• Sexual Health Shanghai

MSM

MSM

The term “men who have sex with men” (MSM) describes a heterogeneous group of men who have varied behaviors, identities, and health-care needs. Some MSM are at high risk for HIV infection and other viral and bacterial STDs because MSM may practice anal sex, and the rectal mucosa is uniquely susceptible to certain STD pathogens. In addition, multiple sex partners, substance use, and sexual network dynamics of MSM increase risk for HIV and STDs in this population. The frequency of unsafe sexual practices and the reported rates of bacterial STDs and incident HIV infection declined substantially in MSM from the 1980s through the mid-1990s. However, since that time, increased rates of early syphilis (primary, secondary, or early latent), gonorrhea, and chlamydial infection and higher rates of sexual risk behaviors have been documented among MSM in the United States and virtually all industrialized countries.

Approximately two thirds of the cases of primary and secondary syphilis diagnoses in the United States are in MSM, particularly those in ethnic minority groups. Increased syphilis screening in MSM demonstrated a doubling of early syphilis detection; however, 71% of the syphilis diagnoses occurred when the patient sought care for symptoms. Acute HIV infection has been associated with a recent or concurrent STD, including syphilis, among men at a municipal STD clinic and in the multisite iPrex study and several studies have demonstrated that early syphilis is associated with HIV infection among MSM Factors associated with increases in syphilis among MSM have included substance abuse (e.g., methamphetamine), having multiple anonymous partners, and seeking sex partners through the internet. One study found that 5.9% of MSM had repeat primary or secondary syphilis infection within 2 years of an initial infection; factors associated with repeat syphilis infection were HIV infection, black race, and having ≥10 recent sexual partners. Because of this risk for repeat infection, these data suggest that prevention efforts should include follow up serologic testing.

Gonococcal infection in MSM has been associated with similar risk factors, including having multiple anonymous partners and abuse of substances, particularly crystal methamphetamine. Rectal gonococcal rates are increasing among MSM with HIV infection, underscoring the importance of obtaining an accurate, current sexual history and asking about correlates of increased risk (e.g., anonymous sex and substance use). Insertive oral sex has been associated with urethral gonorrhea acquisition; the prevalence of pharyngeal gonorrhea and pharyngeal chlamydia has been demonstrated to be 7.3% and 2.3%, respectively. In a multicity study, rectal gonorrhea and rectal chlamydia prevalence rates among MSM were 5.4% and 8.9%, respectively. Rectal gonorrhea and chlamydia infections, especially those that are recurrent, have been associated with increased risk for HIV seroconversion among MSM. MSM with new HIV infection diagnoses are more likely than HIV-uninfected MSM to receive a diagnosis of asymptomatic gonorrhea (25.9% versus 10.9%, p<0.001) and chlamydia (18.5% vs 7.8%, p<0.001). Thus, rectal gonorrhea and chlamydia screening in MSM might be a cost-effective intervention in certain urban settings.

MSM remain at disproportionate risk for HIV acquisition and transmission in the United States, particularly those who are black or Hispanic. Factors that increase the risk for HIV infection in MSM include either receptive or insertive anal sex without a condom, having another STD, having sex with anonymous partners without a condom, and using methamphetamines or drugs that enhance sexual performance.

Substantial numbers of MSM remain unaware of their serostatus (up to 44% in one recent survey of young men in minority populations). Unfortunately, many men are not asked about STD-related risks, including the gender of sex partners. Even if gender of sex partners is ascertained, many MSM, including those with HIV infection, are neither asked about risky sexual behaviors nor provided with routine STD testing (especially at anatomic sites of exposure for gonorrhea or chlamydia), often because of the discomfort associated with these discussions. Clinicians should routinely ask sexually active MSM about symptoms consistent with common STDs, including urethral discharge, dysuria, genital and perianal ulcers, regional lymphadenopathy, skin rash, and anorectal symptoms consistent with proctitis (e.g., discharge and pain on defecation or during anal intercourse) and then perform appropriate diagnostic testing. In addition, providers should offer evidence-based counseling on safer sex using interventions that have been demonstrated to decrease STD incidence in clinical-care settings.

Clinicians should be familiar with local resources available to assist MSM with syphilis and HIV partner services as well as HIV linkage and retention in care. In addition, interventions promoting behavior change also might be appropriate. In recent years, medical educational materials have been developed in print and through electronic media to increase primary-care provider knowledge and cultural competency regarding the diagnosis and management of STDs and other clinical conditions in the lesbian, gay, bisexual, and transgender populations. Electronic media is also an important tool for disseminating and collecting information to and from MSM. Because many MSM meet partners online and seek health information from web sites, increased use of the internet for STD prevention might be warranted. MSM are amenable to receiving HIV and STD risk-reduction messages online and willing to respond to requests for partner identification from public health authorities through the internet.

The following screening tests should be performed at least annually for sexually active MSM, including those with HIV infection.

• HIV serology, if HIV status is unknown or negative and the patient himself or his sex partner(s) has had more than one sex partner since most recent HIV test.

• Syphilis serology to establish whether persons with reactive tests have untreated syphilis, have partially treated syphilis, are manifesting a slow serologic response to appropriate prior therapy, or are serofast.

• A test for urethral infection† with N. gonorrhoeae and C. trachomatis in men who have had insertive intercourse§ during the preceding year (testing of the urine using NAAT† is the preferred approach).

• A test for rectal infection† with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse§ during the preceding year (NAAT of a rectal specimen is the preferred approach).

• A test for pharyngeal infection† with N. gonorrhoeae in men who have had receptive oral intercourse§ during the preceding year (NAAT of a pharyngeal specimen is the preferred approach). Testing for C. trachomatis pharyngeal infection is not recommended.
Regardless of condom use during exposure.

Commercially available NAATs have not been cleared by FDA for these indications, but they can be used by laboratories that have met all regulatory requirements for an off-label procedure.

MSM with HIV infection are also at risk for STDs. Data from a study of 557 adults with HIV infection receiving primary care in four U.S. cities demonstrate that 13% had STD at study enrollment, and 7% had incident STD at 6 months; among MSM with HIV infection, STD incidence was 20%. Excluding trichomoniasis, 94% of incident STDs were diagnosed in MSM. All MSM with HIV infection entering care should be screened for gonorrhea and chlamydia at appropriate anatomic sites of exposure, as well as for syphilis. The frequency of follow-up testing might be dictated by subsequent behavior; screening is recommended annually, at a minimum, to include syphilis serologic testing and chlamydia and gonorrhea screening at exposed anatomic sites. STD screening rates in HIV clinics have been suboptimal. In one study involving eight U.S. cities, although syphilis testing was provided to most MSM with HIV infection, <10% were screened for extra-genitourinary gonorrhea or chlamydia, and <20% provided the urine or urethral specimens needed for testing. More frequent STD screening (i.e., for syphilis, gonorrhea, and chlamydia) at 3–6-month intervals is indicated for MSM, including those with HIV infection if risk behaviors persist or if they or their sexual partners have multiple partners. Evaluation for HSV-2 infection with type-specific serologic tests also can be considered if infection status is unknown in persons with previously undiagnosed genital tract infection.

HPV infection and HPV-associated conditions (e.g., anogenital warts and anal squamous intraepithelial lesions) are highly prevalent among MSM. The quadrivalent vaccine is recommended routinely for MSM through age 26 years; the efficacy of this vaccine in preventing HPV associated diseases in men aged >26 years is unknown.

Data are insufficient to recommend routine anal-cancer screening with anal cytology in persons with HIV infection or HIV-negative MSM. More evidence is needed concerning the natural history of anal intraepithelial neoplasia, the best screening methods and target populations, safety of and response to treatments, and other programmatic considerations before screening can be routinely recommended. However, some clinical centers perform anal cytology to screen for anal cancer among high-risk populations (e.g., persons with HIV infection and MSM), followed by high-resolution anoscopy for those with abnormal cytologic results (e.g., ASC-US).
All MSM should be tested for HBsAg to detect chronic HBV infection. Prompt identification of chronic infection with HBV is essential to ensure necessary care and services to prevent transmission to others. Screening among past or current drug users should include HCV and HBV testing. Vaccination against hepatitis A and B is recommended for all MSM in whom previous infection or vaccination cannot be documented. Preimmunization serologic testing might be considered to reduce the cost of vaccinating MSM who are already immune to these infections, but this testing should not delay vaccination. Vaccinating persons who are immune to HAV or HBV infection because of previous infection or vaccination does not increase the risk for vaccine-related adverse events (see Hepatitis A and Hepatitis B).

Sexual transmission of HCV can occur, especially among MSM with HIV infection (see Emerging Issues, Hepatitis C). Serologic screening for HCV is recommended at initial evaluation of persons with newly diagnosed HIV infection. Because of accumulating evidence of acute HCV infection acquisition among persons with HIV infection (especially MSM with HIV infection and because regular screening for HCV infection is cost effective, MSM with HIV infection should be regularly screened for HCV. Screening should be performed at least yearly and more frequently depending on specific circumstances (e.g., local HCV prevalence and incidence, high-risk sexual behavior, and concomitant ulcerative STDs or STD-related proctitis). Screening should be performed using HCV antibody assays followed by HCV RNA testing for those with a positive antibody result.

Useful Resource

  • Shanghai Public Health Clinical Center | shaphc.org
  • Shanghai Municipal Center For Disease Control & Prevention | scdc.sh.cn
  • Shanghai Skin Disease and STD Hospital | shskin.com

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