Abstract
BackgroundThe Centers for Disease Control recommend screening for asymptomatic sexually transmitted infection (STI) among HIV-infected men when there is self-report of unprotected anal-receptive exposure. The study goals were: (1) to estimate the validity and usefulness for screening policies of self-reported unprotected anal-receptive exposure as a risk indicator for asymptomatic anorectal infection with Neisseria gonorrhoeae (GC) and/or Chlamydia trachomatis (CT). (2) to estimate the number of infections that would be missed if anal diagnostic assays were not performed among patients who denied unprotected anorectal exposure in the preceding month.Methods and FindingsRetrospective analysis in HIV primary care and high resolution anoscopy (HRA) clinics. HIV-infected adult men were screened for self-reported exposure during the previous month at all primary care and HRA appointments. Four sub-cohorts were defined based on microbiology methodology (GC culture and CT direct fluorescent antibody vs. GC/CT nucleic acid amplification test) and clinical setting (primary care vs. HRA). Screening question operating characteristics were estimated using contingency table methods and then pooled across subcohorts. Among 803 patients, the prevalence of anorectal GC/CT varied from 3.5–20.1% in the 4 sub-cohorts. The sensitivity of the screening question for self-reported exposure to predict anorectal STI was higher in the primary care than in the HRA clinic, 86–100% vs. 12–35%, respectively. The negative predictive value of the screening question to predict asymptomatic anorectal STI was ≥90% in all sub-cohorts. In sensitivity analyses, the probability of being an unidentified case among those denying exposure increased from 0.4–8.1% in the primary care setting, and from 0.9–18.8% in the HRA setting as the prevalence varied from 1–20%.ConclusionAs STI prevalence increases, denial of unprotected anal-receptive exposure leads to an increasingly unacceptable proportion of unidentified asymptomatic anorectal STI if used as a criterion not to obtain microbiologic assays.
Highlights
The Centers for Disease Control (CDC) recommendation for anorectal screening for asymptomatic sexually transmitted infection (STI) among HIV-infected men who have sex with men (MSM) is ‘‘to test for rectal infection with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) in men who acknowledge anal-receptive intercourse during the preceding year’’ [1]
The questions used to screen for unprotected anorectal exposure were: (a) in the primary care clinic, ‘‘During the past month, did your partner put his penis in your anus without using a condom even once?’’ and (b) in the high resolution anoscopy (HRA) clinic, ‘‘During the last month, with how many people have you had analreceptive sex without using a condom?’’(screening considered positive for one or more partner) The selection of these items was based on patient focus group findings and pilot testing for acceptability and comprehension
Under varying prevalence, the number of undiagnosed asymptomatic anorectal STI cases in a hypothetical cohort of 1000 patients under the assumption that those not disclosing exposure would not be screened with a microbiologic assay, while those acknowledging exposure would all be screened with an assay with 100 percent sensitivity and specificity to detect anorectal gonorrhea and Chlamydia trachomatis infection
Summary
The Centers for Disease Control (CDC) recommendation for anorectal screening for asymptomatic sexually transmitted infection (STI) among HIV-infected men who have sex with men (MSM) is ‘‘to test for rectal infection with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) in men who acknowledge anal-receptive intercourse during the preceding year’’ [1]. The Infectious Diseases Society of America (IDSA) recommends rectal testing for GC/CT infection ‘‘on the basis of report of receptive anal intercourse’’ [2] According to these recommendations, screening for asymptomatic anorectal STI depends on the patient’s self-report of unprotected anal-receptive exposure. The study goals were: (1) to estimate the validity and usefulness for screening policies of self-reported unprotected anal-receptive exposure as a risk indicator for asymptomatic anorectal infection with Neisseria gonorrhoeae (GC) and/or Chlamydia trachomatis (CT). (2) to estimate the number of infections that would be missed if anal diagnostic assays were not performed among patients who denied unprotected anorectal exposure in the preceding month
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