Twelve months ago, almost to the week, gay men were hearing the alarm about STDs on the horizon: a new “super strain” of HIV and a type of chlamydia newly emerging — it seemed — called LGV.
Today, the HIV “super strain” has fallen by the wayside after the full story revealed less about HIV and more about the effects of crystal meth abuse. LGV chlamydia, on the other hand, may just be getting ready for a second act. As the Washington Post warned on Feb. 7, ”A particularly bad strain of chlamydia not usually seen in this country appears to be slowly spreading among gay and bisexual men.”
Hello again, LGV. But did we ever really say good-bye?
Metro Weekly spoke to Dr. Philippe Chiliade, medical director of D.C.’s Whitman-Walker Clinic, in February 2005, asking him to assess the situation at the time in regard to Lymphogranuloma Venereum — or LGV — chlamydia.
”It’s not new,” he said last year, pointing to old cases in the developing world, and new cases in New York, San Francisco and Western Europe. ”It’s painful for people who have it. They can have some really unpleasant symptoms. It can be painful and leave some scars, but there is no long-term effect [after treatment]…. Until we learn more, I would not recommend people to panic.”
Pain and scarring happen daily at tattoo parlors without much fuss at all. The problem with LGV, however, is HIV. The LGV strain of chlamydia may leave the rectum inflamed, or create scar tissue, making the rectum a more likely spot for HIV transmission — in either direction.
”So far, the vast majority of LGV cases from Europe and the United States were in people with HIV, but it’s a possibility that they are more likely to have symptoms,” Chiliade says now of the new reports of the STD. ”The concern we have about LGV is that inflammation of the rectum in a person who is HIV-positive makes it much easier to expose someone to HIV. Or for the rectum to be exposed to HIV. LGV can really facilitate the transmission of HIV. There is also the possibility that people may heal by themselves, but with a lot of scarring. There can be longtime scarring of the rectum, which can give them chronic symptoms.”
And while someone carrying the LGV strain will test positive for chlamydia, the seven-day course of antibiotics used to treat garden-variety chlamydia won’t likely rid a patient of an LGV infection. A more aggressive 21-day course of antibiotics is called for. That’s why Chiliade and his peers need to know if a patient who tests positive for chlamydia has the common strain or the LGV strain. The whole process is quite a bit more cumbersome than one might imagine.
Complicated or not, with cases of LGV popping up elsewhere, Whitman-Walker Clinic has begun searching for it. As it turns out, when Chiliade pointed last year to cases of LGV in San Francisco and New York, D.C. had likely already joined the club.
”We screened people complaining of rectal discharge, blood in their stool…. We’ve heard from the Netherlands that people present with these symptoms. With 10 patients [in 2005], we found chlamydia in the rectum,” says Chiliade, explaining the first step in the process, helped along by approval last year from the Food and Drug Administration for Whitman-Walker to perform nucleic acid amplification tests (NAAT), which allows the clinic to detect rectal chlamydia and gonorrhea infections. Prior to FDA approval — which puts WWC in a fairly exclusive club — the clinic had to send rectal samples off-site for testing.
For step two, the clinic sent the 10 positive rectal chlamydia tests from 2005 to the Centers for Disease Control and Prevention (CDC) to screen for LGV.
”Three, so far, are definitely LGV,” says Chiliade. ”There are three more [specimens] they are not sure about. Four are the regular type of chlamydia. I will not be surprised if half of the samples were infected, making it five [cases of LGV] for last year.”
These few cases, however, don’t provide much insight into how prevalent LGV may be within the community.
”We just heard in January from [clinicians in] the Netherlands that in samples from the last four years, there were more LGV cases from patients with no symptoms,” Chiliade says, explaining that so far Whitman-Walker has only looked for LGV in patients presenting symptoms of rectal chlamydia. ”It looks like there is a lot more LGV in the population with no symptoms, or minimal symptoms.
”The problem is, we’ve never looked for LGV in gay men,” he adds. ”Has it been here for a long time? Maybe it’s spreading. But is it really an outbreak? At this point, we don’t know. Is it stable, or really increasing? We really need to find an answer to that. At this point, we can’t use the word ‘outbreak.’… It’s clear that it’s here. It seems the more we look for it, the more we find it. It’s concerning, but I don’t think we can say at this point it’s an outbreak. And it’s treatable.”
To find the answers — and to help its patients — the clinic is working on two fronts: the past and the present.
With some of the clinic’s 2005 cases of rectal chlamydia testing positive for the LGV strain, the clinic will be sending its 2005 urethral chlamydia samples to the CDC for testing — about 40 to 50 samples, Chiliade estimates. This step is being made retroactively, says Chiliade, for two reasons. One is that LGV infections among men who have sex with men (MSM) have, for the most part, only been found in the rectum, so that’s all the clinic was looking for. The second reason is that now that rectal LGV infections have been confirmed locally, it stands to reason that they got there via some local urethras.
”To my knowledge, I may have heard of one case of LGV found in the urethra,” says Chiliade, granting that this urethra/rectum discrepancy is puzzling. ”It cannot appear in the rectum without being in someone’s urethra…. We are sending all of last year’s chlamydia samples to the CDC [for LGV screening]. There must be some LGV in those specimens. If any come back positive for LGV, we will ask the patient, and their partners, to come in and get tested for LGV.”
The caution, Chiliade explains, is that a patient who tested positive for chlamydia at the clinic in 2005 may have completed the standard treatment of seven days of antibiotics. That treatment would not likely cure the patient of an LGV infection. Instead, that patient may be asymptomatic and still carrying the infection.
While shipping the lot of last year’s chlamydia samples takes care of the retroactive hunt for LGV, the confirmed presence in the area of this bacterial strain means that the clinic will have to take additional steps in screening, as well.
”When we have a chlamydia-positive test, if the patient has no symptoms, we’re going to give the one-week standard [antibiotic] treatment. But if there are symptoms, it’s the three-week treatment with doxycycline,” Chiliade advises. ”We cannot wait for the results to give treatment.”
Chiliade’s advice to the area’s MSM population is to practice safer sex and to get screened regularly for STDs. Anyone who has receptive anal sex, he says, should be screened for rectal gonorrhea and rectal chlamydia. He recommends an annual screening for those with one partner, and twice-a-year screening for those with multiple partners.
Outside Whitman-Walker, other doctors are on the lookout for LGV. Dr. Douglas Ward of Dupont Circle Physicians Group, along with his fellow practitioner, Dr. Ben Stearn, see well over 1,000 patients per year — primarily gay men — Ward estimates. And while they’ve got an eye out for LGV, Ward says they have not seen anything yet.
”We’ve had a couple [recent] cases of chlamydia, but I’ve not seen anything clinically consistent with LGV,” says Ward. ”I get occasional questions about it. People read about it and get really frightened. I’ve told them to practice safer sex and not worry about LGV. Worry about plain-old syphilis or chlamydia. In the same year where I haven’t seen any LGV, I’ve seen maybe up to 50 cases of syphilis…. I would certainly say [LGV] is not a cause for panic, but definitely — and this is nothing new — if you’ve got symptoms of an STD, get it diagnosed and treated.”
Though the clinic and doctors like Ward have LGV in their sights, gay and bisexual men visiting physicians who do not have a substantial number of gay patients may need to be proactive when it comes to getting screened effectively. If symptoms of a rectal LGV infection are present, they may be mistaken for a case of irritable bowel syndrome (IBS).
”Unfortunately, even many good clinicians don’t know how to provide appropriate care to gay and bisexual men,” warns Dr. Robert J. Winn, vice chair of the Gay & Lesbian Medical Association, and medical director of Philadelphia’s Mazzoni Center, a GLBT health center. ”And of course there are many homophobic clinicians. Providing good care related to sexually transmitted infections [STIs] means knowing the signs and symptoms of STIs such as LGV, knowing the most appropriate screening for STIs based on the patient’s sexual behavior, helping patients talk about their sexual behaviors, being nonjudgmental, and understanding issues around partner notification. If your clinician can’t or won’t provide this kind of care, find one who will.”
A secondary caution, Winn adds, regards claiming such screening on one’s insurance. ”Although getting tested for a sexually transmitted infection usually doesn’t place patients at risk for losing their health insurance coverage, people who have individual — as opposed to group — insurance plans should examine their coverage carefully. We’ve had patients whose insurance premiums rose with the diagnosis of STIs.”
Winn clarifies that the premiums rose only with positive test results. Ordering the tests themselves did not trigger an increase.
Acknowledging such concerns, Chiliade says the clinic does screen patients whose tests would otherwise be covered by their insurance.
”We would prefer that people get their screening at the clinic if they’re not open with their provider, or with the charge showing up on the insurance,” he says. ”People who don’t want us to bill their insurance usually pay the full cost.” The full charge, he says, is based on the number is bodily sites checked, each ringing in at $70. For example, checking the rectum is $70, while checking both the rectum and throat would cost $140.
Regardless of where a patient goes for screening, or how he pays for it, Chiliade simply implores men who have sex with men to get tested.
”A lot of STDs can be present with absolutely no symptoms. People shouldn’t wait for symptoms to screen. They should just do it regularly,” he insists. ”At the same time, I don’t want people to use screening as a prevention method [instead of safer sex].”
For more information about STD/HIV screening at Whitman-Walker Clinic, visit www.wwc.org, e-mail the clinic at firstname.lastname@example.org, or call 202-745-6112. To locate a medical provider in the GLMA database, go to www.glma.org.