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Increases in Gonorrhea and Sexual Risk Behaviors Among Men Who Have Sex with Men a 12-Year Trend Analysis at the Denver Metro Health Clinic

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Increases in Gonorrhea and Sexual Risk Behaviors Among Men Who Have Sex with Men a 12-Year Trend Analysis at the Denver Metro Health Clinic UvA-DARE (Digital Academic Repository) Lessons in HIV/STD prevention drs Rietmeijer, C.A.M. Publication date 2004 Link to publication Citation for published version (APA): drs Rietmeijer, C. A. M. (2004). Lessons in HIV/STD prevention. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl) Download date:27 Sep 2021 Increases in Gonorrhea and Sexual Risk Behaviors Among Men Who Have Sex With Men A 12-Year Trend Analysis at the Denver Metro Health Clinic Cornells A. Rletmeljer, MD, Jennifer L. Patnalk, Franklyn N.Judson, MD, and John M. Douglas Jr, MD Background: Recent increases in rates of sexually transmitted diseases (STDs) and decreases in safe sex behaviors among men who have sex with men (MSM) in several American and European cities have been noted by researchers. It has been suggested that these trends are the result of perceptions that HIV/AIDS is less serious because of the availability of highly active antiretroviral therapy (HAART). Goal: The goal of the study was to examine trends in STD rates and risk behaviors among MSM and men who have sex with women (MSW) visiting a public STD clin­ ic in Denver and to determine whether there is an ecological association with the avail­ ability of HAART. Study Design: This is a two-part retrospective analysis of male visits to the Denver Metro Health Clinic (DMHC). The first part describes gonorrhea and early (primary and secondary) syphilis trends among MSM between 1982 and 2001. For the second part, data were grouped into two 6-year time periods to represent pre-HAART and post-HAART time frames, 1990 to 1995 and 1996 to 2001. Results: Gonorrhea and early syphilis cases among MSM declined precipitously between 1982 and 1988 and then stabilized at low rates. The proportion of male vis­ its to the clinic made by MSM decreased from 14.1% in 1990 to 7.2% in 1995 and then increased to 13.0% in 2001. Gonorrhea positivity rates among MSM increased after 1995 and were significantly higher in the period 1996 to 2001 (12.9%) than in the period 1990 to 1995 (8.1%; P < 0.0001). Conversely, gonorrhea rates among MSW dropped from 11.2% in the first period to 6.9% in the second (V < 0.0001). 99 Among MSM known to be HIV-infected, gonorrhea rates increased from 11.6% in the first time period to 24.0% in the second period (P < 0.0001). Reports of anal sex among MSM increased from 64.4% to 70.9% (P < 0.0001). Reporting more than one sex partner increased for MSM from 65.2% to 70.3% (P < 0.0001), but it sig­ nificantly decreased from 52.6% to 46.2% forMSW(P < 0.0001). No or inconsis­ tent condom use increased from 60.9% to 63.0% for MSM (P = NS) and decreased from 85.1 % to 82.4% amongMSW(P < 0.0001). Conclusions: These trends appear to reflect a change toward higher risk-taking behaviors among MSM but not MSWsince the time HAART became available and raise concerns about the potential for increased HIV transmission in this group. The onset of the AIDS epidemic in the United States in die early 1980s brought about strong grassroots efforts within the gay communities that led to rapid increases in safer sex behaviors and decreases in rates of sexually transmitted diseases (STDS) among men who have sex with men (MSM).1-2 In Denver, for example, rectal gonorrhea among MSM, an important indicator of unprotect­ ed anal sex, showed an almost 40% decline between 1982 and 198 3, while gon­ orrhea rates among non-MSM and women remained stable. 3 However, recent gonorrhea and syphilis outbreaks associated with increases in high risk sexual behaviors among MSM have been reported from several American and European cities.4"6 Some studies have shown that these developments are occurring in the Hiv-infected population as well as among the uninfected.7-9 One common hypothesis for these trends is that increases in STD and risk behaviors among MSM are related to the widespread availability of highly active antiretroviral therapy (HAART), HAART has prolonged and improved lives for the Hiv-infected and has potentially lowered infectivity rates. These advance­ ments may have affected the sexual practices of MSM by influencing their per­ ceptions of the risk and consequences of HIV infection.10 This current study had two goals: (1) to describe trends in gonorrhea and syphilis among MSM making visits to the Denver Metro Health (STD) Clinic (DMHC) over the 20 years since the first case of AIDS was diagnosed in Colorado in 1982 and (2) to compare trends in STD and sexual risk behaviors among MSM and men having sex with women (MSW) making visits to DMHC in two 6-year time-frames before and after the introduction of HAART in 1996, in order to determine any ecolog­ ical association of these trends with HAART availability. Methods DMHC is the largest public STD clinic in the Rocky Mountain region. There are approximately 12,500 patient visits for a new problem each year, of which about 8000 are by men. Gonorrhea and Svphilis Trends, 1982-2001 For the first part of this study, we summed gonorrhea and primary and second­ ary syphilis cases among MSM reported from DMHC for each year in the 20 year 100 interval, MSM were defined as men who reported having sex with another man in the previous 12 months. The definition of a gonorrhea case included a diag­ nosis of urethral, pharyngeal, or rectal gonorrhea. Infections at multiple anatomical sites at the same visit were counted as one case, but a single person could contribute multiple cases if he or she had gonorrhea diagnosed on more than one occasion. The latter definition also applied to primary and secondary syphilis, i.e., a single person could contribute multiple cases if repeated infec­ tions were diagnosed. Before 1987, all cases were entered in a written log. In January 1987 the DMHC database became fully computerized, and all subse­ quent analyses were conducted with statistical computer programs. Comparative Trend Analyses, 1990-2001 This part of the study was a retrospective analysis of the DMHC patient comput­ er database. Patients' demographic, risk behavior, and clinical information is collected by clinic staff members during visits with a computer-scannable form and is maintained in a computerized medical record. A total of 91,524 records from male clients who visited DMHC for a new problem between January 1990 and December 2001 were analyzed. For purposes of this analysis, MSW were defined as men who self-reported sex with a woman within the previous 12 months but denied having sex with a man in this time period. Men who had sex with both men and women during this interval were included in the MSM group. Men who claimed to have had no sex within the past year were excluded from the analysis. Positivity rates for MSM and MSW were calculated for the following STDS, for which all men were routinely evaluated: gonorrhea, nongonococcal urethritis (NGU), and primary and secondary syphilis. Routine screening of men for chlamydia was not performed until 1996; therefore, those data are presented only for the latter period. Rates of HIV infection were based on current test results or, if these results were unavailable, on past testing results. Sexual risk behaviors were queried over the 4 months before the clinic visit; these includ­ ed engaging in receptive or insertive anal sex, having more than one sex part­ ner, and condom use for anal or vaginal sex (categorized as never, sometimes, or always). Inconsistent condom use was defined as never or sometimes using condoms. HAART became widely available for HIV disease in 1996. To evaluate the (eco­ logical) association of STD trends with the availability of HAART, the 12 years of data were grouped into two 6-year periods, before and after the introduction of HAART: 1990 to 1995 and 1996 to 2001. In addition, for certain STDS and behaviors, data are also presented by year to better demonstrate trends over the 12 year interval. All analyses were conducted with use of the SAS 8.1 statistical software package (SAS Institute, Cary, NC). We used the chi-square test for statistical significance of categorical data in the bivariate analysis. Laboratory Procedures STD diagnoses were based on the following: gonorrhea was diagnosed by cul- 101 ture of urethral, rectal, and pharyngeal specimens on Thayer Martin choco­ late agar plates; nongonococcal urethritis was diagnosed when four or more polymorphonuclear cells were detected by high power examination of a gram stained urethral smear. Routine chlamydia screening of urine samples from men began in 1996 with use of the Roche Amplicor polymerase chain reaction (PCR), which was replaced with the ProbeTec strand displacement assay (SDA; Becton Dickinson, Cockeysville, MD) in July 2000.
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