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?
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.
It’s not sexy to suggest this but… have we given up condoms too soon?
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 favour within our gay community and continue to wrap it up.
This article first appeared in DNA #213. Buy the back issue online here.