Preventive Health Care of Men Who Have Sex With Men

Aka: Preventive Health Care of Men Who Have Sex With Men, Health Maintenance for Gay Men, Preventive Care for Homosexual Men, Men who have Sex with Men, Male Homosexuality, Gay Men

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II. Definitions

  1. Men who have Sex with Men (MSM)
    1. Phenotypic male who has insertive or receptive sex with other phenotypic males (including Transgender)
    2. Includes penile-oral and penile-anal sex

III. Epidemiology

  1. Incidence: 4% of men in the United States

IV. History: Sexual

  1. Number of sexual partners in the last year
    1. Sex with men, women or both?
    2. Sex after using Alcohol or drugs?
    3. Is your current sexual partner a longterm partner? Are you monogamous?
    4. Sex with strangers or acquaintances?
    5. Have you been sexually active in the last year?
      1. How many sexual partners have you had in the last 2 months? Last 12 months?
    6. Do you use Condoms always?
      1. How often do you not use Condoms?
    7. How many Sexually Transmitted Infections have you had in the past?
      1. Chlamydia or Gonorrhea?
      2. Genital Warts?
      3. Herpes?
      4. Syphilis?
      5. HIV?
  2. Types of sex (oral, vaginal, anal)?
    1. Insertive anal sex (top partner)
      1. Higher risk than oral sex for Sexually Transmitted Infection
    2. Receptive anal sex (bottom partner)
      1. Highest risk for Sexually Transmitted Infection

V. History: Social

  1. Domestic Abuse or rape?
    1. Current abusive relationship?
  2. Support system
    1. Who are the other people in your home?
    2. Monogamous relationship?
    3. Family support (spouse, parents, siblings, children)?
    4. Close friends?

VI. Labs

  1. Gonorrhea PCR (Nucleic Acid amplification test or NAAT)
    1. Oral Gonorrhea PCR if oral intercourse history in past year
    2. Anal Gonorrhea PCR if anal insertive or receptive intercourse in past year
    3. Urine Gonorrhea PCR if anal insertive intercourse in past year
  2. Chlamydia PCR (Nucleic Acid amplification test or NAAT)
    1. Anal Chlamydia PCR if anal insertive or receptive intercourse in past year
    2. Urine Chlamydia PCR if anal insertive intercourse in past year
  3. HIV Test
    1. Test at least annually in high risk patients (offer for all annually)
  4. Hepatitis A Serology
    1. Hepatitis A Vaccine if not immune
  5. Hepatitis B Serology (e.g. HBsAg)
    1. Test at least annually in high risk patients (offer for all annually)
    2. Hepatitis B Vaccine if not immune
  6. Hepatitis C
    1. Screen at least annually in high risk patients
    2. High risks include IVDA history, HIV Infection, multiple sex partners, unprotected sex
  7. Herpes Simplex Virus Testing
    1. Consider sceening for Genital HerpesSerology if status unknown (per CDC)
  8. Syphilis Screening (e.g. RPR, VDRL)
    1. Screen annually (esp. in high risk groups)

VII. Evaluation: STD Screening in low risk groups

  1. Criteria
    1. Monogamous relationship OR
    2. Consistent Condom use
  2. Testing is optional
    1. Annual HIV Test
    2. Other Sexually Transmitted Infections (see above)

VIII. Evaluation: STD Screening in high risk groups

  1. Criteria
    1. Multiple sexual partners OR
    2. Inconsistent Condom use
  2. Evaluate every 3 to 6 months evaluate STI risks
    1. See Immunizations below
    2. Obtain HIV Test and Hepatitis B testing at least annually
    3. Consider annual testing of Hepatitis C
    4. Gonorrhea and Chlamydia testing as described above
    5. Reinforce prevention practices below (includes Immunizations and HIV prevention)
    6. Consider additional tests as above

IX. Prevention

  1. See Health Maintenance in Men
  2. General measures
    1. Always use Condoms
      1. Exception: Longterm monogamous couples without STI
    2. Stay aware of partner's Sexually Transmitted Infection (STI) status
    3. Avoid high risk behavior (e.g. sex while intoxicated, multiple sexual partners)
  3. Immunizations
    1. Hepatitis A Vaccine (per CDC)
    2. Hepatitis B Vaccine (per CDC, USPTF)
    3. HPV Vaccine
      1. Indicated in all males age 26 years and younger
      2. Offer to Men who have Sex with Men, ages 27 to 45 years old
    4. Meningococcal Vaccine
      1. Indicated in Men who have Sex with Men (MSM) AND one other risk factor (e.g. healthcare career)
  4. HIV Prevention
    1. See HIV Preexposure Prophylaxis
    2. See HIV Postexposure Prophylaxis
  5. Anal Cancer (due to HPV Infection)
    1. Digital Rectal Exam yearly (IDSA)
      1. Exam for hard irregular lumps or ulcers, or localized thickening
    2. Baseline and annual anal pap test indicated in HIV Infection (per NY Dept Health)
      1. Controversial and operator dependent
  6. Mental Health Screening
    1. Higher risk for Intimate Partner Violence, and for victimization and threats of Violence
    2. Higher risk of Homelessness and poverty
    3. Major Depression rates in MSM are >17% (>40% if HIV positive)
    4. Suicidality risk is highest in Homelessness, Substance Abuse, Bullying, parental abuse and victimization
    5. Substance use during sex (ChemSex)
      1. Higher risk of Major Depression, Anxiety Disorder and other Substance Abuse

X. Complications: Sexually Transmitted Infections in Men who have Sex with Men (MSM)

  1. Chlamydia
    1. As with Gonorrhea, rectal and anal infections are often missed
  2. Gonorrhea
    1. As with Chlamydia, rectal and anal infections are often missed
    2. Higher risk with HIV Infection, recreational drug use
  3. Hepatitis A
    1. Men who have Sex with Men (MSM) represent 10% of new cases
  4. Hepatitis B
    1. Men who have Sex with Men (MSM) represent 20% of new cases
  5. Hepatitis C
    1. Higher risk with HIV Infection, receptive intercourse, multiple partners
    2. Global Prevalence in MSM 1.5% if HIV negative and 6.3% if HIV positive and >30% if IVDA
  6. Genital Herpes
    1. Higher risk of acquiring HIV Infection
  7. HIV Infection or AIDS (Relative Risk: 44)
    1. Men who have Sex with Men (MSM) account for >50% of those with HIV, and >60% of those newly diagnosed
    2. Highest risk group is, black MSM 13 to 24 years old
  8. Human Papillomavirus (HPV) and Anal Cancer (Relative Risk: 17)
    1. Higher risk with HIV Infection
    2. HPV (esp. types 16 and 18) causes 88% of anal cancers in MSM
  9. Proctocolitis (infectious Proctitis, enteritis)
    1. Gonorrhea, Chlamydia, HSV, Syphilis and Lymphogranuloma venereum transmitted via receptive anal intercourse
  10. Syphilis
    1. Increasing risk among Men who have Sex with Men (MSM), especially among minority groups
    2. Prevalence in MSM cohort is as high as 5-10% in U.S. (esp. HIV positive patients)
  11. Monkeypox
    1. Peaked in 2022 in U.S. and since then Prevalence has been low
    2. Two Vaccine options are available for high risk patients

XI. References

  1. Knight (2015) Am Fam Physician 91(12): 844-51 [PubMed]
  2. Mayer (2012) Lancet 380(9839): 378-87 [PubMed]
  3. McMullan (2024) Am Fam Physician 109(4): 324-32 [PubMed]

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