From the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
Correspondence: Catherine McLean, MD, Centers for Disease Control and Prevention, MS E-04 Atlanta, GA 30333. E-mail: email@example.com.
Received for publication May 18, 2006, and accepted May 22, 2006.
TWENTY-FIVE YEARS AFTER THE first case of AIDS was identified, access to antiretroviral medications is rapidly increasing for HIV-infected persons worldwide, and promising HIV prevention methods such as circumcision, candidate microbicides, and periexposure HIV prophylaxis are on the horizon. As these exciting and important developments in HIV prevention and care are pursued, fundamental public health principles such as access to high-quality medical services, early HIV and sexually transmitted disease (STD) diagnosis and treatment, partner testing and treatment, and the provision of up-to-date prevention counseling must be renewed in practice. In this issue of Sexually Transmitted Diseases, Ko and colleagues provide a window into one high-risk community—men who have sex with men (MSM) visiting bathhouses—which presents a strong case for renewing basic HIV and STD prevention efforts not only for the bathhouse setting, but for MSM in the community.1
Contributing to the limited published literature on HIV and STDs in MSM in Asia, Ko et al tested specimens for HIV, STDs, and viral hepatitis from MSM visiting bathhouses in Taiwan. In this setting, 8% of the MSM tested as part of this study (and not previously aware of being HIV-positive) tested HIV-positive. Furthermore, 24% of MSM had not been HIV tested previously, an especially high percentage given this high sexual risk-taking environment. Their findings highlight several prevention opportunities. HIV counseling and testing and the facilitation of access to care for those who are HIV-infected are critical interventions for limiting the spread of HIV. The men who were newly identified as HIV-positive in this study were in a particularly high-risk environment where they may have transmitted HIV to others. Counseling, testing, and education about how to minimize personal health risks and limit the risk of HIV transmission to others may alter their behavior and limited further transmission. As the number of people living with HIV increases worldwide, early HIV diagnosis and prevention activities for HIV-positive persons are increasingly important.2
As the complex biologic and behavioral relationships between STD and HIV infections are unraveled, early STD diagnosis and effective treatment should continue to be fundamental components of HIV/STD prevention programs for both HIV-infected and -uninfected persons.3,4 Potential implications of HIV and STD coinfection such as the increase in HIV infectivity of persons coinfected with some STDs, the reduction in HIV plasma viral load after effective STD treatment, and the potential increased morbidity of some STDs in those who are immune-compromised must be part of the education and counseling of persons at risk of HIV. This information is especially important to share with those in high-risk communities such as MSM, and those who are HIV-positive.4–7
Ko and colleagues also presented serologic test results for viral hepatitis. Consistent with previous studies,8 hepatitis A and B immunization in MSM tested as part of this study was suboptimal: 8% of MSM had evidence of immunity to hepatitis A, and 61% had evidence of immunity to hepatitis B. Although these serologic test results include both previous infection and vaccination, the findings in this high-risk population of bathhouse visitors underscore missed opportunities for vaccinating MSM for hepatitis A and B not only in the bathhouses, but also by clinicians in the community.9 In settings such as the Taiwanese bathhouses described in this study, revaccination of an already immunized individual for hepatitis A or B is safe and can be provided without obtaining prevaccination serologies.9
Sexual contact may also facilitate transmission of gastrointestinal infections through oral–genital, oral–anal, and anal sex. Several gastrointestinal syndromes including proctitis, proctocolitis, and enteritis can result from sexually transmitted microbes such as Neisseria gonorrhoeae, Chlamydia trachomatis (including lymphogranuloma venereum [LGV]), Treponema pallidum, herpes simplex virus, Campylobacter sp., Shigella sp., Entamoeba histolytica, and Giardia lambia.9 In addition to being offered hepatitis A and B vaccination, persons practicing oral and anal sex need accurate and updated information about the oral and anal manifestations of STDs and the possible sexual transmission of enteric infections. A broad range of infections not typically considered sexually transmitted may be sexually acquired. Ko and colleagues report that 58% of MSM reported unprotected oral sex at the most recent bathhouse visit. Their sexual practices may place MSM at especially high risk. Comprehensive sexual health care should include accurate information about these potential risks, especially for those who are HIV-infected or otherwise immune-compromised.
Although exciting developments, including potentially new, effective HIV prevention methods, are drawing attention in the field of HIV and STD prevention and treatment, it is more important than ever that communities at high risk, clinical providers, and STD and HIV prevention programs enhance the fundamental public health efforts of HIV and STD counseling, screening, effective and timely treatment, and vaccination for high-risk populations. Broadening the mandate to incorporate hepatitis vaccination and enteric disease prevention education is important, especially for the MSM population. Ko and colleagues have provided a window into a very high-risk community of MSM in Asia. Their findings speak to the need for more active prevention, including education, testing, and vaccination, not only in the bathhouses, but in the MSM community, a population at high risk of a whole host of infections. There is room to do a better job.
1. Ko N, Lee H, Chang J. Prevalence of HIV and sexually transmitted infections and risky behaviors among men visiting gay bathhouses in Taiwan. Sex Transm Dis 2006; 33:000–000.
2. Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic—United States, 2003. MMWR Morb Mortal Wkly Rep 2003; 52:329–332.
3. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75:3–17.
4. Cohen MS, Hoffman IF, Royce RA et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: Implications for prevention of sexual transmission of HIV-1. Lancet 1997; 349:1868–1873.
5. Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Morb Mortal Wkly Rep 2003; 52:1–17.
6. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and the heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000; 342:921–929.
7. Scheer S, Chu PL, Klausner JD, Katz MH, Schwarcz SK. Effect of highly active antiretroviral therapy on diagnosis of sexually transmitted diseases in people with AIDS. Lancet 2001; 357:432–435.
8. Centers for Disease Control and Prevention. Hepatitis B vaccination among high-risk adolescents and adults—San Diego, California, 1998–2001. MMWR Morb Mortal Wkly Rep 2002; 51:618–621.
9. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines. MMWR Morb Mortal Wkly Rep 2002; 51(RR-6).