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A Recent Increase in the Incidence of Male Urethritis in France

MASSARI, VÉRONIQUE PhD; RETEL, OLIVIER PhD; FLAHAULT, ANTOINE MD, PhD

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Sexually Transmitted Diseases: June 2002 - Volume 29 - Issue 6 - p 319-323
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Abstract

IN DECEMBER 1999, France was (and still is) one of the European countries most affected by AIDS. The cumulative frequency of AIDS was 836 per million inhabitants (355 per million in Europe as a whole), and 46% of cases (i.e., 729 cases per million inhabitants) had been diagnosed in the Paris area. 1 Forty-four percent of all AIDS cases involved homosexuals and 20% involved heterosexuals. Since 1998, however, these proportions have been reversed, with 43% of cases affecting heterosexuals and 29% homosexuals.

In France, prevention campaigns targeting sexual transmission of HIV have mainly been directed at the general population rather than at-risk groups. In the early 1990s, there was a gradual decrease in AIDS cases, but this trend was falsely reassuring. Furthermore, the introduction of highly active antiretroviral therapies in 1996 and of postexposure treatment in 1997 changed the representation of the disease among the general population and the most vulnerable groups. HIV disease/AIDS is now perceived as any other chronic disease. 2 There are now indications, particularly among the homosexual and bisexual community, that prevention of sexually transmitted disease (STD) is being neglected. 3

Recent studies show increases in the incidence of STDs in both Europe 4,5 and the United States, 6 indicating a return to unprotected sexual practices 3 and an increased risk of HIV infection.

In France, male urethritis is mainly diagnosed by general practitioners. 7 After analyzing the practitioner-based Sentinelles Network dataset, 8 spanning the years 1985 to 1988, we reported a gradual decrease in the incidence of urethritis, although the homosexual/bisexual population remained at higher risk than heterosexual men. 9 We now report on an analysis of the dataset for 1989 to 2000 for recent trends in the incidence of male urethritis.

METHODS

Launched in November 1984, the Sentinelles Network comprises approximately 500 sentinel general practitioners (SGPs) who are geographically representative of all general practitioners in mainland France 10 (excluding French overseas territories). The SGP sample represents approximately 1% of all French general practitioners. These unpaid volunteers participate in monitoring eight communicable diseases, including male urethritis. Once a week, each SGP connects to the network database through an online computer system (Minitel) and enters the number of cases they have diagnosed (even if the number is zero) and related information.

Urethritis is defined as micturitional pain and/or purulent or mucoid discharge. A new case of urethritis is defined as a case reported for the first time by an SGP. For each case, the practitioner sends information on the patient’s age and the presence or absence of discharge. Sexual preference has been recorded since April 1990, and the history of STD during the previous year or years, microbiologic analyses, and identified pathogens have been recorded since 1997.

Data are analyzed each week. The practitioners are contacted by telephone or electronic mail if the patient’s age is less than 15 years or if more than two cases are reported during the same week.

Each SGP has an identification code, which is entered with each case report; cases are reported anonymously. To exclude recurrent and persistent urethritis, the dataset of each SGP is checked each year for identical records. Two or more cases with the same characteristics are counted as a single case.

In France, patients are not registered with specific doctors, general practitioners are not gatekeepers, and patients are free to go to the doctor of their choice. Thus, information on a given general practitioner’s patient population is not available. Calculations of incidence rates are based on the assumption that, for common diseases, the unknown fraction of the French population under surveillance by the Sentinelles Network is representative of the total population consulting general practitioners.

Because some SGPs do not connect every week and others connect more than once a week, two corrections were used when incidence rates were computed on a national scale. The first takes into account the number of days of participation (interval between two successive connections) by each SGP. The second corrects for differences between the regional distribution of SGPs who connect during a given week and the regional distribution of all French general practitioners. 11

To obtain national projections, we multiply the mean number of cases per SGP in the network (standardized to SGP participation and SGP geographic distribution) by the total number of general practitioners in France, and then we divide by the total number of males older than 14 years of age, obtained from the French national population census.

Descriptive analysis, restricted to patients 15 to 64 years old, was performed with SAS software, version 6.12 (SAS Institute, Cary, NC). Comparisons between percentages over time were made with trend tests, 12 and chi-square statistics were used to evaluate intergroup differences in the distribution of categorical variables. Calculation of 95% CIs was based on the assumption that reported cases followed Poisson’s distribution.

RESULTS

Overall Trends

The annual incidence rates of adult male urethritis (Figure 1) decreased from 630 to 180 per 100,000 between 1989 and 1995 in France. Between 1996 and 1998, the incidence increased from 180 to 270 per 100,000 (P = 0.01) and then remained relatively stable. The annual incidence rate was higher in the Paris area but followed a similar trend, falling from 770 to 200 per 100,000 between 1989 and 1995, rising to 320 in 1996, and stabilizing thereafter at approximately 280.

Fig. 1
Fig. 1:
Annual incidence rates of male urethritis (per 100,000 males older than age 14 years) in France.

Characteristics of the Patients With Urethritis

The mean age of the 2320 patients with documented urethritis (87% of all reported cases) was 35.2 years (SD, 12.4). The proportion of homosexual men among those with urethritis, recorded since 1990, was 10% (95% CI, 8.9–11.9%), ranging from 7.5% to 14.6% according to the year; this proportion was higher in the Paris area, at 17% (95% CI, 13.6–21.5%), compared with 8% (95% CI, 6.5–9.6%) in the rest of France (P < 0.01). Overall, a discharge was noted in 66% of cases; this proportion decreased from 67% in 1989 to 54% in 2000 (P = 0.003). Homosexual/bisexual patients were significantly younger than heterosexual patients (33.2 versus 35.5 years;P = 0.0001), both throughout the study and each year. The mean age of heterosexual patients increased between 1989 and 2000 from 33.3 to 38.6 years (P = 0.0004). The frequency of discharge was higher among homosexual/bisexual men than heterosexual men (81% versus 64%;P = 0.001) and reached 94% among homosexual men in the Paris area. With regard to the variables reported since 1997, one or more previous episodes of STD were reported by 39% of patients (95% CI, 31–47%), and 36% of these patients had had an STD during the year preceding the current episode.

Homosexual/bisexual patients were more likely to report a history of STD than were heterosexual patients (68% versus 34%;P = 0.001). Overall, 38% of patients reported at least two sex partners (95% CI, 30–46%), but this percentage reached 79% among homosexual/bisexual men, versus 34% among heterosexual men (P = 0.001).

A urethral swab specimen was taken from 63% of patients (95% CI, 52–71%), a proportion similar to that of inpatients with or without discharge, but heterosexual patients were more likely to have had a swab specimen obtained than were homosexual/bisexual patients (64% versus 43%;P = 0.02). Results of microbiologic identification have been reported for 75% of patients for whom an analysis was prescribed. The relative frequencies of etiological agents during the 4-year period were 13% for Neisseria gonorrhoeae, 18% for Chlamydia trachomatis, and 3% for Trichomonas vaginalis.

DISCUSSION

This survey of the period 1989 to 2000 shows an initial decrease in the incidence of male urethritis, with a significant increase in 1996 followed by relative stability. The proportion of cases among homosexual/bisexual men remained stable at approximately 10% and was higher in the Paris area (17%). However, homosexual/bisexual cases were characterized by younger age, a higher frequency of discharge, a more frequent history of STDs, and a larger number of sex partners than among heterosexual men. On the basis of data available since 1997, the main causative organisms are chlamydiae (18%) and N gonorrhoeae (13%).

Because this survey spans more than 10 years, turnover of participating general practitioners must be taken into account. Since 1996, the percentage of new SGPs entering the surveillance network per year is approximately 6% (less than before 1996), and the percentage of SGPs leaving the network is approximately 14%. Between 1995 and 2000, the median cumulative “survival” of an SGP, 13 defined as the duration of compliance with the surveillance protocol, was stable at approximately 1.6 years. This is similar to the figure reported in 1998. 13 Because the calculated figure is the mean number of cases per SGP (weighted by the geographic distribution of participating SGPs per week), it is unlikely that the trends in the incidence of urethritis observed here can be attributed to SGP turnover.

As the survey is based on SGP notification, the observed changes might have been related to changes in the utilization of health care facilities by patients with urethritis and STDs as a whole. No reliable longitudinal data on the utilization of health care facilities by STD patients in France are available, but indirect evidence does not support major changes: data from the study of sexual behaviors of the French population (ACSF) performed in 1991 on a random sample of the French population 14 showed that 60% of men older than 18 years of age with a history of STD during the previous 5 years had consulted a general practitioner. This number does not differ markedly from that observed in 1978 7 or that stated in the national gonorrhea laboratory network (RENAGO) reports in 1995 15 and 2001. 16 Because homosexual men are more likely than heterosexual men to have gonococcal infection, part of the change in incidence could be explained by a certain percentage of homosexual men shifting from general practitioners to STD clinics, or vice-versa. This was apparently not the case, as data from the STD clinic survey show that the number of patients decreased by 50% between 1991 and 1997 and that the proportion of homosexual men among men with acute STDs decreased from 15.2% to 11.7%. 17,18

The mean age of our patients was 35.2 years, which is older than in other European countries, suggesting that younger cases are being seen elsewhere. However, this figure is consistent with data obtained by other (French) data collection systems. 16,17 The ASCF survey showed that the incidence of bacterial STDs was maximal in the age group of 25 to 34 years, whereas viral STDs predominated in the age group of 18 to 24 years. 19

The case definition of urethritis remained the same throughout the study period. It was based on simple clinical criteria, 20 making a diagnostic bias unlikely.

The increase in incidence noted in 1996 could have been due to an increase in the number of patients with persistent or recurrent urethritis, but this is unlikely, as each SGP dataset is checked yearly for identical records and 80% of SGPs report fewer than three cases annually.

Microbiologic analysis has been done routinely since 1997 and now represents approximately 47% of all cases in the dataset.

The trends in male urethritis observed here are consistent with overall trends in STDs reported by other surveillance systems, both in France 16 and in other European countries. 5 This reinforces the view that new studies of sexual behavior are required, particularly among homosexual/bisexual men, who appear to be most at risk. Indeed, in our survey the percentage of homosexual/bisexual men with urethritis was higher than in the ACSF study, 14 both throughout France (10% versus 4%) and in the Paris area (17% versus 6%).

A French cohort study of HIV-infected patients between 1988 and 1992 showed an incidence of urethritis among male homosexuals twice that among male heterosexuals. 21 An increase in the incidence of STDs in the homosexual population has been reported in recent years in several countries. 22–24 The stable proportion of homosexuals among SGP patients and the recent increase in rectal gonococcal infection 16 trigger an alert for this population, which seems to be particularly exposed to the risk of STDs and therefore to HIV infection. The higher frequency of a history of STD and the larger number of sex partners per patient among homosexual/bisexual men than among heterosexual men are consistent with a higher frequency of at-risk behavior among the former.

We did not distinguish between homosexual and bisexual men in this study, despite the known heterogeneity of risk behaviors. 25 Although homosexual and bisexual men were overrepresented in our study population, the number of cases recorded is too small to compare the two categories of patients. Likewise, most European STD and AIDS surveillance systems do not distinguish between these two groups.

The frequency of discharge was higher in homosexual/bisexual men than in heterosexual men, suggesting that the etiologies of urethritis may differ. Data from another French study 21 showed that the incidence of gonorrhea among all STDs was higher among homosexuals than among heterosexuals (42% versus 20%;P = 0.001). This is important, because gonorrhea appears to be more closely linked with behaviors in the core group than is infection with C trachomatis. 26,27 The frequency of discharge decreased significantly during the study period among both homosexual/bisexual and heterosexual men.

Trends observed by the French national gonococcal laboratory network (RENAGO) 15 were similar. The mean number of gonococcal isolates from men with urethritis declined from 10.7 per laboratory in 1986 to 1.7 in 1991 15 but increased again after 1998. 16

If the observed rise in STDs is associated with an increased risk of HIV infection, the impact of related behavioral changes on the incidence of AIDS would be seen only after several years. However, in countries such as France in which highly active antiretroviral treatments are widely available, the incidence of AIDS no longer provides a reliable indicator of trends in the HIV transmission rate. The French data published by EuroHIV (http:/http://www.ceses.org/aidsSurv/) show a persistent decline in AIDS incidence rates. Notification of newly diagnosed HIV infections (including AIDS cases) is not yet operational in France, and no information is currently available.

The results of this and other surveys in France and elsewhere are alarming. The decrease in the incidence of male urethritis between 1984 and 1995, observed in our previous study 9 and more recent surveys, shows that HIV and STD prevention campaigns can induce changes in sexual behavior. AIDS is no longer perceived as a deadly disease, and prevention campaigns targeting both homosexual/bisexual men and the general population must be urgently adjusted.

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