Faiza Ali MD, Ericka Hayes MD, Gaurav Kaushik MPH, Nicole Carr RN , Katie Plax MD

1. Prevalence of pharyngeal, rectal and GU Chlamydia and gonorrhea in a high risk urban youth MSM population: Urine screening alone significantly underestimates infections Faiza Ali MD, Ericka Hayes MD, Gaurav Kaushik MPH, Nicole Carr RN, Katie Plax MD Washington University School Of Medicine Department of Pediatrics

2. Presenter Disclosure • I have no relationships to disclose.

3. CDC estimates approximately 19 million new cases of STIs in a given year – almost 50% occurring in youth ages 15 to 24. • Cost to treat these and their complications is estimated to be more than $8 billion per year. CDC. STD Treatment Guidelines. MMWR 2010;59 (RR-12). • Gonococcal infections have been identified as one of the strongest and most consistent risk factors associated with HIV seroprevalence and seroconversion. (1-3). • 85% of GC/ CT infections are asymptomatic. 1.Chmiel JS et al. Factors associated with prevalent human immunodeficiency virus (HIV) infection in the Multicenter AIDS Cohort Study. Am J Epidemiol. 1987;126:568-577.   2. Coates RA et al. Risk factors for HIV infection in male sexual contacts of men with AIDS or an AIDS-related condition. Am J Epidemiol. 1988;128:729-739. 3. Craib KJ et al. Rectal gonorrhoea as an independent risk factor for HIV infection in a cohort of homosexual men.Genitourin Med. 1995;71:150-154.

4. HIV Infection and STIs In Men Who Have Sex with Men • Between 2006- 2010, there was an estimated 21% increase in HIV incidence for people aged 13-29 years. • For MSM a history of 2 rectal STI infections was associated with an 8 fold increased risk of acquiring HIV infection. (Bernstein et al J Acquir Immune DeficSyndr, 2010)

5. Current CDC Recommendations • Yearly screening for C. trachomatis and N. gonorrhea of all sexually active females aged ≤25 years. • Screening of sexually active young men should be considered in high prevalence settings(e.g., adolescent clinics, correctional facilities, and STD clinics). • MSM with relevant exposures be screened for urethral and rectal CT/ GC, and for pharyngeal gonorrhea, at least annually and consider every 3 to 6 months for men at highest risk.

6. HYPOTHESIS • Asymptomatic non-genital Chlamydia/Gonorrhea infections contribute to a high burden of infection. • Pharyngeal and rectal Chlamydia/Gonorrhea screening along with urine/genital screen can increase the yield of positive cases in a high risk population of young men who have sex with men.

7. AIMS • Detect prevalence of infection in MSM youth at genital and non genital sites (oral and rectal). • Identify the number of infections missed by urine screening alone.

8. METHODS: • Patient Population: Youth MSM population (13- 24 years old) seen at the SPOT (Supporting Positive Opportunities for Teens) for medical services from April 01,2012 to October 10, 2013. • 67% African American, 27% Caucasian, 6% multiracial • 4% self identified as Transgender (Male to Female) • Specimen Collection: Pharyngeal, genital and rectal swabs (Samples self collected/ provider obtained). • Lab Method: CT/ GC nucleic acid amplification testing (NAAT) performed by Centers for Disease Detection lab ( internal validation of the assay on pharyngeal and rectal specimens performed in a manner consistent with the Centers for Disease Control (CDC) and the Association of Public Health Laboratories).

9. The SPOT(Supporting Positive Opportunities with Teens) One-stop, drop-in center, which provideshealth and social services with youth 13-24. More than 114,816 Total Encounters • STD Testing/Medical/HIV • Drop In • Food • Phones/computers • Transportation • Case Management • Job search • Mental Health • Pregnancy Tests • Contraception

10. Testing results • MSM (14- 24 years) screened at all three sites (urine, rectum and throat), with 250 unique individuals tested. • 103 out of 250 patients had a positive test (41%). • Total positive tests for GC or CT were 205 of 2052 (10%) specimens. • 65 positive Chlamydia tests in 50 patients. • 140 positive Gonorrhea tests in 86 patients. • Note some patients had positive tests at multiple sites and 33 patients were positive for both infections.

11. Cumulative Results of Positive Tests

12. Chlamydia Infections by Site

13. Gonorrhea Infections by Site

14. Percentage of Infections that Would be Missed by Testing by Site

15. Total positive tests for GC or CT were 205 of 2052 (10%) specimens. • (+) Genital site - Urine: 36/205(18%) • (+) Non-genital site: 169/205(82%) • Positive rectal specimens: 101 of 664 (15%). (+) CT in 45 of 332 (14%) specimens. • Only 5 of 45 (11%) of the corresponding urine specimens was positive. (+) GC in 56 of 332 (17%) specimens. • Only 15 of 56 (27%) of the corresponding urine specimens were positive. • Positive pharyngeal specimens: 68 of 694 (10%). (+) CT in 9 of 347 (3%) specimens. • Only 1 of 9 (11%) of the corresponding urine specimens was positive (+) GC in 59 of 347 (17%) specimens. • Only 9 of 59 (15%) of the corresponding urine specimen were positive. • Positive urine specimens: 36 of 694 (5%). (+) CT in 11 of 347 (3%) specimens. (+) GC in 25 of 347 (7%) specimens.

16. Conclusions: • Urine screening alone is not a reliable proxy for all sites for GC and CT infections in a youth MSM population. • Rectal specimens had the highest rate of positive testing, while urine specimens had the lowest. • Urine screening alone would have failed to detect at least 70% of the infected individuals with CT and GC infections. • For HIV-uninfected patients, an STD diagnosis is both a marker for possible high-risk activity and a potential cofactor for HIV acquisition. • Considering increases in potentially resistant GC infections and ongoing transmission, more attention should be focused on the potential role that extra-genital infections play.

17. Thank You! Dr. Faiza Ali Dr. Ericka Hayes Dr. Katie Plax The SPOT/Project ARK WUSM Gaurav Kaushik MPHGregory A. Storch, MD Nicole Carr Rachel Presti, MD Lawrence Lewis Bradley Stoner, MD All support staff David Hunstad, MD All of our patients