Centers for Disease Control and Prevention

Sexually Transmitted Diseases Treatment Guidelines, 2010
Recommendations and Reports December 17, 2010 / Vol. 59 / No. RR-12

Men Who Have Sex with Men (MSM)
Subgroups of MSM are at high risk for HIV infection and other viral and bacterial STDs. The frequency of unsafe sexual practices and the reported rates of bacterial STDs and incident HIV infection declined substantially in MSM from the 1980s through the mid-1990s. However, since that time, increased rates of early syphilis (primary, secondary, or early latent), gonorrhea, and chlamydial infection and higher rates of unsafe sexual behaviors have been documented among MSM in the United States and virtually all industrialized countries (103,104). The effect of these behavioral changes on HIV transmission has not been ascertained, but preliminary data suggest that the incidence of HIV infection is increasing among MSM in some urban centers, particularly among MSM from racial and ethnic minority groups (105) and among those who use nonprescription drugs during sex, particularly methamphetamine and volatile nitrites (also known as “poppers”). These adverse trends likely reflect the 1) changing attitudes concerning HIV infection that have accompanied advances in HIV therapy, resulting in improved quality of life and survival for HIV-infected persons; 2) changing patterns of substance abuse; 3) demographic shifts in MSM populations; and 4) changes in sex partner networks resulting from new venues for partner acquisition (e.g., the internet). Increases in bacterial STDs are not necessarily accompanied by increases in HIV incidence; for example, oral sex may permit efficient spread of bacterial STDs but not HIV, as does serosorting (preferential selection of sex partners of the same serostatus) among HIV-infected MSM (106,107).

Clinicians should assess the STD-related risks for all male patients, including a routine inquiry about the sex of sex partners.

MSM, including those with HIV infection, should routinely undergo nonjudgmental STD/HIV risk assessment and client-centered prevention counseling to reduce the likelihood of acquiring or transmitting HIV or other STDs. Clinicians should be familiar with the local community resources available to assist MSM at high risk in facilitating behavioral change and to enable the conduct of partner notification activities. Clinicians also should routinely ask sexually active MSM about symptoms consistent with common STDs, including urethral discharge, dysuria, genital and perianal ulcers, regional lymphadenopathy, skin rash, and anorectal symptoms consistent with proctitis, including discharge and pain on defecation or during anal intercourse. Clinicians should perform appropriate diagnostic testing on all symptomatic patients.

Routine laboratory screening for common STDs is indicated for all sexually active MSM. The following screening tests should be performed at least annually for sexually active MSM:

• HIV serology, if HIV negative or not tested within the previous year;
• syphilis serology, with a confirmatory testing to establish whether persons with reactive serologies have incident untreated syphilis, have partially treated syphilis, or are manifesting a slow serologic response to appropriate prior therapy;
• a test for urethral infection with N. gonorrhoeae and C. trachomatis in men who have had insertive intercourse† during the preceding year; testing of the urine using nucleic acid amplification testing (NAAT) is the preferred approach;
• a test for rectal infection§ with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse* during the preceding year (NAAT of a rectal swab is the preferred approach); and
• a test for pharyngeal infection§ with N. gonorrhoeae in men who have had receptive oral intercourse† during the preceding year (NAAT is the preferred approach). Testing for C. trachomatis pharyngeal infection is not recommended.

Evaluation for HSV-2 infection with type-specific serologic tests also can be considered if infection status is unknown; knowledge of HSV-2 serostatus might be helpful in identifying persons with previously undiagnosed genital tract infection.

Because of the increased incidence of anal cancer in HIV-infected MSM, screening for anal cytologic abnormalities can be considered; however, evidence is limited concerning the natural history of anal intraepithelial neoplasias, the reliability of screening methods, the safety and response to treatments, and the programmatic support needed for such a screening activity.

More frequent STD screening (i.e., at 3–6-month intervals) is indicated for MSM who have multiple or anonymous partners. In addition, MSM who have sex in conjunction with illicit drug use (particularly methamphetamine use) or whose sex partners participate in these activities should be screened more frequently. All MSM should be tested for HBsAg to detect HBV infection.

Prompt identification of chronic infection with HBV is essential to ensure necessary care and services to prevent transmission to others (108). HBsAg testing should be made available in STD treatment settings. In addition, screening among past or current drug users should include HCV and HBV testing.

Vaccination against hepatitis A and B is recommended for all MSM in whom previous infection or vaccination cannot be documented (2,3). Preimmunization serologic testing might be considered to reduce the cost of vaccinating MSM who are already immune to these infections, but this testing should not delay vaccination. Vaccinating persons who are immune to HAV or HBV infection because of previous infection or vaccination does not increase the risk for vaccine-related adverse events (see Hepatitis B, Prevaccination Antibody Screening). Sexual transmission of hepatitis C virus infection can occur, especially among HIV-infected MSM. Serologic screening for hepatitis C infection is recommended at initial evaluation of newly diagnosed HIV-infected persons. HIV-infected MSM can also acquire HCV after initial screening; therefore, men with new and unexplained increases in alanine aminotransferase (ALT) should be tested for acute HCV infection. To detect acute HCV infection among HIV-infected MSM with high-risk sexual behaviors or concomitant ulcerative STDs, routine HCV testing of HIV-infected MSM should be considered.

† Regardless of history of condom use during exposure.
§ Commercially available NAATS are not FDA cleared for these indications, but they can be used by laboratories that have met all regulatory requirements for an off-label procedure.