[Question #7831] How can I reduce health risk from gonorrhea and chlamydia in my situation?

8 days ago

After writing for two hours and trying a way to condense my story and my question, I came up with this:

 

If you (a) were living in a country where it is almost impossible to get reliable test for gonorrhea and chlamydia, and (b) you would not want to stop having sex altogether, and (c) for various reasons 1 out of 10 times you would not want to use a condom, and (d) for various reasons you would not be able to live in a sexually monogamous relationship, then what would you deem to be the best choice for your health?

Option 1: Taking PreP AND 100 mg of doxycycline daily and damaging my intestinal health and suffering from the side effects from the doxy (like dizziness and malaise). Option 2: Taking 2g of azithromycin and perhaps a shot of ceftriaxone regularly – perhaps ever 2 months

Option 3: Living with gonorrhea and chlamydia and hoping it won’t lead to a prostatitis or other severe complications

 

I did have chlamydia and a really bad bacterial prostate infection two years ago (PSA was 5,2 (at 38 years old) – took 960mg of Cotrim twice per week for 8 weeks + doxy for 7 days). The doctor was not sure if this was STD related. But he said there was a risk of sepsis - and that repeated chlamydia infections put you at serious risk of lasting damage to your urethra. That really scared me. Since I have taken 100 mg of doxy for 6 months (next to PreP). But I stopped when the side effects got too debilitating. Since I have taken 2g of azithromycin twice and a 500 mg injection of ceftriaxone once (also within 6 months). I tried it with a combination of monogamy, regular testing and condoms. But testing turns out to be super unreliable in Thailand (gram stain tests with very confusing results), in terms of monogamy it takes two to tango and condoms so often turn making love into fucking – and I don’t like to fuck, but I love to make love. So again, what option do you think would pose the least health risk? Or: Do you see another option that isn’t on my radar yet?

 

I read a lot of your answers on MedHelp and found these super-super useful. I am not aware of any other source of reliable, specific in-depth information on STDs. Very few doctors seem knowledgeable about STDs. So, I thank you so much for your work!

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
8 days ago
Welcome to the forum. What an interesting question -- the first of its sort in 15 years, that I recall. I'll get to it in all seriousness and respect -- but I hope you don't mind a tongue in cheek opening. I'm reminded of an old joke about how to maximize survival skydiiving without a parachute:  from a stationary airplane on the ground.

As the joke implies, I don't agree with your basic choices. Why not condoms? The non-latex types are virtually imperceptible to many men, e.g. polyurethane or natural membrane. (Yes, natural membrane condoms do provide excellent protection. The micrscopic pores and organisms leaking through are mostly urban myth.) I also understand that this is a different issue than your love/fucking dichotomy. But loads of sex experts have alll sorts of advice about integrating condom use into caring, mutually satisfying sex.

I also question the opening premise:  there may indeed be countries where accurate STI evaluation and testing is not available, but I can't think of any. Thailand has a vibrant, highly professional STI community, world class in all respects -- in Bangkok for sure, and probably others, perhaps like Chiang Mai. (I'm sure there also are second- or third-class operations that should be avoided -- but it should be possible to get reliable knowledge about which is which.) 

Having said my piece, for my replies to follow, I'll take the premises at face value -- but also would encourage you to investigate what resources might actually be available, and to think more about condoms.

Forget option 3. Gonorrhea and chlamydia (and syphilis) are far too dangerous to contemplate "living with" them. Many infected people indeed get away without serious complications, even untreated for long periods. But would you play Russian roulette with a pistol with 1,000 chambers? I wouldn't.

Option 1, HIV PrEP and also antibiotic PrEP for bacterial STIs:  HIV PrEP is highly effective and nontoxic; I definitely recommend it. But look into PrEP on demand, rather than continuous anti-HIV treatment. For relatively infrequent expsores (e.g. monthly or less often, and when sexual exposure is anticipated at least a few hours ahead), on-demand PrEP is equally effective as continuous. Just 3 doses of anti-HIV drug:  6-24 hr prior to exposure than once daily for 2 days afterward. (Check official advice from a knowledgeable source:  the details may vary between drug products and local public health recommendations.)

For STI PrEP:  Doxycycline is fine, but not alone; also cefixime 800 mg to prevent gonorrhea. The downsides, including antibiotic resistance and the less direct health effects (intestinal and more), would depend a lot on frequency. Weekly wouldn't be smart, but if you're potentially exposed say monthly or less often, I doubt you would have any health problem. You overstate the side effects of doxycycline:  having treated thousands of patients with it over 40 years, I don't recall a single case of dizziness or malaise, and few other signiciant side effects. (Not to be confused with minocycline, a closely related antibotic that does cause dizziness.) The biggest single risk, especially in a sun-drenched setting like Thailand much of the year, is called photosensitivity:  doxy, mino and other tetracyclines can dramatically increase propensity for sunburn, with as few as 10-20 minutes causing severe sunburn with blistering. It's important to stay covered to the extent possible, especially outside rainy season, and use high-potency sunblock for exposed sites like face and hands. In summary, this is an OK option for relatively infrequent high risk exposures.

Option 2 really is a variation on Option 1, and carries the disadvantage of finding a provider or clinic for IM injection of ceftriaxone. The same schedule with cefixime 800 mg would be OK. I would choose between option 1 and 2 based frequency of unprotected vaginal or anal sex with potentially high risk partners. If exposed more than monthly, I would recommend option 2; less often, option 1.

Not much to say about your infection(s) a few years ago. Contrary to some internet memes, chlamydia isn't known to cause prostatitis. Gonorrhea can do so, however. 

Finally, going back to your rejected option of periodic testing:  First, with this sesual lifestyle, you really must have blood tests from time to time (at least yearly, maybe every 3-6 months) for HIV and syphilis, so you're going to have to find a clinic or other option with that frequency. I can pretty much guarantee that any physician, clinic or lab in Thailand that offers HIV and syphilis tests also uses modern technology -- urinary nucleic acid amplification tests (NAAT, i.e. DNA/RNA testing) -- for gonorrhea and chlamydia. The same test kits and same excellent test performance as in any industrialized country. So your prior approach, periodic screening, is required for HIV and syphilis and should work for gon & chl. This remains my first choice for you, plus condoms

I hope these comments are helpful. Thanks again for a question requring some careful thought and contemplation. Let me know if anything isn't clear.

HHH, MD
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8 days ago
Thank you so much for your time and for taking my questions seriously in spite of disagreeing with my basic choices. And your joke did make me laugh out loud. I know what you mean. And I know I am kind of weird in that way. I am a really emotionally sensitive person/man - and it is so hard to find a woman that can meet me on that level - if I would find her, then both condoms and monogamy would be fine. Hope that will happen some day soon.  Or that I will change somehow.  (I think I am a person that some psychologists would classify as highly sensitive + high sensation seeking - which makes me not a good match for most). 

Regarding testing availability: I think you overestimate the sophistication of what is available at the "ground level." I only know one clinic in Thailand that offers good testing: The Pulse clinic in Bangkok. (The problem is that I can only afford to go there twice per year - which I do - and currently Covid travel restrictions also often make it difficult or impossible.)  But clinics that administer ceftriaxone injections are actually very easy to find - and you get it for 30 USD for 500mg. The mantra seems to be: focus on treatment not testing. The rest I contacted all do gram stain test for Gonorrhea only - and I think many do not even know how to do a proper swap. And I went there and tested with two women I was with for a longer period when I considered stopping the meds. Both times she was negative and I was positive for gonorrhoea - which is virtually impossible considering how many times (20+) we had sex w/o a condom. And then they refused to take meds with me - because they trusted their negative result. Even in Germany it is crazy: So many doctors I went to told me there is no need for testing unless you have symptoms. Only when I found a doctor catering to the LGBTQ community, I found someone that was knowledgeable. I think in reality, in many countries, the hetero-community is pretty ignorant and underserved when it comes to STDS - everyone panics about HIV and the other STDs are basically off the radar for them. Also I am often deeply shocked, saddened and rendered really helpless by the great number of women that really don't give a shit about their health. (70% of women I met in my life initiated sex w/o a condom without even asking about my status.) That has been my experience in the real world as I found it. And interestingly I had zero issues with photosensitivity on doxy (but I always use sunblock). 

I do have a few follow-up questions: 
1. Regarding gram stain tests: Do you know the exact rates regarding false positives and false negatives? 
2. In another post (years back on MedHelp), you said: "Before antibiotics were developed (pre 1940s), it appeared that gonorrhoea cleared up in most infected men in a few weeks and in women within 6-8 months.  Chlamydia probably lasts longer, probably up to a few months in men and a year or so in women." This made me wonder: Why treat it at all if that is the case? Why not wait until complications arise? Because complications are TOO dangerous? 
3. Regarding Option 1: 100 mg Doxy and 800 mg cefixime on what schedule for prevention? On demand, too? 
4. And regarding Option 2, you mean 2 mg of azithromycin + 800mg of cefixime alternatively to 2 mg of azithromycin + 250 or 500 mg ceftriaxone injection - perhaps every 2 months if there have been high risk exposures and no good testing is available? 
5. In how many cases is azithromycin currently ineffective against Gonorrhea - is there a recent statistic - I couldn't find it? 
Finally: Is there a way to send a greater contribution to your organisation for support - because I think your answers are worth way more than 25 USD (and your knowledge really is priceless) and I want to support your cause even more - because I think it is desperately needed.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
7 days ago
Thanks for the follow-up information. You obviously have more street-level understanding and experience with STD services in Thailand than I do. To your questions:

1. Urethral gram stain is wildly inaccurate in absence of symptoms and should not be done if there is no discharge, painful urination, etc. In presence of discharge, Gram stain accurately detects ~95% of gonorrhea (i.e. observation of intracellular gram negative diplococci) -- i.e. presence of GNID indicates gonorrhea almost certainly. Absence of GNID is strong evidence but not proof of NGU rather than gonorrhea; probably up to 10% of cases without GNID nevertheless have gonorrhea. This depends quite a bit on the experience of the examiner.

2. The statement is true. Prevening complications, as well as the potential for continued transmission to new partners, are the main reasons. Complications themselves often leave irreversible scarring and ongoing problems. Early treatment is almost always more effective, cheaper, and quicker.

3. I covered this above. Re-read and let mw know if still unclear.

4,5. The azithromycin doses are 1 or 2 g (grams), not mg. Combination treatment with 1 g AZM and 800 mg cefixime (or 500 mg ceftriaxone) is effective for both gonorrhea and chlamydia. For treatment of established gonorrhea, 2 g azithromycin is ~98% effective. 1 g often would work, but probably would be effective only ~80-90% of the time.

Thank you for considering a contribution to STD prevention beyond the posting fee. The sposor of the forum -- the American Sexual Health Association is the most respected private organization devoted to sexual health in general and STD prevention in particular, a strong ally of CDC and other public health agencies. (Full disclosure, both Dr. Hook and I are former ASHA board members.) They welcome donations -- I hope you'll check it out:  www.ashasexualhealth.org.
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6 days ago
Thank you very much once again :)

I think I get it now: Option 1 is 100mg doxy daily + 800mg cefixime WHEN EXPOSED - but no more than 1 time per month, yes? 

I am starting to wonder if I even had gonorrhea: I didn't have any discharge - the positive gram stain was urin-based - and my partner's cervical swap was negative. I did have a mild burning sensation when urinating. But I noticed that I also sometimes have that for a few days after I have used a condom. Which brings me to my last questions:

1. Is a mild burning sensation when urinating caused perhaps by friction-related micro-trauma a common phenomenon after intercourse? 
2. How common are NGUs in men after vaginal sex and how risky are they (in terms of prostatitis or other complications)? 
3. How reliable is a gram stain test for women? Is it also depended on the presence of discharge? And is discharge in women common or not (when it comes to gonorrhea)? I understand in men it is present in about 90% of the cases?

Perhaps I overestimate my infection risk, because became hyper-focused on urinary tract sensations since my prostatitis that had come out of nowhere and that had freaked me out. I think I really need to invest into more regular reliable testing in order to get clarity regarding wether or not I can trust my sensations - before I start overdoing it with antibiotics. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
6 days ago
Correct on Option 1.

In absence of overt discharge, gonorrhea is unlikely; and Gram stains are not normally done on urine.

1) Spermicides are irritating to the urethra -- that's a good bet if you use condoms with spermicide. Or perhaps an allergic or chemical reaction to latex. Fricintion isn't a likely explanation.

2) NGu has few if any complications. It isn't known to cause prostatitis (although it hasn't been disproved as perhaps doing so somteimes). NGU is overall the most common form of sexually transmitted urethritis, but I am unaware of any data on frequency, such as per-exposure risk level.

3) Gram stain performe very poorly in women, even in highly experienced hands. If clearly positive on a properly collected specimen (from the cervical opening, not a vaginal swab), the result is reliable. But even properly obtained specimens with experienced examiners miss at least half of all gonorrhea in women. It can be helpful as a clue, but nothing more, and never should be used as the only gonorrhea test in women.

That winds up this thread. I hope the discussion has been helfpul.
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