Intersecting Epidemics and Educable Moments: Sexually Transmitted Disease Risk Assessment and Screening in Men Who Have Sex With Men

THE 1970s BROUGHT the first reports of high rates of gonorrhea, syphilis, and other sexually transmitted diseases (STDs) in men who have sex with men (MSM). 1,2 Although unappreciated at the time, by 1980 HIV was already spreading in this population; indeed, in retrospect such transmission undoubtedly was accelerated by concomitant inflammatory STDs. 3,4 However, soon after the appearance of AIDS in the early 1980s, rates of STDs and of risky sexual behaviors in MSM declined as a result of education and other prevention measures, often emanating from community-based prevention organizations as well as public health agencies. While STDs remained common in some MSM, by the mid-1990s tenfold or greater declines in reported cases of gonorrhea and syphilis in MSM had been observed across the United States, and similar trends were apparent in other industrialized countries. 1,2

Unfortunately, this trend has been reversed and several recent reports have documented rising STD rates in MSM and increased frequencies of unprotected sex and other risky behaviors. 5-13 Among men with gonococcal urethritis surveyed at 29 STD clinics in the national Gonococcal Isolate Surveillance Project, the proportion of cases occurring in MSM rose from 4.5% in 1992 to 13.2% in 1999. 5 Syphilis, having been eliminated from King County, Washington, reappeared in 1997, and by 1999 had risen to an estimated incidence of 160 per 100,000 MSM. 6,7 In San Francisco, in MSM the incidence of chlamydia has increased in addition to rectal gonorrhea, which rose 80% from 21 cases per 100,000 men in 1994 to 38 cases per 100,000 men in 1997. 8,9 Similar trends were reported for both gonorrhea and chlamydial infection in MSM in King County from 1996 to 1999. 6 Still more recently, reports of similar trends have come from Chicago, Philadelphia, New York, Washington, Boston, several counties in Southern California, and from Canada, Australia, and western Europe. 10-17

An alarming aspect of the recent reports is that 50% to 70% of MSM with infectious syphilis have also been infected with HIV at some centers, as have 20% to 50% of those with gonorrhea or chlamydial infection. 6,10-17 In parallel, the increased STD rates in San Francisco have been accompanied by rising HIV incidence in MSM. 16 It seems likely that HIV infection rates also are rising in MSM in other geographic areas, most of which lack the sophisticated HIV surveillance systems and public health infrastructure of San Francisco. As predicted by these morbidity trends, prospective cohort studies and other data from Seattle, San Francisco, and elsewhere have documented high and rising rates of unsafe sexual practices in MSM. 17-19

The explanations for these trends are incompletely understood, but likely factors include hubris about the efficacy of potent antiretroviral therapy in preventing HIV transmission and the ability of antiviral chemotherapy to make HIV disease seem less serious, perhaps especially to persons who never knew someone with overt AIDS. 20,21 Some authorities have focused on the contextual associations of recent upsurges in recreational drug use, particularly in specific venues such as circuit parties and environments that are oriented to multi-partnered and anonymous sex (e.g., bath houses), while others have described battle fatigue among previously vigilant MSM. 18,21 Some jurisdictions have reported a predominance of resurgent STD cases in older MSM, suggesting behavioral relapse in men who had previously pursued safer practices, but others have described increased rates in younger men or among minority communities. Clearly, there is substantial demographic and behavioral heterogeneity in these trends, and one scenario does not fit all.

Even before the rising STD rates were fully appreciated, there was a growing consensus that national HIV prevention strategies had overemphasized self-protection by HIV-negative persons and de-emphasized the importance of prevention efforts directed toward those living with HIV infection. That emphasis may have resulted in part from an effort to destigmatize the epidemic and target limited prevention resources. Current trends underscore the need to engage persons infected with HIV to understand both their personal vulnerability to new STDs and their responsibilities to help protect their uninfected partners from HIV infection. It has been estimated that about two thirds of persons infected with HIV in the United States are aware of their infections and are receiving care in health systems that should be able to provide ongoing monitoring for STDs as well as risk-reduction counseling. 22 The Centers for Disease Control and Prevention 4 and the US Preventive Services Task Force 23 recommend routine STD risk assessment in all patients receiving primary health care and selective screening of persons at risk, but to date few if any published guidelines stipulate indicators of STD risk or the specific screening tests that should be done, apart from Chlamydia trachomatis screening of women and HIV serology. Indeed, Tao et al 24 found that most primary care providers do not routinely assess their patients' STD risks, and Elford et al 25 made a similar observation among MSM. It is difficult for many clinicians to routinely incorporate such prevention strategies into their practices without specific procedural guidelines. 24,26

Important steps have now been taken to fill this void. Elsewhere in this issue, two thoughtful and specific sets of guidelines are presented, 27,28 which will facilitate the necessary conversation between local public health officials and clinicians as to how to approach sexual risk assessment and STD screening of MSM and of persons infected with HIV in their communities. The guidelines were developed by the California STD Controllers Association and Public Health-Seattle & King County (the local health department for metropolitan Seattle). Although these guidelines cannot be described as truly evidence-based, they were largely derived from systematic surveys of STD prevalence and sexual behaviors and practices among MSM and other local data. 6-10,17,18,29

The two documents are generally similar and either is likely to be useful for clinicians and public health agencies in other jurisdictions, while awaiting national recommendations or more specific locally derived ones. Both sets of guidelines emphasize the importance of healthcare providers' understanding that many or most of their patients infected with HIV remain sexually active and may continue to engage in unprotected intercourse, so that active risk assessment is essential. The California guidelines address STD prevention among persons infected with HIV, whereas Seattle's recommendations are for both STD and HIV screening and prevention among MSM, whether HIV-negative or positive. Thus, Seattle but not California calls for HIV counseling and testing of MSM without known HIV infection. The Seattle guidelines emphasize STD/HIV risk assessment and screening, with only a succinct description of the principles of risk-reduction counseling, whereas the California document recommends specific counseling strategies and procedures as well as STD screening guidelines.

Both documents recommend initial screening of MSM that includes a serological test for syphilis, a pharyngeal culture for Neisseria gonorrhoeae and, if the patient has had receptive anal intercourse, a rectal culture for N gonorrhoeae. California calls for screening for urethral N gonorrhoeae and C trachomatis infection, using a nucleic acid amplification test on voided urine. Seattle does not recommend screening for urethral infection, citing local data showing the prevalence of both chlamydial infection and gonorrhea to be < 1% among asymptomatic MSM tested by urine ligase chain reaction. 18 The costs and benefits of screening asymptomatic men for urethral STDs will need further study in communities with varying prevalences of both infections, and any local decision should be subject to revision as relevant data emerge.

Seattle's guidelines recommend screening for rectal chlamydial infection in asymptomatic MSM who acknowledge receptive anal intercourse, based on local data 18 that showed 4% to 5% prevalences among HIV-infected and HIV-negative MSM, using an accurate culture technique that is readily available in Seattle through a highly skilled laboratory. In most other areas of the country, the only readily available tests for C trachomatis are DNA or antigen-detection assays that have been little studied for this indication and are not approved for rectal specimens. In addition, it is unknown whether the relatively high prevalence of rectal chlamydial infection in MSM reported by the Seattle investigators would be replicated in other settings. Therefore, while such testing may be warranted in the Seattle area, its utility elsewhere is uncertain and requires study.

Both California and Seattle recommend consideration of serological testing for herpes simplex virus type 2 (HSV-2) infection, using newly developed type-specific assays for antibody to HSV glycoprotein G. 30 This recommendation is based on data showing that most HSV-2 infections are subclinical, and that both symptomatic and asymptomatic HSV-2-infected persons are at enhanced risk for HIV transmission (if HIV-infected) or acquisition (if HIV-negative). 31,32 Further studies will be needed, however, to determine whether MSM who know their HSV-2 infection status are more apt to engage in protective behavior, and the role of chronic suppressive therapy with acyclovir or related drugs in preventing transmission of HSV or HIV is not yet known. Thus, the guidelines' characterization of HSV-2 serological screening as optional is appropriate, pending further evidence of its utility.

The California and Seattle guidelines are similar in most other details. Seattle recommends annual STD screening for all sexually active MSM, whereas California recommends screening at the initial visit. Both guidelines recommend repeat screening at suggested intervals of 3 months to 6 months for persons at especially high risk. California offers diagnosis of an STD as an indicator of such risk, whereas Seattle emphasizes specific risk behaviors, such as multiple or anonymous partnerships or sex in association with substance abuse; either indicator undoubtedly is valid. Seattle's guidelines remind clinicians to perform diagnostic tests in patients with symptoms of STD, which is implied, if not overtly stated, in the California recommendations. Both sets of guidelines recommend immunization against hepatitis A and hepatitis B.

The rising incidence of HIV infection in MSM in San Francisco and the high prevalence of STD-HIV coinfection are ominous reminders of the inevitable synergy between HIV and STDs 3,4 and a warning of the pressing need to develop strategies to prevent further widening of these resurgent epidemics. It is hoped that publication of the California and Seattle STD/HIV screening guidelines will engender wide discussion of the need to mobilize clinicians to assess their patients' sexual risks and provide screening and counseling services in order to attenuate the new crisis. The public discourse over optimal screening algorithms should help remind providers and public health officials that STD screening of MSM at risk must be regarded as standard, normative, necessary, and an indicator of optimal primary care.

Even with specific guidelines, some providers may be reluctant to routinely screen appropriate patients because of their personal discomfort and perceived professional constraints, and MSM often are reluctant to raise such issues themselves. 25 Many practitioners lack training in discussing sexual risks and practices, and others have the perception that their busy clinic schedules and constraints imposed by managed care plans will not allow them the luxury of doing so. The public health and academic communities must respond to these impediments. 24-26 Educational efforts for providers, people infected with HIV, and sexually active MSM should assure that they understand that routine STD screening helps prevent the spread of HIV as well as other STDs. Health departments can facilitate STD screening in the private sector by offering free or low-cost tests, or through other kinds of support. Behavioral scientists will need to develop targeted interventions for providers in order to enhance their comfort level with eliciting sexual histories and with screening for HIV and other STDs when appropriate. Ethnographic studies have indicated that some MSM are disappointed when their providers seem unwilling or uncomfortable with discussing sex and other intimate, but important, aspects of their lives (Bloom F, personal communication, May 29, 2001). The vigorous media that have developed for MSM and people infected with HIV in many cities can be mobilized to enhance community understanding that routine sexual risk assessment and STD screening are components of primary care that are as important as the measurement of plasma viral load and CD4 count. Social marketing campaigns are needed to create the expectation among people living with HIV and in MSM that they are not receiving optimal health care if their doctors are not providing these services.

In light of present knowledge, failure of clinicians to assess sexual risks among their MSM patients and to screen for HIV and other STDs when indicated is tantamount to malpractice, and providers, health departments, health maintenance organizations, and managed care plans must not wait for further studies and campaigns to implement these strategies. The impediments to changing provider and high risk consumer attitudes and behaviors are substantial, but most can be addressed at the local level, and should not be an excuse for inaction. The early AIDS epidemic's spread was slowed by community and public health responses long before the most effective prevention strategies were understood or antiretroviral therapy was introduced. The challenges in this later stage of the epidemic among MSM are how best to take advantage of the facts that most people infected with HIV are regularly in contact with healthcare providers, that most MSM know their HIV status, that most persons at risk are aware that they remain vulnerable to HIV infection, that they still want to avoid becoming infected or infecting others, and that most MSM will readily accept sexual risk assessment and STD or HIV screening when their providers offer these services in a straightforward, nonjudgmental manner. The Seattle and California guidelines are important contributions to the health of MSM. Together they should stimulate other jurisdictions to develop more effective strategies to enhance HIV and STD prevention.