Extragenital Chlamydia and Gonorrhea Among Community Venue–attending Men Who Have Sex With Men — Five Cities, United States, 2017

Five Cities, United States, 2017

Michelle L. Johnson Jones, MPH; Johanna Chapin-Bardales, PhD; Destani Bizune, MPH; John R. Papp, PhD; Christi Phillips; Robert D. Kirkcaldy, MD; Cyprian Wejnert, PhD; Kyle T. Bernstein, PhD; National HIV Behavioral Surveillance Sexually Transmitted Infection Study Group


Morbidity and Mortality Weekly Report. 2019;68(14):321-325. 

In This Article

Abstract and Introduction


Sexually transmitted diseases (STDs) disproportionately affect gay, bisexual, and other men who have sex with men (MSM) in the United States.[1] Because chlamydia and gonorrhea at extragenital (rectal and pharyngeal) anatomic sites are often asymptomatic, these anatomic sites serve as a reservoir of infection, which might contribute to gonococcal antimicrobial resistance[2] and increased risk for human immunodeficiency virus (HIV) transmission and acquisition.[3] To ascertain prevalence of extragenital STDs, MSM attending community venues were recruited in five U.S. cities to provide self-collected swabs for chlamydia and gonorrhea screening as part of National HIV Behavioral Surveillance (NHBS). Overall, 2,075 MSM provided specimens with valid results, and 13.3% of participants were infected with at least one of the two pathogens in at least one of these two extragenital anatomic sites. Approximately one third of participating MSM had not been screened for STDs in the previous 12 months. MSM attending community venues had a high prevalence of asymptomatic extragenital STDs. The findings underscore the importance of sexually active MSM following current recommendations for STD screening at all exposed anatomic sites at least annually.[4]

According to a systematic review of studies from 2000 to 2016, the estimated prevalences of rectal chlamydia and gonorrhea among MSM were 9.0% and 6.1%, respectively.[5] Fewer data are available on pharyngeal chlamydia and gonorrhea; prevalence estimates were 0%–3.6% for pharyngeal chlamydia and 0%–16.5% for pharyngeal gonorrhea among MSM.[6] Nearly all reported prevalences of extragenital infections among MSM have been estimated from clinic-based samples of patients. Because men in these samples sought clinical care (and could be at elevated risk for STDs, especially if seen at an STD clinic), reported estimates might not reflect prevalences among a broader population of MSM. To inform the epidemiology of bacterial STDs among MSM, extragenital chlamydia and gonorrhea screening was offered to MSM recruited to participate in NHBS at MSM-frequented venues in five U.S. cities (Houston, Texas; Miami, Florida; New York City, New York; San Francisco, California; and Washington, DC). NHBS assessed adherence to current screening recommendations using the question "In the past 12 months, were you tested by a doctor or other health care provider for a sexually transmitted disease like gonorrhea, chlamydia, or syphilis? Do not include tests for HIV or hepatitis."

NHBS conducts anonymous behavioral surveys on a rotating basis among populations with elevated HIV risk in the United States.[7] In 2017, MSM participants were recruited from MSM-frequented community venues (e.g., bars, clubs, fitness centers, and other locations patronized by MSM) and were eligible if they were male at birth, identified as male, were aged ≥18 years, reported ever having sex with a male, were residing in the city of administration, had not previously completed the NHBS survey in the current cycle, and could complete the survey in English or Spanish. This analysis was restricted to participants who had sex with a male in the previous 12 months. Participants completed an interviewer-administered standardized computer-assisted personal interview survey that collected sociodemographic and epidemiologic characteristics. All participants were offered an anonymous HIV test. Monetary tokens of appreciation for participating were provided to participants; amounts were determined locally. NHBS activities were reviewed at CDC as nonengaged research and approved by local institutional review boards for each participating location.

NHBS participants were offered additional tokens of appreciation for providing anonymous self-collected rectal and pharyngeal swabs for chlamydia and gonorrhea testing. CDC tested specimens from four of the cities using the Aptima Combo 2 Panther system (Hologic), and the San Francisco Department of Public Health Laboratory tested specimens from San Francisco using the same assay. Test results were communicated back to local NHBS teams for notification and treatment referrals when indicated, using numeric identifiers to maintain participants' anonymity. Test results were linked with completed survey data and HIV test results. STD prevalence was calculated as the number of persons with positive test results divided by the total number of persons tested with a valid result, stratified by anatomic site (rectum and oropharynx) and STD (chlamydia and gonorrhea) with 95% Wald confidence intervals (CIs) and bivariate analyses for comparing characteristics. Analyses were performed using SAS software (version 9.4; SAS Institute).

Among 2,371 eligible MSM who participated in NHBS in the five cities, 2,077 (87.6%) provided specimens for STD testing, 2,044 (98.4%) of whom provided both rectal and pharyngeal swabs. Analysis included 2,075 participants, after excluding two who lacked valid results. Overall, 13.3% (95% CI = 11.8%–14.8%) of participants were infected with at least one of the two STDs at one or two anatomic sites. Prevalence of rectal chlamydia (7.3%) was higher than that of rectal gonorrhea (4.5%; p<0.001), whereas prevalence of pharyngeal gonorrhea (4.6%) was higher than that of pharyngeal chlamydia (1.4%; p<0.001) (Figure). Rectal gonorrhea prevalence was higher among MSM who reported being HIV-positive than among those who were HIV-negative (8.2% versus 3.3%; p<0.001) (Table). Prevalences of both pharyngeal infections were similar among those testing HIV-positive and HIV-negative. Prevalence of infection was higher in younger men (aged 18–29 years), compared with older men for each type and anatomic site of infection except pharyngeal chlamydia. Black and Hispanic MSM had higher prevalences of pharyngeal gonorrhea than did white MSM, otherwise, no differences were observed by racial/ethnic categories. San Francisco had the lowest prevalences for each pathogen and anatomic site; prevalences for each infection varied by city of residence (Table).


Prevalence of extragenital chlamydia and gonorrhea among community venue–attending* men who have sex with men, by anatomic site — National HIV Behavioral Surveillance, five U.S. cities, 2017
Abbreviations: HIV = human immunodeficiency virus; STD = sexually transmitted disease.
*Community venues include bars, clubs, fitness centers, and other locations frequented by men who have sex with men.
Houston, Texas; Miami, Florida; New York City, New York; San Francisco, California; Washington, DC.

Overall, 698 (33.6%) MSM participants reported that they had not been tested for an STD in the previous 12 months (Table). Prevalence was similar for MSM who did and did not report recent STD testing, irrespective of anatomic site or pathogen.