Trends in Gonorrhea in Homosexually Active Men -- King County, Washington, 1989

Analysis of gonorrhea morbidity in King County, Washington, shows an increase in gonorrhea among homosexually active men in 1989. During the 1980s, substantial declines in the occurrence of gonorrhea in homosexual and bisexual men have been documented in the United States and other countries (1-3). These trends have been considered to reflect changes in sexual behavior in response to the epidemic of acquired immunodeficiency syndrome (AIDS).

King County has a population of 1.4 million and includes Seattle (population 496,000). Gonorrhea cases are reported to the Seattle-King County Department of Public Health by age, gender, race/ethnicity, and anatomic site of infection. Patients diagnosed in the Seattle-King County Department of Public Health's sexually transmitted disease (STD) clinic at Harborview Medical Center are further classified as heterosexual, homosexual, or bisexual on the basis of the reported gender of their sex partners.

From 1982 through 1988, declines occurred for the annual number of cases of gonorrhea in homosexual and bisexual men attending the STD clinic, and of rectal gonococcal infection reported by the private medical sector (Figure 1). STD clinic gonorrhea cases in homosexually active men declined from 720 in 1982 to 27 in 1988 (-96%). However, 71 cases were reported in the first 9 months of 1989. Based on this observation, an estimated 100 cases (seasonally adjusted) are anticipated in 1989. A similar decline occurred for cases of rectal gonococcal infection in men reported by the private medical sector: from 217 cases in 1982 to six in 1988 (-97%). Eight cases were reported through September 1989, and 12 are projected for the year.

In contrast, the number of gonorrhea cases in the total population continued to decrease in 1989. Total reported gonorrhea cases in King County declined 27%, from 4709 (371 per 100,000 population) in 1982 to 3443 (244 per 100,000 population) in 1988. Through September 1989, 2416 cases were reported, with an estimated 3200 cases (223 per 100,000 population) projected for the year, a further 6% decline.

The age distribution of public clinic cases in homosexual and bisexual men remained relatively constant from 1982 through September 1989. In 1989, 79% of the homosexual or bisexual men with gonorrhea were non-Hispanic whites, 13% were non-Hispanic blacks, and 8% belonged to other racial or ethnic groups (primarily Hispanics); this distribution did not change from 1982 to 1989. Among STD clinic heterosexuals with gonorrhea in 1989, 36% were non-Hispanic whites, 50% were non-Hispanic blacks, and 13% belonged to other racial or ethnic groups. Reported by: HH Handsfield, MD, B Krekeler, MHA, STD Control Program, RM Nicola, MD, Seattle-King County Dept of Public Health, Washington. Div of Sexually Transmitted Diseases, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: These data suggest that the number of gonorrhea cases in homosexually active men in King County may triple in 1989 from 1988. This increase cannot be readily explained by differences in screening or testing procedures at the STD clinic. Throughout the 1980s, patient-care approaches have been constant, case reporting systems for the private sector have not been revised, and emphasis on partner referral activities for patients with gonorrhea has not been modified. In addition, the age and race distributions of homosexually active men with gonorrhea have not changed during the 1980s. These demographic patterns suggest that the increase is not limited to a group of younger men nor to a specific racial group for which different levels of commitment to safer sex practices may exist.

Although reasons for this increase are uncertain, at least two hypotheses can be considered. First, the increase may be confined to men who have never fully adopted safer sex practices. Strains of Neisseria gonorroheae may have been introduced or reintroduced into a subpopulation of men with stable high-risk patterns of sexual behavior. Thus, the increase might reflect variation within existing STD core populations (4). Second, the frequency of high-risk behavior may have increased. For example, because of declining incidence of STD and human immunodeficiency virus (HIV) infections, some homosexually active men may have relaxed behaviors regarding sexual safety (1-3,5). In addition, maintenance of profound lifestyle changes, such as abstinence or monogamy, may become more difficult with time and "risky sexual relapse" (6) could occur. Additional efforts may be required to maintain positive lifestyle changes of homosexually active men. These positive behavior changes are considered to have contributed to the substantial overall decline during the 1980s in gonorrhea among homosexually active men in King County (Figure 1).

Studies of homosexually active men with gonorrhea are now being planned in Seattle-King County to evaluate these two possible explanations. However, these data from King County support the need for continued careful monitoring of STD trends in homosexual and bisexual men at the local level. State and local health departments are encouraged to implement such monitoring in areas where it is not under way.

References

1. Judson FN. Fear of AIDS and gonorrhea rates in homosexual men. Lancet 1983;2:159-60.

2. Handsfield HH. Decreasing incidence of gonorrhea in homosexually active men--minimal effect on risk of AIDS. West J Med 1985;143:469-70.

3. Peterson CS, Sndergaard J, Wantain GL. AIDS related changes in pattern of sexually transmitted disease (STD) in an STD clinic in Copenhagen. Genitourin Med 1988;64:270-2.

4. Rothenberg RB. The geography of gonorrhea: empirical demonstration of core group transmission. Am J Epidemiol 1983;117:688-92.

5. Hessol NA, O'Malley P, Lifson A, et al. Incidence and prevalence of HIV infection among homosexual and bisexual men, 1978-1988 (Abstract). V International Conference on AIDS. Montreal, June 4-9, 1989:50.

6. Ekstrand ML, Stall RD, Coates TJ, McKusick L. Risky sex relapse, the next challenge for AIDS prevention programs: the AIDS Behavioral Research Project (Abstract). V International Conference on AIDS. Montreal, June 4-9, 1989:699.

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