Dr Katie Conway

1. STIs in men who have sex with
men (MSM)
Dr Katie Conway
October 2015

2. Introduction
• Epidemiology of STIs in MSM
• Reasons for high rates in MSM
• Changing epidemics
• Cases
• Learning points

3. Epidemiology

4. PHE report on MSM in London - 2014
• 2% of London adult population
• 24% of all new STI diagnoses
• Rising rates of STIs
– 46% syphilis
– 32% gonorrhoea
– 26% chlamydia
• High re-infection rates
• High burden of gonorrhoea and syphilis
Public Health England: HIV and STIs in men who have sex with men in London, September 2014

5. Public Health England: HIV and STIs in men who have sex with men in London, September 2014

6. Percentage of all STI diagnoses in men which were
among MSM: England, 2009-2013
39 Public Health England: 2013 STI Slide Set
• Data from routine GUM service returns
• * First episode; **Includes diagnoses of primary, secondary & early latent syphilis
• Chlamydia data from 2012 onwards are not comparable to data from previous years (please see ‘Notes’ slide for more details)
• Data type: service data

8. HIV
• 50% new diagnoses are in MSM
• Globally MSM have disproportionate burden
of HIV infection

9. Epidemiology

11. HIV in SriLanka
National STD/AIDS Control Programme Annual Report 2014

12. Sunday Observer -27/11/2011
http://www.sundayobserver.lk/2011/11/27/fea06.asp

13. STI / HIV transmission in MSM
Biological
Behavioural
Social

14. HIV transmission in MSM
• Biological factors
– Receptive anal sex
– Concurrent STIs – often asymptomatic

15. Behavioural
• High partner numbers:
– EMIS1 2010: 60% sexual contact within 7 days
70% >1 partner within 12 months
HIV –ve MSM 34% 10 partners in 1 year
– NATSAL 20002: Skewed distribution
Median 1 partner per year
15% > 10 partners per year
– Overlapping / concurrent partners
– Sexual mixing of MSM with high and low partner no.s
1EMIS. Vital Statistics 2010:The UK Gay Men's Sex Survey Data Report All London SHA by PCT area
of residence. 2010.
2Mercer C Fk et al. Increasing prevalence of male homosexual partnershipsand practices in Britain
1990-2000: evidence from national probability surveys. AIDS 2004. 2004;18:1453-8.

16. Behavioural
• Survey MSM London gyms3: 36% UPAI in last 3/12
• EMIS1: 40% UPAI last sexual intercourse
• GMSHS, 20084; in the last year:
– UPAI in HIV +ve MSM – 57.7% (49.6% in 2000)
– UPAI in HIV –ve MSM – 46.6% (42.2% in 2000)
• Seroadaptive behaviour
• ‘Chemsex’
3Lattimore S TA et al; Changing patterns of sexual risk behavior among London gay men: 1998-2008. Sex Transm
Dis. 2011;38(3):221-9.
4Wayal S FS et al; Gay Men's Sexual Health Survey, London 2008. Centre for Sexual Health & HIV Research,
Research Department of Infection & Population health, University College London, 2008.

17. Other factors
• Stigma
• Rates of engagement with services (UK)
• Often ‘hidden’ epidemics in many countries
• Often difficult partner notification
• High rates of depression / mental health
problems

19. Depression and sexual behaviour in
MSM – Aurah study. BASHH 2015

20. STIs in MSM
Specific epidemics:
• Lymphogranuloma Venereum (LGV)
• Shigella flexneri
• Hepatitis C (HCV)
• Syphilis

21. LGV
• Chlamydia trachomatis
• D to K = genital infection
• L1 , L2 & L3 = lymphogranuloma venereum (LGV)
– Infect lymphocytes & macrophages
– Invasive pathogens
• Primary – ulcer / proctitis (98%)
– Incubation period 4-21 days
• Secondary – inguinal syndrome
– Incubation period 10 days to 6 months
• Tertiary stages

22. 1980s
Original
descriptions of
MSM with LGV
proctitis in
Seattle & San
Francisco
1990s
LGV not
reported
in Western
MSM
Jan
2003
First of four cases of
LGV in Hamburg
MSM, 2003
Australian
LGV L2 bubo
case - no
travel history
Aug
2004
Dutch LGV
cases reach
>100
Sep
2004
Oct
2004
First US cases in
San Francisco
Nov
2004
Dec
2004
Barcelona
case
First
Swedish &
Canadian
cases
Jan
2004
Appearance of LGV in
Rotterdam, then
Amsterdam, Antwerp
and Paris
Feb
2003
Sustained
LGV
outbreaks
within
Europe, UK
and USA
2005-2014
2000
to
2003
Retrospective analysis of MSM
rectal specimens Amsterdam,
Paris and London = 126 cases
LGV L2
A recent timeline of LGV infection in MSM

23. LGV
Public Health England: HIV and STIs in men who have sex with men in London, September 2014

24. LGV
• Associations:
– 82% HIV +ve; 20% Hep C Ab +ve
– UPAI
– Fisting
– Partners through the internet / saunas / sex
parties
– Dense sexual networks
– Simultaneous contacts
– Poly-drug use
Health Protection Agency. Syphilis and Lymphogranuloma Venereum: Resurgent
Sexually Transmitted Infections in the UK. In: Agency HP, editor. 2009.

25. Shigella flexneri 3a isolates, adult males
with no/unknown travel history: 2005-2013
• 750% rise 2008-13
• 60% cases in London

26. Hepatitis C
• 2002-2006: 20% increase in incidence per year
• HIV positive MSM
• Associated with:
– Previous syphilis infection
– Another recent STI diagnosis
– UPAI
– IDU
– Recreational drug use
– High rates of partner change
Public Health England: HIV and STIs in men who have sex with men in London, September 2014

27. Syphilis
• Treponema Pallidum – spirochete bacterium
• Transmission – sexual / vertical /(blood borne)
• 1/3 sexual contacts of infectious syphilis will develop
disease
• 4 stages:
– Primary / secondary / early latent - infectious
– Late latent
– Tertiary
• Histopathological hallmarks:
– Endarteritis
– Plasma cell–rich infiltrate

29. Cases

30. Case 1
• 25 year old MSM, Italian
• No PMH / DH
• PC:
– Worsening perianal pain and discharge 2/12
– Accident and Emergency department 04/2015
– Admitted under surgical team
– Diagnosed with a fissure
– Discharged with diltiazem topical cream

31. Case 1
• Seen in surgical OP 6 weeks later
• Ongoing symptoms
• Took a sexual history and referred to GU clinic
• Examination:
– Perianal ulcer
– Rectal discharge and contact bleeding
• Full STI screen done
• Treated empirically with doxycycline and aciclovir

32. Case 1
• Provisional results:
– Treponema pallidum antibody positive
– RPR 1:64
– Ulcer swab – TP PCR positive (HSV negative)
– HIV 1 Ag/Ab positive
– Rectal CT NAAT positive
– Rectal GC NAAT positive
– Hepatitis C antibodies positive

33. Case 1
• Treated with:
– Ceftriaxone 500mg im
– Doxycycline completed 3 weeks
• LGV specific DNA positive
• HIV
– CD4 1446 cells/mm3
– VL 76000 copies/mL
• Hepatitis C RNA 4 million
• Genotype 1a

34. Issues
• Partner notification:
– Reported 1 RMP since last sexual health screen 3
months before
• Further management
– Offer HIV treatment
• Hepatitis C treatment - discuss
• Feedback to surgical team and A&E

35. Case 2
• 60 year old MSM
• HIV positive, stable on ART
• CD4 600, VL < 20 copies/mL
• RMP – monogamous relationship, 2 years
• Presented to GP with right inguinal lump
• Referred to surgeons ? Hernia
• US – lymph node mass

36. Case 2
• Discussed the differential diagnoses:
– Syphilis
– LGV
– Lymphoma
– Mycobacterial infection
– KS

37. Case 2
• Partner admits he was diagnosed with syphilis
few days ago…
• Treated with benzathine penicillin and
doxycycline 3/52 to cover both syphilis and
LGV

38. Case 2
• Results:
• TP Antibody positive
• RPR 1:128
• Rectal, throat and urine NAATs negative for
GC/CT
• After 1 week – LN still enlarged and painful

39. Case 2
• Repeat US – no collection
• FNA:
– no malignant cells
– AFB smear negative
– NAAT positive for chlamydia
– LGV specific DNA detected
• Completed 3 weeks of doxycycline
• Buboe ruptured
• Required a further 1 week Azithromycin until resolved

40. Case 3
• 46 year old MSM
• Unwell for >6 months
• Chronic diarrhoea
• Peeling skin
• “covered in rashes”
• Patchy alopecia
• Seen in private sector ? Psoriasis ? IBD

41. Hands

42. A week later

43. Feet

44. • Seen by several specialties
• Several investigations done including colonoscopies
• Treated with prednisolone and mesalazine for
?eosinophilic colitis and for psoriasis
• Everything got worse
• HIV serology: positive
• Last negative test was 18/12 before

45. • Referred to GU services
• Diagnosed with secondary syphilis
• Confirmatory serology:
– treponemal antibody detected
– RPR 1:512
• Rectal chlamydia & gonorrhoea positive
• Pharyngeal gonorrhoea positive
• Treated with doxycycline (penicillin allergy)

46. Post
treatment

48. RPR follow up
• Skin & hair much better
• Started ARVs
• Doing well
• Feedback to other specialties – gastro / derm

49. Case 4
• 35 year old eastern European man
• Found acting oddly on public transport
• Confused ?had a seizure
• Dropped GCS on admission
• Febrile & tachycardic
• HIV test positive

50. Imaging
• Initial CT Brain: low attenuation L internal capsule
?acute infarct
• Repeat 3/7 later: large R MCA infarct with midline
shift
• CD4 count 154 cells/mm3, VL 93703 copies/mL
• Wide differential: opportunistic infections vs non HIV

51. Other investigations
• CSF: WCC 27, protein 1.04, normal glucose
ratio
• CSF virology: negative
• Treponemal DNA DETECTED
• Serology:
– Treponemal antibody DETECTED
– RPR 1:256

52. MRI Brain

53. Conclusion:
• Large subacute right MCA territory infarct with
additional smaller infarcts in the left MCA and right ACA
territory.
• MRA shows distal ICA and MCA occlusion on the right side
and moderate to severe terminal ICA and A1/M1 origin
narrowing on the left side
Suggestive of a vasculitic process
Presumed diagnosis: meningovascular syphilis

54. Treatment
• Started on intravenous benzylpenicillin every 4hrs
• Also given steroids
• Unfortunately deterioration of condition despite full
active treatment
• Deemed in best interests to be DNAR
• Died within 4 weeks of admission

55. Learning points
• STIs and HIV common in MSM
• Often concurrent infections
• Often present to other services
• Communication and education very important
• STI epidemiology can change
• Surveillance is key
• In HIV, STIs are often atypical

57. Thank you for your attention!