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The past quarter century has seen an exponential growth in both the quantity and quality of research on sexually transmitted infections (STI) among men who have sex with men (MSM). This development has been in response to the substantial public health need for this research as distinct epidemics of STIs have emerged and become highly prevalent within MSM communities over the past 25 years. In addition, the challenges posed by the global AIDS epidemic have contributed in no small degree to the urgency with which researchers seek to find innovative ways to control STI epidemics among MSM. It has now become abundantly clear that if researchers can demonstrate the effectiveness of new approaches to the prevention, control and treatment of STI epidemics, important contributions will be made not only to the health of MSM communities but also the larger communities in which MSM reside.
The challenge of finding effective responses to STI epidemics among MSM is made more difficult by the adverse social and cultural settings in which MSM communities are often located.1 These hostile social settings, as well as the sexual risk and sexual partner turnover patterns found within many MSM communities,2 mean that standard approaches to STI control may need to be tailored if they are to be effective. Because the constellation of factors that drive STI epidemics among MSM is often unique, culturally competent approaches to public health practice, research design, theory and even clinical management must be developed and tested for effectiveness within these populations. Thus, both the substantial public health need for this research focus and the complexity of this research agenda suggests that the continuing evolution of a sub-specialty in STI research among MSM will serve the public’s health well. This special issue has been designed to further this goal and this editorial highlights several areas of increasing importance in the control of STIs among MSM.
THE NEED FOR A PUBLIC HEALTH RESEARCH AGENDA FOR MSM IN DEVELOPING WORLD SETTINGS
It was not so long ago that the very existence of homosexual behaviour was denied by highly placed public health officials across vast regions of the globe. Such denials have been made untenable both by the emergence of relatively open communities of MSM in societies around the world but also by the demonstrated importance of MSM sexual contacts in STI transmission in these same regions. However, these very recent historical denials reflect a pervasive homophobic cultural context that still exists in many countries—one that lessens the effectiveness of STI control efforts among MSM profoundly.1 These efforts can be compromised in a variety of ways, among them diminished access to medical care,3 particularly among men who experience homophobia in healthcare settings,4 the experience of violence that functions to raise sexual risk levels,5 broader sociological forces that raise vulnerability of MSM to STI transmission even further6 7 as well as aspects of emerging MSM culture itself.7 This list is far from exhaustive and other variables important to STI transmission and greater vulnerability to health problems among MSM in developing world settings will doubtless be expanded upon as this area of research continues to mature. That said, as is already clear from the existing literature, STI research among MSM must take a global view if our efforts to promote health in this population are to be realised. Hence, the field must make it a priority to find ways to improve the level of scientific, clinical and public health work among MSM communities in developing world settings. These advances may well be of benefit to MSM communities in both industrialised and developing world settings, especially if ongoing surveillance activities for MSM8 9 can also be used to monitor the rise of emerging infections that may spread through global MSM sexual networks.
IDENTIFYING CORRELATES OF STI INFECTIONS AND/OR RISK-TAKING
The identification of correlates of STI infections and/or risk-taking is useful in identifying the characteristics of men most vulnerable to STI transmission—insights that are in turn valuable in developing intervention strategies. These correlates may well change across time and across societies and their identification should be regarded as a fluid process. We are now in the position to observe the emergence of new correlates of STI risk among MSM that result from cultural or technological innovations, the identification of “new” correlates that result from theoretical advances as well as the enduring effects of “old” correlates. For example, papers in this issue explore newly emerging correlates of STI risk such as erectile enhancing drugs,10 the increasingly recognised effects of the sexual networks of MSM in enhancing STI risk, sexual self-control variables and life-course issues,11 12 as well as the long-established effects of contextual variables such as drug use during sex and other psychosocial health issues.13–15 It is highly likely that the list of established correlates of STI transmission risk will grow as this body of research is taken even further within a global health context. Despite these complexities, this ongoing body of work is necessary to ensure that both behavioural and biomedical interventions that are designed to control STI epidemics among MSM reach those at greatest risk and ensure that control strategies are culturally appropriate and actually implemented.
ACCEPTANCE BY MSM COMMUNITIES OF INTERVENTIONS TO PREVENT STI TRANSMISSION
In reading the literature on the development of behavioural, biomedical and structural interventions to prevent the spread of STIs among MSM, one might be excused for drawing the conclusion that acceptance of these innovations is easily achieved. This conclusion would be wrong, despite the fact that the current literature on intervention research is overwhelmingly concerned with developing interventions supported by evidence of efficacy with a much smaller emphasis on the challenges in translating these research innovations into standard public health practice. Experience has shown that the development of behavioural interventions to reduce high-risk sex requires substantial and ongoing development of capacity in community-based/non-governmental organisations if interventions are to be delivered with fidelity. Bringing these efforts to scale so that participation in these programmes by MSM is widespread will require considerable effort and creativity.
Even biomedical interventions such as vaccines to prevent STIs are not always met with widespread acceptance. For example, hepatitis B is a viral infection that can result in significant morbidity and even mortality among MSM, is highly prevalent in this group and for which a safe and effective vaccine exists. Yet the literature reports low uptake of the hepatitis B vaccine among MSM even given this epidemiological background. Other future biological interventions to prevent STI epidemics may not fare much better or be used in ways that disrupt full efficacy due to uptake and/or adherence issues; see Tai et al for a measure of uptake of long-standing biomedical screening technologies by MSM in the United States.16
Accordingly, the field would be well served by a greater emphasis on studying uptake of new STI interventions by MSM. Such research would not only focus on understanding more about the actual procedures that are used in practice by non-governmental organisations as they field “proven” interventions, but also to identify the individual and structural barriers to uptake of biomedical interventions. The editorial by McGowan17 makes a compelling case for the development of microbicides to prevent STI transmissions; the papers by Carballo-Dieguez et al18 and Alexander et al19 illustrate the careful work that must be done to ensure that these interventions are accepted. The editorial by Cranston20 shows that the issues of uptake are not restricted to patients alone: interventions to change clinical practice to ensure that the healthcare needs of MSM are met are also necessary. Without this focus, the field risks developing a set of interventions that yield efficacious results in randomised trials yet very little in the way of effectiveness in real world settings.
IMPROVING STI CONTROL AMONG MSM BY ADDRESSING INTERCONNECTED EPIDEMICS
One of the lessons that accrued from HIV research among MSM in industrialised countries is that these communities are often characterised by high prevalence rates of many different psychosocial conditions, among these substance use/abuse, depression and violence and victimisation, and these conditions are intimately interconnected with STI epidemics. In this edition we have a number of reports of co-occurring conditions that function to raise levels of risk among MSM.5 10 13–15 Thus, if we wish to improve the effectiveness of STI control efforts, we should find ways to partner with agencies whose mission is to combat epidemics of substance abuse, mental health problems and violence and victimisation among MSM.
Although this phenomenon is widely recognised, the procedures to address it have not been defined in terms of day-to-day STI control efforts. Perhaps a starting point to define best practice in this area would be to conduct re-analyses of behavioural intervention trials designed to lower rates of high-risk sex among MSM to measure the extent to which co-occurring psychosocial health conditions function to disrupt behavioural risk reduction within specific cities. Once these analyses are completed, it might then be possible to work with partner agencies that address co-occurring psychosocial health problems that are especially potent in terms of raising STI risks to combine forces to raise both psychosocial and sexual health levels among MSM in tandem. These sorts of demonstration projects are not amenable to randomised trials to prove efficacy, but might well be the source of new approaches supporting a broader health movement among MSM to which considerable effectiveness can be attributed.
STI PREVENTION AMONG HIV SEROPOSITIVE MSM
We cannot ignore the ongoing impacts of HIV in that MSM have been one of the communities most affected by AIDS—an onslaught that continues to exact a heavy toll among MSM communities.21 22 It should be noted that at the height of the MSM AIDS epidemic there were dramatic reductions in STIs as behavioural adaptations to AIDS resulted in increased levels of condom use and safer sex practices. Prior to 1996, a diagnosis of HIV was, in most cases, a death sentence. Post-1996, HIV positive MSM find themselves in a very different context.
Antiretroviral treatment (ART) has made possible very welcome benefits in terms of longevity as well as quality of life to people living with HIV. However, the extraordinary success of ART strategies to treat HIV has also functioned to raise the “prevalence pool” of sexually active HIV positive MSM, many of whom have lived for years with a death sentence hanging over their heads and who now, understandably, want to return to living full lives. For many MSM, this includes a rich sexual life and not all HIV positive men chose to restrict their sexual expressions to condom use every time that they have sex. Therefore, it is not a coincidence that we have seen upturns in STIs among MSM in developed countries where ART is widely available—that “old” STIs (such as syphilis) have returned and “new” STIs have emerged (lymphogranuloma venereum, hepatitis C). HIV positive men account for the majority of these cases (almost exclusively for lymphogranuloma venereum and hepatitis C) in many locations, partly due to the widespread practice of HIV “serosorting” (engaging in unprotected sex with partners of concomitant HIV status). While serosorting may not contribute to increased HIV transmission, it is very likely that it has facilitated the increase in other STIs among HIV positive MSM.
This is a major individual and public health challenge. How do we prevent the transmission of curable STIs (gonorrhoea, chlamydia, syphilis, lymphogranuloma venereum) in HIV positive MSM, many of whom perceive that they have already paid the full price of condomless sex and that other infections are somehow more benign? How, in short, do we best encourage sexual health among MSM living with HIV infection?
THE EFFECTS OF CULTURAL AND TECHNOLOGICAL CHANGES ON THE SEXUAL HEALTH OF MSM
One of the most welcome sociocultural developments that occurred as the 20th century drew to a close and the 21st century began has been the growing tolerance and even acceptance of lesbian, gay, bisexual, transgender (LGBT) communities around the globe. While much work to ensure human rights for LGBT populations remains to be done, and the rate of change across different regions of the world remains very uneven, it is probably fair to say that the legal and social contexts in which MSM in general find themselves have changed for the better over the past quarter century. The ongoing evolution of LGBT communities towards achieving full citizenship rights may also result in greater integration within the larger society in which these communities reside. If so, the pressure for MSM to aggregate within urban communities with very dense social and sexual networks may ease and MSM may adopt residential and social patterns that reflect their greater acceptance within the larger community. Thus, this profound cultural change may work to lower the prevalence of STIs among MSM by disentangling the very tight sexual networks that have historically existed within urban gay ghettos. Changes in relationship law, including the right of men to marry each other, may also contribute to this same outcome. The ongoing study of how greater social acceptability and increased citizenship rights of MSM affects how STI epidemics operate within MSM communities will be an area of study that will yield very important policy conclusions about how best to support health and wellbeing in marginalised communities.
The sociocultural changes described above are also occurring in an era of extraordinarily rapid technological change. MSM communities have been among the first to embrace these technologies and to use them to enlarge their social and sexual networks. The internet is now being used by MSM communities around the globe as a communications, community-building and sexual-networking tool. The internet is now commonly implicated in STI outbreaks among MSM in many locations but, at the same time, tools to use the internet as a way of increasing access to HIV and STI prevention methods among MSM are currently in development.
We can assume that the enormous technological and cultural changes affecting MSM communities will evolve in ever surprising ways and function, in the end, as double-edged swords that bring both positive and harmful effects to the health of MSM. That said, we are in the midst of an uncontrolled experiment on how social, cultural and technological changes affect the health of MSM in societies across the globe. Ongoing monitoring of these changes, and their health effects, may well yield important insights as to how best to take advantage of changes that support health among MSM and ways to reduce the harm caused by these changes.
MSM were and are everywhere. We are found in every era, race, ethnic group, age group, religious tradition, political party and continent. At present, we constitute an emerging global community for whom the creation of culturally competent and effective health promotion efforts may provide important test cases that will benefit other communities that stand on the edge of globalisation. The challenges to the prevention and care of STIs among MSM are daunting, but the public health impact and the scientific interest intrinsic to this work are enormous. We, and the larger field, look forward to seeing the benefits of the continuing evolution of STI research among MSM and in finding ways to utilise the growing sophistication of this sub-specialty to global health efforts.
Competing interests: None.
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