STDs in Men Who Have Sex with Men

Public Health Impact

Compared to women and men who have sex with women only, MSM are at increased risk for STDs.^1–4 Because STDs and the behaviors associated with acquiring them increase the likelihood of acquiring and transmitting HIV infection,⁵ STDs among MSM may be associated with an increase in HIV diagnoses.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, 9} 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.¹⁰ 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.¹¹

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.¹² Data from enhanced surveillance projects are presented in this section to provide information on STDs in MSM.

STD Surveillance Network (SSuN)— Monitoring Trends in Prevalence of STDs Among MSM Who Visit STD Clinics, 2012

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.¹³ SSuN currently includes 12 collaborating local and state health departments. In 2012, 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.¹⁴ 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 2012, the proportion of MSM who tested positive for gonorrhea and chlamydia at STD clinics varied by SSuN site (Figure T). A larger proportion of MSM who visited SSuN STD clinics tested positive for gonorrhea than tested positive for chlamydia in all cities except Seattle, Birmingham, 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 (22,007) and chlamydia (21,767). The median site-specific gonorrhea prevalence was 16.4% (range by site: 9.84%–30.4%). The median site-specific chlamydia prevalence was 12.0% (range by site: 6.4%–22.2%). 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 2012, the proportion of MSM who presented to SSuN clinics with P&S syphilis infection who also were infected with HIV ranged from 18.5% in Los Angeles to 66.7% in Birmingham (Figure U). The median site-specific proportion co-infected with HIV was 44.8%. 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 V). The prevalence of P&S syphilis was 2.5% among HIV negative MSM and 9.8% among HIV-positive MSM. Urethral gonorrhea positivity was 10.1% in MSM who were HIV-negative and 15.0% in HIV-positive MSM. Pharyngeal gonorrhea positivity was 7.4% in MSM who were HIV-negative and 10.0% in HIV-positive MSM; rectal gonorrhea positivity was 8.9% in MSM who were HIV-negative and 16.4% in HIV-positive MSM. Urethral chlamydia was 7.1% in MSM who were HIV-negative and 7.6% in HIV-positive MSM; rectal chlamydia positivity was 11.4% in MSM who were HIV-negative and 22.2% in HIV-positive MSM.

Nationally Notifiable Syphilis Surveillance Data

Primary and secondary syphilis among MSM has been increasing at least since 2000. ^{3, 15} In 33 areas reporting sex of partner data for P&S syphilis cases among MSM increased 15% during 2011 – 2012, a larger increase in previous years. In 2012, MSM accounted for 75% of all P&S syphilis cases in 49 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 40). 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 N. gonorrhoeae strains in the United States.¹⁶ GISP has demonstrated that gonococcal isolates from MSM are more likely to exhibit antimicrobial resistance than isolates from MSW.⁴ Overall, the proportion of isolates from MSM in selected STD clinics from GISP sentinel sites has increased steadily, from 4.6% in 1990 to 33.1% in 2012 (Figure W). The reason for this increase is unclear, but might reflect changes in the epidemiology of gonorrhea or in health care seeking behavior of men infected with gonorrhea. The proportion of isolates from MSM varies geographically, with the largest proportion reported from the West Coast (Figure X).

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. Trends in HIV/AIDS diagnoses among men who have sex with men — 33 States, 2000– 2006. MMWR Morb Mortal Wkly Rep. 2008; 57:681–686.

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4 Kirkcaldy RD, Zaidi A, Hook EW 3rd, Holmes KK, Soge O, del Rio C, 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):321–8.

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10 Mays VM, Cochran SD, Zamudio A. HIV prevention research: are we meeting the needs of African American men who have sex with men? J Black Psychol. 2004;30:78.

11 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.

12 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 Rietmeijer K, Donnelly J, Bernstein K, Bissette J, Martins S, Pathela P, et al. Here comes the SSuN—early experiences with the STD Surveillance Network. Pub Health Rep. 2009;124(Suppl 2):72-77.

14 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: U.S. Department of Health and Human Services; 2012.

15 Heffelfinger JD, Swint EB, Berman SM, Weinstock HS. Trends in primary and secondary syphilis among men who have sex with men in the United States. Am J Public Health. 2007 Jun;97(6):1076-83.

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.