Basics
Description
- A recent National survey showed that 3.4% of all Americans identify themselves as lesbian, gay, bisexual, or transgender (LGBT). This may be an underestimation as men and women between 18 and 29 years old are more likely to identify themselves as LGBT at 4.6% and 8.3%, respectively.
- These percentages may not reflect all men who have sex with men (MSM). MSM may identify themselves as gay, bisexual, homosexual, or heterosexual. Current studies suggest 8% of the U.S. population engage in same-gender sexual activity.
- LGBT individuals may hide their orientation in fear of stigma and discrimination, which may be exploited.
- The 2012 U.S. census reported a total of over 305,000 households headed by male same-sex partners.
- Primary care specified toward MSM will be addressed here; lesbian and transgender health care will be discussed under their respective topic headings.
General Prevention
- It is recommended that MSM should receive hepatitis A and B immunizations (1)[A].
- Centers for Disease Control and Prevention (CDC) recommends testing for hepatitis B (1)[A].
- CDC does not recommend testing for hepatitis C unless individuals were born from 1945 through 1965, have HIV, or engage in risky behaviors (i.e., sharing needles or other equipment of injected drugs, unprotected sex, or multiple partners) (1)[A].
- Screening for hepatitis A infection is not recommended.
Diagnosis
- Sexually transmitted infections (STIs)
- STIs among MSM are increasing. Behaviors that increase risk of non-HIV STI also increase risk of HIV acquisition.
- Risk factors include the following:
- Higher numbers of lifetime sex partners
- Higher rates of partner change
- Unprotected sex
- Studies among Black and Hispanic MSM have linked financial hardship and poor emotional or social support with increased sexual risk-taking behaviors.
- Physicians should advocate for safe sex practices to include routine use of barrier methods.
- In 2008, MSM accounted for 63% of new cases of primary and secondary syphilis (1).
- Annual screening of asymptomatic sexually active gay men should include syphilis, chlamydia, and gonorrhea.
- Urine testing with nucleic acid amplification testing (NAAT) for Neisseria gonorrhoeae and Chlamydia trachomatis for insertive intercourse within the last year
- Rectal swab NAAT for N. gonorrhoeae and C. trachomatis for anal receptive intercourse within the last year
- Pharyngeal swab NAAT for N. gonorrhoeae for oral receptive intercourse within the last year. Pharyngeal swab for C. trachomatis is not recommended (1)[A].
- HIV
- 56% of persons living with HIV in the United States were MSM in 2010.
- 63% of new cases of HIV diagnosed in 2010 were among MSM (2).
- MSM represent 48% of all AIDS-related deaths in 2010 (2).
- There is a race discrepancy among young HIV-infected MSM between the ages of 13 and 24 years, where nearly 2/3 are African American.
- Sexually active MSM should be screened at least annually for HIV (1)[A].
- Educate MSM on preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) in the case of an unsafe sexual encounter.
- Indications for PrEP
- Adult man without HIV infection
- Any male sex partners in last 6 months
- Not in monogamous relationship with an HIV-negative man
- And at least one of the following:
- Anal sex without condoms in past 6 months
- Any STI diagnosed in past 6 months
- In a sexual relationship with HIV-positive partner
- The only FDA-approved regimen for PrEP includes daily oral combination of tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg in a single daily pill, which has shown to be safe and effective in reducing the risk of sexual transfer of HIV (3)[A].
- Additional medications or replacement with other antiretroviral medications is not recommended (3)[A].
- Although TDF alone is approved for heterosexual men and women as well as intravenous (IV) drug users, its use is not recommended in MSM as it has not been studied in this patient population (3)[A].
- Monitor HIV status every 3 months and renal function at least every 6 months.
- Indications for PEP
- ≤72 hours after exposure to known HIV-positive partner
- PEP not recommended if >72 hours or partner HIV negative.
- PEP generally involves 28-day course of highly active antiretroviral therapy (HAART) in a three-drug combination:
- Two nucleoside reverse transcriptase inhibitors (NRTIs) and either a protease inhibitor (PI) or a nonnucleoside reverse transcriptase inhibitor (NNRTI) or integrase inhibitor
- There are no data on the most efficacious PEP regimens.
- Selection of medications are based on side-effect profiles, patient compliance, and patient convenience.
- "Preferred"� regimens include the following:
- Efavirenz plus lamivudine or emtricitabine plus zidovudine or tenofovir
- Lopinavir/ritonavir (Kaletra) plus lamivudine or emtricitabine plus zidovudine
- Counsel on safer sex and risk reduction for repeated exposures.
- Cancer
- MSM that are HIV positive have an 80-fold increased risk for anal cancer.
- Anal carcinoma has been linked to certain high-risk subtypes of HPV.
- There is an increasing prevalence of anal HPV infection in MSM regardless of HIV status.
- Screening for anal dysplasia with anal cytology may be considered for at-risk populations, which include HIV-infected MSM, but further research is needed for appropriate screening intervals (4)[A].
- HPV vaccine is recommended for all boys age 11-12 years and young MSM through age 26 years (5)[C].
- Substance and tobacco abuse
- Alcohol and substance dependence is 1.5 times higher in gay, lesbian, and bisexual populations (6).
- Smoking is more common among gay men than heterosexual men.
- Counseling on tobacco cessation should be provided when appropriate.
- Alcoholism has also been found to be more prevalent among gay men than the general population.
- There is an increased use of methamphetamines among MSM.
- Substance abuse treatment programs implementing cognitive behavioral intervention from a harm reduction perspective is beneficial in reducing stimulant use and sexual risk-taking behavior.
- Behavioral health
- Risk of major depressive, bipolar, and anxiety disorders are 1.5 times higher in lesbian, gay, and bisexual population (6).
- Risk of deliberate self-harm is also increased among gay and bisexual men (6).
- Lifetime prevalence of suicide attempt is up to 4 times greater among gay and bisexual men compared to the general population (6).
- Rates of body image and eating disorders among gay adolescent and young men are also increased.
- Domestic violence
- Screen for intimate partner violence (IPV).
- Screen patient alone.
- "Does your partner ever hit, kick, hurt, or threaten you?"�
- "Do you feel safe at home?"�
- Despite rates of domestic violence among gay couples being equal to heterosexual couples, there is a lack of attention in IPV among the LGBT population as a whole.
- A National Violence Against Women survey found 21.5% of men reporting a history of cohabitation with a same-sex partner had experienced physical abuse in their lifetimes.
Ongoing Care
Obtaining a history �
- Establish with patients that information related to sexual orientation is asked of all patients to assist in health care prevention decisions.
- Providers should discuss with patients in an open and nonjudgmental fashion.
- Avoid labeling patient as gay, lesbian, bisexual, or transgender unless prompted by the patient.
- Issues to target include HIV/AIDS, infectious disease including STI, substance and tobacco abuse, behavioral health, domestic violence, and immunizations.
- Take into account the context in which risk-taking behaviors occur.
- Identify their sexual lifestyle with key questions.
- During your life, with whom have you had sexual contact?
- Do you have a significant other?
- Do you feel comfortable with your sexuality?
- Are you sexually attracted to men, women, or both?
- Have you ever been sexually active with men, women, or both?
Patient Education
- Counsel patients on importance of safe sexual practices to include barrier methods (i.e., condoms) and PEP.
- Educate patients on warning signs of depression and resources for treatment.
References
1.Workowski �KA, Berman �S; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110. �
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2.Centers for Disease Control and Prevention. Estimated HIV incidence in the United States, 2007-2010. HIV Surveillance Supplemental Report. 2012;17(4):1-26.3.U.S. Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States: Clinical Practice Guideline-2014. Washington, DC: U.S. Public Health Service. 2014;1-67.4.Machalek �DA, Poynten �M, Jin �F, et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol. 2012;13(5):487-500. �
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5.Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human papillomavirus vaccine in males-Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60(50):1705-1708. �
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6.King �M, Semlyen �J, Tai �SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008;8:70.
Additional Reading
- Ard �KL, Makadon �HJ. Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. J Gen Intern Med. 2011;26(8):930-933. �
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- Carrico �AW, Flentje �A, Gruber �VA, et al. Community-based harm reduction substance abuse treatment with methamphetamine-using men who have sex with men. J Urban Health. 2014;91(3):555-567. �
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- Centers for Disease Control and Prevention (CDC). HIV testing and risk behaviors among gay, bisexual, and other men who have sex with men-United States. MMWR Morb Mortal Wkly Rep 2013;62(47):958-962. �
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- Gates �GJ, Newport �F. Special report: new estimates of the LGBT population in the United States. The Williams Institute Web site. http://williamsinstitute.law.ucla.edu/resaerch/census-lgbt-demographics-studies/gallup-lgbt-pop-feb-2013/.
- Gay and Lesbian Medical Association. Guidelines for the Care of Lesbian, Gay, Bisexual and Transgender Patients. San Francisco, CA: Gay and Lesbian Medical Association; 2006. http://www.glma.org.
- Institute of �Medicine. The health of lesbian, gay, bisexual and transgender people: building a foundation for better understanding. Washington, DC: National Academies Press; 2011.
- Kreuter �A, Wieland �U. Human papillomavirus-associated diseases in HIV-infected men who have sex with men. Curr Opin Infect Dis. 2009;22(2):109-114. �
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- Smith �DK, Grohskopf �LA, Black �RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep. 2005;54(RR-2):1-20. �
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- van der Zee �RP, Richel �O, de Vries �HJ, et al. The increasing incidence of anal cancer: can it be explained by trends in risk groups? Neth J Med. 2013;71(8):401-411. �
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Codes
ICD09
- V73.89 Special screening examination for other specified viral diseases
- V01.79 Contact with or exposure to other viral diseases
- V69.2 High-risk sexual behavior
- V01.6 Contact with or exposure to venereal diseases
- V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis
ICD10
- Z11.59 Encounter for screening for other viral diseases
- Z11.4 Encounter for screening for human immunodeficiency virus
- Z72.52 High risk homosexual behavior
- Z20.2 Contact w and exposure to infect w a sexl mode of transmiss
- Z20.6 Contact w and (suspected) exposure to human immunodef virus
- Z20.828 Contact w and exposure to oth viral communicable diseases
- Z23 Encounter for immunization
- Z72.53 High risk bisexual behavior
SNOMED
- 252404004 Hepatitis A antigen screening (procedure)
- 171121004 Human immunodeficiency virus screening (procedure)
- 288311000119103 High risk homosexual behavior (finding)
- 444451006 Exposure to sexually transmissible disorder (event)
- 171122006 Hepatitis B screening (procedure)
- 288291000119102 High risk bisexual behavior (finding)
Clinical Pearls
- Sexually active gay men should be offered annual screening for HIV, syphilis, gonorrhea, and chlamydia.
- Immunize gay men for hepatitis A and B as well as HPV for all young men through age 26 years.
- Routine screening for substance misuse, behavioral health conditions as well as IPV in this population should be performed regularly.