STDs in Men Who Have Sex with Men

Public Health Impact

Gay, bisexual, and other men who have sex with men (MSM) are at increased risk for STDs, including emergence of antimicrobial resistance when compared to women and exclusively heterosexual men.^1–4 Because STDs, and the behaviors associated with acquiring them, increase the likelihood of acquiring and transmitting HIV infection, STD incidence among MSM may also be an indicator of higher risk for subsequent HIV infection.^{5, 6}

Population-level factors such as limited or overlapping social and sexual networks are associated with higher rates of STDs, including HIV among MSM.⁷ Additionally, individual-level risk behaviors, such as number of lifetime sex partners, rate of partner exchange and frequency of unprotected sex, may contribute to rates of STDs.

MSM of lower economic status may be particularly vulnerable to poor health outcomes, especially if they belong to racial and ethnic minority populations.^{8, 9} Among black MSM, factors such as community isolation and limited social support may influence sexual risk-taking. 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.¹⁰

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. Testing strategies are also evolving to include more extragenital screening, which may increase detection of asymptomatic infections. Until recently, testing for gonorrhea and chlamydia in MSM largely focused on detecting urethral infections, which are more likely to be symptomatic than pharyngeal or rectal infections.¹¹ Data from sentinel 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, 2014

The STD Surveillance Network (SSuN), established in 2005, is an ongoing collaboration of states and independently funded cities collecting enhanced clinical and behavioral information among patients attending participating SSuN STD clinics.¹² Data for 2014 were obtained from 6 jurisdictions (including 26 STD clinics) continuously participating in SSuN since 2008. For data reported in this section, MSM were defined as men who either reported having one or more male sex partners 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. Additional information about SSuN can be found in Section A2.2 of the Appendix.

Gonorrhea and Chlamydial Infection

In 2014, 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 STD clinics tested positive for gonorrhea than tested positive for chlamydia.

Across the participating STD clinics, 18,568 MSM were tested for gonorrhea and 18,414 MSM were tested for chlamydia. The median site-specific gonorrhea prevalence among those tested was 19.2% (range by site: 14.5%–25.3%). The median site-specific chlamydia prevalence among those tested was 14.9% (range by site: 7.0%–17.9%). 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 participating STD clinics with P&S syphilis infection in 2014, the proportion who were also infected with HIV ranged from 9.1% in Los Angeles to 53.2% in Baltimore (Figure W). The median site-specific proportion of MSM co-infected with HIV (41.9%) was similar to the proportion of co-infection in MSM observed in 2014 case report data (51.6%). P&S syphilis was identified by provider diagnosis, and HIV status 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 MSM living with HIV than among HIV-negative MSM (Figure X). The prevalence of P&S syphilis was 10.4% among MSM living with HIV and 3.5% among HIV-negative MSM. Among MSM living with HIV, urethral gonorrhea positivity was 11.4%, pharyngeal gonorrhea positivity was 6.7%, and rectal gonorrhea positivity was 12.4% (compared to 8.6%, 7.4%, and 5.5%, respectively, among HIV-negative MSM). Among MSM living with HIV, urethral chlamydia positivity was 6.1% and rectal chlamydia positivity was 12.1% (compared to 5.7% and 7.5%, respectively, among HIV-negative MSM).

Nationally Notifiable Syphilis Surveillance Data

The number of reported cases of P&S syphilis among MSM has been increasing since at least 2000.^3,14 Twenty-seven states reported sex of sex partner data for at least 70% of all cases of P&S syphilis each year during 2007–2014. Among these states, cases among MSM increased 8.8% during 2013–2014, and 47.9% during 2010–2014 (Figure 32). In 2014, MSM accounted for 82.9% of all male P&S syphilis cases with known information about sex of sex partners (Figure 41), and MSM accounted for more cases than MSW or women in all racial and ethnic groups (Figure 42). More information about syphilis can be found in the Syphilis section of the National Profile.

Gonococcal Isolate Surveillance Project (GISP)

GISP is a national sentinel surveillance system designed to monitor trends in antimicrobial susceptibilities of N. gonorrhoeae strains in the United States.¹⁵ Overall, the proportion of isolates from MSM in selected STD clinics from GISP sentinel sites has increased steadily, from 4.6% in 1990 to 37.1% in 2014 (Figure Y). The reason for this increase is unclear, but might reflect changes in the epidemiology of gonorrhea or in health care seeking behavior 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 2007–2014, 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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1 Brewer TH, Schillinger J, Lewis FM, Blank S, Pathela P, Jordahl L, et al. Infectious syphilis among adolescent and young adult men: implications for human immunodeficiency virus transmission and public health interventions. Sex Transm Dis. 2011;38(5):367-71.

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 gonorrhoeae antimicrobial 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.

5 Fleming DT, Wasserheit JN. From epidemiologic synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. 1999;75:3-17.

6 Hall HI, Song R, Rhodes P, Prejean J, An Q, Lee LM, et al, for the HIV Incidence Surveillance Group. Estimation of HIV incidence in the United States. JAMA. 2008;6;300(5):520-9.

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.

8 Alvy LM , McKirnan DJ, Du Bois SN , Jones K, Ritchie N, Fingerhut D. Health Care Disparities and Behavioral Health Among Men Who Have Sex with Men. J Gay Lesbian Soc Serv. 2011;23(4): 507-522.

9 McKirnan DJ, Du Bois SN, Alvy LM, Jones K. Health Care Access and Health Behaviors Among Men Who Have Sex With Men: The Cost of Health Disparities. Health Educ Behav. 2013;40(1):32-41.

10 Díaz RM, Ayala G, Bein E. Sexual risk as an outcome of social oppression: data from a probability sample of Latino gay men in three U.S. cities. Cultur Divers Ethnic Minor Psychol. 2004;10(3):255-267.

11 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.

12 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.

13 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: U.S. Department of Health and Human Services; 2012.

14 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.

15 Schwarcz S, Zenilman J, Schnell D, Knapp JS, Hook EW III, Thompson S, et al. National surveillance of antimicrobial resistance in Neisseria gonorrhoeae. JAMA. 1990;264(11):1413-7

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