During this study period, 4.6% (9471/205,689) of the reported GCs occurred among persons with previously diagnosed HIV: 5.5% (5930/107,786) in NYC, 7.3% (1312/17,910) in DC, 4% (1504/40,214) in MDC, and 2% (725/39,779) in AZ. The percent of GCs with HIV coinfection increased in all jurisdictions over the study period from 3% (367/12,314) in 2000 to 7% (752/10,553) in 2008 in NYC (P < 0.001), 6.4% (142/2211) to 6.7% (155/2302) in DC (P < 0.001), 2% (91/3917) to 4% (165/4265) in MDC (P < 0.001), and 0.7% (31/4400) to 3% (91/3486) in AZ (P < 0.001) (Fig. 1). The overall male-to-female ratio of HIV-GC coinfected cases for the period was 6.4 in NYC, 3.2 in both DC and MDC, and 29.2 in AZ (Table 1). Across all the 4 jurisdictions, 7.4% of male GCs had been previously diagnosed with HIV. The highest male coinfection rates were 10.5% in DC and 9.3% in NYC. In each of the 4 jurisdictions, the majority of HIV/GC coinfections were among men: 87% (5127/5927) in NYC, 76% in both DC (1000/1311) and MDC (1144/1504), and 97% (701/725) in AZ. Among male GCs in each jurisdiction, HIV coinfection was highest among the age groups 40–44 and 45–49 years. Among male GCs, the race/ethnicity group with the highest percent HIV coinfection was white non-Hispanic in each jurisdiction: 22% in NYC, 11% in DC (11%), 11% in MDC, and 7% in AZ (Table 1).
Only 1.5% of female GCs occurred among women with previously diagnosed HIV. Of the female cases in the 4 study sites, DC had the highest coinfection (3.7%) followed by MDC (1.9%) (Table 1). Similar to men, among women in each jurisdiction, coinfections were most common among those in the age groups of 40–44 year olds and 45–49 year olds. Among female GCs, the race/ethnicity group with the highest percent HIV coinfection was white non-Hispanic in NYC (4.5%) and DC (5.6%) and black non-Hispanic in MDC (2.4%) and AZ (0.2%) (Table 1).
Matching STD and HIV surveillance registries allowed us to identify and describe the persons who acquired gonorrhea subsequent to HIV diagnosis in 4 diverse jurisdictions. Despite declines in overall GC counts in 3 of the 4 jurisdictions and only a modest increase in MDC, the proportion of GCs that occurred in persons with existing HIV infection increased during 2000–2008 in all of the 4 jurisdictions, with some more than doubling. The majority of GC-HIV coinfections occurred among men. Using surveillance data, we identified groups of HIV-infected persons who are at increased risk for transmitting HIV, as indicated by subsequent acquisition of GC. These data can inform efforts to target STD prevention services to high-risk persons living with HIV/AIDS.
When HIV-infected persons acquire other STDs, there is clear evidence of unprotected sexual contact and thus the potential for HIV transmission to uninfected partners. In accordance with earlier CDC guidance,5 these persons and their partners should be prioritized for HIV prevention efforts. Presumably, many of these patients are receiving HIV primary care at the time of STD diagnosis. National recommendations include antiretroviral treatment initiation for all HIV-infected patients.15 HIV care providers should prioritize HIV-infected patients with STDs for prevention strategies such as initiation of antiretroviral therapy and adherence support,2 behavioral counseling3,4, partner testing and referral,8 routine STD screening,5 and possibly preexposure prophylaxis for HIV for their uninfected sexual partners.6
The high male-to-female ratios we found suggest that many GC-HIV coinfections are occurring in the population of men who have sex with men (MSM), a hypothesis supported by increases in syphilis among men, particularly MSM, in each jurisdiction over the same interval16 and that MSM represent the bulk of prevalent and new HIV diagnoses among men in each jurisdiction.17–20 Rectal gonorrhea has been linked to an increased risk of HIV acquisition,21,22 and Neisseria gonorrhoeae with reduced susceptibility to cephalosporins has emerged among MSM in multiple regions, further supporting the need for enhanced surveillance and intervention among this group.23 Annual gonorrhea screening rates among HIV-infected MSM in various jurisdictions are estimated to be quite low, ranging from 14% to 18% for urethral screening and from 2.0% to 8.5% for oral/rectal screening.24 Once locally validated for off-label use, nucleic acid amplification testing, typically used for urethral, cervical, and urine testing, can be used for the detection of gonorrhea infection in oral and rectal sites and should be incorporated into annual screening protocols for HIV-infected and noninfected MSM.25 HIV primary care sites continue to serve as sentinel surveillance and intervention sites for HIV and STD prevention. HIV providers have a responsibility to engage their patients in preventing the spread of HIV using a full range of current HIV prevention strategies.
Notifying sex partners of HIV and/or STD exposure and referring them for testing and treatment remains an effective public health method for identifying undiagnosed infection.8 Within each of the 4 jurisdictions, persons with syphilis and those with newly diagnosed HIV infection are prioritized for partner services. This analysis identified a large number of GC infections diagnosed among persons previously diagnosed with HIV. Current, administratively separated surveillance practices and programs would neither identify nor prioritize these cases for partner services or confirmation of linkage to primary HIV care. Efforts to improve HIV/STD data and program integration in local health departments may result in improvements in these public health services. Limited data exist on the outcomes of partner services for patients coinfected with HIV and another STD; however, partner service efforts may benefit from on-site assignment of communicable disease investigators within large HIV care clinics.26,27 Public health programs should work within local legal frameworks28 to evaluate the prioritization of HIV-infected persons with incident STDs for intensive partner services, behavioral counseling, and HIV case management as a recommended part of CDC's Program Collaboration and Service Integration initiative.29
There are several limitations to this analysis and the use and interpretation of these data. Underestimates of coinfections likely occurred due to differences in matching variables, jurisdictional reporting, and reporting delays. Information regarding risks of HIV transmission, such as sexual network, risk behaviors, condom use, and HIV medication adherence were not analyzed; therefore, these data cannot be used to describe contemporaneous HIV medical control efforts or ongoing risk behaviors. These data reflect increases in coinfection case counts and not rates at which persons with HIV acquire GC. Anatomical site of GC infection was not available for these cases, thus genital versus nongenital (oral, rectal) infection could not be quantified. This analysis did not consider chlamydial infections because the number of chlamydia cases reported among HIV-infected persons is smaller (given the female preponderance of reported chlamydia) and did not allow for a detailed analysis. Finally, these data do not control for screening practices. Thus, increases in coinfections could be due to increases in routine screening for STDs among persons with HIV, especially at nongenital sites.
Public health programs with interest in prioritizing high-risk HIV-infected persons should consider the use of real-time data integration and analysis to identify STD/HIV coinfected persons and consider restructuring priorities for partner service delivery for those who might not otherwise receive public health interventions, including HIV care review, referral, and behavioral counseling. Although this cross-match of the STD and HIV registries at the 4 sites yielded valuable surveillance trends and identified opportunities for future real-time identification of coinfected persons for public health intervention purposes, the process was retrospective and labor intensive. Routine even real-time integration of STD/HIV surveillance data systems should be evaluated as a means to improve prevention and intervention services for persons exposed to or infected with HIV and other STDs.
1. Prejean J, Ruiguang S, Hernandez A, et al.. Estimated HIV incidence in the United States, 2006-2009. PLoS One. 2011;6:1–13.
2. Cohen MS, Chen YQ, McCauley M, et al.. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505.
3. Marks G, Richardson JL, Crepaz N, et al.. Are HIV care providers talking with patients about safer sex and disclosure? A multi-clinic assessment. AIDS. 2002;16:1953–1957.
4. Richardson JL, Milam J, McCutchan A, et al.. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS. 2004;18:1179–1186.
5. Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2003;52:1–24. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm
6. Centers for Disease Control and Prevention. Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR Morb Mortal Wkly Rep. 2011;60:65–68.
7. Centers for Disease Control and Prevention, Council of State and Territorial Epidemiologists. Technical Guidance for HIV/AIDS Surveillance Programs, Volume III: Security and Confidentiality Guidelines. Atlanta, GA: Centers for Disease Control and Prevention; 2006.
8. Centers for Disease Control and Prevention. Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection. MMWR Recomm Rep. 2008;57:1–64.
9. Centers for Disease Control and Prevention. Data Security and Confidentiality Guidelines for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Programs: Standards to Facilitate Sharing and Use of Surveillance Data for Public Health Action. Atlanta, GA: U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; 2011.
10. Golden MR, Hogben M, Handsfield HH, et al.. Partner notification for HIV and STD in the United States: low coverage for gonorrhea, chlamydial infection and HIV. Sex Transm Dis. 2003;30:490–496.
11. Su JR, Weinstock HS. Epidemiology of co-infection with HIV and syphilis in 34 states, United States, 2009 [abstract 1874]. Presented at: National HIV Prevention Conference; August 14-17, 2011; Atlanta, GA.
12. Dowell D, Gaffga NH, Weinstock H, et al.. Integration of surveillance for STDs, HIV, Hepatitis, and TB: a survey of U.S. STD control programs. Public Health Rep. 2009:124:31–38.
13. Newman LM, Samuel MC, Stenger MR, et al.. Practical considerations for matching STD and HIV surveillance data with data from other sources. Public Health Rep. 2009;124:7–17.
16. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; 2009.
21. Bernstein KT, Marcus JL, Nieri G, et al.. Rectal gonorrhea and chlamydia reinfection is associated with increased risk of HIV seroconversion. J Acquir Immune Defic Syndr. 2012;53:537–543.
22. Jin F, Prestage GP, Imriw J, et al.. Anal sexually transmitted infections and risk of HIV infection in homosexual men. J Acquir Immune Defic Syndr. 2010;53:144–149.
23. Centers for Disease Control and Prevention. Cephalosporin susceptibility among Neisseria gonorrhoeae isolates—United States, 2000-2010. MMWR Morb Mortal Wkly Rep. 2007;506;332–336.
24. Hoover KW, Butler M, Workowski K, et al.. STD screening of HIV-infected MSM in HIV clinics. Sex Transm Dis. 2010;37:771–776.
25. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:44–45.
26. Taylor MM, Mickey T, Winscott MM, et al.. Improving partner services by embedding Disease Intervention Specialists (DIS) in HIV-clinics. Sex Trans Dis. 2010;37:1–4.
27. Udeagu CN, Tsega A, Klingler EJ, et al.. Outcomes of HIV partner services for people with HIV and STD coinfection versus new HIV diagnosis: Implications for HIV prevention strategies. Sex Transm Dis. 2011;38:887–888.
28. Center for HIV Law and Policy, Positive Justice Project. Ending and defending against HIV criminalization a manual for advocates: State and federal laws and prosecutions. 2010;(1):2–3. Available at: www.hivlawandpolicy.org
. Accessed September 14, 2012.