Rectal chlamydia infection in women Have we been missing the point? Dr Harriet Wallace On behalf of M Loftus-Keeling, H Ward, C Hulme, M Wilcox, JD Wilson BASHH conference - Oxford 2016

Introduction BASHH/MEDFASH Standards 2014

Introduction BASHH/MEDFASH Standards 2014

Introduction Using only vulvovaginal NAATs for chlamydia (CT) and gonorrhoea (NG) in women may miss infection at extragenital sites1 Increased case finding after introduction of rectal screening UK sites2 Identifying rectal CT infection may affect the management required3 Recent Swedish study identified a rectal CT prevalence in women of 9.1% by routine screening4 Trebach J et al Sex Trans Dis 2015;42(5):233-9 Garner et al. Int J STD&AIDS 2015;26(7):462-6 Kong FYS et al J Antimicrob Chemother 2015;70(5): 1290-7 Anersson N et al Int J STD&AIDS online 2016 doi:10.1177/0956462416653510

Methods ‘SYSTEMATIC’ trial Inclusion criteria: 16yrs+, no antibiotics in the last 4 wks, no rectal symptoms, willing for extragenital tests NAATs from pharyngeal and rectal sites for chlamydia (CT) and gonorrhoea (NG) using Aptima Combo 2: (randomised order) 1 x clinician-taken sample 2 x self samples (1 analysed individually, 1 pooled into single collection pot together with VVS NAATs) Patient infected status: at least 2 positive confirmed samples Site infected status: PIS positive plus at least 1 positive from site

Results 1191 women recruited Median age 23 years (16-71) Ethnicity: 83% white British/white other 38% had a previous STI 15% were a contact of infection (9.5% chlamydia contacts) 31% attended with symptoms consistent with a urogenital infection discharge, dysuria, lower abdo pain, deep dyspareunia, IMB, PCB

Results: Sexual history 1190 (99.9%) reported ever having vaginal sex 1142 (95.9%) ever given oral sex to a male partner 548 (46%) ever had receptive anal sex

Results: Chlamydia (CT) infection 227 women CT positive at any site (VVS, Rectal, Pharynx), overall prevalence 19.1% Prevalence by site: Rectal 17.5% (n=209) VVS 16.5% (n=197) Pharyngeal 4.7% (n=56) Site Number of cases CT positive Rectal & VVS 146 Rectal & VVS & Pharyngeal 41 Rectal only 17 VVS only 8 Pharyngeal only Rectal & Pharyngeal 5 VVS & Pharyngeal 2

Results: Chlamydia (CT) infection 227 women CT positive at any site (VVS, Rectal, Pharynx), overall prevalence 19.1% Prevalence by site: Rectal 17.5% (n=209) VVS 16.5% (n=197) Pharyngeal 4.7% (n=56) Site Number of cases CT positive Rectal & VVS 146 Rectal & VVS & Pharyngeal 41 Rectal only 17 VVS only 8 Pharyngeal only Rectal & Pharyngeal 5 VVS & Pharyngeal 2 41% reported no previous anal sex

Comparison of those women with rectal Chlamydia vs those without With rectal CT (n=209) Without rectal CT (n=982) p value

Comparison of those women with rectal Chlamydia vs those without With rectal CT (n=209) Without rectal CT (n=982) p value Median age (years) 21 (IQR 19-24) 24 (IQR 20-28) p=0.026 (Chi2)

Comparison of those women with rectal Chlamydia vs those without With rectal CT (n=209) Without rectal CT (n=982) p value Median age (years) 21 (IQR 19-24) 24 (IQR 20-28) 0.026 (Chi2) Contact of STI 82 (39%) 96 (10%) <0.001 (Chi2)

Comparison of those women with rectal Chlamydia vs those without With rectal CT (n=209) Without rectal CT (n=982) p value Median age (years) 21 (IQR 19-24) 24 (IQR 20-28) 0.026 (Chi2) Contact of STI 82 (39%) 96 (10%) <0.001 (Chi2) Contact of CT 78 (37%) 38 (4%)

Comparison of those women with rectal Chlamydia vs those without With rectal CT (n=209) Without rectal CT (n=982) p value Median age (years) 21 (IQR 19-24) 24 (IQR 20-28) 0.026 (Chi2) Contact of STI 82 (39%) 96 (10%) <0.001 (Chi2) Contact of CT 78 (37%) 38 (4%) Contact of GC only 2 (1%) 27 (2.8%) 0.212 (Fisher’s Exact)

Comparison of those women with rectal Chlamydia vs those without With rectal CT (n=209) Without rectal CT (n=982) p value Median age (years) 21 (IQR 19-24) 24 (IQR 20-28) 0.026 (Chi2) Contact of STI 82 (39%) 96 (10%) <0.001 (Chi2) Contact of CT 78 (37%) 38 (4%) Contact of GC only 2 (1%) 27 (2.8%) 0.212 (Fisher’s Exact) History of a previous STI 88 (42%) 368 (37%) 0.211 (Chi2)

Comparison of those women with rectal Chlamydia vs those without With rectal CT (n=209) Without rectal CT (n=982) p value Median age (years) 21 (IQR 19-24) 24 (IQR 20-28) 0.026 (Chi2) Contact of STI 82 (39%) 96 (10%) <0.001 (Chi2) Contact of CT 78 (37%) 38 (4%) Contact of GC only (1%) 27 (2.8%) 0.212 (Fisher’s Exact) History of a previous STI 88 (42%) 368 (37%) 0.211 (Chi2) Symptoms of urogenital infection 82 (40%) 294 (30%) 0.922(Chi2)

Comparison of those women with rectal Chlamydia infection vs those without Sexual history With rectal CT (total group =209) Without rectal CT (total group =982) p value Ever had anal sex 106/209 (51%) 442/982 (45%) 0.133 (Chi2)

Comparison of those women with rectal Chlamydia infection vs those without Sexual history With rectal CT (total group =209) Without rectal CT (total group =982) p value Ever had anal sex 106/209 (51%) 442/982 (45%) 0.133 (Chi2) Condom use anal sex ‘never’ 75/102 (74%) 4 missing 266/383 (69%) 59 missing 0.415 (Chi2) Condom use anal sex ‘always’ 18/102 (18%) 82/383 (21%) 0.404 (Chi2)

Comparison of those women with rectal Chlamydia infection vs those without Sexual history With rectal CT (n=209) Without rectal CT (n=982) p value Condom use vaginal sex ‘never’ 106 (51%) 442/976 (45%) 6 missing 0.153 (Chi2)

Comparison of those women with rectal Chlamydia infection vs those without Sexual history With rectal CT (n=209) Without rectal CT (n=982) p value Condom use vaginal sex ‘never’ 106 (51%) 442/976 (45%) 6 missing 0.153 (Chi2) Condom use vaginal sex ‘always’ 12 (6%) 113 /976 (12%) 0.013 (Chi2)

Conclusions CT prevalence higher on rectal NAATs then VVS in this population (rectal 17.5% vs VVS 16.5%) NOT testing for rectal CT infection in this group would have missed 10% of the total chlamydia infections (sole rectal or rectal/ph infection only) possible incomplete management in 95% of those who tested positive for CT on VVS who were also rectally infected

Conclusions Rectal CT infection was NOT significantly associated with: Self report of previous anal sex Self report of a previous STI Presentation with symptoms of urogenital infection Is it time for a discussion on universal rectal screening in women?

harriet.wallace@nhs.net Acknowledgements NHS National Institute Health Research, Research for Patient Benefit Programme This presentation presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0212-27041). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Hologic for providing the extra swabs for the pooled samples and the sample kits and reagents for the environmental samples All the staff and patients at Leeds Sexual Health