By Dr Jenny McCloskey, Sexual Health Physician, RPH
Gonorrhoea is significantly increasing in metropolitan Perth, with cases having more than doubled in the last five years. In all my years as a sexual health physician I have never seen STI rates so high in the metropolitan region.
In 2017 there were over 3300 cases of gonorrhoea in WA with 20% being in women in their twenties. Why younger women are increasingly infected is unknown – do you have the answer? Write to us with your ideas? Cases in heterosexuals now outstrip those in men who have sex with men (MSM).
Women may not develop a symptomatic discharge so the diagnosis can be missed until their partner develops symptoms. Even if they are asymptomatic they are still at risk of complications such as pelvic inflammatory disease and consequent ectopic pregnancy and infertility. Pregnant women need to be screened to prevent transmission to their child at birth and in high prevalence areas screening should be done a second time prior to delivery.
Given the escalating gonorrhoea infections in Perth, antibiotic resistance will be a real public health problem as a satisfactory alternative to the currently used ceftriaxone/azithromycin combination does not exist for routine use. If you have a patient in whom you have made the diagnosis it is really important to have tested all possible sites of infection and this includes the throat and rectum as these are the sites where treatment failures occur. Patients are quite obliging with doing many of their own swabs these days but they are not able to successfully perform their own throat swabs.
Treatment to prevent HIV infection by taking emtricitrabine/tenofovir daily has just been released on the PBS. Guidelines for its use are listed on the ASHM website and training courses for doctors interested in providing this to their patients are rapidly being developed.
PrEP has been shown to significantly reduce HIV acquisition and it is thought it may lead to the end of HIV. In WA there has been a 47% reduction in HIV amongst MSM in the last 12 months. Patients taking the medication are still encouraged to use condoms to reduce their risk of exposure to HIV and other STIs such as gonorrhoea, chlamydia and syphilis.
However, there is emerging evidence the use of condoms is falling.
In addition to encouraging condom use, three-monthly screening for STI’s (HIV, syphilis, oral, rectal and urethral gonorrhoea and chlamydia) is recommended as well as a check of renal function (protein/creatinine ratio).
Long term there is a slightly increased risk of osteoporosis and in older men the long term effect on renal function is not fully understood, however compared to the risks of HIV acquisition this prophylactic medication is being rapidly taken up and promoted.
For those who want access to free medication rather than through the PBS system the Fremantle and Royal Perth Hospital Sexual Health Clinics, and the M clinic are running a clinic trial with the HDWA and Kirby Institute to see how quickly the roll out of this medication can reduce the incidence of HIV in WA. The trial ends in April 2019.
Findings from the RPH Anogenital Wart Database
A recently published paper in Papillomavirus Research (McCloskey et al) has provided a novel understanding of cofactors in the development of anal intraepithelial neoplasia.
Using patients with genital warts co-infected with a high-risk strain of HPV as the baseline the authors found that the risk of anal pre-cancer was increased by HIV infection (odds ratio 11.1) as well as other STI’s such as syphilis (OR 5.58), gonorrhea (OR 6.45), chlamydia (OR4.80) and genital herpes (OR 7.85). Therefore, with the reduction in condom use the authors predict there may be a serious increase in anal pre-cancer particularly among MSM. The paper discusses the various mechanisms as to how the increase may occur such as chlamydia increasing the persistence of high-risk HPV, gonorrhoea acting similarly by the inflammation it causes and genital herpes is recognized to be a mutagen so it may work synergistically with HrHPV to increase the risk of anal pre-cancer. This work highlights the importance of vaccinating MSM.
Changes to the treatment of NSU
As antibiotic resistance to Mycoplasma genitalium is emerging, the days of single dose treatment for STI’s are fading rapidly. At most world sexual health conferences the emergence of highly drug resistant gonorrhoea is discussed. Doxycycline 100mg bd for 7 days is now the recommended treatment for NSU. Testing for Ureaplasma sp is not recommended.
Mycoplasma genitalium. A new diagnostic test for Mycoplasma genitalium is available which also provides azithromycin sensitivity/resistance data at the time the diagnosis is released. This will enable appropriate treatment to be given. Guidelines for treatment vary on the sensitivity and are evolving so it is a good idea to discuss treatment with a Sexual Health or ID Physician.
Acknowledgments: HDWA for provision of data.
Author competing interests: nil relevant.
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