NOTE

Prevalence and Characteristics of Rectal Chlamydia

and Gonorrhea Cases Among Men Who Have Sex
With Men After the Introduction of Nucleic Acid
Amplification Test Screening at 2 Canadian Sexually
Transmitted Infection Clinics
Jennifer Gratrix, MSc,* Ameeta E. Singh, BMBS, Joshua Bergman, MPH, Cari Egan, PhD,
Justin McGinnis, MD, Steven J. Drews, PhD, and Ron Read, MD
Abstract: We sought to determine the prevalence of rectal chlamydia
and gonorrhea after the introduction of nucleic acid amplification tests
for screening in men reporting receptive anal intercourse. The rectal chlamydia prevalence was 14.1% (95% confidence interval, 11.9Y16.3), and
the gonorrhea prevalence was 5.9% (95% confidence interval, 4.4Y7.3).
Most cases were positive only from the rectum.

hlamydia and gonorrhea (CT/GC) are 2 of the most common notifiable diseases in Canada, with the incidence increasing since 1998. In 2011, the national CT/GC rates were 290.2
per 100,000 and 33.1 per 100,000 respectively, whereas in Alberta,
the rates were 369.5 per 100,000 and 39.4 per 100,000, respectively.1,2 Most CT patients are asymptomatic, whereas symptoms
are more likely with GC; both can result in significant morbidity
in men, including epididymitis, proctitis, and acquisition of HIV.3
Extragenital sites are believed to serve as hidden reservoirs for
ongoing transmission of infection. Although no nucleic acid amplification tests (NAATs) have been approved for use with rectal
specimens in Canada by Health Canada, NAATs are now widely
regarded as the preferred test for CT/GC screening because of its
high sensitivity and specificity.4,5 The use of NAATs with extragenital samples in men who have sex with men (MSM) has increased case finding substantially with the prevalence of rectal
CT reported between 7.9% and 23% and rectal GC reported between 3.8% and 10.2%.6Y12
In July 2012, 2 Alberta sexually transmitted infection (STI)
clinics changed their testing platform for rectal CT from cell
From the *STI Centralized Services, Alberta Health Services (AHS), Edmonton,
Canada; STI Clinic, AHS, Edmonton, Canada, STI Clinic, AHS, Calgary,
Canada; University of British Columbia, Vancouver, Canada; and
Provincial Laboratory for Public Health, AHS, Calgary, Canada

Acknowledgments: The authors wish to acknowledge Chris Bell for his

support and assistance with the chart review and the staff of the
Calgary and Edmonton STI Clinics.
Declarations: Preliminary data from this project were presented as a poster
at STI and AIDS World Congress; Vienna, Austria; July 14Y17, 2013:
Jennifer Gratrix, Joshua Bergman, Caroline Egan, Ameeta E. Singh,
Steve Drews, Ron Read. Prevalence and Correlates of Rectal-only
Chlamydia at Two Canadian STI Clinics.
Funding: No additional funding was obtained for this study.
The authors have declared no conict of interest.
Correspondence: Ameeta Singh, BMBS(UK), MSc, FRCPC, AHSYEdmonton
STI Clinic, 3B20-11111 Jasper Ave, Edmonton, AB, Canada T5K0L4.
E-mail: ameeta@ualberta.ca.
Received for publication February 20, 2014, and accepted July 9, 2014.
DOI: 10.1097/OLQ.0000000000000176
Copyright * 2014 American Sexually Transmitted Diseases Association
All rights reserved.

Sexually Transmitted Diseases

&

culture to NAAT using the Gen-Probe Aptima COMBO 2 Assay.

This change allowed for the dual testing of CT and GC using
NAAT, in addition to the GC cultures that were routinely collected. The rectal screening guidelines for the clinics included
exposure-based testing for all MSM who reported any receptive
anal intercourse (RAI) since last testing. A significant increase in
the proportion of rectal site infections among male CT/GC cases
diagnosed at the STI clinics occurred after the introduction of
NAAT (CT: 1.5% pre-NAAT vs. 16.6% post-NAAT [P G 0.001]
and GC: 18.7% pre-NAAT vs. 30.6% post-NAAT [P G 0.004]).
We sought to examine the prevalence and characteristics of rectal CT/GC cases among MSM after the introduction of NAAT.
Specimens were collected by registered nurses at 2 provincial STI clinics, in Edmonton and in Calgary. Patients reporting RAI were offered both rectal and genitourinary screening.
Rectal specimens were collected by inserting a swab 2 to 3 cm
into the rectum. Urogenital specimens included either urine or
urethral specimens. Urethral specimens were only offered when
a client could not provide a urine sample. Urine samples were
obtained by collecting 20 to 30 mL of first-catch urine. Urethral
specimens were obtained by inserting a swab 2 to 4 cm into urethra, rotating the swab for 2 to 3 seconds. Samples from each anatomical site were placed in separate collection tubes. Chlamydia
and gonorrhea testing was conducted with Gen-Probe Aptima
COMBO 2 (Hologic Gen-Probe, San Diego, CA) by the Provincial Laboratory for Public Health (ProvLab) according to the manufacturers directions. Presently, the Gen-Probe Aptima COMBO 2
Assay test is not approved for use in Canada from extragenital
sites but has undergone in-laboratory validation and is widely
used in Alberta for CT/GC screening from extragenital sites.
An extract of STI Clinic testing data was obtained from
the ProvLab. All positive CT/GC results were matched to reported
cases in the provincial STI database to obtain demographics, clinical history, and contact to an STI as a reason for the clients visit.
Clinical findings were aggregated into the following categories:
asymptomatic, rectal symptoms, and genitourinary symptoms.
Genitourinary symptoms included urethral discharge, dysuria, or
testicular pain. Rectal symptoms included rectal discharge, itching, or redness. A chart review was conducted to ascertain variables related to sexual behavior. Sexual histories in the last 2
months (or last encounter) included number of partners, type of
sexual activity, any episodes of unprotected sexual contact, and
whether any partners were HIV positive.
The testing prevalence was calculated by dividing the
number of positive results by the total number of specimens tested
by NAAT during the study period. Descriptive analyses were aggregated into 3 categories based on the site of infection: genitourinary only, multisite, and rectal only. Analyses were completed

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Gratrix et al.

TABLE 1.

Prevalence of Genitourinary and Rectal CT/GC Among Men Reporting RAI, Alberta STI Clinics, July to December 2012
(n = 972 Screening Visits)

CT
Site Tested
Rectal
Genitourinary
Patient (all sites)
Anatomical Sites
Rectal only
Multisite
Genitourinary only

GC

Positive Test Result, n (%)

95% CI

Positive Test Result, n (%)

95% CI

137 (14.1)
42 (4.3)
162 (16.7)
CT Cases (n = 158)*
115 (72.8)
16 (10.1)
27 (17.1)

11.9Y16.3
3.1Y5.6
14.3Y19.0
GC Cases (n = 63)
40 (63.5)
16 (25.4)
7 (11.1)

57 (5.9)
23 (2.4)
63 (6.5)

4.4Y7.3
1.4Y3.3
4.9Y8.0

*Four of the positive screening test results were positive test result of cures for previously identified cases.

using IBM SPSS Statistics 19 (IBM, Armonk, NY). Ethics approval was obtained from the University of Albertas Health Research Ethics Board.
During the study period, 972 visits for rectal and genitourinary screening were completed. The median age at time
of testing was 29 years (interquartile range, 24Y38 years).The
overall prevalence of CT was 16.7% (95% confidence interval
[CI], 14.3%Y19.0%) and 6.5% (95% CI, 4.9%Y8.0%) for GC. The
site-specific prevalence ranged from 2.4% (95% CI, 1.4%Y3.3%)
for genitourinary GC to 14.1% (95% CI 11.9%Y16.3%) for rectal
CT (Table 1).
Screening resulted in a total of 158 CT cases and 63 GC
cases. Most infections were positive solely from the rectum (73.1%
CT and 63.5% GC). Gonorrhea cases were more likely to be
multisite than CT cases (25.4% vs. 10.2%, P = 0.004; Table 1).
Although most patients were asymptomatic, GC patients
were more likely to report rectal symptoms than CT patients
TABLE 2.

(17.5% vs. 4.4%, P = 0.001). One-third of patients reported

being a contact to an STI, and approximately 20% of patients
reported that their partner was HIV positive. Coinfection with
CT/GC occurred in 41.3% of GC cases and 16.5% of CT
cases. In addition, 25% (n = 14) of those with rectal GC and
12.2% (n = 9) of rectal CT cases were coinfected with HIV
(Table 2).
After implementing NAAT for rectal screening among
men reporting RAI, our study found a prevalence of 14.1%
for rectal CT and 5.9% for rectal GC, within the prevalence
range (3.6%Y24%) of other studies.7Y13 Very few of our cases
reported rectal symptoms, resulting in 95% of our rectal CT
cases and more than 80% of our rectal GC cases being missed
if using symptom-based screening. Rectal screening identified an
additional 115 rectal-only CT cases, increasing case detection
nearly 4-fold from 43 cases to 158 cases. For GC, case finding increased 2.7-fold from 23 cases to 63 cases. Our data add to the

Characteristics of CT/GC Cases Among MSM by Site of Infection, STI Clinics, July 20 to December 31, 2012

CT (n = 158)
Genitourinary
Only (n = 27)
Age, median (IQR), y
Ethnicity
White
Aboriginal
Other
Sexual behavior in the last
Insertive oral sex
Receptive oral sex
Insertive anal sex
Receptive anal sex
Unprotected sex
No. partners
Sexual partners
Same sex
Both sexes
HIV+ partner
Contact to STI
Ever drug use
Clinical findings
Asymptomatic
Genitourinary
symptoms
Rectal symptoms
Concurrent infections
GC/CT coinfection
HIV+

29 (23Y38)

GC (n = 63)

Multisite
(n = 16)

Rectal Only
(n = 115)

Total*
(n = 158)

Genitourinary
Only (n = 7)

Multisite
(n = 16)

Rectal Only
(n = 40)

Total*
(n = 63)

30 (25Y32)

28 (24Y38)

29 (24Y36)

25 (24Y37)

26 (22Y40)

27 (22Y38)

26 (23Y37)

23 (85.2)
12 (75.0)
1 (3.7)
2 (12.5)
3 (11.1)
2 (12.5)
2 mo/last exposure
22 (95.7)
15 (93.8)
21 (91.3)
16 (100)
16 (72.7)
15 (93.8)
17 (77.3)
14 (87.5)
21 (95.5)
16 (100)
2 (1Y3)
2 (2Y2)
23 (85.2)
4 (14.8)
7 (33.3)
5 (19.2)
11 (47.8)

133 (84.2)
6 (3.8)
19 (12.0)

4 (57.1)
1 (14.3)
2 (28.6)

15 (93.8)
0
1 (6.3)

34 (85.0)
1 (2.5)
5 (12.5)

53 (84.1)
2 (3.2)
8 (12.7)

101 (92.7)
105 (96.3)
87 (79.1)
95 (86.4)
99 (91.7)
2 (1Y2)

138
142
118
126
136
2

(93.2)
(95.9)
(79.7)
(85.1)
(93.2)
(1Y2)

6 (100)
6 (100)
5 (83.3)
3 (50.0)
6 (100)
2 (2Y6)

16 (100)
16 (100)
14 (87.5)
13 (81.3)
16 (100)
2 (1Y7)

32 (86.5)
34 (91.9)
22 (59.5)
35 (94.6)
35 (94.6)
2 (1Y4)

54 (91.5)
56 (94.9)
41 (69.5)
51 (86.4)
57 (96.6)
2 (1Y4)

16 (100)
0
1 (8.3)
5 (31.3)
3 (25.0)

104 (90.4)
11 (9.6)
18 (19.1)
47 (41.2)
53 (53.0)

143 (90.5)
15 (9.5)
26 (20.5)
57 (36.5)
67 (49.6)

7 (100)
0
2 (33.3)
0
3 (50.0)

14 (87.5)
2 (12.5)
5 (31.3)
1 (6.3)
9 (60.0)

35 (87.5)
5 (12.5)
6 (16.7)
21 (52.5)
21 (56.8)

56 (88.9)
7 (11.1)
13 (22.4)
22 (34.9)
33 (56.9)

13 (48.1)
12 (44.4)

9 (56.3)
7 (43.8)

92 (80.7)
13 (13.0)

114 (72.6)
34 (21.5)

0
7 (100)

2 (12.5)
14 (87.5)

26 (65.0)
4 (10.0)

28 (44.4)
25 (39.7)

2 (7.4)

5 (4.3)

7 (4.4)

1 (14.3)

1 (6.3)

9 (22.5)

11 (17.5)

23 (20.0)
9 (8.1)

26 (16.5)
11 (7.1)

4 (57.1)
1 (14.3)

5 (31.3)
4 (28.6)

17 (42.5)
10 (26.3)

26 (41.3)
15 (25.4)

2 (7.4)
2 (7.4)

1 (6.3)
0

98 (85.2)
3 (2.6)
14 (12.2)

*Denominators may change due to missing data.

590

Sexually Transmitted Diseases

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Rectal Chlamydia and Gonorrhea Cases Among MSM

growing body of evidence that urine screening alone is ineffective in detecting infections among men reporting RAI.6Y13
Both the Canadian and American STI guidelines recommend rectal screening for CT/GC in those reporting RAI. Although, there are no Canadian data, a survey from the US STD
Surveillance Network from 2010 through 2012 found that only
50% of MSM were screened for rectal STI.11 Chesson et al.14
reported that selective screening for rectal CT is cost-effective
in reducing HIV infection in MSM at a cost per quality-adjusted
life year of US $16,300. A recent study by Van Liere et al.6
reported that universal testing (regardless of reported RAI) increased rectal case finding by 50% more than using selective
screening criteria. Cachay et al. also found rectal STI among men
denying RAI, supporting the call from other authors for further
studies to refine screening guidelines.6,11,15,16
Our study has several limitations. First, owing to the sensitivity of NAAT, it is possible that some positive test results
were not true rectal infections, resulting in a higher estimate of
overall rectal disease prevalence. Possible explanations may include the transit of DNA through the gastrointestinal tract infection from elsewhere (e.g., pharynx) or false-positive test results.
However, a preliminary evaluation of a subset of the positive
rectal CT specimens from this study showed that 76 (93.8%) of
81 rectal CT specimens testing positive with the Gen-Probe
Aptima were confirmed with a second NAAT test (S. Drews,
personal communication, Alberta Provincial Lab for Public Health),
thus reducing the likelihood that our findings represent false
positives. Second, assessment of RAI and other sexual risk behaviors was based on self-report and assessed by clinic staff using
face-to-face interview methods and may be impacted by social
desirability bias; therefore, some men may have missed the opportunity to be screened. Third, because of the retrospective design, missing data for some variables could not be determined.
Finally, we did not have information on serovars and were therefore unable to assess anatomic site preference by serovar.
In conclusion, early detection and treatment of rectal STI
in MSM is likely to be a critical strategy in reducing the transmission of CT/GC.16 Our data add further support for rectal STI
screening in MSM reporting RAI and not based on symptoms
alone because most rectal infections are asymptomatic. Although
more recent studies have suggested that universal screening for
anorectal STI in MSM would increase case finding, no studies
have been done to assess the cost-effectiveness of this approach
in preventing HIV infections or reducing CT/GC transmission
and sequelae.
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