Men Who Have Sex with Men (MSM)
MSM comprise a diverse group in terms of behaviors, identities, and health care needs (179). The term “MSM” often is used clinically to refer to sexual behavior alone, regardless of sexual orientation (e.g., a person might identify as heterosexual but still be classified as MSM). Sexual orientation is independent of gender identity. Classification of MSM can vary in the inclusion of transgender men and women on the basis of whether men are defined by sex at birth (i.e., transgender women included) or current gender identity (i.e., transgender men included). Therefore, sexual orientation as well as gender identity of individual persons and their sex partners should be obtained during health care visits. MSM might be at increased risk for HIV and other STIs because of their sexual network or behavioral or biologic factors, including number of concurrent partners, condomless sex, anal sex, or substance use (180–182). These factors, along with sexual network or higher community disease prevalence, can increase the risk for STIs among MSM compared with other groups (183,184).
Performing a detailed and comprehensive sexual history is the first step in identifying vulnerability and providing tailored counseling and care (3). Factors associated with increased vulnerability to STI acquisition among MSM include having multiple partners, anonymous partners, and concurrent partners (185,186). Repeat syphilis infections are common and might be associated with HIV infection, substance use (e.g., methamphetamines), Black race, and multiple sex partners (187). Similarly, gonorrhea incidence has increased among MSM and might be more likely to display antimicrobial resistance compared with other groups (188,189). Gonococcal infection among MSM has been associated with similar risk factors to syphilis, including having multiple anonymous partners and substance use, especially methamphetamines (190). Disparities in gonococcal infection are also more pronounced among certain racial and ethnic groups of MSM (141).
HIV Risk Among Men Who Have Sex with Men
MSM are disproportionately at risk for HIV infection. In the United States, the estimated lifetime risk for HIV infection among MSM is one in six, compared with heterosexual men at one in 524 and heterosexual women at one in 253 (191). These disparities are further exacerbated by race and ethnicity, with African American/Black and Hispanic/Latino MSM having a one in two and a one in four lifetime risk for HIV infection, respectively. For HIV, transmission occurs much more readily through receptive anal sex, compared with penile-vaginal sex (192). Similar to other STIs, multiple partners, anonymous partners, condomless sex, and substance use are all associated with HIV infection (193–196). Importantly, other STIs also might significantly increase the risk for HIV infection (197–199). An estimated 10% of new HIV infections were attributable to chlamydial or gonococcal infection (81). A substantial number of MSM remain unaware of their HIV diagnosis (200). Clinical care involving MSM, including those who have HIV infection, should involve asking about STI-related risk factors and routine STI testing. Clinicians should routinely ask MSM about their sexual behaviors and symptoms consistent with common STIs, including urethral discharge, dysuria, ulcers, rash, lymphadenopathy, and anorectal symptoms that might be consistent with proctitis (e.g., discharge, rectal bleeding, pain on defecation, or pain during anal sex). However, certain STIs are asymptomatic, especially at rectal and pharyngeal sites, and routine testing is recommended. In addition, clinicians should provide education and counseling regarding evidence-based safer-sex approaches that have demonstrated effectiveness in reducing STI incidence (see HIV Infection, Detection, Counseling, and Referral).
Pre-Exposure Prophylaxis for HIV Prevention
PrEP is the use of medications for preventing an infection before exposure. Studies have demonstrated that a daily oral medication TDF/FTC is effective in preventing HIV acquisition, and specifically among MSM (74,75,201). PrEP guidelines provide information regarding sexually active persons who are at substantial risk for acquiring HIV infection (having had anal or vaginal sex during the previous 6 months with either a partner with HIV infection, a bacterial STI in the past 6 months, or inconsistent or no condom use with a sex partner) or persons who inject drugs (injecting partner with HIV infection or sharing injection equipment) (80). Those guidelines provide information regarding daily PrEP use for either TDF/FTC (men or women) or tenofovir alafenamide and emtricitabine for MSM. Screening for bacterial STIs should occur at least every 6 months for all sexually active patients and every 3 months among MSM or among patients with ongoing risk behaviors. MSM taking PrEP might compensate for decreased HIV acquisition risk by using condoms less frequently or modifying their behavior in other ways (202,203), although data regarding this behavior are inconsistent. Studies have reported that MSM taking PrEP have high rates of STIs, and frequent screening is warranted (204–206).
Importance of Rectal and Pharyngeal Testing
Rectal and pharyngeal testing by NAAT for gonorrhea and chlamydia is recognized as an important sexual health consideration for MSM. Rectal gonorrhea and chlamydia are associated with HIV infection (82,207), and men with repeat rectal infections can be at substantially higher risk for HIV acquisition (208). Pharyngeal infections with gonorrhea or chlamydia might be a principal source of urethral infections (209–211). Studies have demonstrated that among MSM, prevalence of rectal gonorrhea and chlamydia ranges from 0.2% to 24% and 2.1% to 23%, respectively, and prevalence of pharyngeal gonorrhea and chlamydia ranges from 0.5% to 16.5% and 0% to 3.6%, respectively (171). Approximately 70% of gonococcal and chlamydial infections might be missed if urogenital-only testing is performed among MSM (212–216) because most pharyngeal and rectal infections are asymptomatic. Self-collected swabs have been reported to be an acceptable means of collection for pharyngeal and rectal specimens (217–219), which can enhance patient comfort and reduce clinical workloads.
A detailed sexual history should be taken for all MSM to identify anatomic locations exposed to infection for screening. Clinics that provide services for MSM at high risk should consider implementing routine extragenital screening for N. gonorrhoeae and C. trachomatis infections, and screening is likely to be cost-effective (220).
STI screening among MSM has been reported to be suboptimal. In a cross-sectional sample of MSM in the United States, approximately one third reported not having had an STI test during the previous 3 years, and MSM with multiple sex partners reported less frequent screening (221). MSM living with HIV infection and engaged in care also experience suboptimal rates of STI testing (222,223). Limited data exist regarding the optimal frequency of screening for gonorrhea, chlamydia, and syphilis among MSM, with the majority of evidence derived from mathematical modeling. Models from Australia have demonstrated that increasing syphilis screening frequency from two times a year to four times a year resulted in a relative decrease of 84% from peak prevalence (224). In a compartmental model applied to different populations in Canada, quarterly syphilis screening averted more than twice the number of syphilis cases, compared with semiannual screening (225). Furthermore, MSM screening coverage needed for eliminating syphilis among a population is substantially reduced from 62% with annual screening to 23% with quarterly screening (226,227). In an MSM transmission model that explored the impact of HIV PrEP use on STI prevalence, quarterly chlamydia and gonorrhea screening was associated with an 83% reduction in incidence (205). The only empiric data available that examined the impact of screening frequency come from an observational cohort of MSM using HIV PrEP in which quarterly screening identified more bacterial STIs, and semiannual screening would have resulted in delayed treatment of 35% of total identified STI infections (206). In addition, quarterly screening was reported to have prevented STI exposure in a median of three sex partners per STI infection (206). On the basis of available evidence, quarterly screening for gonorrhea, chlamydia, and syphilis for certain sexually active MSM can improve case finding, which can reduce the duration of infection at the population level, reduce ongoing transmission and, ultimately, prevalence among this population (228).
Preventive screening for common STIs is indicated for all MSM. The following screening recommendations summarize published federal agency and USPSTF clinical prevention guidelines for MSM and should be performed at least annually.
HIV serologic testing is indicated if HIV status is unknown or if HIV negative and the patient or their sex partner has had more than one sex partner since the most recent HIV test.
Syphilis serologic testing is indicated to establish whether persons with reactive tests have untreated syphilis, have partially treated syphilis, or are manifesting a slow or inadequate serologic response to recommended previous therapy.
Gonorrhea and Chlamydia
The following testing is recommended for MSM:
- A test for urethral infection* with N. gonorrhoeae and C. trachomatis among men who have had insertive intercourse during the preceding year (urine NAAT is preferred).
- A test for rectal infection* with N. gonorrhoeae and C. trachomatis among men who have had receptive anal intercourse during the preceding year (rectal NAAT is preferred).
- A test for pharyngeal infection* with N. gonorrhoeae among men who have had receptive oral intercourse during the preceding year (pharyngeal NAAT is preferred).
- Testing for C. trachomatis pharyngeal infection is not recommended.
* Regardless of condom use during exposure.
Basing screening practices solely on history might be suboptimal because providers might feel uncomfortable taking a detailed sexual history (229), men might also feel uncomfortable sharing personal sexual information with their provider, and rectal and pharyngeal infections can be identified even in the absence of reported risk behaviors (171). Furthermore, the role of saliva, kissing, and rimming (i.e., oral-rectal contact) in the transmission of N. gonorrhoeae and C. trachomatis has not been well studied (230–232).
Rectal and pharyngeal testing (provider-collected or self-collected specimens) should be performed for all MSM who report exposure at these sites. Testing can be offered to MSM who do not report exposure at these sites after a detailed explanation, due to known underreporting of risk behaviors. All MSM with HIV infection entering care should be screened for gonorrhea and chlamydia at appropriate anatomic sites of exposure as well as for syphilis.
More frequent STI screening (i.e., for syphilis, gonorrhea, and chlamydia) at 3- to 6-month intervals is indicated for MSM, including those taking PrEP and those with HIV infection, if risk behaviors persist or if they or their sex partners have multiple partners. In addition, providers can consider the benefits of offering more frequent HIV screening (e.g., every 3–6 months) to MSM at increased risk for acquiring HIV infection.
Hepatitis B Virus
All MSM should be screened with HBsAg, HBV core antibody, and HBV surface antibody testing to detect HBV infection (233). Vaccination against both HAV and HBV is recommended for all MSM for whom previous infection or vaccination cannot be documented. Serologic testing can be considered before vaccinating if the patient’s vaccination history is unknown; however, vaccination should not be delayed. Vaccinating persons who have had previous infection or vaccination does not increase the risk for vaccine-related adverse events (see Hepatitis A Virus; Hepatitis B Virus).
Hepatitis C Virus
CDC recommends HCV screening at least once for all adults aged ≥18 years, except in settings where the prevalence of HCV infection (HCV RNA positivity) is <0.1% (156). The American Association for the Study of Liver Diseases/ Infectious Diseases Society of America guidelines recommend all MSM with HIV infection be screened for HCV during the initial HIV evaluation and at least annually thereafter (https://www.hcvguidelines.org). More frequent screening depends on ongoing risk behaviors, high-risk sexual behavior, and concomitant ulcerative STIs or STI-related proctitis. Sexual transmission of HCV can occur and is most common among MSM with HIV infection (234–237). Screening for HCV in this setting is cost-effective (238,239). Screening should be performed by using HCV antibody assays followed by HCV RNA testing for those with a positive antibody test. Suspicion for acute HCV infection (e.g., clinical evidence of hepatitis and risk behaviors) should prompt consideration for HCV RNA testing, despite a negative antibody test.
HPV infection and associated conditions (e.g., anogenital warts and anal squamous intraepithelial lesions) are highly prevalent among MSM. The HPV vaccination is recommended for all men, including MSM and transgender persons or immunocompromised males, including those with HIV infection, through age 26 years (11). More information is available at https://www.cdc.gov/hpv/downloads/9vhpv-guidance.pdf.
A digital anorectal examination (DARE) should be performed to detect early anal cancer among persons with HIV and MSM without HIV but who have a history of receptive anal intercourse. Data are insufficient to recommend routine anal cancer screening with anal cytology in populations at risk for anal cancer (see Anal Cancer). Health centers that initiate a cytology-based screening program should only do so if referrals to high-resolution anoscopy (HRA) and biopsy are available.
Herpes Simplex Virus-2
Evaluation for HSV-2 infection with type-specific serologic tests also can be considered if infection status is unknown among persons with previously undiagnosed genital tract infection (see Genital Herpes).
Postexposure Prophylaxis and Pre-Exposure Prophylaxis for STI Prevention
Studies have reported that a benefit might be derived from STI PEP and PrEP for STI prevention. One study demonstrated that monthly oral administration of a 1-g dose of azithromycin reduced infection with N. gonorrhoeae and C. trachomatis but did not decrease the incidence of HIV transmission (240). Among MSM, doxycycline taken as PEP in a single oral dose ≤24 hours after sex decreased infection with Treponema pallidum and C. trachomatis; however, no substantial effect was observed for infection with N. gonorrhoeae (93). Doxycycline taken as STI PrEP as 100 mg orally once daily also demonstrated a substantial reduction in gonorrhea, chlamydia, and syphilis among MSM (90). However, these studies had limitations because of small sample size, short duration of therapy, and concerns about antibiotic resistance, specifically regarding N. gonorrhoeae (241). Further study is needed to determine the effectiveness of using antimicrobials for STI PrEP or PEP.
Doxy-PEP as an STI Prevention Strategy: Considerations for individuals and healthcare providers of gay or bisexual men or transgender women
Counseling and Education Approaches
Different counseling and STI prevention strategies are needed to effectively engage different groups of MSM. Outreach efforts should be guided by local surveillance efforts and community input. Engaging MSM at risk through social media, specifically online hookup sites, is an important outreach effort to consider. Hookup sites are Internet sites and mobile telephone applications that men might use for meeting other men for sex. Internet use might facilitate sexual encounters and STI transmission among MSM, and many men report using hookup sites to meet partners (242–245). The ease and accessibility of meeting partners online might reduce stigma and barriers of meeting partners through other settings. Moreover, these sites offer an opportunity for effective STI prevention messaging (246), although the cost might be limiting (247). Different groups of MSM might use different hookup sites, and efforts should be guided by local community input. Studies have demonstrated the acceptability and feasibility of reaching MSM through these hookup sites to promote STI prevention efforts (248,249).
Enteric Infections Among Men Who Have Sex with Men
The importance of sexual transmission of enteric pathogens among MSM has been recognized since the 1970s, after the first report of MSM-associated shigellosis was reported in San Francisco (250,251). Global increases in the incidence of shigellosis among adult MSM have been more recently observed (252–256). Sporadic outbreaks of Shigella sonnei and Shigella flexneri have been reported among MSM (257–262). Transmission occurs through oral-anal contact or sexual contact, and transmission efficiency is enhanced by both biologic or host and behavioral factors. HIV without viral suppression can be an independent risk factor that can contribute to transmission by increasing shedding of the enteric pathogen, increasing susceptibility of the host, or both (255,263). Surveillance data in England during 2004–2015 demonstrated that 21% of nontravel-associated Shigella diagnoses among MSM were among persons with HIV infection (255).
Other enteric organisms might also cause disease among MSM through sexual activities leading to oral-anal contact, including bacteria such as Escherichia coli (264) and Campylobacter jejuni or Campylobacter coli (265,266); viruses such as HAV (267); and parasites such as Giardia lamblia or Entamoeba histolytica (268,269). Behavioral characteristics associated with the sexual transmission of enteric infections are broadly similar to those associated with other STIs (e.g., gonorrhea, syphilis, and lymphogranuloma venereum [LGV]). This includes multiple sex partners and online hookup sites that increase opportunities for sexual mixing, which might create dense sexual networks that facilitate STI transmission among MSM (270). Specific behaviors associated with sexually transmitted enteric infections among MSM involve attendance at sex parties and recreational drug use including chem sex (i.e., using crystal methamphetamine, gamma-butyrolactone, or mephedrone before or during sex), which might facilitate condomless sex, group sex, fisting, use of sex toys, and scat play (253,271). The growing number of sexually transmitted enteric infections might be attributable in part to the emergence of antimicrobial resistance. This is well reported regarding Shigella species, for which rapid intercontinental dissemination of a S. flexneri 3a lineage with high-level resistance to azithromycin through sexual transmission among MSM (272) and clusters of multidrug resistant shigella cases among MSM have recently been reported (273). Multidrug-resistant Campylobacter species have also been documented (266,274). For MSM patients with diarrhea, clinicians should request laboratory examinations, including stool culture; provide counseling about the risk for infection with enteric pathogens during sexual activity (oral-anal, oral-genital, anal-genital, and digital-anal contact) that could expose them to enteric pathogens; and choose treatment, when needed, according to antimicrobial drug susceptibility.