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Editor’s note: Dr. Katz is a physician working in public health. He is a board-certified dermatologist, an Associate Adjunct Professor at the Graduate School of Public Health at San Diego State University, and an Associate Member of the National Coalition of STD Directors. The views expressed in this article do not necessarily reflect those of organizations with which he is affiliated.
Researchers reported this past weekend that they have identified, in Japan, a strain of Neisseria gonorrhoeae – the bacterium that causes gonorrhea – that's exceptionally resistant to all antibiotics typically used to treat it. The emergence of that resistant strain makes it all the more important that we do our best here in the United States in our fight against gonorrhea.
Unfortunately, one big challenge to our fight against gonorrhea in San Diego stems from how Kaiser Permanente, the large managed care organization that serves a whopping half a million members in San Diego alone, approaches STD testing for gay men.
Imagine if Kaiser offered simple and potentially lifesaving laboratory tests – think Pap smears, for example, or cholesterol checks – only to patients who specifically asked for them, and who were willing to make a separate visit to a special clinic to get them.
There would be an uproar.
But tragically, that’s exactly how Kaiser approaches STD testing for gay men in San Diego. Kaiser makes it incredibly challenging for gay men to get the STD tests they need. Those hurdles help fuel the spread of STDs in our community – including HIV, which is more likely to be transmitted or acquired when STDs are present.
There should be an uproar.
I know this firsthand. Until recently I was a Kaiser member. In April I emailed my Kaiser doctor, requesting HIV and STD tests. My sex partners are men, I wrote, and I had no symptoms. But HIV and many STDs can show no symptoms, and rates of HIV and STDs are higher among gay men. For those reasons, public health agencies – including the Centers for Disease Control and Prevention (CDC), the California Department of Public Health, and the County of San Diego – recommend that sexually active gay men get tested for HIV (if their last test was negative) and certain STDs at least every year.
In my email, I referenced CDC’s guidelines. In addition to an HIV test, I requested a blood test for syphilis and tests for gonorrhea and chlamydia of the urethra (penis), throat, and rectum. [See Footnote 1] Urethral tests can be done on urine; throat and rectal tests can be done on specimens collected from swabbing those areas.
By the way, those guidelines for gay men are not new. CDC has recommended all of the tests I mentioned since 2002. Moreover, since 2006 CDC has recommended using a very sensitive type of test, called a nucleic acid amplification test (or NAAT, pronounced “gnat”), for chlamydia. And since December 2010 CDC has, for the same reason, also recommended NAATs for gonorrhea. [See Footnote 2]
In her response, my doctor said she could order HIV and syphilis tests and a NAAT for urethral gonorrhea and chlamydia. But for gonorrhea of the throat, she could order only a (less accurate) culture test, not a NAAT. That’s because, she said, Kaiser’s lab in San Diego cannot perform NAAT tests on throat specimens. And she could not order any tests at all for rectal gonorrhea or chlamydia. The computer system, she said, does not include “rectum” as an option.
Well, I took what I could get, and I got the tests she offered.
And then I formally complained to Kaiser. “Why is Kaiser Permanente, in 2011, still not able to meet my health needs as a gay man?” I wrote, after explaining what had happened. “And what remedies does Kaiser propose to rectify its inability to do so?”
Kaiser responded in May. NAAT tests of the throat and rectum, Kaiser wrote, are available – if the specimens are sent to a non-Kaiser laboratory, run by a company called Quest. That’s fine with me; I don’t care which laboratory does the test. I do care, however, whether my doctor knows that she can send specimens to that other laboratory. She clearly did not. And her colleagues likely don’t either; that would explain why the nurse who swabbed my throat told me she’d never before seen a doctor’s order for a throat swab for gonorrhea.
Then came the most concerning part of Kaiser’s response: “You can contact the Kaiser Permanente San Diego Medical Center Infectious Disease Department if you wish to for [sic] these tests to be performed and sent to Quest; specimens will be obtained at any infectious disease clinic.”
In other words: Yes, I can get the tests I need. Presumably other gay Kaiser members can, too. But only if we know to ask specifically for them, and if we make separate visits to a special Kaiser clinic. How many of us will jump through those hoops? Practically speaking, most of us won’t. That means STDs will go undiagnosed and untreated, leading to further spread of STDs, including HIV, in our community.
That’s a travesty.
Kaiser needs to change its approach to STD testing for gay men in San Diego. It should do the following:
•Offer gay members all of the recommended types of STD tests, at all recommended anatomic sites, during routine primary care visits. It’s not that difficult. Clinics in Kaiser’s Northern California region have been doing it for years already. So have the County of San Diego's STD clinics.
•Ensure that Kaiser clinicians take complete sexual histories, know which STD tests to order and how to order them, and are trained to obtain swab specimens.
•Educate gay Kaiser members about the importance of routine STD and HIV testing. The part of Kaiser's website that focuses on STD testing, for example, recommends routine syphilis testing for men who have sex with men, but it doesn’t mention routine chlamydia or gonorrhea testing. Kaiser should change its website to reflect current public health recommendations.
At the same time, we as a community need to make sure our doctors, including those at Kaiser, meet our health needs, by doing the following:
•Knowing which tests we need, and how often we need them. That information can be found in this explanation of HIV and STD testing for gay men and in this handy guide, which can be taken when seeing a doctor.
•Complaining to our doctors, health insurance plans, and employer benefit programs if we don’t get what we need. To complain to Kaiser, call (800) 464-4000 or use Kaiser’s website.
Kaiser has already demonstrated that it can take some aspects of LGBT health seriously, with many of its medical centers (including its San Diego facility) scoring well on the Human Rights Campaign's recent evaluation of hospital policies regarding LGBT patients and staff.
It’s not enough. For the sake of our health and the health of our community, Kaiser needs to change its approach to STD testing for gay men in San Diego. And so, for that matter, do other doctors and managed care organizations in San Diego and elsewhere that don’t meet national, state, and local standards.
As public health challenges posed by resistant gonorrhea, other STDs, and HIV continue and intensify, let the uproar in San Diego begin.
 Strictly speaking, CDC and the California Department of Public Health do not recommend pharyngeal tests for chlamydia – only for gonorrhea. However, NAATs commonly test simultaneously for chlamydia as well as gonorrhea. In practice, both tests are often performed by laboratories using NAATs to test pharyngeal specimens.
 Although NAAT tests have not been FDA-approved for testing specimens from the throat or rectum, many laboratories – including those at the County of San Diego and at Kaiser Permanente Northern California – have performed simple verification tests that, once completed, enable use of NAATs for testing throat and rectal specimens.