STDs in Men Who Have Sex with Men
Public Health Impact
Notifiable disease surveillance data on syphilis and data from GISP suggest that some STDs in MSM, including men who have sex with both women and men, are increasing. 1–4 Because STDs and the behaviors associated with acquiring them increase the likelihood of acquiring and transmitting HIV infection,5 the rise in STDs among MSM may be associated with an increase in HIV diagnoses among MSM.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 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.9 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, data on national trends in STDs among MSM in the United States are not currently available. 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.11 Data from enhanced surveillance projects are presented in this section to provide information on STDs in MSM.
STD Surveillance Network—Monitoring Trends in Prevalence of STDs Among MSM Who Visit STD Clinics, 2010
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.12 SSuN currently includes 12 collaborating local and state health departments. In 2010, a total of 41 STD clinics at these 12 sites collected enhanced behavioral and demographic information on patients who presented for care to these clinics. During 1999–2008, similar enhanced surveillance data were collected in eight STD clinics, including three community-based gay men’s health clinics, through the MSM Prevalence Monitoring Project.13
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. More detailed information about SSuN methodology can be found in the STD Surveillance Network section of the Appendix, Interpreting STD Surveillance Data.
Gonorrhea and Chlamydial Infection
In 2010, the proportion of MSM who tested positive for gonorrhea and chlamydia at SSuN STD clinics varied by city (Figure W). A larger proportion of MSM who visited SSuN STD clinics tested positive for gonorrhea than tested positive for chlamydia in all cities except Birmingham (where the proportions were equal), Baltimore, and Hartford/New Haven (where the proportion for chlamydia was higher).
Across the participating sites, about the same number of MSM were tested for gonorrhea (18,462) and chlamydia (17,915). The median site-specific gonorrhea prevalence was 15.5% (range by site: 9.4%–25.8%). The median site-specific chlamydia prevalence was 13.0% (range by site: 7.5%–19.2%). For this report, a person who tested positive for gonorrhea or chlamydia more than one time was counted only once for each disease.
Co-infection with P&S Syphilis and HIV
In 2010, the proportion of MSM who presented to SSuN clinics with P&S syphilis infection who also were infected with HIV ranged from 25% in Hartford/New Haven to 54% in San Francisco (Figure X). The median site-specific proportion was 38.0%. P&S syphilis was identified by provider diagnosis and HIV was identified by laboratory report, self-report, or provider diagnosis.
HIV status and STDs
When comparing the prevalence of STDs by HIV status in MSM visiting SSuN STD clinics, the prevalence was lower among HIV-negative MSM or MSM of unknown status than among HIV-positive MSM (Figure Y). The prevalence of P&S syphilis was 2.6% among HIV-negative MSM or MSM of unknown status and 10.5% among HIV-positive MSM. Urethral gonorrhea positivity was 10.3% in MSM who were HIV-negative or of unknown status and 15.2% in HIV-positive MSM. Rectal gonorrhea positivity was 8.1% in MSM who were HIV-negative or of unknown status and 14.4% in HIV-positive MSM; pharyngeal gonorrhea positivity was 6.3% in MSM who were HIV-negative or of unknown status and 7.6% in HIV-positive MSM. Urethral chlamydia was 7.8% in MSM who were HIV-negative or of unknown status and 8.4% in HIV-positive MSM; rectal chlamydia positivity was 11.7% in MSM who were HIV-negative or of unknown HIV status and 19.6% in HIV-positive MSM.
Nationally Notifiable Syphilis Surveillance Data
In 2008, the male-female rate ratio decreased to 5.0, but increased to 5.6 in 2009, increasing to 7.2 in 2010 (Figure 35). These increases support analyses of case report data showing increases in P&S syphilis among MSM during 2005–2008, particularly among black and Hispanic MSM, and MSM aged 15–29 years.14
In 2010, MSM accounted for 67% of all P&S syphilis cases in 44 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 43). 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 strains of N. gonorrhoeae in the United States.4,15 GISP also reports the percentage of N. gonorrhoeae isolates obtained from MSM. Overall, the proportion of isolates from MSM in selected STD clinics from GISP sentinel sites has increased steadily, from 4.6% in 1990 to 28.9% in 2010 (Figure Z). The proportion of isolates from MSM varies geographically, with the largest proportion reported from the West Coast (Figure AA).
More information on GISP can be found in the Gonorrhea section of the National Profile.
2 Centers for Disease Control and Prevention. Primary and secondary syphilis among men who have sex with men—New York City, 2001. MMWR Morb Mortal Wkly Rep. 2002;51:853-6.
3 Helms DJ, Weinstock HS, Asbel LE, Ciesielski C, Cherneskie T, Furness BW, et al. Increases in syphilis among men who have sex with men attending STD clinics, 2000–2005. In: Program and abstracts of the 17th Biennial Meeting of the ISSTDR; 2007 Jul 29-Aug 1; Seattle, WA. Abstract No. P-608.
4 Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2007 supplement: Gonococcal Isolate Surveillance Project (GISP) annual report 2007. Atlanta: U.S. Department of Health and Human Services; 2009.
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.
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 Mahle KC, Helms DJ, Golden MR, Asbel LE, Cherneskie T, Gratzer B, et al. Missed gonorrhea infections by anatomic site among asymptomatic men who have sex with men (MSM) attending U.S. STD clinics, 2002–2006. In: Program and abstracts of the 2008 National STD Prevention Conference; 2008 March 10-13; Chicago, IL. Abstract No. A1d.
13 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2008. Atlanta: U.S. Department of Health and Human Services; 2009.
14 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 Aug 2;155(3):145-51.