de Vrieze, Nynke H.N. MD*; van Rooijen, Martijn S. MSc†; Schim van de Loeff, Maarten MD, PhD†‡; de Vries, Henry J.C. PhD, MD†‡§
From the *Department of Dermatology/Allergology, University Medical Center Utrecht, Utrecht, the Netherlands; †STI Outpatient Clinic, Cluster of Infectious diseases, Public Health Service Amsterdam, Amsterdam, the Netherlands; ‡Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, Amsterdam, the Netherlands; and §Department of Dermatology, Academic Medical Center, Amsterdam, the Netherlands.
Competing interests: None.
Correspondence: Henry J.C. de Vries, PhD, MD, STI Clinic, Cluster Infectious Diseases, Public Health Service Amsterdam, 1000 CE Amsterdam, the Netherlands. E-mail: firstname.lastname@example.org.
Received for publication March 18, 2014, and accepted May 14, 2014.
HIV postexposure prophylaxis (PEP) is a 4-week course of antiretroviral treatment recommended to persons exposed to human body fluids possibly infected with HIV to prevent HIV acquisition.1 It was first introduced to reduce the transmission risk after needle-stick accidents and other occupational exposures to HIV.2 In 1997, it was introduced for use after sexual exposure.3 Since 2010, the sexually transmitted infection (STI) outpatient clinic of the Public Health Service in Amsterdam, the Netherlands, offers PEP to HIV-negative patients who have had a considerable risk of recent HIV exposure through unsafe sex.
Individuals presenting for PEP after sexual exposure are at risk for concurrent STI. Therefore, a PEP request is an ideal opportunity for STI screening and safe sex promotion. Early incubating Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (Ng) infections acquired during the sexual exposure for which PEP is sought are possibly missed if STI screening is only performed at the consultation during which an indication for PEP initiation is established. Therefore, we aimed to determine if chlamydia and gonorrhea screening should be repeated in men who have sex with men (MSM) 2 weeks after a PEP indication.
If the client requests PEP or the history suggests that there has been considerable risk for HIV transmission in the previous 72 hours, the option to start PEP is discussed. A medical doctor decides whether PEP is indicated based on the criteria of the Dutch guidelines for sexual exposure,4 which are in agreement with European guidelines1 and the Centers for Disease Control and Prevention recommendations.5
At the STI clinic, testing for gonorrhea, chlamydia, syphilis, hepatitis B, and HIV is offered to all MSM patients who visit the clinic, as described before.6–9 Urine and rectal swabs are collected and screened for Ct (Aptima Ct single system; GEN-PROBE, San Diego, CA). Pharyngeal swabs are tested for Ct and Ng (Aptima Combo 2 system; GEN-PROBE). At the initial visit, a trained laboratory technician examines urethral and rectal Gram-stained smears for a presumptive gonorrhea diagnosis (i.e., gram-negative diplococci in polymorphonuclear leukocytes) or a nongonococcal infection (i.e., >10 polymorphonuclear leukocytes per light microscopic high-power field, no gram-negative diplococci). Urethral and rectal cultures are used for the definitive Ng diagnosis. HIV antibody rapid testing (Determine 1–2; Abbott Laboratories, Abbott Park, IL) is offered to all patients. Serum samples are also further tested by line immunoassay (Inno-Lia HIV I-II Score; Innogenetics, Ghent, Belgium); this result will follow after a few working days. Condylomata acuminata are diagnosed clinically.
Postexposure prophylaxis is not started if the HIV rapid test result is positive. In case the HIV antibody rapid test result is negative or inconclusive, but the result of the line immunoassay result, when it becomes available a few days later, is positive, continuation of PEP medication as treatment of HIV is reviewed with an infectious disease specialist. If the source person of the risk event is tested at the STI clinic and found to be HIV negative, PEP is considered not indicated, and if PEP was already started, it is therefore discontinued. Patients are free to decline PEP. If PEP is accepted, a visit is planned 2 weeks later to repeat screening for urethral, pharyngeal, and anal Ng and Ct infections.
We included all MSM visiting the STI outpatient clinic in Amsterdam with a PEP request after sexual exposure from April 2010 until December 2012. Men who have sex with men with multiple PEP requests during the inclusion period were included in the analysis multiple times, and thus, we report about “presentations” instead of individuals. An STI presentation could involve multiple sexually transmissible pathogens, or the same pathogen at more than 1 anatomical location. All statistical analyses were performed in SPSS version 19 (SPSS Inc, Chicago, IL). Ethical clearance was not sought because this was an analysis on routinely collected, anonymized data.
From April 2010 until December 2012, a total of 26,733 consultations were performed in MSM. We analyzed 473 PEP requests from 438 unique individual MSM. In 78 (16.5%) of those 473 presentations, at least 1 STI was found (Fig. 1). In 334 presentations, PEP was indicated (70.6%). The STI positivity among the 139 presentations in which PEP was not indicated was 16.5% (23/139): 11 attendees (7.9%) were HIV positive, and in 12 presentations (8.6%), 16 STIs other than HIV were diagnosed. In the presentations in which PEP was indicated, 68 STIs were found in 55 (16.5%) of 334. Two attendees had a coinfection, 9 had the same STI at multiple anatomical places, and 1 had a triple infection (both Ng and Ct and Ng at multiple anatomical places). The rectum was the most common anatomical place for an STI in 27 (49.1%) of 55 presentations. Only 6 (10.9%) of 55 presentations with a PEP indication and an STI were symptomatic at screening.
In 14 presentations, PEP was discontinued: in 2, the confirmation of the line immunosorbent assay of the index proved positive; in 9, the partner involved in the sex accident proved HIV negative; in 3, the patient discontinued PEP at own initiative. The remaining 320 completed PEP. A follow-up visit after 2 weeks (range, 10–17 days) was performed in 218 (68.1%) of 320 presentations. In 9 (4.1%) of 218 presentations, at least 1 previously undiagnosed infection was found: 3 rectal Ct, 3 rectal Ng, 1 pharyngeal Ct, and 2 rectal Ct/Ng coinfections. No urethral infections were detected at the 2-week visit. All of 9 presentations with a previously undiagnosed infection denied sexual contact since the last consultation.
This study demonstrates that screening for STI in MSM with a request for PEP after sexual HIV exposure is worthwhile. Of all 473 presentations requesting PEP, 16.5% had at least 1 STI. Of great importance are the 13 (2.7%) of 473 previously undiagnosed HIV infections. Moreover, reconfirming negative/inconclusive HIV rapid test results with HIV immunoassay in MSM is of importance because 2 additional HIV infections were thus diagnosed. We consider these by rapid test missed HIV primary infections. Because primary HIV infections are known to have very high viral loads, these are of great consequences for ongoing transmission.10,11
Repeated chlamydia and gonorrhea screening 2 weeks after the PEP indication revealed 4.1% additional, possibly early incubating, Ct and/or Ng infections. Our observed prevalence of STI (16.5%) is higher compared with other reported studies in MSM receiving PEP.12,13 Similar to earlier studies, in 31.9% consultations, the attendees in which PEP was indicated did not show for the follow-up visit.12,14 Most MSM with an STI were asymptomatic; the same was reported recently by Jamani et al.,14 who found that more than 90% of cases with chlamydia and gonorrhea diagnoses were asymptomatic. This underlines the importance of providing STI screening to all individuals after high-risk exposures regardless of symptoms, unlike the recommendations in the UK PEP guidelines.15 Offering PEP and prompt STI testing creates an opportunity to shorten the duration of infectiousness of an STI and facilitates discussion regarding risk reduction and safer sex.16
Strengths of this study are that our test policy did not change over time, and all PEP requesters were screened routinely, both at the initial visit and 14 days afterward.
Limitations of our study are the no-show ratio for a repeat screening of approximately 32% after 2 weeks and that we cannot exclude that attendees with a new Ct or Ng infection after 2 weeks did not have sexual intercourse within that period, although they all denied having had sex between the 2 visits. Our outcome differs from a similar report in which 28.1% of the presentations reported sexual activity between the baseline and the 2-week visit.12 Sampling errors during the baseline visit could have produced false-negative results that were considered “new” infections found during the return visit. Because trained nurses supervised all sample collections and highly sensitive nucleic acid amplification tests were used, we consider the occurrence of sampling error highly unlikely.
Based on these data, we consider that STI and HIV screening should be offered to all MSM with a PEP request after a sexual HIV exposure regardless of symptoms. Immediate screening yields a high rate of especially gonorrhea and chlamydia infections. Moreover, it seems advisable to repeat screening for gonorrhea and chlamydia a few weeks later, to detect infections not apparent at the baseline screening. Whether these later diagnoses were early incubating or newly acquired infections remains unclear. The considerable proportion of patients that will not return for repeat screening a few weeks after the PEP request makes immediate screening indispensable.
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