Abstract
BackgroundMycoplasma genitalium (MG) causes a sexually transmitted infection (STI) with a rising rate of antimicrobial resistance. Currently, guidelines do not recommend screening asymptomatic men who have sex with men (MSM). We developed a mathematical model of MG transmission to examine the impact of various screening strategies on the incidence and prevalence of MG among MSM attending a sexual health clinic.MethodsA compartmental mathematical model of MG transmission among MSM was constructed and calibrated using data from the Melbourne Sexual Health center, where resistance-guided therapy provides high treatment effectiveness (92–95%). The model stratified men by symptom status, sexual risk behaviours and whether or not they had MG with macrolide resistance. We simulated the impact on endemic steady-state MG prevalence and incidence of the following screening scenarios, namely screening: 1) no MSM; 2) only symptomatic MSM (the current recommendation); 3) all symptomatic and high-risk asymptomatic MSM; and 4) all MSM. Our base case analysis assumed a treatment effectiveness of 92–95% using resistance-guided therapy. We also examined the impact of treatment effectiveness (i.e. the proportion of detected MG that were cured) and screening coverage (i.e. testing rate) on MG prevalence.FindingsThe model predicts that the overall endemic MG prevalence is 9.1% (95% CI: 7.9–10.0) in the current situation where screening is only offered to symptomatic MSM (base-case). This would increase to 11·4% (95% confidence intervals (CI): 10.2–13.7) if no MSM are offered screening, but would decrease to 7.3% (95% CI: 5.7–8.4) if all symptomatic and high-risk asymptomatic MSM were offered screening and 6.4% (95% CI: 4.7–7·7) if all MSM were offered screening. Increasing coverage of MSM screening strategies shows a similar effect on decreasing endemic MG incidence. When evaluating the simultaneous impact of treatment effectiveness and screening coverage, we found that offering screening to more MSM may reduce the overall prevalence but leads to a higher proportion of macrolide-resistant MG, particularly when using treatment regimens with lower effectiveness.InterpretationBased on the available treatment options, offering screening for MG to other MSM (beyond the currently recommended group of symptomatic MSM) could slightly reduce the prevalence and incidence of MG. However, further increasing screening coverage must be weighed against the impact of lower treatment effectiveness (i.e. when not using resistance-guided therapy), increasing the selection of macrolide resistance, and other negative consequences related to AMR and management (e.g. unnecessary psychological morbidity from infections that do not need treatment).
Highlights
Mycoplasma genitalium (MG) is a bacterium, first discovered and named in the 1980s, that causes sexually transmitted infection (STI) and disease in the lower and upper reproductive tract of women, and non-gonococcal urethritis in men. [1,2,3] Reported overall MG prevalence ranges from 1.3% (in countries with a high/very high Human Development Index (HDI)) to 3.9%. [4] In many countries, MG is the second most common bacterial STI, after Chlamydia trachomatis
For the current practice of screening, the model was well-calibrated to the observed prevalence of MG among high- and low-risk men who have sex with men (MSM) seen at the Melbourne Sexual Health center (MSHC)
The model predicts that the overall MG prevalence will be 11.4% (95% confidence intervals (CI): 10.2–13.7) if no MSM are offered screening (Scenario 1); 9.1% if screening is mainly offered to symptomatic MSM (Scenario 2, the current practice scenario); 7.3% if offered to symptomatic and high-risk asymptomatic MSM (Scenario 3); and 6¢4% if offered to all MSM (Scenario 4)
Summary
Mycoplasma genitalium (MG) is a bacterium, first discovered and named in the 1980s, that causes sexually transmitted infection (STI) and disease in the lower and upper reproductive tract of women, and non-gonococcal urethritis in men. [1,2,3] Reported overall MG prevalence ranges from 1.3% (in countries with a high/very high Human Development Index (HDI)) to 3.9% (in countries with a lower HDI). [4] In many countries, MG is the second most common bacterial STI, after Chlamydia trachomatis. A critical strategy underpinning control of non-vaccine preventable infectious diseases is to screen and treat the pathogen to reduce the duration of infectiousness and, the likelihood of ongoing transmission in the population This is important for infections like that caused by MG where the majority of those infected presenting to sexual health clinics are asymptomatic, i.e. 93% of anorectal infections and 79% of urethral infections in MSM. [8] it is not clear how ongoing transmission in this large reservoir of MGinfected but asymptomatic individuals is contributing to the prevalence and incidence of MG and, its effect on AMR It is unclear what type of screening strategies could reduce the prevalence and incidence of MG infections and macrolide-resistant MG strains, and what level of coverage might be needed to achieve this. Further increasing screening coverage must be weighed against the impact of lower treatment effectiveness (i.e. when not using resistance-guided therapy), increasing the selection of macrolide resistance, and other negative consequences related to AMR and management (e.g. unnecessary psychological morbidity from infections that do not need treatment)
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