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Unequal OpportunityHealth Disparities Affecting Gay and Bisexual Men in the United States$

Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri

Print publication date: 2007

Print ISBN-13: 9780195301533

Published to Oxford Scholarship Online: September 2009

DOI: 10.1093/acprof:oso/9780195301533.001.0001

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Sexually Transmitted Infections among Gay and Bisexual Men

Sexually Transmitted Infections among Gay and Bisexual Men

Chapter:
(p.159) 6 Sexually Transmitted Infections among Gay and Bisexual Men
Source:
Unequal Opportunity
Author(s):

Ronald O. Valdiserri

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780195301533.003.0006

Abstract and Keywords

This chapter provides a overview of prevalent sexually transmitted diseases (STDs) among gay and bisexual men. Descriptive epidemiology is presented for bacterial (gonorrhea, syphilis, chlamydia), viral (human papillomavirus, herpes simplex virus, and human herpes virus 8), and enteric STDs. It discusses various factors responsible for disparate rates of STDs among MSM and identifies promising approaches for resolving disparities, including enhanced surveillance, improved and expanded testing and treatment services, and enhanced community-based responses to STDs among gay and bisexual men.

Keywords:   sexual health, STDs, sexually transmitted diseases, Gonorrhea, Syphilis, Chlamydia, Human papillomavirus, genital herpes, Human herpesvirus 8, Enteric STDs, health promotion

In 1997, when the Institute of Medicine issued its groundbreaking analysis of sexually transmitted diseases (STD) in the United States, The Hidden Epidemic, the report estimated that approximately $10 billion were spent annually in the United States on major STDs other than AIDS (acquired immunodeficiency syndrome).1 More recent estimates suggest annual direct medical costs for STDs, including human immunodeficiency virus (HIV), as high as $15.5 billion dollars.2 Notably, these estimates do not include indirect costs, such as lost productivity, lost wages, and out-of-pocket expenses—which would drive the economic cost even higher. Undeniably, STDs continue to represent a major threat to the health of many Americans.

As this chapter will document, STDs are an especially important health concern for gay and bisexual men. Compared to heterosexual men, gay and bisexual men in the United States are at disproportionate risk for many STDs, including HIV. Reasons for disparate STD rates are multiple and complex, and cannot be explained solely on the basis of differences in sexual practices or number of sexual partners. A variety of social, behavioral, and physiological factors also contribute to these disparities and will be described in subsequent sections of this chapter. Certainly, one cannot minimize the fact that within the already stigmatized domain of sexually transmitted diseases, the added burden of anti-gay prejudice and stigma3 engenders further barriers to effective STD prevention and control efforts.

The first part of this chapter will present information about the prevalence of various STDs among gay and bisexual men in the United States—compared to their heterosexual counterparts. With the exception of HIV and hepatitis A, B, and C, which are covered in separate chapters within this volume, descriptive epidemiology will be provided for all major sexually transmitted diseases. Next will follow an analysis of what is known about the genesis of these disparities—with an emphasis on promising approaches to resolving them. To conclude (p.160) the chapter, research questions that address major gaps in knowledge will be posed. For ease of communication, the term “men who have sex with men,” or MSM, will be used to describe men who engage in same sex activities—regardless of their sexual identification.

Prevalence of STDs among Men Who Have Sex with Men (MSM)

As will soon become apparent to the reader, there are many significant gaps in public health's ability to accurately describe the incidence and prevalence of STDs among MSM—particularly among various subgroups. A major reason for this significant information deficit is the fact that nationally notifiable surveillance data do not routinely include information on sexual practices—nor the gender of sexual partner. Therefore, much of the MSM-specific information that is available comes from clinic- or community-based samples, enhanced surveillance projects, and specific research studies.4 Some population-based studies are reported in the literature, but these are the exception rather than the rule.

Despite less than complete data, the preponderance of available evidence supports the finding that many STDs occur at disproportionately high rates among MSM. Further, after a period of substantial declines in STDs among MSM in the early 1980s—due to AIDS-related decreases in sexual risk behaviors—an increasing number of MSM now appear to be acquiring STDs.5–10

Bacterial STDs

As stated above, information on the incidence and prevalence of STDs in the United States is far from complete, and varies in quality, depending upon the source of the data.11 Even national health surveys, designed to provide nationally representative samples, include relatively small numbers of STDs in their samples—thus leading to wide confidence intervals in various subpopulations.11 Data limitations are especially pronounced when we consider incidence and prevalence estimates of STDs for the subset of MSM. Therefore, MSM-specific data are often derived from special studies or from samples of men attending clinics for the treatment of STDs. Of the three bacterial diseases reviewed in this section, there is substantial evidence for disparate rates of gonorrhea and syphilis among MSM (Table 6-1). In the case of chlamydia, specific serovars, or strains, appear to be disproportionately higher among MSM—although many cases of rectal chlamydia may remain undiagnosed in MSM (see Table 6-1).

Gonorrhea

Before the onset of widespread sexual behavior changes brought about in response to the AIDS epidemic, MSM in the United States typically had higher (p.161)

Table 6-1. Prevalence of selected bacterial STDs in men who have sex with men (MSM) vs. men who have sex with women (MSW), selected studies

STD

Setting

Year(s)

Prevalence (MSM vs MSW)

Reference

Gonorrhea

STD clinic

1977–1978

30.3% vs. 19.8% (p < .001)

16

Gonorrhea

STD clinic

1980

25% vs. 12% (p < .01)

17

Gonorrhea

STD clinic

1996–2001

12.9% vs. 6.9% (p < .0001)

8

Gonorrhea

STD clinic

1997

44.6% vs. 25.6% (p < .001)

28

Syphilis

STD clinic

1977–1978

1.08% vs. 0.34% (p < .001)

16

Syphilis

STD clinic

1981–1982

7.1% vs. 2.2% (p <. 001)

34

Syphilis

Early syphilis cases, San Francisco

2003

94.4% vs. 5.6%*

43

Chlamydia

STD clinic

1980

5% vs. 14% (p <. 01)

17

Chlamydia

STD clinic

1996–2001

6.7% vs. 12.7% (p <. 0001)

8

(*) Includes heterosexual female cases

rates of gonorrhea compared to the general population.12–14 Among some four thousand MSM surveyed in 1977, 39% reported a previous gonorrhea infection.15 Judson and colleagues compared MSM to heterosexual men visiting an STD clinic in Denver between July 1977 and December 1978 and found the prevalence of gonorrhea to be 30.3% (1601/5282) for MSM compared to 19.8% (2360/11,903) for heterosexual clients (p < 0.001).16 Similarly, among men presenting to a Seattle STD clinic in 1980 with new symptoms or for screening, 25% (40/161) of MSM had positive gonorrhea cultures, compared to 12% (53/435) of heterosexual men (p < 0.01).17

But in the years immediately following the onset of AIDS in the United States, several metropolitan areas, including New York,18 Denver,19 Seattle,20 Los Angeles,21 and San Francisco21 reported declines in gonorrhea rates among MSM. These declines were broadly attributed to increased publicity about the deadly epidemic, behavior changes in response to fear of AIDS, and community-based programs to encourage the adoption of safer behaviors among sexually active MSM.22–25 This trend began to reverse itself in the 1990s, when several US cities reported increases in gonorrhea rates among MSM6–8; furthermore, (p.162) reported gonorrhea increases among MSM were taking place in the face of continuing overall declines in gonorrhea in the United States.4

Results from a national sentinel surveillance system to monitor trends in antimicrobial resistance in Neisseria gonorrhoeae reported that, between the years of 1992 and 1999, MSM accounted for an “increasing proportion of gonococcal urethritis cases” collected annually from participating STD clinics in 29 US cities.26 Whereas in 1992, MSM accounted for 4.5% of annual cases collected through a protocol blinded to sexual orientation, that proportion had increased to 13.2% by 1999 (p < .001).26 Of note, because the Gonococcal Isolate Surveillance Project (GISP) includes only men with urethral gonorrhea, these figures likely underestimate the true scope of the increase in MSM—excluding, as they do, cases of pharyngeal and rectal gonorrhea.27

Reminiscent of disparities noted in the pre-AIDS era, most recent reports indicate rates of gonorrhea among STD clinic attendees that are higher for MSM compared to heterosexual men. Among men coming to the Denver Metro Health STD Clinic for services between 1996 and 2001, the gonorrhea positivity rate for MSM (from all anatomic sites) was 12.9%, compared to 6.9% among heterosexual men (p < .0001).8 Reviewing data from 1997 for men presenting to the San Francisco City Clinic with urethritis, the isolation of Neisseria gonorrhoeae in MSM was 44.6% (112/251) compared to an isolation rate of 25.6% (212/829) among heterosexual men (p < .001).28 In a separate analysis, reported by Katz and his colleagues, rates of male rectal gonorrhea in San Francisco increased from 72 per 100,000 in 1992 to 160 per 100,000 in 1996.29 Coincidental with increasing rates of rectal gonorrhea were increasing self-reports of unprotected (i.e., no condom used) anal sex and multiple male partners, collected from cross-sectional surveys of MSM in San Francisco.29 The increased incidence of male rectal gonorrhea described in San Francisco in the mid- to late 1990s was seen in all racial/ethnic and age groups but was reported to be highest among men aged 25–34 years.7

Several recent analyses have documented that among MSM diagnosed with gonorrhea, a disproportionate number are also infected with HIV.30–32 Data from eight US cities (Chicago, Denver, District of Columbia, Houston, Long Beach, Philadelphia, San Francisco, and Seattle), reporting on gonorrhea among MSM attending STD clinics in those cities in 2002, described the median gonorrhea positivity among MSM as 17.1% (clinic range 11.4% to 23.0%).30 Whether for urethral, rectal, or pharyngeal gonorrhea, positivity rates were higher for HIV-infected MSM (21%, 10.3%, and 7.7%, respectively) compared to MSM who were HIV negative or who did not know their serostatus (12.5%, 5.5%, and 3.9%, respectively).30

Syphilis

In the 1970s, MSM were overrepresented among persons diagnosed with infectious syphilis in the United States. One telling analysis reckoned that the (p.163) proportion of patients with infectious syphilis who named same-sex contacts, largely male, had risen from 25% in 1970 to nearly 49% in 1980.33 Two large studies comparing STD rates among clients attending STD clinics carried out in the late 1970s and the early 1980s, respectively, showed significantly higher rates of syphilis among MSM versus heterosexual men: 1.08% versus 0.34% (p < 0.001)16 and 7.1% versus 2.2% (p < 0.001).34 And in a survey of over four thousand MSM conducted in 1977, men with “four or more years of homosexual experience” reported past syphilis infections at rates ranging from 11% to 21.4% depending, respectively, on whether they lived in small cities or large metropolitan areas.15

Much like the trends observed for gonorrhea, rates of syphilis among MSM declined in the years following the onset of AIDS in the United States.35 Although the overall incidence of primary and secondary syphilis increased in the United States between 1981 and 1989, significant declines in the incidence of syphilis among white men—from 10 cases per 100,000 persons in 1982 to 3.2 cases per 100,000 in 1989—were largely attributed to fewer cases among MSM.36 This same report indicated that similar, albeit smaller, decreases may have occurred among black MSM.36

Following syphilis declines among MSM, reported during the 1980s and the early to mid-1990s, several US cities, including New York,9 , 37 Seattle,10 San Francisco,38 Los Angeles,38 , 39 and Chicago40 reported significant increases in the number and proportion of primary and secondary syphilis cases occurring among MSM. National trends corroborated this reversal. After a decade of overall national declines in primary and secondary syphilis beginning in 1990, the national rates of primary and secondary syphilis in the United States increased in 2001, 2002, 2003, and 2004.4 , 41 Further, overall increases in rates during 2000–2004 were observed only among men.4 A model developed to determine the proportion of all nationally reported cases of primary and secondary syphilis occurring among MSM estimated that the proportion had increased from 5% in 1999 to 47% in 2002.42 The model revealed that the increases were “most dramatic” among white MSM—but also “large” among Hispanic and African American MSM.42 In San Francisco, of 522 cases of early syphilis reported in 2003, 97% of all reported cases were male, 94% of all reported cases were among MSM, and only 6% were among heterosexual men and women.43

Epidemiologic investigations into syphilis outbreaks among MSM have revealed several associated factors. Among the most prominent is the emerging use of the Internet as a “virtual venue” for sexually active MSM to meet male sex partners. Of the 434 cases of early syphilis among MSM reported to the San Francisco Department of Public Health in 2002, 33% of the men reported meeting sex partners on the Internet44; similar findings have been reported from outbreak investigations in Los Angeles.45 , 46 Among MSM diagnosed with syphilis in California between 2001 and 2003, those who reported meeting partners through the Internet had higher numbers of partners and greater (p.164) numbers of nonlocatable partners, compared to those who had not used the Internet.47

Increases in illegal methamphetamine use, reported in the western United States in the 1990s,48 have been associated with high risk sexual behavior among MSM49 and, in some analyses, higher rates of STDs—including syphilis.50 A nested case-control study of some twenty-six hundred MSM, using data collected online in 2001, showed that men with an incident STD were twice as likely to report methamphetamine use.51

Another significant observation is that MSM with primary and secondary syphilis are more likely to be infected with HIV. Investigation of a syphilis outbreak among MSM in southern California in 2000 revealed that, of the men who knew their HIV serostatus, 60% were positive.52 A chart review of MSM receiving syphilis testing at a New York City STD clinic in 2002 found that syphilis seropositivity was nearly five times higher among men infected with HIV compared to men who were not.53 Another New York City study compared 88 MSM with syphilis to 176 controls, finding that HIV prevalence among those with syphilis was 48% compared to 15% among the controls (p <.001).54 Epidemiologists, estimating the rate of primary and secondary syphilis in persons living with HIV in the United States in 2002, concluded that the rate of primary and secondary syphilis in persons with HIV is considerably higher than the rate among the general population—with extraordinarily high estimated syphilis rates among HIV positive MSM: 336 cases per 100,000, compared to a general population rate of 2.4 cases per 100,000.55

Chlamydia

Chlamydia trachomatis is the most commonly reported notifiable disease in the United States.56 Generally, rates for genital chlamydia infection in women are higher than rates among men,4 but chlamydia trends among MSM have not been well described. A handful of clinic-based surveys conducted prior to the onset of the AIDS epidemic showed that MSM with urethritis were usually less likely to have urethral chlamydia infection, compared to heterosexual men with urethritis.17 , 57

In the late 1990s, some STD clinics began to report increases in rates of laboratory-confirmed chlamydia infections among MSM.10 , 58 For example, Geisler and colleagues reported that anorectal chlamydia infection increased from 4% (1994–1996) to 7.6% (1997–1999) among MSM attending an STD clinic in Seattle (p < .005).58

A survey of 4860 MSM who presented to San Francisco's Municipal STD Clinic in 2002 found that, overall, 5.3% had urethral chlamydia and 9.2% had rectal chlamydia.59 And surveillance data collected in 2003 from MSM visiting STD clinics in health departments and in community-based organizations in ten U.S. cities (Boston, Chicago, Denver, Houston, Long Beach, New York City, Philadelphia, San Francisco, Seattle, and Washington, DC) revealed substantial (p.165) rates of chlamydia infection.4 A median of 82% of men visiting participating clinics were tested, and the median urethral chlamydial positivity was 6% (range: 5% to 8%).4

Although the evidence is not extensive, rates of chlaymdia urethritis generally appear to be higher among heterosexual men attending STD clinics compared to MSM in those same settings8 , 17 (see Table 6-1). Non-STD-clinic based samples of men also support the finding that chlamydia urethritis is more common among heterosexual men compared to MSM.60–62 But this does not mean that chlamydia is an insubstantial problem for MSM. Of some 3,400 San Francisco MSM tested for pharyngeal, urethral, and rectal chlamydia in 2003, most of the infections were detected in the rectum (8%), followed by the urethra (4%) and the pharynx (1%).63 Furthermore, nearly 85% of rectal chalymdia infections were asymptomatic. This clinical fact, along with the knowledge that, at the time of this writing, culture (which is expensive and cumbersome) is the only approved FDA chlaymdia test for rectal specimens—suggests that many cases of rectal chlamydia infection among MSM remain undiagnosed.63

Where one does observe significant chlamydia disparities between heterosexual and homosexual men is with reported cases of lymphogranuloma venereum (LGV). LGV is a systemic, sexually transmitted disease caused by one of three specific serovars, or strains, of Chlamydia trachomatis: L1, L2, and L3.64 LGV occurs rarely in North America and Europe, though it is endemic in some parts of the world, including West Africa, India, and parts of Southeast Asia.64 It should be noted that non-LGV strains of chlamydia can produce proctitis,58 but these cases are generally less severe than the intense inflammatory proctitis seen with LGV-specific strains of chlaymdia.65

In late 2004 and early 2005, health departments in San Francisco,66 New York City,67 Boston,68 and Atlanta69 issued health alerts/advisories warning of documented cases of LGV among sexually active MSM—several of whom were infected with HIV. These LGV outbreaks, still under investigation at the time of this writing, follow recent reports of outbreaks of LGV in MSM from the Netherlands, Belgium, France, and Sweden.70 In 2004, 27 cases of LGV were reported to the US Centers for Disease Control and Prevention.4

Viral STDs

This section will address human papillomavirus (HPV), genital herpes simplex virus (HSV), and human herpesvirus 8 (HHV-8); HIV and hepatitis A, B, and C viruses will be addressed separately, in subsequent chapters. While numerous studies have documented the disproportionate impact of HIV on MSM, it would be a mistake to ignore or minimize the health impact of other sexually transmitted viral pathogens (see Table 6-2). Among all men in the United States, both homosexual and heterosexual, viral diseases (including HIV) account for the majority of sexual behavior–attributed health burden.71 (p.166) And two of the pathogens discussed in this section, HPV and HHV-8, are associated with the development of malignancies in MSM—especially men whose immune systems are compromised.

Human Papillomavirus (HPV)

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States72—with an estimated three-quarters of reproductive-aged persons having been infected with genital HPV.11 A small percentage of infected men and women will develop anogenital warts as a consequence of HPV infection,73 but the far more serious consequence is the development of anogenital cancers among a subset of persons infected with oncogenic HPV types,74 especially type 16.72 Although a vaccine against HPV (effective against the two HPV strains that account for most uterine cervical cancer and the two strains that cause almost all genital warts) was licensed in June 2006, at the time of this writing, it is only recommended for females.75

Because of inadequate patient education efforts and incomplete media coverage, many sexually active US women do not fully understand the link between HPV and uterine cervical cancer.76 Perhaps even more poorly understood, or recognized, is the link between HPV and anal cancer—especially among MSM. Higher rates of anal cancer among “never married” men have long suggested an epidemiological association between HPV and male-to-male sexual behavior77–79—especially the strong association of anal cancer with the specific sexual practice of receptive anal intercourse.80 While, overall, rates of

Table 6-2. Prevalence of selected viral STDs in men who have sex with men (MSM) versus men who have sex with women (MSW), selected studies

STD

Setting

Year(s)

Prevalence (MSM vs. MSW)

Reference

HPV-16

Population-based survey

1991–1994

37.7% vs. 8.1% (p <. 05)

72

HSV-2

Community-based survey

1988–1989

40% vs. 20%

96

HSV-2

HIV test site

1997–2000

24.1% vs. 13%

97

HSV-2

Population-based survey

1999–2002

23.9% vs. 12.8%

*

HHV-8

Population-based sample

1984–1985

37.6% vs. 0% (p <. 001)

111

HHV-8

Cross-sectional survey

1997–1998

6% vs. 5%

116

(*) unpublished data, Dr. Gerry McQuillan, NCHS, CDC

(p.167) anal cancer are higher among US women than men,79 when one considers sexual orientation, MSM have annual incidence rates of anal cancer approaching 35/100,000—“which approximates the incidence of cervical cancer in women before the advent of routine cervical pap smear screening.”81

HPV is not a reportable disease in the United States, and estimates of prevalence and incidence are complicated by the fact that the majority of persons who are infected with the virus have neither clinical signs nor symptoms.73 Fortunately, important information on the seroprevalence of HPV-16, perhaps the most common oncogenic viral type associated with anal cancer,82 is available from a population-based survey of American adolescents and adults.72 Examining sera from a nationally representative sample of the US population, collected between 1991 and 1994, Stone and colleagues demonstrated extremely high rates of HPV-16 seropositivity for MSM.72 Overall, HPV-16 seroprevalence was higher among women (17.9%) than men (7.9%). Men who reported never having sex with another man had an HPV-16 seroprevalence of 8.1% compared to a 37.7% seroprevalence among men who reported ever having sex with another man; controlling for other factors, including race and age, MSM were over six times as likely to be infected with HPV-16 compared to heterosexual men.72

A 2001–2002 study of 1218 HIV-negative MSM from four American cities (Boston, Denver, New York, San Francisco) found that 57% of the participants had anal HPV infection and that 26% were infected with a viral type associated with the development of cancer.83 HPV infection was independently associated with a history of receptive anal intercourse and more than five sex partners during the preceding six months.83 Other studies have documented a strong association between HIV and HPV84–86—which may be due, in part, to reactivation of previous HPV infection.87 Reactivation of previous HPV infection secondary to HIV is suggested by a study of over eighteen hundred HIV-positive women, which showed that “a substantial fraction of incident HPV detection … is not related to recent sexual activity.”88

Given that HIV infection can influence the progression of HPV infection, it is not surprising that HIV-infected persons, including HIV-infected MSM, are at increased risk for anogenital HPV-associated cancers.89 , 90 Data from 11 state and metropolitan AIDS and cancer registries were linked between 1995 and 1998, showing that for men who contracted HIV through homosexual contact, anal cancer occurred in “extreme excess,” with a relative risk of 99.8 for in-situ cancer and 59.5 for invasive anal cancer.89 An analysis of anal cancer trends in California between 1973 and 1999 showed a near doubling of incidence, between 1988 and 1999, among men who lived in San Francisco County.90 Although information on sexual orientation was not available, the researchers noted that a high proportion of men from San Francisco with anal cancer were single and never married—suggesting that the men were likely homosexual. The researchers opined that “HIV-related immunosuppression may have accelerated the development of anal cancer and that longer survival of HIV positive men may have allowed cancers with a longer latency to develop.”90

(p.168) Herpes Simplex Virus (HSV)

Genital herpes, caused by herpes simplex virus type 2 (HSV-2) and, less frequently, by HSV-1,91 is one of the three most prevalent STDs in the U.S.11 , 92 Population-based surveys estimate that nearly one in five Americans older than age 12 have been infected with HSV-2,93 with women exhibiting higher rates of infection compared to men.94 Not surprisingly, higher rates of HSV-2 seroprevalence have been found in persons attending STD clinics. A sample of 4128 heterosexual men and women recruited in the mid-1990s from five inner-city US STD clinics found an overall HSV-2 seroprevalence of 40.8%; seroprevalence was higher in women (52.0%) than men (32.4%) and in blacks (48.1%) compared to non-blacks (29.6%).95

Seroprevalence surveys of HSV-2 infection among MSM show rates ranging from 26% in a cohort of 578 HIV negative Seattle men62 to 40% in a cross-sectional community-based survey conducted in three San Francisco neighborhoods.96 In the latter study, 20% of heterosexual men were positive for HSV-2, compared to 40% of MSM.96 Among 987 persons seeking anonymous HIV testing in San Francisco, two or more times between 1997 and 2000, 23.5% were seropositive for HSV-2 antibodies; by sexual orientation: 13% of heterosexual men were positive for HSV-2 compared to 24.1% of MSM and 28.7% of women.97 An age-adjusted analysis of the National Health and Nutrition Examination Survey (NHANES), a population-based survey conducted during 1999–2002, revealed an HSV-2 prevalence of 23.9% for MSM compared to 12.8% for heterosexual men (unpublished data, Dr. G. McQuillan).

Rates of HSV-2 infection are even higher among MSM who are infected with HIV. Among 109 MSM recruited from a Seattle AIDS project in the mid-1980s, HSV-2 antibodies were found among 73% of 49 men with HIV infection, compared to 32% of 60 men who were HIV seronegative (p < .0001).98 A large case-control study conducted prospectively among MSM in six U.S. cities (Boston, Chicago, Denver, New York, San Francisco, Seattle) during the 1990s demonstrated that previous HSV-2 infection was associated with a nearly twofold increased likelihood of HIV acquisition—independent of other risk factors.99 Also, it has been shown that acute infection with HSV, as well as a recurrent outbreak, can increase retroviral load among those infected with HIV.100

Human Herpesvirus 8 (HHV-8)

Human herpesvirus 8, also known as the Kaposi's sarcoma-associated herpesvirus, was first identified in 1994, when unique viral DNA fragments were isolated from Kaposi's sarcoma (KS) tissues obtained from AIDS patients.101 But even prior to the identification of HHV-8, a sexually transmitted factor, other than HIV, was long suspected in the etiology of Kaposi's sarcoma—because of the disproportionate occurrence of the malignancy among MSM with AIDS, compared to persons who acquired HIV through nonsexual routes.102–104 Subsequent research strengthened the supposition of a causative (p.169) role of HHV-8 in the development of KS. British researchers demonstrated that the detection of HHV-8 in peripheral blood cells of HIV-infected persons, without KS, predicted the subsequent development of KS lesions.105 A retrospective analysis of stored sera from 40 HIV-infected MSM who eventually developed KS showed that most (80%) developed antibodies to HHV-8 before the clinical development of KS.106

While the study of HHV-8 is far from complete, current evidence suggests that infection is uncommon among the general US population. Overall, it is estimated that approximately 3% of US blood donors are seropositive for HHV-8.107 In addition to the strong association of HHV-8 infection among persons with KS,105 , 106 , 108 , 109 relatively high rates of HHV-8 infection have been found among women with multiple sex partners,110 injection drug users,104 , 110 and MSM.111–115 Among US MSM, studies have shown prevalences of HHV-8 infection ranging from 20% to 48%, with the highest rates being observed among men who are also infected with HIV.111–113 , 115 However, a 1997–1998 serosurvey of young MSM, aged 15 to 22 years, revealed a much lower rate of HHV-8 seroprevalence—6%—comparable to rates observed among similarly aged young heterosexual men, recruited in the same venues.116 The authors suggested that past estimates of HHV-8 seroprevalence among MSM may have been higher because of a number of factors, including differences in laboratory methods and declining rates of HHV-8 infection among MSM—after a peak in the 1980s.116

Although the precise mode ofHHV-8 transmission is unknown, the fact that HHV-8 seroprevalence is higher among MSM with increased numbers of male sex partners111 , 112 and evidence of past STDs,113 , 117 strongly suggests a sexual mode of transmission. However, other potential modes of transmission, including exposure to infectious saliva, have been suggested.118 What is known is that MSM who are dually infected with HIV and HHV-8 are at high risk of developing Kaposi's sarcoma104 , 113—although widespread use of highly active antiretroviral therapy in the United States has been associated with significant declines in the incidence of KS among HIV-infected MSM.119

Enteric STDs

A wide variety of pathogens can be sexually transmitted among MSM as a result of oral-anal sexual activity or fecal contamination in the context of oral-genital sex (i.e., indirect oral-anal contact). Thus, infections typically associated with fecally contaminated food or water, such as shigellosis,120–122 typhoid fever,123 giardiasis,124–125 and amebiasis,126–127 can be sexually transmitted among MSM. Hepatitis A, another important enterically transmitted pathogen, will be discussed in Chapter 7.

For most sexually transmitted enteric infections among MSM, detailed prevalence and incidence data are not available. However, a number of studies conducted in the late 1970s and early 1980s documented high rates of infection with various enteric pathogens among MSM. Stool specimens from a (p.170) convenience sample of 89 sexually active MSM attending an STD treatment facility in New York City in 1977 revealed that 26% harbored pathogenic protozoa.128 A subsequent study of 180 consecutive male and female patients at an STD clinic in New York City, carried out between 1978 and 1979, showed that exclusively homosexual men had a prevalence of Giardia lamblia and/or Entamoeba histolytica of 21.5%, compared to 6.2% in bisexual men; none of the heterosexual men or women in this study were infected with these pathogens.129 In the early 1980s, a survey of MSM with intestinal symptoms130 and another one studying MSM recruited from a medical practice setting131 revealed even higher rates of infection with enteric pathogens.

More recent reports suggest that sexually transmitted Shigella infection remains a health problem for at least some populations of MSM. An analysis of 228 culture-confirmed cases of shigellosis in San Francisco during 1996, by HIV status and sexual orientation, showed substantially elevated incidence rates for persons who were infected with HIV—especially gay men.132 Annual incidence rates, per 100,000 population, were determined to be 12.4 for HIV-negative heterosexuals (men and women); 60.1 for HIV-negative gay men; 378 for HIV-positive heterosexuals; and 442 for HIV-positive gay men.132

In 2000–2001, public health officials in San Francisco reported an outbreak of Shigella sonnei infection, largely among men.122 Upon further investigation, it was determined that 61% of men with positive cultures were homosexual; 8% were heterosexual; and sexual behavior was unknown for 31%.122 Consistent with the previous study, about half of the men were also infected with HIV.122 Outbreaks of S. sonnei were also reported among MSM from Massachusetts and New York City, during that same time period (i.e., 2000–2001).133

Understanding Disparate Rates of STDs among MSM

Because of the manner in which they are contracted, that is, through intimate sexual relations, STDs continue to carry substantial stigma.1 This stigma may be further amplified by strong negative attitudes about homosexuality and homosexual practices,3 thus interfering with an objective assessment of the various factors that result in disparate rates of STDs observed among some populations of MSM. For example, while increased numbers of partners is a major variable influencing STD risk, and some MSM report large numbers of sexual partners,12 , 15 , 16 settling on indiscriminant sexual behavior as the sole reason for increased STDs among MSM is overly simplistic and ignores the influence of other individual and societal determinants of sexual behavior. In order to identify effective strategies to reduce STD disparities among MSM, it is critical that we consider, in detail, the panoply of factors, including increased partner number, that contribute to disparate rates of infection. The following discussion will briefly review these variables; readers should note that several are covered, in depth, in other chapters in this volume.

(p.171) Physiological Factors

Compared to the female sex organs, the penis is highly “effective” at inoculating pathogens during the process of ejaculation, and this physiological reality has been cited as one reason for increased rates of STD transmission amongmenwho have sex with other men.134 Also, as noted by Daniel William—an American pioneer in the diagnosis and treatment of STDs among gay and bisexual men—“the functional overlap between the human genital and excretory systems poses a further disease hazard to gay men in regard to an important part of their sexual activity.”135 Unlike the vagina, which is lined by a thick layer of stratified squamous epithelium, the more delicate columnar epithelium of the rectum proves a far less formidable physical barrier to pathogenic microorganisms it might encounter during the act of anal intercourse.

MSM Sexual Behaviors and STD Disparities

Accurate descriptions of sexual behaviors among US MSM are limited, in part, by incomplete estimates of the size of this population. Earlier studies, which did not rely on representative samples, estimated that as many as 8% of US men may be exclusively homosexual.136 However, more recent estimates suggest that same gender sexual contact among US men ranges from 2% to 5%, depending upon the time frame studied and the behavioral definitions employed.136–140

Studies conducted in the 1970s, prior to the onset of the AIDS epidemic and in the first decade of the US “gay liberation” movement, indicated that homosexual men “were more likely than heterosexual men to have had a very large number of sexual partners.”136 Although these early studies were often based on convenience samples,141 more recent analyses, with better sampling strategies, continue to document some differences in partner number when comparing homosexual to heterosexual men. For example, a 1997 national survey of over 13,000 US college students found that, compared to heterosexual males, men with same sex partners were significantly more likely to report two or more sexual partners in the 30 days prior to survey.139 For college men with only female partners, 8.6% reported two or more recent partners, compared to 15.9% of bisexual men reporting two or more partners and 20.4% of exclusively homosexual men reporting two or more partners (p < 0.001).139

While it is plausible to surmise that negative societal reactions to homosexual attraction, as witnessed by the widespread absence of legal recognition of same sex partnerships, contribute to multiple sexual partnerships and thus elevated rates of STDs among MSM,142 , 143 a more fundamental reason may lie in the fecund domains of sex and gender. The International Sexuality Description Project, a cross-cultural survey of some 16,000 people across ten major world regions, has demonstrated that “sex differences in the desire for sexual variety are culturally universal.”144 This international collaboration documented that men, regardless of sexual orientation or culture, consistently desired larger numbers of sexual partners than women.144 Further, compared (p.172) to women, men required less time to elapse before consenting to sexual intercourse with a new partner and were more likely to seek short-term “mateships” than women.144 Therefore, even in the circumstance of a neutral societal reaction to same sex attraction, one might predict that two men would be more likely to have larger partner numbers, on average, than a male-female pair bond—and thus be more likely to become exposed to sexual pathogens.

Sexual Networks and STD Disparities

Of course, we do not live in a society that is neutral on the issue of homosexuality.145 Undoubtedly, stigma plays a role in the expression of sexual behaviors among MSM. Perhaps the most distinctive manifestation of stigma's impact on MSM sexual behavior is seen in the phenomenon of “public sex environments” (PSEs). PSEs are typically public (e.g., public toilets, parks, etc.) and sometimes commercial (e.g., adult bookstores, bathhouses) venues where men can meet other men for furtive, often anonymous, sex.146 , 147 According to gay historian Allan Berube, legal sanctions against homosexuality forced MSM to become “sexual outlaws” who developed special expertise in “stealing moments of privacy and at finding the cracks in society where they could meet and not get caught.”148 In Berube's analysis, PSEs fulfill an important social function for some MSM.

Some of the men who meet male partners in PSEs, including bathhouses, do not identify themselves as gay—and a substantial percentage report having female partners.149 Given the mix of anonymity, risky sexual behavior, and multiple partners, it is not surprising that meeting sexual partners in PSEs is associated with an increased risk for acquiring or transmitting STDs.150 , 151 Thus, another contributor to the disparate risk of STDs for some MSM relates to the fact that they meet their partners in venues where high-risk sexual activities take place and/or partners who are at high risk for transmitting STDs are likely to be encountered.152

The Internet is an interesting, evolving example of a “sexual risk” venue for some MSM. As mentioned earlier, meeting partners online has been associated with outbreaks of syphilis among MSM.44–47 , 153 While it is unclear how much the Internet may actually increase or potentiate unsafe sexual behavior, it is clear that some MSM are using the Internet to seek sexual partners with whom to engage in high risk sexual activities.154–156 As such, from a sexual network perspective, the Internet can be considered as an effective mechanism through which “core transmitters” of STDs (in this instance, MSM at high risk of transmitting STDs) can rapidly acquire new, susceptible partners.

Sexual network characteristics are considered increasingly germane to understanding the spread of STDs and, by extension, conceptualizing interventions to prevent or interrupt the spread of infection. An early study of HIV transmission among MSM in Iceland suggested that sexual contact in the community was disassortative (i.e., sexual contact occurring between men of disparate sexual activity levels), with the prediction of an extensive spread of HIV (p.173) throughout the MSM community.157 Laumann and Youm hypothesized that highly disassortative partner choice with regard to risk (i.e., the pairing of high risk with low risk partners), along with more racially segregated partnering (i.e., African Americans are more likely to choose other African American sexual partners), results in “substantially higher” STD rates for African Americans, compared to other racial/ethnic groups in the United States.158 Similar dynamics have been invoked to explain the high rates of HIV observed in African American MSM: specifically, the pairing of younger MSM, at lower risk for infection, with older MSM—who are more likely to have been previously exposed to HIV.159–160

As observed by Wohlfeiler and Potterat, “MSM have created efficient ways of finding sexual partners,”161 including the Internet and “traditional” public sex environments like bathhouses and adult bookstores. While further study is needed to better understand them, mounting evidence suggests that sexual networks are a potent variable influencing disparate risk for STD acquisition and transmission among MSM.152 , 161

Developmental and Psychological Factors

In general, US adolescents and young adults are at high risk for acquiring STDs4; this observation may be especially true for young MSM. Although data are patchy, studies suggest that young MSM initiate same sex sexual contact earlier than their heterosexual counterparts.136 , 162 , 163 If young MSM seek older, more sexually experienced partners, who have higher levels of risky behavior and are more likely to be infected with STDs, youths’ risk of STD exposure will increase. In fact, this may often be the case. A community-based sample of 156 gay, lesbian, and bisexual youth recruited in the early 1990s in New York City revealed that, for male youths, “their first male partners were, on average, approximately six years older than they were.”163

Sexual relations between younger and older MSMare not just imbalanced in terms of disparate risk of past STD exposure. They may also be imbalanced in terms of younger men's ability to adopt—or insist upon—protective behaviors that could reduce their risk of acquiring an STD, should they be exposed to a pathogen. Compared to older MSM, young MSM have less experience discussing, negotiating, or planning for safer sex. Also, some young MSM, coming to terms with their sexuality, may bear the additional burden of lower selfesteem and internalized homophobia.136 , 164 , 165 Although the published literature does not report a consistent relationship between gay identity and sexual risk (i.e., both increases and decreases in safer sex have been reported),166 it is not unreasonable to assume that some younger MSM may have difficulty accepting their sexual orientation—which could lead to less willingness to insist upon safer sexual practices.167

Finally, as has been extensively covered in Chapter 3 in this volume, a history of childhood sexual abuse among MSM is associated with high risk sexual behaviors—often mediated through the use of alcohol and other drugs.168 , 169

(p.174) Contribution of Alcohol and Drug Use to Disparate STD Rates

At the time of this writing, crystal methamphetamine use has garnered widespread attention as a serious public health problem, especially—though not exclusively—among MSM.170–173 Particularly pronounced has been the association between “crystal meth” use and syphilis outbreaks among MSM—especially on the West Coast of the United States.50–52 , 174 Use of the erectile dysfunction drug sildenafil has also been associated with syphilis outbreaks among MSM.174

Recent increased attention to crystal methamphetamine use among MSM is understandable, but readers should realize that this is not the only substance of concern. Alcohol and drug use are common among US MSM (see Chapter 5). A venue-based study of nearly 3500 young MSM, conducted between 1994 and 1998 in seven US urban areas (Baltimore, Dallas, Los Angeles, Miami, New York, San Francisco, Seattle), revealed that 88% reported alcohol use in the past six months and two-thirds reported using illegal drugs in the past six months.175 In 2001, an online survey of 2916 MSM revealed that 45% of the overall sample reported any illicit drug use, and about half reported drinking alcohol before or during sex.176

Recreational alcohol and drug use has been clearly shown to be associated with increased sexual risk176–182 and thus mediates, in part, disparate rates of STDs among MSM. What is less clearly appreciated is the role that substance use may play in the sexual lives of some MSM, especially in terms of decreasing anxiety and blunting awareness of the omnipresent association between highly pleasurable sexual acts and stigma—including the persistent associations between gay sexuality and disease.183 , 184

Promising Approaches to Resolving Disparate Rates of STDs among MSM

Given the multiplicity of factors influencing the disparate rates of STDs among MSM, it is highly unlikely that a single approach will effectively resolve these disparities. However, a comprehensive approach that encompasses improved surveillance, increased diagnostic and treatment capabilities, strengthened prevention efforts, and a vigorous community response could help to substantially narrow STD disparities. This section will highlight interventions and approaches that show promise, and will identify areas where additional study, or investment, is needed to further reduce disparities.

Enhanced Surveillance

Surveillance is the foundation of effective public health action. Because national notifiable STD surveillance data reported to the US Centers for Disease Control and Prevention (CDC) have not historically included information on (p.175) gender of sexual partners, national trend data on MSM are not available. Recommendations from the recent past have noted this deficiency,5 and advocacy groups have called for the inclusion of “sexual orientation and gender identity measures” in the STD surveillance data reported to CDC by state and local health departments.185

Although, at the time of this writing, our nation still lacks complete STD surveillance data on MSM, important progress has been made in closing this information gap. Most notably, in March 2005, CDC requested that health department STD program directors confidentially provide information on the gender of sex partners for each reported STD case.186 Although these data are not yet available for analysis, this action represents an important step forward in being able to monitor national STD trends among MSM.

Another effort that will provide much-needed information is the CDC's implementation, in 2002, of a national behavioral surveillance system to monitor high risk sexual behaviors among MSM. Men, aged 18 years and older, are systematically sampled from randomly selected venues where MSM congregate, including bars, clubs, and other community venues, in seventeen U.S. cities.187 Using ethnographic techniques, venues are first observed to develop sampling time frames that allow for optimal MSM recruitment.188 Results from this system have been used to direct HIV prevention services to high risk sexually active MSM, and will likely inform future STD prevention efforts, as well.

Significant improvements notwithstanding, it is important to recognize that lack of adequate information about STD trends among MSM is a serious impediment to timely and targeted public health responses at both a community and a national level.189 Equally important is the need for surveillance information to inform public health actions targeted to racial/ethnic subpopulations of MSM. Nor should we limit ourselves to surveillance information from traditional sources such as STD clinics and doctors’ offices. Community and institutional venues, like correctional facilities, are important potential sources of useful information about STD prevalence and incidence among MSM.190

Improved and Expanded Testing and Treatment Services

A number of innovative approaches have been described for improving and expanding STD testing and treatment services for MSM. These can be broadly divided into services that are based in health care facilities and those found in community-based settings. Although advances in diagnostic testing, STD therapies, and preventive vaccines will also contribute to improved efforts to prevent and treat STDs in MSM, their enumeration is beyond the scope of this chapter and will not be covered in this section.

Health Care Facility–Based STD Services

In the mid-1990s, only about one-quarter of US adults reported being asked about STDs during routine medical checkups, representing many missed (p.176) opportunities for STD prevention.191 A survey of 48 ambulatory clinics (mostly STD clinics) in 29 US states conducted in 2000–2003 showed that, even in clinics devoted primarily to STD care, “fewer than one in five clinics asked questions designed to elicit risk histories from MSM specifically.”192 Failure to take an accurate sexual history may be especially problematic when considering younger MSM who may be loath to spontaneously discuss same-sex behaviors with health care providers.193

Improved sexual history taking will result in more complete and accurate clinical assessments—including improved screening for STDs—for both heterosexuals and homosexuals. Given societal attitudes about homosexuality, clinicians should keep in mind that a straightforward, nonjudgmental approach to sexual history taking among MSM clients is especially important.194 STD treatment guidelines issued by the CDC in 2006 call for routine inquiry about the sex of patients’ partners and, for sexually active MSM, at least annual screening for HIV, gonorrhea, chlamydia and syphilis.195

One way to encourage the clinical adoption of routine sexual history taking is to employ written or electronic protocols. A survey of 48 HIV primary care clinics in Los Angeles revealed that clinics with written or electronic STD screening protocols were “significantly more likely to report questioning patients at each visit regarding their sexual practices.”196 Although not specific to MSM populations, another encouraging approach to improving STD screening practices employs the Internet to provide continuing medical education modules to practicing physicians who might not otherwise have the time to receive this updated clinical information.197 Finally, during specific outbreaks of STDs among MSM, health departments have found that direct communication with medical providers, via email, FAX, regular mail, and other communication strategies, can successfully alert providers to the need for increasing screening rates among their gay and bisexual patients.198

In response to syphilis outbreaks among MSM, several US metropolitan public health departments have supplemented traditional “partner notification” efforts by placing Disease Intervention Specialists (DIS) in the offices of physicians who diagnose large numbers of MSM with syphilis.199 As such, patients can be interviewed about their sexual partners, who have been potentially exposed to infectious syphilis, in a convenient and comfortable setting. From the health department's perspective, this approach may result in a more timely identification of infected partners.

Another partner service under evaluation at the time of this writing is “expedited partner therapy.”200 Expedited partner therapy (EPT) “bypasses” the traditional requirement that partners receive a complete medical examination prior to therapy; instead, sexual contacts may receive therapy from public health personnel, designated pharmacy staff, or from patients themselves.200 Although patient-delivered partner therapy may be an effective approach to reducing STD disparities for some MSM, it may also conflict with existing state laws and, as such, be difficult to implement beyond narrowly defined circumstances.

(p.177) Community-Based STD Services

Providing STD services in nonmedical venues frequented by MSM is not a new idea. Descriptions of programs to screen for syphilis and gonorrhea in gay bathhouses can be found in the public health literature of the late 1970s.201 , 202 Despite the fact that intensive screening for STDs in sex venues, by itself, may not be capable of reducing prevalence of infection,203 offering STD screening and treatment services in high risk venues is an important component of a comprehensive approach to reducing STD disparities among MSM and may reach some men who might not otherwise be encountered in medical settings.

Unfortunately, STD screening services are often not available in high risk gay venues. A 1996–1997 survey of 63 US gay bathhouses and sex clubs found that while 40% provided HIV testing on site, only 21% provided some type of on-site STD testing.204 Even in cities with large, well-organized gay populations, community-based STD services may be deficient. For example, a 2003 survey of gay sex clubs in San Francisco reported that none offered ongoing HIV or syphilis counseling and testing on-site.205

Somewhat more encouraging are the 2005 findings of Ciesielski and colleagues, who surveyed health departments in Chicago, Houston, Miami, Fort Lauderdale, Los Angeles, New York, and San Francisco to learn more about the scope and yield of MSM-targeted syphilis screening taking place in nonmedical settings.206 These health departments reported a variety of targeted screening efforts in response to syphilis outbreaks among MSM, including screening in bathhouses and other commercial sex venues, mobile vans, and jails. Although the yield was relatively low (105 new cases of early syphilis among 14,143 syphilis screening tests), the investigators suggested that secondary public health benefits, such as increased community awareness, may be substantial.206

New opportunities for improving access to community-based STD services are also emerging from the domain of the Internet. Innovations, including using the Internet to facilitate partner notification207 and “online” syphilis testing (i.e., printing lab requisitions and receiving results online)208 hold great promise for increasing the uptake of STD services among MSM who use the Internet to find sexual partners. Other nontraditional approaches include street outreach with client education, followed by self-collection of rectal specimens for chlamydia and gonorrhea screening among MSM attending gay community street fairs.209

Improved Health Promotion

In a nationally representative telephone survey of adolescents conducted in 2001–2002, 51% of 15- to 17-year-olds indicated that they would like to know more about how to bring up sexual health issues, such as STDs, with health care providers.210 When US office–based physicians serving adolescent (p.178) patients were surveyed in the late 1990s, only 5% reported that they included any risk reduction counseling on HIV/STD transmission during adolescents’ visits for general medical/physical examination.211 A nationally representative survey of office and outpatient medical visits from the late 1990s found that only “35% of visits had documented evidence of HIV/STD counseling at the time when HIV or STD testing was done.”212 One strongly suspects that this number would be lower still were it possible to determine the frequency of MSM-specific counseling.

Yet, rigorously evaluated studies have demonstrated that health care providers can prevent new STDs through short counseling interventions—especially interventions that focus on personalized risk reduction plans.213 , 214 However, because time constraints may limit the ability of health care providers to deliver effective health promotion interventions,215 health care delivery systems may need to be reconfigured to fully achieve the benefits of clinically mediated health promotion.216

Enhancing and enabling the health promotion practices of medical care providers is not the only means of improving risk reduction among sexually active MSM. Community-based organizations must play a critical role in educating MSM clients about the ways in which they can prevent or reduce their risk of sexually transmitted infections. Here again, the Internet is proving to be an important component of outreach and education.217–219 Other important dimensions of health promotion for sexually active MSM include: creating “safe spaces” where gay youth can receive comprehensive and sensitive health promotion services220; implementing policies and structural interventions that minimize risk, especially in public sex venues221; and ensuring that services for the prevention and treatment of drug and alcohol use are available to MSM clients who need them.222

Social marketing campaigns are another important way to address STD disparities, especially campaigns that aim to raise awareness, including symptom recognition, and prompt testing for STDs. In response to syphilis outbreaks among MSM, health departments from several American cities have worked closely with community representatives to develop and implement syphilis awareness campaigns for sexually active MSM.223 Based on formative market research, the campaigns varied from “Syphilis is Back” to the “Healthy Penis”; preliminary evaluation results suggest an increase in syphilis testing among MSM in Chicago, Houston, Los Angeles, and San Francisco following the campaigns.223

Strengthened Community Response

Some policy analysts suggest that community participation in health is the “cornerstone of modern public health.”224 As such, perhaps the most important ingredient of a comprehensive approach to reducing STD disparities among MSM is the recognition, by MSM communities themselves, of the disproportionate health toll of these preventable infections. Undeniably, the (p.179) history of the US AIDS epidemic is replete with well-documented examples where gay community mobilization resulted in measurable reductions in viral transmission and other positive health impacts.25

A recent example of the essential role of community in reducing STD disparities was cited above, that is, syphilis awareness campaigns developed with strong community input and endorsement.223 , 225 A further manifestation of community mobilization in support of reducing STD disparities among MSM comes from the Pacific Northwest. A community group, known as the “MSM HIV/STD Prevention Task Force,” issued a manifesto in the Fall of 2003, calling for increased community recognition and responsibility for prevention of the transmission of HIV and other STDs.226 The manifesto emphasized the need for all gay and bisexual men to begin a “community dialogue” on the importance of stopping the transmission of STDs, including HIV.

Conclusion

A critical mass of information is currently available to practitioners and policy makers who seek strategies to prevent and control STDs among men who have sex with men. However, as highlighted in this chapter, important research questions about the disproportionately high rates of STDs among MSM remain unanswered or understudied. Table 6-3 summarizes key epidemiological, behavioral, medical and social research priorities that, when addressed, will help to eliminate STD disparities by filling important gaps in our knowledge base.

Table 6-3. Research Priorities to Decrease Disparate Rates of STDs among MSM

Improve estimates of the incidence and prevalence of STDs among MSM—especially for racial-ethnic subpopulations

Better characterize the social determinants of STD risk for MSM and develop and test policy and program interventions to mediate risk

Develop and test community-specific interventions to increase STD awareness, promote STD prevention, and encourage early diagnosis of sexually acquired infections—including Internet-based interventions

Develop and test practical interventions to improve health care providers' capacity to assess and address the sexual health needs of MSM clients

Evaluate structural interventions to reduce risk in public sex environments

Develop and test new approaches to partner notification, diagnosis and treatment—especially approaches based on social network constructs

Continue to develop improved methods to prevent (e.g., vaccines and rectal microbicides), diagnose and treat STDs among MSM

(p.180) No single sector or constituency can solve this complex problem on its own. Further, approaches that are monolithic will be doomed to failure. Finally, it would be wise to recognize that when it comes to reducing and eventually eliminating STD disparities among MSM, we must think of “health” in its broadest possible embodiment. Not just as “the absence of disease or infirmity,” but as “a state of complete physical, mental, and social well-being.”227 This will require that public health and medical professionals actively engage and support MSM communities in their own vision of what it means to be healthy. Successful efforts to reduce STD disparities among MSM must use societal resources to promote healthy, safe, and fulfilled persons—not just disease-free genital tracts.

Author's Note

The findings and conclusions in this chapter are those of the author and do not necessarily represent the views of the US Department of Veterans Affairs.

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