A Nested Case Control Study of Anorectal Lymphogranuloma Venereum Infection Diagnosed Among Men Who Have Sex with Men in NYC STD Clinics, 2007-2009

Background: Men attending NYC STD clinics reporting receptive anal intercourse are screened for anorectal Chlamydia trachomatis (Ct) by nucleic acid amplification test (NAAT). NAAT-positive specimens are tested for Lymphogranuloma venerum (LGV; L-2 serovar); results are available a median of 21 days after collection.

Objectives: Identify predictors of anorectal LGV to guide presumptive treatment.

Methods: Cases were men with laboratory-confirmed anorectal LGV infection 11/01/2007-6/30/2009. Two control groups (each with 3 controls/case) were selected; (1) men with Ct-positive, LGV-negative anorectal infection (Ctpos), (2) men with Ct-negative anorectal NAAT results (Ctneg). Bivariate odds ratios, Chi-square p-values were calculated.

Results: During the study period 3520 men reported receptive anal intercourse. Forty-six had LGV; only 7 (15%) of them were presumptively treated for LGV, and an additional 26 (57%) were presumptively treated for non-LGV Ct infection. Cases were significantly more likely than both sets of controls to be Black non-Hispanic (cases 70%[32/46]; controls: Ctpos 30%[41/138],  Ctneg 34%[47/138]), HIV-positive (cases 60%[27/46]; controls: Ctpos 22%[29/138], Ctneg 15%[21/138]), have syphilis history (cases 51%[23/46]; controls: Ctpos 26%[35/138], Ctneg 25%[34/138]), chief complaint of anal discharge (cases  46%[21/46]; controls: Ctpos 4%[6/138], Ctneg 6%[9/138]). None of the following were significantly associated: number male sex partners, condom use with receptive anal sex, lymphadenopathy, concurrent rectal/urethral gonorrhea, urethral Ct, syphilis, contact to gonorrhea, syphilis, HIV.

Conclusions: Men with anorectal LGV differ from men with non-LGV anorectal Ct in several notable ways. Using chief complaint of anal discharge would have presumptively treated 21 (46%) LGV cases, however it would have unnecessarily treated for LGV ~5% of the tested men (n=150)  over the 20 month study period.

Implications for Programs, Policy, and/or Research: LGV testing, if not timely, may not inform patient management. Programs without resources for Ct anorectal NAATs or LGV testing may use complaint of anal discharge to guide presumptive treatment for LGV.