GONORRHEA IS A major cause of pelvic inflammatory disease, tubal factor infertility, and ectopic pregnancy in women, and is associated with an increased risk for HIV.1–4 Although the overall rate of reported gonorrhea in the United States decreased 68% from 468 per 100,000 persons in 1975 to 150 per 100,000 persons in 1995, rates remain high among black adolescents and young adults in many urban areas.5,6 The reported rate of gonorrhea in non-Hispanic blacks in 1995 was almost 40 times the rate in non-Hispanic whites, and the rate in the 63 largest US cities was approximately twice the national rate.5
Studies have shown that gonorrhea is associated with young age; the black race; multiple, new, or casual sex partners; crack, marijuana, or alcohol use; and exchange of sex for money or drugs.7–10 Risk factors, however, vary by place and phase of epidemic. Condom use has been shown to protect against gonorrhea transmission,11,12 but condom use in many populations is inconsistent and often incorrect.13,14 Because the reported rate of gonorrhea remained high in Newark, NJ, at five times the national rate in the mid-1990s despite declining rates in the rest of New Jersey, we assessed risk factors and possible prevention measures for gonorrhea in Newark. At a sexually transmitted disease (STD) clinic in Newark, where the majority of the city's reported gonorrhea cases are diagnosed and treated, we conducted a case-control study of male adolescents and young adults. We assessed recent sexual behavior, condom use, substance abuse, and the willingness of newly diagnosed persons to practice preventive measures in order to develop more effective control activities for gonorrhea in Newark.
The study was conducted at an STD clinic in Newark, NJ, from September 12, 1995, to March 31, 1996. Cases were male clinic patients 15 to 29 years with positive gonorrhea cultures, and controls were male clinic patients of the same age group who received a diagnosis of “no STD” and who tested negative for both gonorrhea and syphilis. Written informed consent was obtained from all patients interviewed, and patients were enrolled only once. At the time of the study, enrollment for a large, randomized clinical trial of HIV-prevention counseling had been completed15; those already enrolled in that study who were returning for follow-up visits were not eligible for this study.
Cases and controls were interviewed by trained interviewers after examination and treatment by the clinician but before risk-reduction counseling by the disease intervention specialist. Because of concern about detaining patients in the clinic for too long, eligible study participants were interviewed only if an interviewer was available within 15 minutes. Data collected during a 10- to 20-minute interview included demographic information; sexual behavior, condom use, and substance abuse during the month before the clinic visit; and the willingness to adopt specific STD/HIV prevention behaviors as assessed on a five-point scale (from “definitely yes” to “definitely no”). For sexual behavior questions, subjects were asked about someone they considered as their “main” sex partner and about persons other than their main partner with whom they had had sex (i.e., “casual” partners). Results of laboratory tests, including gonorrhea cultures, serologic nontreponemal tests for syphilis, and enzyme immunoassays and Western blot analyses for HIV were obtained from clinic records.
The significance of the association between gonococcal infection and categorical variables was examined using the chi-square test. Significance between infection and continuous variables was assessed using simple linear rank statistics for medians. The odds ratio was used to estimate the magnitude of the association between gonococcal infection and categorical demographic, clinical, and behavioral variables. Logistic regression was used to estimate the association between infection and having a casual sex partner, controlling for other variables significant in the univariate analysis. The final model was obtained by backwards elimination until only variables with P values < 0.10 were included. The significance of scientifically meaningful interaction terms was determined using the “chunk test.”16 Because having a casual partner during the preceding month was strongly associated with gonococcal infection, we developed a separate logistic regression model using the procedures described previously only for cases and controls who reported at least one casual partner. We estimated the association between infection and having a new casual partner, having unprotected sex with a casual partner, having a casual partner with an unknown number of other partners, or engaging in more than four sex acts with casual partners during the preceding month.
During the study period, 239 (54%) of an estimated 440 males 15 to 29 years with positive cultures for Neisseria gonorrhoeae who were eligible for the study were invited to participate. Of these 239 eligible participants, 25 (10%) refused, and 214 (90%) enrolled.
Some eligible males were not approached because an interviewer was not available, because they chose not to wait, or because they had already been enrolled in the other large study referred to previously. Of the 214 cases interviewed, 213 had a positive urethral culture, including 6 with a positive pharyngeal culture, and 1 had a positive pharyngeal culture only. Almost all patients (96%) reported symptoms of urethral discharge or dysuria. For controls, 95 males with a diagnosis of “no STD” during the study period were invited to participate, of whom 2 refused. Of the 93 controls, 11% reported symptoms; however, no STD was diagnosed. The majority of participants (57%) came to the clinic because they were worried about STDs or wanted a “check up.”
Assessment of Risk Factors
Cases were more likely than controls to be black, 15 to 19 years, or to have ever spent a night in jail (Table 1). For cases and controls older than 18 years, there was no significant difference in the percentage finishing 12 years of school (83% versus 72%) or having a job (49% versus 56%). Approximately 40% of cases and controls lived in zip codes within or contiguous to that of the STD clinic.
A previous diagnosis of gonorrhea was reported by 41% of cases and 29% of controls. History of another STD was reported by 17% of cases and 25% of controls. Only one case and no controls reported being told previously that they had HIV infection.
Approximately two thirds of both cases and controls had a main partner during the month before the clinic visit (Table 1). All but two cases and one control reported that their main sex partners were female. Of male cases, 52% with a main partner reported that this partner had had no other sex partners during the preceding month, 9% reported that their main partner had at least one other sex partner, and 39% reported that they did not know their main partners' number of partners. No significant difference was noted between cases and controls.
Cases were significantly more likely to report at least one casual sex partner during the month before the clinic visit than were controls (73% versus 37%) (Table 1). No cases and only one control reported having male casual partners. There was no significantly increased risk for gonorrhea from having multiple casual partners compared with having one casual partner (Table 1). Likewise, there was no increased risk for gonorrhea from engaging in more than four vaginal sex acts with casual partners during the preceding month compared with engaging in one to four sex acts (Table 1). Having a new casual partner (i.e., sex with most-recent casual partner for less than 1 month) was strongly associated with gonococcal infection, compared with not having a casual partner; having a casual partner of longer standing (i.e., sexual relationship with most recent casual partner of at least 1 month's duration) also was associated with infection, although less strongly (Table 1). Most males with casual partners did not know the details of their most recent casual partner's sex life; 92% of cases and 71% of controls said they did not know how many other partners their most-recent casual partner had had during the preceding month. Not knowing this information was significantly associated with infection (Table 1). Few cases (4%) or controls (3%) reported exchanging money or drugs for sex.
There were no significant differences between cases and controls regarding condom use. Only 31% of cases and 34% of controls reported using a condom during the most-recent sexual contact with their main partners. Approximately half of cases (54%) and controls (57%) reported using condoms during the most-recent sexual contact with their most-recent casual partner. Of cases with casual partners, 63% had had unprotected sex at least once during the preceding month, compared with 50% of controls. Because a higher percentage of cases than controls had casual partners, unprotected sex with a casual partner was significantly associated with infection (Table 1). Having only protected sex with a casual partner also was associated with infection, compared with not having a casual partner.
Of males reporting sex during the preceding month, 75% of cases and 66% of controls reported using condoms during the preceding month. Many of these males used them incorrectly at least once. Cases and controls were equally likely to have reported starting sex without a condom, taking a condom off before finishing sex, or starting to put it on inside out and then flipping it over to put it on correctly (Table 2). About half the cases and controls who used condoms reported at least one of these errors. Only a small percentage of cases and controls reported that a condom slipped off. A significantly higher percentage of cases (47%) than controls (28%), however, reported condoms breaking while wearing them during the preceding month. The majority of condom-using cases and controls reported a condom error, slippage, or breakage during the preceding month.
To understand why males having only protected sex with casual partners or males without casual partners acquired gonorrhea, we looked at the behavior of these two groups. For those cases who reported only protected sex with casual partners, 78% reported condom breakage or some type of condom error during the preceding month. For those cases who did not report a casual partner, 6% had had a new main partner of less than 1 month. Of those with a main partner for more than 1 month, 6% said that their main partner had had another partner during the preceding month, and 53% did not know how many other partners their main partner had had.
Only 1% of both cases and controls reported crack use during the preceding month; none reported injecting drugs during the same period. Of cases, however, 44% reported smoking marijuana during the preceding month, compared with 28% of controls (unadjusted OR, 2.1; 95% CI, 1.2-3.5). Most marijuana-smoking cases (77%) but less than half of marijuana-smoking controls (39%) reported having sex after using marijuana; thus, 34% of all cases but only 11% of all controls reported having sex after using marijuana (Table 1). Marijuana use for cases and controls was associated with having at least one casual partner (P = 0.01), but was not significantly associated with lack of condom use or improper condom use.
The multivariate model indicated that having a casual sex partner was significantly associated with gonococcal infection in males (Table 3). Having sex after using marijuana during the preceding month, being black, being 15 to 19 years, and having spent a night in jail also were independently associated with gonococcal infection. Interaction terms did not contribute significantly to the model.
For males who reported at least one casual partner during the preceding month, sex with the most-recent casual partner for less than 1 month, having unprotected sex with a casual partner during the preceding month, and not knowing how many other partners the most-recent casual partner had had during the preceding month were all associated with gonococcal infection (Table 3). Reporting condom breakage and having sex after using marijuana during the preceding month also were associated with infection. The variables for age group, race, having spent a night in jail, having engaged in more than four sex acts with casual partners, or having had multiple casual partners during the preceding month were not significantly associated with gonococcal infection in males with casual partners and were removed from the model.
Willingness to Practice Preventive Measures
In response to questions about what they will be able to do now and in the future, males with gonorrhea were more likely to answer “definitely yes” to questions about seeking appropriate treatment and refraining from sex when symptomatic than to questions about using condoms or restricting the number of sex partners (Table 4). More than 90% of those responding said that they would definitely come to the clinic as soon as they developed symptoms, that they would avoid sex if they or their partners had symptoms, and that they would ensure that their main partner were treated. Only 59% of respondents said that they would definitely use a condom every time they had sex, and only 43% said that they would definitely have just one main partner and no others.
In this study, having a casual sex partner was strongly associated with gonorrhea in males. Of 214 cases interviewed, 73% reported having a casual partner; almost all of these reported either unprotected sex, condom breakage, or condom-use errors that could explain acquisition of gonorrhea. Of note, few of these casual sexual partnerships involved crack-cocaine use or exchange of sex for money or drugs. For the 27% of cases without casual partners, some had a new main partner, and some had main partners having sex with other partners. Our findings supplement earlier studies in urban settings that report that recent exposure to a new partner or a casual partner is associated with gonorrhea in males attending an STD clinic.7,8
The prevalence of lack of proper condom use in this study is alarming. Approximately half the males did not use condoms during the most recent sexual encounter with a casual partner, and over one fourth did not use condoms at all during the preceding month. Of those using condoms at least once, approximately three fourths reported errors, slippage, or breakage. Approximately half of males with gonorrhea reported condom breakage, which, at face value, represents an unrecognized major problem in condom quality. However, rather than assuming inherent flaws in the condoms, it is possible that incorrect use led to higher breakage rates. In addition, it is possible that rather than acknowledging sex without condoms, the males overreported breakage. Error rates and breakage here are much higher than previously reported.13,17,18 Previously published studies, however, did not involve STD-clinic patients who have an STD or who are worried about having an STD and are therefore more likely to have experienced condom failures. Our data imply that condom information, especially pertaining to skills in correct use, remains an important area for STD/HIV prevention that clearly has not yet been effectively addressed in this population.
Client-centered counseling that assesses a person's readiness for behavior change is now accepted as a tenet of current STD/HIV-prevention counseling19 and has been shown to be effective at the individual level in preventing STDs.15 In this investigation, we attempted to use this principle of assessing a person's preferences and willingness to change to incorporate these preferences into a population-level intervention strategy in Newark. This aspect of the investigation suggested some resistance to eliminating casual sex and to using condoms consistently with main partners, but high levels of willingness to seek health care promptly and to use condoms with casual partners. It is possible that incorporating the target population's preferences into specific prevention strategies will lead to more efficacious and cost-effective programs; we recommend rigorous evaluation of prevention activities that attempt to incorporate subjects' preferences into intervention design.
Because 100% condom use and monogamy may be difficult to achieve in this population, secondary prevention strategies to identify infected persons may be needed, such as expanding screening or increasing partner-notification efforts. Given the high percentage of cases in our study who have been to jail and the high prevalence of gonorrhea in adolescents and young adults entering juvenile detention facilities and jails in other parts of the country, corrections facilities may be an appropriate place for expanded screening.20–22 Partner notification by the health department in Newark was discontinued in 1991 because priority was given to partner-notification services for syphilis and HIV. Since then, persons with gonorrhea have been asked to refer their sex partners for treatment; however, patient-initiated referral only may lead to a small percentage of partners being evaluated and treated.23
Unlike other studies,9,10 neither exchange of money or drugs for sex nor crack use was associated with gonorrhea; little of either type of activity was reported by cases or controls. Marijuana use, and sex after marijuana use in particular, was more common and was independently associated with gonococcal infection. Schwarcz et al9 also found an association between gonorrhea and recent marijuana use among black female adolescents in San Francisco; however, crack use and alcohol use also were associated with gonorrhea in that population. Boyer et al24 found that at a health maintenance organization teen clinic, youth who used marijuana at least once per week were more likely than those who did not to have an STD. The exact role of marijuana in gonorrhea transmission is unclear.
In summary, sex with casual partners is strongly associated with gonococcal infection in males in Newark, NJ. Many males with gonorrhea are not willing to change their behavior to always use condoms or to have just one partner. Strategies to identify and treat asymptomatic infected females may be needed to prevent transmission. A mathematical model of data from this investigation suggested that notification of sex partners by health department personnel or more targeted screening of high-risk groups may be the most effective way to reduce the prevalence of gonorrhea in Newark.25 However, a well-designed package of interventions that addresses the risk factors observed in gonorrhea patients in Newark while incorporating subjects' preferences and willingness to change could be more cost effective than either current efforts or enhancements of traditional case-finding activities. Well-evaluated field interventions are needed to determine what prevention measures will reduce the prevalence of gonorrhea in inner-city minority populations.
1. Westrom L, Eschenbach D. Pelvic inflammatory disease. In: Holmes KK, Sparling PF, Mardh PA, et al, eds. Sexually Transmitted Diseases. 3rd ed. New York: McGraw-Hill, 1999:783–809.
2. Laga M, Manoka A, Kivuvu M, et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS 1993; 7:95–102.
3. Moss GB, Overbaugh J, Welch M, et al. Human immunodeficiency virus DNA in urethral secretions in men: association with gonococcal urethritis and CD4 cell depletion. J Infect Dis 1995; 172:1469–74.
4. Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. Lancet 1997; 349:1868–1873.
5. US Department of Health and Human Services Public Health Service. Sexually transmitted disease surveillance, 1995. Atlanta: Centers for Disease Control and Prevention, September 1996.
6. Fox KK, Whittington BA, Levine WC, Moran JS, Zaidi AA, Nakashima AK. Gonorrhea in the United States, 1981–1996: demographic and geographic trends. Sex Transm Dis 1998; 25:386–393.
7. Upchurch DM, Brady WE, Reichart CA, Hook EW. Behavioral contributions to acquisition of gonorrhea in patients attending an inner city sexually transmitted disease clinic. J Infect Dis 1990; 161:938–941.
8. Hook EW, Reichart CA, Upchurch DM, Ray P, Celentano D, Quinn TC. Comparative behavioral epidemiology of gonococcal and chlamydial infections among patients attending a Baltimore, Maryland, sexually transmitted disease clinic. Am J Epidemiol 1992; 136:662–672.
9. Schwarcz SK, Bolan GA, Fullilove M, et al. Crack cocaine and the exchange of sex for money or drugs. Sex Transm Dis 1992; 19:7–13.
10. Marx R, Whittington WL, Aral SO. Gender differences in sexual risk behaviors for gonorrhea (abstract no. C-14–067). Presented at the 9th meeting of the International Society for Sexually Transmitted Disease Research. Banff, Canada, 1991.
11. Stone KM, Timyan J, Thomas EL. Barrier methods for the prevention of sexually transmitted diseases. In: Holmes KK, Sparling PF, Mardh PA, et al., eds. Sexually Transmitted Diseases. 3rd ed. New York: McGraw-Hill, 1999:1307–1321.
12. d'Oro LC, Parazzini F, Naldi L, La Vecchia C. Barrier methods of contraception, spermicides, and sexually transmitted diseases: a review. Genitourin Med 1994; 70:410–417.
13. Warner L, Clay-Warner J, Boles J, Williamson J. Assessing condom use practices: implications for evaluating method and user effectiveness. Sex Transm Dis 1998; 25:273–277.
14. Spruyt A, Steiner MJ, Joanis C, et al. Identifying condom users at risk for breakage and slippage: findings from three international sites. Am J Public Health 1998; 88:239–244.
15. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases. JAMA 1998; 280:1161–1167.
16. Kleinbaum DG. Logistic Regression: A Self-Learning Text. New York: Springer-Verlag, 1994.
17. Steiner M, Piedrahita C, Glover L, Joanis C. Can condom users likely to experience condom failure be identified? Fam Plann Perspect 1993; 25:220–226.
18. Rosenberg MJ, Waugh MS. Latex condom breakage and slippage in a controlled clinical trial. Contraception 1997; 56:17–21.
19. US Department of Health and Human Services Public Health Service. HIV Counseling, Testing, Referral Standards, Guidelines. Atlanta: Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, May 1994.
20. US Department of Health and Human Services Public Health Service. Sex Transm Disease Surveillance, 1997. Atlanta: Centers for Disease Control and Prevention, Division of STD Prevention, September 1998.
21. Oh MK, Cloud GA, Wallace LS, Reynolds J, Sturdevant M, Feinstein RA. Sexual behavior and sexually transmitted diseases among male adolescents in detention. Sex Transm Dis 1994; 21:127–132.
22. Alexander-Rodriguez T, Vermund SH. Gonorrhea and syphilis in incarcerated urban adolescents: prevalence and physical signs. Pediatrics 1987; 80:561–564.
23. Phillips L, Potterat JJ, Rothenberg RB, Pratts C, King RD. Focused interviewing in gonorrhea control. Am J Public Health 1980; 70:705–708.
24. Boyer CB, Shafer MA, Teitle E, Wibbelsman CJ, Seeberg D, Schachter J. Sexually transmitted diseases in a health maintenance organization teen clinic: associations of race, partner's age, and marijuana use. Arch Pediatr Adolesc Med 1999; 153:838–844.
25. Garnett GP, Mertz KJ, Finelli L, Levine WC, St. Louis ME. The transmission dynamics of gonorrhoea: modelling the reported behaviour of infected patients from Newark, New Jersey. Philos Trans R Soc Lond B Biol Sci 1999; 354:787–797.