1. MSM: Factors Potentiating HIV/STI Epidemics Kenneth H. Mayer, M.D.
STI 2018 Pre-Conference, Amsterdam
July 21st, 2018

2. Multifactorial Drivers of MSM HIV/STI Risk
Biology
Anal intercourse ↑susceptibility to HIV and STI
Role versatility: receptive can be insertive, ↑ efficiency
Individual Behavior
Number of partners over time
Social Networks (↑ risk of encountering HIV/STI)
Sexual venues, e.g. bathhouses, social media
Assortative mixing in sub-groups, e.g. minorities
Structural/Societal
Homophobia → early developmental stress → syndemics → depression, lack of self-efficacy, and risk
Criminalization and discrimination in health care settings delay receipt of timely health services

3. “MSM” is an epidemiological term People’s lives are more complex
One size does not fit all
MSM Cosmology in Mumbai

4. HIV/STD Prevalence Among Mumbai MSM
(Mayer et al, STD, 2015)
Infection
Married MSM
(N=95)
Unmarried MSM
(N=212)
P-Value
Crude
RDS adjusted
HIV
9.5%
14.4%
7.6%
14.3% NS
Syphilis
4.3%
1.0%
3.9%
8.3%
Gonorrhea
3.2%
8.5%
3.3%
5.3%
Chlamydia
13.8%
14.0%
8.0%
9.2%
Any STD
17.9%
18.3%
12.7%
20%

5. Different practices transmit different infections
HIV mainly transmitted via penile-rectal sex
Syphilis readily transmitted via most mucosal contact, including fellatio
Efficiency of GC/CT transmission via receipt of oral oral sex debated
Kissing and GC transmission debated
Condoms less protective for viral STI

7. Sexual positioning among American MSM (Spicknall, IUSTI meeting, 2018; NSFG, 2011-2015)
Among men who have had sex with other men in the past year, (click) only 46% reported versatility (meaning both insertive and receptive anal sex) in the past year.
(click) 20% reported insertive anal sex and not receptive anal sex in the past year, (click) and only 8% reported receptive anal sex and not insertive sex in the past year.
Surprisingly, 27%, of men reported exclusively oral sex with other men.

8. Condomless anal sex can lead to mucosal changes that increase HIV risk without STI
41 HIV- MSM who reported condomless receptive anal sex (CRAS) with an HIV- partner were compared to 21 who never engaged in CRAS
Rectal CD8+ T cells in CRAS+ MSM showed greater proliferation status (i.e. ↑ Ki-67, CD38, CCR5, α4β7)
Rectal CD4+T cells showed ↑ IL-17, and CD8+T cells showed ↑ pro-inflammatory cytokines
Rectal microbiota of CRAS+MSM was enriched for prevotellaceae, associated with mucosal injury and repair.
Kelley, Mucosal Immunol, 2017

9. Rectal gonorrhea and syphilis are predictive of future HIV infection
Let’s switch gears to look at STI infection among HIV-negative men and what that means for future HIV infection.
In an STD clinic population in Seattle & King County, more than 20% of individuals with a rectal GC infection acquired HIV over 5 years of follow-up. Those with early syphilis were also highly likely to acquire HIV infection over the follow-up period. These data again emphasize the overlap of sexual networks that facilitate rectal GC and syphilis transmission and those networks that facilitate HIV transmission.
Katz et al. Sex Trans Dis. 43(4): , 2016.
Also Bernstein et al from SF and Pathela et al from NYC

10. STIs among MSM in South Africa and Nigeria
STI among MSM in Nigeria
Lagos
Gonorrhea 28.1%
Chlamydia 18.3%
Syphilis 19.6%
All Asymptomatic
STI among MSM in South Africa
Source : Babajide Keshinro, MHRP, Nigeria, Kevin Rebe, Anova Health Institute, South Africa

11. Increasing bacterial STI rates include HIV+ and HIV- GC, CT, Syphilis, by HIV status and PrEP Use (Fenway Health, )
Mayer, OFID, 2017

12. Factors associated with ↑STI risk: 3 US snapshots
19.2% of MSM diagnosed with syphilis reported meth use and 36.4% met sex partners online1
Rectal GC assoc. with anonymous sex in HIV+ MSM, but with substance use among HIV- MSM2
Of 454 Black and 349 White MSM in Atlanta, Black MSM were more likely to be younger, bisexual, unemployed, poorer. They had fewer anal partners, but more racially concordant partners, and were more likely to have rectal CT or GC.
Chew Ng, AJPH, 2012
Kim, STD, 2003
Sullivan, PLoS ONE, 2014

13. Black and Latino MSM using mobile phones and internet for sex had ↑STI rates
853 Black and Latino MSM were recruited online and via community venues
23% reported an STI in the prior year.
29% reported using a mobile phone app for sex.
28% reported using an internet site to meet sex partners
22% used both.
Adjusting for N of partners, HIV status, and demographic variables, MSM reporting using both mobile phone and computer-based sites were more likely to report an STI (AOR=2.59, 95% CI )
Allen, STD, 2017

14. Prevalence of meeting sex partners online among MSM in SSA by country and age
Source : Stahlman, et al, JMIR, 2015

15. Associations of Meeting Male Sex Partners Online among MSM
Lesotho (n=530)
Swaziland (n=322)
Source : Stahlman, et al, JMIR, 2015

16. Prevalence_____ HIV 2.3% HCV 2.2% Syphilis 2.0% GU CT 1.0% GU GC 0.1%

17. Is group sex a higher-risk setting for HIV/STI, compared to dyadic sex, for MSM?
35% of 465 MSM participating in Amsterdam cohort studies reported some group sex
Condomless sex was more often reported during dyadic than group sex, OR=3.6 (95% CI )
Men who reported group sex were more likely to be diagnosed with gonorrhea compared to those who only reported dyadic sex, OR= 1.71 (95% CI ) but this did not persist in multivariable model
Paradox: more condom use in group sex, but greater STI risk, possibly because of more partners and inconsistent condom use
van den Boom, STI, 2016

18. Mental Health Issues
40% of MSM become depressed, X the lifetime rate of heterosexuals
Predictors of major depression are: not having a partner, experiencing anti-gay threats or violence, non-identification as gay
Panic disorder, social phobia, generalized anxiety disorder are more common among MSM (20% lifetime incidence)
Culturally-tailored treatment may involve groups that enhance community identification
(Sandfort, Arch Gen Psych, 2001; Gilman, AJPH, 2001; Lewis, Health Place, 2010; Safren, Health Psychology, 2012)

19. Depression and HIV/STI among MSM in Lesotho
527 MSM completed structured survey instrument, biologic testing for HIV and Syphilis
Defined positive depression screen as a PHQ-9 score of 10 or more
Outcome variable
Adj. OR
95% C.I.
Lab test result:
Positive for syphilis
2.75*
1.07, 7.08
Positive for HIV
1.58
0.85, 2.94
Self-report:
Diagnosed with any STI, past 12 months
2.04*
1.02, 4.06
Diagnosed with HIV
1.27
0.61, 2.63
Sources: Stahlman, et al, AIDS Behav, 2015

20. Homophobia impedes addressing HIV/STI
Prejudice, threats and violence against MSM,
Criminalization of same sex behavior,
Lack of training for health care workers
All lead to avoidance of care
Cultural competence training programs exist, so providers should be able to create welcoming environments (
(Gonser, J Cult Divers, 2000; Meyer, AJPH, 2001; Mayer, AJPH, 2008; Bettancourt, Cultural Competence in Health Care, 2002)

21. Conclusions MSM HIV/STI burden is multifactorial
Drivers include unique biology, patterns of behavior, networks, efficient venues to meet partners, internalized stigma due to societal homophobia which may lead to risky behaviors.
In the era of TasP and PrEP, STI rates may continue to increase, unless
-societal discrimination is reduced
-health care systems are more responsive
-community education is enhanced

22. Thank you Stef Baral Linda-Gail Bekker Chris Beyrer Andrew Grulich
Jeanne Marrazzo
Tim Menza
Matthew Mimiaga
Conall O’Cleirigh
Kevin Rebe
Sari Reisner
Steven A. Safren
Ian Spicknall
Ron Stall
Patrick Sullivan
NIAID, NIMH, NIDA, NICHD, CDC, HRSA,
Mass DPH, Gilead, ViiV