• gonorrhoea
• homosexual men
• STD centre
• France

Editor,—A substantial increase in cases of gonorrhoea in an STD centre in Toulouse, France, was noted between October 1999 and September 2000. It was associated both with predominant transmission in a homosexual population with oral sex practices and high HIV seroprevalence.

Approximately 8500 patients are seen annually at the Hospital La Grave STD centre; this number has remained stable in the last 10 years. Almost 20–25% of patients complain of STD symptoms and 5–6% of the men are defined as homosexual.

Between October 1999 and September 2000, 41 gonorrhoea episodes in 33 patients were diagnosed. Thirty (81%) cases were male; among the male population, 25 (83.3%) patients described homosexual contact. There were three cases of acute anal gonorrhoea, two of asymptomatic gonococcal pharyngitis, and 28 gonococcal typical acute ureteritis giving a total of 33 episodes.

Twenty one (84%) of the 25 homosexual men described oral sex with an occasional partner without anal intercourse. Five patients were HIV seropositive, 10 were negative at the entry, 10 refused HIV testing. There was no HIV in the heterosexual population.

Between 1989 and 1996, the total number of patients with gonorrhoea attending in La Grave STD centre fell from 71 to two cases per year; in 1999 and 2000, this number was multiplied by more than 6, to rise to 31 cases in 2000.

The number of cases in the homosexual population fell between 1989 and 1993, to stay stable at three cases a year until 1998; in 2000 the rate was multiplied by 8 (fig 1).

HIV seroprevalence in patients diagnosed with gonorrhoea remained steady at 6–11% throughout 1989–94 and declined from 7% to 0% between 1995 and 1999. In 2000, this prevalence dramatically increased to rise by 33% of total cases; all were men having sex with men.

This recent rise in total cases of gonorrhoea is notable because it concerns a very limited subgroup of homosexual men with high HIV seroprevalence and it is now well established that sexually transmitted diseases facilitate HIV transmission.¹

A recent increase in gonococcal infections was also noted in England and Wales, the Netherlands, and France.^{2, 3}

Our results suggest that the predominant mode of transmission is the practice of “safer sex” in a homosexual population, participating in only oral sex practices with occasional partners. Asymptomatic pharyngeal carriage may facilitate this epidemic course.

High HIV seroprevalence in homosexual patients with gonorrhoea became a real problem during the last year of the serosurvey. All knew their serostatus, no one was found to be positive at the first visit, but 10 patients (50%) refused the HIV test.

Among seropositive men, all participated in only oral sex practices, suggesting that they thought they were having safe sex.

In New York City a longitudinal incidence study conducted in one of the STD clinics identified a history of gonorrhoea as a predictor of HIV seroconversion⁴ and recent features suggest that oral sex is an independent risk factor of HIV transmission.⁵

Our study represents only a few cases in a limited cohort of patients attending an STD centre. It may not reflect the tendency in the general population but may shed light on a new epidemic mode of transmission of gonococcal disease in a core group of highly HIV positive homosexual men practising oral safe sex. More studies must be done to determine if gonococcal asymptomatic carriage in oral sex can facilitate HIV oro-genital transmission with follow up for HIV serology in seronegative patients.

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Figure 1

Cases of gonorrhoea.