MSM - Men who have sex with men
Overview
- There is a high prevalence and incidence of almost all STIs in men who have sex with men (MSM).
- More than 80% of newly acquired HIV and greater than 90% of syphilis and gonorrhoea diagnosed in major cities and regional areas are diagnosed in MSM.
- Anal and throat STIs are particularly unrecognised and under detected.
- HIV positive MSM are at risk of other STIs because of higher unprotected anal intercourse with casual partners (UAIC).
Testing advice
All of the STI tests listed in the table below should be offered to all MSM at least once a year.
All MSM who fall into one or more of the following categories should be offered testing up to 4 times a year:
- any unprotected anal sex
- more than 10 sexual partners in six months
- participate in group sex
- use recreational drugs during sex
- HIV-positive MSM should have:
- syphilis testing at each occasion of CD4/VL monitoring
- chlamydia/gonorrhoea testing should be considered at each occasion of CD4/VL monitoring.
| Infection | Consideration |
|---|---|
| Gonorrhoea | Collect ano-rectal swab and pharyngeal swab. Consider Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. Urethral gonorrhea is rare in men without urethral symptoms, so urethral/urine testing is not recommended in asymptomatic men. However, combined Chlamydia trachomatis / Neisseria gonorrhoea assays are typically used in Australian laboratories. |
| Chlamydia | Collect FPU, ano-rectal swab and pharyngeal swab. Consider Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. The prevalence of gonorrhoea and chlamydia is different in the throat and urethra. However, currently most Australian laboratories use a combined chlamydia and gonococcus NAAT test. |
| Syphilis |
If clinical suspicion of syphilis, refer to the syphilis guideline. |
| Hepatitis A |
Vaccinate if not immune. Further testing unnecessary after completing vaccination. |
| Hepatitis B |
Vaccinate if not immune. Consider serological testing after completing vaccination if high risk. |
| Hepatitis C |
Test if concurrent HIV or if history of injecting drug use. Hepatitis C is not considered an STI except between HIV infected men having unprotected anal sex. |
| HIV |
Repeat test if patient exposed within previous 12 weeks (window period). |
| NAAT - Nucleic Acid Amplification Test FPU – First pass urine |
|
Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Clinical indicators for testing:
- It is not recommended to routinely test for herpes and genital warts with serology. Consider testing for herpes and genital warts only if there are clinical signs and symptoms.
- Seek specialist advice about diagnostic testing for other less common, non-routinely screened infections such as M. genitalium.
- STIGMA Guidelines provides additional information.
Follow up
Consider discussing the availability of non-occupational post-expoure prophylaxis and pre-exposure prophylaxis.
If test results are positive, refer to the management section for the relevant STI:
Even if all test results are negative, use the opportunity to:
- Educate about condom use and risk minimisation
- Vaccinate for hepatitis A and B, if susceptible
- Consider vaccination for human papillomavirus (HPV), depending on age and number of sexual partners
- Discuss recreational drug use and harm minimisation
- Discuss and activate clinical and personal reminders for regular testing according to risk, especially if their behaviours indicate the need for more frequent testing
Auditable outcomes
90% of MSM are screened according to these guidelines.