Caring for Men Who Have Sex With Men in Primary Care

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Caring for men who have sex with men (MSM) presents many challenges for the primary care practitioner. A recent article in The New England Journal of Medicine is a very comprehensive and readable review of currently-recommended approaches and diagnostic studies to order at each visit.¹

What follows is a summary list of the article’s key recommendations, along with some additional comments of my own.

• Become comfortable discussing sexual orientation and specific sexual practices in all persons in care. Doing so at each visit will often allow site-specific testing (eg, rectum, pharynx) for certain pathogens such as the gonococcus.
• The risk of acquiring HIV infection is highest among men who have receptive anal intercourse (risk estimated at 1.43% per sex act with an HIV-infected partner). In contrast the risk of acquiring HIV infection among those men who have insertive anal sex is estimated at 0.16% per sex act with an HIV-infected partner, or almost 10 times lower.²
• Emphasize HIV prevention (risk reduction) at every visit. Consistent use of condoms during anal sex has been associated with a 70% reduction in risk of HIV infection.³
• Consider Pre-exposure prophylaxis (PrEP) with daily oral tenofovir/emtricitabine.
• Discuss the importance of adherence to the once daily schedule.
• Prescribe only a 90 day supply, and test every 3 months for HIV infection
• Consider frequent (every 3 months – 6 months) testing for HIV in this population even in the absence of PrEP
• Vaccinations:
• HAV (consider serologic testing before vaccination)
• HBV (consider serologic testing before vaccination)
• HPV (at least up to age 26, after which exposure may have occurred already)
• Meningococcus (several outbreaks have occurred in MSM)
• Screening for STDs
• Neisseria gonorrhea: obtain specimens for nucleic acid amplification from the urethra, rectum, and pharynx at least twice annually. Positive results are twice as likely to be found from doing rectum plus pharynx in this population than by limiting testing to the urethra.  In MSM, the majority of rectal infections are asymptomatic, and a large percentage of pharyngeal infections also are asymptomatic. Targeted screening, based on specific type of sexual activity, can be considered.
• Chlamydia trachomatis: twice annual testing is recommended, and many of the infections from any of the sites are asymptomatic. Targeted screening, based on specific type of sexual activity, can be considered.
• HPV: it is unclear whether anal pap smears in this population are warranted, despite the higher rate of anal cancer in this population. A clinical trial to assess the benefit of screening is ongoing (ClinicalTrials.gov number NCT02135419)
• Syphilis: Annual or twice annual screening. Also test those with symptoms (eg, non-pruritic rash) consistent with syphilis
• HIV: “frequent” testing (see above) is recommended. Become familiar with signs and symptoms of the acute retroviral syndrome and draw an HIV RNA level if recent infection is suspected.
• HCV: annual screening probably will suffice. The increased risk in this population is not due to sexual activity, per se, but rather from the likely increase in exposure to blood.
• Other screening
• Depression
• Tobacco, alcohol, “recreational drugs”.  Use of, especially, crystal methamphetamines, increases the likelihood of participating in unsafe sexual practices. Alcohol use lowers inhibitions, and often impairs judgement

References:

1. Wilkin T. Primary care for men who have sex with men. N Engl J Med. 2015;373:854-862.
2. Jin F, Jansson J, Law M, et al. Per-contact probability of HIV transmission in homosexual men in Sydney in the era of HAART. AIDS. 2010;24:907-13.
3. Smith DK, Herbst JH, Zhang X, Rose CE. Condom effectiveness for HIV prevention by consistency of use among men who have sex with men in the United States. J Acquir Immune Defic Syndr. 2015;68:337-344.