Gonorrhoea in MSM: Is kissing a major means of transmission?

Main Points:

• Significantly higher rates of gonorrhoea in MSM compared to heterosexual men => Why?
• Much higher incidence of of pharyngeal gonorrhoea in MSM compared to rectal infections & urethral (urethral = lowest)
• Prevalence of pharyngeal gonorrhoea in MSM is ~ 11% => ??why so high compared to other sites, especially when anal sex &/or oral-penile, oral-anal sex is reported to be LOW
• Working hypothesis: pharyngeal gonorrhoea is most likely transmitted through kissing, ?related to high rates of MSM kissing multiple partners in e.g. clubs & pubs

Personal reflection on personal practice => I remember a patient who was married (to a woman) who frequently engaged in MSM sex. This patient was Dx'd with pharyngeal gonorrhoea & stringently denied any sex with his wife for a very long time but had kissed her. His wife was admitted to hospital with Reactive Arthritis related to gonorrhoea infection. Based on patient report: the only possible means of gonorrhoea transmission to his wife could be through kissing

Gollow Lecture by Rebecca Guy:

• Focus on the ever-increasing utility of the various (existing, new & emerging) IT platforms & applications for:

1. improving client & patient care experience
2. increased efficiencies / time savings for clinical staff and thus also for the service as a whole
3. the potential and actual role(s) for technology to be utilised in both primary & secondary prevention

Examples of efficacious technology utilisation:

• Sydney Sexual Health:

1. electronic patient self-registration + appointment self-arrival system reduces the amount of time spent in reception by (a significant) 4 minutes
2. Benefits of CASI (computer assisted self interviewing): "most people don't want to discuss their sex lives in detail with doctors and nurses" => much easier to respond honestly to questions on a screen than go through the 'gruelling agony' of a face to face interview with a clinician

• Computer prompts for GP's shown in one study to increase opportunistic testing of e.g. chlamydia by a significant 30%
• Significant improvement in partner notification via websites such as 'Drama Down Under' & 'Let Them Know'
• Significant increase in re-testing rates utilising an SMS reminder system (NB: ~20% of people have a reinfection within 12 months of a +ve result) => in 2009 SSHC instituted an SMS reminder service. Result: 64% return rate for re-testing; a significant increase in re-testing rates vs a verbal recommendation after Rx. of the first infection
• * Very interesting 'side discussion' re: the use of online dating & hook-up apps => not only the domain of the young; rather, people of ALL ages are using these platforms. Also of note => people who use these online / dating apps are more likely to have had an STI in the past & more likely to have a higher number of casual partners

• ?? The Future:

1. Online Clinics?
2. Home STI testing?

• Finally: Rebecca promoted clinicians to access the freely available Kirby Institute Data sets: http://www.data.kirby.unsw.edu.au/

HPV

• SPANC: http://kirby.unsw.edu.au/projects/study-prevention-anal-cancer-spanc

1. Prospective 3 year study on anal HPV in older gay/MSM i.e. 35 years & older; important because this will be a mostly unvaccinated cohort
2. HPV 16: ~ 50% of all HPV related cancers plus it is the type least likely to be cleared
3. HSIL (high grade intra-epithelial lesion): found in 30-50% of HIV +ve men
4. Cochrane review: there is no current evidence that treatment of high grade lesions prevents progression to cancer
5. Research being done into the potential for anal cancer biomarkers to predict disease persistence

Syphilis

• Australian surveillance data 2006 - 2015: 14,200 notifications for syphilis
  
• Indigenous Australians are 6 times more likely to be infected with syphilis
  
• Significant increase in syphilis in MSM during the 10 years to 2015
• Rates of syphilis in MSM in Victoria => approx. the same rates in both HIV +ve & HIV -ve men (differs from epidemiology data in other jurisdictions where the rates of syphilis in HIV +ve men tend to be far higher than in HIV -ve men)

Gonorrhoea

• Studies into gonorrhoea site-specific infections in MSM couples => the number of gonorrhoea infections in certain sites did not correlate with the expected # of infections (in certain sites) when considering reported sexual behaviours e.g. far more throat infections than expected => leading to the hypothesis that kissing may be a significant factor in gonorrhoea transmission
  
• Condom use: even when condom use is reported to be high (for anal intercourse) there was no significant difference in the rates of gonorrhoea transmissions overall

IDU

• significantly higher numbers of all STI's in IDU vs non-IDU
  
• far more HIV +ve MSM inject drugs vs HIV -ve MSM

Testing for MSM

• Community based testing services are far more likely to attract gay/MSM plus have a significantly higher STI yield when compared to non-community based services. Conclusion: very important to maintain community based testing services