A Cross Sectional Analysis of Gonococcal and Chlamydial Infections among Men-Who-Have-Sex-with-Men in Cape Town,South Africa

Background

Men-who-have-sex-with-men (MSM) are at high risk of HIV and sexually transmitted infection (STI) transmission. Asymptomatic STIs are common in MSM and remain undiagnosed and untreated where syndromic management is advocated. Untreated STIs could be contributing to high HIV rates. This study investigated symptomatic (SSTI) and asymptomatic STIs (ASTIs) in MSM in Cape Town.

Methods

MSM, 18 years and above, were enrolled into this study. Participants underwent clinical and microbiological screening for STIs. Urine, oro-pharyngeal and anal swab specimens were collected for STI analysis, and blood for HIV and syphilis screening. A psychosocial and sexual questionnaire was completed. STI specimens were analysed for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infection.

Results

200 MSM were recruited with a median age of 32 years (IQR 26–39.5). Their median number of sex partners within the last year was 5 (IQR 2–20). 155/200 (78%) reported only male sex partners while 45/200 (23%) reported sex with men and women. 77/200 (39%) reported transactional sex. At enrolment, 88/200 (44%) were HIV positive and 8/112 (7%) initially HIV-negative participants seroconverted during the study. Overall, 47/200 (24%) screened positive for either NG or CT. There were 32 MSM (16%) infected with NG and 7 (3.5%) of these men had NG infections at two anatomical sites (39 NG positive results in total). Likewise, there were 23 MSM (12%) infected with CT and all these men had infections at only one site. Eight of the 47 men (17%) were infected with both NG and CT. ASTI was more common than SSTI irrespective of anatomical site, 38 /200 (19%) versus 9/200 (5%) respectively (p<0.001). The anus was most commonly affected, followed by the oro-pharynx and then urethra. Asymptomatic infection was associated with transgender identity (OR 4.09 CI 1.60–5.62), ≥5 male sex partners in the last year (OR 2.50 CI 1.16–5.62) and transactional sex (OR 2.33 CI 1.13–4.79) but not with HIV infection.

Conclusions

Asymptomatic STI was common and would not have been detected using a syndromic management approach. Although molecular screening for NG/CT is costly, in our study only four MSM needed to be screened to detect one case. This supports dual NG/CT molecular screening for MSM, which, in the case of confirmed NG infections, may trigger further culture-based investigations to determine gonococcal antimicrobial susceptibility in the current era of multi-drug resistant gonorrhoea.     

Septic Gonococcal Dermatitis

The overall incidence in gonorrhoea of septic gonococcal dermatitis was found to be 1·9% (3% for the females and 0·7% for the males). In 23 patients the common presenting symptoms were arthritis or arthralgia and bouts of fever, but the characteristic skin lesions served as an early clue to the diagnosis, and Neisseria gonorrhoeae was isolated from the genitourinary tract or from the blood. With the use of immunofluorescent techniques gonococci were also found in smears prepared from the skin lesions. An immune response to gonococci was found with the complement fixation technique in 90% of the patients. The response to treatment with penicillin was prompt, with complete relief from joint pains and fever, usually within two to seven days. The skin lesions faded within a few days, but scars could be observed for up to four weeks.     

Studies on Gonococcal Infection

Macrophages from mice were infected with Neisseria gonorrhoeae type 1 cells, and their ultrastructure was studied by electron microscopy. The macrophages showed various stages of engulfment and digestion of gonococci 2 hr after infection. Infected macrophages seemed to develop pseudopodia for phagocytosis, and could engulf more than 30 gonococcal cells. Some engulfed bacteria appeared morphologically intact, while others appeared lysed and some structures resembling the L form of N. gonorrhoeae were also seen. These observations suggest that gonococcal cells may be able to survive intracellularly with normal or altered forms of morphology, and that macrophages containing these bacteria may disseminate gonococcal infection in man.     

Microflocculation Assay for Gonococcal Antibody

An antigen suspension consisting of cholesterol-lecithin particles sensitized with an extract of gonococci was used in a flocculation assay for the detection of human antibodies to Neisseria gonorrhoeae. With culturally and clinically diagnosed cases of uncomplicated gonorrhea, sera from 70 (49.6%) of 141 males and 207 (79.0%) of 262 females were reactive in the assay. Sera from four (7.3%) of 55 males and 11 (5.4%) of 203 females, all presumed normal, were reactive. The assay utilized equipment available in most clinical and public health laboratories.