STDs in Men Who Have Sex with Men

Public Health Impact

Gay, bisexual, and other men who have sex with men (collectively referred to as MSM) are at increased risk for STDs, including antimicrobial resistant gonorrhea, when compared to women and exclusively heterosexual men.^1–4 Because STDs, and the behaviors associated with acquiring them, increase the likelihood of acquiring and transmitting HIV infection, STD incidence among MSM may also be an indicator of higher risk for subsequent HIV infection.^{5, 6}

Individual-level risk behaviors, such as number of lifetime sex partners, rate of partner exchange and frequency of unprotected sex, may contribute to disparities observed in the sexual health of MSM. However, population-level factors such as limited or overlapping social and sexual networks are also associated with higher rates of STDs, including HIV among MSM.⁷

MSM of lower economic status may be particularly vulnerable to poor health outcomes, especially if they belong to racial and ethnic minority populations.^{8, 9} Among Black MSM, factors such as community isolation and limited social support may drive sexual risk taking. Similarly, for Hispanic MSM, 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 also 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 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.¹¹

Data from the STD Surveillance Network (SSuN), a sentinel and enhanced surveillance project established in 2005, are presented in this section to provide supplemental information on STDs in MSM. SSuN is an ongoing collaboration of state, county and city health departments collecting enhanced provider and patient based information among a random sample of reported gonorrhea cases, as well as clinical and behavioral information among all patients attending STD clinics in collaborating jurisdictions.¹² Additional information about SSuN can be found in Section A2.2 of Appendix A.

Incidence of Gonorrhea among MSM, STD Surveillance Network, 2010–2013

The proportion of all diagnosed and reported gonorrhea cases attributable to MSM was estimated based on patient interviews conducted among a random sample of cases reported to collaborating health departments between January 2010 and June 2013. Estimates of the size of the MSM population in each area were developed to calculate the incidence of gonorrhea among all MSM. The estimated incidence of gonorrhea among MSM in SSuN sites increased from 1,169.7 cases per 100,000 MSM in 2010 to 1,474.4 cases per 100,000 MSM in 2013.¹³ The estimated rate-ratio of MSM to female and MSM to heterosexual males during the study period ranged from 10.7 to 13.9 demonstrating a substantial and increasing inequality in the burden of disease between MSM and heterosexuals.¹³

Prevalence of STDs among MSM Who Visit STD Clinics, STD Surveillance Network, 2015

Data for 2015 were obtained from 30 STD clinics in ten SSuN jurisdictions. For data reported in this section, MSM were defined as men who either reported having one or more male sex partners or who self-reported as gay/homosexual or bisexual. Men who have sex with women (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.

Gonorrhea and Chlamydial Infection

In 2015, the proportion of MSM who tested positive for gonorrhea and chlamydia at STD clinics varied by SSuN jurisdiction (Figure W). Among jurisdictions providing sexual behavior data, a larger proportion of MSM who visited STD clinics tested positive for gonorrhea than tested positive for chlamydia (except Massachusetts, Multnomah County, and Philadelphia).

Across the participating STD clinics, 26,878 MSM were tested for gonorrhea and 26,694 MSM were tested for chlamydia. The median site-specific gonorrhea prevalence among those tested was 19.0% (range by site: 10.9%–22.7%). The median site-specific chlamydia prevalence among those tested was 16.0% (range by site: 11.8%–17.6%). For this report, a person who tested positive for gonorrhea or chlamydia at any anatomic site more than one time in a year was counted only once for each infection.

Primary and Secondary Syphilis and HIV

Among MSM who presented to participating STD clinics with primary and secondary (P&S) syphilis infection in 2015, the proportion who were also infected with HIV ranged from 20.9% in Los Angeles to 58.6% in Baltimore (Figure X). P&S syphilis was identified by provider diagnosis and HIV was identified by laboratory report, self-report, or provider diagnosis.

HIV Status and STDs

Among MSM visiting SSuN STD clinics, the burden of STDs was higher among HIV-positive MSM than among HIV-negative MSM (Figure Y). Among HIV positive MSM, 10.3% were diagnosed with P&S syphilis compared to 2.6% among HIV-negative MSM. Among HIV-positive MSM, urethral gonorrhea positivity was 11.3%, pharyngeal gonorrhea positivity was 9.2%, and rectal gonorrhea positivity was 17.1% (compared to 6.8%, 7.7%, and 7.3%, respectively, among HIV-negative MSM). Among HIV-positive MSM, urethral chlamydia positivity was 5.6% and rectal chlamydia positivity was 18.6% (compared to 6.4% and 8.1%, respectively, among HIV-negative MSM).

Nationally Notifiable Syphilis Surveillance Data

The number of reported cases of P&S syphilis among MSM has been increasing since at least 2000.^3,14 Thirty seven states were able to classify at least 70% of reported P&S syphilis cases as MSM, MSW, or women each year during 2011–2015. Among these states, cases among MSM increased 12.8% during 2014–2015, and 56.1% during 2011–2015 (Figure 31). Among all cases reported in 2015, MSM accounted for 81.7% of all male P&S syphilis cases with known information about sex of sex partners (Figure 40). In 31 states able to classify at least 70.0% of reported P&S syphilis cases as MSM, MSW, or women and at least 70.0% of reported cases as HIV-positive or HIV-negative, 49.8% of MSM with P&S syphilis were also reported to be HIV-positive (Figure 41). Among MSM P&S cases, the proportion attributed to White MSM was 37.8% while the proportion of cases attributable to Black MSM was 33.0%, and 23.4% for Hispanic MSM, demonstrating a significant inequality in the burden of disease for non-White MSM. Moreover, non-Whites comprise a large plurality of cases reported among MSW and women as well (Figure V). More information about syphilis can be found in the Syphilis section of the National Profile.

Gonococcal Isolate Surveillance Project

The 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.¹⁵ Overall, the proportion of isolates from MSM in selected STD clinics from GISP sentinel sites has increased steadily, from 3.9% in 1989 to 38.1% in 2015 (Figure Z). 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. GISP has demonstrated that gonococcal isolates from MSM are more likely to exhibit antimicrobial resistance than isolates from MSW.⁴ During 2007–2015, the prevalence of elevated ceftriaxone minimum inhibitory concentrations (MICs) (≥0.125 μg/ml) was higher in isolates from MSM than from MSW (Figure AA).

More information on GISP can be found in the Gonorrhea section of the National Profile.

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13 Stenger MR, Bauer H, Torrone E, et al. Denominators matter: trends in Neisseria gonorrhoeae incidence among gay, bisexual and other men who have sex with men (GBMSM) in the US – findings from the STD Surveillance Network (SSuN) 2010–2013, Sex Transm Infect 2015;91(Suppl 2) A178-A179 doi:10.1136/sextrans-2015-052270.464

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15 Schwarcz S, Zenilman J, Schnell D, et al. National surveillance of antimicrobial resistance in Neisseria gonorrhoeae. JAMA. 1990;264(11): 1413-7.

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