STDs in Men Who Have Sex with Men
Background
The incidence of many STDs in gay, bisexual, and other men who have sex with men (collectively referred to as MSM) – including primary and secondary (P&S) syphilis and antimicrobial-resistant gonorrhea – is greater than that reported in women and men who have sex with women only (MSW).1-6 In addition to the negative effects of untreated STDs, elevated STD burden is of concern because it may indicate high risk for subsequent HIV infection. Annual increases in reported STD cases could reflect increased frequency of behaviors that transmit both STDs and HIV (e.g., condomless anal sex), and having an STD increases the risk of acquisition or transmission of HIV.7-14
The relatively high incidence of STD infection among MSM may be related to multiple factors, including individual behaviors and sexual network characteristics.15-17 The number of lifetime or recent sex partners, rate of partner exchange, and frequency of condomless sex each influence an individual’s probability of exposure to STDs.15 However, MSM network characteristics such as high prevalence of STDs, interconnectedness and concurrency of sex partners, and possibly limited access to healthcare also affect the risk of acquiring an STD.15, 18 Furthermore, experiences of stigma – verbal harassment, discrimination, or physical assault based on attraction to men – are associated with increased sexual risk behavior among MSM.19
Disparities among MSM reflect those observed in the general population, with disproportionate incidence of STDs reported among racial minority and Hispanic MSM, MSM of lower socioeconomic status, and young MSM.20-24 The higher burden of STDs among MSM with these characteristics, relative to the general population of MSM, may suggest distinct mixing patterns in their sexual networks, reduced access to screening and treatment, and differential experiences of stigma and discrimination, rather than greater numbers of sexual partners or frequency of condomless sex.15, 21-22, 24-26 Furthermore, disparities may be more pronounced for racial minority and Hispanic MSM who are also unemployed, young, and/or of lower socioeconomic status.26-27
With the exception of reported syphilis cases, nationally notifiable STD surveillance data do not routinely include information on sexual behaviors, and these data are missing for the majority of gonorrhea and chlamydia cases reported to CDC. 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.28
For data reported in this chapter, MSM were defined as men who either reported having one or more male sex partners 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. Data presented in this chapter are derived from the National Notifiable Diseases Surveillance System (NNDSS), the Gonococcal Isolate Surveillance Project (GISP), and the STD Surveillance Network (SSuN), a sentinel and enhanced surveillance project established in 2005 to provide supplemental information on STDs.
Nationally Notifiable Diseases Surveillance System
MSM accounted for 68.2% of reported P&S syphilis cases among women or men with information about sex of sex partners in 2017 (Figure 39). Among men exclusively, MSM accounted for 79.6% of reported cases with information on sex of sex partners. Of MSM P&S syphilis cases, 36.5% were White, 28.0% were Black, and 24.0% were Hispanic (Figure W). Relative to the percentage of the US population that is White (61.2%), Black (12.5%), and Hispanic (17.9%),30 this represents a significant inequality in the burden of disease for non-White MSM, which was also evident among MSW and women. In addition, among MSM P&S syphilis cases with known HIV status in 2017, 45.5% were also reported to be HIV-positive (Figure 46).
In 2017, 43 states provided data to classify at least 70% of cases as MSM, MSW, or women. Among these areas, estimated rates of P&S syphilis cases in MSM ranged from 55.7 cases per 100,000 MSM in Wyoming to 798.3 cases per
100,000 MSM in Nevada, with 27 states (63%) estimated to have rates between 200 and 500 cases per 100,000 MSM (Figure AA).
When examining reported P&S syphilis cases over time, 37 states were able to classify at least 70% of reported P&S syphilis cases as MSM, MSW, or women each year during 2013–2017. In these states, cases among MSM increased 8.6% during 2016–2017 and 64.2% during 2013–2017 (Figure 41). However, the percentage of P&S syphilis cases that were attributed to MSM in those states fell slightly from 74.0% in 2013 to 66.5% in 2017.
A description of the methods for estimating MSM population sizes for syphilis rate denominators can be found in Section A1.2 of the Appendix. 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 Neisseria gonorrhoeae strains in the United States.3 Overall, the proportion of isolates collected in selected STD clinics participating in GISP that were from MSM increased steadily, from 3.9% in 1989 to a high of 38.5% in 2017 (Figure BB). The reason for this increase over time is unclear, but might reflect changes in the epidemiology of gonorrhea or in healthcare-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.3, 4 During 2011–2016, the proportion of isolates with elevated azithromycin minimum inhibitory concentrations (MICs) (≥2.0 μg/ml) and elevated ceftriaxone MICS (≥0.125 μg/ml) was higher in isolates from MSM than from MSW (Figure CC). The proportion of isolates with elevated azithromycin MICs remained higher among MSM relative to MSW in 2017; however, no cases of elevated ceftriaxone MICs were identified among MSM in 2017.
Information on the antimicrobial susceptibility criteria used in GISP can be found in Section A2.3 of the Appendix. More information about GISP and additional data can be found at https://www.cdc.gov/std/GISP.
STD Surveillance Network
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.29 Data for 2017 were obtained from 30 STD clinics in 10 SSuN jurisdictions.
Estimated rates of reported gonorrhea among MSM based on SSuN data are provided in the Gonorrhea section of the National Profile (Figure 25).
Additional information about SSuN can be found in Section A2.2 of the Appendix.
Gonorrhea and Chlamydia in STD Clinics, 2017
In 2017, 31,052 unique MSM presented for care in the 30 STD clinics in 10 SSuN jurisdictions. In total, 27,430 unique MSM were tested for urogenital gonorrhea and/or chlamydia (27,407 for gonorrhea, 27,337 for chlamydia). The proportion of men tested for urogenital infections was similar across SSuN jurisdictions, although the proportion who tested positive (positivity) varied by SSuN jurisdiction (Figure DD). Urogenital gonorrhea positivity was higher than urogenital chlamydia positivity in 6 of the 10 jurisdictions: Baltimore, Los Angeles, New York City, Philadelphia, San Francisco, and Seattle. Urogenital chlamydia positivity was higher than urogenital gonorrhea positivity in Florida; Massachusetts; Multnomah County, OR; and Minnesota. The median urogenital positivity for gonorrhea among MSM was 8.5% (range: 4.6%–13.5%) and for chlamydia was 4.8% (range: 6.6%–10.7%) across the 10 jurisdictions.
A total of 20,883 unique MSM were tested for rectal gonorrhea and/or chlamydia in 2017 (20,861 for gonorrhea, 20,817 for chlamydia) (Figure EE). In most jurisdictions, similar proportions of MSM were tested for rectal gonorrhea and chlamydia, likely reflecting use of dual diagnostic tests. Compared to urogenital testing, a lower proportion of MSM were tested for rectal infection. The median positivity for rectal gonorrhea among MSM was 14.7% (range: 10.0%–24.4%) and for rectal chlamydia was 16.8% (range: 12.8%–21.1%) among the SSuN jurisdictions.
During 2017, 23,301 MSM were tested at the oropharyngeal site for gonorrhea (Figure FF). The median positivity for oropharyngeal gonorrhea among MSM was 13.4% (range: 6.9%–17.2%) across the 10 jurisdictions. Oropharyngeal chlamydia data are not shown as some of the SSuN jurisdictions do not offer routine testing for oropharyngeal chlamydia infections.
HIV Status and STDs in STD Clinics, 2017
Among HIV-positive MSM visiting SSuN STD clinics in 2017, urogenital chlamydia positivity was 7.1% and urogenital gonorrhea positivity was 12.0% (compared to 6.8% and 8.2%, respectively, among HIV-negative MSM) (Figure GG). Among HIV-positive MSM, 8.5% were diagnosed with P&S syphilis compared to 3.8% of HIV-negative MSM. Percentages represent the overall average of the mean value by jurisdiction.
Summary
The number of reported P&S syphilis cases among MSM continued to rise in 2017, and the majority of P&S syphilis cases remained among MSM. Furthermore, the proportion of GISP isolates with elevated MICs to antimicrobials currently used to treat gonorrhea was higher among MSM than among MSW. Beyond STD burden in the general MSM population, the data indicated heterogeneity of STD prevalence among MSM according to geography, race, Hispanic ethnicity, and HIV status. State-specific P&S syphilis rate estimates among MSM varied from 55.7 to 798.3 cases per 100,000 MSM, and the prevalence of diagnosed STDs among MSM differed by SSuN jurisdiction. Reported P&S syphilis was disproportionately prevalent among Black and Hispanic MSM, and data from MSM who attended SSuN clinics suggested that P&S syphilis, urogenital gonorrhea, and urogenital chlamydia may be more prevalent among MSM living with diagnosed HIV infection than among HIV-negative MSM.
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