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There were at least two significant infectious disease trends in the early 1980s. One of those was the advent of HIV infection. The other was the beginning of a long decline in gonorrhea rates. Perhaps due in part to the safe-sex practices made popular because of the risk of HIV infection, gonorrhea rates continued to decline throughout the 1980s and the 1990s until 1999. However, gonorrhea rates among HIV-infected men who have sex with men more than doubled to 19.7% between 1995 and 1999 in Denver. This finding, reported by the Centers for Disease Control and Prevention in Atlanta, was yet another indicator that fewer men who have sex with men are engaging in safe sex practices.
"For the first time in two decades, we’re seeing increases in gonorrhea rates in the United States," says Ronald O. Valdiserri, MD, MPH, deputy director of the National Center for HIV, STD, and TB Prevention at the CDC. Valdiserri spoke at the National STD Prevention Conference held Dec. 4 in Milwaukee. Three factors are contributing to the trend of increased gonorrhea cases:
• There are increased screening activities, because the test for gonorrhea is being administered at the same time as the test for chlamydia.
• There are more sensitive diagnostic tests and improved reporting.
• More people, particularly men who have sex with men, are becoming infected.
It’s the latter factor that worries public health officials and HIV advocates.
"First, an increase in gonorrhea cases is evidence of multiple acts of unsafe sex, which are probably resulting in the transmission of other STDs, including HIV," says Susan Wang, MD, of the Division of STD Prevention of the National Center for HIV, STD, and TB Prevention. "Second, infection with gonorrhea increases the infected person’s likelihood of acquiring HIV if she or he isn’t infected with HIV, or of transmitting HIV if he or she already is infected with HIV," Wang adds. "If more people are infected with gonorrhea, those gonorrhea infections will facilitate HIV transmission in the population."
AIDS advocates also express concern. "Any time we see an increase in a sexually transmitted disease rate, it indicates we may well see an increase down the road in HIV rates," says Tanya Ehrmann, director of public policy for AIDS Action in Washington, DC. "This is not only because it indicates people are not having safe sex, but because of the vectors of transmission and increasing one’s risk of HIV," Ehrmann adds.
In recent years, prevention efforts and the fear of HIV have held new HIV infection rates at about 40,000 per year in the United States. This and the ready availability of antiretroviral medications have led to decreases in AIDS cases. But the increase in gonorrhea rates may be an early signal that prevention efforts are failing, despite the recent renewed focus on targeting youths and minorities. One solution to this problem is for health care providers to take a more aggressive and active interest in providing STD counseling to youths, says Judith Wasserheit, MD, MPH, director of the Division of STD Prevention of the National Center for HIV, STD, and TB Prevention.
CDC research shows that many high school students do not discuss STDs or pregnancy prevention with their physicians during routine check-ups. "Of high school students, about two-thirds had an appointment with a health care provider in the prior year, and less than half of those individuals had their provider actually talk with them about STD prevention or pregnancy prevention," Wasserheit says. "Many teens are sexually experienced; in these data, about half of the high school students were sexually experienced, and by grade 12, 65% are sexually experienced." The study also shows that about one in five teens have more than five partners.
Gonorrhea rates, like HIV rates, have hit the African-American community hardest. The gonorrhea rate among blacks is close to 3,500 per 100,000 population and about 3.5% of African-American teens. "That’s a huge number," Wasserheit notes.
There have been recent outbreaks of gonorrhea rates among men who have sex with men in Washington, DC, in the Pacific Northwest, and on both coasts, Valdiserri says.
"There’s been a lot of focus and attention on this issue within the context of HIV transmission," Valdiserri adds. "The factors involved include the fact that high-risk sexual behavior no longer carries the extreme consequences it once did because of improvements in HIV treatment." Also, many gay and bisexual men do not understand the relationship between HIV and other STDs, he says. "And sometimes substance abuse has been involved in these outbreaks," he notes.
The message nationwide is that outbreaks of gonorrhea infection often have gay and bisexual men as a common denominator, and this may be due to their misconception that unsafe sex is no longer as risky as it once was, Valdiserri says.