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How do we tackle the poor sexual health of gay and bisexual men? The lives of many men-who-have-sex- with-men (MSM) in the UK, as in many other Western liberal democracies, have undergone the most extraordinary social changes in less than two decades. In the UK, these have included the legalisation of marriage, equality in health, parental and employment rights and an increasing mainstream acceptance of gay (and to a lesser extent bisexual) men that extends from sport to soap operas.
In stark contrast, rates of Human Immunodeficiency Virus (HIV) infection in MSM, compared with most other groups, are stable or rising in almost allhigh, middle and low income nations including the UK. Sexually Transmitted Infections (STIs), in particular syphilis and gonorrhoea, continue to affect MSM disproportionately, and rates of other health problems, from tobacco use and depression to anal cancer, may be higher in MSM than in heterosexual men.
The British association of Sexual Health and HIV (BASHH) MSM special interest group was formed in 2011 in response to this complex but fascinating challenge. We have addressed strategic priorities through co-ordinating BASHH feedback to Public Health England (PHE) consultations on the ‘strategic framework to improve the health and wellbeing of gay, bisexual and other men who have sex with men’ and on ‘increasing the uptake of HIV testing among MSM’. We have provided clinical guidance through input to the BASHH recommendations on STI testing for MSM, a BASHH/British HIV Association (BHIVA) position statement on Pre Exposure Prophylaxis for HIV (PrEP) and the Joint Committee on Vaccination and Immunisation (JCVI) interim statement on Human Papillomavirus (HPV) vaccination in MSM. A UK National Guideline on the Sexual Healthcare of MSM is currently in development. We have also contributed to the HPE response to outbreaks of non-travel-associated outbreaks of Shigella flexneri, S. sonnei and VTEC0117 in MSM. Our first national meeting, ‘Sex, Drugs and MSM’, was held in November 2013 in Birmingham and was enormously popular with delegates; a further meeting is planned for 2015.
So, what do our services in 2015 need to look like? Adapting our successful niche services for MSM, born out of a prejudice that has largely disappeared, to the new era of integrated sexual health may be daunting. Improved and expanded specialist and outreach MSM services present an obvious solution to the problem, but they are only part of it.1 On one hand, 49% of new HIV infections in MSM diagnosed in 2010–2012 were diagnosed on their first HIV test. Opt-out HIV testing is clearly the appropriate approach for MSM in all settings, but MSM are still less likely to be ‘out’ to their General Practitioner (GP) than their boss, family or colleagues. On the other hand, 19% of MSM were diagnosed within 5 months of acquiring HIV infection, consistent with a high incidence of infection, so repeat testing for STIs and HIV, as often as every 3 months for many men, is required and generates significant, though surmountable, capacity issues.2 The successful use of home sampling for HIV both in the NHS and the third sector and the legalisation of home testing kits for HIV offer opportunities to explore new ways of encouraging first and repeat testing that must be fully used. Availability of and access to Post Exposure Prophylaxis for Sexual Exposure to HIV (PEPSE) will be the subject of revised guidelines in 2015, and the early discontinuation of the deferred arm of the UK PRe-exposure Option for reducing HIV in the UK (PROUD) study of PrEP in late 2014, closely followed by the Intervention Préventive de l'Exposition aux Risques avec et pour les hommes Gays (IPERGAY) study in France, increases the urgency with which access to this prevention intervention, already comprehensively supported by CDC Guidance in the USA, is resolved in the UK. To this end, BASHH is represented on the National Health Service (NHS) England PrEP group for the Clinical Reference Group for HIV (CRG). It is clear that the differing needs of younger men, men from ethnic minorities, migrants and men who do not identify as homosexual or bisexual cannot be met exclusively through services in Level 3 GUM Clinics. Medical Research Council (MRC) Bar-based survey data suggest that men under 25 are more likely to report Unprotected Anal Intercourse (UPAI) with two or more partners in the past year than men over 25,3 yet younger men across the world are disadvantaged in accessing services and may prefer to attend generic young people's sexual health services rather than MSM-specific clinics. We must expand our view beyond the GUM clinic and work to ensure that all services, including youth services, Contraception and Sexual Health Services (CASH) and general practice provision, are truly inclusive and offer services both to men who want to attend specialist MSM clinics and the many who, for a range of reasons, do not. It is no longer acceptable for any NHS-commissioned service, integrated or not, to offer STI testing that does not meet the needs of MSM.
All members of the BASHH MSM Special Interest Group contributed to the discussions leading to the development of this article.
Contributors DC conceived and wrote the paper based on the work and discussions of the BASHH MSM Special Interest Group. Group members Dr David Asboe, Dr Tristan Barber, Dr Carol Emerson, Dr Martin Fisher and Dr Andy Williams, commented on the draft. DC is the guarantor of the paper and responsible for the opinions expressed.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.