Narrative Review: Assessment of Neisseria gonorrhoeae Infections Among Men Who Have Sex With Men in National and Sentinel Surveillance Systems in the United States

Factors Associated With Delays in Presentation and Treatment of Gonorrhea, Massachusetts 2015-2019

BACKGROUND

Rates of gonorrhea are increasing across the United States. Understanding and addressing contributing factors associated with longer time to diagnosis and treatment may shorten the duration of infectiousness, which in turn may limit transmission.

METHODS

We used Massachusetts data from the US Centers for Disease Control and Prevention Sexually Transmitted Disease Surveillance Network collected between July 2015 and September 2019, along with routinely reported surveillance data, to assess time from gonorrhea symptom onset to presentation to care, and time from presentation to care to receipt of treatment. Factors associated with longer time to presentation (TTP) and time to treatment (TTT) were assessed using Cox proportional hazard models with a constant time variable.

RESULTS

Among symptomatic patients (n = 672), 31% did not receive medical care within 7 days of symptom onset. Longer TTP was associated with younger age, female gender, reporting cost as a barrier to care, and provider report of proctitis. Among patients with symptoms and/or known contact to gonorrhea (n = 827), 42% did not receive presumptive treatment. Longer TTT was associated with female gender, non-Hispanic other race/ethnicity, and clinics with less gonorrhea treatment experience. Among asymptomatic patients without known exposure to STI (n = 235), 26% did not receive treatment within 7 days. Longer TTT was associated with sexually transmitted disease clinic/family planning/reproductive health clinics and a test turnaround time of ≥3 days.

CONCLUSIONS

Delays in presentation to care and receipt of treatment for gonorrhea are common. Factors associated with longer TTP and TTT highlight multiple opportunities for reducing the infectious period of patients with gonorrhea.

Diverging Neisseria gonorrhoeae Morbidity in Non-Hispanic Black and White Females: Application of Group-Based Trajectory Modeling to Trends in County-Level Morbidity 2003-2018

National trends in gonorrhea rates may obscure informative local variations in morbidity. We used group-based trajectory models to identify groups of counties with similar gonorrhea rate trajectories among non-Hispanic White (NHW) and non-Hispanic Black (NHB) females using county-level data on gonorrhea cases in US females from 2003 to 2018. We assessed models with 1-15 groups and selected final models based on fit statistics and identification of divergent trajectory groups with distinct intercepts and/or slopes. We mapped counties by assigned trajectory group and examined the association of county characteristics with group membership. We identified 7 distinct gonorrhea trajectory groups for NHW females and 9 distinct trajectory groups for NHB females. All identified groups for NHW female morbidity experienced increasing gonorrhea rates with a limited range (11.6-183.3/100,000 NHW females in 2018); trajectories of NHB female morbidity varied widely in rates (146.6-966.0/1000 NHB females in 2018) and included 3 groups of counties that experienced a net decline in gonorrhea rates. Counties with higher NHW female morbidity had lower adult sex ratios, lower health insurance coverage, and lower marital rates among NHW adults. Counties with higher NHB female morbidity were more urban, experienced higher rates of poverty, and had lower rates of marriage among NHB adults. Morbidity patterns did not always follow geographic proximity, which could be explained by variation in social determinants of health. Our results demonstrated a highly heterogenous gonorrhea epidemic among NHW and NHB US females, which should prompt further analysis into the differential drivers of gonorrhea morbidity.

Non-conventional interventions to prevent gonorrhea or syphilis among men who have sex with men: A scoping review

Objectives

We assessed nonconventional interventions that did not traditionally focus on increasing condom use and/or testing among men who have sex with men (MSM) and the evidence for these interventions.

Methods

Guided by the Participants, Concept and Context (PCC) framework, we searched five online databases from inception to 9 August 2021 for original research on interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis in MSM. Two researchers screened titles and abstracts to assess eligibility, reviewed articles' full text and resolved discrepancies through discussion. We charted relevant study information, and the included studies were critically appraised.

Results

Of 373 articles retrieved, 13 studies were included. These studies were conducted in Australia (n = 3), Belgium (n = 2), China (n = 3), the Netherlands (n = 1) and the US (n = 4). Two randomized controlled trials (RCTs) of doxycycline as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) reduced any STI incidence (gonorrhea, syphilis, or chlamydia), but only doxycycline PEP significantly reduced syphilis incidence. Six studies of interventions that facilitated self-collection, self-examination, and self-testing, found varied evidence for gonorrhea and/or syphilis prevention. Four RCTs and one single-arm trial examined the efficacy of mouthwash, but the evidence remains inconclusive on whether mouthwash use can prevent transmission between men.

Conclusion

We found evidence for doxycycline PEP in reducing syphilis incidence, evidence on the use of mouthwash to prevent gonorrhea transmission between men remains inconclusive. More evidence is needed for interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis.

Antimicrobial Susceptibility of Urogenital and Extragenital Neisseria gonorrhoeae Isolates Among Men Who Have Sex With Men: Strengthening the US Response to Resistant Gonorrhea and Enhanced Gonococcal Isolate Surveillance Project, 2018 to 2019

BACKGROUND

We investigated differences in gonococcal antimicrobial susceptibility by anatomic site among cisgender men who have sex with men (MSM) using specimens collected through the Centers for Disease Control and Prevention's enhanced Gonococcal Isolate Surveillance Project and Strengthening the US Response to Resistant Gonorrhea.

METHODS

During the period January 1, 2018-December 31, 2019, 12 enhanced Gonococcal Isolate Surveillance Project and 8 Strengthening the US Response to Resistant Gonorrhea sites collected urogenital, pharyngeal, and rectal isolates from cisgender MSM in sexually transmitted disease clinics. Gonococcal isolates were sent to regional laboratories for antimicrobial susceptibility testing by agar dilution. To account for correlated observations, linear mixed-effects models were used to calculate geometric mean minimum inhibitory concentrations (MICs), and mixed-effects logistic regression models were used to calculate the proportion of isolates with elevated or resistant MICs; comparisons were made across anatomic sites.

RESULTS

Participating clinics collected 3974 urethral, 1553 rectal, and 1049 pharyngeal isolates from 5456 unique cisgender MSM. There were no significant differences in the geometric mean MICs for azithromycin, ciprofloxacin, penicillin, and tetracycline by anatomic site. For cefixime and ceftriaxone, geometric mean MICs for pharyngeal isolates were higher compared with anogenital isolates (P < 0.05). The proportion of isolates with elevated ceftriaxone MICs (≥0.125 μg/mL) at the pharynx (0.67%) was higher than at rectal (0.13%) and urethral (0.18%) sites (P < 0.05).

CONCLUSIONS

Based on data collected from multijurisdictional sentinel surveillance projects, antimicrobial susceptibility patterns of Neisseria gonorrhoeae isolates may differ among MSM at extragenital sites, particularly at the pharynx. Continued investigation into gonococcal susceptibility patterns by anatomic site may be an important strategy to monitor and detect the emergence of antimicrobial resistant gonorrhea over time.

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.

More Screening or More Disease? Gonorrhea Testing and Positivity Patterns Among Men in 3 Large Clinical Practices in Massachusetts, 2010-2017

BACKGROUND

Gonorrhea diagnosis rates in the United States increased by 75% during 2009-2017, predominantly in men. It is unclear whether the increase among men is being driven by more screening, an increase in the prevalence of disease, or both. We sought to evaluate changes in gonorrhea testing patterns and positivity among men in Massachusetts.

METHODS

The analysis included men (aged ≥15 years) who received care during 2010-2017 in 3 clinical practice groups. We calculated annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive result, among men tested. Log-binomial regression models were used to examine trends in these outcomes. We adjusted for clinical and demographic characteristics that may influence the predilection to test and probability of gonorrhea disease.

RESULTS

On average, 306 348 men had clinical encounters each year. There was a significant increase in men with ≥1 gonorrhea test from 2010 (3.1%) to 2017 (6.4%; adjusted annual risk ratio, 1.12; 95% confidence interval, 1.12-1.13). There was a significant, albeit lesser, increase in the percentage of tested men with ≥1 positive result (1.0% in 2010 to 1.5% in 2017; adjusted annual risk ratio, 1.07; 95% confidence interval, 1.04-1.09).

CONCLUSIONS

We estimated significant increases in the annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive gonorrhea test result between 2010 and 2017. These results suggest that observed increases in gonorrhea rates could be explained by both increases in screening and the prevalence of gonorrhea.

Comparison of Trends in Rates of Sexually Transmitted Infections Before vs After Initiation of HIV Preexposure Prophylaxis Among Men Who Have Sex With Men

IMPORTANCE

There have been concerns that HIV preexposure prophylaxis (PrEP) may be associated with increases in sexually transmitted infections (STIs) because of subsequent reductions in condom use and/or increases in sexual partners.

OBJECTIVE

To determine trends in STI test positivity among high-risk men who have sex with men (MSM) before and after the start of HIV PrEP.

DESIGN, SETTING, AND PARTICIPANTS

A before-after analysis was conducted using a subcohort of a single-group PrEP implementation study cohort in New South Wales, Australia (Expanded PreEP Implementation in Communities in New South Wales [EPIC-NSW]), from up to 1 year before enrollment if after January 1, 2015, and up to 2 years after enrollment and before December 31, 2018. STI testing data were extracted from a network of 54 sexual health clinics and 6 primary health care clinics Australia-wide, using software to deidentify, encrypt, and anonymously link participants between clinics. A cohort of MSM dispensed PrEP for the first time during the study, with 2 or more STI tests in the prior year and who tested during follow-up, were included from the EPIC-NSW cohort of HIV-negative participants with high-risk sexual behavior. Data analysis was performed from June to December 2019.

EXPOSURES

Participants were dispensed coformulated tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP.

MAIN OUTCOMES AND MEASURES

The main outcome was STI, measured using test positivity, defined as the proportion of participants testing positive for an STI at least once per quarter of follow-up. Outcomes were calculated for Chlamydia trachomatis and Neisseria gonorrhoea by site of infection (anorectal, pharyngeal, urethral, or any) and for syphilis.

RESULTS

Of the EPIC-NSW cohort of 9709 MSM, 2404 were included in the before-after analysis. The mean (SD) age of the participants was 36 (10.4) years, and 1192 (50%) were Australia-born. STI positivity was 52% in the year after PrEP (23.3% per quarter; 95% CI, 22.5%-24.2% per quarter) with no significant trend (mean rate ratio [RR] increase of 1.01 per quarter [95% CI, 0.99-1.02]; P = .29), compared with 50% positivity in the year prior to PrEP (20.0% per quarter [95% CI, 19.04%-20.95% per quarter]; RR for overall STI positivity, 1.17 [95% CI, 1.10-1.24]; P < .001), with an increase in quarterly STI positivity (mean RR of 1.08 per quarter, or an 8% increase per quarter [95% CI, 1.05-1.11]; P < .001; RR, 0.93 [95% CI, 0.90-0.96]; P < .001). Findings were similar when stratified by specific STIs and anatomical site.

CONCLUSIONS AND RELEVANCE

STI rates were high but stable among high-risk MSM while taking PrEP, compared with a high but increasing trend in STI positivity before commencing PrEP. These findings suggest the importance of considering trends in STIs when describing how PrEP use may be associated with STI incidence.

Associations between oral sex practices and frequent mouthwash use in men who have sex with men: implications for gonorrhoea prevention

Background Rates of gonorrhoea continue to rise among men who have sex with men (MSM) in Australia and worldwide. Recently, it has been proposed that oropharyngeal gonorrhoea may play a role in its onward transmission and that mouthwash use may be an effective intervention for gonorrhoea prevention and control. The objective of this study was to determine the association between specific oral sex practices and frequency of mouthwash use.

METHODS

A questionnaire-based study was conducted among MSM attending the Melbourne Sexual Health Centre in Australia from March to September 2015. Logistic regression was performed to examine the association between frequent mouthwash use (i.e. daily or weekly mouthwash use) and four oral sex practices (tongue kissing, receptive fellatio with or without ejaculation, and insertive rimming) among MSM.

RESULTS

Of the 918 MSM included in the final analysis, 490 men (53.4%) were frequent mouthwash users. Participants aged 24-34 years were 2.13-fold (95% CI 1.52-2.98) and those ≥35 years were 2.64-fold (95% CI 1.83-3.83) more likely to use mouthwash frequently than those aged ≤24 years. The most common oral sex practice was tongue kissing (n=874; 95.2%), followed by receptive fellatio without ejaculation (n=839; 91.4%), receptive fellatio with ejaculation (n=610; 66.5%), then insertive rimming (n=356; 38.8%). No significant association was found between frequent mouthwash use and tongue kissing, receptive fellatio with or without ejaculation, or insertive rimming with regular or casual male partners in the previous 3 months.

CONCLUSIONS

Younger MSM are less likely to use mouthwash. There is no association between engaging in oral sex practices and frequent mouthwash use among MSM.

Epidemiology of gonorrhoea: a global perspective

Although understanding the local epidemiology of gonorrhoea is critical for local efforts, understanding the multinational epidemiology may support development of national and international prevention and control policies and strategies. In this paper, current epidemiology of gonorrhoea is reviewed through an international lens and with a focus on selected populations. The World Health Organization (WHO) estimates that ~87 million new gonococcal infections occurred among people aged 15-49 years in 2016. Gonorrhoea rates are rising in many countries. Gay, bisexual and other men who have sex with men, racial or ethnic minorities, Indigenous populations and sex workers appear to bear disproportionate burdens of gonorrhoea. International travel can facilitate spread of gonorrhoea, including resistant strains, across international borders. Critical gaps in epidemiological knowledge are highlighted, including data on gonorrhoea among transgender persons and the burden of extragenital gonorrhoea. Even as further data are gathered, action - informed by currently available data - is needed now to confront this growing international threat.

Increases in the Estimated Number of Reported Gonorrhea Cases Among Men Who Have Sex With Men: The Role of Testing

The rate of reported gonorrhea among men who have sex with men has been steadily increasing in recent years, but little is known about how much changing testing practices and incidence each contribute to this trend. We report that both factors are likely contributing to the observed rate increases.

The frontiers of addressing antibiotic resistance in Neisseria gonorrhoeae

The sexually transmitted infection gonorrhea, caused by the Gram-negative bacterium Neisseria gonorrhoeae, can cause urethritis, cervicitis, and systemic disease, among other manifestations. N. gonorrhoeae has rapidly rising incidence along with increasing levels of antibiotic resistance to a broad range of drugs including first-line treatments. The rise in resistance has led to fears of untreatable gonorrhea causing substantial disease globally. In this review, we will describe multiple approaches being undertaken to slow and control this spread of resistance. First, a number of old drugs have been repurposed and new drugs are being developed with activity against Neisseria gonorrhoeae. Second, vaccine development, long an important goal, is advancing. Third, new diagnostics promise rapid detection of antibiotic resistance and a shift from empiric to tailored treatment. The deployment of these new tools for addressing the challenge of antibiotic resistance will require careful consideration to provide optimal care for all patients while extending the lifespan of treatment regimens.

The Laboratory Diagnosis of Neisseria gonorrhoeae: Current Testing and Future Demands

The ideal laboratory test to detect Neisseria gonorrhoeae (Ng) should be sensitive, specific, easy to use, rapid, and affordable and should provide information about susceptibility to antimicrobial drugs. Currently, such a test is not available and presumably will not be in the near future. Thus, diagnosis of gonococcal infections presently includes application of different techniques to address these requirements. Microscopy may produce rapid results but lacks sensitivity in many cases (except symptomatic urogenital infections in males). Highest sensitivity to detect Ng was shown for nucleic acid amplification technologies (NAATs), which, however, are less specific than culture. In addition, comprehensive analysis of antibiotic resistance is accomplished only by in vitro antimicrobial susceptibility testing of cultured isolates. As a light at the end of the tunnel, new developments of molecular techniques and microfluidic systems represent promising opportunities to design point-of-care tests for rapid detection of Ng with high sensitivity and specificity, and there is reason to hope that such tests may also provide antimicrobial resistance data in the future.