Sexually Transmitted Disease and HIV Screening Guidelines for Men Who Have Sex With Men

The following recommendations for screening men who have sex with men (MSM) were developed by Public Health—Seattle & King County in response to rising rates of syphilis, gonorrhea, and chlamydial infection among MSM in King County, WA, 1–3 with attendant increased risk of transmission of HIV infection. These guidelines, which include a summary of counseling strategies for prevention of HIV infection and other sexually transmitted diseases (STDs), have been widely distributed among healthcare providers and populations at risk in King County. The guidelines are one component of several prevention strategies developed in collaboration with community partners, including agencies and individuals representing MSM at risk. Some elements of the screening recommendations are based on local studies of the prevalence of STD and of behavioral risks among MSM in King County, 4 whereas others are based on local clinical experience and expert opinion. The resurgence of STD and of behavioral risks for HIV transmission appear to be widespread among MSM in industrialized countries, 5–7 and it is likely that these recommendations are broadly applicable to MSM in other geographic areas. However, local trends and regionally derived data should be used whenever possible to develop guidelines that will be most useful in particular geographic areas and populations. For example, the recommendation for routine screening for rectal but not urethral gonococcal and chlamydial infection in asymptomatic MSM is based on extensive screening data in King County, 4 but may not be applicable in all settings. The remainder of this document reproduces the recommendations distributed in King County. Other local, state, and national health agencies and professional organizations also should move promptly to address this public health crisis. Guidelines The frequencies of gonorrhea, chlamydial infection, and infectious syphilis have risen dramatically since 1997 in MSM in King County, indicating an increased risk for transmission of HIV, the cause of AIDS. Similar trends are being seen among MSM in many other geographic areas in North America and Europe. Local surveillance has documented high rates of STD among King County MSM both with and without HIV infection, and has also demonstrated high frequencies of unprotected sex, sex with anonymous partners, and related behaviors among many MSM. The reasons for these trends are uncertain, but several signs point to improved management of HIV infection and enhanced survival, which in turn probably have direct and indirect effects on sexual behavior. “Epidemic fatigue” and “safer sex burnout” also are likely to be involved. Public Health—Seattle & King County, in collaboration with community partners, has taken numerous steps to address the resurgence of STD infection and HIV risk among MSM. In addition, Public Health now makes the following recommendations for STD/HIV screening for agencies and clinicians who provide health care to MSM. This document also summarizes longstanding recommendations for counseling MSM for STD/HIV prevention. Screening Recommendations Sexual history: Using a straightforward, nonjudgmental approach, clinicians should routinely determine whether their male adult and teen patients are sexually active with other men, women, or both, and should ask MSM whether they have been sexually active with men in the preceding year. All men who have had sex with other men in the preceding year should have the following screening tests at least once a year: –HIV serology (if HIV negative or not previously tested) –Syphilis serology –Pharyngeal culture for Neisseria gonorrhoeae* MSM who have had receptive anal intercourse in the preceding year also should have the following tests at least once a year: –Rectal culture for N gonorrhoeae* –Rectal culture for C trachomatis* More frequent screening (e.g., every 3–6 months) with the above tests should be considered for MSM who acknowledge sex with anonymous partners or multiple partners, who use crystal methamphetamine or inhaled nitrites (“poppers”), or whose partners participate in these activities. Screening for urethral infection: Asymptomatic urethral infection with N gonorrhoeae or C trachomatis is uncommon in MSM. Urethral or urine screening for these infections is not indicated in MSM without symptoms or signs of urethritis. Condoms and HIV status: These recommendations should be implemented whether condoms are employed for anal intercourse, and regardless of the patient’s HIV status. Diagnostic testing: In evaluating MSM, clinicians should routinely elicit symptoms of STD, including urethral discharge, dysuria, anorectal symptoms (e.g., pain, pruritus, discharge, bleeding), genital or anorectal ulcers or other lesions, and skin rash. Men with such symptoms should have appropriate diagnostic tests. Viral hepatitis: MSM without past histories of infection with hepatitis A virus (HAV) or hepatitis B virus (HBV) and who have not been vaccinated against these viruses should have serological testing for them. If follow-up is uncertain, the first dose of HAV and HBV vaccine should be administered at the time of the serological test, as immunization is not harmful in previously infected or vaccinated persons. The immunization course (one additional dose of HAV vaccine and two additional doses of HBV vaccine) should be continued in MSM found to be susceptible. Herpes simplex virus infection: Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) infections are highly prevalent in MSM, and symptomatic and asymptomatic HSV infection increases the risk of acquiring and transmitting HIV. In addition, persons with HIV infection are at risk for chronic, disabling mucocutaneous ulcers and other complications. Therefore, some experts recommend routine HSV serological testing for MSM. Such testing should be undertaken only with a type-specific test for antibody to HSV glycoprotein G; no other serological test accurately differentiates HSV-1 from HSV-2 antibody. HSV-seropositive MSM, especially if antibody to HSV-2 is present, should be informed of the increased risk of acquiring or transmitting HIV and recognition of the symptoms of anogenital herpes, including prodrome and other mild and nonspecific symptoms. Reporting Public Health—Seattle & King County should be promptly notified when a reportable STD is diagnosed. Reporting helps STD and HIV prevention by contributing to understanding of local and regional epidemiology, which permits targeting of prevention resources. In selected cases, reporting may facilitate notification and treatment of patients’ sex partners. In Washington State, notifiable STDs include HIV infection, syphilis, chlamydial infection, gonorrhea, viral hepatitis, and first-episode anogenital herpes. Reporting by telephone is encouraged. Counseling The importance of counseling MSM to reduce the potential for acquiring or transmitting HIV and other STDs to other persons cannot be overemphasized. A comprehensive review of counseling strategies, goals, and methods is beyond the scope of this document. Risk evaluation and counseling should be undertaken in a direct, nonjudgmental manner, with attention to the patient’s particular needs, insight, and readiness to make specific behavior changes (“client-centered” counseling). At a minimum, clinicians should address the following basic prevention strategies with their MSM patients. MSM should be advised to know and disclose their HIV infection status to all sex partners, and to learn their partners’ HIV status. MSM should be counseled to use condoms correctly and consistently for both insertive and receptive anal intercourse with men, and for vaginal or anal intercourse with women, except when both partners are of the same HIV serostatus and in a mutually monogamous relationship of at least three months duration. MSM should be advised to avoid or minimize sex with multiple or anonymous partners, as well as sex in conjunction with drug use, especially crystal methamphetamine, inhaled nitrites (“poppers”), or excessive alcohol. Clinicians should counsel MSM to recognize the common symptoms of STDs and HIV infection and avoid sex (even with condoms) when symptoms are present. MSM should be advised to follow the above strategies even in the presence of a low plasma HIV viral load, and whether on antiretroviral therapy. Low plasma HIV levels do not necessarily reduce transmission risk, because HIV can be present in semen or asymptomatic genital lesions when HIV cannot be detected in the blood. Clinicians should encourage patients infected with HIV or other STDs to inform their sex partners and encourage them to seek evaluation and treatment. Clinicians may seek assistance from Public Health—Seattle & King County in notifying patients’ sex partners.