient-managed biomedical STI prevention strategy for a selected population. CDC recommends that MSM and TGW who have had a bacterial STI (specifically syphilis, chlamydia, or gonorrhea) diagnosed in the past 12 months should receive counseling that doxy PEP can be used as postexposure prophylaxis to prevent these infections. Following shared decision-making with their provider, CDC recommends that providers offer persons in this group a prescription for doxy PEP to be self-administered within 72 hours after having oral, vaginal, or anal sex. The recommended dose of doxy PEP is 200 mg and should not exceed a maximum dose of 200 mg every 24 hours.Doxy PEP, when offered, should be implemented in the context of a comprehensive sexual health approach, including risk reduction counseling, STI screening and treatment, recommended vaccination and linkage to HIV PrEP, HIV care, or other services as appropriate. Persons who are prescribed doxy PEP should undergo bacterial STI testing at anatomic sites of exposure at baseline and every 3-6 months thereafter. Ongoing need for doxy PEP should be assessed every 3-6 months as well. HIV screening should be performed for HIV-negative MSM and TGW according to current recommendations.

Prevalence of cefixime-resistant Neisseria gonorrhoeae in Melbourne, Australia, 2021-2022.

While ceftriaxone remains the first-line treatment for gonorrhoea, the US CDC recommended cefixime as a second-line treatment in 2021. We tested 1176 Neisseria gonorrhoeae isolates among clients attending the Melbourne Sexual Health Centre in 2021-2022. The prevalence of cefixime resistance was 6.3% (74/1176), azithromycin resistance was 4.9% (58/1176) and ceftriaxone resistance was 0% (0/1176). Cefixime resistance was the highest among women (16.4%, 10/61), followed by men-who-have-sex-with-women (6.4%, 7/109), and men-who-have-sex-with-men (5.8%, 57/982). The prevalence of cefixime-resistant N. gonorrhoeae exceeds the threshold of the 5% resistance level recommended by the World Health Organization; and thus, cefixime treatment would have limited benefits in Australia.

Randomized Multicenter Trial for the Validation of an Easy-to-Administer Algorithm to Define Penicillin Allergy Status in Sexually Transmitted Infection Clinic Outpatients.

BACKGROUND: Approximately 15% of patients in sexually transmitted infection (STI) clinics report penicillin allergies, complicating treatment for syphilis and gonorrhea. Nonetheless, >90% do not have a penicillin allergy when evaluated. We developed and validated an algorithm to define which patients reporting penicillin allergy can be safely treated at STI clinics with these drugs. METHODS: Randomized controlled trial to assess feasibility and safety of penicillin allergy evaluations in STI clinics. Participants with reported penicillin allergy answered an expert-developed questionnaire to stratify risk. Low-risk participants underwent penicillin skin testing (PST) followed by amoxicillin 250 mg challenge or a graded oral challenge (GOC)-amoxicillin 25 mg followed by 250 mg. Reactions were recorded, and participant/provider surveys were conducted. RESULTS: Of 284 participants, 72 (25.3%) were deemed high risk and were excluded. Of 206 low-risk participants, 102 (49.5%) underwent PST without reactions and 3 (3%) had mild reactions during the oral challenge. Of 104 (50.5%) participants in the GOC, 95 (91.3%) completed challenges without reaction, 4 (4.2%) had mild symptoms after 25 mg, and 4 (4.2%) after 250-mg doses. Overall, 195 participants (94.7%) successfully completed the study and 11 (5.3%) experienced mild symptoms. Of 14 providers, 12 (85.7%) completed surveys and 11 (93%) agreed on the safety/effectiveness of penicillin allergy assessment in STI clinics. CONCLUSIONS: An easy-to-administer risk-assessment questionnaire can safely identify patients for penicillin allergy evaluation in STI clinics by PST or GOC, with GOC showing operational feasibility. Using this approach, 67% of participants with reported penicillin allergy could safely receive first-line treatments for gonorrhea or syphilis. Clinical Trials Registration. Clinicaltrials.gov (NCT04620746).

A Participatory Approach to Identifying Gaps in and Recommendations for Sexually Transmitted Infection and Preexposure Prophylaxis Clinical Services in Pierce County, Washington.

BACKGROUND: Pierce County, Washington, has a high burden of sexually transmitted infections (STIs) relative to Washington State and the United States. We used a participatory approach to identify gaps in STI and preexposure prophylaxis (PrEP) service provision in Pierce County and generate recommendations to address these gaps. METHODS: In collaboration with the Tacoma-Pierce County Health Department (TPCHD), we conducted 14 key informant interviews with local STI/PrEP providers from varied clinical settings. Using rapid qualitative analysis, we identified key gaps and strengths in service provision. Local, state, and national HIV/STI subject matter experts (SMEs) prioritized the gaps and recommendations to address them via an online survey. RESULTS: The primary 6 gaps ranked by SMEs (N = 32) in order of importance included the following: (1) inadequate availability of STI and PrEP services, (2) lack of awareness of STI and PrEP services, (3) need for free/low cost STI and PrEP care, (4) need for stronger relationships among providers and TPCHD, (5) reduced accessibility related to geographically distributed population and centralized services, and (6) frequent referrals pose a service barrier. Subject matter experts prioritized recommendations for each gap as follows: (1) create an STI specialty clinic, (2) implement an STI/PrEP service availability outreach campaign, (3) strengthen referral relationships between TPCHD and free/low-cost providers, (4) develop a provider support network, (5) create a mobile STI clinic, and (6) develop an STI specialty clinic. CONCLUSIONS: Sexually transmitted infection specialty clinics were prioritized by SMEs to improve access to STI and PrEP care in Pierce County, and to serve as a resource for local providers.

Oral sexual exposures can lead to viable rectal Chlamydia trachomatis infection.

BACKGROUND: Chlamydia trachomatis (CT) acquired orally may survive passage through the gastrointestinal tract and establish an infection in the rectum, but how often this occurs is unknown. METHODS: In 2019-2022 we enrolled individuals assigned male at birth who reported sex with men and denied receptive anal sex in the past 2 years. Participants enrolled at the Seattle Sexual Health Clinic or online. Participants completed a behavioral survey and self-collected rectal swabs for CT nucleic acid amplification testing (NAAT) and culture and viability PCR (vPCR). We defined oral exposures as fellatio, cunnilingus, and oral-anal (i.e., rimming). RESULTS: We enrolled 275 men; 60 (22%) reported only oral exposures in the past 12 months. Of these, five (8.3%) tested positive for rectal CT by NAAT; 1 (2%) had viable CT detected (culture-positive; vPCR-positive). Another 43 participants reported only oral exposures in the past 2 months but rectal exposures 3-12 months ago. Of these, 4 (9%) tested NAAT-positive for rectal CT; 1 had viable CT detected (culture-negative; vPCR-positive). CONCLUSIONS: Passage of CT from the mouth to the rectum occurs, but is most often nucleic acid remnants rather than viable bacteria. Nonetheless, it appears possible to establish a viable rectal CT infection via oral exposures.

Sexually Transmitted Infection Partner Services Outcomes Before and During the SARS-CoV-2 Pandemic in King County, WA.

BACKGROUND: SARS-CoV-2 pandemic mitigation efforts resulted in reallocation of public health personnel, likely impacting provision of timely sexually transmitted infection partner services (PS). We describe PS outcomes before and during the pandemic in King County, WA. METHODS: We examined PS outcomes for syphilis and gonorrhea cases diagnosed in 2019 and 3 periods in 2020 (pre-lockdown: January 1, 2020-March 23, 2020; lockdown: March 24, 2020-June 5, 2020; post-lockdown: June 6, 2020-December 31, 2020). We described changes over time in 3 PS outcomes: cases initiated, interviewed, and with named sex partners. We calculated adjusted prevalence ratios (aPRs) with Poisson regression comparing these outcomes in the 2020 periods with 2019. RESULTS: Reported gonorrhea (4611 vs. 4179) and syphilis (665 vs. 586) cases declined from 2019 to 2020. In 2019, 60.7% of cases were initiated, compared with 42.1% before lockdown (aPR, 0.74; 95% confidence interval [CI], 0.70%-0.78%), 41.7% during lockdown (aPR, 0.79; 95% CI, 0.73-0.85), and 41.7% after lockdown (aPR, 0.81; 95% CI, 0.77-0.85). Among initiated cases, the proportion interviewed also seemed to drop in the 3 lockdown periods (52.4%, 41.0%, 44.1%) compared with 2019 (55.7%). However, in adjusted analyses, the prevalence of interview among case patients was only lower pre-lockdown (aPR, 0.91; 95% CI, 0.85-0.99), and higher during (aPR, 1.10; 95% CI, 1.01-1.20) and after (aPR, 1.12; 95% CI, 1.06-1.19). Interviewed patients named partners more often during (21.4%; aPR, 1.35; 95% CI, 1.05-1.74) and less often after lockdown (16.0%; aPR, 0.63; 95% CI, 0.51-0.79), compared with 2019 (26.6%). CONCLUSIONS: These results underscore the need for a trained public health worker reserve, and plans for deployment of existing workers and prioritization of cases to continue essential sexually transmitted infection public health activities during public health crises.

Trans-inclusive Sexual Health Questionnaire to Improve Human Immunodeficiency Virus/Sexually Transmitted Infection (STI) Care for Transgender Patients: Anatomic Site-Specific STI Prevalence and Screening.

BACKGROUND: In 2018, the municipal Sexual Health Clinic in Seattle, implemented trans-inclusive questions about sexual behavior, anatomy, gender-affirming surgeries, and sexually transmitted infection (STI) symptoms in the clinic's computer-assisted self-interview (CASI) to improve care for transgender and nonbinary (TNB) patients. METHODS: We calculated test positivity, the proportion of TNB patient visits that received testing for human immunodeficiency virus (HIV); syphilis; pharyngeal, rectal, and urogenital gonorrhea (GC); and chlamydia (CT) before (5/2016-12/2018) and after (12/2018-2/2020) implementation of new CASI questions, and the proportion of asymptomatic patients who received anatomic site-specific screening based on reported exposures. RESULTS: There were 434 TNB patients with 489 and 337 clinic visits during each period, respectively. Nonbinary patients assigned male at birth (AMAB) had the highest prevalence of GC (10% pharyngeal, 14% rectal, 12% urogenital). Transgender women, transgender men, and nonbinary people AMAB had a high prevalence of rectal CT (10%, 9%, and 13%, respectively) and syphilis (9%, 5%, and 8%). Asymptomatic transgender women, transgender men, and nonbinary patients AMAB were more likely to receive extragenital GC/CT screening compared with nonbinary patients assigned female at birth. After implementation of trans-inclusive questions, there was a 33% increase in the number of annual TNB patient visits but no statistically significant increase in HIV/STI testing among TNB patients. CONCLUSIONS: TNB people had a high prevalence of extragenital STIs and syphilis. Implementation of trans-inclusive medical history questions at a clinic that serves cisgender and transgender patients was feasible and important for improving the quality of affirming and inclusive sexual healthcare.

Prior Exposure to Azithromycin and Azithromycin Resistance Among Persons Diagnosed With Neisseria gonorrhoeae Infection at a Sexual Health Clinic: 2012-2019.

BACKGROUND: There is conflicting evidence on whether prior azithromycin (AZM) exposure is associated with reduced susceptibility to AZM (AZMRS) among persons infected with Neisseria gonorrhoeae (NG). METHODS: The study population included Public Health-Seattle and King County Sexual Health Clinic (SHC) patients with culture-positive NG infection at ≥1 anatomic site whose isolates were tested for AZM susceptibility in 2012-2019. We used multivariate logistic regression to examine the association of time since last AZM prescription from the SHC in ≤12 months with subsequent diagnosis with AZMRS NG (minimum inhibitory concentration [MIC], ≥2.0 µg/mL) and used linear regression to assess the association between the number of AZM prescriptions in ≤12 months and AZM MIC level, controlling for demographic, behavioral, and clinical characteristics. RESULTS: A total of 2155 unique patients had 2828 incident NG infections, 156 (6%) of which were caused by AZMRS NG. AZMRS NG was strongly associated with receipt of AZM from the SHC in the prior 29 days (adjusted odds ratio, 6.76; 95% confidence interval [CI], 1.76 to 25.90) but not with receipt of AZM in the prior 30-365 days. Log AZM MIC level was not associated with the number of AZM prescriptions within ≤12 months (adjusted correlation, 0.0004; 95% CI, -.04 to .037) but was associated with number of prescriptions within <30 days (adjusted coefficient, 0.56; 95% CI, .13 to .98). CONCLUSIONS: Recent individual-level AZM treatment is associated with subsequent AZMRS gonococcal infections. The long half-life and persistence of subtherapeutic levels of AZM may result in selection of resistant NG strains in persons with recent AZM use.

A Quantitative Intersectionality Analysis of HIV/STI Prevention and Healthcare Access Among Transgender and Nonbinary People.

BACKGROUND: Transgender and nonbinary people experience substantial barriers to accessing healthcare, including prevention of HIV and other sexually transmitted infections (HIV/STI), due to structural inequities. We examined differences in insurance, HIV/STI prevalence, testing, and preexposure prophylaxis use among transgender and nonbinary people living in Washington State by race and ethnicity and gender. METHODS: We pooled data from five 2019-2021 Washington State HIV/STI surveillance data sources to obtain a large and diverse sample of 1648 transgender and nonbinary participants. We calculated the risk difference (RD) for each outcome and used Poisson regression to estimate a surrogate measure of additive interaction-attributable proportion (AP)-that measures the proportion of the excess prevalence of the outcome observed at the intersection of gendered and racialized experience, beyond that expected from gender or race and ethnicity alone. RESULTS: Participants reported overall high levels of poverty (29% incomes <$15,000 and 7% unstable housing). Certain groups, especially racial/ethnic minority transgender women, were disproportionately impacted by HIV/STIs (RDs from 20% to 43% and APs from 50% to 85%) and less likely to currently have insurance (RDs from 25% to 39% and APs from 74% to 93%) than that expected based on gendered or racialized experience alone. CONCLUSIONS: Our findings highlight the heterogeneity in insurance access, HIV/STI positivity, and prevention utilization within transgender communities. We observed that a large proportion of increased HIV/STI prevalence among racial/ethnic minority transgender women was attributable to the intersection of gender and race and ethnicity. Our findings highlight the importance of trans-inclusive models of HIV/STI prevention that address multilevel barriers rooted in cissexism and structural racism.

Inadequate performance of a risk score to predict asymptomatic Neisseria gonorrhoeae and Chlamydia trachomatis infection among cisgender men who have sex with men.

OBJECTIVES: Epidemiological treatment of persons who are sexual contacts to partners with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) often results in treatment of uninfected persons, which may increase the risk of antibiotic-resistant infections. We sought to identify the predictors of NG and/or CT infections to develop a risk score that could be used to limit epidemiological treatment to persons most likely to have these infections. METHODS: We included visits to the Public Health - Seattle & King County Sexual Health Clinic by asymptomatic cisgender men who have sex with men (MSM) aged ≥18 who presented as a sexual contact to partner(s) with CT or NG infection between 2011 and 2019. We used logistic regression to estimate the odds of CT and/or NG infections associated with demographic and clinical predictors, selecting the final set of predictors using the Akaike information criteria and obtaining score weights from model coefficients. We used a cross-validation approach to obtain average model discrimination from each of 10 models, leaving out 10% of the data, and evaluated sensitivity and specificity at various score cut-offs. RESULTS: The final model for predicting NG or CT infection included seven predictors (age <35 years, HIV status, receptive oral sex in the prior 2 months, CT diagnosis, condomless receptive anal intercourse, condomless insertive anal intercourse and methamphetamine use in the prior 12 months). Model discrimination, as measured by the receiver operating curve, was 0.60 (95% CI 0.54 to 0.66). Sensitivity for detection of infection was ≥90% for scores ≥3, ≥5 and ≥7; specificity for these cut-offs was <16%. At scores ≥9, ≥12 and ≥14, specificity increased but sensitivity decreased to ≤76%. CONCLUSIONS: Our risk score did not sufficiently discriminate between asymptomatic MSM with and without NG/CT infection. Additional studies evaluating epidemiological treatment as a standard of care in diverse populations are needed to guide best practices in the management of contacts to NG/CT infection.

Pharyngeal Gonorrhea in Heterosexual Male and Female Sex Partners of Persons With Gonorrhea.

BACKGROUND: Current guidance from the US Centers for Disease Control and Prevention recommends empiric treatment for persons exposed to sexually transmitted infections, including Neisseria gonorrhoeae ( NG ). As an antimicrobial stewardship measure, some clinics now recommend a test and treat strategy, but reliance on urogenital testing only may miss cases. METHODS: We conducted a descriptive analysis of pharyngeal NG infection in men who have sex with women (MSW) and women seeking care at a sexual health clinic in Seattle, WA, from February 2017 to July 2021 because of sexual contact to a partner diagnosed with gonorrhea. We also explored behavioral factors associated with pharyngeal NG positivity (by culture or nucleic acid amplification test by χ2 analysis. RESULTS: Among 352 NG contacts tested for urogenital or pharyngeal infection, 34% were positive for NG at ≥1 anatomic site (27% for MSW and 40% for women). Among 161 NG contacts tested at the pharynx, 30% (n = 48) were positive: 20% of 54 MSW (n = 11) and 35% (n = 37) of 107 women. If only urogenital testing were performed, 36% of MSW NG infections (n = 5) and 19% of female NG infections (n = 9) would have remained unidentified. CONCLUSIONS: Pharyngeal NG is relatively common among MSW and women who have been exposed to NG, and likely represents an underdiagnosed reservoir of NG infection. If empiric treatment is abandoned in favor of testing and treating, testing the throats of heterosexuals will be necessary.

Heterogeneity in HIV/Sexually Transmitted Infection Prevalence and Prevention Among the Partners of Transgender and Nonbinary People.

BACKGROUND: Transgender and nonbinary (TNB) people are diverse in their sexual orientation and partnerships. We describe the epidemiology of HIV/sexually transmitted infection (STI) prevalence and prevention utilization among the partners of TNB people in Washington State. METHODS: We pooled data from five 2017 to 2021 cross-sectional HIV surveillance data sources to generate a large sample of TNB people and cisgender people who had a TNB partner in the past year. We described characteristics of recent partners of trans women, trans men, and nonbinary people and used Poisson regression to assess if having a TNB partner was associated with self-reported HIV/STIs prevalence, testing, and preexposure prophylaxis (PrEP) use. RESULTS: Our analysis included 360 trans women, 316 trans men, 963 nonbinary people, 2896 cis women, and 7540 cis men. Overall, 9% of sexual minority cis men, 13% of sexual minority cis women, and 36% of TNB participants reported having any TNB partners. There was significant heterogeneity in HIV/STI prevalence, testing, and PrEP use among the partners of TNB people by study participant gender and the gender of their sex partners. In regression models, having a TNB partner was associated with a higher likelihood of HIV/STI testing and PrEP use but was not associated with higher HIV prevalence. CONCLUSIONS: We observed significant heterogeneity in HIV/STI prevalence and preventative behaviors among the partners of TNB people. Given that TNB people are diverse in their sexual partnerships, there is a need to better understand individual-, dyad-, and structural-level factors that facilitate HIV/STI prevention across these diverse partnerships.

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

BACKGROUND: In the United States, annual screening for rectal gonorrhea and chlamydia is only recommended for men who report receptive anal sex (RAS), but other behaviors (e.g., rimming) may lead to rectal Chlamydia trachomatis and Neisseria gonorrhoeae acquisition. METHODS: We enrolled individuals assigned male sex at birth who reported sex with men and denied RAS in the past 2 years or reported RAS 1 to 2 years ago but were tested and treated since last RAS. Participants enrolled in-person at the Sexual Health Clinic in Seattle, Washington (December 2019-July 2022), or online (July 2021-March 2022). Participants completed a survey that asked about 13 non-RAS behaviors and self-collected a rectal swab for gonorrhea/chlamydia nucleic acid amplification testing. We used log binomial regression to estimate the prevalence of rectal gonorrhea/chlamydia (adjusted prevalence ratio [aPR]) by behavior, adjusting for all other behaviors. RESULTS: We enrolled 292 participants (247 in-person and 45 online); 277 (95%) had nucleic acid amplification testing results. Rectal gonorrhea/chlamydia test positivity was 14.1% overall: 10.5% for rectal chlamydia and 4.3% for rectal gonorrhea. Most participants (70%) reported ≥1 behavior that involved direct contact with their anus. We observed a higher risk of rectal chlamydia for those who did versus did not report perianal play at 12 months (aPR, 2.39; 95% confidence interval, 1.10-5.22) and 2 months (aPR, 2.21; 95% confidence interval, 1.02-4.79). This was the only behavior significantly associated with testing positive. CONCLUSIONS: Rectal C. trachomatis and N. gonorrhoeae prevalence was high among men who deny RAS, suggesting other possible routes of acquisition. Rectal screening for those who deny RAS should be made with careful consideration of individual- and population-level effects.

Safety of Longer-Term Doxycycline Use: A Systematic Review and Meta-Analysis With Implications for Bacterial Sexually Transmitted Infection Chemoprophylaxis.

BACKGROUND: Sexually transmitted infections (STIs) such as syphilis, gonorrhea, and chlamydia have significantly increased over the past decade in the United States. Doxycycline as chemoprophylaxis (i.e., postexposure prophylaxis) offers promise for addressing bacterial STIs. The goal of the current study was to evaluate the safety of longer-term doxycycline use (defined as 8 or more weeks) in the context of potential use as STI chemoprophylaxis through a systematic literature review and meta-analysis. METHODS: This review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to search MEDLINE/PubMed for clinical studies published from August 2003 to January 2023 that reported on adverse events with doxycycline use with a focus on side effects and metabolic effects of long-term use. RESULTS: A total of 67 studies were included in the systematic review. Overall, studies on longer-term doxycycline use reported 0% to greater than 50% adverse events ranging from mild to severe. Most common adverse events included gastrointestinal symptoms (i.e., nausea, vomiting, and abdominal pain), dermatologic (i.e., rash), and neurological (i.e., headache and dizziness) symptoms. Discontinuation of doxycycline due to adverse events was relatively uncommon in most studies. A meta-analysis of placebo controlled clinical trials (N = 18) revealed that gastrointestinal and dermatological adverse events were more likely to occur in the doxycycline group. CONCLUSIONS: Longer-term (8+ weeks) doxycycline use is generally safe and may be associated with minor side effects. Further research is needed on the potential metabolic impact of longer-term doxycycline use.

Previous Sexually Transmitted Infections and Partner Services Interviews as Predictors of Subsequent Interview Completion Among Cisgender MSM: Partner Services Fatigue?

BACKGROUND: Anecdotal reports suggest that partner services (PS) are less successful among people with repeat sexually transmitted infection (STI) diagnoses and/or previous PS interactions. We examine whether having repeated STI diagnoses and/or PS interactions is associated with PS outcomes among men who have sex with men (MSM). METHODS: With STI surveillance and PS data for MSM diagnosed with gonorrhea, chlamydia, and/or syphilis from 2007 to 2018, in King County, WA, we used Poisson regression models to examine the relationships between PS outcomes (e.g., completing a PS interview and providing identifying information for a contact) with (1) number of previous STI case episodes and (2) number of previous PS interviews completed. RESULTS: Of the 18,501 MSM STI case patients initiated for interview in the analytic period (2011-2018), 13,232 (72%) completed a PS interview, and 8,030 (43%) had at least 1 prior PS interview. The proportion of initiated cases successfully interviewed declined from 71% among those with no previous PS interview to 66% among those with ≥3 prior interviews. Similarly, the proportion of interviews with ≥1 partner identified declined with greater numbers of previous PS interviews (from 46% [0 interviews] to 35% [≥3 interviews]). In multivariate models, having ≥1 prior PS interview was negatively associated with completing a subsequent interview and providing partner locating information. CONCLUSIONS: Having a history of STI PS interviews is associated with less PS engagement among MSM. New approaches to PS should be explored to address the growing epidemic of STIs among MSM.

Frequency and Combination of Sequential Sexual Acts That May Lead to Sexually Transmitted Infections at Different Anatomic Sites Within the Same Person.

Modeling studies suggest that transmission of gonorrhea and chlamydia to multiple anatomic sites within the same person is necessary to reproduce observed high rates of extragenital gonorrhea/chlamydia. Limited empiric behavioral data support this idea. In this cross-sectional study, we enrolled individuals assigned male at birth who reported sex with men (MSM) and denied receptive anal sex (RAS) in the past 2 years. Participants enrolled in-person at the Sexual Health Clinic in Seattle, Washington (December 2019-September 2021) or online (July 2021-September 2021), and completed a sexual history questionnaire that asked about specific sexual acts and sequence of those acts during their last sexual encounter. We enrolled 210 MSM during the 16-month recruiting period. The median number of sex acts reported at last sexual encounter was 4 (interquartile range 3-5). The most commonly reported acts at last sex were: kissing (83%), receiving oral sex (82%), and insertive anal sex (65%). There was substantial variability in the sequence of acts reported; no unique sequence of sex acts was reported by more than 12% of the population. Ninety percent of participants reported sequences of behaviors that could lead to gonorrhea or chlamydia transmission within the same person (respondent or partner); the most common of these combinations was kissing followed by receiving oral sex (64% reporting). Engaging in multiple sex acts within a single sexual encounter is common and may lead to gonorrhea/chlamydia transmission within the same person. This complicates empiric measurements of transmission probabilities needed to estimate population-level transmission.

Management of Neisseria gonorrhoeae in the United States: Summary of Evidence From the Development of the 2020 Gonorrhea Treatment Recommendations and the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Treatment Guidelines.

INTRODUCTION: Neisseria gonorrhoeae has developed resistance to all first-line recommended therapies, making gonococcal antimicrobial resistance a major public health concern given limited antibiotic options currently and an even smaller antimicrobial development pipeline. Since the release of the Centers for Disease Control and Prevention (CDC) 2015 STD Treatment Guidelines, azithromycin, part of the 2015 dual-drug treatment regimen, has had a rapid rise in resistance. The 2020 CDC Gonorrhea Treatment Recommendations and the 2021 Sexually Transmitted Infections (STI) Treatment Guidelines were developed weighing the priorities of treating the individual, protecting the population, and preventing antimicrobial resistance. METHODS: Gonorrhea subject matter experts (SME) generated 8 key questions and conducted a literature review of updated data from 2013 to 2019 on gonorrhea antimicrobial resistance, treatment failures, clinical trials, and other key topics. More than 2200 abstracts were assessed, and 248 clinically relevant articles were thoroughly reviewed. SMEs also evaluated N gonorrhoeae antimicrobial resistance data from the Gonococcal Isolate Surveillance Project (GISP). EVIDENCE: Although there have been reports of ceftriaxone treatment failures internationally, GISP data suggest that ceftriaxone minimal inhibitory concentrations (MICs) have remained stable in the United States, with < 0.1% exhibiting an "alert value" MIC (> 0.25 mcg/mL). However, GISP documented a rapid rise in the proportion of isolates with an elevated MIC (≥ 2.0 mcg/mL) to azithromycin-nearly 5% in 2018. At the same time, new pharmacokinetic/pharmacodynamic data are available, and there is greater recognition of the need for antimicrobial stewardship. SUMMARY: The 2021 CDC STI Treatment Guidelines now recommend 500mg ceftriaxone intramuscularly once for the treatment of uncomplicated gonorrhea at all anatomic sites. If coinfection with chlamydia has not been excluded, cotreatment with doxycycline 100mg twice daily for 7 days should be added. Few alternative therapies exist for persons with cephalosporin allergies; there are no recommended alternative therapies for N gonorrhoeae infection of the throat.

Incidence and Duration of Pharyngeal Chlamydia Among a Cohort of Men Who Have Sex With Men.

BACKGROUND: The prevalence of pharyngeal chlamydia is low, but its incidence and duration are unknown. A high incidence or duration may support the role of pharyngeal chlamydia in sustaining chlamydia transmission. METHODS: From March 2016 to December 2018, we enrolled men who have sex with men (MSM) in a 48-week cohort study in Seattle, Washington. Participants self-collected pharyngeal specimens weekly. We tested specimens using nucleic acid amplification testing at the conclusion of the study. In primary analyses, we defined incident pharyngeal chlamydia as >2 consecutive weeks of a positive pharyngeal specimen. In sensitivity analyses, we defined incident chlamydia as >1 week of a positive specimen. We estimated duration of pharyngeal chlamydia, censoring at loss to follow-up, receipt of antibiotics, or end of study. RESULTS: A total of 140 participants contributed 70.5 person-years (PY); 1.4% had pharyngeal chlamydia at enrollment. In primary analyses, there were 8 pharyngeal chlamydia cases among 6 MSM (incidence = 11.4 per 100 PY; 95% confidence interval [CI]: 6.0-21.9). In sensitivity analysis, there were 19 cases among 16 MSM (incidence = 27.1 per 100 PY; 95% CI: 18.5-39.8). The median duration was 6.0 weeks (95% CI: 2.0-undefined) in primary analysis and 2.0 weeks (95% CI: 1.1-6.0) in sensitivity analysis. Duration was shorter for those with a history of chlamydia compared with those without (3.6 vs 8.7 weeks; P = .02). CONCLUSIONS: Pharyngeal chlamydia has a low incidence and duration relative to other extragenital sexually transmitted infections. Its contribution to population-level transmission remains unclear.

The Natural History of Rectal Gonococcal and Chlamydial Infections: The ExGen Study.

BACKGROUND: The duration of rectal gonococcal and chlamydial infection remains unknown. This basic epidemiologic parameter is needed to understand transmission dynamics. METHODS: We conducted a prospective, longitudinal, observational cohort study of 140 men who have sex with men (MSM) at risk of gonorrhea and chlamydia acquisition. For 48 weeks, enrolled men collected rectal swabs (Aptima multi-test kit) at home and responded to an electronic survey about sexual behavior and health conditions weekly. Swabs remained untested until participants completed the study. We used Kaplan-Meier estimates to determine the median duration of infection, censoring infections for treatment, loss to follow-up, and end-of-study. We used log-rank test to compare duration of infection by human immunodeficiency virus (HIV) status, history of infection with gonorrhea or chlamydia, and coinfection with the other pathogen. RESULTS: 140 enrolled MSM contributed 70.5 person-years of follow-up. Eighteen men had 20 incident rectal gonococcal infections, which persisted for 2-23 weeks; 30% were censored for treatment. The estimated median duration of rectal gonorrhea was 9 weeks (95% confidence interval [CI]: 3-12 weeks). Twenty-four men experienced 32 rectal chlamydial infections, persisting between 2 and 42 weeks; 60% were censored. The estimated duration of rectal chlamydia was 13 weeks (95% CI: 6 weeks-undefined). There were no differences in the duration of rectal gonorrhea or chlamydia by HIV status, history of chlamydia/gonorrhea, or coinfection. CONCLUSIONS: On average, rectal gonorrhea and chlamydial infections last 2-3 months, although some infections persisted for 6-11 months. Further understanding into predictors of persistence is needed.

Time to Clearance of Neisseria gonorrhoeae RNA at the Pharynx following Treatment.

The number of days until pharyngeal Neisseria gonorrhoeae nucleic acid amplification test (NAAT) results become negative after treatment remains unknown. Between March 2019 and April 2021, we enrolled men who have sex with men (MSM) who had a clinical positive pharyngeal N. gonorrhoeae Aptima Combo 2 test result but had not yet been treated in a prospective longitudinal cohort study. MSM were enrolled on their day of treatment and self-collected daily pharyngeal specimens for 21 days at home. We used Kaplan-Meier estimates to determine the median time to clearance and the >95% time to clearance and the log rank test for equality to evaluate factors associated with time to clearance. Sixty-four men were enrolled in the study. Analyses excluded 8 men (12.5%) who were N. gonorrhoeae negative by NAAT at enrollment and 11 (17%) who failed to return any home-collected specimens. Among the 45 men included in the analysis, the median time to N. gonorrhoeae NAAT clearance was 3 days (95% confidence interval [CI], 2 to 5 days). Time to clearance for >95% of the cohort was 12 days (95% CI, 10 days to an undefined time). Men with a history of N. gonorrhoeae infection cleared faster than men without such history (8 days versus 17 days for >95% time to clearance; P = 0.03). In the absence of reexposure, positive N. gonorrhoeae Aptima Combo 2 assay results obtained prior to 12 days after treatment are likely false-positive results.