” Fools rush in ……..”
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, 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.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, 2011
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 2011, a total of 42 STD clinics at these 12 sites collected enhanced behavioral and demographic information on patients who presented for care to these clinics.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 2011, the proportion of MSM who tested positive for gonorrhea and chlamydia at STD clinics varied by SSuN site (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 Hartford/New Haven (where the proportion for chlamydia was higher).
Across the participating sites, about the same number of MSM were tested for gonorrhea (20,333) and chlamydia (19,957). The median site-specific gonorrhea prevalence was 14.5% (range by site: 2.8%–21.0%). The median site-specific chlamydia prevalence was 11.3% (range by site: 6.5%–23.1%). 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 P&S Syphilis and HIV
In 2011, the proportion of MSM who presented to SSuN clinics with P&S syphilis infection who also were infected with HIV ranged from 14.3% in Los Angeles to 65% in Baltimore (Figure X). The median site-specific proportion co-infected with HIV was 40.4%. 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 status than among HIV-positive MSM (Figure Y). The prevalence of P&S syphilis was 2.6% among HIV-negative MSM and 10.1% among HIV-positive MSM. Urethral gonorrhea positivity was 9.0% in MSM who were HIV-negative and 12.5% in HIV-positive MSM. Pharyngeal gonorrhea positivity was 5.5% in MSM who were HIV-negative and 6.6% in HIV-positive MSM; rectal gonorrhea positivity was 7.2% in MSM who were HIV-negative and 12.9% in HIV-positive MSM. Urethral chlamydia was 7.4% in MSM who were HIV-negative and 8.3% in HIV-positive MSM; rectal chlamydia positivity was 10.8% in MSM who were HIV-negative and 20.6% in HIV-positive MSM.
Nationally Notifiable Syphilis Surveillance Data
In 33 areas reporting sex of partner data, cases among women and among men having sex with women only (MSW) have declined since 2008, while cases among MSM have increased each consecutive year (Figure 37). Increases in primary and secondary syphilis among MSM have been increasing since 2000. 14,15 In 2011, MSM accounted for 72% of all P&S syphilis cases in 46 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 47). 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.4,16 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 29.7% in 2011 (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.
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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.
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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.
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13 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2008. Atlanta: U.S. Department of Health and Human Services; 2009.
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16 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.