Issue: May 2020
Source/Disclosures
Disclosures: Bernstein and Hurt report no relevant financial disclosures. Hoenigl reports receiving grant funding from Gilead Sciences. Marrazzo reports serving on advisory committees for BD Diagnostics, BioFire and Gilead Sciences. Prior is an employee of the National Coalition of STD Directors.
May 21, 2020
12 min read
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Ending STD epidemic in MSM requires ‘the action of many’

Issue: May 2020
Source/Disclosures
Disclosures: Bernstein and Hurt report no relevant financial disclosures. Hoenigl reports receiving grant funding from Gilead Sciences. Marrazzo reports serving on advisory committees for BD Diagnostics, BioFire and Gilead Sciences. Prior is an employee of the National Coalition of STD Directors.
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STDs are an ongoing and significant public health challenge in the United States, especially among men who have sex with men.

According to the CDC, the incidence of many STDs in men who have sex with men (MSM), including primary and secondary syphilis and antibiotic-resistant gonorrhea, is greater than that reported in women and men who have sex with women only.

“While anyone who has sex can get an STD, sexually active gay, bisexual and other MSM are at higher risk for these diseases,” Kyle Bernstein, PhD, MPH, chief of the Epidemiology and Statistics Branch in CDC’s Division of STD Prevention, told Infectious Disease News. “In addition to having higher rates of syphilis, more than half of all new HIV infections occur among MSM. There are many factors that contribute to the higher rates of STDs among MSM.”

Although rates of syphilis, gonorrhea and chlamydia have increased in recent years, the numbers are “nowhere near” the historical peaks that were seen for the rates of syphilis or gonorrhea in the early to mid 1970s in the U.S., according to Christopher B. Hurt, MD, associate professor of medicine and director of the North Carolina HIV Training & Education Center and principal site investigator for the Ryan White HIV/AIDS Program Part D at the University of North Carolina Infectious Diseases Clinic. The steep decline in the rates of gonorrhea and primary and secondary syphilis in the 1980s and 1990s were due, in large part, to action in the gay community, and then in the general public, to “normalize” condom use before effective HIV treatments were available, Hurt said.

Jeanne Marrazzo, MD, MPH, FACP, FIDSA
STDs “are increasingly a problem for all of us and for MSM in particular,” according to Jeanne Marrazzo, MD, MPH, FACP, FIDSA.
Source: UAB Photo.

The current uptick in the rates of STDs among MSM appears to be driven by a number of factors, including novel patterns of transmission and setbacks in prevention efforts. Infectious Disease News spoke with Bernstein, Hurt and other experts in the field about these factors, the impact of pre-exposure prophylaxis (PrEP) on the rates of STDs in MSM and what strategies are needed to combat the STD epidemic in this population.

‘Disproportionate burden’

Matthew Prior, MPH, director of communications for the National Coalition of STD Directors, told Infectious Disease News that increases in the number of infections are being seen in every population.

“If you are having sex in the U.S., regardless of your age, gender or sexual preference, you are at increased risk for getting an STD,” Prior said.

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According to the most recent data published by the CDC, reported cases of syphilis, gonorrhea and chlamydia in the U.S. reached more than 2.4 million in 2018 — the fifth straight record-breaking year for STDs. In total, there were a reported 1,758,668 cases of chlamydia, 583,405 cases of gonorrhea, and 115,045 cases of all stages of syphilis, including 35,063 cases of primary and secondary syphilis.

The experts who spoke with Infectious Disease News noted that the observed increases are not likely to be explained by increased screening alone — they are reflective of new and changing transmission patterns, cuts to STD programs at both state and local levels and decreased condom use among vulnerable groups, including MSM.

“Unfortunately, MSM bear a disproportionate burden of the STD and HIV epidemics for a number of reasons, including sexual network characteristics, stigma and a system that is not built to meet the needs of these populations,” Prior explained.

CDC data show that, in 2017, MSM accounted for 68.2% of reported primary and secondary syphilis cases among women or men and 77.6% of cases among men exclusively for whom information about the sex of their partners was available. Through the Gonococcal Isolate Surveillance Project — a national sentinel surveillance system that tracks patterns in antimicrobial susceptibilities of Neisseria gonorrhoeae strains in the U.S. — the CDC determined that the proportion of gonococcal isolates obtained from MSM in select STD clinics rose steadily, from 3.9% in 1989 to a high of 38.5% in 2017, dipping slightly to 37.2% in 2018.

“Among MSM with syphilis, more than a third are also coinfected with HIV,” Prior said. “Research shows that 10% of new HIV infections in MSM are caused by gonorrhea and chlamydia; it is estimated that the risk of transmission from syphilis is even greater.”

‘Fewer condoms, more STDs’

Despite the significant positive impact of PrEP on rates of new HIV infections among MSM, increasing use of the strategy in this group has “almost certainly” decreased condom use as a primary STD prevention strategy. Some experts believe this may be the reason for the increase in STD rates among MSM.

Martin Hoenigl, MD
Martin Hoenigl

“There is clear evidence that shows increasing incident STD rates in those who initiate PrEP,” Martin Hoenigl, MD, assistant professor of medicine at the University of California, San Diego, told Infectious Disease News. “We have to be careful, however, because these are correlations — proof on any causal relationship is lacking.”

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Hoenigl added that many individuals who plan to increase risky sexual behavior may appropriately decide to start PrEP before doing so, thus making it unclear what comes first — the intention to increase risk behavior or the uptake of PrEP.

“The term in the literature is ‘risk compensation.’ In other words, if you think you’re invincible, you may take greater risks or at least are less concerned about negative outcomes,” Hurt said. “This was something that the investigators of the major PrEP studies were definitely attuned to. Early data suggested that indices of risk, including episodes of condomless sex, number of sex partners or incident bacterial STDs, were either stable or reduced among participants in the first randomized controlled trials and demonstration projects on PrEP.”

One key study, according to Hurt, is the double-blind phase of the randomized ANRS IPERGAY trial, which examined PrEP use based on sexual activity among high-risk MSM. In total, 400 participants completed online questionnaires about sexual behavior and PrEP adherence.

On average, 42.6% of the most recent episodes of sexual intercourse reported involved PrEP as “the unique mode of prevention,” regardless of sexual partner and sexual behavior. More than 28% of the most recent episodes of sexual intercourse occurred without the use of PrEP, including 16.7% during condomless anal sex. In addition, 70.3% and 69.3% of participants reported condomless anal and condomless receptive anal intercourse, respectively, during their most recent sexual encounter, with no significant change in follow-up.

“It’s important to keep in mind two factors when thinking about those data,” Hurt explained. “The Hawthorne effect says that people’s behaviors are different if they know they’re being watched. Social desirability bias points to the idea of not wanting to report behavior that you believe will be judged or looked down upon by the person to whom you’re reporting that behavior.”

Another analysis published in 2018 examined open-label studies that reported sexual risk outcomes in the context of daily oral PrEP use among HIV-negative MSM and transgender women. The results demonstrated a greater incidence of STDs among people using PrEP. Specifically, PrEP use was associated with a significant increase in rectal chlamydia (OR = 1.59; 95% CI, 1.19-2.13) and an increase in any STD diagnosis (OR = 1.24; 95% CI, .99-1.54).

“The results of the paper reflected my own clinical practice with patients taking PrEP: A small number appear to be abandoning condoms completely and are acquiring a disproportionately large number of STDs,” Hurt said. “Other patients seem to be less consistent with condoms when they’re on PrEP — but haven’t abandoned them entirely.”

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Christopher B. Hurt
Christopher B. Hurt

He continued: “Most MSM who get on PrEP feel less anxious about HIV, in general. That’s a double-edged sword, though. It’s great to be able to have sex that’s less anxiety provoking or scary, but it means that the potential protective element of that anxiety or vigilance is diminished — the little voice in the back of your head reminding you to at least consider a condom before you have sex is not as loud as it maybe once was.”

Jeanne Marrazzo, MD, MPH, FACP, FIDSA, director of the division of infectious diseases and C. Glenn Cobbs, MD, Endowed Professor in Infectious Diseases at the University of Alabama at Birmingham School of Medicine, said that this is only one part of the issue.

“PrEP has virtually eliminated the risk of transmitting HIV whether or not MSM use condoms. But fewer condoms, more STDs is part of the story,” Marrazzo, an Infectious Disease News Editorial Board Member, said. “The other contributor is that PrEP use puts people into the system for STD screening even when no symptoms are present, so we are probably also detecting more STDs than we would have otherwise.”

Another part of the story may be the stigma and disparities associated with STDs, sexual history and PrEP. Prior built on that idea, noting that the same forces that drive HIV also drive STDs and that both are fueled by health disparities and stigma.

“Biomedical advances, such as PrEP and treatment as prevention, have offered an unprecedented opportunity to end the HIV epidemic, but a few recent studies found a higher prevalence of STDs among those on PrEP,” he said.

Prior added: “It’s difficult to tell if these increases are because of better coordinated testing or behavior change, but it’s likely both. To meet the full promise of PrEP, efforts to combat STDs and HIV must work hand-in-hand in promotion of broader sexual health.”

According to Bernstein, there is no conclusive evidence that PrEP plays a role in the rates of STDs among MSM.

“It’s possible that some of the reported increases in STDs among PrEP users may be the result of improved screening and diagnosis. More studies are needed to better assess the relationship between PrEP and STD diagnoses.”

Social, institutional factors

Experts have differing opinions about whether STD intervention and prevention efforts have successfully reached MSM.

Hoenigl said there are two important factors contributing to higher rates of STDs among MSM besides traditional factors like risk compensation. The first is how easy it has become to find sexual partners.

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“More than 60% of MSM in the U.S. use the internet and smartphone-based geospatial networking apps to find sex partners and Grindr is the most used app,” Hoenigl said. “We recently found that among MSM who underwent community based-testing for HIV and other STDs, Grindr users reported significantly higher risk behavior, defined as a greater number of male partners and condomless sex, and were about twice as likely to test positive for chlamydia or gonorrhea (8.6%) than nonusers (4.7%; P = .005).”

He added: “At the same time, Grindr users were aware of their risk and more likely to be on PrEP. Strikingly, Grindr users were also nearly twice as likely as nonusers to initiate PrEP after the testing visit.”

The second of these factors, according to Hoenigl, is the use of stimulant substances, such as methamphetamine, before sex, an activity referred to as “party and play.”

Hoenigl and colleagues conducted a cohort study to examine recent self-reported methamphetamine use and sexual risk behaviors among 8,905 MSM receiving the “Early Test,” or SDET, a community-based HIV screening program in San Diego. The researchers determined that methamphetamine use during the last 12 months was reported by 8.5% of MSM and that SDET scores were significantly higher among MSM with recent methamphetamine use compared with those with none (P < .001). The study also revealed higher SDET scores among 82 repeat testers who started using methamphetamine between testing encounters.

Prior blamed the lack of support for STD prevention or research infrastructure and insufficient federal funding.

“STD prevention needs to be a focus of our nation’s Ending the HIV Epidemic initiative,” he said. “There are plans to significantly ramp up HIV preventive services as part of this initiative, but we won’t end HIV on the back of an exploding STD crisis.”

Everyone has a role to play in this crisis, Prior continued.

“As public health practitioners, we need to be educating the medical field and the public on the latest trends in STDs and arming people with the facts,” he explained. “We need doctors to be doing a thorough, culturally competent sexual health work-up that includes taking a sexual health history. People will continue to have sex, so we need to prepare them with the facts and risk reduction strategies to live healthier lives.”

Bernstein added that gay and bisexual men may not be able to access culturally competent health care, which would include taking a sexual history at every visit and ensuring STD screening occurs.

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“Homophobia, stigma and discrimination can negatively influence the health of gay and bisexual men,” he said.

Hurt agreed that action is needed to reduce stigma.

“At the social level, we need to continue making progress to destigmatize being a same-sex-loving person in this country,” he said.

Hurt explained that there are a number of papers linking homophobia to an increased risk for HIV among gay and bisexual men and that, as long as society continues to label MSM as “deviant” or allow legalized discrimination against LGBTQ people at the federal level, there will be inequities in access to key health services for LGBTQ people.

Kyle Bernstein
Kyle Bernstein

“To me, the fact that we still see such stark differences in health outcomes between whites and blacks more than 50 years after the Civil Rights Act was signed into law means that, even if the Equality Act is passed by Congress and signed by a future president, we still have a lot of work to do before we see a shift in institutional attitudes toward LGBTQ folks.”

Hurt said there has been progress at an institutional level when addressing cultural humility in medical settings, including helping providers learn best practices in regard to sexual orientation and gender identity. However, he said this has only just begun.

“Institutional homophobia is arguably as prevalent — if not more so — as institutional racism in medicine. Every time a gay person seeks medical care, they have to make a decision about the pros and cons of coming out to their provider.”

‘The action of many’

The clinicians who spoke with Infectious Disease News all agreed that more solutions are needed to decrease the high rates of STDs in MSM.

“Sexual health is human health and sexual rights are human rights,” Marrazzo said. “We have made sex safer where HIV transmission risk is concerned through PrEP, but we haven’t figured out a way to do that for other STDs, which are increasingly a problem for all of us and for MSM in particular.”

Clinicians must continue to work on solutions, according to Marrazzo.

In December 2019, Congress increased federal funding for STD prevention for the first time in almost 2 decades, adding $3.51 million in base funding to the CDC’s STD prevention program.

Fast Facts

According to Prior, the increased funding will ultimately, but indirectly, address the rates of STDs in MSM.

“To truly succeed in addressing these disparities, we need targeted efforts for MSM that are culturally relevant and free of stigma and judgment,” he explained. “What’s been missing for years in our national response to STDs is funding that supports direct services such as testing and treatment.”

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As of now, Prior said this does not exist, but the National Coalition of STD Directors is advocating for establishing a direct STD service federal funding line that will be essential to the national response to this crisis.

According to Bernstein, the CDC is also working on solutions by monitoring national STD trends and providing guidance on the most up-to-date screening, treatment and prevention strategies for health care providers. The agency is providing funding for health departments to conduct local surveillance and translate these local data into programmatic action, as well as conducting contact tracing and other innovative strategies for the rapid detection and treatment of STDs.

“However, the CDC cannot do it alone,” Bernstein said. “Turning back the rise in STDs requires the action of many.”

“Health departments can monitor and analyze local STD burden,” he continued. “They can identify and link people who have STDs — and their partners — to treatment and care and disseminate up-to-date disease trends and clinical/preventive resources to health care providers.”

Health care providers can take sexual histories as part of routine medical exams and screen, rapidly diagnose and treat their patients and the partners of patients according to CDC recommendations, Bernstein said. Individuals can, and should, talk openly and honestly with their partners about sex and STDs to identify strategies that enable them to protect their sexual health, such as using condoms the right way.

“Researchers can help by investigating new diagnostic tools and innovative prevention strategies, including the development of vaccines,” Bernstein said.

In general, though, the basics are the best solution.

“Most STDs are usually asymptomatic. Getting tested is important to protect your health,” Bernstein said. “If you are sexually active, talk to your health care provider about STD testing and which tests may be right for you. If you are diagnosed with an STD, seek timely treatment and encourage your partner to get tested and, if necessary, treated.” – by Caitlyn Stulpin

Disclosures: Bernstein and Hurt report no relevant financial disclosures. Hoenigl reports receiving grant funding from Gilead Sciences. Marrazzo reports serving on advisory committees for BD Diagnostics, BioFire and Gilead Sciences. Prior is an employee of the National Coalition of STD Directors.

Click here to the read At Issue to this Cover Story, “Are higher STD rates among MSM an unavoidable consequence of increased PrEP use?