For many gay and bi men, it’s a perennial point of contention: Are “minor” sexually transmitted infections—like chlamydia or gonorrhea—a cause for serious concern or major behavior modification? They’re no fun, to be sure, and left untreated, they can cause problems more severe than a bit of burning or discharge. But then again, like many maladies we don’t irrationally stigmatize, they’re curable with a course of antibiotics, right?
For the most part they are. But a recent study by the Centers for Disease Control and Prevention, featured in its Morbidity and Mortality Weekly Report, found a significant rise in resistance to one of the drugs used to treat gonorrhea: azithromycin. Among the 5,093 samples taken from men who have sex with men (MSM), men who have sex with men and women (MSMW), and men who have sex with women (MSW), across 24 state and city health departments, the resistance to this drug has increased by more than 300 percent between 2013 and 2014. To be clear, resistance starts out low; in practical terms, its risen from 0.6 percent of cases to 2.5 percent of cases. But it’s important to note that the report shows antibiotic-resistant strains of gonorrhea are more prevalent among men who have sex with men than other demographics. Is 2.5 percent something that gay and bi men should be worried about? I spoke to Dr. Robert D. Kirkcaldy at the CDC, who has spent the last six years researching gonorrhea resistance, to find out.
“This is not a new phenomenon, because since penicillin was introduced, this bug has mutated so rapidly that it’s developed this remarkable ability to develop resistance to each of the drugs that we’ve thrown at it,” Kirkcaldy explained. “What’s changing is that … we’re running out of new drugs. The antibiotic pipeline is dwindling, and the bug is developing resistance to the last line of treatment.”
The dual therapy used to treat gonorrhea, which has been recommended for use by the CDC since 2010, includes azithromycin and ceftriaxone. (Resistance to ceftriaxone is about 1 percent.) If an infection is resistant to one of these drugs, the other will work, though both drugs used in combination is the best way to combat the STI.
“Dual therapy is still highly effective,” Kirkcaldy assures, “but we’re starting to see trends that it’s quite possible in the next few years that if resistance of these two drugs emerges, then that could jeopardize our last recommended treatment for gonorrhea, and we could be left with treatments that don’t work for everybody.”
Drug resistance aside, STI infection rates, including for syphilis and chlamydia, have been increasing since 2006. With gonorrhea, there are more than 300,000 reported cases each year, and likely many more that are undetected or not reported. Between 2013 and 2014 alone, there was a 5.1 percent increase in transmission. Bugs spread quickly. So does resistance.
“A lot of these things that we’re seeing now in increasing rates and also resistance are the warning signs—they’re sort of the clouds that are starting to come together on the horizon, telling us that there is a perfect storm brewing,” Kirkcaldy said. “The question is what can be done and what are people willing to do now to prevent this brewing crisis?”
Screening is no doubt a crucial part of preventing a true crisis, and it’s important for sexually active gay and bi men, particularly those who are having condomless or “bareback” anal sex, to be tested for all STIs every three to six months. We also know that many STIs can be asymptomatic, so it’s possible to be infected and not know it. And it’s necessary to ask for the right kind of tests, namely throat and rectal swabs. A urine test alone may come out negative for gonorrhea because it’s living in the throat or rectum. Some health care providers may not include these additional tests unless requested, so it’s important to actively request the right care.
Kirkcaldy has a few more recommendations, even if they’re ones that some sexually active gay and bi men may not want to hear: condom use, abstinence, and reducing the number of one’s sexual partners. This flies in the face of the pleasure movement that we’re seeing, particularly among users of the HIV prevention strategy PrEP who choose to bareback. After dealing with HIV for 35 years, many gay and bi men associate sex with death, so such a movement can feel like something that we both need and deserve in spite of the other STIs.
Kirkcaldy also understands that there’s more to sex than fearing these infections, but he’s still practical when it comes to prevention and public health. “It’s important for people to have healthy sex lives and to enjoy their sex lives,” he explained, adding:
Obviously there’s a lot more to it than the absence of disease. There’s emotional, physical, and spiritual well-being. But I think a part of sexual health, both emotional and physical, is also being free of disease. So being cognizant of the infections that can impact your sexual health and those of your partners still is important. Continuing to screen is an important component because at least that can catch it and prevent it from future partners, but what it doesn’t do is prevent people from getting it in the first place.
There’s a lot of truth to that, especially if one happens to run into an antibiotic-resistant strain. Unlike HIV in the 1980s and ’90s, though, gonorrhea is not a death sentence, which could account for the lack of worry within certain parts of the gay community. But what are the real health implications if an infection occurs? And are they severe enough to alter our sex lives?
Since gonorrhea can be silent, particularly in the throat or rectum, one may not experience symptoms—which to the selfish, may seem like good news. Still, it can be spread to other partners who may not be as lucky, particularly if they acquire a genital infection, where pain and discharge could be significant. Untreated, it can cause damage in the testicles and, in some cases, sterility. In rare instances, it can get into the blood stream and cause life-threatening infections in the joints, heart, or in very extreme instances, the brain. Untreated gonorrhea is also thought to help facilitate HIV transmission. In any case, it’s more severe than one might realize and shouldn’t be taken lightly.
Although we don’t have any drugs to fall back on if the dual therapy becomes ineffective, several drug companies have stepped up and started clinical trials for new ones. However, it takes time for these to come to market, and it’s unclear if they’re even going to work. That’s why it’s important that we keep the current drugs as effective as possible for as long as possible. “These drugs are still effective,” Kirkcaldy said. “The sky is not falling right now, but there are a lot of warning signs both from the data about emerging resistance and the historical perspective—what we know about this bug.”
So if resistance in 2.5 percent of cases seems low, it is. But the speed and size of increase—again, about 300 percent in one year—is cause for concern. For comparsion, ciprofloxacin, a drug that was used to treat gonorrhea in the 2000s, saw an increase in resistance that grew from less than a one percent of cases to ten percent in under five years. “All we have to do is look back at history and see that for each of the drugs that have been used [for gonorrhea], it was only a matter of time before resistance to those drugs emerged. And it sometimes emerged really quickly,” Kirkcaldy says. “This bug is so unpredictable that it can happen within a few years.”