The Centers for Disease Control and Prevention has released its 2003 data showing a rise in U.S. drug-resistant gonorrhea cases among gay and bisexual men. Preliminary data from New York and Boston suggests that åhreefold in the gay and bisexual male community between 2002 and 2003 – from 1.8 percent to 4.9 percent. San Diego’s rates reflect this national trend.

Dr. Robert Gunn, director of the STD and Hepatitis Prevention Program at Public Health Services of San Diego County, estimates that 15 to 20 percent of the males who come to the clinic for treatment for gonorrhea have a drug resistant strain. Of the men that the clinic sees, 75 percent are men who have sex with men (MSM).

“The bulk of the data when looked at in its totality clearly suggests that we’re seeing an increase in STDs – gonorrhea and syphilis – in the gay population, and we’re seeing a concomitant rise in that group in particular in the different sites where we test people for HIV,” Gunn said. “San Francisco has seen some of the same things… Clearly it’s unsafe behavior that makes it happen, but at the same time we think the STDs themselves play a role in facilitating [HIV] transmission. It makes biological sense – when your defenses are disrupted through inflammation or ulceration, you increase the risk of a virus like HIV being transmitted.”

According to Dr. John Douglas, M.D., director of the CDC’s STD prevention treatment programs, drug-resistant gonorrhea is one of many serious STD prevention challenges facing gay and bisexual men today.

“Recently we’ve seen a concerning increase nationally of syphilis among this population, as well as a significant increase in HIV diagnosis,” he said. “There is mounting evidence that these increasing STD rates are fueled by a variety of factors. These include relaxed safer sex practices, substance abuse – particularly the use of crystal methamphetamines – and the availability of the Internet as a method for meeting sex partners.”

The CDC’s results are based on a CDC study of men seen at sexually transmitted disease clinics in 23 U.S. cities as well as on data gathered from regional health centers and local health professionals. According to the National HIV Surveillance System, the most recent analysis of data from the 29 states that have ongoing HIV reporting indicate that between 1999 and 2002 there was a 17 percent increase in HIV diagnosis among gay and bisexual men.

“It is important to point out that reported cases of HIV infection are based on testing behavior, meaning that if more testing is occurring among gay and bisexual men, you’ll have more cases diagnosed and reported,” Douglas said. “So it doesn’t truly prove that there is an increased number. But if you will, we’re pulling in several lines of information – that sort of data, the STD data – to triangulate our concern that we may be awaiting or potentially seeing a true increase in HIV infection among MSM.”

“Gonorrhea probably increases the risk about twofold,” Gunn said. “If you have gonorrhea and you’re exposed [to HIV], your risk doubles to get it and if you have HIV and gonorrhea, your risk of spreading it doubles.”

“One of the CDC’s guidelines is for sexually active men who have sex with men to have regular STD screening, at least twice a year at this juncture, and I think more adherence to that on the part of providers might help curtail the epidemic,” said Kenneth Mayer, M.D., medical research director of Fenway Community Health in Boston.

The gonorrhea incubation period is two to five days, chlamydia is five to seven days, syphilis is three weeks, and HIV is about four weeks, though it is recommended that those who have been exposed to HIV should get tested as far out as six months after initial exposure.

Gunn recommends that MSM who have multiple partners, especially if they are having unprotected sex, should get tested monthly. “Not having safe sex just because you’re both HIV positive, you still run the risk of getting other STDs that are not so benign.”

The CDC does not know exactly why rates of drug-resistant gonorrhea are higher among gay and bisexual men. “Our best hunch is that we know that [in] certain parts of the world, including our own West coast of the U.S. – Hawaii and California, there have been impressively high rates of fluoroquinolone-resistant gonorrhea now for several years… Travel has led individuals to be exposed and acquire infection where resistance is higher, and that is then brought back to communities where we believe that within sexual networks, resistant gonorrhea acquired in a place where prevalence is higher may be more easily transmitted,” Douglas said. Other parts of the world where higher rates of fluoroquinolone-resistant gonorrhea have been found include Eastern Asia and Southeast Asia.

Another hypothesis is that gay and bisexual men who have practiced anal intercourse may have anorectal infections that are less likely to become symptomatic and be detected as readily as urethral gonorrhea. In theory, there may be a longer carriage for anorectal infection, which could promote the persistence of a resistant strain once acquired.

“As a result of this significant increase in fluoroquinolone-resistant gonorrhea, CDC is issuing new treatment recommendations for gonorrhea in men who have sex with men,” Douglas said. “Data show that the prevalence of fluoroquinolone-resistant gonorrhea cases among MSM nationally is now approximately five percent. This level of resistance is often used as the level at which a therapeutic regimen should be changed. For this reason, CDC is now recommending that fluoroquinolon es no longer be used as the first-line treatment for gonorrhea among MSM anywhere in the United States.”

Gunn said California clinics have been recommending alternative treatments for gonorrhea since mid-2003 for male and female gonorrhea patients. “[Drug resistant gonorrhea] is also somewhat in the heterosexual population, although not much,” Gunn said. “But it is more northern California than southern California for some reason, but certainly the [rates for] MSM in San Diego is what’s being seen now throughout the country.”

The CDC recommends the use of one of two injectable antibiotics as first-line treatment for gay and bisexual men with gonorrhea. The choice of antibiotic used depends on the site of infection, and gay and bisexual men should consult with their physician about their treatment options.

“The key messages here are, number one, treatment among those men who identified as having sex with other men now needs to change,” Douglas said. “Secondly, the message for individual doctors is ‘You need to ask people who they’re having sex with.’ Taking a sexual history among men with gonorrhea, which has always been important for lots of different reasons, now becomes more important than ever. Individual doctors also need to be reminded that travel histories matter. … [The broader gay community] is a group we are interested in hearing and appreciating this message.”

The CDC’s findings can be found in the April 30 issue of CDC’s Morbidity and Mortality Weekly Report (MMWR).