STDs in Men Who Have Sex with Men
The incidence of many STDs in gay, bisexual, and other men who have sex with men (MSM)—including primary and secondary (P&S) syphilis and antimicrobial-resistant gonorrhea—is greater than that reported in women and men who have sex with women only (MSW).1-6 In addition to the negative effects of untreated STDs, elevated STD burden is of concern because it may indicate high risk for subsequent HIV infection. Annual increases in reported STD cases could reflect increased frequency of behaviors that transmit both STDs and HIV (e.g., condomless anal sex), and having an STD increases the risk of acquisition or transmission of HIV.7-14
The relatively high incidence of STD infection among MSM may be related to multiple factors, including individual behaviors and sexual network characteristics.15-17 The number of lifetime or recent sex partners, rate of partner exchange, and frequency of condomless sex each influence an individual’s probability of exposure to STDs.15 However, MSM network characteristics such as high prevalence of STDs, interconnectedness and concurrency of sex partners, and possibly limited access to healthcare also affect the risk of acquiring an STD.15, 18 Furthermore, experiences of stigma – verbal harassment, discrimination, or physical assault based on attraction to men – are associated with increased sexual risk behavior among MSM.19
Disparities among MSM reflect those observed in the general population, with disproportionate incidence of STDs reported among racial minority and Hispanic MSM, MSM of lower socioeconomic status, and young MSM.20-24 The higher burden of STDs among MSM with these characteristics, relative to the general population of MSM, may suggest distinct mixing patterns in their sexual networks, reduced access to screening and treatment, and differential experiences of stigma and discrimination, rather than greater numbers of sexual partners or frequency of condomless sex.15, 21-22, 24-26 Furthermore, disparities may be more pronounced for racial minority and Hispanic MSM who are also unemployed, young, and/or of lower socioeconomic status.26-27
With the exception of reported syphilis cases, nationally notifiable STD surveillance data do not routinely include information on sexual behaviors, and these data are missing for the majority of gonorrhea and chlamydia cases reported to CDC. Therefore, trends in STDs among MSM in the United States are based on findings from sentinel and enhanced surveillance systems. Testing strategies are also evolving to include more extragenital STD 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.28
For data reported in this chapter, 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. Data presented in this chapter are derived from the National Notifiable Diseases Surveillance System (NNDSS), the Gonococcal Isolate Surveillance Project (GISP), and the STD Surveillance Network (SSuN), a sentinel and enhanced surveillance project established in 2005 to provide supplemental information on STDs.
Nationally Notifiable Diseases Surveillance System
MSM accounted for 64.3% of reported P&S syphilis cases among women or men with information about sex of sex partners in 2018 (Figure 39). Among men exclusively, MSM accounted for 77.6% of reported cases with information on sex of sex partners. Of MSM P&S syphilis cases, 36.0% were White, 29.0% were Black, and 24.0% were Hispanic (Figure Z). Relative to the percentage of the US population that is White (60.4%), Black (12.5%), and Hispanic (18.3%),29 this represents a higher burden of disease for non-White MSM, which was also evident among MSW and women. In addition, among MSM P&S syphilis cases with known HIV status in 2017, 35.5% were also reported to be HIV-positive (Figure 46).
In 2018, 44 states provided data to classify at least 70% of cases as MSM, MSW, or women. Among these areas, estimated rates of P&S syphilis cases in MSM ranged from 108.9 cases per 100,000 MSM in Vermont to 962.3 cases per 100,000 MSM in Mississippi, with 28 states (64%) estimated to have rates between 200 and 500 cases per 100,000 MSM (Figure AA).
When examining reported P&S syphilis cases over time, 36 states were able to classify at least 70% of reported P&S syphilis cases as MSM, MSW, or women each year during 2014–2018. In these states, cases among MSM increased 5.3% during 2017–2018 and 51.5% during 2014–2018 (Figure 41). However, despite the increase in cases, the percentage of P&S syphilis cases that were attributed to MSM in those states decreased from 72.4% in 2014 to 62.7% in 2018 due to larger relative increases in reported P&S syphilis cases among MSW and women.
A description of the methods for estimating MSM population sizes for syphilis rate denominators can be found in Section A1.2 of the Appendix. 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 Neisseria gonorrhoeae strains in the United States.3 Overall, the proportion of isolates collected in selected STD clinics participating in GISP that were from MSM increased steadily, from 3.9% in 1989 to a high of 38.5% in 2017 (Figure BB). In 2018, this proportion was 37.2%. The reason for this increase over time is unclear, but might reflect changes in the epidemiology of gonorrhea or in healthcare-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.3, 4 In 2018, the proportion of isolates with elevated azithromycin minimum inhibitory concentrations (MICs) (≥2.0 μg/mL) and elevated ceftriaxone MICs (≥0.125 μg/mL) was higher in isolates from MSM than from MSW (Figure CC). For azithromycin, 8.2% of isolates from MSM had elevated MICs compared to 2.4% in MSW. For ceftriaxone, the proportion was slightly higher at 0.22% in MSM compared to 0.16% in MSW.
Information on the antimicrobial susceptibility criteria used in GISP can be found in Section A2.3 of the Appendix. More information about GISP and additional data can be found at https://www.cdc.gov/std/GISP.
STD Surveillance Network
The STD Surveillance Network (SSuN) is an ongoing collaboration of state, county, and city health departments conducting sentinel and enhanced surveillance activities. These include collecting enhanced clinical and behavioral information among all patients attending selected STD clinics, among women aged 15–44 years in selected reproductive health clinics, and conducting enhanced patient and provider investigations on a representative sample of gonorrhea cases diagnosed and reported from all reporting sources in their jurisdiction (See Section A2.2 of the Appendix). Estimated rates of reported gonorrhea among MSM based on SSuN data are provided in the Gonorrhea section of the National Profile (Figure 25).
Urethral and Extragenital Gonorrhea and Chlamydia in STD Clinics, 2018
In 2018, 31,650 unique MSM presented for care in 18 STD clinics in nine SSuN jurisdictions. In total, 26,159 unique MSM were tested for urogenital gonorrhea and/or chlamydia (26,151 for gonorrhea and 26,087 for chlamydia) (Figure DD). Urogenital testing varied between jurisdictions, with the proportion tested for urogenital gonorrhea ranging from 49.7%–94.7% and the proportion tested for urogenital chlamydia ranging from 48.7% to 94.7%. However, the proportion tested for urogenital gonorrhea and for urogenital chlamydia was similar within each jurisdiction. When examining positivity among MSM tested for each disease, urogenital gonorrhea positivity was higher than urogenital chlamydia positivity in seven of the nine jurisdictions: Baltimore, Miami, Multnomah County, New York City, Philadelphia, San Francisco, and Seattle. Urogenital chlamydia positivity was equal or higher than urogenital gonorrhea positivity in Massachusetts and Minnesota. The median urogenital positivity for gonorrhea among MSM was 7.9% (range: 4.3%–13.3%) and for chlamydia was 5.8% (range: 4.3%–11.1%) across the nine jurisdictions.
In 2018, there were 20,838 unique MSM tested for rectal gonorrhea and/or chlamydia (20,798 for gonorrhea and 20,755 for chlamydia) (Figure EE). When compared to urogenital testing, rectal testing occurs less frequently in the majority of jurisdictions. The median positivity for rectal gonorrhea among MSM was 14.8% (range: 7.6%–18.1%) and for rectal chlamydia was 16.1% (range: 10.2%–20.8%) in SSuN jurisdictions.
During 2018, 23,739 MSM were tested at the pharyngeal site for gonorrhea and/or chlamydia (23,695 for gonorrhea and 21,767 for chlamydia) in eight of the 10 SSuN jurisdictions where data was available (Figure FF). Pharyngeal testing varied between 52.2%–86.5% for gonorrhea and between 68.2–76.6% for chlamydia. Among MSM who were tested at the pharyngeal site for gonorrhea, the median positivity was 12.9% (range: 8.0%–19.8%). In contrast, MSM tested at the pharyngeal site for chlamydia was 2.7% (range: 2.0%–3.1%). Pharyngeal chlamydia testing data was not available for Minnesota.
HIV Status and STDs in STD Clinics, 2018
Among HIV-positive MSM attending SSuN STD clinics in seven of the 10 SSuN jurisdictions in 2018, urogenital chlamydia positivity was 6.1% and urogenital gonorrhea positivity was 12.7% (compared to 6.7% and 7.6%, respectively, among HIV-negative MSM) (Figure GG). Among HIV-positive MSM, 7.0% were diagnosed with P&S syphilis compared to 3.4% of HIV-negative MSM. Percentages represent the overall average of the mean value by jurisdiction.
Anogenital Warts in STD Clinics, 2010–2016
Human papillomavirus (HPV) is a common sexually transmitted infection in the United States.31 MSM are at elevated risk for clinical sequelae of HPV infection, including anal intraepithelial neoplasia, anal cancer, and anogenital warts.32,33 Since late 2011, routine use of HPV vaccine has been recommended for males aged 11–12 years, with catchup vaccination through age 21;34-36 this age limit was recently extended to 26 years.37 Vaccination through age 26 has been recommended since late 2011 for MSM and persons who are immunocompromised (including those infected with HIV).34 For more information on HPV infections and HPV vaccination, see Other STDs.
An analysis of data from 27 clinics participating in SSuN observed significant declines in prevalence of anogenital warts during 2010–2016 among MSM of all ages.38 Although some of the observed declines may be due to HPV vaccination, changes over time in attributes of STD clinic patients or clinical practices, such as a decrease in physical examinations resulting in fewer anogenital warts diagnoses, may partially account for these findings.
The number of reported P&S syphilis cases among MSM continued to rise in 2018, and the majority of P&S syphilis cases remained among MSM. Furthermore, the proportion of GISP isolates with elevated MICs to antimicrobials currently used to treat gonorrhea was higher among MSM than among MSW. Beyond STD burden in the general MSM population, the data indicated heterogeneity of STD prevalence among MSM according to geography, race/Hispanic ethnicity, and HIV status. State-specific P&S syphilis rate estimates among MSM varied from 108.9 to 962.3 cases per 100,000 MSM. Reported P&S syphilis was disproportionately prevalent among Black and Hispanic MSM, and data from MSM who attended SSuN clinics suggested that P&S syphilis and urogenital gonorrhea may be more prevalent among MSM living with diagnosed HIV infection than among HIV-negative MSM.
- An Q, Wejnert C, Bernstein K, et al. Syphilis screening and diagnosis among men who have sex with men, 2008–2014, 20 US cities. JAIDS. 2017;75(Suppl 3):S363–S369.
- de Voux A, Kidd S, Grey JA, et al. State-specific rates of primary and secondary syphilis among men who have sex with men — United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(13):349–354.
- Kirkcaldy RD, Harvey A, Papp JR, et al. Neisseria gonorrhoeae antimicrobial susceptibility surveillance — the Gonococcal Isolate Surveillance Project, 27 sites, United States, 2014. MMWR Surveill Summ. 2016;65(No. SS–7):1–19.
- Kirkcaldy RD, Zaidi A, Hook EW 3rd, 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):321–328.
- Patton ME, Su JR, Nelson R, et al. Primary and secondary syphilis — United States, 2005–2013. MMWR Morb Mortal Wkly Rep. 2014;63(18):402–406.
- Peterman TA, Su J, Bernstein KT, et al. Syphilis in the United States: on the rise? Expert Rev Anti Infect Ther. 2015;13(2):161–168.
- Solomon MM, Mayer KH. Evolution of the syphilis epidemic among men who have sex with men. Sex Health. 2014;12(2):96–102.
- Buchacz K, Patel P, Taylor M, et al. Syphilis increases HIV viral load and decreases CD4 cell counts in HIV-infected patients with new syphilis infections. AIDS. 2004;18(15):2075–2079.
- Fleming DT, Wasserheit JN. From epidemiological 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(1):3–17.
- Jarzebowski W, Caumes E, Dupin N, et al. Effect of early syphilis infection on plasma viral load and CD4 cell count in human immunodeficiency virus- infected men: Results from the FHDH- ANRS CO4 cohort. Arch Intern Med. 2012;172(16):1237–1243.
- Katz DA, Dombrowski JC, Bell TR, et al. HIV incidence among men who have sex with men after diagnosis with sexually transmitted infections. Sex Transm Dis. 2016;43(4):249–254.
- Kelley CF, Vaughan AS, Luisi N, et al. The effect of high rates of bacterial sexually transmitted infections on HIV incidence in a cohort of black and white men who have sex with men in Atlanta, Georgia. AIDS Res Hum Retroviruses. 2015;31(6):587–592.
- Pathela P, Braunstein SL, Blank S, et al. HIV incidence among men with and those without sexually transmitted rectal infections: Estimates from matching against and HIV case registry. Clin Infect Dis. 2013;57(8):1203–1209.
- Solomon MM, Mayer KH, Glidden DV, et al. Syphilis predicts HIV incidence among men and transgender women who have sex with men in a preexposure prophylaxis trial. Clin Infect Dis. 2014;59(7):1020–1026.
- Glick SN, Morris M, Foxman B, et al. A comparison of sexual behavior patterns among men who have sex with men and heterosexual men and women. J Acquir Immune Defic Syndr. 2012;60(1):83–90.
- Paz-Bailey G, Mendoza MCB, Finlayson T, et al. Trends in condom use among MSM in the United States: The role of antiretroviral therapy and seroadaptive strategies. AIDS. 2016;30(12):1985–1990.
- Spicknall IH, Gift TL, Bernstein KT, et al. Sexual networks and infection transmission networks among men who have sex with men as causes of disparity and targets of prevention. Sex Transm Infect. 2017;93(5):307–308.
- Alvy LM, McKirnan DJ, Du Bois SN, et al. Health care disparities and behavioral health among men who have sex with men. J Gay Lesbian Soc Serv. 2011;23(4):507–522.
- Balaji AB, Bowles KE, Hess KL, et al. Association between enacted stigma and HIV-related risk behavior among MSM, National HIV Behavioral Surveillance System, 2011. AIDS Behav. 2017;21(1):227–237.
- Brewer TH, Schillinger J, Lewis FM, 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):367–371.
- Jeffries WL, Marks G, Lauby J. Homophobia is associated with sexual behavior that increases risk of acquiring and transmitting HIV infection among black men who have sex with men. AIDS Behav. 2013;17(4):1442–1453.
- McKirnan DJ, Du Bois SN, Alvy LM, et al. 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.
- Su JR, Beltrami JF, Zaidi AA, et al. 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):145–151.
- 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 US cities. Cultur Divers Ethnic Minor Psychol. 2004;10(3):255–267.
- Millett GA, Flores SA, Peterson JL, et al. Explaining disparities in HIV infection among black and white men who have sex with men: A meta-analysis of HIV risk behaviors. AIDS. 2007;21(15):2083–2091.
- Sullivan PS, Peterson J, Rosenberg ES, et al. Understanding racial HIV/STI disparities in Black and White men who have sex with men: A multilevel approach. PLoS One. 2014;9(3):e90514.
- Mayer KH, Wang L, Koblin B, et al. Concomitant socioeconomic, behavioral, and biological factors associated with the disproportionate HIV infection burden among black men who have sex with men in 6 US cities. PLoS One. 2014;9(1):e87298.
- Patton ME, Kidd S, Llata E, 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):1564–1570.
- U.S. Census Bureau. Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States, States, and Counties: April 1, 2010 to July 1, 2018, Table PEPSR6H; generated by Jeremy Grey; using American FactFinder. 2019. Available at: https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtmlexternal icon. Accessed August 1, 2019.
- Rietmeijer K, Donnelly J, Bernstein K, et al. Here comes the SSuN — early experiences with the STD Surveillance Network. Pub Health Rep. 2009;124(Suppl 2):72–77.
- Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: Prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187–193.
- Jin F, Prestage GP, Kippax SC, et al. Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study. Sex Transm Dis. 2007;34(7):488–493.
- Chin-Hong PV, Palefsky JM. Natural history and clinical management of anal human papillomavirus disease in men and women infected with human immunodeficiency virus. Clin Infect Dis. 2002;35(9):1127–1134.
- Petrosky E, Bocchini Jr. JA, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: Updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2015;64(11):300–304.
- Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human papillomavirus vaccine in males — Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60(50):1705–1708.
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- Meites E, Szilagyi PG, Chesson HW, et al. Human papillomavirus vaccination for adults: Updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019; 68(32):698–702.
- Mann LM, Llata E, Flagg EW, et al. Trends in the prevalence of anogenital warts among patients at sexually transmitted disease clinics — Sexually Transmitted Disease Surveillance Network, United States, 2010–2016. J Infect Dis. 2019;219(9):1389–1397