An ongoing dialogue on HIV/AIDS, infectious diseases,
January 7th, 2015
Are the STI Screening Guidelines for Gay Men Overkill? (And Pedro Video.)
Our “healthcare system” recently distributed a set of guidelines entitled, Primary care for gay men: screening and treatment recommendations.
It included, among other things, recommendations for screening for sexually transmitted infections (STIs) and anal cancer. The former it adopted from CDC guidelines, which are this this:
Screening at least once a year for syphilis, chlamydia, and gonorrhea for all sexually active gay, bisexual, and other men who have sex with men (MSM). [Emphasis theirs.] MSM who have multiple or anonymous partners should be screened more frequently for STDs (i.e., at 3-to-6 month intervals)
The anal cancer screening guidelines were kind of made up — pretty much like all recommendations for this form of cancer, since we don’t have solid data linking screening to a reduction in cases of invasive anal cancer and/or death. But in essence the guidelines recommend annual screening with anal pap smears for HIV positive men, and to “consider” screening HIV negative gay men every 2-3 years.
(Brief reminder here: Cancer screening — prostate, breast, colon, lung, ovarian, you name it — is kind of a complex issue. That, my friends, is so far the understatement of this baby year. In short, just because we can screen for some cancers, doesn’t mean we should. )
Anyway, the release of these guidelines prompted an email from one of my colleagues, a primary care physician, as follows:
I was reading the guidelines regarding recommendations for STI screening in all MSM (including annual HIV, urethral/rectal GC/chlamydia swabs, pharyngeal gonorrhea swab and syphilis testing) — is this something that you recommend in practice? I have a number of MSM patients in monogamous relationships so my approach has been to screen if new partners, etc. — and I have not been screening for everything, e.g., asymptomatic pharyngeal gonorrhea… seems silly, what’s the evidence?
They are also recommending consideration of anal pap 2-3 years in MSM who are HIV negative… Is that something you recommend? I worry that the benefits of downstream evaluation/treatment are not clear. Thanks so much for your wisdom!
Emily [Not her real name #1]
Moments after this Emily query, along came this, from a different physician-colleague, who is a gay man:
Hi Paul,
Wondering what you think of these recommendations for STI and anal cancer screening for gay men. I can tell you that my PCP read aloud the guidelines from his computer screen during a routine office visit. He did not ask me about specific risk behaviors and did not take a sexual history, but recommended anal pap because “according to the guidelines” I should have it done. Because I respected and liked him so much, I did not object, even though I thought it was a ridiculous waste of time and money. It would be helpful to know the strength of the evidence for doing an anal pap in HIV-negative men.
Charles [Not his real name #2]
So what’s going on here? Why did both these smart doctors — one as a clinician, the other as a patient — question the guidelines?
As usual, when faced with this kind of clinical quandary, I turned to the most brilliant person I know about patient dynamics, challenging encounters, and the mysterious emotional world of the people we see in clinic — our extraordinary social worker Susan Larrabee. Here’s her comment, quoted in full since it gets “right to the heart” of the issue, if I may use a phrase commonly employed by one of my favorite writers.
Is it possible some MD’s avoid difficult conversations (i.e. conversations they are uncomfortable having) by doing tests? And perhaps some of these same MDs are making these recommendations? I’m not above this in my own life, especially with my teenage kids and their visits with their pediatricians… they’re certainly not telling me (or maybe not their doc) everything. That is to say, there are many difficult conversations and many ways to compensate for our discomfort or the discomfort of our patients, with over-testing perhaps being one.
Susan [her real name]
This is, of course, exactly the issue. In fact, if one reads the guidelines carefully, it includes this key phrase: “these recommendations should be tailored to an individual patient’s risk profile.”
In other words, you can modify the screening according to the risk behaviors of the patient — but only if you take the time to assess it. Cynics will say that everyone lies about their sexual behaviors, but do we know if that’s really true? Better to ask and to talk about this stuff than just proceed blindly.
Speaking of brilliant, I enthusiastically agree that Pedro Martinez deserved his first-ballot induction into the Hall of Fame. (OK, admittedly a sudden transition, hence the Dominican Republic flag above.) He was perhaps the most extraordinary pitcher I’ve ever seen pitch live, and I’ve seen this guy, this guy, and this guy too.
Baseball fans, see what you think:
10 Responses to “Are the STI Screening Guidelines for Gay Men Overkill? (And Pedro Video.)”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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Great stuff as always Paul. And as an added bonus, the Clemens and Guidry games you highlighted happen to be two of the seminal experiences of my life as a baseball fan.
Great post Paul. Everyone should know how to take a sexual history in a sensitive yet matter-of-fact way.
Paul,
I agree with you that screening men in long-term, mutually monogamous relationships is not needed. Below are the 2010 Public Health – Seattle & King County STD Screening Guidelines for MSM. I think that they still apply.
Clinicians should ask all men if they’ve been sexually active with men, women, or both.
1.HIV testing and STD screening should be performed on all sexually active MSM annually except those in long-term (> 1 year), mutually monogamous, HIV concordant relationships. Sexually active MSM include all MSM engaging in any anal, or oral sex. Screening should include the following tests:
1.HIV (if patient is not previously known to be HIV infected)
2.Serological testing for syphilis (i.e. RPR or other syphilis screening test)
3.Rectal cultures or nucleic acid amplification tests for gonorrhea and chlamydial infection (men who report receptive anal sex only)+
4.Pharyngeal culture or NAAT for gonorrhea+
1.Repeat HIV and STD testing (as above) should be performed every 3 months in MSM with any one or more of the following risks:
1.Diagnosis of a bacterial STD in the prior year (gonorrhea, chlamydial infection or early syphilis**)
2.Methamphetamine or popper use in the prior year
3.>10 sex partners (anal or oral) in the prior year
4.Unprotected anal intercourse with a partner of unknown or discordant HIV status in the prior year
* Screening refers to testing in the absence of signs, symptoms or known exposure to an STD.
+ Existing data suggest that the Aptima Combo 2 test performs well on rectal and pharyngeal specimens and is more sensitive than culture. Laboratories performing the test must first perform an internal validation study. Clinicians should use caution in interpreting results of the Roche PCR (Roche Diagnostics) assay for gonorrhea, which is not specific, and the Becton Dickenson strand displacement assay, which has not been well studied and may be insensitive.
** Persons with early syphilis should be retested at 1, 3, 6, 9 and 12 months. Persons rescreening following an episode of urethral gonorrhea or chlamydial infection should be retested for urethral gonorrhea and chlamydia.
http://www.kingcounty.gov/healthservices/health/communicable/std/providers/msmstd.aspx
Evidence supporting our criteria for frequent rescreening can be found in the following citation:
Menza TW, Hughes JP, Celum CL, Golden MR. Prediction of HIV acquisition among men who have sex with men. Sex Transm Dis. 2009 Sep;36(9):547-557.
Amazing pitcher indeed! However, don’t love that you picked the clip where Pedro was striking out so many Yankees.
I am an HIV+ gay nan who has been in a strictly monogamous relationship with a still HIV- man for 26-1/2 years. The STI recommendation is ridiculous for us. There is absolutely no way either of us could acquire an STI, except a toilet seat ;<)! Further, we are, for obvious reasons, very, very careful about our sexual behaviors with each other.
However, I was in a very promiscuous relationship with a man who died the week my (now legal husband) and I met. I have anal warts and am a Kaiser Permanente San Francisco member, so I do follow its protocol to have my occasionally stage 1 lesions inspected and, when necessary, treated every three months, until the last time when I was told there was no need to come back for screening for a year.
Whether frequency and scope (3 site vs. urine) of sexually transmitted infection screening among MSM should be based on self-reported behavioral risk is indeed an important question and should be addressed by evidence-based cost-effectiveness studies. However, I was struck by the findings reported by van Liere et al (Sex Transm Dis. 2013 Apr;40(4):285-9) that “Sensitivity of selective symptom- and sexual history-based testing for anorectal STD was 52% for homosexual MSM, 40% for bisexual MSM, 43% for bisexual male swingers, 40% for heterosexual
male swingers, and 47% for female swingers.” If the sensitivity of risk-based screening is that low, a policy of universal screening is certainly rational.
I think one of the things that has been missed is that pharyngeal and rectal GC/CT is quite often asymptomatic, and I have heard it hypothesized that these are the areas that are likely leading to recurrent exposures and infections which then lead to resistance. As I start to discuss this with my HIV+ patients, I am impressed with how many have never been tested there and have come back positive. Let’s just say I’m buying stock in ceftriaxone…
Very nice review and approah Paul. As you said guidelines (almost for every single disease) need to be tailor based on patient clinical situation and characteristic. The real lack of epi and biological info of some diseases in some patients sometimes deserve to overact or at least point to that trend.
By the way I’m in full agreement with you Pedro deserves to enter in Hall of Fame shortly. Sometimes it takes long time to incle an obvious star into the Hall. Pedro probably is THE best latino pitcher in the history,
Best regards
Emilio
I agree that the guidelines should be tailored to risk factor. It is a form of discrimination to assume that “negative” males in a monogamous relationship are required to undergo these screenings if it isn’t necessary. The lack of communication of the doctors is also unprofessional and they should be more vocal about why these are required,
I agree with Paul on this one.