MSM - Men who have sex with men

Overview

  • Most sexually transmitted infections (STIs) are asymptomatic. Testing and treatment of asymptomatic men who have sex with men (MSM) is the most effective method to interrupt transmission and reduce the burden of illness.
  • In particular, syphilis is increasingly common, is often asymptomatic, and can cause significant morbidity.
  • The main barriers to STI control are insufficient frequency of testing and incomplete testing in MSM. For example, chlamydia and gonorrhoea tests should be performed at all three sites (swab of oropharynx and anorectum, and first pass urine), and syphilis serology should be performed every time a HIV test or HIV treatment monitoring is performed.
  • HIV is now a medically preventable infection. All men who are eligible under the Australian HIV Pre-Exposure guidelines should be actively offered PrEP: www.ashm.org.au/HIV/PrEP
  • All people with HIV should be advised to commence treatment and, where possible, have an undetectable viral load.

These guidelines are intended for all MSM, including trans men who have sex with other men.

Testing advice

After appropriate pre-test discussion, all of the STI tests listed should be offered:

3-monthly testing for sexually transmitted infections in all men who have had any type of sex with another man in the previous 3 months*

 

Blood Tests

NAAT/PCR^ tests for gonorrhoea and chlamydia:

 

  • HIV antibody/antigen: If not known to be HIV-positive

 

  • Hepatitis A antibody: Test if not vaccinated. Vaccinate if antibody negative

 

  • Hepatitis B surface antigen, core antibody, surface antibody: Test if not vaccinated. Vaccinate if no history or documentation of full vaccination course

 

  • Hepatitis C: Test once a year in people living with HIV, on PrEP or with history of injecting drug use
  • Oropharyngeal swab
  • First pass urine defined as the first part of the urine stream, not the first urine of the day

 

 

 

 

 

 

 ^NAAT - Nucleic Acid Amplification Test test e.g. Transcription- Mediated Amplification (TMA), Strand Displacement Amplification (SDA), Polymerase Chain Reaction (PCR).

 

* Men who have sex with men (MSM) who are not sexually active or in monogamous relationships may be tested less frequently, but at least annually.

 

Specimen collection

Clinician collected |
Self-collection

Screening for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) using NAAT/PCR. Confirmation of positive NG result by culture is not necessary and should not delay treatment, but to assist surveillance for antimicrobial resistance, gonorrhoea culture should be collected prior to administering antibiotics. 

All people living with HIV should be tested for STIs three-monthly, including a blood test for syphilis (even if they are only having six-monthly viral load monitoring) unless they are not sexually active or are at low risk.

All HIV-positive MSM should have at least annual HCV testing.



Infections for which testing is not recommended: 

Lymphogranuloma venereum (LGV): asymptomatic testing not recommended. Pleas see anal-rectal syndromes for testing patients with proctitis.

Sexually transmitted hepatitis C virus
is rare in HIV-negative MSM, and testing is not recommended unless blood-borne virus risk factors are present (e.g. injecting drug use) or if the patient is on PrEP, to align with PrEP guidelines.

Herpes simplex virus:
serology is not recommended in any group due to unclear benefit and and difficult interpretation of results.

Mycoplasma genitalium
testing in asymptomatic MSM is not recommended because the benefits of screening have not been established. Testing recommendation in symptomatic MSM or contacts of infection can be found at mycoplasma genitalium.

Trichomonas vaginalis
is rare in MSM and asymptomatic testing is not recommended.

Human papilloma virus (HPV)
testing in asymptomatic MSM is not recommended because the benefits of screening and optimal screening technology have not been established. However, an annual digital anorectal examination for HIV-positive MSM older than 50 years is advised to detect early HPV-related anal cancers.

For trans MSM with a cervix, cervical screening tests are recommended in accordance with national guidelines. Self collected swabs may be an option for eligible people - National Cervical Screening Guidelines.



Follow up

PrEP 
PrEP is highly effective in preventing HIV infection and should be actively offered to any person at medium or high risk. All patients taking PrEP or eligible for it should be tested three-monthly, including STIs and renal function, in accordance with Australian PrEP guidelines: www.ashm.org.au/HIV/PrEP

Repeat testing 
Patients with any positive test should be tested every three months to detect re-infection and because they may be at ongoing risk of other STIs. 

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.

References

Australian Sexually Transmitted Infection & HIV Testing Guidelines 2019

Last Updated: Monday, 10 February 2020