STDs in Men Who Have Sex with Men
Public Health Impact
Compared to women and men who have sex with women only, gay, bisexual, and other men who have sex with men (collectively known as MSM) are at increased risk for STDs and antimicrobial resistance.1–4 Because STDs and the behaviors associated with acquiring them increase the likelihood of acquiring and transmitting HIV infection,5 STDs among MSM may be associated with an increase in HIV diagnoses.6
Although a number of individual-level risk behaviors (e.g., higher numbers of lifetime sex partners, higher rates of partner change and partner acquisition rates, and unprotected sex) significantly contribute to the ongoing disparities in the sexual health of MSM, other interpersonal and societal-level factors have also been associated with higher rates of sexually transmitted infections, including HIV among MSM.7 MSM who have lower economic status are particularly vulnerable to poorer health outcomes, especially if they belong to racial and ethnic minority populations.8, 9 For example, studies show that for black MSM, factors such as emotional and social support can drive sexual risk-taking and, in addition, broader societal factors such as power, privilege, and position in society also play a significant role.10 Similarly, for Hispanic men, the relationship between individual experiences of oppression (e.g., social discrimination and financial hardship) and risk for sexually transmitted infections in the United States has been documented.11
With the exception of reported syphilis cases, most nationally notifiable STD surveillance data do not include information on sexual behaviors; therefore, trends in STDs among MSM in the United States are based on findings from sentinel surveillance systems. Furthermore, testing strategies are often suboptimal for detecting STDs in MSM. Testing for gonorrhea and chlamydia in MSM largely focuses on detecting urethral infections, which are more likely to be symptomatic than pharyngeal or rectal infections.12 Data from enhanced surveillance projects are presented in this section to provide information on STDs in MSM.
STD Surveillance Network (SSuN) — Monitoring Trends in Prevalence of STDs Among MSM Who Visit STD Clinics, 2012
In 2005, SSuN was established to improve the capacity of national, state, and local STD programs to detect, monitor, and respond rapidly to trends in STDs through enhanced collection, reporting, analysis, visualization, and interpretation of disease information.13 SSuN is a sentinel surveillance system comprised of 42 STD clinics within 12 collaborating jurisdictions that follow common protocols for data collection and management.14 For data reported in this section, MSM were defined as men who either reported having a male sex partner or who self-reported as gay/homosexual or bisexual. MSW were defined as men who reported having sex with women only or who did not report the sex of their sex partner, but reported that they considered themselves straight/heterosexual. For more detailed information about SSuN methodology see the STD Surveillance Network (SSuN) in the Appendix.
Gonorrhea and Chlamydial Infection
In 2013, the proportion of MSM who tested positive for gonorrhea and chlamydia at STD clinics varied by SSuN site (Figure V). A larger proportion of MSM who visited SSuN STD clinics tested positive for gonorrhea than tested positive for chlamydia in all cities except Birmingham, Denver, and Hartford/New Haven (where the proportion for chlamydia was higher).
Across the participating sites, 20,955 MSM were tested for gonorrhea and 20,710 MSM were tested for chlamydia. The median site-specific gonorrhea prevalence was 16.9% (range by site: 10.4%–28.1%). The median site-specific chlamydia prevalence was 15.2% (range by site: 7.4%–30.7%). For this report, a person who tested positive for gonorrhea or chlamydia more than one time in a year was counted only once for each infection.
Co-infection of Primary and Secondary (P&S) Syphilis and HIV
Among MSM who presented to seven SSuN clinics with P&S syphilis infection in 2013, the proportion who were also infected with HIV ranged from 15.8% in Los Angeles to 47.4% in Philadelphia (Figure W). The median site-specific proportion of MSM co-infected with HIV (45.5%) was comparable to the proportion of co-infection in MSM observed in 2013 case report data (51.6%). P&S syphilis was identified by provider diagnosis, and HIV was identified by laboratory report, self-report, or provider diagnosis.
HIV status and STDs
Among MSM visiting SSuN STD clinics, prevalence of STDs was higher among HIV-positive MSM than among HIV-negative MSM (Figure X). The prevalence of P&S syphilis was 9.0% among HIV-positive MSM and 2.6% among HIV-negative MSM. Among HIV-positive MSM, urethral gonorrhea positivity was 15.0%, pharyngeal gonorrhea positivity was 10.0%, and rectal gonorrhea positivity was 16.4% (compared to 10.1%, 7.4%, and 8.9%, respectively, among HIV-negative MSM). Among HIV-positive MSM, urethral chlamydia positivity was 7.6% and rectal chlamydia positivity was 22.2% (compared to 7.1% and 11.4%, respectively, among HIV-negative MSM).
Nationally Notifiable Syphilis Surveillance Data
P&S syphilis among MSM has been increasing since at least 2000.3,15 In 33 areas reporting sex of partner data for 70% or more of cases of P&S syphilis each year during 2007–2013, cases among MSM increased 7% during 2012–2013 (Figure 31). In 2013, MSM accounted for 75% of all P&S syphilis cases in 49 states and the District of Columbia that provided information about sex of sex partners. MSM accounted for more cases than MSW or women in all racial and ethnic groups (Figure 41). More information about syphilis can be found in the Syphilis section of the National Profile.
Gonococcal Isolate Surveillance Project
GISP is a national sentinel surveillance system designed to monitor trends in antimicrobial susceptibilities of N. gonorrhoeae strains in the United States.16 Overall, the proportion of isolates from MSM in selected STD clinics from GISP sentinel sites has increased steadily, from 4.6% in 1990 to 35.1% in 2013 (Figure Y). The reason for this increase is unclear, but might reflect changes in the epidemiology of gonorrhea or changes in healthcare seeking behaviors of men infected with gonorrhea. GISP has demonstrated that gonococcal isolates from MSM are more likely to exhibit antimicrobial resistance than isolates from MSW.4 During 2007–2013, the prevalence of elevated ceftriaxone MICs (≥0.125 µg/ml) was higher in isolates from MSM than from MSW. (Figure Z).
More information on GISP can be found in the Gonorrhea section of the National Profile.
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2 Centers for Disease Control and Prevention. Trends in HIV/AIDS diagnoses among men who have sex with men — 33 States, 2000–2006. MMWR Morb Mortal Wkly Rep. 2008; 57:681–686.
3 Su JR, Beltrami JF, Zaidi AA, Weinstock HS. Primary and secondary syphilis among black and Hispanic men who have sex with men: case report data from 27 States. Ann Intern Med. 2011; 155(3):145-51.
4 Kirkcaldy RD, Zaidi A, Hook EW 3rd, Holmes KK, Soge O, del Rio C, et al. Neisseria gonorrhoeaeantimicrobial resistance among men who have sex with men and men who have sex exclusively with women: The Gonococcal Isolate Surveillance Project, 2005–2010. Ann Intern Med. 2013; 158(5 Pt 1):321–8.
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7 Koblin BA, Husnik MJ, Marla JB, Colfax GC, Huang Y, Madison ME, et al. Risk factors for HIV infection among men who have sex with men. AIDS. 2006;20(5):731-739.
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12 Patton ME, Kidd S, Llata E, Stenger M, Braxton J, et al. Extragenital gonorrhea and chlamydia testing and infection among men who have sex with men--STD Surveillance Network, United States, 2010-2012. Clin Infect Dis. 2014;58(11):1564-70.
13 Rietmeijer K, Donnelly J, Bernstein K, Bissette J, Martins S, Pathela P, et al. Here comes the SSuN—early experiences with the STD Surveillance Network. Pub Health Rep. 2009;124(Suppl 2):72-77.
14 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: U.S. Department of Health and Human Services; 2012.
15 Heffelfinger JD, Swint EB, Berman SM, Weinstock HS. Trends in primary and secondary syphilis among men who have sex with men in the United States. Am J Public Health. 2007 Jun;97(6):1076-83.
16 Schwarcz S, Zenilman J, Schnell D, Knapp JS, Hook EW III, Thompson S, et al. National surveillance of antimicrobial resistance in gonorrhoeae. JAMA. 1990;264(11):1413-7.