• ANTIMICROBIAL RESISTANCE
• STD CLINIC
• ANOGENITAL CANCER
• HOMOSEXUALITY

This issue focuses on gay, bisexual and other men who have sex with men (MSM), a population greatly affected by coexistent HIV and STI epidemics in many parts of the world. Indeed, gay-related immune deficiency (GRID) was the name first proposed in 1982 to describe AIDS before HIV was recognised as the cause. Even in the earliest epidemiological studies of AIDS, it was understood that there was a link to sexual practices and a history of STI diagnoses.1 New STIs are emerging and disproportionately affecting gay men living with HIV, such as lymphogranuloma venereum, hepatitis C virus (HCV) and human papillomavirus (HPV)-induced anal cancer. Increased access to antiretroviral therapy (ART) for people living with HIV has induced a return to normalcy. This has claimed to contribute to the re-emergence of syphilis among MSM.

Homosexual male–male activity is as old as mankind, and a part of life for many men in societies across the world. There is no evidence that men are more likely to be gay or otherwise MSM in any part of the world, though safety and social support to live as a gay man does vary greatly. Moreover, HIV disproportionately affects gay and bisexual men due to the efficiency of HIV transmission during condomless anal sex with serodiscordant and viraemic partners. The first part of this issue consists of a series of commissioned reviews and non-commissioned original articles describing the diverse responses to HIV and STIs among MSM around the world. A consistent message is the sustained disparity in the burden of HIV and STIs among MSM even in higher-income settings. Among gay and bisexual men in England, Hickson et al found that HIV prevalence remains higher among black men and white men who are not white British.2 Moreover, the previously documented protective effect of an Asian background appears no longer to pertain.

Amirkhanian3 describes the disparities in HIV epidemic control measures for MSM in Eastern European states. Most countries outside the former Soviet Union implemented relatively effective public health policies, with initiatives involving the lesbian, gay, bisexual and transgender (LGBT) community. In stark contrast, counterproductive steps targeted against the LGBT community were widely implemented in the former Soviet countries including Russia. Here, measures ranging from banning safe sex promotion materials to the persecution and criminalisation of gay men have had detrimental effects on the spread of HIV. Moreover, their HIV epidemic is increasingly difficult to measure given the increased stigma.

A study in Abuja and Lagos recruited Nigerian MSM through respondent-driven sampling, initiated at trusted community centres.4 Here, 28.0% of 492 men were diagnosed with an incident rectal gonorrhoea and/or chlamydia infection. HIV, older sex partners and the use of alcohol were associated with incident rectal STI. Since same-sex practices are culturally and legally unacceptable in Nigeria, stigma and depression may trigger alcohol consumption. Given the high proportion of asymptomatic infections, the authors conclude that it is time to move beyond individual interventions and syndromic surveillance, and get ‘out there’ in STI management. Mmbaga et al 5 describe the disproportionate HIV and STI burden affecting Tanzanian MSM and point out that social, cultural and legal circumstances hinder HIV prevention programmes from addressing the needs of key populations. These have been further b by a government-imposed ban on services for MSM challenging the ability to address their HIV prevention and treatment needs. Reports from Asia, the Pacific and Europe reinforce that universal treatment for those living with HIV is insufficient as a response, highlighting the need to scale up Pre-Exposure Prophylaxis (PrEP).6 7

The second part of this special issue focusses on new and re-emerging sexually transmitted infections found predominantly among MSM. Van de Laar and Richel address the emergence of HCV and HPV-induced anal cancers found among HIV-positive MSM since the advent of cART. Although recent curative treatments for HCV and preventive options such as HPV vaccines are available, financial and political hurdles have hindered their wider implementation. In the UK, a diagnosis of early syphilis was associated with a high risk of consequent HIV seroconversion. To prevent HIV transmission, the authors advocate prioritised access to prevention measures including PrEP and presumptive STI testing for MSM diagnosed with early syphilis.8

The final part of this issue addresses the emergence of new interventions and implementation approaches needed to tackle the sustained and often growing STI and HIV burdens among MSM. PrEP is fundamentally changing the dynamic of sex for many men. Decisions around how and when to use condoms will alter during scale-up, posing challenges to prevention campaigns focused on bacterial STIs.9 In a paper addressing condomless anal intercourse with casual partners, Down et al stress that beyond condom use, sexual positioning and other key contextual information are essential to understanding sexual risk behaviour among gay and bisexual men. To explain why MSM are disproportionally affected by STI, Spicknall et al 10 describe sexual network characteristics in a mathematical model. Finally, Hightow-Weidman and Muessig discuss the role that social media play in the daily lives of MSM, both to seek new partners, and the potential for online apps as specific tools for the delivery of HIV/STI prevention and care interventions.11 The authors conclude that most online interventions are not tailored for MSM and remain US centric. As ever, additional studies are necessary.

A Canadian study by Closson et al 12 shows that age-disparate relationships were more common among younger men living with HIV and among older HIV-negative men. They conclude that sexual health promotion must respond to to data on how relationships actually form, including mixing between younger and older gay and bisexual men. In a review on the associations between the use of illicit substances and sexual risk behaviour among MSM, Bourne and Weatherburn13 suggest that the nature and pathway of drug use and sex remain understudied and consequently poorly understood.13 Moving forward requires an understanding how the use of alcohol and drugs affect the broader health and well-being of MSM.

The epidemiology of HIV and STIs around the world is more similar than different, and indeed MSM are vulnerable to infection throughout the world. Effective cost-effective and scalable prevention and treatment programmes are available to enable MSM to have healthy and enjoyable sex. Yet, these programmes require political will to be implemented. Right now, in large parts of the world, gay, bisexual and other MSM are faced with increasing oppression—Chechnya and Indonesia are just two recent examples of violence and persecution of MSM. Elsewhere, multiple intersecting stigmas affecting MSM are more subtly integrated into society.

Lastly, healthcare workers dealing with MSM who have STI-related complaints or seek STI screening must obtain a thorough sexual history.14 Although this may seem a relatively simple undertaking, many clinicians still feel ill equipped to do so. Therefore, STI care and the diversity of sexual orientation of patients should be provided throughout the medical and healthcare curricula. Taken together, there is a need for a global effort to finally accept the diversity of human sexuality within our society and provide evidence-based, human rights affirming and cost-effective interventions available to all.15 The articles collected here demonstrate that highly effective prevention strategies like PrEP, vaccines and treatments are available to curb the syndemics of HIV and other STIs among MSM. Yet, as is often the case, prioritisation, political advocacy, infrastructural and financial resources stand in the way of effective implementation and the roll out of targeted programmes.