Gay Health

BASICS

MSM: men who have sex with men; behavior-based term regardless of sexual orientation
Sexual orientation is independent of gender identity
MSM face disparities in healthcare access, mental health, substance use, and STI burden
Minority stress and structural barriers contribute to health disparities
Primary care should deliver equal quality care regardless of orientation

CDC and USPSTF recommend at least annual screening for HIV, syphilis, gonorrhea, and chlamydia at all sites of contact
Hepatitis B serology and vaccination for susceptible MSM
Hepatitis C screening once in lifetime for all, annually if HIV-positive MSM
Hepatitis A vaccination recommended, but routine screening not required
Annual digital anorectal exam for anal cancer screening; anal cytology screening remains controversial
Routine vaccination per ACIP: Hep A, Hep B, HPV (11–26 years, possibly beyond), meningococcal (MenB and MenACWY), and smallpox/monkeypox in high-prevalence areas
Cultivate nonjudgmental, welcoming clinical environment to reduce stigma

Use 5Ps approach: partners, practices, protection, past STI history, pain/pleasure
Screen behaviors increasing STI risk: multiple partners, anonymous sex, inconsistent condom use, substance use, sex work
Screen all sexually active MSM annually for HIV, syphilis, gonorrhea, chlamydia (urethral, rectal, pharyngeal sites)
Hepatitis C screening at initial visit, annually if HIV-positive
Monitor for sexual transmission of enteric pathogens (Shigella, E. coli, Campylobacter, Giardia)
Monitor recent monkeypox outbreaks concentrated in MSM

MSM account for 69% of new HIV cases (2018 data)
Disproportionately affects Black, Latinx MSM, young MSM, and transgender women
Up to 44% unaware of HIV status
PrEP reduces HIV transmission by >90% with adherence
Indications for PrEP: HIV-negative, sexually active, non-monogamous or partner HIV-positive, recent STI, unprotected sex
FDA-approved PrEP regimens: oral TDF/FTC, TAF/FTC (renal-sparing), injectable cabotegravir
Follow-up every 3 months for HIV/STI testing; renal function monitored semiannually
PEP indicated within 72 hours of exposure; 28-day course of antiretrovirals recommended

MSM have 5-fold higher incidence than general population; risk increased up to 168-fold if HIV-positive
Linked to high-risk HPV types 16 and 18
Anal cytology screening considered for high-risk (esp. HIV-positive), but evidence for routine screening limited
HPV vaccine recommended ages 11–26, consider beyond 26 in MSM

MSM have higher rates of substance use and disorders
“Chem sex”: drug use concurrent with sex (poppers, stimulants, GHB, ketamine, alcohol)
Associated with increased sexual risk-taking and STI/HIV transmission
Harm-reduction based cognitive behavioral therapy effective
Avoid stigmatizing assumptions about substance use

Mental illness rates 2-3 times higher in MSM compared to other men
Elevated suicide and self-harm risk, especially in youth due to stigma, bullying, rejection
Screen for mental health, support family/peer connections, and community acceptance

High prevalence of physical (~21%) and psychological (~50%) abuse in sexual minority men
IPV in MSM may be underrecognized or dismissed
Screen privately and connect to LGBTQ-friendly resources

Obtain sexual orientation and behavior confidentially for all patients
Take inclusive, detailed sexual histories without assumptions
Use culturally appropriate terminology (“top,” “bottom”)
Provide tailored counseling on safer sex, PrEP, PEP, and substance use harm reduction
Create welcoming environments with LGBTQ-positive materials and symbols

Safer sex and risk reduction strategies: condoms, PrEP, PEP, limiting substance use during sex
Access to LGBTQ-specific resources for mental health, substance abuse, IPV

Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.
Centers for Disease Control and Prevention. Men who have sex with men (MSM). https://www.cdc.gov/std/treatment-guidelines/msm.htm. Accessed July 30, 2023.
Centers for Disease Control and Prevention. US Public Health Service: Preexposure prophylaxis for the prevention of HIV infection in the United States—2021 Update: a clinical practice guideline. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prepguidelines-2021.pdf. Accessed July 30, 2023.