A new Clinical Practice article covers primary care for men who have sex with men. Care should include a detailed sexual history to assess the risk of infection with HIV, the use of preexposure prophylaxis for those at high risk, and appropriate vaccinations and regular testing for sexually transmitted infections.
Men who have sex with men, many of whom identify themselves as gay, are a distinct population that is at increased risk for certain health conditions. Some, but not all, of these conditions are directly related to sexual behavior.
• What is the current trend in the HIV infection rate among men who have sex with men?
HIV infection continues to be the major health problem affecting men who have sex with men. In this population, the HIV infection rate increased by 12% between 2009 and 2013, with nearly 31,000 new infections annually.
• What measures are recommended for HIV prevention?
In order to counsel patients about the risk of acquiring HIV and other sexually transmitted infections, providers should first inquire about types of sexual activity (e.g., oral sex, anal sex, and oral-anal sex) and the use or nonuse of condoms during various sexual activities. The consistent use of condoms during anal sex has been associated with a risk of HIV acquisition that is 70% lower than the risk without the consistent use of condoms. Men who have sex with men should be offered routine HIV testing once or twice a year. As part of a comprehensive risk-reduction strategy, preexposure prophylaxis and postexposure prophylaxis should be considered for men who have sex with men if they are at high risk for HIV infection. The CDC recommends preexposure prophylaxis for men who have an HIV-infected sexual partner, who have recently had syphilis or infection with Neisseria gonorrhea or Chlamydia trachomatis, or who have had a high number of sexual partners, a history of anal sex without the use of condoms, or a history of commercial sex work. An alternative approach to the prevention of infection with HIV is postexposure prophylaxis. This strategy involves the use of antiretroviral medications (e.g., tenofovir disoproxil fumarate-emtricitabine and raltegravir) soon after an isolated incident of high-risk exposure (within 72 hours, and preferably within 24 hours) in conjunction with HIV testing; treatment is continued for 28 days.
Morning Report Questions
Q: What other screening tests are routinely recommended for men who have sex with men?
A: Even in the absence of symptoms, screening for sexually transmitted infections — including serologic testing for HIV and syphilis and oral, rectal, and urinary testing for N. gonorrhea and C. trachomatis — is recommended for sexually active men who have sex with men and should be performed once a year or, for patients at higher risk, twice a year. Unlike urethral infections, rectal gonorrhea and chlamydial infections are often asymptomatic. A meta-analysis that included 25 studies of lesbian, gay, and bisexual people reported that these groups were at a significantly higher risk for depression, anxiety, and alcohol dependence than heterosexual people. Men who have sex with men should be screened periodically for alcohol and drug use. They are also more likely than heterosexual men to use tobacco and should be asked about tobacco use periodically. Anal infection with high-risk types of human papillomavirus (HPV) can lead to anal cancer. It is unclear whether screening for anal cancer is warranted in men who have sex with men. Screening should be considered for men who have sex with men if trained providers are available to perform these procedures, but patients should understand that diagnostic procedures and precancer treatments for anal cancer have associated risks, including the risk of anal pain and bleeding, and that high-quality data showing that screening reduces the risk of anal cancer are not available. The CDC recommends regular screening for hepatitis C virus (HCV) infection among HIV-infected men who have sex with men and recommends one-time HCV testing before the initiation of preexposure HIV prophylaxis and for all persons born between 1945 and 1965.
Q: What vaccinations are recommended for men who have sex with men?
A: Men who have sex with men are at increased risk for several vaccine-preventable infections. Unvaccinated men who have sex with men should be tested for hepatitis B virus (HBV) infection, and vaccination should be offered if tests for HBV surface antigen and surface antibody are negative. Men who have sex with men are at increased risk for the acquisition of hepatitis A virus (HAV) infection if they engage in sexual practices such as oral-anal sex; outbreaks of HAV infections in this population have been reported. Vaccination should be offered to men who have sex with men if they do not have a documented history of HAV vaccination and are not immune according to the results of serologic testing. The Advisory Committee on Immunization Practices (ACIP) recommends routine human papillomavirus vaccination of men who have sex with men through 26 years of age. A 9-valent version of this vaccine was recently approved by the Food and Drug Administration and is preferred over the quadrivalent vaccine, since it offers broader protection than the quadrivalent vaccine. Data are lacking on the efficacy of vaccination in men older than 26 years of age who have sex with men, but the safety and immunogenicity of vaccination in this age group have been established. This population is reported to have an increased prevalence of oropharyngeal colonization with Neisseria meningitidis as compared with the general population, but population-level data are lacking to confirm whether they are at increased risk for meningococcal disease. Current guidelines from the ACIP do not include men who have sex with men as a group that is at high risk for meningococcal disease and do not recommend routine vaccination. However, vaccination of men who have sex with men is recommended by many local health departments and is prudent for men in this population who are living in or traveling to areas with reported outbreaks.