• • A thorough sexual history is requisite to identifying sexual risk behaviors and the subsequent risk for sexually transmitted diseases (STDs) in men who have sex with men (MSM).
• • Epidemiology of STDs and individual risk behavior guide prevention, screening, and clinical management practices.

MSM are a diverse population defined by their sex and sexual behavior. They include men who identify as gay, bisexual, or heterosexual in their sexual orientation.

The epidemiology of STDs in MSM has changed considerably since the mid-1980s. Declines in the incidence of STDs that occurred in the late 1980s through mid-1990s have been followed by recent increases in the incidence of syphilis, gonorrhea, and HIV among MSM in the United States and Europe. These documented increases in STDs parallel the reversal in AIDS morbidity and mortality with the advent of highly active antiretroviral therapy (HAART).

Paradoxically, the success of HAART may have contributed to higher risk sexual behaviors as a result of reduced fears of HIV transmission among MSM who are infected with the virus and of HIV acquisition among MSM who are not infected. Decreases in condom use, increases in the number of sex partners, and changes in sex practices (from oral sex to anal intercourse) have been reported in MSM in major urban areas throughout the United States since the mid-1990s.

Changes in community norms resulting from HIV treatment optimism and the improved physical well-being of HIV-infected persons are some associated factors that may have contributed to these increases. Social factors that may have contributed to recent changes in sexual behaviors include the advent of the Internet as a means of meeting new sex partners, increased availability and use of methamphetamine and other drugs, and the use of the mass media for direct-to-consumer HIV medication advertising, mitigating the severity of HIV and AIDS.

Because some MSM are not gay-identified, it is essential that clinicians ask open-ended questions in a behavioral risk assessment and not make assumptions about the sex of a patient’s sex partners. Building trust and rapport with patients will facilitate the disclosure of sexual behaviors. Every patient evaluation should include a risk assessment for STDs that includes a nonjudgmental and direct ascertainment of sexual behaviors. A thorough sexual history includes the delineation of anal, digital, oral, and vaginal sexual contact exposures (see Table 24–1; see also Chapter 31). The following sexual behaviors are associated with STD transmission in MSM: anal sex (insertive or receptive), oral sex (insertive or receptive), vaginal sex (insertive or receptive), oral-anal or anal-oral sex, and anal-digital or digital-anal sex. Sexually transmissible pathogens and associated syndromes that are most frequently identified in MSM are listed in Table 24–2.

Medical providers should understand the psychosocial contexts of increased sexual risk-taking among some MSM. Common factors associated with increased sexual risk-taking among some MSM include recreational drug use and the use of sexual venues. Alcohol and recreational drug use, such as methamphetamines, inhaled nitrates, ketamine, and MDMA (methylenedioxymethamphetamine) have been associated with high-risk sexual behavior and are prevalent among subpopulations of MSM. Additionally, some MSM use venues such as bathhouses, private sex parties, public sex areas, and the Internet to meet sex partners. Since sexual venues facilitate multiple sexual partnerships, anonymous sexual encounters, and are associated with higher risks sexual behaviors, clinicians should engage patients in discussions about venue use in the context of the individual’s sexual health. Providers should talk about recreational drug use, both alone and in the context of sexual encounters, because these interactions may contribute to an increased risk for STD and HIV infection in some MSM.

Nevertheless, despite careful and nonjudgmental history taking by the clinician, some patients may not disclose their sexual behaviors, as it often takes time to build trust and rapport between a patient and the clinician. The key to conducting a successful sexual risk assessment includes creating a nonjudgmental and safe environment for the patient, making no assumptions about sexual behaviors, and making sexual risk assessments routine for all patients at the time of the initial visit and on a regular basis unreturned visits, as patients’ circumstances and behaviors might change over time.

Prevention of STDs in MSM includes primary and secondary prevention approaches. Primary prevention focuses on reducing the potential exposures of MSM to sexually acquired infections through partner number reduction, increased condom usage, and encouraging behaviors that are less likely to transmit STDs such as oral sex and non-penetrative sex play. Primary prevention was successfully adopted by MSM in the mid- and late 1980s. As previously noted, these behavioral changes resulted in profound declines in the incidence of new STDs and HIV infections. With the reversal in safer sex practices observed in subpopulations of MSM, particularly HIV-infected MSM, following the advent of successful HIV therapy, intervention programs and affected communities have embraced secondary prevention strategies focused on increased health care-seeking behavior, increased screening, early detection of infection, and individual and partner treatment strategies.

As STDs declined during the AIDS epidemic, general awareness of STDs declined, along with their basic knowledge of signs and symptoms of STDs, STD transmission, and the value of routine screening for STDs. With noninvasive, accurate, and even self-collected screening tests now available for gonorrhea and chlamydia, MSM and their providers can screen for and treat these infections at an early stage, thereby reducing the duration of infection and the subsequent prevalence of these diseases. Reductions in prevalence should be followed by declines in incidence. However, for screening measures to be effective, medical providers and public health departments need to engage the gay community as partners in STD prevention efforts that include enhanced health promotion and awareness, the building community coalitions, increasing access to medical and laboratory services, and enhancing awareness of STDs among community organizations, and health providers.

Several groups, including the California STD Controllers’ Association, the Seattle-King County STD Program, and the Centers for Disease Control and Prevention (CDC), have developed screening recommendations for STDs in HIV-infected MSM and MSM in general. These guidelines recommend screening at least twice a year in sexually active MSM based on sexual behaviors that place MSM as risk for infections at specific anatomic sites. The guidelines recommend pharyngeal gonorrhea screening, urine-based gonorrhea and chlamydia screening, rectal gonorrhea and chlamydia screening, and serologic tests for herpes simplex virus type 2 (HSV-2), syphilis, and HIV. Guidelines from the Infectious Disease Society of America and the Department of Health and Human Services echo these recommendations in HIV-infected persons in care. A summary of current screening recommendations appears in Table 24–3.