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MSM, STDs and HIV: What Are We Missing?

April is STD Awareness month.  This article is one in a series published by RH Reality Check in partnership with the National Coalition of STD Directors, focused on aspects of STD prevention, treatment and funding and the public health implications of neglecting STDs.

I often reflect on how much goes on in the STD world that needs to be hollered from the proverbial rooftops.  Recently, my friend and NCSD Board Member, Susan Philip, who directs the STD program in San Francisco, has been helping me understand the import of having more frank and open conversations about the unique challenges that men who have sex with men (MSM) face in protecting their sexual health.

Across the United States and worldwide, MSM continue to be a group disproportionately affected by STDs and HIV, but we still need better data and better tools to guide prevention efforts.  This is particularly true for STDs.

For example, we have had a large national emphasis on syphilis elimination since 1999 and have more recently worked to address both issues of co-infection in HIV-infected persons and also the increased risk of HIV infection in HIV-uninfected patients with syphilis.

And while much deserved attention is paid to syphilis in this regard, we should not forget that chlamydia and gonorrhea are much more common STDs, although we are less able to measure their impact on the health of MSM.  Patients who are diagnosed with infectious syphilis are typically interviewed by local or state health department staff (individuals are always given the option to decline answering some or all of these questions), and this information includes the numbers and gender of partners they have had, where they met them and the types of sex they had with partners.  This information helps local STD programs, as well as the CDC and other partners in sexual health, better understand who is at risk for syphilis, and most importantly, direct prevention resources more effectively.

However, obtaining these data are possible because there are specific federal funds to support syphilis control and prevention efforts, and because even in areas with high syphilis morbidity, the case counts are much lower than for gonorrhea or chlamydia.  Yet, in many other places across the country, it is often not feasible to interview all of the individuals diagnosed with gonorrhea and chlamydia.  Because we lack this type of interview information about partners, we don’t reliably know which individuals with gonorrhea and chlamydia are MSM, and therefore cannot assess the impact of these STDs on health.  Recognizing that we cannot begin to address sexual health disparities in MSM without good data, several states and cities including California are changing reporting requirements to include gender of sex partners when providers or laboratories report new cases of STDs to health officials.

In areas where gender of sex partners is collected routinely, STD disparities are commonly found.  In San Francisco in 2010, an estimated 1 in 100 MSM was infected with early syphilis, but diagnoses of chlamydia or gonorrhea were twice as common as syphilis.  Furthermore, gonorrhea rates were 18 times higher in MSM than in heterosexual men.  For chlamydia, they were 8 times higher.

However, we won’t be able to diagnose and treat these infections unless there are comprehensive sexual health services available to MSM.  This requires obtaining an accurate sexual history and providing the best type of tests – for not only urine, but also the throat and rectum if individuals have receptive oral and anal sex.  These areas have been shown to be common sites of gonorrhea or chlamydia infection.  In addition, the majority of infections are asymptomatic, and more than half of all infections are missed if only urine testing is done.  In other words – a whole bunch of folks think they are STD-free when given their results from a urine screening, when in fact, they have active infections in these other sites.

Why is this important?  Certainly these STDs should be identified and treated to prevent complications in the infected individual, transmission to partners, and from potentially entering into larger sexual networks (a major issue in some urban areas and among those seeking sex in on-line sex seeking venues).  In addition, we must continue to educate even ourselves that observational data have shown that STDs are associated with increased risk of acquiring HIV. 

For example, in data published in the Journal of AIDS in 2010, Kyle Bernstein and colleagues in San Francisco were able to show that for HIV-uninfected men at City Clinic, the municipal STD clinic in San Francisco, having a rectal chlamydia or gonorrhea infection was associated with a two times greater risk of becoming newly HIV-infected in the following two years.  Strikingly, the risk was further increased in those with two rectal infections, and was higher still in those diagnosed with rectal chlamydia or gonorrhea three times during the study period.  From these data, we cannot distinguish whether the rectal STDs are causing an increased risk of new HIV infections or are just associated with a new HIV diagnosis.  But, does it really matter?  These data suggest that by identifying HIV-uninfected MSM with rectal infections, we are identifying a group that is at very high risk for HIV infection and could potentially benefit from focused prevention resources – this of course begins with STD treatment and regularized screening of all potential infections sites, but extends as well to behavioral interventions such as risk reduction counseling, motivational interviewing, and skills building and other biomedical interventions, such as HIV pre-exposure prophylaxis.

Given the challenges of improving sexual heath for all Americans, we must do a better job of both documenting the disparities that MSM face in sexual health, as well as employing all available prevention tools in our efforts to address them.


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