Gay, bisexual, and other men who have sex with men (MSM) in the United States are disproportionately affected by HIV, representing 86% of 35,571 men newly diagnosed as having HIV in 2014.1 Men who have sex with men are likewise disproportionately affected by the 2 most prevalent sexually transmitted diseases (STDs) in the United States, Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT).2 Among MSM tested in STD clinics sampled for sentinel STD surveillance in 2014, 19% tested positive for GC and 15% tested positive for CT. The proportion of MSM who tested positive for GC was roughly twice the proportion among men who have sex with women and 4 times the proportion among women.3
Sexually transmitted disease testing is an important component of HIV care for MSM, given common sexual risk behaviors for HIV and other STDs.2 Testing and treating HIV-infected persons for GC and CT infection benefits their health and reduces ongoing STD transmission, and subsequently may also reduce HIV transmission.4 Furthermore, incident STDs indicate ongoing sexual risk behavior, so diagnoses present opportunities for HIV prevention interventions.
N. gonorrhoeae and CT infections in MSM occur most often in the anorectum and pharynx, and extragenital testing substantially improves diagnostic yield.5 Per US guidelines, providers should obtain a sexual history and test for GC and CT at anatomical sites of sexual contact among all HIV-infected MSM at least annually.2 Reported frequencies of extragenital GC and CT testing have been low; however, previous studies comprise mostly convenience samples of urban MSM and may not have been representative of current testing practices nationally.6,7 Our objective was to generate nationally representative estimates of testing for GC and CT by anatomical site among MSM in HIV medical care in the United States.
The Medical Monitoring Project (MMP) is a surveillance system that produces nationally representative estimates of the clinical and behavioral characteristics of HIV-infected adults (>18 years) receiving medical care in the United States. The MMP used a 3-stage sampling strategy to produce estimates: US states and territories, HIV care facilities, and patients with at least 1 HIV medical care visit from January to April in any given year; for this analysis, data from 2013 to 2014 are included. Facility response rates ranged from 76% to 85% by year; approximately 50% of sampled patients completed an interview and had a medical record abstracted.8 We included data collected from sexually active HIV-infected MSM. In accordance with the federal human subject protection regulations at 45 Code of Federal Regulations 46.101c and 46.102d and with the Guidelines for Defining Public Health Research and Public Health Non-Research, MMP was determined to be a nonresearch, public health surveillance activity used for disease control program or policy purposes.9,10 As such, MMP is not subject to review by a federal institutional review board. Participating states or territories and facilities obtained local institutional review board approval to conduct MMP if required locally. Informed consent was obtained from all interviewed participants.
We estimated weighted percentages and corresponding 95% confidence intervals (CIs) of GC and CT testing during the previous 12 months among sexually active MSM in HIV medical care. Demographic and sexual behavior data were obtained through self-reported interviews. Patients who reported any sexual activity (ie, oral, vaginal, or anal) within the previous 12 months of interview were categorized as sexually active. Testing data on STD were abstracted from medical records at the participant's primary source of HIV care. We assessed urine, anorectal, and pharyngeal testing. We defined “tested” as having documentation of at least 1 test, separately for urine and each anatomical site, and separately for GC and CT. As a sensitivity analysis, we also explored the effect of expanding the time frame for estimating GC and CT testing from 12 to 24 months. Data were weighted to account for unequal selection probabilities and nonresponse. We assessed test positivity for each test type (type of STD by anatomical site); however, the same patients could have tested positive at multiple anatomical sites, precluding statistical comparisons of test positivity by test type. Analyses were conducted using SAS 9.3 (SAS Institute, Cary, NC).
Among 3118 sexually active MSM in HIV care meeting the inclusion criteria, the median age was 44 years (interquartile range, 33–51 years), 43.9% were non-Hispanic white, 27.9% were non-Hispanic black, 23.3% were Hispanic, and 4.8% were of other race/ethnicity. Overall, 47.2% of sexually active MSM had documented testing for GC and 47.2% for CT during the previous 12 months; test positivity was 6.0% for GC and 6.9% for CT (Table 1). Approximately 13% of MSM were tested for each STD with no anatomical site specified.
Overall, 11.6% (95% CI, 8.4–14.8) of MSM were tested for either GC or CT at any extragenital site (either anorectum or pharynx) in the previous 12 months; expanding the time frame to 24 months did not yield a substantially different estimate (15.4% [95% CI, 10.9–19.4]). Testing of urine for GC (29.3%) was more frequent than testing of the anorectum (9.4%) or pharynx (9.0%); however, positivity was higher among anorectal (14.0%) and pharyngeal (9.6%) samples than among urine samples (2.5%). Similarly, testing of urine for CT (29.0%) was more frequent than testing of the anorectum (9.3%) or pharynx (8.2%), although CT positivity was higher for anorectal samples (17.8%) than for urine samples (3.3%). Pharyngeal sample positivity for CT (3.4%) was similar to that observed for urine samples. Testing of the urethra was infrequent (2.8% [95% CI, 1.9–3.6]), precluding estimation of test positivity.
In our analysis of nationally representative data on MSM who received HIV medical care in the United States, less than half were tested for GC or CT, with only 11.6% tested for either STD at an extragenital site in the previous 12 months. Testing sexually active MSM for STDs at any anatomical site was higher in our analysis (2013–2014) compared with an analysis of MMP data from an earlier period (2008–2010)11 (47% vs 23% for GC and 47% vs 22% for CT), suggesting that there may have been some increase in STD testing in recent years, similar to trends recently documented in this population.12 Nonetheless, our finding that 53.6% of MSM in HIV care were not tested for GC or CT in the previous 12 months suggests that testing per recommendations is unacceptably low in the United States.
The percentages of GC and CT testing at any anatomical site reported here are higher than the range of those previously published from studies conducted among convenience samples in large urban HIV clinics in the United States (19%–39%)6,7; this difference further suggests that there may have been some improvement in STD testing in recent years. Our findings regarding GC and CT testing at extragenital sites are also higher to those reported from prior studies, which indicate approximately 4% anorectal testing for both GC and CT and 3% pharyngeal testing for GC.6,7
Our analysis has several limitations. First, medical records were only abstracted from the primary source of HIV care; therefore, if a patient were tested for GC or CT at another health care facility and these results were not reported to the HIV care provider, then they would not have been captured in our estimates. Second, approximately 13% patients did not have the anatomical site of testing specified for GC and CT; however, even if all of these patients had been tested at extragenital sites, extragenital testing would have still been suboptimal. Third, during the years of this study, MMP included only people in HIV care; therefore, our estimates may not be generalizable to all HIV-infected MSM in the United States, some of whom had not initiated or been retained in HIV care and may have even less frequent STD testing than those in our study.
Suboptimal testing for GC and CT, particularly at extragenital sites, represents missed opportunities for treatment of STDs and prevention of ongoing HIV and STD transmission. Testing for GC and CT facilitates diagnosis and treatment, which benefits the health of the patient by alleviating current symptoms or averting future symptoms. Anorectal diagnosis of GC and CT in HIV-infected MSM also indicates engagement in unprotected, receptive anal intercourse. Although less risky for the HIV-uninfected partner than unprotected insertive anal intercourse, this may be a marker for engagement in other HIV transmission risk behaviors. Behavioral interventions, including promotion of condom use, can help prevent transmission of HIV as well as exposure to and transmission of other STDs. Biomedical interventions including antiretroviral medication for the HIV-infected patient and preexposure prophylaxis for the HIV-uninfected partner can help prevent HIV transmission; partner services can facilitate delivery of behavioral and biomedical interventions to sexual partners. Although all HIV-infected MSM should routinely receive STD prevention counseling, HIV-infected MSM diagnosed as having anorectal GC or CT may need additional counseling and other behavioral interventions.2
Previously reported barriers to extragenital screening for GC and CT include lack of regulatory approval for use of nucleic acid amplification testing of anorectal and pharyngeal specimens, and the additional time and skill required of providers to conduct a detailed sexual history and collect specimens accordingly.6,7 Systems approaches, such as electronic health systems that include prompts for STD testing and use of patient self-collected specimens, may help minimize these barriers and facilitate extragenital testing.13
Extragenital testing for GC and CT among HIV-infected MSM in HIV care in the United States has marginally increased in recent years but remains low. Increased testing in this population is essential to diagnose and treat STDs and prevent ongoing transmission of STDs and HIV.
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. Accessed August 12, 2017.
9. Centers for Disease Control and Prevention. Guidelines for Public Health Research and Public Health Non-Research 1999.
10. US Department of Health and Human Services. Protection of human subjects. Title 45 Code of Federal Regulations, Pt 46 1995.
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13. Bernstein KT. Systems approaches to improving rates of extragenital chlamydia and gonorrhea screening among men who have sex with men engaged in human immunodeficiency virus care. Sex Transm Dis 2015; 42:599–600.