Sexually transmitted infections in men who have sex with men
Introduction
Homosexual male-male activity is as old as mankind and a part of life for many men throughout society. A large sex survey conducted by Kinsey et al. in 1970 indicated that a minimum of 20.3% of adult men in the United States in 1970 had sexual contact to orgasm with another man at some time in life; 6.7% had such contact after age 19; and between 1.6% and 2.0% within the previous year.1 In a more recent report, approximately half the men estimated to have homosexual contacts were currently or previously married.2 These estimates incorporated adjustments for missing data and the likelihood of underreporting; yet, they still might reflect lower bounds on the prevalence of same-gender sex among men.
Although the American Psychiatric Association removed homosexuality from its list of disorders more than 35 years ago, homophobia among physicians is widely prevalent.3 Many specialists dealing with sexually transmitted infection (STI) patients are not immune to these feelings of aversion, even if they have experience with the larger spectrum of human sexual behavior and desire.4 Even today, homosexuality is considered aberrant and a danger to society in many parts of the world. Anti-homosexual feelings, prosecution, and exclusion of homosexuals have led to undeserved suffering and threaten the health and well-being of many individuals, as well as society at large. Health care workers should do all they can to alleviate the vehemence and take a stand against homophobic attitudes and practices in society.
In the first part of this contribution, I shall address MSM as an epidemiological risk group for relatively newly occurring STIs like lymphogranuloma venereum (LGV), hepatitis C, and multidrug resistant N gonorrhea strains. The second part is dedicated to STI related proctitis and STI-related diseases found often in HIV positive MSM, such as anal carcinoma and neurosyphilis. The final part concludes with recommendations to reduce the STI burden in MSM.
Section snippets
The acronym MSM (men who have sex with men)
Being homosexual can have different meanings. First it can describe someone’s behavior; that is, a person engaging in sexual contacts with persons of the same sex.4 To assess the risk of having an STI, health care providers prefer to use the term “men who have sex with men” (MSM) over terms like homosexuals or bisexuals. Today, few physicians know the true meaning of these names. The same vocabulary men who have sex with women (MSW), and women who have sex with men (WSM) are used nowadays in
Classical and new risk groups for STI
STIs are associated with risk groups that engage in sex with multiple partners. From a historical perspective, sailors, soldiers, and sex workers (prostitutes) were individuals with a polygamous life style and were thus often exposed to STI. Even today, travelling abroad, either for labor or leisure, is associated with risky contact and can be seen in countries where work related migration is on the rise.7., 8.
Homosexual male-male activity as a strong risk factor for STI is a relatively modern
Criminalization of homosexuality
Although homosexuality is becoming more and more accepted in many countries of the world, in large parts of society it is still considered as deviant, unnatural, and to be discouraged.11 Although considered a crime already in medieval Western Europe, homosexuals were not persecuted systematically until the 19th century under the ruling of Victorian/puritanistic influences in society.,12., 13. It was then that engaging in homosexual acts became considered illegal and punished with jail
MSM and the HIV/AIDS epidemic
It was already apparent in the 1970’s and 1980’s that gonorrhea and syphilis were especially affecting the gay community.10 When the HIV/AIDS epidemic was heralded in the beginning of the 1980’s, a downturn in the syphilis and gonorrhea epidemic curves started. The first case reports of AIDS patients described homosexual men with a history of multiple STIs and engaging in promiscuous sex.20 This led to further condemnation of promiscuity among gay men, but when a few years later it proved that
Emerging STI in MSM
In 2004, dermatologists in Rotterdam, The Netherlands diagnosed an HIV positive MSM with anorectal LGV infection.28 Detailed contact tracing revealed a network of men, the vast majority HIV seropositive that engaged in unprotected sex with multiple men during sex parties through out Europe.29 Until that time, LGV was seen only sporadically as imported STI among patients who got infected in tropical regions where LGV was known as endemic infection.30 Soon after the first reports from Rotterdam,
Distinct STI networks across MSM populations
Phylogenetic techniques have helped to unravel the network of HCV strains that spread via sexual intercourse among HIV positive MSM. “Fingerprint” typing and subsequent cluster analysis has recently opened the possibility to unravel other STI transmission networks in more detail and increased the insight into transmission mechanisms in MSM.38 Through molecular fingerprinting it was found that the LGV epidemic that had gone unnoticed until 2004 must have circulated in MSM at least from the
Proctitis in MSM
Anal sexual intercourse is widely practiced among heterosexuals and especially in MSM.44 As a consequence, rectal infections should be routinely excluded when MSM are screened for STI. Even when a man does not practice receptive anal intercourse, N gonorrhoea can be transmitted easily to the anal canal via fingering.45
Proctitis is defined as an inflammatory syndrome of the distal 10 to 12 cm of the anal canal, also called the rectum. The clinical manifestations of proctitis include itching,
Anal carcinoma in HIV infected MSM
HIV-related morbidity and mortality have considerably decreased since the introduction of highly active antiretroviral therapy (HAART).53 As a result of the significantly prolonged life span of HIV-positive patients in the HAART era, new causes of morbidity and mortality have become evident. Non-AIDS defining malignancies like anal carcinoma are observed in excess in HIV-positive MSM. Between the early 1990s and 2004, the incidence of anal cancer in HIV-positive individuals has risen from 11 to
Neurosyphilis in HIV infected MSM
With the reoccurrence of syphilis in MSM from the mid-1990s on, there were several reports on a rising incidence of neurosyphilis, especially associated with HIV co-infection.66 In HIV-infected individuals: 1) syphilis antibody responses were less reliable; 2) progression to the next stage of syphilis, including neurosyphilis, occurred earlier despite adequate therapy.67., 68. These publications date from before or during the introduction of ART and they predominantly included patients with low
Recommendations to reduce the burden of STI among MSM
In the recent past, MSM have proven to be a vulnerable group for STI throughout the world. Prevention, treatment, and care programs dedicated to high risk MSM are required. In large parts of Africa, Eastern Europe, and the Islamic World repression of homosexuals is increasing.13., 15. As a result, access to good health care for MSM is a challenge. Sub-Saharan countries mostly affected by the HIV epidemic should initiate and adequately fund evidence-based and targeted prevention programs for MSM.
References (69)
Sexually transmitted infections and HIV among travellers: A review
Travel Med Infect Dis
(2006)- et al.
Successes and challenges of HIV prevention in men who have sex with men
Lancet
(2012) - et al.
Men who have sex with men: Stigma and discrimination
Lancet
(2012) - et al.
Common roots: A contextual review of HIV epidemics in black men who have sex with men across the African diaspora
Lancet
(2012) - et al.
Men who have sex with men and HIV/AIDS in sub-Saharan Africa
Lancet
(2009) - et al.
Kaposi's sarcoma in homosexual men—A report of eight cases
Lancet
(1981) - et al.
Evidence of a large, international network of HCV transmission in HIV-positive men who have sex with men
Gastroenterology
(2009) - et al.
Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: A systematic review and meta-analysis
Lancet Oncol
(2012) - et al.
Treatment of anal intraepithelial neoplasia in HIV + men: A randomised clinical trial comparing imiquimod, topical 5-Fluorouracil and electrocautery
Lancet Oncol
(2013) - Gebhard, PH. Incidence of overt homosexuality in the United States and Western Europe. In: Livingood JM, ed. National...
Prevalence and patterns of same-gender sexual contact among men
Science
Homophobia among doctors
BMJ
Homosexuality, Bisexuality and Sexual Orientation
Seeking and engaging in Internet sex: A survey of patients attending genitourinary medicine clinics in Plymouth and in London
Int J STD AIDS
The trouble with "MSM" and "WSW": Erasure of the sexual-minority person in public health discourse
Am J Public Health
Travel and sexually transmitted infections
J Travel Med
Sexually transmitted diseases and traumatic problems in homosexual men
Ann Intern Med
The gay bowel
Gut
Coming Out: Homosexual Politics in Britain from the Nineteenth Century to the Present
Issues of human rights and HIV
Guest commentary. AIDSlink
Homophobia as a barrier to comprehensive media coverage of the Ugandan anti-homosexual bill
J Homosex
HIV Prevalence, Risks for HIV Infection, and Human Rights among Men Who Have Sex with Men (MSM) in Malawi, Namibia, and Botswana
PLoS One
Uban Action Networks: HIV/AIDS and Community Organizing in New York City
Can syphilis be eradicated from the world?
Curr Opin Infect Dis
Sexually transmitted infections as a cause of proctitis in men who have sex with men
Dis Colon Rectum
Sexual risk behaviour, increases and is associated with HIV optimism among HIV-negative and HIV-positive gay men in Sydney over the 4 year period to February 2000
AIDS
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
Unusual presentation of early lymphogranuloma venereum in an HIV-1 infected patient: Effective treatment with 1 g azithromycin
Sex Transm Infect
Resurgence of lymphogranuloma venereum in Western Europe: An outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men
Clin Infect Dis
Lymphogranuloma Venereum
Manifestations and management of lymphogranuloma venereum
Curr Opin Infect Dis
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