ORIGINAL STUDY High Chlamydia and Gonorrhea Incidence and Reinfection Among Performers in the Adult Film Industry Binh Y. Goldstein, PhD, Jane K. Steinberg, PhD, Getahun Aynalem, MD, MPH, and Peter R. Kerndt, MD, MPH Background: Adult film industry (AFI) performers engage in unpro- tected oral, vaginal, and anal sex with multiple partners, increasing the likelihood of acquisition and transmission of human immunodeficiency virus and other sexually transmitted diseases. Current industry practice does not require condom use; instead it relies upon limited testing. We sought to estimate the annual cumulative incidence of chlamydia (CT) and gonorrhea (GC) and assess the rate of reinfection among AFI performers. Methods: We retrieved all CT and GC cases diagnosed among per- formers between 2004 and 2008 in Los Angeles, CA and reported to the health department surveillance registry. Using 2008 data, we estimated ranges for CT and GC annual cumulative incidences based on assumptions of the population size of performers. For cases reported between 2004 and 2007, we determined the CT and/or GC reinfection rate within 1 year. Results: Lower bounds for the annual cumulative incidences of CT and GC among AFI performers were estimated to be 14.3% and 5.1%, respec- tively. The reinfection rate within 1 year was 26.1%. Female performers were 27% more likely to be reinfected as compared with male performers (prevalence ratio, 1.27; 95% confidence interval, 1.09 –1.48). Conclusion: CT and GC infections are common and recurrent among performers. Control strategies, including promotion of condom use, are needed to protect workers in this industry, as testing alone will not effectively prevent workplace acquisition and transmission. Addi- tional legislation that places more responsibility on the production companies is needed to ensure the safety and health of performers. S ince the legalization of adult (X-rated) film production in the State of California in 1988 with the California Supreme Court’s ruling in People v. Freeman, 1 the adult film industry (AFI) has expanded tremendously and is estimated to have gross revenues nearly of $13 billion annually. 2 It is estimated that 2000 to 3000 performers (of whom 2000 are in California) are employed by approximately 200 production companies in Los Angeles County (LAC), CA. 3–5 The career of a performer is generally short-lived, with an average duration estimated at just 18 months. 6 Although many production centers have arisen throughout the world, for example, in Florida, Brazil, Hungary, Czech Republic, and Japan, the largest production center for the AFI remains in LAC. Although adult film has gained acceptance with expanding audiences through its availability on the internet, cable TV, and in major hotel chains, industry standards for protecting adult film performers lag far behind established worker health and safety standards. Adult film performers routinely engage in anal and vaginal sex without condoms, including prolonged and repeated sexual acts with multiple sexual partners over short periods. 3 These practices often lead to rectal and/or vaginal mucosal trauma with exposure to seminal and vaginal fluids, fecal material, and blood, a combination that is ideal for transmission of human immunodeficiency virus (HIV), other sexually transmitted dis- eases (STDs), and fecal pathogens. The director of a clinic, which provides the majority of STD testing for performers, stated that “an average popular male in the industry, through partner-to- partner-to-partner transmission, reaches approximately 198 people in 3 days.” 7 Although the total population of performers at any one time may appear small, they have a very large sexual network and serve as a bridge population for STD transmission to and from the general population. 6 The current industry standard for performers in the het- erosexual segment of the AFI is voluntary STD and HIV testing every 30 days, as recommended by clinics serving AFI per- formers. This standard is implemented by requiring performers to provide a negative test result within the previous 30 days in order to work. 8 Testing facilities that serve the majority of the heterosexual performer population typically provide a urine- based nucleic acid amplification test for chlamydia (CT) and gonorrhea (GC). Performers are not routinely screened orally or rectally, and performers pay for the testing costs. 8 Between 1998 and 2008, 17 HIV cases were reported among performers. 4 The need for improvements in AFI policies was illuminated by the latest HIV outbreak in April 2004, when 3 of 14 female performers exposed to HIV became infected from a single-infected male performer. The index case had 61 primary and secondary sexual contacts within 23 days, and the attack rate was 23%. 5,8,9 The infected male performer had consistently followed the industry standard of voluntary, monthly HIV testing. In response to the outbreak, the Califor- nia Occupational Safety and Health Administration (Cal/ OSHA) issued citations to 2 production companies for not complying with the Bloodborne Pathogens Standard. 8,10 Despite the extremely high risks for STD acquisition and transmission among AFI performers, there exists little pub- lished data on STD morbidity within this population. The goals of this study are to assess (1) the annual cumulative incidences of CT and GC among performers and (2) the rate of reinfection with CT and GC. From the Sexually Transmitted Disease Program, Los Angeles County Department of Public Health, Los Angeles, CA The authors thank Ruel Torres of the Los Angeles County Department of Public Health, Public Health Laboratory. They also thank Elda Kong, Michael W. Chien, Ellen T. Rudy, Kai-Jen Cheng, and Joselene Samson of the Los Angeles County Department of Public Health, Sexually Transmitted Disease Program. Correspondence: Binh Y. Goldstein, PhD, Sexually Transmitted Dis- ease Program, Los Angeles County Department of Public Health, 2615 S. Grand Ave, Room 500, Los Angeles, CA 90007. E-mail: bgoldstein@ph.lacounty.gov. Received for publication April 20, 2010, and accepted December 21, 2010. DOI: 10.1097/OLQ.0b013e318214e408 Copyright © 2011 American Sexually Transmitted Diseases Association All rights reserved. 644 Sexually Transmitted Diseases ● Volume 38, Number 7, July 2011