HEALTH: THE CLAP IS BACK!

THE AR­RIVAL OF DRUG-RE­SIS­TANT GONORRHOEA REP­RE­SENTS A MA­JOR CHAL­LENGE TO THE SEX­UAL HEALTH OF GAY MEN. IN THE AGE OF PREP, DO WE NEED TO RE­DIS­COVER THE CONDOM?

DNA Magazine - - CONTENTS -

Erad­i­ca­tion of dis­ease is of­ten what the sci­en­tific com­mu­nity strives for. How­ever, if we use the Res­i­dent Evil films as a metaphor, erad­i­ca­tion can some­times bring other prob­lems such as multi-re­sis­tant strains or en­tirely new or­gan­isms.

Over the past year, in Aus­tralia and around the world, there has been a resur­gence in the preva­lence of many sex­u­ally trans­mit­ted ill­nesses (STIs) and an in­crease in their drug re­sis­tance.

Let’s look at some statis­tics, just from New South Wales, as an ex­am­ple: in 2016 no­ti­fi­ca­tions of gonorrhoea in­fec­tions rose 28 per cent from the pre­vi­ous year. The Sex­u­ally Trans­mis­si­ble In­fec­tions Data Re­port of 2016 shows that 81 per cent of all in­fec­tions were among men. The re­port noted that gonorrhoea in­fec­tions are more preva­lent among men who have sex with men. It should also be noted that PrEP tri­als re­quire par­tic­i­pants to be STI tested reg­u­larly and so many cases are be­ing di­ag­nosed ear­lier than may be usual.

The cur­rent most prob­lem­atic STI be­com­ing drug-re­sis­tant is gonorrhoea and, just as Milla Jovovich was forced to be­come stronger to de­feat the Res­i­dent Evil out­break, so too do our an­tibi­otics. But can they out­pace the evo­lu­tion of the out­break?

There is cur­rently very lit­tle clin­i­cal re­search to sup­port the the­ory but many in the com­mu­nity, health­work­ers and med­i­cal prac­ti­tion­ers as­so­ciate the rise in STI trans­mis­sion with de­creased condom use due, in part, to the pre­scrip­tion of Pre-Ex­po­sure Pro­phy­laxis of HIV or PrEP.

Since PrEP, many gay men have stopped us­ing con­doms, per­haps un­der the il­lu­sion that PrEP will not only pro­tect them from HIV but from other STIs as well.

Most of us have heard of “su­per bugs” that arise from the overuse of an­tibi­otics – whether in­cor­rectly pre­scribed, used in­cor­rectly or, in some coun­tries, added to the food chain in farmed an­i­mals. Some agen­cies fore­see drug-re­sis­tant in­fec­tions killing as many as 10 mil­lion peo­ple by 2050.

Multi-drug re­sis­tant or “su­per” gonorrhoea is evolv­ing new ways to com­bat an­tibi­otic ther­a­pies, so much so that some new strains of the virus are com­pletely im­mune to cur­rent first-line an­tibi­otics. John Turnidge, se­nior med­i­cal ad­vi­sor at the Aus­tralian Com­mis­sion On Safety And Qual­ity In Health­care, says of Neis­se­ria gon­or­rhoeae that “they’re the bugs we can’t af­ford to let get out of hand”.

So, what is gonorrhoea? It’s a sex­u­ally trans­mit­ted in­fec­tion that likes to live in the warm, moist ar­eas of the body such as the ure­thra, throat, eyes, vagina, anus and fe­male re­pro­duc­tive tract. This kind of bac­te­ria is only trans­mit­ted via sex­ual con­tact. Oral, vagi­nal and anal sex are the most com­mon ways of trans­mis­sion. How­ever, there are cases where gonorrhoea has con­tacted the sur­face of the eye – I will let you use your imag­i­na­tion as to how that hap­pened. Ejac­u­la­tion does not need to oc­cur for it to be trans­mit­ted and a per­son can be re-in­fected af­ter be­ing treated for the bac­te­ria. The bac­te­ria can­not sur­vive very long out­side of the body – prob­a­bly only min­utes de­pend­ing on the con­di­tions.

Symp­toms of gonorrhoea vary from per­son to per­son. Most men with gonorrhoea are asymp­to­matic – they carry the dis­ease with­out show­ing symp­toms. How­ever, do not mis­take this for mean­ing that you can­not trans­mit it to other peo­ple. Those who do dis­play signs of gonorrhoea will typ­i­cally show ure­thral in­fec­tions caus­ing white, yel­low or green discharge, nor­mally around the 14-day pe­riod af­ter be­ing in­fected. Along with the discharge there can also be pain on uri­na­tion as well as scro­tal and/or tes­tic­u­lar pain.

Rec­tal in­fec­tions of gonorrhoea are nor­mally asymp­to­matic, how­ever, in some cases there can be un­con­trol­lable discharge, anal itch­ing, bleed­ing, sore­ness and painful bowel move­ments.

Pha­ryn­geal in­fec­tions (the throat, be­low the noise and at the back of the tongue) can also show up caus­ing a painful pus­tu­lar ton­sil­li­tis. There have been some cases of the dis­ease be­ing passed through oral sex from the throat to other mu­cosal ar­eas.

Those who are sex­u­ally ac­tive, in­clud­ing those who only par­take in oral sex, should still be tested for all STIs in­clud­ing gonorrhoea with anal, pha­ryn­geal, pe­nile and/or vagi­nal swabs ev­ery three months or af­ter any oc­ca­sion where you think you may have put your­self at in­creased risk of ex­po­sure.

Gonorrhoea is di­ag­nosed typ­i­cally by us­ing a urine sam­ple, how­ever, those who are hav­ing anal and oral sex should test those ar­eas as well (usu­ally us­ing a cot­ton swab); it is sim­ple, easy, and does not hurt.

Most physi­cians will use a dual ther­apy method for treat­ing some­one in­fected with gonorrhoea. The med­i­ca­tion should never be shared with any­one and the en­tire dosage of the an­tibi­otics should be taken as pre­scribed. This is key in treat­ing gonorrhoea as in­com­pleted an­tibi­otic cour­ses as­sist the bac­te­ria to evolve and to come back and cre­ate im­mu­nity over time. Peo­ple who have been treated in the past may re­quire a dif­fer­ent treat­ment plan and/or an­tibi­otics as mul­ti­ple treat­ments can cre­ate fu­ture prob­lems in treat­ment – so let your doc­tor know.

The rise of drug-re­sis­tant gonorrhoea has the po­ten­tial to cre­ate a cat­a­strophic epi­demic over time if not con­tained now be­fore it evolves to be re­sis­tant to all cur­rent an­tibi­otic ther­a­pies. With the rise of a su­per-bug STI more data must be col­lected to fully un­der­stand how we can con­trol and treat those in­fected.

If you are sex­u­ally ac­tive and not in a monog­a­mous re­la­tion­ship where both par­ties have been tested, then reg­u­lar test­ing and condom use is the only way to stop the spread of STIs. PrEP should be used to help pre­vent HIV while also us­ing ap­pro­pri­ate pro­tec­tion.

“The data show that more can be done in terms of condom use, which is the best way to pre­vent the trans­mis­sion of an in­fec­tion,” says Dr Chris­tine Selvey, an epi­demi­ol­o­gist at NSW Health.

It’s not sexy or fash­ion­able to sug­gest this but… have we given up con­doms too soon? Let’s do ev­ery­one a fa­vor within our gay com­mu­nity and con­tinue to wrap it up.

It’s not sexy or fash­ion­able to sug­gest this but… have we given up con­doms too soon?

MORE: Dr Zac Turner (MBBS RN Bsc) can be con­tacted at www.drzac.co

MULTI-DRUG RE­SIS­TANT OR “SU­PER” GONORRHOEA IS EVOLV­ING NEW WAYS TO COM­BAT AN­TIBI­OTIC THER­A­PIES, SO MUCH SO THAT SOME NEW STRAINS OF THE VIRUS ARE COM­PLETELY IM­MUNE TO CUR­RENT FIRST-LINE AN­TIBI­OTICS.

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