Abstract
BackgroundSymptom- and sexual history-based testing i.e., testing on indication, for anorectal sexually transmitted infections (STIs) in women is common. Yet, it is unknown whether this strategy is effective. Moreover, little is known about alternative transmission routes i.e. by fingers/toys. This study assesses anorectal STI prevalence and infections missed by current testing practice, thereby informing the optimal control strategy for anorectal STIs in women.MethodsWomen (n = 663) attending our STI-clinic between May 2012-July 2013 were offered routine testing for anorectal and urogenital Chlamydia trachomatis and Neisseria gonorrhoeae. Data were collected on demographics, sexual behaviour and symptoms. Women were assigned to one of the categories: indication (reported anal sex/symptoms), fingers/toys (only reported use of fingers/toys), or without indication.ResultsOf women, 92% (n = 654) participated. There were 203 reports (31.0%) of anal sex and/or symptoms (indication), 48 reports (7.3%) of only using fingers/toys (fingers/toys), and 403 reports (61.6%) of no anal symptoms, no anal sex and no anal use of fingers/toys (without indication). The overall prevalence was 11.2% (73/654) for urogenital chlamydia and 8.4% (55/654) for anorectal chlamydia. Gonorrhoea infections were not observed. Prevalence of anorectal chlamydia was 7.9% (16/203) for women with indication and 8.6% (39/451) for all other women (P = 0.74). Two-thirds (39/55) of anorectal infections were diagnosed in women without indication. Isolated anorectal chlamydia was rare (n = 3): of all women with an anorectal infection, 94.5% (52/55) also had co-occurrence of urogenital chlamydia. Of all women with urogenital chlamydia, 71.2% (52/73) also had anorectal chlamydia.ConclusionsCurrent selective testing on indication of symptoms and sexual history is not an appropriate control strategy for anorectal chlamydia in women visiting an STI clinic. Routine universal anorectal testing is feasible and may be a possible control strategy in women. Yet costs may be a problem. When more restricted control measures are preferred, possible alternatives include (1) anorectal testing only in women with urogenital chlamydia (problem: treatment delay or loss to follow up), and (2) direct treatment for urogenital chlamydia that is effective for anorectal chlamydia as well.
Highlights
Symptom- and sexual history-based testing i.e., testing on indication, for anorectal sexually transmitted infections (STIs) in women is common
It is suggested that treatment of anorectal infections in women can help limit the spread of STI in the population [4,5,6] and can reduce complications in infected individuals, such as anal cancer, anal squamous intraepithelial lesions [15,16] and reduce HIV risk [5,6]
Anal use of fingers was reported by 20.3% (133/654) of the women, anal use of toys by 8.9% (58/654), anal sex with a steady partner by 24.0% (157/654), anal sex with a casual partner by 13.1% (86/654) and anal symptoms by 3.1% (20/654)
Summary
Symptom- and sexual history-based testing i.e., testing on indication, for anorectal sexually transmitted infections (STIs) in women is common It is unknown whether this strategy is effective. Guidelines in UK, US and the Netherlands do not recommend routine anorectal testing, but restricted testing in people who are in high-risk groups, report anal sexual behaviour, or have anal symptoms [12], i.e., selective testing on indication [12,13]. This is in contrast to urogenital testing, which is a routine procedure in STI care services in these countries. The rectum might act as a reservoir and thereby play a major role in repeat positive urogenital infections [4]
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